Diagnosis, Assessment and

Management of OCD
CHAIRPERSON:
DR.MANJU
BHASKAR

Introduction
Obsessivecompulsive disorder (OCD) is an

intriguing and often debilitating syndrome

characterized by the presence of two
distinct phenomena: obsessions and
compulsions.
Obsessions are intrusive, recurrent,
unwanted ideas, thoughts, images or
impulses that are difficult to dismiss despite
their disturbing nature.
The intrusive and inappropriate quality
ego-dystonic.

Compulsions are repetitive behaviors,

either observable or mental, that are

intended to reduce the anxiety
engendered by obsessions.
Obsessions or compulsions that clearly
interfere with functioning and/or cause
significant distress are the hallmark of
OCD.

Types
1. Contamination
2.Need for symmetry
3.Somatic Obsessions
4.Sexual and Aggressive Obsessions
5.Pathological Doubt


In a recent meta-analysis ,Bloch et al (2008)

included 21 studies over 5000 participants and

generated 4 symptom factors:
Symmetry obsessions and repeating,ordering,
and counting compulsions.
Forbidden thoughts: aggression, sexual, religious
and somatic obsessions and checking
compulsions.
Cleaning: cleaning and contamination.
Hoarding: hoarding obsessions and compulsions.

Epidemiology
Community studies: lifetime prevalence-2-

5% and 1yr- 0.5-2.1% in adults.

Lifetime prevalence- 1-2.3% and 1yr
prevalence-0.7% in children.
In adults M=F, in children boys> girls.
Indian study- life time prevalence of 0.6%.

Course
Age of onset: adolescence or early

childhood.
Modal age: males:6-15yrs; females:2029yrs.
Majority: chronic- waxing and waning.
Exacerbated by stress.
15%- progressive deterioration
5%- episodic.

DIAGNOSIS
DSM-IV TR Obsessive- Compulsive
Disorder (300.3)

A.Either obsessions or compulsions.

Obsessions as defined by (1), (2), (3), and
(4):
(1) recurrent and persistent thoughts,
impulses, or images that are experienced,
at some time during the disturbance, as
intrusive and inappropriate and that cause
marked anxiety or distress.

(2) the thoughts, impulses, or images are

not simply excessive worries about real-life

problems.
(3) the person attempts to ignore or

suppress such thoughts, impulses, or

images, or to neutralize them with some
other thought or action.

(4) the person recognizes that the

obsessional thoughts, impulses, or images

are a product of his or her own mind(not

Compulsions as defined by (1) and (2):

repetitive behaviors (e.g., hand washing, ordering,

checking) or mental acts (e.g., praying, counting,

repeating words silently) that the person feels driven to
perform in response to an obsession, or according to
rules that must be applied rigidly.

the behaviors or mental acts are aimed at preventing or

reducing distress or preventing some dreaded event or

situation; however, these behaviors or mental acts either
are not connected in a realistic way with what they are
designed to neutralize or prevent or are clearly excessive.

B. At some point during the course of the disorder,

the person has recognized that the obsessions or

compulsions are excessive or unreasonable.
Note: This does not apply to children.

C. The obsessions or compulsions cause marked

distress, are time consuming (take more than 1
hour a day), or significantly interfere with the
persons normal routine, occupational (or
academic) functioning, or usual social activities or
relationships.

D. If another Axis I disorder is present, the content

of the obsessions or compulsions is not restricted

to it (e.g.,preoccupation with food in the presence
of an Eating Disorder; hair pulling in the presence
of Trichotillomania; concern with appearance in the
presence of Body Dysmorphic Disorder;
preoccupation with drugs in the presence of a
Substance Use Disorder; preoccupation with
having a serious illness in the presence of
Hypochondriasis; preoccupation with sexual urges
or fantasies in the presence of a Paraphilia; or
guilty ruminations in the presence of Major
Depressive Disorder).

E. The disturbance is not due to the direct

physiological effects of a substance (e.g., a

drug of abuse, a medication) or a general
medical condition.
Specify if: With Poor Insight.

International Classification of Disorders-10

diagnostic criteria for F42 ObsessiveCompulsive Disorder

A.Either obsessions or compulsions (or both), present
on most days for a period of at least two weeks.
B. Obsessions (thoughts, ideas or images) and

compulsions (acts) share the following features, all of

which must be present:
(1) They are acknowledged as originating in the mind

of the patient, and are not imposed by outside persons

or influences.

(2) They are repetitive and unpleasant, and at least one

obsession or compulsion must be present that is

acknowledged as excessive or unreasonable
(3) The subject tries to resist them (but if very long-

standing, resistance to some obsessions or compulsions

may be minimal). At least one obsession or compulsion
must be present which is unsuccessfully resisted.

(4)Carrying out the obsessive thought or compulsive act

is not in itself pleasurable.(This should be

distinguished from the temporary relief of tension or
anxiety).

C. The obsessions or compulsions cause distress or

interfere with the subject's social or individual

functioning, usually by wasting time.

D. Most commonly used exclusion criteria: not due to

other mental disorders, such as schizophrenia and

related disorders (F2), or mood [affective] disorders
(F3).
Includes: anankastic neurosis, obsessive-compulsive
neurosis
Excludes: obsessive-compulsive personality disorder.

The diagnosis may be specified by the

following four character codes:

F42.0 Predominantly obsessional thoughts
and ruminations
F42.1 Predominantly compulsive acts
F42.2 Mixed obsessional thoughts and acts
F42.8 Other obsessive-compulsive
disorders
F42.9 Obsessive-compulsive disorder,
unspecified

FEATURES

DSM-IV

ICD-10

Duration

Not mentioned

2weeks

Time consumption

1hour

Not mentioned

Patient realizes they are

excessive and
unreasonable

Yes, with exclusion in

children

Yes, no exclusion criteria

for children

Number of obsessions

Not mentioned

Atleast one
obsession/compulsion
must be present that is
considered excessive
and unreasonable.

If other Axis I disorder is

present,obsessional or
compulsive con tent not
restricted to it

Yes

Mentions co-morbidity of
depression.

Exclusion of GMC &

substance

Yes

No

Mention about insight

Yes

No

IMPROVING DIAGNOSIS AND

DISSEMINATION
The diagnostic criteria for OCD have

remained relatively unchanged since the

publication of DSM-II.
DSM-IV field trials examined three issues:
1.The requirement that symptoms be
viewed as excessive or unreasonable.
2.The presence of mental compulsions.
3.The ICD subcategories(e.g.,
predominantly obsessive versus
predominantly compulsive).

There remains several concerns about DSM-

IV definitions of Obsessions and Compulsions.

1.The term impulse in the criteria is possibly
confusing.
2. Although it is important to differentiate
OCD obsessions from worries about real-life
problems, this component of the definition is
confusing.
3. The definition of compulsion, unlike
obsession, doesnot refer to or specify
different forms of avoidance.

 4. Whether to delete the criterion that

pertains to the persons recognition that

the obsessions and compulsions are
excessive and unreasonable.
5.The criteria on time duration of one hour
or more a day- question of debate.
6. To document the presence of prominent
symptom dimensions through the use of
specifiers.
7.The question of including hoarding as a
specifier or a separate category is raised.

Proposed criteria of Obsessive Compulsive

Disorder in DSM-V
A.Either obsessions or compulsions:
Obsessions as defined by (1) and (2):
1. Recurrent and persistent thoughts,
urges, or images that are experienced, at
some time during the disturbance, as
intrusive and unwanted and that in most
individuals cause marked anxiety or
distress.

2.The person attempts to ignore or

suppress such thoughts, urges, or images,

or to neutralize them with some other
thought or action (i.e., by performing a
compulsion)
Compulsions as defined by (1) and (2):
1. Repetitive behaviors (e.g., hand
washing, ordering, checking) or mental acts
(e.g., praying, counting, repeating words
silently) that the person feels driven to
perform in response to an obsession, or
according to rules that must be applied
rigidly.

2. The behaviors or mental acts are aimed

at preventing or reducing anxiety or

distress, or preventing some dreaded event
or situation; however, these behaviors or
mental acts either are not connected in a
realistic way with what they are designed
to neutralize or prevent, or are clearly
excessive
B.The obsessions or compulsions are time
consuming (for example, take more than 1
hour a day), or cause clinically significant
distress or impairment in social,
occupational, or other important areas of

C.(formerly Criterion E.). Theobsessive-

compulsive symptoms arenot due to the

direct physiological effects of a substance
(e.g., a drug of abuse, a medication) or a
general medical condition.

D.The content of the obsessions or

compulsions is not restricted to the

symptoms of another mental disorder (e.g.,
excessive worries about real life problems
in Generalized Anxiety Disorder;
preoccupation with food or ritualized eating
behaviorin an Eating Disorder; hair pulling
in Hair Pulling Disorder(Trichotillomania);
stereotypies in Stereotypic Movement
Disorder;
CONTD.

preoccupation with appearance in Body

Dysmorphic Disorder; preoccupation with

drugs in a Substance Use Disorder;
preoccupation with having a serious illness
in Hypochondriasis; preoccupation with
sexual urges or fantasies in a Paraphilia
orHypersexual Disorder; preoccupation
with gambling or other behaviors in
behavioral addictions or impulse control
disorders;guilty ruminations in Major
Depressive Disorder;paranoia or thought
insertion in a Psychotic Disorder; or
repetitive patterns of behavior in Autism

Specify whether OCD beliefs are currently

characterized by:
Good or fair insight
Poor insight:
Absent insight
Specify if:
Tic-related OCD: The individual has a

lifetime history of a chronic tic disorder.

DIFFERENTIAL DIAGNOSIS

1.Obsessive compulsive disorder

Lifelong maladaptive personality style.
Ego-syntonic
Seek treatment because the behaviours

cause problems in functioning or family

friction.
Pharmacological trial

2.OTHER ANXIETY DISORDERS

Differentiating features between OCD & other
anxiety disorders:
The age of onset for OCD is young compared with

that for patients with panic disorder.

In OCD, there is an equal distribution of men and
women.
Patients with OCD do not develop increased
symptoms after administration of anxiogenic
compounds such as lactate, yohimbine, and caffeine.
They are refractory to anxiolytic medications &
tricyclic antidepressants .
Making a diagnosis of OCD can help clinicians avoid
the use of nonserotonergic medications that will
likely be ineffective

Generalized anxiety disorder:

The person experiences them as excessive

concerns about real-life circumstances

More ego-syntonic.
Social phobia and specific phobia:
Fears are circumscribed and related to

specific triggers (in specific phobia) or

social situations (in social phobia).
Panic disorder:
Panic attacks occur spontaneously.

3.Depression
Mood congruent brooding.
Not ego-dystonic
When both of them co-occur:
In an acute episode of disorder:

Precedence
Predominance
In chronic disorders: Persistence

4.Psychotic Disorder
Not characterized by prominent ritualistic

behaviors.
Schizophrenia may be characterized by obsessional
thinking, & other characteristic features of the
disorder, such as prominent hallucinations or
thought disorder, are also present.
The ruminative delusional thoughts and bizarre
stereotyped behaviors that occur in schizophrenia
are not ego-dystonic and are not subjective to
reality testing.

With regard to delusional disorder, paranoid

and grandiose concerns are generally not

considered to fall under the OCD rubric.
However, some other types of delusional
disorders, such as the somatic and jealous
types, seem to bear a close resemblance to
OCD and are not always easily
distinguished from it.

5.Tourettes Disorder:
No mental urge, only physical urge
Just right phenomenon
6.Stereotypic movement disorder
7.Body dysmorphic disorder
8.Hypochondriasis
9.Impulse control disorders.
10.Eating disorders
11.Paraphilias/Non-paraphilic Sexual addiction
12.Pathological jealousy

13.SUPERSTITIONS AND REPETITIVE

CHECKING BEHAVIOUR
14.ANXIETY DISORDERS DUE TO GENERAL
MEDICAL CONDITION/SUBSTANCE
This diagnosis is made when the
obsessions and compulsions are judged to
be the direct physiological consequence of
a specific GMC based on history, physical
examination and laboratory findings.

Assessment
1.Assess the patients current
symptoms and severity
A. Diagnostic Interviews
i)Structured Clinical Interview for DSM-IV,

Axis I (SCID-I)
ii)MINI plus
iii)Anxiety Disorders Interview Schedule .

B.Observer Rated Scales

Objective assessment is needed:

To assess baseline severity
To document changes
To assess treatment response

i)Yale Brown Obsessive Compulsive Scale

(YBOCS)
Devised by Goodman et al(1989).
It is a semi-structured interview
Assesses OCD symptom severity
independent of the number and type of
obsessions and compulsions present.
It comprises three sections.
Section 1: Contains definitions and
examples of obsessions and compulsions.
Section 2: consists of 64-item target
symptom list.
Section 3: Consists of 10 core items and 11
investigational items

 The 10 core items are used to rate the

clients prominent obsessions and

compulsions on the following parameters:
Amount of time spent/frequency
Subjective distress
Interference in social and occupational
functioning
Degree of Resistance
Perceived Control over symptoms

Each item is rated on a five-point (0-4)

scale
SCORING: 0-7 = SUBCLINICAL
8-15=MILD
16-23=MODERATE
24-31=SEVERE
32-40=EXTREME

ii) National Institute of Mental Health Global

Obsessive- Compulsive Scale(NIMH-GOCS)

It is a single-item,clinician-administered
measure of global severity of OCD
symptoms.
Score range from 1(minimal symptoms) to
15(very severe obsessive compulsive
behaviour).
Scores fall within 5 clusters of severity( i.e
1-3,4-6, 7-9,10-12,13-15) .

 iii)Compulsive Activity Checklist

It is a 62-item ,clinician administered

interview, developed to assess the extent

to which obsessive-compulsive symptoms
interfere with day to day activities.
Each item lists an activity and the ability to
perform that behavior is rated on a four
point(0-3) scale.
4criteria: Frequency, duration, avoidance
and oddity of behavior.
iv) OCD subscale of CPRS

c. Self reported Scales

i)Maudsley Obsessive-Compulsive Inventory
o 30-item ,true-false questionnaire consisting of 4

subscales: Washing, Checking, slowness and

doubting.
o Scores reflect the amount of time consumed by
obsessive-compulsive symptoms.
ii)MOCI Revised
o Designed to overcome the shortcomings inherent in
the original version.
o It addresses a wider range of obsessions and
compulsions, includes avoidance behaviors and
beliefs commonly found in OCD.
o The previous dichotomous response format has been
replaced by a five-point scale.

iii)Padua Inventory
It has 4 subscales: contamination,

checking, impaired control of mental

activities,urges & worries over losing
control over motor behaviours.
Each item is scored on a five point (0-4)
scale according to the degree of
disturbance caused.
iv)Leyton Obsessional Inventory
It is a 69-item questionnaire designed to
assess obsessional symptoms and traits.
In addition to yes and no responses for
each item ,scores are obtained for
resistance and interference.

 v)Likert scales
vi)Obsessive- Compulsive Inventory
It is 42-item self-report measure.
It comprises 7 subscales : washing ,

checking, doubting, ordering, obsessing,

hoarding and mental neutralizing.
Each item is rated on a five point (0-4)
scale for both frequency and distress.

D.Behavioural Avoidance Tests

They are designed to assess in vivo fear
and avoidance behavior.
Several types of BAT has been developed
for use in OCD.
The single-task BAT involves the patient
approaching as near as possible to a feared
stimulus and reporting his or her subjective
uinits of distress(SUDs).
The SUDs rating is an index of fear and
distress measured on a 0-100 scale,where
0-no fear or distress and100-maximum fear

Investigations
1.Blood chemistry & urine analysis.
2.5hr GTT
3.Serum B12 and B6.
4.Neuroimaging & EEG
5.Biological challenges
6.Biological markers
7.Immunological findings

2. Evaluate the effects of symptoms on

well-being, functioning, and quality of life

3.Evaluate the safety of the patient and

others
Assessing the risk for suicide and self-injurious
behavior, as well as the risk for harm to others,
is crucial.
The psychiatrist should also evaluate the
patients potential for harming others.
4.Assessment of psychiatric co-morbidity
Particular attention should be given to mood

disorders and Other anxiety disorders.

5.Assessment of past history

Specific attention has to be given to the
i)Course of symptoms
ii)Treatment history, including

hospitalizations and trials of medications

and psychotherapies, with details of
treatment adequacy, duration, response,
and side effects
iii)Past histories of co-occurring disorders
that may influence treatment (e.g., mood
or substance use disorders; panic attacks.

6. Assessment of General Medical Conditions

The general medical history should document any

current general medical conditions, recent or

relevant hospitalizations, and any history of head
trauma, loss of consciousness, or seizures.
History of recurrent beta hemolytic streptococcal
infections and any treatment received for the
same.
Current medications and doses should be reviewed
to determine potential pharmacokinetic and
pharmacodynamic interactions with psychotropic
drugs.

Herbal or natural remedies must also be inquired

about, along with hormonal therapies, vitamins,

other over-the-counter medications, and other
alternative or complementary treatments.

Allergies and sensitivities to medications, including

the nature of the patients reaction, should be

recorded.
In performing the review of systems, the
psychiatrist should record the presence and severity
of somatic or psychological symptoms that could be
confused with medication side effects.

7. DEVELOPMENTAL,PSYCHOSOCIAL AND
SOCIO-CULTURAL HISTORY
i)Developmental transitions in childhood
and adulthood
ii)The patients capacity to achieve stable
and gratifying familial and social
relationships.
iii)Sexual History
iv)Educational & Occupational History
v)Primary and socio-cultural support group
vi)Assessment of psychosocial stressors

8.Assessment of Family History

A family history of other psychiatric

disorders especially Careful exploration for

bipolar disorder in view of the risk of
precipitating hypomania or mania with antiOCD medications
Family history of tics or Tourette disorder.
9.Performing a mental status
examination

Management
Psychiatric management consists of an

array of therapeutic actions that may be

offered to all patients with OCD during the
course of their illness at an intensity
consistent with the individual patients
needs and capacities .

1.ESTABLISHMENT OF THERAPEUTIC ALLIANCE

The therapeutic alliance allows the psychiatrist to

obtain the information needed to plan effective

treatment.
The excessive doubting that is characteristic of OCD
may require special approaches to building the
alliance.
Increased attention to excessive worry about
medication side effects, perfectionism, or checking
behaviors may be needed.
Treatment of patients with OCD has a
potential for transference and/or
countertransference issues that may
disrupt adherence and the therapeutic
alliance.

2. ESTABLISHING GOALS OF TREATMENT

Goals of treatment include:

i)decreasing symptom frequency and severity,
ii) improving the patients functioning,
iii)helping the patient to improve his or her
quality of life.
iv) Enhancing the patients ability to cooperate
with care despite the frightening cognitions that
are typical of OCD.
v) Helping the patient develop coping strategies.
vi)Minimizing any adverse effects of treatment
and
vii)Educating the patient and family regarding
the disorder and its treatment.

Reasonable treatment outcome targets

include:
Less than 1 hour per day spent obsessing
and performing compulsive behaviors
No more than mild OCD-related anxiety;
An ability to live with uncertainty;
Little or no interference of OCD with the
tasks of ordinary living.

3.ESTABLISHING APPROPRIATE SETTING

FOR TREATMENT
In general, patients should be cared for in the
least restrictive setting that is likely to be safe
and to allow for effective treatment.
Consequently, the appropriate treatment
setting will depend on a number of factors:
a.Hospital treatment: may be indicated by:
i)suicide risk,
ii)an inability to provide adequate self-care,
danger to others

iii) need for constant supervision or

support,
iv) An inability to tolerate outpatient
medication trials because of side effects,
v)need for intensive CBT,
vi)the presence of medical conditions that
necessitate hospital observation while
medications are initiated, or by cooccurring conditions that themselves
require hospital treatment, such as severe
or suicidal depression, schizophrenia, or
mania.

b.Residential treatment :may be indicated in

i)individuals with severe treatmentresistant OCD,
ii)who require multidisciplinary treatment .
c.Partial hospitalization may be indicated by:
i)a need for daily CBT and monitoring of
behavior or medications or a supportive
milieu with other adjunctive psychosocial
interventions, or
ii) to stabilize and increase the gains made
during a period of full hospitalization.

d.Home-based treatment may be necessary for:

i)patients with hoarding or, initially, for those
with contamination fears or other symptoms so
impairing that they cannot come to the office or
clinic.
ii)individuals who experience symptoms
primarily or exclusively at home.
e. Outpatient treatment is usually sufficient for the
treatment of OCD, but the intensity may vary
from daily psychotherapy, such as intensive
CBT, to treatment less than once a week.

4.ENHANCEMENT OF TREATMENT

ADHERENCE
To enhance treatment adherence, the
psychiatrist should consider factors related
to the illness, the patient, the physician,
the patient-physician relationship, the
treatment, and the social or environmental
milieu.
The patients beliefs about the nature of
the illness and its treatments will influence
adherence, providing patient and family
education may enhance adherence.

5. EDUCATING THE PATIENT AND FAMILY

Patients often have little knowledge of the nature,

biology, course, and treatment of their disorders.

Those with childhood onset of OCD may confuse
symptoms with aspects of their innate selves.
All patients with OCD should be provided with information
and access to educational materials explaining the nature
of the disorder and the range of available treatments.
Education will help destigmatize the illness and allow the
patient to make more fully informed decisions about
treatments.
Education may also increase the patients motivation
and ability to cooperate in care.

6.MANAGEMENT OF
ACUTE PHASE
A. Choosing an Initial Treatment Modality
CBT and SRIs are recommended on the

basis of clinical trial results as safe and

effective
first-line treatments for OCD.
SRIs include clomipramine
and all of the SSRIs.

Whether to recommend a form of CBT, an

SRI, or combined treatment will depend on

a number of factors. These include:
The nature and severity of the patients
symptoms,
The nature of any co-occurring psychiatric
and medical conditions and their
treatments,
The availability of CBT, and
The patients past treatment history,
current medications, and preferences.

The evidence base for the form of CBT that

relies primarily on behavioral techniques,

such as ERP , is the strongest.
CBT alone, consisting of ERP, is
recommended as initial treatment for a
Patient who is not too depressed, anxious,
or severely ill to cooperate with this
treatment modality, or who prefers not to
take medications.
The patient must be willing to do the work
that CBT requires (e.g., regular behavioral
homework).

Combined treatment should be considered

for patients with:

An unsatisfactory response to
monotherapy,
Those with co-occurring psychiatric
conditions for which SRIs are effective,
Those who wish to limit the duration of
treatment with medication.
Patients with severe OCD, since the
medication may diminish symptom severity
sufficiently to allow the patient to engage
in CBT.

B. Choosing a Specific Pharmacological

Treatment
Clomipramine, fluoxetine, fluvoxamine,
paroxetine, and sertraline, which are
approved by the FDA for treatment of OCD,
are recommended pharmacological agents.
Although meta-analyses of placebocontrolled trials suggest greater efficacy for
clomipramine than for fluoxetine,
fluvoxamine, and sertraline, the results of
head to- head trials comparing
clomipramine and SSRIs directly do not
support this impression.

SSRIs have a less troublesome side-effect

profile than clomipramine , an SSRI is preferred

for a first medication trial.
In choosing among the SSRIs, the psychiatrist
should consider:
i.The safety and acceptability of particular side
effects for the patient, including any applicable
FDA warnings,
ii.Potential drug interactions and the degree to
which they alter metabolism through the
hepatic cytochrome P450 enzyme system or
uridine 5-diphosphate glucuronosyltransferases
(UGTs), act at the P-glycoprotein transporter, or
displace drugs tightly bound to plasma proteins.

iii.Past treatment response, and

iv.The presence of co-occurring general

medical conditions.

a.IMPLEMENTING PHARMACOTHERAPY
SRI(mg/d)

STARTING

USUAL
TARGET

USUAL
MAXIMA
L

OCCASIONALLY
PRESCRIBED
MAXM

CLOMIPRAMI
NE

25

100-250

250

Pl.level>5OOng/
ml SEIZURES &
CONDUCTION
DELAY

CITALOPRAM

20

40-60

80

120

ESCITALOPRA 10
M

20

40

60

FLUOXETINE

20

40-60

80

120

FLUOXAMINE

50

200

300

450

SETRALINE

50

200

200

400

PAROXETINE

20

40-60

60

100

Start with half the dose:

patients who are worried about side effects
patients with co-occurring anxiety

disorders.
Elderly
Most patients will not experience
substantial improvement until 46 weeks
after starting medication.
Some patients, such as those who have had
little response to previous treatments and
are tolerating the medication well, may
benefit from even higher doses

CLOMIPRAMINE
Clomipramine ,the 3-chloro analogue of the
tricyclic imipramine, is unique among the
tricyclics in its marked potency for blocking
serotonin reuptake.
Clomipramine was the first FDA approved
drug for OCD(1989).
Desmethylclomipramine, a major
metabolite of clomipramine, potently
blocks reuptake of both 5-HT and
norepinephrine.

Several studies of IV clomipramine were

promising as they demonstrated quicker

onset of action and fewer side effects than
the oral form and maybe even effective in
patients who donot respond to oral
clomipramine.

FLUOXETINE
Initially, on the basis of fluoxetines

selectivity for serotonin receptors,

researchers were hopeful that this
medication would be more efficacious than
clomipramine, which has affinity for
cholinergic, adrenergic, and histaminic
receptors in addition to serotonergic ones.
Approved by FDA in 1994.
Fluoxetines long half-life, which is unique
among the SRIs, is 24 days for the parent
compound and 416 days for its active
metabolite.

 This long half-life can be beneficial for patients who

do not comply with treatment, because relatively high

steady-state levels are maintained even when several
doses are missed.

However, the long half life can present problems

when switching or discontinuing fluoxetine, because 5

weeks or more may be required for the medication to
be completely cleared from the body.
Hence the added delay, 5 weeks rather than 2 weeks

for the other SRIs, is required when switching from

fluoxetine to an MAOI.

FLUOXAMINE
It is a unicyclic agent that differs from the

other SSRIs in that it does not have an

active metabolite.
Approved by FDA in 1994.

SERTRALINE
Sertraline is a naphthalenamine derivative
with an active metabolite, n
desmethylsertraline.
Approved by FDA in 1997.

In the fixed-dose study, there was a trend

toward 200 mg/day being more effective

than 50 mg/day or 100 mg/day.
PAROXETINE
Paroxetine is a phenylpiperidine compound
that is marketed as an antidepressant and
that, like sertraline, shows promise in the
treatment of OCD. Its efficacy, is
comparable to that of other SRIs.
Approved by FDA in 1996.

CITALOPRAM/ESCITALOPRAM
Citalopram is a cyclic phthalin derivative

with S (active)and R (inactive) enantiomers;

it is unique in its selectivity for serotonin
reuptake compared to the other SRIs.
It has few significant secondary binding
properties, and its minimal effect on
hepatic metabolism probably makes it safer
to combine with other medications.

b.MANAGING SIDE EFFECTS

Clomipramine is more likely to induce:
Anticholinergic effects such as tachycardia, dry
mouth, constipation, and blurred vision, induce
delayed urination or, uncommonly, urinary
retention, although these typically diminish over
time.
Histaminic blockade is associated with weight
gain and sedation.
Adrenergic blockade may lead to orthostatic
hypotension and postural dizziness.
Sodium channel blockade can induce cardiac
arrhythmias or seizures

The most common side effects of the SSRIs

include gastrointestinal distress (especially

in the first weeks of treatment), agitation,
insomnia or somnolence, increased
tendency to sweat, and sexual side effects,
including diminished libido and difficulty
with erection and orgasm.
A first step in managing any side effect is
to consider whether lowering the drug dose
may alleviate the side effect without loss of
therapeutic effect.

Data in children and adolescents- potential

for increases in self-harming or suicidal

behaviors in individuals treated with
antidepressant medications, including SRIs.
SSRIs may be associated with increased
intra-operative blood loss in patients also
taking nonsteroidal anti-inflammatory
drugs and, along with clomipramine, may
interact with anesthetics and opiate pain
relievers.

A drug discontinuation syndrome consisting

most often of dizziness, nausea/vomiting,

headache, and lethargy, but also including
agitation, insomnia, myoclonic jerks, and
paresthesias, may occur if medication is
suddenly stopped.

C. Choosing a Specific Form of Psychotherapy

CBT is the only form of psychotherapy for

OCD whose effectiveness is supported by

controlled trials.
Psychodynamic psychotherapy may still be
useful in helping patients overcome their
resistance to accepting a recommended
treatment.
It may also be useful in addressing the
interpersonal consequences of the OCD
symptoms .
Motivational interviewing may also help
overcome resistance to treatment.

D.Implementing Cognitive Behavioural

Strategies
The introduction of the behavioral

techniques of exposure and response

prevention, a variation of CBT, was a key
advance in the treatment of OCD.
ERP involves systematically exposing a
patient to the thoughts, images, situations
or stimuli that elicit obsessive
fear(exposure), while simultaneously
helping the patient to refrain from
engaging in compulsive rituals.

Technique
a.Behavioural Assessment
The therapist helps the patient to identify

specific triggers for obsessions,

compulsions, rituals, and discomfort.
Triggers are arranged in hierarchies from
least to the most distressing, which guides
patient and the clinician in selecting
appropriate targets of treatment.
The use of YBOCS-symptom checklist, often
helps patients to describe their disorder
more completely.

Identifying all the situations or people

avoided is a key to designing effective

behavior therapy programs.
Information about the involvement of
family, friends and co-workers in the
patients rituals should also be elicited.
They can be used as co-therapists.

b.Education
Patients need an understanding of OCD , an

explanation for how exposure in vivo and ritual

prevention can lead to habituation, and an outline of
the general treatment plan.
Clinicians need to learn about the patients
experiences and naturalistic exposure and ritual
prevention, preferences regarding speed of treatment,
time available for treatment, effects of anxiety and
other discomfort, and the availability of co-therapists
and other supporters while the BT is proceeding.
Rapport results from mutual understandings and
agreements.

c.Intensity and Length of exposure

Setting specific goals for exposure and

ritual prevention is a joint task.

After hierarchies have been prepared ,
agreement is reached on the first trigger to
be treated.
A scale of discomfort should be developed
to aid both patient and clinician in deciding
which trigger to tackle, how much distress
the exposure and ritual prevention sessions
produce, and how long it takes for
habituation to occur.

The length of the session depends on

patients rate of habituation.

In general,sessions lasts till the patients
discomfort has diminished significantly. It
may vary from 15mins to atleast an hour.

d.Progress through a Hierarchy

After the patient has largely mastered

his/her first target of treatment, the

experience gained can be used to
overcome the next triggers and rituals in
the hierarchy.
After a patient has reduced the maximum

distress rating to a level between 0 and 2

for three or more days, it is appropriate to
add goals to deal with other triggers of
discomfort, obsessions and rituals.

e. Managing Anxiety during sessions

Rituals evolve to control the discomfort after

exposure to triggers.
At the beginning of therapy, therefore, short term

transient increases in obsessions and discomfort

may occur as rituals are prevented.

Coping tactics can be planned to enable patients to

continue exposure until habituation occurs without

restoring to ritualistic behaviors.

Cognitive therapy
individuals with OCD hide their rituals because they

know that others would find them unusual or bizarre

they tell themselves repeatedly that their cognitions

are incorrect, but cannot turn their attention from

them

cognitive therapies aimed at changing faulty

cognitions about risks & responsibility seem logical,

but most studies have not found them effective.

Acceptance and Commitment Therapy

(ACT), a variation of CBT, recently has been

applied to OCD.
It aims to help patients learn to distance
themselves from their thoughts and not to
treat them as literal, while decreasing
experiential avoidance.

Other types of Psychotherapy

The use of psychotherapeutic techniques of

either a psychoanalytic or a supportive

nature has not been proved successful in
treating the specific obsessions and
compulsions that are a hallmark of OCD.
The defense mechanisms of reaction
formation, isolation, and undoing, as well
as a pervasive sense of doubt and need to
be in control, are hallmarks of the
obsessivecompulsive character.

E.Monitoring the patients psychiatric

status
The frequency of follow-up visits after a

new pharmacotherapy is initiated may vary

from a few days to 2 weeks.
The indicated frequency of visits will
depend on the:
Severity of the patients symptoms,
The complexities introduced by cooccurring conditions,
Whether suicidal ideation is present, and
The likelihood of troubling side effects.

Prognostic factors
Good Prognosis

Poor Prognosis

Precipitating event
Episodic nature of
symptoms
Good premorbid
adjustment

Childhood onset
Yielding to compulsions
Bizarre compulsions
Overvalued ideas
Coexisting major depression
Personality disorders
Poor compliance
Poor insight
Obsessive slowness
Cognitive impairment
Need for IP treatment

F.Determining when and whether to change

treatment
DEFINITION

CRITERIA

STAGE 1 RECOVERY/NOT AT
ALL ILL

YBOCS<8

STAGE II REMISSION

YBOCS<16

STAGE III FULL RESPONSE

35% or greater reduction on

YBOCS & cgi 1 or 2

STAGE IV PARTIAL RESPONSE

>25% but <35% reduction in

YBOCS

STAGE V NONRESPONSE

< 25% reduction in YBOCS and

CGI 4

STAGE VI RELAPSE

Symptoms return after 3+

months i.e 25% increase in
YBOCS from remission score or
CGI 6

STAGE VII REFRACTORY

No change or worsening with

available therapies.

The psychiatrist must decide with the patient when,

whether, and how to alter the treatment approach.

In the opinion of CBT experts, 1320 sessions of
weekly outpatient CBT with daily homework or
weekday daily CBT for 3 weeks (about 50 hours,
half therapist guided, half homework) is an
adequate dose after which next steps can be
considered.
With regard to SRIs, expert opinion supports
changing medication strategy (switching or
augmenting) after a trial of 812 weeks with at least
46 weeks at the highest comfortably tolerated
dose .

When the outcome of initial treatment has

been unsatisfactory,the psychiatrist should

first consider the possible contribution of
several factors:
Problems in the therapeutic alliance;
Interference by co-occurring conditions
such as panic disorder, major depression,
alcohol or substance use disorders, tic
disorder or severe personality(schizotypal)
disorder.

 Inadequate patient adherence to treatment;

patients with OCD are generally compliant

except when OC symptoms interfere.
The adequacy of the acute drug trial and
duration of trial was adequate?
The presence of psychosocial stressors;
Patients with a clinical subtype of
OCD-Primary Obsessional Slowness.
The level of family members accommodation
to the obsessive-compulsive symptoms ; and
An inability to tolerate an adequate trial of
psychotherapy or the maximum
recommended drug doses.

G. Pursuing Sequential Treatment Trials

When the patient has an inadequate

response to the initial treatment and no

interfering factor can be identified, the
psychiatrist and patient must decide on
next treatment steps.
Augmentation strategies:
1.Clonazepam
2.Buspirone
3.Lithium
4.Atypical antipsychotics
5.Typical antipsychotics

 6.Fenfluramine
7.L-Tryptophan
8.Trazodone
9.Pindolol
Combination therapy:
1.Clomipramine with SSRIs
2.Clomipramine with MAOI.

Switching antidepressants:
SNRI- venlafaxine
MAOI-B
Nefazodone
Novel strategies:
1.Intravenous clomipramine.
2.MAOIs
3.Clonidine
4.Flutamide

5.Inositol
6.D-cycloserine
7.Non-pharmacological Biological

Approaches: Includes: Electro-Convulsive

Therapy, Neurosurgery, Sleep deprivation,
Phototherapy and Repetitive Transcranial
Magnetic Stimulation.
Stereotactic surgical procedures used in
OCD are reserved for patients with more
severe OCD.

C.DISCONTINUATION OF ACTIVE
TREATMENT
Successful medication treatment should be

continued for 12 years before considering

a gradual taper by decrements of 10%25%
every 12 months while observing for
symptom return or exacerbation.
Successful ERP should be followed by
monthly booster sessions for 36 months,
or more intensively if response has been
only partial.

An open discontinuation study(Ravizza et al

1996) also reported significantly higher 6month, 1-year, and 2-year relapse rates for
the patients whose SRI treatment was
discontinued
Thus, rates of relapse appear to be
increased after discontinuation of SRI
treatment but cannot be precisely
specified.

A review of CBT studies(Foa et al 1996)

consisting of ERP concluded that about

three-quarters of patients receiving ERP
(with and without concomitant medication)
were doing well at a mean follow-up of a
little more than 2 years after the index
treatment course.

SPECIFIC CLINICAL FEATURES

INFLUENCING THE TREATMENT PLAN

A.PSYCHIATRIC FEATURES
1. Chronic Motor Tics
2.Tourettes syndrome
3.Major Depression
4.Bipolar disorder
5.Panic disorder
6.Social Phobia

7.Schizophrenia
8.Substance use disorders
9.Autism & Aspergers disorder.
10.Personality Disorders
11.Neurological conditions

Demographic and Psychosocial Factors

1.Gender
2.Ethnicity
3.Pregnancy and Breast feeding.
4.Children and adolescents
5.Elderly
6.Medical conditions

Conclusion
For many patients with OCD the illness is

lifelong, starting in early childhood and

extending into adulthood.
It is often familial and accompanied by
comorbid conditions including,depression,
other anxiety disorders, Tourettes
syndrome and even psychosis.
However, with a combination of
pharmacologic and behavioral treatment,
at adequate dose and duration, patients
can often have signifi cant improvement in
symptoms and overall function.