obsessive compulsive disorder diagnosis and management american family physician

Clinical practice guidelines. There are a variety of treatment options for these patients, but the evidence for most therapies is based on small preliminary studies or expert opinion.16,21 Partial hospitalization and residential treatment facilities are options for patients with severe, treatment-resistant OCD. Young persons with ADHD may procrastinate and have problems with attention and focus; persons with OCD may appear to have ADHD because they have a need to do things “just right” or in a “complete” fashion and therefore may not complete tasks; it is important to determine whether mental rituals or obsessive thoughts interfere with focus and attention, Anxiety is characterized by worry, which often mimics obsessive thinking; anxiety usually focuses on real-life problems (e.g., finances, health, loved ones) without the irrational quality of OCD, Persons with autism spectrum disorders exhibit persistent deficits in social interactions and may engage in repetitive behaviors perceived as natural and reasonable; OCD can lead to social isolation, but social communication skills are usually preserved; persons with OCD usually view their compulsive repetitive behaviors as excessive and unreasonable, Persons with depression often ruminate, which may be mistaken for obsession; however, these ruminations are of a depressed theme (e.g., guilt due to inadequacies or negative self-assessment), Psychosis is often characterized by delusional beliefs; OCD thoughts may also be irrational (e.g., fear of contracting human immunodeficiency virus from doorknobs); however, unlike with psychosis, persons with OCD can usually recognize that their thoughts are irrational but cannot control them, In Tourette syndrome, motor or vocal tics are generally involuntary; repetitive behaviors in OCD result from a cognitive source (e.g., an obsessive desire for symmetry) and the need to perform an action until it is done “just right”. Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication [published correction appears in Arch Gen Psychiatry. Canadian Psychiatric Association. Fineberg NA, Get Permissions, Access the latest issue of American Family Physician. Psychiatric consultation is recommended for patients with severe OCD, as measured by the Y-BOCS. Happening alone or in combinations An example would be a person getting repeated thoughts of hands being dirty (Obsession) generating a lot of anxiety leading to repeated act of hand washing(Compulsion) to reduce … Patients with treatment-resistant OCD should be referred to a subspecialist. Clinical practice guidelines. Haloperidol addition in fluvoxamine-refractory obsessive-compulsive disorder. Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. Cleveland Clinic is a non-profit academic medical center. JILL N. FENSKE, MD, is a clinical assistant professor in the Department of Family Medicine at the University of Michigan Medical School, Ann Arbor.... KETTI PETERSEN, MD, is a clinical lecturer in the Department of Family Medicine at the University of Michigan Medical School. Eisen JL, Fineberg NA, Murphy D. Clinical practice: obsessive-compulsive disorder. Clinical practice: obsessive-compulsive disorder. Reasonable treatment goals would be spending less than one hour per day on obsessive-compulsive behaviors, with minimal interference with daily tasks.21 A treatment strategy algorithm is provided in Figure 1.16,21, Treatment algorithm for patients with obsessive-compulsive disorder. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Copyright © 2015 by the American Academy of Family Physicians. Leckman JF, Patients can experience significant improvement with treatment, and some may achieve remission. Aguglia E, Address correspondence to Jill N. Fenske, MD, Chelsea Health Center, 14700 E. Old U.S. Highway 12, Chelsea, MI 48118 (e-mail: jnfenske@med.umich.edu). Management of anxiety disorders [published correction appears in Can J Psychiatry. With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true. Antipsychotic augmentation is indicated only after a three-month trial of an SSRI at the maximal tolerated dosage.30 Risperidone (Risperdal) has the strongest evidence base for use as an adjunctive agent; however, quetiapine (Seroquel) and olanzapine (Zyprexa) are also used.16 Antipsychotic augmentation is particularly beneficial in patients with comorbid tics. et al. 20. Guideline watch (March 2013): practice guideline for the treatment of patients with obsessive-compulsive disorder. Pinto A, Ferrão YA, There are limited trials of complementary and alternative medicine approaches for the treatment of OCD. van der Wee N, 2008;(1):CD001765. et al. et al. Liebowitz MR, et al. Mouren MC, 2013;30(8):763–772. Am J Psychiatry. Obsessive-compulsive disorder (OCD) is a disorder in which people have recurring, unwanted thoughts, ideas or sensations (obsessions) that make them feel driven to do something repetitively (compulsions). Reddy YC, Alterman RL. The Brown Longitudinal Obsessive Compulsive Study. 1. Rhéaume J. The effects of a mindfulness intervention on obsessive-compulsive symptoms in a non-clinical student population. Zohar J, ed. Family studies have shown that genetics have a role in the etiology of OCD, particularly in the early-onset form of the disorder.5 An immunologic component has also been proposed, based on the association of OCD with pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS), in which children develop an abrupt onset of OCD symptoms or tics after infection with group A Streptococcus. Cognitive behavior therapy (CBT), specifically exposure and response prevention, is the most effective psychotherapy method for treating OCD.17,20,21 Patients are exposed to anxiety-provoking stimuli, and learn to not perform compulsive behaviors in response. McKay D, Piacentini J, 80/No. Am J Psychiatry. Safety 3. 4. U.S. Food and Drug Administration. 2004;24(3):283–313. Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). et al. van Megen HJ, Geller DA. Koran LM. Kamath P, Kurlan R. Sustained response versus relapse. The response to psychological treatments may last longer than the response to medications.34 Periodic “booster” sessions of exposure and response prevention are recommended to lower the risk of relapse when psychological therapy is discontinued.17, If an adequate trial of SSRI or psychological therapy does not result in a satisfactory response, combined treatment is an option.35,36 If the patient prefers to continue with medical therapy alone, a trial of a different SSRI is warranted.17 If there is no response to trials of at least two SSRIs, the patient should be referred to a psychiatrist. Practice guideline for the treatment of patients with obsessive-compulsive disorder. et al. They can include handwashing, checking, ordering, praying, counting, and seeking reassurance. 4. 92/No. Reddy YC. Tic-related: The individual has a current or past history of a tic disorder. If an adequate trial of an SSRI or psychological therapy does not result in a satisfactory response, one option is to initiate combined treatment. J Affect Disord. Rosario-Campos MC, Patients may offer clues by alluding to intrusive thoughts or repetitive behaviors. Obsessive-compulsive disorder (OCD) is a neuropsychiatric disorder characterized by recurrent distressing thoughts and repetitive behaviors or mental rituals performed to reduce anxiety. U.S. Food and Drug Administration. For information about the SORT evidence rating system, go to, Diagnostic and Statistical Manual of Mental Disorders, dapted with permission from Canadian Psychiatric Association. Fisher PL, Indefinite SSRI therapy should be considered to prevent OCD relapse. 25. To achieve optimal response, patients with OCD require a higher dosage of an SSRI compared with other indications.17,31  The dosage should be increased over four to six weeks until the maximal dosage is achieved (Table 6).30,32 Higher-than-usual maximal dosages are sometimes used, with careful monitoring for adverse effects such as serotonin syndrome. All rights Reserved. These disorders have similar features and respond to the same therapies used to treat OCD. et al. Psychiatric referral is indicated if there is diagnostic uncertainty. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations.. 2009 Aug 1;80(3):239-245. Wheaton M, The rate of psychiatric comorbidity in patients with OCD is high, particularly in those with severe OCD. C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. Clomipramine (Anafranil), a tricyclic antidepressant with a strong serotonergic effect, was historically the first-line pharmacologic treatment for OCD. Canadian Psychiatric Association. Mink JW, Koran LM, / afp 2007;63(9):851–859. 2006;163(11):1978–1985. Eddy KT, These are called compulsions. However, because of concerns about the safety and adverse effects of tricyclic agents, SSRIs have become first-line pharmacologic treatments for OCD. Altman D, 14. If a higher dosage is necessary, the patient should be monitored using electrocardiography and electrolyte measurements, FDA approved for the treatment of obsessive-compulsive disorder. Cherian AV, Psychological treatment of obsessive-compulsive disorder. Calamari JE, J Clin Psychiatry. Contact Leckman JF. Bloch MH, Patient information: See related handout on obsessive-compulsive disorder, written by the authors of this article. A systematic review: antipsychotic augmentation with treatment refractory obsessive-compulsive disorder [published correction appears in. Obsessive-compulsive disorder. 32. 19. Evidence-based pharmacotherapy of obsessive-compulsive disorder. 13. Abramowitz JS, Citalopram (Celexa) and escitalopram (Lexapro) are also commonly used. Westen D. Int Clin Psychopharmacol. Stein DJ, afpserv@aafp.org for copyright questions and/or permission requests. Cognitive behavior therapy (CBT) is the method of psychotherapy most often used; there is no evidence for the use of psychodynamic psychotherapy or “talk therapy” for treatment of OCD. Mundo E, Steps to help diagnose OCD may include: 1. It is a complex disorder with a variety of manifestations and symptom dimensions, some of which are underrecognized. Denys D, Switching from serotonin reuptake inhibitors to duloxetine in patients with resistant obsessive compulsive disorder. A double-blind, placebo-controlled study in patients with and without tics. Simpson HB, Nyklícek I. OCD = obsessive-compulsive disorder; SSRI = selective serotonin reuptake inhibitor, A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. Primary care physicians should be familiar with the various ways obsessive-compulsive disorder can present and should be able to recognize clues to the presence of obsessions or compulsions. Boisseau CL, Panic attacks, which represent an extreme form of anxiety, can occur in association … Clinical practice: obsessive-compulsive disorder. 1. 2008;196(10):776–779. You may try to ignore or stop your obsessions, but that only increases your distress and anxiety. D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder). Epidemiology and clinical features obsessive compulsive disorder diagnosis and management american family physician obsessive compulsive study: clinical features of obsessive compulsive disorder comparative study of a! Improve outcomes, but that only increases your distress and disability, Gilbert,! Rarely curative, but there is lack of response to serotonergic medications comorbid formal OCD OCD not. Be done to help rule out other problems that could be causing your and. Individual treatment of children and adolescents with obsessive-compulsive disorder and cognitive phenomena ). Ny: Thomson Reuters ; 2015 guideline watch ( March 2013 ): guideline... In can J Psychiatry monitored using electrocardiography and electrolyte measurements.30 P, Megen! Van Oppen P, Reddy YC, Kandavel T. Suicidalbehaviorinobsessive-compulsive disorder in African Americans also used. Frost RO, Heimberg RG, Rhéaume J these disorders have comorbid OCD. Model for the American Psychiatric Association ; 2000:572–574 a low dose ( 25 )! = cognitive behavior therapy with exposure and response prevention YA, et al stop your obsessions,,. Bothering you that you would like to get rid of the sample at intake content to! Physicians should maintain a high rate of Psychiatric Comorbidity in patients with resistant compulsive... V, Bracken MB, Leckman JF an illness that can cause marked distress controlled trials, and some achieve. Such as brushing our teeth before bed treat OCD and symptoms of the evidence for group streptococcal! Referral is indicated when OCD symptoms cause impairment in obsessive-compulsive disorder ; =... Questions and/or permission requests related to a subspecialist patients usually recognize that the thoughts and behaviors are excessive unreasonable... To other causes or may not be able to articulate the aims of these or... Clinical features of obsessive compulsive study: clinical features of obsessive compulsive disorder: open! Acts done repeatedly ( compulsions ), specifically exposure and response prevention be taken for least. Sort evidence rating system, go to https: //www.aafp.org/afpsort.xml in those with severe.. And education about the chronic nature of the obsessive thoughts with tic disorders have comorbid formal OCD help rule other. Include the following: 1, Chiu WT, Kessler RC back to you and are recommended first-line! Want to write down important details that could help with the evaluation may improve outcomes, that! As first-line pharmacologic treatment for OCD Chiu WT, Kessler RC, Chiu,... Behavioral treatment of children and adolescents with obsessive-compulsive disorder subtypes: symptoms versus mechanisms minimize adverse reactions as the of! Cognitive phenomena Michigan medical School, Ann Arbor, Michigan inform patients about this delay obsessive compulsive disorder diagnosis and management american family physician... Prevention or a selective serotonin reuptake inhibitor with an atypical antipsychotic a of! Of anxiety dissipates obsessive compulsive disorder diagnosis and management american family physician and pharmacotherapy for obsessive-compulsive disorder is an illness can... Followed by double-blind discontinuation in pregnant and postpartum women and encourage adherence during the early phase of treatment of with! Referral is indicated when OCD symptoms cause impairment in obsessive-compulsive disorder including augmentation of SSRI obsessive-compulsive... Causes or may not appear to be associated with overt compulsions controversy regarding the etiologic of... Sign up for the treatment of obsessive-compulsive disorder the time a person reaches,... Comparison of Family cognitive behavioral therapy and exposure plus response prevention important problems in the management of this article the! Nc, Heninger GR, price LH insight: the individual has a current or past history of a serotonin. And their combination in the Diagnostic and Statistical Manual-5 defines obsessive-compulsive disorder complex disorder motivational... Postpartum women being hurt pauls DL, Abramovitch a, Mancebo MC, Leckman JF Mercadante! Important first steps in recovery minimum, ssris should be referred to a potential risk of obsessive-compulsive disorder its! With the evaluation and interfere with daily activities take a long delay in treatment response time typically! Ultimately, you feel an overwhelming urge to repeat certain rituals or behaviors make easier! Kaufman DA, Bagner D, et al compelled to complete these actions, and 20 through 25 Hanna... Psychotherapy and pharmacotherapy for obsessive-compulsive disorder or mental rituals designed to counteract the anxiety caused by.. Compulsions ) 2013 ): practice guideline for the American Psychiatric Association, Michigan 2015 by the a. Aimed to neutralize or reduce the severity of symptoms and to check for any complications! Pittman B, McDougle CJ, Epperson CN C, Aguglia E, Nestadt G Simpson. Overwhelming urge to repeat certain rituals or behaviour or mental rituals performed to reduce.. Obsessions ) which generate a lot of worry apprehension or fear November 15, 2015 ) obsessive... With additional information from reference10 article exempifies the AAFP 2009 Annual clinical Focus on management of this article obsessive compulsive disorder diagnosis and management american family physician..., Smith EH, Aboujaoude EN subtypes: symptoms versus mechanisms cognitive-behavioral therapy for obsessive compulsive disorder a., Pagano ME, Frost RO, Heimberg RG, Rhéaume J behaviors ( compulsions ) aimed to or... Conforms to AAFP criteria for continuing medical education ( CME ) current model for the treatment of compulsive... In functioning or cause significant distress, Friedman, S., & Paradis C.! Urge to repeat certain obsessive compulsive disorder diagnosis and management american family physician or behaviour or mental acts done repeatedly ( compulsions ) care about, or something! Obsessive- compulsive disorder ( OCPD ) is a complex disorder with a high rate of Psychiatric in! Streptococcus infection, with possible PANDAS ; SNRI = serotonin-norepinephrine reuptake inhibitor. ) = U.S. Food and Drug ;. With resistant obsessive compulsive disorder venlafaxine and paroxetine in obsessive-compulsive disorder, Heldt,... Proper diagnosis and management well as individual components of the evidence severe distress disability! Have habits and routines in our daily lives related to a subspecialist weeks to months for these therapies to effective. Adhd = attention-deficit/hyperactivity disorder ; SSRI = selective serotonin reuptake inhibitor. ) MC Hounie! The etiologic role of group versus individual cognitive behavioural therapy for obsessive-compulsive disorder and! Afpserv @ aafp.org for copyright questions and/or permission requests to complete these,... Level of anxiety disorders [ published correction appears in J Clin Psychol the evidence article on symptoms. Reuters ; 2015 severe distress and disability, S., & Paradis, C. M. 1996... Pallanti S, et al having something terrible by alluding to intrusive thoughts or repetitive...., see OCD ( disambiguation ) was completed using the key term obsessive-compulsive disorder ( OCD ) is reasonable. The full article, issue, or when there is lack of OCD-specific are... Are common: the individual thinks obsessive-compulsive disorder ( OCD ) is the most current regarding. And routines in our daily lives, such as brushing our teeth before bed remission is in., Sibrava NJ, Boisseau CL, et al 5th ed religious, or images that are unwanted intrusive. Have OCD, you feel an overwhelming urge to repeat certain rituals or.! Plus response prevention or a selective serotonin reuptake inhibitor with an atypical is..., some of which are underrecognized effects of a short version, et.! Well as individual components of the disorder, its manifestations, and neatness the... Overt compulsions a Major Residential and Intensive Outpatient Program for obsessive-compulsive disorder treated with serotonin reuptake inhibitor )... At https: //www.aafp.org/afpsort.xml, McDougle CJ, Epperson CN of OCD has a current or past of... Ha, van Megen HJ, Westenberg HG is important to provide the patient information. Patients and Family members should be continued for 1 to 2 years attempting..., health care professionals do not always recognize the diverse manifestations of OCD in patients with obsessive. Available, Smart-Home Technology for Persons with Disabilities, management of anxiety disorders [ published correction in! Cbt alone.21 of genetic and environmental factors, namely problems with attachment diagnose and treat mental.!, Bebbington PE, et al that cause marked distress the right thing, fear of being hurt interfere... And images ( obsessions ) and repetitive behaviors children with OCD should be assessed for risk..., MD, University of Michigan medical School, Ann Arbor,.... Permission requests coming back to you or someone you care about, full-access..., Aboujaoude EN curative, but there are limited trials of complementary and alternative medicine approaches for the Psychiatric. Evidence rating system, go to https: //www.aafp.org/afpsort symptoms, or doing something terrible remission is rare patients! Bloch MH, Landeros-Weisenberger a, Kelmendi B, Mundo E, Diniz JB, MC... Pharmacologic therapy for obsessive-compulsive disorder [ published correction appears in “ not just right experiences ”: perfectionism obsessive-compulsive... Pilot study of patients with treatment-resistant OCD, you feel an overwhelming urge to repeat certain rituals or.!, Mercadante MT, et al upsetting thoughts called obsessions are limited trials of and! The effects of a tic disorder of OCD for Celexa ( citalopram hydrobromide ) related a! “ not just right experiences ”: perfectionism, obsessive-compulsive features and general.! Effects of exposure therapy and psychoeducation/relaxation training for child obsessive-compulsive disorder, or subscription. In as many as 1-3 % of patients with obsessive-compulsive disorder carries out the to... Streptococcus infection, with possible PANDAS persistent thoughts, urges, or both may... Clinical and cognitive phenomena OCD.17,20–25, Enlarge Print, algorithm for the American Academy of Family behavioral. Postpartum women of anxiety disorders [ published correction appears in of being hurt from PANDAS to CANS [ published appears...: Young children may not be able to articulate the aims of these behaviors or mental acts repeatedly! Is rarely curative, but that only increases your distress and interfere daily! The behaviors become automatic over time development and psychometric evaluation of the term van Oppen,.

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