Obsessive-Compulsive Disorder (OCD)

Obsessive-Compulsive Disorder (OCD) is a topic covered in the 5-Minute Clinical Consult.

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Basics

Description

  • An anxiety disorder characterized by pathologic obsessions (recurrent intrusive thoughts, ideas, or images) and compulsions (repetitive, ritualistic behaviors or mental acts) causing significant distress
  • Not to be confused with obsessive-compulsive personality disorder

Epidemiology

Incidence
  • Predominant age: mean age of onset is 19.5 years (1).
    • Three subtypes: child/adolescent-onset (<18 years), adult-onset (18 to 39 years) and late-onset (≥40 years)
    • Child/adolescent-onset in 50% of cases (usually by age 18 years) (2)
    • Diagnosis rarely made at >50 years of age
  • Predominant gender: females > males
    • Childhood-onset obsessive-compulsive disorder (OCD) (age <10 years) is more prevalent in males, more likely to be heritable and associated with co-morbid tic disorder.
    • Adolescent-onset OCD is more prevalent in females, although OCD can be precipitated in the peripartum or postpartum period as well.

Pediatric Considerations
Insidious onset; consider brain insult in acute presentation of childhood OCD.

Geriatric Considerations
Consider neurologic disorders in new-onset OCD.

Prevalence
  • 2.3% lifetime in adults
  • 1–2.3% prevalence in children/adolescents (3)

Etiology and Pathophysiology

Exact pathophysiology/etiology unknown. Potential role of:

  • Cognitive-affective dysfunction
  • Dysregulation of serotonergic, catecholaminergic, and glutamatergic pathways
  • Dysfunction of cortico-striatal-thalamo-cortical (CSTC) circuit, involving the orbitofrontal cortex (OFC) and anterior cingulate cortex (ACC)
  • Brain injury (physical trauma, stroke, etc.)
  • Autoimmune insult to basal ganglia, as seen in Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS); controversial
Genetics
  • Polygenic disorder, with variants in serotonergic, catecholaminergic, and glutamatergic genes
  • Positive family history: prevalence rates of 7–15% in first-degree relatives of children/adolescents with OCD
  • Greater concordance in monozygotic twins

Risk Factors

Combination of biologic and environmental factors:

  • Family history of OCD
  • Advanced paternal and maternal age
  • Coexisting psychiatric disorders, most commonly anxiety disorders and schizophrenia
  • Low serotonin levels (Antipsychotics with greater anti-serotoninergic mechanism, such as clozapine and olanzapine, have been associated with onset of OCD.)
  • Brain insult (i.e., encephalitis, pediatric streptococcal infection, or head injury)
  • Perinatal insults (birth complications)
  • History of childhood traumatic events, including social isolation and physical abuse

General Prevention

  • Early diagnosis and treatment can decrease patient’s distress and impairment.

Commonly Associated Conditions

  • Major depressive disorder
  • Panic disorder/phobia/social phobia
  • Tourette syndrome/tic syndromes
  • Substance abuse/eating disorder/body dysmorphic disorder

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Basics

Description

  • An anxiety disorder characterized by pathologic obsessions (recurrent intrusive thoughts, ideas, or images) and compulsions (repetitive, ritualistic behaviors or mental acts) causing significant distress
  • Not to be confused with obsessive-compulsive personality disorder

Epidemiology

Incidence
  • Predominant age: mean age of onset is 19.5 years (1).
    • Three subtypes: child/adolescent-onset (<18 years), adult-onset (18 to 39 years) and late-onset (≥40 years)
    • Child/adolescent-onset in 50% of cases (usually by age 18 years) (2)
    • Diagnosis rarely made at >50 years of age
  • Predominant gender: females > males
    • Childhood-onset obsessive-compulsive disorder (OCD) (age <10 years) is more prevalent in males, more likely to be heritable and associated with co-morbid tic disorder.
    • Adolescent-onset OCD is more prevalent in females, although OCD can be precipitated in the peripartum or postpartum period as well.

Pediatric Considerations
Insidious onset; consider brain insult in acute presentation of childhood OCD.

Geriatric Considerations
Consider neurologic disorders in new-onset OCD.

Prevalence
  • 2.3% lifetime in adults
  • 1–2.3% prevalence in children/adolescents (3)

Etiology and Pathophysiology

Exact pathophysiology/etiology unknown. Potential role of:

  • Cognitive-affective dysfunction
  • Dysregulation of serotonergic, catecholaminergic, and glutamatergic pathways
  • Dysfunction of cortico-striatal-thalamo-cortical (CSTC) circuit, involving the orbitofrontal cortex (OFC) and anterior cingulate cortex (ACC)
  • Brain injury (physical trauma, stroke, etc.)
  • Autoimmune insult to basal ganglia, as seen in Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcus (PANDAS); controversial
Genetics
  • Polygenic disorder, with variants in serotonergic, catecholaminergic, and glutamatergic genes
  • Positive family history: prevalence rates of 7–15% in first-degree relatives of children/adolescents with OCD
  • Greater concordance in monozygotic twins

Risk Factors

Combination of biologic and environmental factors:

  • Family history of OCD
  • Advanced paternal and maternal age
  • Coexisting psychiatric disorders, most commonly anxiety disorders and schizophrenia
  • Low serotonin levels (Antipsychotics with greater anti-serotoninergic mechanism, such as clozapine and olanzapine, have been associated with onset of OCD.)
  • Brain insult (i.e., encephalitis, pediatric streptococcal infection, or head injury)
  • Perinatal insults (birth complications)
  • History of childhood traumatic events, including social isolation and physical abuse

General Prevention

  • Early diagnosis and treatment can decrease patient’s distress and impairment.

Commonly Associated Conditions

  • Major depressive disorder
  • Panic disorder/phobia/social phobia
  • Tourette syndrome/tic syndromes
  • Substance abuse/eating disorder/body dysmorphic disorder

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