Obsessive Compulsive Disorder in Adults

There are many different kinds of obsessions and compulsions.  Some of the more common ones are:

• Fears of dirt, germs, or contamination, often associated with compulsive washing or cleaning.
• Fears of causing harm to self or others, often associated with compulsive checking.
• Excessive concern about order and symmetry, often associated with compulsive arranging or ordering.
• Unwanted, frightening, or repugnant thoughts or mental images, often associated with compulsive mental rituals or repeating behaviors.

OCD is characterized by abnormalities of brain function which are thought to contribute to symptoms.  In particular, evidence points to a hyperactive loop extending from the frontal cortex to the basal ganglia, which affects inhibition of thoughts and behaviors, modulation of emotion, and other aspects of the disorder.  In addition, compulsive behavior and avoidance of feared situations are thought to contribute to the persistence of obsessive fears.  The disorder has a genetic component, although having a genetic predisposition to OCD does not necessarily mean that someone will develop OCD.

First Line Treatments

• Cognitive-behavioral therapy consists of gradually exposing the person to feared objects, activities, or thoughts, while simultaneously refraining from compulsive behavior.
• Antidepressant medications, which are thought to help by improving the amount of serotonin in the brain. Specific first-line medications for OCD include:
• Paroxetine
• Fluoxetine
• Fluvoxamine
• Sertraline
• Clomipramine

For more information about drug prescribing in OCD, click here.

Second Line Treatments

In cases of nonresponse to first-line treatment, alternative treatments with reasonable evidence of efficacy include:

• Antidepressant medications such as citalopram, venlafaxine, or mirtazapine.

• Alternative psychotherapeutic strategies such as cognitive therapy or acceptance and commitment therapy.

• Augmentation of SRI medication with an atypical antipsychotic such as risperidone or aripiprazole.

Third Line Treatments

When patients do not respond adequately to the first- and second-line treatments described above, other strategies might include:

• Alternative medications such as memantine or quetiapine.
• Surgical procedures such as deep brain stimulation, capsulotomy, or cingulotomy.

Additional Treatments to Consider

Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments described above, might be considered.

• Aerobic exercise.
• Repetitive transcranial magnetic stimulation.
• D-cycloserine augmentation of CBT.
• Herbal therapies including milk thistle and valerian root.
• Yoga or meditation strategies.