Obsessive-Compulsive Disorder

Peggy M. A. Richter, MD, FRCPC; Renato T. Ramos, MD Behavioral Neurology and Psychiatry p. 828-844 June 2018, Vol.24, No.3 doi: 10.1212/CON.0000000000000603
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PURPOSE OF REVIEW: This article reviews current knowledge regarding diagnosis, pathophysiology, and treatment trends in obsessive-compulsive disorder (OCD), a severe, underrecognized, and chronic condition frequently encountered in neurologic practice.

RECENT FINDINGS: With a lifetime prevalence estimated at 2.5%, OCD is a common condition that can also present comorbidly with neurologic disease. The core symptoms of OCD are obsessions and compulsions. Obsessions are intrusive repetitive thoughts, urges, images, or impulses that trigger anxiety and that the individual is not able to suppress. Compulsions are repetitive behaviors or mental acts occurring in response to an obsession with the intention of reducing the distress caused by obsessions. Neuroimaging, neuropsychological, and pharmacologic studies suggest that the expression of OCD symptoms is associated with dysfunction in a cortico-striato-thalamo-cortical circuit. Evidence-based treatments for OCD comprise pharmacotherapy and cognitive-behavioral therapy. Selective serotonin reuptake inhibitors (SSRIs) are the first-line drugs recommended for OCD, but significant differences exist in their use for OCD compared to their use for other mood and anxiety conditions, including the need for higher dosage, longer trials necessitated by a longer lag for therapeutic response, and typically lower response rates. Cognitive-behavioral therapy, based on the principles of exposure and response prevention, shows results superior to pharmacologic treatments with lower relapse rates on long-term follow-up and thus should be considered in the treatment plan of every patient with OCD.

SUMMARY: OCD and obsessive-compulsive symptoms are frequently encountered in the neurologic clinic setting and require a high index of suspicion to effectively screen for them and an illness-specific therapeutic approach.

Address correspondence to Dr Peggy M. A. Richter, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Suite FG47, Toronto, ON M4N 3M5, Canada, Peggy.Richter@sunnybrook.ca.

RELATIONSHIP DISCLOSURE: Dr Richter serves on the editorial board of the Journal of Obsessive-Compulsive and Related Disorders, has received personal compensation for speaking engagements from Lundbeck, and receives grant/research support from the Canadian Institutes of Health Research. Dr Ramos reports no disclosure.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Drs Richter and Ramos discuss the unlabeled/investigational use of neuromodulation technology (deep brain stimulation, electroconvulsive therapy, and repetitive transcranial magnetic stimulation) and pharmacologic agents (citalopram, escitalopram, desvenlafaxine, duloxetine, mirtazapine, and venlafaxine) for the treatment of obsessive-compulsive disorder (some of which are approved for use in depression and psychosis).

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© 2018 American Academy of Neurology