Obsessive-Compulsive Disorder (OCD) has: 1) Either obsessions or compulsions: 

Obsessions are recurrent and persistent thoughts, impulses, or images that are intrusive and inappropriate and cause marked anxiety and distress.  They are not just excessive worries about real-life problems. The person attempts to ignore or stop them or neutralize them with some other thought or action.  He recognizes that the obsessions are from his own mind.  

Compulsions are repetitive behaviors like hand washing, ordering, checking or mental acts like praying, counting, repeating words silently, that the person feels driven to perform in response to an obsession, or according to rules that must be followed rigidly.  The behaviors or acts are aimed at preventing or reducing distress or preventing some dreaded event; however, they either are not connected in a realistic way with that they are designed to neutralize or prevent or are clearly excessive.  2) At some point during the disorder, the person has recognized that the obsessions or compulsions are excessive.  3) The obsessions or compulsions cause marked distress, are time consuming (over 1 hours per day), or interfere with normal functioning.  4) If another Axis I disorder is present, the obsessions or compulsions are not restricted to it (e.g. food in Eating Disorders, hair pulling in Trichotillomania, appearance in Body Dysmorphic Disorder). 5) The disturbance is not due to a substance or medical condition.

Surveys find 1-2% of the population has current OCD and 2.5% will have it at some point during their lives.  It has a familial pattern and is higher in monozygotic twins meaning at least some cases are due to genetic abnormalities. 

Research suggests that clomipramine helps the largest percentage of OCD patients.  When this fails, then try an SSRI.  Fluoxetine (Prozac) is by far the least expensive SSRI treatment for OCD and as good as any other.  Venlafaxine has found to be helpful, but inferior to SSRIs and helps only a small percentage of SSRI non-responders.  Therefore, if clomipramine is inadequate in its response, try adding nortriptyline or an atypical anti-psychotic.  My favorite atypical on the grounds of low side-effects and low cost is once a day ziprasidone (Geodon).  Another option is to add inositol.  See Medications for OCD.

The large majority of patients won't fully recover and psychotherapy of the behavioral and cognitive-behavioral variety can have a very useful role.  In fact, a positive response to medication is considered a 35% decrease in symptoms for OCD but a 50% decrease in symptoms for depression.  Often, less than 50% of OCD patient reach a full 35% response, while 60% to 70% of depressed patients routines reach the 50% response level.  There is some evidence that after a year of treatment the response rates are better.

OCD in 3% with OC Symptoms in Another 9%: In a Zurich community study, 591 adults age 19 were followed for 20 years. Lifetime prevalence rate for OCD was 3.5 % (males 1.7%, females 5.4 %) and 8.7 % for obsessive-compulsive syndrome (OCS) (males 9.9%, females 7.5 %). The average onset of OC-symptoms was age 18. The course of symptoms was chronic in 60% but most cases improved considerably over time. OCD reduced quality of life, mostly in the subject's psychological wellbeing and at work, but also in other social roles. Comorbidity was prominent with bipolar disorder, panic disorder and social phobia and also significant with bulimia, binge eating, generalized anxiety disorder and suicide attempts; there was no association with substance abuse/dependence. Obsessive-compulsive severity spectrum in the community: prevalence, comorbidity, and course. Angst J, Gamma A, et al. Zurich University, Switzerland. Eur Arch Psychiatry Clin Neurosci. 2004 Jun;254(3):156-64.

OCD About 3%: Typical of other surveys, a study of 3,012 Turkish adults found a 12-month period prevalence rate of OCD of 3.0%. The average age of onset was 26. Men and women were about equally represented. The relative risk for divorced, separated, or widowed subjects was approximately 4.2 times higher for OCD than others (2.7% v 10.5%). The 1-year prevalence of OCD inversely related to age group in males, but increased with age in females. The prevalence rate of OCD was not different by the level of education, except it was statistically higher among subjects who were literate but had no schooling, of which the causal relationship was high prevalence rate of OCD among female literate-but no schooling subjects. No significant difference was found according to employment, fertility, birth order, and income of the subjects. About 30% of subjects with OCD had only obsessions, whereas 68.5% had both obsessions and compulsions. Only one subject (1.1%) with OCD met compulsion criteria without obsessions. Twelve-month prevalence of obsessive-compulsive disorder in Konya, Turkey. Cillicilli AS, Telcioglu M, et al. University of Selcuk Meram, Turkey. Compr Psychiatry. 2004 Sep-Oct;45(5):367-74. 

Anorexia Nervosa Patients Frequently OCD: A study of 40 AN patients and 58 depressed patients found AN patients frequently had co-morbid OCD, but that this was not the case for the depressed patients. Other disorders, e.g. substance abuse and social phobia, were common in both. Anxiety and psychoactive substance use disorder comorbidity in anorexia nervosa or depression. Jordan J, Joyce PR, Carter FA, Horn J, McIntosh VV, Luty SE, McKenzie JM, Mulder RT, Bulik CM. Int J Eat Disord. 2003 Sep;34(2):211-9

Atypicals Can Cause OCD: Case reports have linked clozapine, (J Clin Psych 92:53:439), risperidone (J Clin Psychoph 94; 14:358) and olanzapine (Cand J Psych 98;43:645) to causing OCD symptoms. The latter case was treatment resistant MDD with psychotic features when loxapine d/c, fluvoxamine continued and olanzapine started. Eventually did OK on olanzapine plus venlafaxine.

Cognitive Impairment in Addition to Obsessions and Compulsions: OCD patients displayed impairments in planning ability, spatial memory and motor speed that persisted after clinical improvement. Netherlands. Neuropsychological performance of OCD patients before and after treatment with fluoxetine: evidence for persistent cognitive deficits. Nielen MM, Den Boer JA. Psychol Med. 2003 Jul;33(5):917-25

Hawaiian Native Students Higher OCD:  In a survey of 619 high school students, Native Hawaiians had a 2-fold higher risk (odds ratio = 2.03) for OCD. Degree of Polynesian ancestry correlated positively with OCD prevalence. Obsessive-compulsive disorder prevalence also correlated positively with crowding in the household; measures of physical illness; and measures of depression, anxiety, aggression, and illicit substance use. Authors wondered what role strep infections play since rheumatic fever is more common in natives. Demographic and clinical characteristics of adolescents in Hawaii with obsessive-compulsive disorder. Guerrero AP, Hishinuma ES, Andrade NN, Bell CK, Kurahara DK, Lee TG, Turner H, Andrus J, Yuen NY, Stokes AJ. Arch Pediatr Adolesc Med. 2003 Jul;157(7):665-70

Causes

Atypical Anti-Psychotics Can Cause OCD: The serotonin-dopamine antagonists currently used in the treatment of schizophrenia can cause OCD in a small percentage of patients treated. The OCD of the three patients responded to fluvoxamine, clomipramine, and paroxetine. Obsessive-compulsive symptoms associated with clozapine and risperidone treatment: three case reports and review of the literature. Ke CL, Yen CF, et al. Kaohsiung Medical University. Taiwan.  Kaohsiung J Med Sci. 2004 Jun;20(6):295-301

A Clozapine OCD Fairly Common: Of 56 schizophrenic patients treated with clozapine and 54 with classic antipsychotic drugs, 46 % of  clozapine-treated showed some OCD symptoms vs. 20% of those with classic antipsychotic drugs (p = 0.005). In all, 21 % of clozapine and 13 % of classic antipsychotic patients met DSM-IV OCD criteria (p = 0.31). Obsessive-compulsive symptoms in schizophrenia during treatment with clozapine and conventional antipsychotic drugs. Galvez-Buccollini JA, Fiestas F, et al. Universidad Peruana Cayetano Heredia, Peru. Actas Esp Psiquiatr. 2004 Jul-Aug;32(4):211-5.

A Nine Olanzapine (Zyprexa) OCD Cases: In six recent reports involving nine cases, for six patients olanzapine caused OCD exacerbation and for three caused a new case of OCD. Obsessive-compulsive symptoms with olanzapine. Alevizos B, Papageorgiou C, Christodoulou GN. Int J Neuropsychopharmacol. 2004 Sep;7(3):375-7

Genetics: hSERT Gene Found in Some Cases: A rare variant of the human serotonin transporter gene has been found in two families with OCD of 30 patients studied.  The gene is necessary to get serotonin into cells.  SSRI treatment does not help these patients. A substitution of Val425 for Ile425 in the sequence caused uptake of serotonin to be too successful and not as easily regulated by the cell. Several individuals had a second hSERT variant, two long alleles of the 5-HTTLPR polymorphism. This variant, associated with increased expression and function and the double variant caused a more severe disease. Some individuals with the I425V mutation also had anorexia nervosa and Asperger's Syndrome. Norio Ozaki, Fujita Health University and NIMH, October 23, 2003, Molecular Psychiatry.

Genetics: BDNF Gene Abnormalities Associated with OCD: Brain-derived neurotrophic factor (BDNF) gene single-nucleotide polymorphisms (SNPs) and one microsatellite marker were found more often causing a susceptibility to obsessive-compulsive disorder (OCD)  in 164 triads with OCD. Sequence variants of the brain-derived neurotrophic factor (BDNF) gene are strongly associated with obsessive-compulsive disorder. Hall D, Dhilla A, Charalambous A, Gogos JA, Karayiorgou M. Am J Hum Genet. 2003 Aug;73(2):370-6

Genetics: Tourette Disorder Offspring High in OCD, ADHD: 34 children of a Tourette's Syndrome parent were compared to 13 controls. Ten of the TS offspring developed tics and three full-blown Tourette's Syndrome.  Eleven offspring developed OCD and 14 developed ADHD. None of the controls developed any of the diseases. Children at familial risk for Tourette's disorder: Child and parent diagnoses. McMahon WM, Carter AS, Fredine N, Pauls DL. Am J Med Genet. 2003 Aug 15;121B(1):105-11

Methylphenidate (Ritalin) Caused OCD in Elderly Man: The case of an 82 year old man with no prior history of OCD reports that OCD symptoms began after starting methylphenidate and resolved within three weeks of stopping methylphenidate. CNS Spectr. 2003 Aug;8(8):612-3.

Strepococcal Infections: OCD & Tourette’s Sometimes Result: 5-15% childhood OCD & Tourette’s linked to streptococcal infections = PANDAS pediatric autoimmune neuropsychiatric disorders assoc with strep. May have genetic predisposition triggered by strep infection. Sci News 9/2/00

Surgical Treatment

Anterior Capsulotomy Helped Two OCDs: Two severe treatment resistant cases, ages 18 and 64, were dramatically improved after neurosurgery at the Univ. of Utah. Anterior capsulotomy for treatment of refractory obsessive-compulsive disorder: results in a young and an old patient. Christensen DD, Laitinen LV, Schmidt LJ, Hariz MI. Stereotact Funct Neurosurg. 2002;79(3-4):234-44

PANDAS OCD Treated with Immunoglobulin and Plasma Exchange: PANDAS OCD characteristics: presence of OCD and/or tic disorder, prepubertal symptom onset, sudden onset or abrupt exacerbations, association with neurological abnormalities during exacerbations (adventitious movements or motoric hyperactivity), and the temporal association between symptom exacerbations and streptococcal infections.  A placebo-controlled trial revealed that both intravenous immunoglobulin and plasma exchange were effective in reducing neuropsychiatric symptom severity (40 and 55% reductions, respectively) for a group of severely ill children in the PANDAS subgroup. NIMH. Childhood-onset obsessive-compulsive disorder and tic disorders: case report and literature review. Snider LA, Swedo SE., J Child Adolesc Psychopharmacol. 2003;13 Suppl 1:S81-8

Tonsillectomy Helps Two PANDAS: Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) is associated with obsessive compulsive disorders (OCD) and tic disorders. The streptococcal infections may trigger an autoimmune reaction that exacerbates these conditions. Recurrent streptococcal tonsillitis is one of the recurrent infections associated with PANDAS. Two brothers, one with OCD and the other with a tic disorder, both improved significantly after undergoing adenotonsillectomy for treatment of their recurrent tonsillitis. Cincinnati Children's Hospital, PANDAS: pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections--an uncommon, but important indication for tonsillectomy. Heubi C, Shott SR. Int J Pediatr Otorhinolaryngol. 2003 Aug;67(8):837-40