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Characteristics
of obsessive–
compulsive
disorder
Presentation
and diagnosis
Treatment
The author
DR LISA LAMPE,
senior lecturer, discipline of
psychological medicine,
Northern Clinical School,
University of Sydney and
CADE Clinic, Royal North Shore
Hospital, St Leonards, NSW.
OBSESSIVE–
COMPULSIVE DISORDER
Background
OBSESSIVE–compulsive disorder
(OCD) is one of the most common
mental disorders, with a prevalence
of about 2% and a slight female
excess.1-3 It commonly has an onset
in childhood, takes a chronic course
and can be highly disabling. Patients
may respond well to cognitive
behaviour therapy, medication, or
both in combination, although 3060% of patients respond poorly and
full remission of symptoms is rare.4,5
Epidemiology
The prevalence of OCD in the community is about 2%, but 13-17%
of individuals without a mental dis-
order also report obsessions and
compulsions suggesting that
humans are prone to such ‘magical’
thinking (figure 1, page 27). 1,2
Obsessions and compulsions are
also common in mental disorders
apart from OCD.
Obsessions and compulsions typically appear for the first time in
childhood. Repetitive behaviours
are common in children aged 3-6
years, but can be differentiated from
significant obsessive–compulsive
symptoms by the fact that these
normal variants do not cause distress or impairment. Fifty per cent
of adults with OCD report that they
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had developed the condition by age
19, although perhaps only 40% of
children with obsessive–compulsive
symptoms go on to develop
OCD. 2,3,6 Earlier age at onset is
more likely to be associated with tic
disorders, other anxiety disorders
and male gender.7
OCD typically takes a chronic
course. Periods of exacerbation and
improvement may be relatively
more common early in the course
of illness, whereas a more chronic
course is typical of OCD of long
duration.8 Exacerbations may occur
even after many years of remission.
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Characteristics of obsessive–compulsive disorder
OCD is characterised by
obsessions
(intrusive,
unwanted thoughts, images
or impulses) and compulsions (urges to act in a way
that is intended to reduce,
undo or prevent feared harm
from occurring). The obsessional thoughts are experienced as uncontrollable,
intrusive and unwanted.
Formerly it was felt that
there was a purely obsessional form of OCD, and
that this was associated with
a poorer outcome. In fact, it
appears that obsessions
alone are uncommon, and
the appearance of a ‘pure
obsessional’ illness is due to
the fact that compulsions
may often be covert, or
mental, rather than obvious
physical behaviours such as
checking, washing or touching. Examples of covert
compulsions include repeating phrases or prayers over
and over in response to
obsessional thoughts, counting and reassurance, for
example, “It’s okay”.
Cognitively, OCD is characterised by intolerance of
uncertainty (it is also
referred to as ‘the doubting
disease’), distrust of memory
Figure 1: ‘Pile of sticks’ to ward off misfortune. Taken at the
Bunge Museum depicting Swedish farming life in the 16th-19th
centuries, Bunge, Gotland, Sweden. [Photo: Dr Lisa Lampe]
(“Did I check it or not?”),
inflated sense of personal
responsibility and the importance of thoughts, and catastrophising; for example,
“Did I remember to lock the
door? If it isn’t locked burglars will get in and we will
lose everything and everyone
will be so unhappy and it
will be all my fault … Since
I’ve had a doubt about
whether I locked the door it
must mean that I haven’t
done it, because why else
would I have the thought?”
A number of subtypes of
OCD have been recognised.
These include obsessions
about contamination (usually associated with compulsions around washing and
checking), obsessional doubt
(associated with compulsions
to check), obsessions of a
sexual, religious, aggressive
or somatic type (often with-
out overt compulsions),
obsessions around symmetry
and perfectionism (with
compulsions around ordering and arranging, repeating
and counting), and hoarding.9
Fears of contamination,
concerns about harm occurring to self or others, and
cleaning and checking compulsions are the most
common
symptoms. 8,10
Hoarding stands out as the
most different subtype, with
some suggestions that it be
considered as a separate disorder.
There may be neurobiological differences underlying the subtypes, and some
gender differences have been
reported, with more women
experiencing contamination
and aggression obsessions
and cleaning compulsions,
and more men experiencing
obsessions with a sexual
theme (eg, concerns about
being a paedophile).11
OCD is often associated
with embarrassment and
shame. A key feature of the
disorder is that individuals
mostly recognise that their
concerns are excessive and
unrealistic. They realise that
their compulsive behaviours
may be regarded by others
as irrational, and this can be
a source of embarrassment.
Some individuals also
experience a sense of shame,
especially in subtypes of
OCD characterised by obsessions perceived as morally
repugnant. Many individuals with sexual, aggressive or
blasphemous obsessions feel
ashamed that thoughts of
such a nature should even
enter their head. This naturally leads to a reticence to
admit to such thoughts.
Comorbidity
As might be expected there
is considerable comorbidity
with major depression and
with other anxiety disorders.
Alcohol misuse is also seen
at higher than community
rates.
Relationship to tic
disorders
OCD occurs at greater than
community rates in individuals with tic disorders, and
their relatives.12 Comorbidity with tic disorders appears
higher in childhood-onset
OCD and in males. A
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HOW TO TREAT Obsessive–compulsive disorder
ship stress can also ensue when a
family member refuses to comply
with demands to engage in ‘decontamination’ strategies, checking rituals or reassurance.
Until very recently anxiety disorders were not considered to represent an increased risk for suicide
unless comorbid with depression.
However, recent studies have consistently reported a risk for suicidal ideation and attempts in anxiety
disorders independent of depression.17-20 This was true for OCD in
epidemiological studies and for suicidal ideation and obsessive–compulsive symptoms in a non-clinical
sample.16,17,21,22
The Te Rau Hinengaro epidemiological survey in New Zealand
found that OCD was associated
with the second-highest rate (after
panic disorder) of suicide attempts
of all the anxiety disorders. At
3.3% over 12 months this rate was
eight times the population rate
(compared with major depression
at 10 times the population rate).21
This points to the importance of
both early treatment of OCD as
well as screening for suicidal
ideation in this group.
from previous page
follow-up study of children with
Tourette syndrome suggests that tics
are likely to show clinically significant improvement by adolescence,
but obsessive–compulsive symptoms are more likely to persist and
even worsen, especially in children
with higher IQs.13
A recent review of paediatric
OCD suggests that children with tic
disorders may respond less well to
SSRI monotherapy, but in adults
the findings are equivocal.14 Studies of treatment-resistant OCD
using augmentation of serotonergic
antidepressants by typical antipsychotics suggest that the likelihood
of response may be greater where
there is a personal or family history
of tic disorders.
Distress and disability
While OCD is often recognised to
be distressing, the level of disability
is often underestimated. Andrews
et al. compared the disability
related to a number of medical and
psychiatric conditions and found
that OCD resulted in more disability and impairment than all the
comparative conditions, including
bipolar disorder, major depression,
chronic bronchitis, diabetes, asthma
and ‘heart trouble’.15
OCD is associated with considerable social impairment, with a
number of studies reporting high
rates of being single, divorced or
separated.16 In some studies these
rates exceed those seen in social
anxiety disorder. Patients may well
seek treatment at the urging of a
spouse or family member and it is
not uncommon in my experience
for these relationships to be at
breaking point as a result of the
patient’s OCD.
Family members are often drawn
into accommodating or assisting the
patient in their compulsions because
they find it hard to see their loved
one suffering so much anxiety, or
because it will keep the peace. However, it can be very disruptive to a
household. Arguments and relation-
Aetiology
A heritable component has been
established for OCD, which may
be strongest for childhood-onset illness.12,23 Estimates put the increased
risk at 4-8 times for relatives of
those with OCD.
Paediatric autoimmune neuropsychiatric disorders associated
with streptococcal infection
(PANDAS) is proposed to constitute a subset of children who
develop OCD and/or tics or
Tourette syndrome after infection
with Group A ß-haemolytic streptococcal infection. Symptoms may
remit and relapse in association
with recurrences of streptococcal
infection. No clinical differences
from ‘idiopathic’ OCD have been
identified, and the validity of the
syndrome remains somewhat controversial.
Neuroimaging/neurobiology
Neuroimaging studies have consistently shown hyperactivity of the
anterior cingulate cortex, caudate
nucleus and orbitofrontal cortex,
which remits with successful pharmacological or behavioural treatment.6,24 What is unclear is whether
this hyperactivity is the cause of
OCD or merely symptomatic of it.
Functionally, cortico-basal ganglia-thalamo-cortical loops involving the anterior cingulate cortex
and orbitofrontal cortex have been
implicated, with one theory proposing a relative imbalance between
direct (excitatory) and indirect
(inhibitory) pathways through the
basal ganglia.6
Presentation and diagnosis
GIVEN the high prevalence
in the community it is highly
likely that GPs will see a
number of patients with
OCD. Recent epidemiological research suggests that
individuals with ‘shameful’
obsessions or fears of harming others may be more likely
to seek help.2 The same study
found that individuals with
comorbid depression (primary or secondary) are also
more likely to seek help.
Other possible clues may
be the patient presenting
with dermatitis of the hands,
or repeated seemingly inappropriate requests to be
tested for bloodborne viruses
because of fears of contamination. Screening questions
may be of assistance (see
box).
In the first National Survey
of Mental Health and Wellbeing, about 42% of individuals who met criteria for
OCD had seen a health professional for this problem in
the past 12 months, with
two-thirds of this group
seeing a mental health specialist.25 As with all the anxiety disorders, it is common
for symptoms to have been
present for some time before
treatment is eventually
sought.
Screening for OCD26
• Do you wash or clean a
lot?
• Do you check things a
lot?
• Is there any thought that
keeps bothering you that
you’d like to get rid of but
can’t? [Author’s variation:
Are there any thoughts
that keep coming into
your head that you find
bizarre or distressing but
can’t seem to control?]
• Do your daily activities
take a long time to finish?
• Are you concerned about
orderliness or symmetry?
Differential diagnoses
The key differential diagnoses to exclude are depression, other anxiety disorders
and psychosis. Violent obsessions could be experienced in
psychopathy (antisocial personality disorder), in which
case it is likely they would be
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| Australian Doctor | 9 October 2009
seen by the individual as justified or reasonable, and not
cause significant distress.
From a treatment perspective
it is important to determine
whether the OCD is primary,
or secondary to a major
depression or other psychiatric disorder.
Obsessional symptoms in
psychotic disorders are
common, with an estimated
prevalence of 10-50% (average about 20%). Studies have
shown an association with
greater symptom levels and
disability.27,28 The co-occurrence was first noted before
the advent of antipsychotic
medication, but it is also evident that many atypical
antipsychotics can exacerbate
or induce obsessive–compulsive symptoms, perhaps especially clozapine.27
Complicating this issue is
the observation that for virtually every atypical antipsychotic there are reports of both
exacerbation and improvement of obsessive–compulsive
symptoms. Much more
research is required to elucidate the effects of atypical
antipsychotics on obsessive–
compulsive symptoms.
In distinguishing OCD
from delusions, one would
look at the nature of the
obsessional ideas: do they fit
into one of the common subtypes of OCD noted earlier
or do they have a more
bizarre theme?
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The next factor to consider
is the level of insight: patients
with OCD are overwhelmingly able to see their
thoughts and ideas as the
product of their own mind;
they are most likely to realise
that their fears are unrealistic
or excessive. However, insight
can vary over time, and a
‘poor insight’ subtype is
recognised by DSM-IV, with
estimates that 10-35% of
those with OCD would fit
28
this category. Note that
schizophrenia and classic
OCD can exist as comorbid
disorders.
It can also be difficult to
distinguish OCD from other
anxiety disorders, for example, when there is excessive
concern about health. However, in OCD there is generally concern about one specific illness, often one that
could be caused by a ‘contamination’ mechanism,
whereas in hypochondriasis
or generalised anxiety disorder there are usually a
number of concerns, or there
may be ‘migration’ of concern around the body.
Ruminations are frequent
in depression but will usually
focus on guilt or loss. As
illustrated in the case history
of Saroja (see Author’s case
study, page 30), her guilty
thoughts arose from failing
to carry out her usual roles,
which she was avoiding not
because she believed herself
unworthy or incapable, but
because she was trying to
avoid causing harm to her
family.
Certain types of OCD
symptoms can cause anxiety
among health professionals
and patients alike, especially
obsessions around aggressive
or sexual themes, as both
patient and professional may
have concerns about the likelihood of the patient acting
on their obsessions. The key
is to take care in elucidating
the exact nature of the concern.
For example, patients
rarely experience ‘an urge to
harm’ someone, although this
is often how the concern is
expressed. Rather, what is
experienced is anxiety that
they may harm someone.
There is no urge to harm —
there is a thought or image
around harming someone,
which is experienced as
abhorrent, and severe anxiety results from worrying that
there may be a loss of control, which in turn leads to
the individual acting on this
highly ego-dystonic obsession.
There is no evidence that
having such obsessional
thoughts renders an individual any more likely to act on
them, and the tendency to
conflate thought and action
is now recognised by the cognitive construct referred to as
‘thought–action fusion’. A
considerable portion of the
distress caused by the aggressive/sexual/religious subtype
of OCD is related to this phenomenon of thought–action
fusion.
Where there is doubt about
the diagnosis in primary care,
referral to a psychiatrist for
review is recommended.
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Treatment
OCD cannot be ‘cured’. The
goals of treatment are good
symptom control and
restoration of function. Firstline treatments with a strong
evidence basis in OCD
include serotonergic antidepressants (clomipramine
and the SSRIs) and CBT.
There is no evidence that
benzodiazepines or antipsychotic monotherapy are of
benefit, although clonazepam and antipsychotics
have been used as augmenting strategies.8
Both CBT and antidepressant pharmacotherapy have
been shown in Cochrane
reviews to have effect sizes
greater than those typically
seen for antidepressants in
the treatment of depression.29-31 This may be at least
partly because the placebo
response rate in OCD is typically low, and because the
threshold for response was
probably set lower than that
for depression.
In general, outcome is
poorer for more severe
OCD, early onset of symptoms and the hoarding subtype, and possibly for obsessions of a religious or sexual
nature.9,10 Washing/cleaning
compulsions may respond
better to exposure and
response prevention (ERP)
than to SSRIs.
year naturalistic follow-up
showed that the proportion
of treated individuals
responding to pharmacotherapy continued to increase
over the first two years,
although rates of full remission were quite low (10% at
year 1, 31% at year 2 and
38% at year 3) and relapse
rates high (60%). 40 Given
these data, it would seem sensible to advise patients to take
the medication for at least
two years.
While there is some evidence of a dose–response relationship, there is also evidence
that lower doses (ie, comparable to those used in depression) can be effective. 31-38
Hence, patients should be
started on lower doses and
the clinician should wait at
least six weeks before judging the dose to be ineffective
and increasing it.
Table 1: Summary of treatment recommendations
Recommended strategy
OCD without significant
depression, especially
cleaning/contamination
subtype
Exposure and response
prevention (ERP) if available from
experienced therapist
OCD with significant
depressive symptoms
SSRI followed by ERP as mood
improves
OCD with poor insight
SSRI; if poor response consider
antipsychotic augmentation
Desire to stop
antidepressant
Gradual reduction over several
months; add ERP if not already
completed
Overall, there is limited evidence in adults to suggest that
the combination of CBT/ERP
and pharmacotherapy may be
superior to CBT/ERP alone
as first-line treatment, but in
children, combination treatment does not appear to be
superior to CBT/ERP alone.8
If
monotherapy
with
CBT/ERP or pharmacotherapy is ineffective, it is recommended to add the other
treatment.41
OCD causing social or
occupational crisis; OCD
with severe symptoms
Start SSRI and add in ERP when
feasible
Focus on carers
CBT
Traditional CBT approaches
to OCD have in fact been
largely behavioural, based on
the technique of ERP. In this
technique, patients are asked
to deliberately confront situations (or engage thoughts or
images) that provoke anxiety,
then resist the urge to complete the compulsions that
would alleviate the anxiety.
Cognitive approaches have
focused on challenging the
content of the thoughts, but
this approach may be less
effective.29,32
More recent, mainly cognitive approaches are based on
the meta-cognitive theories of
Wells, which focus on
patients’ cognitive reactions to
their obsessions as contributing to both the distress and
maintenance of the OCD.33
Meta-cognitive factors include
inflated beliefs about the significance of thoughts (eg, that
they are ‘facts’ or that thinking about an outcome makes
it more likely to occur),
inflated responsibility for negative
outcomes,
and
thought–action fusion.
CBT/ERP approaches
appear to result in fairly
good maintenance of treatment gains, and even some
improvement over time after
ERP if there has been an initial response.34-36 ERP has the
disadvantages that therapists
must be skilled in its use for
it to be effective and refusal
and dropout rates are relatively high (eg, 25% refuse
ERP and about 25% drop
Combination therapy
Clinical situation
37
out). Patients are likely to
require 13-20 sessions and
this should be taken into
account if making a referral
under the Better Outcomes
in Mental Health initiative.38
Antidepressant
pharmacotherapy
Clomipramine was the first
antidepressant demonstrated
to be effective for OCD and is
still regarded by many as the
gold standard, based on metaanalytic reviews suggesting
slight superiority over SSRIs.
However, recent head-to-head
trials have been inconclusive
and the National Institute for
Health and Clinical Excellence (NICE) guidelines concluded that it is unlikely that
there are clinically important
differences.8,38,39
Hence, based on risk and
side-effect profiles, SSRIs are
the recommended first-line
pharmacotherapy. There does
not appear to be any difference in efficacy between individual SSRIs, and so choice
should be based on side-effect
profile and long-term tolerability. Antidepressants may
have an effect independent of
whether there is a comorbid
depressive disorder.
It is important to be aware
that it can take 12 weeks or
more to see a response to
pharmacotherapy. A three-
As noted, OCD puts considerable stress on relationships. It is important that,
whenever possible, carers are
included in psycho-education
and discussion of treatment
options. They need to know
what is involved in treatment, and specific advice
about how they can help is
valuable to both the patient
and carer/s.
Note that the patient
should be given primary
responsibility for learning to
control their symptoms: it is
unhelpful and unreasonable
to expect carers to refrain
from accommodating a
patient’s obsessional concerns as the primary means
of control. It is the patient
who must learn to control
their urges to neutralise, seek
reassurance or attempt to get
loved ones to comply with
their compulsions.
However, in negotiation
with the patient as treatment
proceeds, agreement may be
reached about how it would
be most helpful for a carer
to respond to a request that
might reinforce anxious concerns.
Failure to respond
A number of enquiries
should be considered where
the patient fails to respond
to the first-line treatment
offered:
• Review the diagnosis: is it
OCD? Have complicating
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comorbidities that might
impair response, such as
substance abuse disorders
or
psychosis,
been
excluded? Consider referral to a psychiatrist for
review.
• Has the patient been
adherent to the therapy —
taken their medication reliably or implemented the
ERP strategies exactly as
advised? ERP will be ineffective if the patient uses
distraction or safety behaviours during exposure.
• Is the dose of medication
sufficient and has it been
taken for long enough to
expect to see a response?
Consider increasing the
dose in gradual increments, as tolerated, until
the maximum recommended daily dose has
been achieved for at least a
month, with a total of at
least 12 weeks of
pharmacotherapy.
• Has the ERP conformed to
expert practice guidelines?
Is the practitioner sufficiently experienced? Is a
greater intensity (more frequent sessions) required
because of the severity of
the OCD?
If the answer to each of
the above is ‘Yes’, the following strategies may be
considered:
• If the patient has not yet
tried the combination of
ERP and medication, this
should be considered.
• Changing to another
SSRI. Unlike the depression literature, expert consensus in OCD is that a
patient may respond to a
different SSRI despite failing a trial of one or more
SSRIs.
• Trial of clomipramine.
• Addition of an antipsychotic. This may be useful
if there is a comorbid tic
disorder, poor insight or
comorbid schizotypal personality disorder. There is
most evidence for the addition of risperidone (up to
3mg), haloperidol (up to
5mg but much lower doses
are recommended initially,
eg, 0.5mg) and pimozide.
However, haloperidol presents a high extrapyramidal
side-effect burden, pimozide has an association
with prolonged QTc interval, and both haloperidol
and pimozide carry an
increased risk of tardive
dyskinesia, which is difficult to justify when alternatives are available. There
is less robust evidence for
several other atypical
antipsychotics. Low doses
are indicated. I would recommend that antipsychotic
augmentation is only
undertaken in consultation
with a psychiatrist when
feasible.
Table 1 summarises treatment options.
Summary: general
management
recommendations
• Screen for depression and
substance abuse
• Regularly monitor suicidal
ideation, planning and
intent
• Assess level of
relationship stress (as a
cause of exacerbation but
more often a
consequence of OCD)
• Include family/carer in
psycho-education
sessions
• Assess impact on
occupational functioning
and any risk to job
security
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HOW TO TREAT Obsessive–compulsive disorder
Author’s case study
SAROJA, a 48-year-old married
woman with three adult children,
reported that she was not sleeping,
and was tearful, anxious and at
times agitated. Some days she was
unable to assist her husband in their
small grocery/deli, and she no longer
enjoyed dealing with customers.
She expressed concerns about the
health of family members, frequently asking them whether they
felt well. She was not as involved
in cooking or housekeeping — formerly she had been very houseproud and even ‘over the top’ about
cleaning and tidiness, according to
her daughters.
However, what particularly
alerted both her daughters to there
being a marked change in their
mother was that Saroja seemed to
have lost interest in her first grandchild, whose arrival had been a
cause of great excitement for her.
He was now seven months old.
They had noted these changes in
their mother over about the past six
months.
Saroja and her family had been
patients of the practice for many
years. Her GP knew her as a conscientious, hard-working, somewhat
anxious woman with strong family
and social supports, also as someone who enjoyed the social interaction of her work. On her record it
was noted that she had been treated
for an episode of depression 10 years
ago after her mother died.
There were also several periods of
anxiety when her daughter went
backpacking overseas, when her son
was going through a divorce two
years ago, and when her husband
was diagnosed with high cholesterol
and Helicobacter pylori 12 months
ago. There was a brief note saying
she felt she may have somehow
‘infected’ her husband through her
cooking or poor hygiene and she was
reassured that this was unlikely.
It was evident that Saroja had lost
weight and she appeared tearful and
agitated. She admitted that her mood
and energy levels were low. She said
she felt guilty that she was letting
her husband down by not helping in
the shop, letting her daughter down
by not helping with the baby, and
Conclusion
Figure 2: Cognitive behavioural model of OCD.
avoidance
obsessional belief/s
(I could pass on
germs)
hypervigilance
(check whether others
feeling/looking well)
guilt,
depression
TRIGGER
thought (obsession)
situation (being in shop,
seeing grandson)
feeling (not feeling ‘right’;
feeling ‘dirty’)
Case history: CBT treatment
anxiety
urge to neutralise
reassuranceseeking
compulsive ritual/s
that she was not looking after her
family as she should.
When asked about what seemed
to be making these things difficult
for her, she explained that she longed
to spend time with her grandson but
did not want to put him at risk again
and felt it was the responsible thing
to stay away from him.
When asked to explain further,
Saroja said that the baby had developed a respiratory illness in the neonatal period and required a brief
admission to hospital. She became
convinced that she had passed on
some germ to the baby that she had
acquired from dealing with people
at the shop, although she didn’t
admit this to her family. She became
increasingly concerned about making
other members of the family ill and
so reduced her contact with the general public, and also avoided cooking
or shopping in order to ‘protect’ her
family.
On further questioning she admitted
to greatly increased personal hygiene
practices with repeated handwashing
depression, as she felt guilty about
letting others down (see figure 2).
Because of the significant degree
of comorbid depression and the
severity of her current symptoms, it
is appropriate to start treatment
with an SSRI. When the level of
depression has lifted, Saroja should
be referred for skilled ERP to assist
in relapse prevention and improve
the course of her illness.
and long showers. She began to avoid
housework as it would take her a very
long time to do any task because of
the need to do it very thoroughly, until
it felt right.
Comment
This case illustrates the often close
relationship to depression, which in
this example is secondary to OCD.
Careful exploration of the history
would reveal a longstanding excessive concern about cleanliness and
hygiene, with obsessions and compulsions around cleaning and checking that were generally well tolerated by the patient and family, but
became more intrusive and distressing at times of stress.
The recent illnesses of the patient’s
husband and grandson ‘meshed’ so
closely with her longstanding concerns that they triggered a more
severe episode of OCD. Her
attempts to prevent further harm by
avoiding activities associated with
her roles as wife, mother and grandmother had triggered a secondary
The most important initial task is
psycho-education about OCD and
depression for Saroja and her family.
More specific psycho-education for
ERP must include the rationale
behind ERP — when patients understand and accept this they are much
more likely to engage with the therapy and persevere despite high levels
of anxiety.
The model that I use is to liken
the obsessional thoughts to a blackmailer, who threatens that if the
person does not perform some
behaviour (paying money to a blackmailer or performing compulsions
in OCD) some intolerable harm will
result. As we all know from our
media studies, the blackmailer is
never content with just this one
payoff, but returns again and again
with further demands. The only way
ever to achieve freedom from a
blackmailer is to announce, “Do
your worst. I’m not paying you any
more. I’ll take my chances.”
Similarly, the day the patient can
respond by refusing to perform compulsions and thereby take the risk
about what might happen, is the day
they begin to experience some freedom from the tyranny of obsessions
and compulsions.
So the essence of ERP is to resist
the urge to neutralise by performing overt or covert compulsions.
This can be done in a hierarchical
way beginning with the least anxiety-provoking obsessions, but to be
effective the patient must cognitively
confront the resulting fears and anxiety, and not use distraction or
covert compulsions (eg, mental reassurance) to reduce the anxiety. See
Andrews et al. for a detailed illustra35
tion of ERP.
OCD is a common illness
that results in significant distress and impairment and is
associated with increased
suicidal ideation and
attempts. It puts great stress
on relationships, so it is
important to include carers
in treatment wherever possible.
Serotonergic antidepressants and CBT offer potentially effective treatments,
but recovery rates remain
disappointing.
Given that OCD is likely
to be a lifelong condition,
perseverance and an optimistic, well-planned, evidence-based approach to
treatment trials on the part
of the clinician should eventually be beneficial.
GP’s contribution
Case study
DR MICHELLE CROCKETT
Kingswood, NSW
30
SARAH, 32, had been a
patient for some years. She
had always been quite anxious. She had a supportive
husband and two young children. She presented with quite
severe hand dermatitis.
On close questioning it was
apparent that she was
obsessed with cleanliness and
was concerned about contamination. This was triggered by
a visit to the accident and
emergency department when
one of the children was ill.
She became fearful of anything coloured red, as she was
afraid that it was blood,
which would be the source of
contamination.
She had disposed of all of
the items in the house that
were red, such as articles of
| Australian Doctor | 9 October 2009
clothing. If she saw someone
with red nail polish she would
be fearful that it was blood.
Her husband was becoming
frustrated by her irrational
fear and constant need for
reassurance.
Initial treatment included
referral to a psychologist,
who treated her with a cognitive approach. Her symptoms
only improved a little, and
sertraline was added. The
dose was gradually increased
to 200mg/day, which gave
good control of her symptoms.
She suffered a relapse about
two years later when her
mother was admitted to hospital. She attended a different
psychologist, who used ERP,
which was more successful at
controlling her symptoms.
She has been able to reduce
the sertraline to 100mg/day
but has been unable to wean
off it. Each time the medication is stopped her symptoms
recur. She has been taking sertraline for about 10 years
now.
Questions for the author
Should regular attempts to
wean the medication be
made?
I am not aware of any general contraindication to
taking sertraline in the long
term.
Sarah is fearful of her OCD
recurring (if medication is
stopped). Are there any other
strategies that may reduce the
risk of this?
Current thinking is that
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OCD cannot be ‘cured’.
Therefore, without good
control strategies (such as
sertraline and/or CBT) it is
highly likely that symptoms
would recur, as has been the
case with this patient.
If Sarah did wish once
again to try stopping her sertraline, it would be important to review her application of ERP. Many patients
stop short of confronting all
their obsessional fears or
retain some safety behaviours when there has been
enough functional or symptomatic improvement that
they seem to have reached
their own balance point,
where pushing ERP further
does not seem worth the
effort and anxiety involved.
cont’d page 32
References
Available on request from
julian.mcallan
@reedbusiness.com.au
Online resources
• Clinical Research Unit for
Anxiety and Depression:
www.crufad.org
• Anxiety Recovery Centre
Victoria:
www.arcvic.com.au
• HealthInsite. Obsessive
Compulsive Disorder:
www.healthinsite.gov.au/
topics/Obsessive_
Compulsive_Disorder
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HOW TO TREAT Obsessive–compulsive disorder
from page 30
My first step if Sarah
wished to have another try
at stopping the sertraline
would therefore be to
reassess how thoroughly and
consistently she is using ERP.
General questions for
the author
Can you explain thought–
action fusion a bit further?
Most people are able to
view thoughts as purely
mental phenomena, with no
direct power to influence
the outside world. Simply
thinking a thing doesn’t
make it happen. To turn an
idea into reality requires
action.
This may be a good thing
when we wish harm to
someone in the heat of
anger, and a bad thing when
we would like to win Lotto
or ensure that the weather
is fine for our wedding day,
but nevertheless, that is reality.
Some people, however,
overvalue the importance of
a thought. The individual
with OCD, usually without
being aware of it, may
believe that simply having a
certain thought may result
in some action or event in
the world.
For example, they might
believe that if they worry
How to Treat Quiz
about a loved one having an
accident they may make this
event more likely to happen.
(Where the fusion is between
thinking and events occurring, the phenomenon is
sometimes referred to as
‘thought–event fusion’.)
An even more distressing
version involves the perceived
likelihood that an individual
will act on thoughts. This is
seen commonly with obsessions that are considered
morally repugnant, such as
obsessions with a sexual or
violent theme.
For example, an individual
may experience the thought
that they could push a fellow
passenger in front of an
oncoming train (or even have
an image of themself doing
it).
The individual is aware
that this is an unusual
thought to have. They may
then reason to themselves
that the thought must have
occurred because of some
real propensity to act in this
violent way.
So, the true sequence is:
Thought, then fear of violent behaviour.
But the individual fears
that the following is true:
Violent tendency, then
thought of violent behaviour.
In other words, they are
creating a much stronger link
between thought and action
than really exists, and this is
referred to as thought–action
fusion.
If someone has OCD with
poor insight, what strategies
are useful to improve compliance with therapy?
One approach that may be
helpful is to focus on the distress and disability that is
resulting. Without having to
engage in disputing the rationality of the beliefs, both therapist and patient can agree that
the patient’s experiences are
creating problems for them.
It is unlikely that the
patient will engage in ERP,
but they may agree to some
behavioural changes (eg, to
stop asking for reassurance
from family members or
insisting that others comply
with their compulsions, to reengage in at least some activities they have been avoiding),
which might improve relationships and reduce distress.
Pharmacotherapy is likely to
play a greater role in such
cases.
Are most people with OCD
living ‘functional lives’?
Probably not. Few studies
have approached the question this way, tending to
instead report average
scores for various measures
of disability. However, Hollander reported on a survey
by the Obsessive Compulsive Foundation in the US
in which only 12% of
respondents reported themselves as being without ‘significant interference’ with
social and occupational
functioning. 1 Bobes et al.
reported that levels of social
and role performance, sense
of vitality, and overall
mental health were equivalent to those found in schizophrenia in one study.2
References
1. Hollander, E. Obsessivecompulsive disorder: the
hidden epidemic. Journal of
Clinical Psychiatry 1997;
58[Suppl]:3-6.
2. Bobes J, et al. Quality of life
and disability in patients with
obsessive-compulsive disorder.
European Psychiatry: The
Journal of the Association of
European Psychiatrists 2001;
16:239-45.
INSTRUCTIONS
Complete this quiz online and fill in the GP evaluation form to earn 2 CPD or PDP points. We no longer accept quizzes
by post or fax.
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer.
Obsessive–compulsive disorder
— 9 October 2009
1. Which TWO statements are correct?
a) The prevalence of obsessive–compulsive
disorder (OCD) in the community is about
0.2%
b) OCD is slightly more common in males
c) OCD commonly has an onset in childhood
d) Fifty per cent of adults with OCD report that
they had developed the condition by the
age of 19
2. Which TWO statements are correct?
a) There is no evidence of a heritable
component in OCD
b) OCD occurs at greater than community
rates in individuals with tic disorders
c) Hyperactivity of the anterior cingulate
cortex, caudate nucleus and orbitofrontal
cortex has been clearly demonstrated to be
causal of OCD
d) Patients who have violent obsessions as
part of their OCD fear they may carry out
violent acts, but there is no evidence they
are likely to do so
3. Which TWO statements are correct?
a) In OCD the obsessional thoughts are
experienced as uncontrollable, intrusive and
unwanted
b) Fears of contamination and about harm
occurring to self or others, and cleaning and
checking compulsions are the most
common symptoms
c) There is a purely obsessional form of OCD
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that is associated with a poorer outcome
d) Patients with OCD consistently have good
insight into their condition
4. Which TWO statements are correct?
a) In OCD there is considerable comorbidity
with major depression and with other
anxiety disorders
b) Alcohol misuse in people with OCD occurs
at higher than community rates
c) While OCD may be distressing for patients,
it results in very little disability or impairment
d) Unless comorbid with depression, OCD is
not associated with an increased suicide
risk
5. Which THREE statements are correct?
a) In patients with suspected OCD, a key
differential diagnosis to exclude is psychosis
b) It is important to determine whether the
OCD is primary or secondary to another
psychiatric disorder
c) In general, outcome is poorer in those with
early onset of symptoms
d) Most patients with OCD can achieve full
remission of symptoms
6. Which TWO statements about
cognitive behaviour therapy for OCD are
correct?
a) Therapists must be skilled in the technique
of exposure and response prevention (ERP)
for it to be effective
b) Refusal and dropout rates with ERP are very
low
c) CBT/ERP approaches appear to result in
fairly good maintenance of treatment gains
d) There is not likely to be any improvement
over time after ERP
7. Which TWO statements about
antidepressant pharmacotherapy for OCD
are correct?
a) Antidepressants may have an effect in OCD
independent of whether there is a comorbid
depressive disorder
b) Clomipramine is the recommended first-line
pharmacotherapy for OCD
c) There does not appear to be any difference
in efficacy for OCD between individual
SSRIs
d) Washing/cleaning compulsions definitely
respond better to SSRIs than to ERP
8. Which TWO statements about
antidepressant pharmacotherapy for OCD
are correct?
a) Patients with OCD being treated with
antidepressant therapy should be started on
a low dose
b) If a patient with OCD has shown no
response to the antidepressant after two
weeks, the dose should be increased
c) It may take 12 weeks or more to see a
response to pharmacotherapy for OCD
d) Naturalistic follow-up of patients with OCD
showed no improvement in response to
pharmacotherapy after the first year of
treatment
9. Which TWO statements are
correct?
a) Benzodiazepines have been found to be
beneficial for OCD
b) There is no evidence that antipsychotic
monotherapy is of benefit in OCD
c) The combination of CBT/ERP and
pharmacotherapy has been found to be
superior to CBT/ERP alone in children with
OCD but not adults with OCD
d) Carers should be involved in psychoeducation about OCD and what the
treatment involves
10. Which THREE statements about failure
to respond to therapy for OCD are
correct?
a) If the patient fails to respond to first-line
treatment, review by a psychiatrist should
be considered
b) If a patient has failed to respond to one
SSRI, there is no point in trialling another
SSRI
c) If monotherapy with CBT/ERP or
pharmacotherapy is ineffective, it is
recommended to add the other treatment
d) Addition of an antipsychotic medication
may be useful in patients with poor insight
or a comorbid tic disorder
CPD QUIZ UPDATE
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can complete this online along with the quiz at www.australiandoctor.com.au. Because this is a requirement, we are no longer able to accept the quiz by post
or fax. However, we have included the quiz questions here for those who like to prepare the answers before completing the quiz online.
HOW TO TREAT Editor: Dr Wendy Morgan
Co-ordinator: Julian McAllan
Quiz: Dr Wendy Morgan
NEXT WEEK The next How to Treat discusses early pregnancy bleeding, which affects up to 40% of pregnant women. This an extremely common reason for presentation to general practice and
emergency services. The author is Dr Kristy Milward, sessional obstetric and gynaecological sonologist, ultrasound department, King Edward Memorial Hospital, Subiaco, WA.
32
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