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Obsessive-compulsive disorder.
Last reviewed: 12.07.2025
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Obsessive-compulsive disorder is characterized by disturbing thoughts, images, or urges (obsessions) and urges (compulsions) to do something to relieve this anxiety. The causes of development are unknown. Diagnosis is based on anamnestic information. Treatment consists of psychotherapy, drug therapy, or, in severe cases, a combination of both. Obsessive-compulsive disorder occurs with approximately equal frequency in men and women, it is observed in about 2% of the population.
According to DSM-IV, obsessive-compulsive disorder is a type of anxiety disorder characterized by obsessive repetition of unwanted, unpleasant thoughts, images, or impulses (obsessions) and/or repetitive actions that a person performs compulsively and according to certain rules (compulsions). The presence of both obsessions and compulsions is not necessary for a diagnosis. However, in most patients they are combined, and only in a small number of cases are they observed separately from each other. The patient usually tries to actively suppress or neutralize obsessions, convincing himself of their irrationality, avoiding provoking situations (if any), or implementing compulsions. In most cases, compulsions are performed to relieve anxiety, but often they only increase anxiety, since they require significant expenditure of energy and time.
[ Pathogenesis of obsessive-compulsive disorder
Conditions resembling obsessive-compulsive disorder were first described over 300 years ago. At each stage in the development of ideas about obsessive-compulsive disorder, they have been modified by the intellectual and scientific climate of the era. Early theories explained conditions similar to OCD as perverted religious experiences. English authors of the 18th and late 17th centuries attributed obsessive blasphemous images to the influence of Satan. Even today, some patients with obsessions of conscientiousness still believe themselves to be possessed by the devil and try to exorcise the evil spirit. French authors of the 19th century, discussing obsessions, emphasized the central role of doubt and indecision. In 1837, the French physician Esquirol used the term folie du doute (disease of doubt) to describe this group of symptoms. Later, French authors, including Pierre Janet in 1902, linked the development of obsessive states with loss of will and low mental energy.
For much of the 20th century, psychoanalytic theories of obsessive-compulsive disorder dominated. According to them, obsessions and compulsions are defense mechanisms that represent maladaptive attempts to cope with unresolved unconscious conflicts that originate in the early stages of psychosexual development. Psychoanalysis offers an elegant metaphor for mental activity, but it is not based on evidence from brain research. These theories have lost their appeal because they have not led to the development of effective and reproducible treatments. Psychoanalysts have focused on the symbolic meaning of obsessions and compulsions, but have not paid sufficient attention to the form of symptoms - repeated, unpleasant, meaningless, violent thoughts and actions. The content of symptoms, however, is more likely to indicate what is most important to a given patient or what frightens him or her, but it does not explain why a particular patient developed obsessive-compulsive disorder. On the other hand, the content of some symptoms, such as those associated with purging or hoarding, can be explained by the activation of stereotypical action programs (e.g. immature complex behavioral acts) implemented by those areas of the brain that are involved in OCD.
Symptoms of Obsessive Compulsive Disorder
The dominant theme of obsessions may be harm, risk, contamination, doubt, damage, or aggression. Typically, patients with this disorder feel compelled to engage in repetitive, goal-directed ritual behaviors to reduce their obsessions. For example, washing counteracts fear of contamination, checking counteracts doubt, and hoarding counteracts thoughts of damage. Patients may avoid people who are aggressive toward their fear-driven behavior. Most rituals, such as hand washing or checking locks, are obvious, but some, such as compulsive counting, are less obvious.
To some extent, patients with obsessive-compulsive disorder understand that their obsessions are unfounded and that their behavior aimed at reducing anxiety is excessive and inappropriate. The preservation of criticism, even to an imperfect degree, allows us to differentiate obsessive-compulsive disorder from psychotic disorders in which contact with reality is lost.
Because of embarrassment or stigma, patients with obsessive-compulsive disorder often hide their obsessions and rituals, which they may engage in for up to several hours each day. Relationships are often disrupted, and school performance and work performance may decline. Depression is often a secondary symptom.
Diagnosis of obsessive-compulsive disorder
Clinical diagnosis is based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Exposure therapy and ritual prevention therapy are effective; their main element is being in provocative situations or with people who initiate the patient's obsessive thoughts and actions. After exposure, the patient refrains from performing rituals, allowing anxiety to increase, and then decrease as a result of habituation. Recovery occurs over several years, especially in patients who use this approach and after the main course of treatment. However, not all patients experience complete recovery.
Obsessive Compulsive Disorder - Diagnosis
Treatment of obsessive-compulsive disorder
Most experts believe that the best effect is achieved with a combination of psychotherapy and drug therapy, especially in severe cases. SSRIs and clomipramine (a tricyclic antidepressant with a pronounced serotonergic effect) are effective. For most SSRIs, low doses (e.g., fluoxetine 20 mg/day once, fluvoxamine 100 mg/day once, sertraline 50 mg/day once, paroxetine 40 mg/day once) are usually as effective as high doses.
In the past, obsessive-compulsive disorder was considered a treatment-resistant condition. Traditional psychotherapy methods based on psychoanalytic principles were rarely successful. The results of using various medications were also disappointing. However, in the 1980s, the situation changed due to the emergence of new methods of behavioral therapy and pharmacotherapy, the effectiveness of which was confirmed in large-scale studies. The most effective form of behavioral therapy for obsessive-compulsive disorder is the method of exposure and response prevention. Exposure involves placing the patient in a situation that provokes the discomfort associated with obsessions. At the same time, patients are given instructions on how to resist performing compulsive rituals - response prevention.
The main treatments for obsessive-compulsive disorder are currently clomipramine or selective serotonin reuptake inhibitors (SSRIs). Clomipramine, being a tricyclic, is a serotonin reuptake inhibitor.
The modern era of pharmacotherapy for obsessive-compulsive disorder began in the second half of the 1960s with the observation that clomipramine, but not other tricyclic antidepressants (such as imipramine), was effective in obsessive-compulsive disorder. Clomipramine, a 3-chlorine analogue of the tricyclic imipramine, is a 100-fold stronger inhibitor of serotonin reuptake than the parent substance. These distinctive clinical and pharmacological properties of clomipramine have led to the hypothesis that serotonin plays a role in the pathogenesis of obsessive-compulsive disorder. The superiority of clomipramine over placebo and nonserotonergic antidepressants has been confirmed by numerous double-blind studies. The effect of clomipramine in obsessive-compulsive disorder has been studied most thoroughly. Clomipramine was the first drug to receive FDA approval in the United States for obsessive-compulsive disorder.