Editorial: Obsessive-Compulsive Disorder

Article excerpt

The way we view Obsessive-Compulsive Disorder (OCD) has gone through a true revolution since we started our residency Twenty-five years ago, OCD was considered a rare, refractory disorder of psychological origin. All of these notions have been entirely reversed. It is clear now that the quoted prevalence of 0.05% does not reflect the true prevalence of OCD, which has been repeatedly found to be around 1.62%(1). Moreover, the prevalence of OCD is the same in developed as compared to developing countries. OCD has been classified as one of the ten most disabling disorders by the WHO (this list refers to all, not only psychiatric, disorders)(2). It has been suggested that the egodystonic nature of OCD, i.e., that the individuals involved are fully aware that their behavior is unreasonable or excessive, might contribute to this.

What is even more impressive is that from a treatment refractory disorder about which very little was known vis-à-vis how to offer an effective treatment to the patient, OCD has become one of the disorders in which there are a vast amount of impressive treatment studies. The unique therapeutic role of the tricyclic clomipramine and the specific serotonin reuptake inhibitors (SSRIs), with an emphasis on the need to give medium to high doses for extended periods of time (10-15 weeks), is well established (3-5). Those findings, along with the impressive data in regard to the usefulness of cognitive behavioral therapy (CBT) in OCD (6, 7), give a very powerful armamentarium in the hands of the clinician treating OCD patients.

The third milestone in the revolution that OCD went through is derived from the two above-mentioned findings - the realization that OCD is so prevalent, along with the unique response of OCD patients to 5HT reuptake blockers - fuelled research into this intriguing disorder. The biological formulation of OCD in 2008 has dramatically changed from that of 1980. The perspective has shifted from a neurosis to a disorder with a well-defined brain circuitry and carefully explored 5HT pathophysiology (8). In this sense, OCD might provide a unique example in regard to the progress that psychiatry has made in the last 25 years.

Nowadays, OCD is on the verge of another revolution - a revolution which focuses on looking at obsessive-compulsive disorders rather than looking at OCD as a single disorder (9). This approach also calls for removing OCD from anxiety disorders and including in the obsessive-compulsive spectrum disorders such as hypochondriasis, body dysmorphic disorder, trichotillomania, etc. (8-11). The motive of this new classification concept is the endophenotype motive, which calls to look beyond the phenotype, looking at the intermediate phases between the gene and the symptom expression (12). Looking at OCD along these lines suggests that the pathology is not limited only to the compulsive end of the spectrum, but might be presented along the continuum of compulsivity-impulsivity.

However, the great challenge in OCD is still the most basic one - diagnosis. The paper of Naomi Fineberg et al. specifically addresses the issue of how obsessive-compulsive disorders which are frequently overlooked during medical and psychiatric evaluations could be better identified. Our experience is that unless you actually look specifically for obsessive-compulsive symptoms, you will not find them. This is the case for any psychiatric interview, and is especially true for individuals with OCD.

Two further papers in this issue, one by David Greenberg and Gaby Shefler, and the other by Asaf Caspi et al., bring the reader back to the basic questions of the interaction of the environment and the disorder. Greenberg and Shefler touch upon important issues such as how to peel back the religious/cultural layer - to look beyond the religious rituals, and to separate them from the compulsions. This paper and that of Caspi et al. pave the way to the question of epigenetics, while touching upon questions such as early life trauma and their relationship with OCD. …