Journal Article:

OCD_nejmcp1402176

Summary:

Daniel DeMarco Journal Article Assignment           Rotation #7: Psychiatry

 

Obsessive-Compulsive Disorder

Jon E. Grant, J.D., M.D., M.P.H

New England Journal of Medicine

 

What is it?:

• Neuropsychiatric disorder in which a patient has obsessions (repetitive and persistent thoughts, images, or urges that cause distress and/or anxiety) or compulsions (repetitive behaviors or mental acts performed in response to an obsession to temporarily relieve anxiety) or both
• Usually chronic with waxing and waning symptoms, especially when untreated; it is estimated that only ⅓ of patients with OCD receive appropriate pharmacotherapy and <10% of patients receive proper psychotherapy

 

Who gets it?:

• The 4th most common psychiatric illness with a lifetime prevalence of one to three percent
• M:F Ratio is approximately 1:1, though onset is typically earlier in boys than girls
• Age of onset is bimodal; onset occurs either in childhood (mean age of 10yo) or adolescence/young adulthood (mean age of 21yo)

 

What causes it?:

• Cause of OCD is poorly understood
• Genetics: Childhood-onset OCD estimated to be 45-65% heritable, while adolescent/adulthood-onset OCD estimated to be 27-47% heritable
• Neurobiology/Neuropsychology: Potential implicated regions include the orbitofrontal cortex, caudate, anterior cingulate cortex, thalamus, amygdala, parietal cortex

 

What are the diagnostic criteria?:

• Presence of obsessions or compulsions that are time consuming, occupying more than one hour per day; clear evidence that the symptoms are causing the person distress or reduce the quality of social, academic, or occupational functioning; symptoms cannot be explained by another mental disorder and are not substance-induced

 

How is it treated?:

• Psychotherapy: Exposure-and-Response-Prevention Therapy (The patient is instructed to expose themselves to the feared obsession and they are instructed to abstain from the compulsive behavior; the goal is for the patient to learn that anxiety naturally will decrease); Cognitive Therapy (Disprove errors in cause and effect thinking by challenging the patient’s beliefs)
• Pharmacotherapy: Clomipramine (a TCA) or SSRIs, which are the first-line pharmacologic treatment (Paroxetine, Fluvoxamine, Fluoxetine, Citalopram, Escitalopram, Sertraline); According to what limited data is available, there is no significant difference in efficacy between different SSRIs or between SSRIs and Clomipramine.
• Use of ERP combined with medication has resulted in superior outcomes to medication alone but not to ERP alone
• Procedures: Deep-Brain Stimulation or Ablative Neurosurgery (e.g. Capsulotomy and Cingulotomy) considered in patients with severe, incapacitating OCD that is unresponsive to ERP, two or more trials of SSRIs, trial of clomipramine, and at least three trials of augmentation therapy

 

What is the future of research?:

• Data on long-term benefits and risks of all treatment modalities
• Data in children and elderly patients
• Research into other predictors of poor outcomes (Poor Insight and Comorbid Tic Disorder are currently described as having poor outcomes)
• Further research into genetic factors that predispose to OCD and possible environmental factors