Academic journal article South African Journal of Psychiatry

Obsessive Compulsive Disorder

Academic journal article South African Journal of Psychiatry

Obsessive Compulsive Disorder

Article excerpt

1. Introduction

This guideline focuses on the pharmacotherapy of obsessive-compulsive disorder (OCD). OCD is characterised by obsessions and compulsions. A number of other disorders are also characterised by repetitive thoughts and rituals and may also respond to modifications of standard OCD treatment. These so-called OCD spectrum disorders include body dysmorphic disorder (characterised by recurrent concerns with imagined ugliness), hypochondriasis (characterised by recurrent concerns with imagined illness), trichotillomania (characterised by recurrent hair-pulling), and obsessive-compulsive personality disorder. [1] The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [2] has a new chapter on obsessive-compulsive and related disorders, which includes several of these conditions.

2. Diagnosis and clinical characteristics

Evidence indicates that OCD is commonly underdiagnosed and undertreated. [3] There is also the converse possibility that various disorders with intrusive symptoms, such as post-traumatic stress disorder or generalised anxiety disorder, can be misdiagnosed as OCD. Diagnostic criteria for OCD are provided in Table 1. [4]

3. Assessment

Most patients with OCD have both obsessions (which increase anxiety) and compulsions (which aim to decrease anxiety), particularly given that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [2] definition of compulsion includes mental rituals. The most common obsessions centre around concerns of contamination, harm, hoarding, and sexual, somatic and religious preoccupations, while the most common compulsions include washing, checking, repeating, ordering, counting, and hoarding. [5] The disorder is highly comorbid with obsessive-compulsive and related disorders, major depressive disorder, anxiety disorders, alcohol dependence, eating disorders and tic disorders. [6,7] Evaluation should include assessment of symptom pattern, severity, and functional impairment. Comorbid Axis I and II disorders, including tic disorders, as well as medical conditions (including pregnancy) and disorders need to be accurately identified. There is growing evidence that OCD and/or tics in some patients, particularly children, are precipitated or exacerbated by streptococcal or other infections. [8]

Evaluation of the OCD patient also requires attention to psychosocial factors that may have precipitated or exacerbated OCD symptoms. For example, are family members involved in the patient's rituals? What is the patient's explanatory model of OCD--does he or she regard it as a sign of weakness or as evidence of brain dysfunction?

4. Treatment

4.1 Treatment goals

The goals of treatment of OCD are to reduce symptom frequency and severity and to improve functioning and quality of life. Treatment goals also encompass minimising medication adverse effects, helping the patient develop coping strategies for their OCD and related stressors, and educating the patient and family regarding the disorder and its treatment. [7]

4.2 General aspects of treatment

In this discussion, we assume that the patient is an adult. Nevertheless, there are increasing data on the pharmacotherapy of OCD in children. [9,10] Indeed, the algorithm (see Fig. 1 below) can readily be adapted for children, bearing in mind considerations such as differences in dosing and differences in risk-benefit determination (e.g. clinicians are less likely to use untested augmentation strategies in children). Consultation with a child psychiatrist may well be indicated in such cases.

The initial treatment of OCD can arguably be either medication or psychotherapy as both approaches are efficacious. Several factors may complicate OCD, thus impacting on decisions about the choice of pharmacotherapy and other interventions. The most important factors, along with their treatment implications, are listed below. …

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