research paper on ocd

Information

Author Services

Initiatives

You are accessing a machine-readable page. In order to be human-readable, please install an RSS reader.

All articles published by MDPI are made immediately available worldwide under an open access license. No special permission is required to reuse all or part of the article published by MDPI, including figures and tables. For articles published under an open access Creative Common CC BY license, any part of the article may be reused without permission provided that the original article is clearly cited. For more information, please refer to https://www.mdpi.com/openaccess .

Feature papers represent the most advanced research with significant potential for high impact in the field. A Feature Paper should be a substantial original Article that involves several techniques or approaches, provides an outlook for future research directions and describes possible research applications.

Feature papers are submitted upon individual invitation or recommendation by the scientific editors and must receive positive feedback from the reviewers.

Editor’s Choice articles are based on recommendations by the scientific editors of MDPI journals from around the world. Editors select a small number of articles recently published in the journal that they believe will be particularly interesting to readers, or important in the respective research area. The aim is to provide a snapshot of some of the most exciting work published in the various research areas of the journal.

Original Submission Date Received: .

Active Journals
Find a Journal
Proceedings Series
For Authors
For Reviewers
For Editors
For Librarians
For Publishers
For Societies
For Conference Organizers
Open Access Policy
Institutional Open Access Program
Special Issues Guidelines
Editorial Process
Research and Publication Ethics
Article Processing Charges
Testimonials
Preprints.org
SciProfiles
Encyclopedia

Article Menu

Subscribe SciFeed
Recommended Articles
PubMed/Medline
Google Scholar
on Google Scholar
Table of Contents

Find support for a specific problem in the support section of our website.

Please let us know what you think of our products and services.

Visit our dedicated information section to learn more about MDPI.

JSmol Viewer

Cognitive–behavioral treatment of obsessive–compulsive disorder: the results of a naturalistic outcomes study.

1. Introduction

2. materials and methods, 2.1. participants, 2.2. procedure, 2.3. measure, 2.4. treatment, 3.1. repeated-measures anova, 3.2. wilcoxon signed-rank test, 3.3. reliable change index and clinical significance, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

Phase	Contents of the Treatment	Mean Number of Psychotherapy Sessions
	Reconstruction and sharing of the functioning scheme of patient’s disorder and specific symptomatology	4
	Modulate beliefs that support the negative or threat evaluation of the critical event and that sustain the motivation: cognitive restructuring techniques	5
	Accepting the risk (threat) to reduce investments in prevention: cognitive techniques to facilitate willingness to accept feared stimuli exposure and the progressive renunciation of compulsions	8
	Exposure and response prevention (ERP)	10
	Intervention to reduce OCD historical vulnerability	5

After analyzing the advantages and disadvantages of the obsessive activity, the therapist proposes that patients alternately sit in each of the two chairs.
When sitting in the first chair, patients list all of the costs connected to the threat and, therefore, the benefits of prudence.
When sitting in the second chair, patients must instead list all the costs of prevention and the benefits of an eventual reduction in the search for absolute certainty.
At this point, the objective is to render explicit the internal dialectic by asking that the two positions be discussed constructively for the purpose of highlighting the costs of the two operations, namely ‘preventing’ and ‘accepting’ a threat of being responsible for future harm (or compromising the goal of being morally perfect). In this way, patients can, on the one hand, simultaneously and more accurately represent the benefits of acceptance and the costs of investment and, on the other hand, they prepare themselves to consider both sets of costs and benefits together.
Kessler, R.C.; Chiu, W.T.; Demler, O.; Walters, E.E. Prevalence, Severity, and Comorbidity of 12-Month DSM-IV Disorders in the National Comorbidity Survey Replication. Arch. Gen. Psychiatry 2005 , 62 , 617–627. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
Ruscio, A.M.; Stein, D.; Chiu, W.T.; Kessler, R.C. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol. Psychiatry 2010 , 15 , 53–63. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
Foa, E.B.; Franklin, M.E. Obsessive compulsive disorder. In Clinical Handbook of Psychological Disorders ; Barlow, D.H., Ed.; Guilford Press: New York, NY, USA, 2001. [ Google Scholar ]
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®) ; American Psychiatric Pub: Washington, DC, USA, 2013. [ Google Scholar ]
Hollander, E.; Stein, D.J.; Fineberg, N.A.; Marteau, F.; Legault, M. Quality of Life Outcomes in Patients With Obsessive-Compulsive Disorder. J. Clin. Psychiatry 2010 , 71 , 784–792. [ Google Scholar ] [ CrossRef ] [ PubMed ]
Hollander, E.; Doernberg, E.; Shavitt, R.; Waterman, R.J.; Soreni, N.; Veltman, D.J.; Sahakian, B.; Fineberg, N.A. The cost and impact of compulsivity: A research perspective. Eur. Neuropsychopharmacol. 2016 , 26 , 800–809. [ Google Scholar ] [ CrossRef ] [ PubMed ]
Leonard, H.L.; Swedo, S.E.; Lenane, M.C.; Rettew, D.C.; Hamburger, S.D.; Bartko, J.J.; Rapoport, J.L. A 2- to 7-Year Follow-up Study of 54 Obsessive-Compulsive Children and Adolescents. Arch. Gen. Psychiatry 1993 , 50 , 429–439. [ Google Scholar ] [ CrossRef ] [ PubMed ]
Skoog, G.; Skoog, I. A 40-Year Follow-up of Patients With Obsessive-compulsive Disorder. Arch. Gen. Psychiatry 1999 , 56 , 121–127. [ Google Scholar ] [ CrossRef ] [ Green Version ]
Stewart, S.E.; Geller, D.A.; Jenike, M.; Pauls, D.; Shaw, D.; Mullin, B.; Faraone, S.V. Long-term outcome of pediatric obsessive-compulsive disorder: A meta-analysis and qualitative review of the literature. Acta Psychiatr. Scand. 2004 , 110 , 4–13. [ Google Scholar ] [ CrossRef ]
Fineberg, N.A.; Dell’Osso, B.; Albert, U.; Maina, G.; Geller, D.; Carmi, L.; Sireau, N.; Walitza, S.; Grassi, G.; Pallanti, S.; et al. Early intervention for obsessive compulsive disorder: An expert consensus statement. Eur. Neuropsychopharmacol. 2019 , 29 , 549–565. [ Google Scholar ] [ CrossRef ] [ Green Version ]
Franklin, M.E.; Foa, E.B. Treatment of Obsessive-Compulsive Disorder. Annu. Rev. Clin. Psychol. 2011 , 7 , 229–243. [ Google Scholar ] [ CrossRef ]
National Institute for Health and Clinical Excellence. Obsessive Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder ; Clinical Guideline No. 31; National Institute for Health and Clinical Excellence: London, UK, 2005. [ Google Scholar ]
Kozak, M.J.; Foa, E.B.; Clark, D.A. Mastery of Obsessive-Compulsive Disorder: A Cognitive-Behavioral Approach Therapist Guide. J. Cogn. Psychother. 2001 , 15 , 273–276. [ Google Scholar ] [ CrossRef ]
Foa, E.B. Cognitive behavioral therapy of obsessive-compulsive disorder. Dialogues Clin. Neurosci. 2010 , 12 , 199–207. [ Google Scholar ] [ CrossRef ] [ PubMed ]
Olatunji, B.O.; Davis, M.L.; Powers, M.B.; Smits, J.A. Cognitive-behavioral therapy for obsessive-compulsive disorder: A meta-analysis of treatment outcome and moderators. J. Psychiatr. Res. 2013 , 47 , 33–41. [ Google Scholar ] [ CrossRef ] [ PubMed ]
Öst, L.-G.; Havnen, A.; Hansen, B.; Kvale, G. Cognitive behavioral treatments of obsessive–compulsive disorder. A systematic review and meta-analysis of studies published 1993–2014. Clin. Psychol. Rev. 2015 , 40 , 156–169. [ Google Scholar ] [ CrossRef ] [ PubMed ]
Rosa-Alcazar, A.I.; Sánchez-Meca, J.; Gómez-Conesa, A.; Marín-Martínez, F. Psychological treatment of obsessive–compulsive disorder: A meta-analysis. Clin. Psychol. Rev. 2008 , 28 , 1310–1325. [ Google Scholar ] [ CrossRef ]
Hunsley, J.; Elliott, K.; Therrien, Z. The efficacy and effectiveness of psychological treatments for mood, anxiety, and related disorders. Can. Psychol. 2014 , 55 , 161–176. [ Google Scholar ] [ CrossRef ]
Franklin, M.E.; Foa, E.B. Cognitive-behavioral treatments for obsessive compulsive disorder. In A Guide to Treatments That Work ; Nathan, P.E., Gorman, J.M., Eds.; Oxford University Press: Oxford, UK, 1998; pp. 339–357. [ Google Scholar ]
Emmelkamp, P.M.; Foa, E.B. (Eds.) Failures are a change. In Failures in Behavior Therapy ; Wiley: New York, NY, USA, 1983; pp. 1–9. [ Google Scholar ]
Kozak, M.; Liebowitz, M.; Foa, E.B. Cognitive Behavior therapy and pharmacotherapy for obsessive–compulsive disorder: The NIMH-Sponsored collaborative study. In Obsessive–Compulsive Disorder ; Goodman, W.K., Ed.; Erlbaum: Mahwah, NJ, USA, 2000; pp. 501–530. [ Google Scholar ]
Abramowitz, J.S. The Psychological Treatment of Obsessive—Compulsive Disorder. Can. J. Psychiatry 2006 , 51 , 407–416. [ Google Scholar ] [ CrossRef ] [ Green Version ]
Skapinakis, P.; Caldwell, D.; Hollingworth, W.; Bryden, P.; Fineberg, N.; Salkovskis, P.; Welton, N.; Baxter, H.; Kessler, D.; Churchill, R.; et al. A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive–compulsive disorder in children/adolescents and adults. Health Technol. Assess. 2016 , 20 , 1–392. [ Google Scholar ] [ CrossRef ] [ Green Version ]
Reid, J.E.; Laws, K.R.; Drummond, L.; Vismara, M.; Grancini, B.; Mpavaenda, D.; Fineberg, N.A. Cognitive behavioural therapy with exposure and response prevention in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of randomised controlled trials. Compr. Psychiatry 2021 , 106 , 152223. [ Google Scholar ] [ CrossRef ]
Cottraux, J.; Note, I.; Yao, S.N.; Lafont, S.; Note, B.; Mollard, E.; Bouvard, M.; Sauteraud, A.; Bourgeois, M.; Dartigues, J.-F. A Randomized Controlled Trial of Cognitive Therapy versus Intensive Behavior Therapy in Obsessive Compulsive Disorder. Psychother. Psychosom. 2001 , 70 , 288–297. [ Google Scholar ] [ CrossRef ]
Kushner, M.G.; Kim, S.W.; Donahue, C.; Thuras, P.; Adson, D.; Kotlyar, M.; McCabe, J.; Peterson, J.; Foa, E.B. D-Cycloserine Augmented Exposure Therapy for Obsessive-Compulsive Disorder. Biol. Psychiatry 2007 , 62 , 835–838. [ Google Scholar ] [ CrossRef ]
Leeuwerik, T.; Cavanagh, K.; Strauss, C. Patient adherence to cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. J. Anxiety Disord. 2019 , 68 , 102135. [ Google Scholar ] [ CrossRef ] [ PubMed ]
Ong, C.W.; Clyde, J.W.; Bluett, E.J.; Levin, M.E.; Twohig, M.P. Dropout rates in exposure with response prevention for obsessive-compulsive disorder: What do the data really say? J. Anxiety Disord. 2016 , 40 , 8–17. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
Swift, J.K.; Greenberg, R.P. A treatment by disorder meta-analysis of dropout from psychotherapy. J. Psychother. Integr. 2014 , 24 , 193–207. [ Google Scholar ] [ CrossRef ] [ Green Version ]
Mancini, F.; Barcaccia, B.; Capo, R.; Gangemi, A.; Gragnani, A.; Perdighe, C.; Rainone, A.; Romano, G. Trattamento cognitivo-comportamentale nel Disturbo Ossessivo-Compulsivo:risultati di uno studio di esito naturalistico in aperto con follow-up a 6,12 e 24 mesi. Riv Psichiatr. 2006 , 41 , 99–106. [ Google Scholar ] [ CrossRef ]
Mancini, F.; Gangemi, A. Cognitive Processes in Obsessive-Compulsive Disorder. In The Obsessive Mind: Understanding and Treating Obsessive-Compulsive Disorder ; Mancini, F., Ed.; Routledge: New York, NY, USA, 2019; pp. 73–92. [ Google Scholar ]
Zaccari, V.; Gragnani, A.; Pellegrini, V.; Caiazzo, T.; D’Arienzo, M.C.; Magno, A.; Femia, G.; Mancini, F. An Observational Study of OCD Patients Treated With Cognitive Behavioral Therapy during the COVID-19 Pandemic. Front. Psychiatry 2021 , 12 , 1822. [ Google Scholar ] [ CrossRef ]
Jacobson, N.S.; Christensen, A. Studying the effectiveness of psychotherapy: How well can clinical trials do the job? Am. Psychol. 1996 , 51 , 1031–1039. [ Google Scholar ] [ CrossRef ]
Franklin, M.E.; Abramowitz, J.S.; Kozak, M.J.; Levitt, J.T.; Foa, E.B. Effectiveness of exposure and ritual prevention for obsessive-compulsive disorder: Randomized compared with nonrandomized samples. J. Consult. Clin. Psychol. 2000 , 68 , 594–602. [ Google Scholar ] [ CrossRef ]
Morris, S.B.; DeShon, R.P. Combining effect size estimates in meta-analysis with repeated measures and independent-groups designs. Psychol. Methods 2002 , 7 , 105–125. [ Google Scholar ] [ CrossRef ]
Stewart, R.E.; Chambless, D.L. Cognitive–behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. J. Consult. Clin. Psychol. 2009 , 77 , 595–606. [ Google Scholar ] [ CrossRef ] [ Green Version ]
Hans, E.; Hiller, W. A meta-analysis of nonrandomized effectiveness studies on outpatient cognitive behavioral therapy for adult anxiety disorders. Clin. Psychol. Rev. 2013 , 33 , 954–964. [ Google Scholar ] [ CrossRef ]
First, M.; Williams, J.; Karg, R.; Spitzer, R. Structured Clinical Interview for DSM-5 (SCID-5 for DSM-5) ; American Psychiatric Association: Arlington, VA, USA, 2017. [ Google Scholar ]
Goodman, W.K.; Price, L.H.; Rasmussen, S.A.; Mazure, C.; Fleischmann, R.L.; Hill, C.L.; Heninger, G.R.; Charney, D.S. The Yale-Brown Obsessive Compulsive Scale. I. Development, Use, and Reliability. Arch. Gen. Psychiatry 1989 , 46 , 1006–1011. [ Google Scholar ] [ CrossRef ] [ PubMed ]
Hénin, M. Yale–Brown Obsessive–Compulsive Scale, In Disturbo Ossessivo-Compulsivo. Questionari e Interviste per la Valutazione Clinica ; Sica, C., Ed.; Erickson: Trento, OH, USA, 2012. [ Google Scholar ]
Melli, G.; Avallone, E.; Moulding, R.; Pinto, A.; Micheli, E.; Carraresi, C. Validation of the Italian version of the Yale–Brown Obsessive Compulsive Scale–Second Edition (Y-BOCS-II) in a clinical sample. Compr. Psychiatry 2015 , 60 , 86–92. [ Google Scholar ] [ CrossRef ] [ PubMed ]
Ellis, A. Reason and Emotion in Psychotherapy ; Lyle Stuart: New York, NY, USA, 1962. [ Google Scholar ]
Wells, A. Cognitive Therapy of Anxiety Disorders: A Practice Manual and Conceptual Guide ; John Wiley and Sons: Honoken, NJ, USA, 1997; Volume 12. [ Google Scholar ] [ CrossRef ]
Van Oppen, P.; Arntz, A. Cognitive Therapy for Obsessive-compulsive disorder. Behav. Res. Ther. 1994 , 32 , 79–87. [ Google Scholar ] [ CrossRef ]
Vos, S.P.F.; Huibers, M.J.H.; Arntz, A. Experimental investigation of targeting responsibility versus danger in cognitive therapy of obsessive-compulsive disorder. Depress. Anxiety 2012 , 29 , 629–637. [ Google Scholar ] [ CrossRef ]
Leahy, R.L. Cognitive Therapy Techniques: A Practitioner’s Guide ; Guilford Press: New York, NY, USA, 2003. [ Google Scholar ]
Abramowitz, J.S.; Whiteside, S.; Kalsy, S.A.; Tolin, D.F. Thought control strategies in obsessive-compulsive dis-order: A replication and extension’. Behav. Res. Ther. 2003 , 41 , 529–540. [ Google Scholar ] [ CrossRef ]
Rachman, S.; de Silva, P. Abnormal and normal obsessions. Behav. Res. Ther. 1978 , 16 , 233–248. [ Google Scholar ] [ CrossRef ]
Perdighe, C.; Gragnani, A.; Rainone, A. Accepting risk: Cognitive Techniques. In The Obsessive Mind: Understanding and Treating Obsessive-Compulsive Disorder ; Mancini, F., Ed.; Routledge: New York, NY, USA, 2019; pp. 221–249. [ Google Scholar ]
Perdighe, C.; Mancini, F. Dall’investimento alla rinuncia: Favorire l’accettazione in psicoterapia. Cogn. Clin. 2012 , 9 , 116–134. [ Google Scholar ]
Gangemi, A.; Tenore, K.; Mancini, F. Two Reasoning Strategies in Patients With Psychological Illnesses. Front. Psychol. 2019 , 10 , 2335. [ Google Scholar ] [ CrossRef ]
Salkovskis, P.; Westbrook, D.; Davis, J.; Jeavons, A.; Gledhill, A. Effects of neutralizing on intrusive thoughts: An experiment investigating the etiology of obsessive-compulsive disorder. Behav. Res. Ther. 1997 , 35 , 211–219. [ Google Scholar ] [ CrossRef ]
Salkovskis, P.M.; Forrester, E.; Richards, C. Cognitive–behavioural approach to understanding obsessional thinking. Br. J. Psychiatry 1998 , 173 , 53–63. [ Google Scholar ] [ CrossRef ]
Gragnani, A.; Buonanno, C.; Saettoni, M. Techniques of cognitive Restructuring. In The Obsessive Mind: Understanding and Treating Obsessive-Compulsive Disorder ; Mancini, F., Ed.; Routledge: New York, NY, USA, 2019. [ Google Scholar ]
Mancini, F.; Gragnani, A. L’esposizione con prevenzione della risposta come pratica dell’accettazione. Cognitivismo Clinico 2005 , 2 , 38–58. [ Google Scholar ]
Mancini, F.; Gragnani, A. Gli Homework Nel Disturbo Ossessivo-Compulsivo. In Homework: Un’antologia di Prescrizioni Terapeutiche ; Baldini, F., Ed.; McGraw-Hill: Milan, Italy, 2004; pp. 105–136. [ Google Scholar ]
Pugh, M. Cognitive Behavioural Chairwork: Distinctive Features ; Routledge: Oxon, UK, 2019. [ Google Scholar ]
Gragnani, A.; Toro, B.; De Luca, L.; Cavagnoli, M.; Mancini, F. L’efficacia delle tecniche cognitive nella riattribuzione della stima della probabilità. Psicoter. Cogn. Comport. 2003 , 9 , 91–108. [ Google Scholar ]
Foa, E.B.; Yadin, E.; Lichner, T.K. Exposure and Response (Ritual) Prevention for Obsessive Compulsive Disorder ; Oxford University Press: Oxford, UK, 2012. [ Google Scholar ] [ CrossRef ] [ Green Version ]
Luppino, O.I.; Pontillo, M. Exposure with Response Prevention as a Practice of Acceptance. In The Obsessive Mind: Understanding and Treating Obsessive-Compulsive Disorder ; Mancini, F., Ed.; Routledge: New York, NY, USA, 2019; pp. 250–274. [ Google Scholar ]
Mancini, F.; Gangemi, A. Fear of guilt from behaving irresponsibly in obsessive? compulsive disorder. J. Behav. Ther. Exp. Psychiatry 2004 , 35 , 109–120. [ Google Scholar ] [ CrossRef ]
Chiang, B.; Purdon, C.; Radomsky, A.S. Development and initial validation of the Fear of Guilt Scale for obsessive-compulsive disorder (OCD). J. Obs. Compuls. Relat. Disord. 2016 , 11 , 63–73. [ Google Scholar ] [ CrossRef ]
Salkovskis, P. Obsessional-compulsive problems: A cognitive-behavioural analysis. Behav. Res. Ther. 1985 , 23 , 571–583. [ Google Scholar ] [ CrossRef ]
Rachman, S. Obsessions, responsibility and guilt. Behav. Res. Ther. 1993 , 31 , 149–154. [ Google Scholar ] [ CrossRef ]
Rachman, S. A cognitive theory of compulsive checking. Behav. Res. Ther. 2002 , 40 , 625–639. [ Google Scholar ] [ CrossRef ]
Rachman, S. Fear of Contamination: Assessment and Treatment ; Oxford University Press Inc.: New York, NY, USA, 2006. [ Google Scholar ]
Salkovskis, P.M.; Forrester, E. Responsibility. In Cognitive Approaches to Obsessions and Compulsions ; Frost, R.O., Steketee, G., Eds.; Elsevier Science: Oxford, UK, 2002. [ Google Scholar ]
Mancini, F.; Gangemi, A. Fear of deontological guilt and fear of contamination in obsessive compulsive patient. Psicoter. Cogn. Comport. 2011 , 17 , 395–404. [ Google Scholar ]
Tenore, K.; Gragnani, A. Intervention on Historical Vulnerability. In The Obsessive Mind: Understanding and Treating Obsessive-Compulsive Disorder ; Mancini, F., Ed.; Routledge: New York, NY, USA, 2019; pp. 310–322. [ Google Scholar ]
Basile, B.; De Sanctis, B.; Fadda, S.; Luppino, O.I.; Perdighe, C.; Saliani, A.M.; Mancini, F. Early life experiences in ocd and other disorders: A retrospective observational study using imagery with rescripting. Clin. Neuropsychiatry 2018 , 15 , 299–305. [ Google Scholar ]
Luppino, O.I.; Tenore, K.; Mancini, F.; Basile, B. A Theoretical Integration of Schema Therapy and Cognitive Therapy in OCD Treatment: Goals and Beliefs of the Obsessive Mind (Part I). Psychology 2018 , 9 , 2261–2277. [ Google Scholar ] [ CrossRef ] [ Green Version ]
Tenore, K.; Basile, B.; Mancini, F.; Luppino, O.I.L. A theoretical integration of Schema Therapy and Cognitive Therapy in OCD treatment: Conceptualization and rationale (Part II). Psychology 2018 , 9 , 2278–2295. [ Google Scholar ] [ CrossRef ] [ Green Version ]
Veale, D.; Page, N.; Woodward, E.; Salkovskis, P. Imagery Rescripting for Obsessive Compulsive Disorder: A single case experimental design in 12 cases. J. Behav. Ther. Exp. Psychiatry 2015 , 49 , 230–236. [ Google Scholar ] [ CrossRef ] [ PubMed ] [ Green Version ]
Tenore, K.; Basile, B.; Cosentino, T.; De Sanctis, B.; Fadda, S.; Femia, G.; Gragnani, A.; Luppino, O.I.; Pellegrini, V.; Perdighe, C.; et al. Imagery Rescripting on Guilt-Inducing Memories in OCD: A Single Case Series Study. Front. Psychiatry 2020 , 11 , 543806. [ Google Scholar ] [ CrossRef ] [ PubMed ]
Gragnani, A.; Tenore, K. Preventing relapses and concluding therapy. In The Obsessive Mind: Understanding and Treating Obsessive-Compulsive Disorder ; Mancini, F., Ed.; Routledge: New York, NY, USA, 2019; pp. 180–200. [ Google Scholar ]
Lakens, D. Calculating and reporting effect sizes to facilitate cumulative science: A practical primer for t-tests and ANOVAs. Front. Psychol. 2013 , 4 , 863. [ Google Scholar ] [ CrossRef ] [ Green Version ]
Fritz, C.O.; Morris, P.E.; Richler, J.J. Effect size estimates: Current use, calculations, and interpretation. J. Exp. Psychol. Gen. 2012 , 141 , 2–18. [ Google Scholar ] [ CrossRef ] [ Green Version ]
Jacobson, N.S.; Truax, P. Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. J. Consult. Clin. Psychol. 1991 , 59 , 12–19. [ Google Scholar ] [ CrossRef ]
Lemon, J.; Lemon, M.J. Package ‘clinsig’. 2016. Available online: https://CRAN.R-project.org/package=clinsig (accessed on 29 December 2021).
Rachman, S. A cognitive theory of obsessions. Behav. Res. Ther. 1997 , 31 , 793–802. [ Google Scholar ] [ CrossRef ]
Mancini, F.; D’Olimpio, F.; D’Ercole, S. Responsibility attitude, obsession and compulsion: Further support in a non-clinical sample. Clin. Psychol. Psychother. 2001 , 8 , 274–281. [ Google Scholar ] [ CrossRef ]
Mancini, F. Il Disturbo Ossessivo-Compulsivo. In Il Manuale di Terapia Cognitiva ; Bollati Boringhieri: Torino, Italy, 2005. [ Google Scholar ]
Mancini, F.; Gangemi, A.; Perdighe, C.; Marini, C. Not just right experience: Is it influenced by feelings of guilt? J. Behav. Ther. Exp. Psychiatry 2008 , 39 , 162–176. [ Google Scholar ] [ CrossRef ]
Summerfeldt, L.J.; Kloosterman, P.H.; Antony, M.M.; Swinson, R.P. Examining an obsessive-compulsive core dimensions model: Structural validity of harm avoidance and incompleteness. J. Obs. Compuls. Relat. Disord. 2014 , 3 , 83–94. [ Google Scholar ] [ CrossRef ]
Zaccari, V.; Rogier, G.; Pulsinelli, D.; Mancini, F.; D’Olimpio, F. Explaining Interaction of Guilt and Obses-sive-Compulsive Symptoms In Not Just Right Experiences. Clin. Neuropsychiatry 2022 , 19 , 39–44. [ Google Scholar ] [ CrossRef ] [ PubMed ]
Hayes, S.C.; Strosahl, K.D.; Wilson, K.G. Acceptance and commitment therapy. In The Process and Practice of Mindful Change , 2nd ed.; The Guilford Press: New York, NY, USA, 2012. [ Google Scholar ]
Kabat-Zinn, J. Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness ; Dell Publishing: New York, NY, USA, 1990. [ Google Scholar ]
Barcaccia, B. Accepting Events: Topicality of Seneca’s Stoic Proposal. Ph.D. Thesis, Roma Tre University, Rome, Italy, 2007. (In Italian). [ Google Scholar ]
Barcaccia, B. Accepting Limitations of Life: Leading Our Patients through a Painful but Healing Path ; Invited Lecture Conducted from Ludwig-Maximilians-University, Munich Department Psychologie: Munich, Germany, 2008. [ Google Scholar ]
Mancini, F.; Carlo, E. La mente non accettante. Cogn. Clin. 2017 , 14 , 222–237. [ Google Scholar ]
Carlo, E.; Brasini, M.; Giacomantonio, M.; Mancini, F. Accettazione, Amor fati e Ordine naturale: Una prospettiva cognitivista. Cogn. Clin. 2021 , 18 , 67–86. [ Google Scholar ] [ CrossRef ]
Romano, G.; Trincas, R. Constructing a Diagrammatic Model for Understanding the Disorder. In The Obsessive Mind: Understanding and Treating Obsessive-Compulsive Disorder ; Mancini, F., Ed.; Routledge: New York, NY, USA, 2019; p. 173. [ Google Scholar ]

Click here to enlarge figure

Variables	Frequency	Percentage

Male	25	58.1
Female	18	41.9

Italian	42	97.7
Other	1	2.3

Yes	17	39.5
No	26	60.5

	32.70	8.91
	93.42	100.14


APD	2	4.7
BD-II	1	2.3
BIP 2	1	2.3
BN	1	2.3
BPD	3	7.0
BPD (Tr)	2	4.7
DEP	7	16.3
DPD (Tr)	3	7.0
IAD	1	2.3
NPD	1	2.3
NPD (Tr)	4	9.3
OCPD (Tr)	2	4.7
PAN	4	9.3
PPD	1	2.3
PPD (Tr)	1	2.3
SAD	1	2.3
NONE	8	18.6

BPD	1	2.3
DEP	2	4.7
DPD	1	2.3
NPD (Tr)	1	2.3
NPD and DEP	1	2.3
OCPD	2	4.7
PPD	1	2.3
PPD (Tr)	3	7.0
SAD	3	7.0
UPD	3	7.0
NONE	25	58.1


AS	2	4.7%
C and W	9	20.9%
CH	14	32.6%
U	17	39.5%
Washer	1	2.3%

C and W	5	11.6%
CH	10	23.3%
U	6	14.0%
None	22	51.2%

Measures	Time	Mean	SD	Median	IQR
Y–BOCS	t0	28.03	5.30	28.00	8
	t1	14.95	6.58	15.50	9
OBS	t0	14.65	2.45	14.50	4
	t1	8.13	3.84	8.50	5
COM	t0	13.38	3.50	14.00	4
	t1	6.83	3.79	7.00	5

Measures	Negative Ranks	Positive Ranks	Ties	Total	z	p
Y–BOCS	40	0	0	40	−5.51	<0.001
OBS	39	1	0	40	−5.49	<0.001
COM	39	0	1	40	−5.45	<0.001

MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

Gragnani, A.; Zaccari, V.; Femia, G.; Pellegrini, V.; Tenore, K.; Fadda, S.; Luppino, O.I.; Basile, B.; Cosentino, T.; Perdighe, C.; et al. Cognitive–Behavioral Treatment of Obsessive–Compulsive Disorder: The Results of a Naturalistic Outcomes Study. J. Clin. Med. 2022 , 11 , 2762. https://doi.org/10.3390/jcm11102762

Gragnani A, Zaccari V, Femia G, Pellegrini V, Tenore K, Fadda S, Luppino OI, Basile B, Cosentino T, Perdighe C, et al. Cognitive–Behavioral Treatment of Obsessive–Compulsive Disorder: The Results of a Naturalistic Outcomes Study. Journal of Clinical Medicine . 2022; 11(10):2762. https://doi.org/10.3390/jcm11102762

Gragnani, Andrea, Vittoria Zaccari, Giuseppe Femia, Valerio Pellegrini, Katia Tenore, Stefania Fadda, Olga Ines Luppino, Barbara Basile, Teresa Cosentino, Claudia Perdighe, and et al. 2022. "Cognitive–Behavioral Treatment of Obsessive–Compulsive Disorder: The Results of a Naturalistic Outcomes Study" Journal of Clinical Medicine 11, no. 10: 2762. https://doi.org/10.3390/jcm11102762

Article Metrics

Article access statistics, further information, mdpi initiatives, follow mdpi.

Subscribe to receive issue release notifications and newsletters from MDPI journals

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings
My Bibliography
Collections
Citation manager

Save citation to file

Email citation, add to collections.

Create a new collection
Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed, obsessive-compulsive disorder, affiliations.

1 University Hospital
2 West Virginia University, William R Sharpe Jr Hospital
3 Icahn School of Medicine at Mount Sinai
PMID: 31985955
Bookshelf ID: NBK553162

Obsessive-compulsive disorder (OCD) is a disabling condition estimated to affect 1% to 3% of individuals throughout their lifetime. This psychiatric disorder is characterized by obsessions and compulsions, which consume a significant amount of time and lead to notable distress and impairment. Obsessions refer to intrusive and repetitive thoughts, urges, or mental images that are challenging to control. These thoughts often lack a clear purpose and are accompanied by distress. Compulsions involve repetitive actions or mental events that individuals with OCD feel compelled to perform to alleviate the distress caused by the obsessions or to prevent a feared consequence from occurring. Additionally, individuals with OCD may also engage in avoidance behaviors of obsession-triggering situations.

OCD is a heterogeneous condition that arises from a complex interplay of genetic and environmental risk factors. Most adults are distressed by the ego-dystonic nature of their obsessions and are aware that their compulsive behaviors are abnormally excessive. Children often have difficulty describing their obsessions. In OCD patients, common obsessions and their associated compulsive behaviors include fear of contamination leading to excessive cleaning, fear of harm linked to repetitive checking of security measures, intrusive, aggressive, or sexual thoughts paired with mental rituals, and a focus on symmetry accompanied by ordering or counting. Though hoarding behaviors are usually specific to hoarding disorder, they can occur in OCD to prevent perceived harm. These behavior sets are consistently observed worldwide, suggesting a degree of commonality in OCD symptom dimensions. OCD can also present with rarer symptoms, including scrupulosity, obsessive jealousy, and musical obsessions.

The understanding of OCD has evolved significantly over time. Historically framed in religious terms as a moral failing or demonic possession, OCD was first medically described by Esquirol. Freud subsequently characterized the condition using the term obsessive neurosis , positing that OCD originated with a regression in the anal phase of psychosexual development. In the third edition of the Diagnostic and Statistical Manual (DSM-III), OCD was grouped with phobias under a single diagnosis. Later, the DSM-IV classified the condition as an anxiety disorder. The DSM-5 has reclassified OCD into the category "Obsessive-Compulsive and Related Disorders," alongside conditions like hoarding and body dysmorphia. This reclassification acknowledges shared characteristics, such as phenomenology, comorbidity, and underlying neurobiological factors. WHO lists OCD as 1 of the 10 most disabling conditions caused by financial loss and decreased quality of life. In The Diagnostic and Statistical Manual of Mental Disorders fifth edition Text Revision (DSM-5 TR), which was published by the American Psychiatric Association (APA) in 2022, OCD sits under the category of o bsessive-compulsive and related disorders where the following subcategories were placed:

Body dysmorphic disorder (BDD)

Hoarding disorder

Trichotillomania

Excoriation (ie, skin-picking) disorder

Substance or medication-induced obsessive-compulsive and related disorder

Obsessive-compulsive and related disorder as a result of another medical condition

Other specified obsessive-compulsive and related disorder

Unspecified obsessive-compulsive and related disorder

The diagnosis of OCD is based on clinical assessment determining whether the DSM-5 TR criteria are met, which specify that either obsessions or compulsions must be present, the behaviors must be time-consuming, taking ≥1 hour per day, and significantly disrupting daily life. (Refer to the History and Physical Examination section for more information on the diagnostic criteria for OCD).

PubMed Disclaimer

Conflict of interest statement

Disclosure: Hannah Brock declares no relevant financial relationships with ineligible companies.

Disclosure: Abid Rizvi declares no relevant financial relationships with ineligible companies.

Disclosure: Manassa Hany declares no relevant financial relationships with ineligible companies.

Continuing Education Activity
Introduction
Epidemiology
Pathophysiology
History and Physical
Treatment / Management
Differential Diagnosis
Complications
Consultations
Deterrence and Patient Education
Enhancing Healthcare Team Outcomes
Review Questions

Publication types

Search in PubMed
Search in MeSH
Add to Search

Related information

Linkout - more resources, full text sources.

NCBI Bookshelf

Miscellaneous

NCI CPTAC Assay Portal

Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

Subscribe to journal Subscribe
Get new issue alerts Get alerts
Submit your manuscript

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Clinical advances in obsessive-compulsive disorder: a position statement by the International College of Obsessive-Compulsive Spectrum Disorders

Fineberg, Naomi A. a,,b,,c ; Hollander, Eric d ; Pallanti, Stefano e,,f ; Walitza, Susanne g,,h,,i ; Grünblatt, Edna g,,h,,i ; Dell’Osso, Bernardo Maria j,,k,,l,,m ; Albert, Umberto n ; Geller, Daniel A. o ; Brakoulias, Vlasios p,,q ; Janardhan Reddy, Y.C. r ; Arumugham, Shyam Sundar r ; Shavitt, Roseli G. s ; Drummond, Lynne t ; Grancini, Benedetta b,,j ; De Carlo, Vera b,,j ; Cinosi, Eduardo a,,b ; Chamberlain, Samuel R. u,,v ; Ioannidis, Konstantinos u,,v ; Rodriguez, Carolyn I. k,,w ; Garg, Kabir b ; Castle, David x ; Van Ameringen, Michael y,,z ; Stein, Dan J. aa ; Carmi, Lior bb,,cc ; Zohar, Joseph bb,,dd ; Menchon, Jose M. ee

a University of Hertfordshire, Hatfield

b Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire

c University of Cambridge School of Clinical Medicine, Cambridge, UK

d Department of Psychiatry and Behavioral Sciences, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA

e Istituto di Neuroscienze, University of Florence, Firenze, Italy

f Albert Einstein College of Medicine, Bronx, New York, USA

g Department of Child and Adolescent Psychiatry and Psychotherapy, University Hospital of Psychiatry Zurich, University of Zurich

h Neuroscience Center Zurich, University of Zurich and ETH Zurich

i Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland

j University of Milan, Department of Biomedical and Clinical Sciences Luigi Sacco, Ospedale Sacco-Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy

k Department of Psychiatry and Behavioural Sciences, Stanford University, California, USA

l CRC ‘Aldo Ravelli’ for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Milan

m Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford

n Department of Medicine, Surgery and Health Sciences, UCO Clinica Psichiatrica, University of Trieste, Trieste, Italy

o Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

p Western Sydney Obsessive-Compulsive and Related Disorders Service, Western Sydney Local Health District, Blacktown Hospital, Blacktown, New South Wales

q Translational Research Health Institute (THRI), Clinical and Health Psychology Research Initiative (CaHPRI) and School of Medicine, Western Sydney University, Sydney, Australia

r OCD Clinic, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India

s OCD Spectrum Disorders Program, Institute and Department of Psychiatry, Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo, Sao Paulo-SP, Brazil

t Consultant Psychiatrist, SW London and St George’s NHS Trust and St George’s, University of London, London

u Department of Psychiatry, University of Cambridge, Cambridge

v Cambridgeshire and Peterborough NHS Foundation Trust, Cambridge, UK

w Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA

x St. Vincent’s Hospital Melbourne and The University of Melbourne, Melbourne, Australia

y Department of Psychiatry and Behavioural Neurosciences, McMaster University

z Hamilton Health Sciences, Hamilton, Ontario, Canada

aa SA MRC Unit on Risk and Resilience in Mental Disorders, Department of Psychiatry and Neuroscience Institute, University of Cape Town, Cape Town, South Africa

bb The Post Trauma Center, Chaim Sheba Medical Center, Ramat Gan

cc The Data Science Institution, The Interdisciplinary Center, Herzliya

dd Tel Aviv University, Tel Aviv-Yafo, Israel

ee Department of Psychiatry, Bellvitge University Hospital-IDIBELL, University of Barcelona, Cibersam, Barcelona, Spain

Received 27 January 2020 Accepted 16 March 2020

Correspondence to Kabir Garg, Hertfordshire Partnership University NHS Foundation Trust, Welwyn Garden City, Hertfordshire, UK, E-mail: [email protected]

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CC-BY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

In this position statement, developed by The International College of Obsessive-Compulsive Spectrum Disorders, a group of international experts responds to recent developments in the evidence-based management of obsessive-compulsive disorder (OCD). The article presents those selected therapeutic advances judged to be of utmost relevance to the treatment of OCD, based on new and emerging evidence from clinical and translational science. Areas covered include refinement in the methods of clinical assessment, the importance of early intervention based on new staging models and the need to provide sustained well-being involving effective relapse prevention. The relative benefits of psychological, pharmacological and somatic treatments are reviewed and novel treatment strategies for difficult to treat OCD, including neurostimulation, as well as new areas for research such as problematic internet use, novel digital interventions, immunological therapies, pharmacogenetics and novel forms of psychotherapy are discussed.

Introduction

Once a neglected illness, obsessive-compulsive disorder (OCD) is now recognized as a common, highly disabling and potentially treatable early-onset brain disorder. Clinical and translational research in OCD grows apace, and over the past 10 years has contributed to substantial advances in understanding of the phenomenology, brain-based biology and treatment response, leading to innovations in nosological conceptualizations, therapeutic interventions and services. Recent changes in the DSM-5 ( American Psychiatric Association, 2013 ) and ICD-11 ( WHO, 2018 ) diagnostic classification systems have set OCD at the head of a new family of obsessive-compulsive spectrum disorders [otherwise known as Obsessive-Compulsive or Related Disorders, or, Obsessive-Compulsive and Related Disorders (OCRDs)], including body dysmorphic, hoarding, hair-pulling, skin picking and olfactory reference disorders and hypochondriasis, all sharing compulsive behaviour as a cardinal characteristic. Serotonin reuptake inhibitors [selective serotonin reuptake inhibitors (SSRIs), clomipramine] or cognitive behavioural therapy (CBT) involving exposure and response prevention (ERP), represent the mainstay of contemporary treatment for OCD, with emerging evidence suggesting that early intervention produces better outcomes ( Fineberg et al., 2019 ). However, a substantial minority of patients still fail to respond either in any meaningful way, or in terms of residual symptoms. Treatment-resistant OCD has become a fruitful research focus for clinical treatment and specialist services development, worldwide.

A number of evidence-based clinical guidelines for managing OCD have been published ( Bandelow et al., 2012 ; Baldwin et al., 2014 ; Sookman et al., 2015 ). However, recent feedback from topic experts and stakeholders (National Institute for Health and Care Excellence, 2019) has identified the need for an update, highlighting that clinical practice has progressed in many areas. This includes evidence of efficacy for new pharmacological interventions and augmentation therapies among treatment-resistant groups, advances in invasive and noninvasive neurostimulation technology as well as rapid advances in information technology and telecommunications and the introduction of technology-enhanced interventions. Yet, in many parts of the world, access to recommended treatments and specialist care services, in particular for children, remains limited.

The International College of Obsessive-Compulsive Spectrum Disorders (ICOCS; www.ICOCS.org ) is a global network of expert clinicians, researchers and ‘experts by experience of OCD’, whose principal objective is to support and stimulate the study and treatment of obsessive-compulsive spectrum disorders. In recognition of the need for updated clinical guidance on the treatment of OCD, the ICOCS has developed this position statement, based on expert consensus and including a balanced representation of genders, child versus adult psychiatrists and early career scientists, with global and ethnic diversity. Agreement was reached on the key issues to be covered at a series of meetings, and the authors of each section were chosen based on their expertise in that area. An initial draft was prepared, based on a literature review, and circulated first among the authors and then to all ICOCS members and iterative edits were incorporated. In sum, we have selected those recent therapeutic advances judged by a range of experts to be of most relevance to the treatment of OCD, including products that are not licensed or labelled for treatment of OCD by the US Food and Drug Administration (FDA) ( Table 1 ), which are marked with an asterisk (*) throughout the article, based on new and emerging evidence from clinical and translational science

Global assessment of obsessive-compulsive disorder

A comprehensive assessment of OCD requires trained clinicians who perform direct interviews with the patient and, whenever possible, with family members, so that an accurate diagnosis can be determined and individualized treatment can be tailored. The hallmarks of OCD are obsessions (recurrent, intrusive, unwanted thoughts, images or impulses and compulsions (repititive behaviours or mental acts that the individual feels compelled to perform), these can present together or separately.The most common symptom dimensions of OCD are contamination/washing, aggression/checking, symmetry/ordering/arranging, sexual/religious (also known as ‘taboo thoughts’) and hoarding ( Rosario-Campos et al., 2006 ). Importantly, according to DSM-5, a diagnosis of Hoarding Disorder should be assigned when symptoms pertain to this single dimension ( American Psychiatric Association, 2013 ). The presence and severity of symptoms can be measured by validated instruments ( Goodman et al., 1989 ; Rosario-Campos et al., 2006 ; Storch et al., 2010 ), which is relevant to tailoring the behavioural treatment and monitoring treatment response objectively. For the OCD diagnosis, while free-form interviews by clinicians are commonly used, structured interviews offer advantages in terms of objectivity and psychometric properties ( Rapp et al., 2016 ). Suitable interviews for the diagnosis of OCD in adulthood include the Structured Clinical Interview for DSM-5 Disorders ( First et al., 2016 ), or the Mini International Neuropsychiatric Interview ( Sheehan et al., 1998 ). The Yale–Brown Obsessive-Compulsive Scale (Y-BOCS) is the gold-standard for assessing symptom severity in diagnosed adult patients, and incorporates a detailed checklist for individual symptoms ( Goodman et al., 1989 ). For initial screening, six brief questions can be used. These include as follows: (1) Do you wash or clean a lot? (2) Do you check things a lot? (3) Is there any thought that keeps bothering you that you would like to get rid of but can’t? (4) Do your daily activities take a long time to finish? (5) Are you concerned about orderliness or symmetry? (6) Do these problems trouble you? Positive response to one or more statements would indicate a need for more detailed assessment ( Fineberg et al., 2008 ).

Obsessions and compulsions tend to occur concomitantly in the vast majority of people with OCD ( Shavitt et al., 2014 ). In addition, compulsions are commonly preceded not only by obsessions but also by subjective experiences of incompleteness, or ‘not feeling just-right’, or so-called sensory phenomena (perceptual experiences that precede or accompany compulsions) ( Shavitt et al., 2014 ). We could expect these phenomena to be targeted by cognitive-behavioural techniques in a way similar to the premonitory urges in the behavioural treatment of tic disorders ( McGuire et al., 2015 ).

Another relevant clinical feature that merits attention when assessing subjects with OCD is the degree of insight, meaning the extent to which the person recognizes that his/her beliefs are not true ( Eisen et al., 1998 ). Insight (good or fair insight, poor insight, absent insight/delusional beliefs) is a diagnostic specifier for OCD, body dysmorphic disorder (BDD) and hoarding disorder in the DSM-5 ( American Psychiatric Association, 2013 ). In general, subjects with OCD have at least good insight, with only a minority presenting poor insight or delusional OCD ( Shavitt et al., 2014 ). The presence of tic symptomatology represents another clinically relevant diagnostic specifier in the DSM-5, as tic may predict a more favourable response to dopamine antagonist agents ( Bloch et al., 2006 ). Finally, the clinician must obtain information regarding avoidance behaviours, which commonly occurs as a means to handle the distress evoked by the obsessions and constitutes one of the main targets of the cognitive-behavioural treatment for this disorder ( Drummond, 2014 ). Functional impairment varies in OCD. It is an important domain that reflects clinical severity and constitutes an indirect measure of improvement during treatment. Impairment can be measured indirectly with OCD severity scales or with specific measures [e.g., the WHO Disability Assessment Schedule 2.0 ( Üstün et al., 2010 ) or the Cognitive Assessment Instrument of Obsessions and Compulsions ( Dittrich et al., 2011 )].

Comorbidity is almost always present with OCD and is often ‘phase-specific’ ( Pallanti and Grassi, 2014 ). Assessment of specific comorbidities, like tic disorders, anxiety and depressive disorders, disruptive disorders, eating disorders, autism spectrum disorder (ASD), attention deficit hyperactivity disorder (ADHD) and schizophrenia ( Zohar, 1997 ), is essential in guiding the formulation of an effective treatment strategy. Comorbidity has also been a focus of emerging genetic studies of OCD. For example, a recent study in 4645 OCD patients found different genotypes to be associated with different OCD comorbidities. Thus, OCD comorbid with bipolar disorders was associated with COMT , OPRM1 and GRIK1 genotypes; OCD and depressive disorders were associated with OPRM1 and CYP3A4/5 genotypes; OCD comorbid with ADD/ADHD was associated with 5HT2C genotypes; and OCD comorbid with anxiety was associated with CYP3A4/5 genotypes ( Nezgovorova et al., 2018 ). However, these findings should be viewed with caution, as the ‘candidate gene’ approach, in which specific genes are tested for association with specific disorders, chosen for the biological plausibility of their relationship, using relatively small samples of affected subjects and healthy controls, has been criticized for overestimating statistical associations. Attempts to replicate the findings have tended to produce disappointing results. Therefore, more unbiased forms of the association study, such as genome-wide association studies (GWAS), which test the association between a disease and multiple genetic variants across the whole genome, are to be preferred ( Gordon, 2018 ; National Advisory Mental Health Council Workgroup on Genomics, 2019 ). A recent meta-analysis of GWAS of eight psychiatric disorders identified a common genetic factor linking OCD, anorexia nervosa and Tourette’s syndrome (Lee et al ., 2019b).

Interestingly, comorbid disorders that start before the onset of OCD symptoms seem to influence the occurrence of additional comorbidities over time. In a cohort of 1001 patients with OCD, separation anxiety disorder preceded OCD in 17.5% of individuals and was associated with a higher lifetime frequency of posttraumatic stress disorder; ADHD preceded OCD in 5.0% of subjects, and was associated with higher lifetime frequencies of substance abuse and dependence; tic disorders preceded OCD in 4.4% of subjects and were associated with higher lifetime frequencies of OCD spectrum disorders ( de Mathis et al., 2013 ). In children and adolescents, in addition to the considerations for the adult subjects, a history of paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) should be taken, as this could also have treatment implications ( Wilbur et al., 2019 ). Taken together, these findings emphasize the importance of identifying comorbid disorders, as they may serve as markers of different biological or clinical substrates of potential relevance for treatment planning (see section Future directions for research).

OCD needs to be differentiated from: anxiety disorders presenting with recurrent fears (as in the phobias) and excessive worry (as in generalized anxiety disorder); ruminations accompanying depressive mood in depressive disorders; OCD-related disorders like BDD (where there are specific concerns with one’s appearance), hair-pulling disorder (the only compulsion); tic disorders; eating disorders (concerns focussed on weight and shape and food); psychotic disorders (especially in poor-insight OCD and so-called schizo-obsessive disorder) and obsessive-compulsive personality disorder (with the hallmarks of enduring rigidity and perfectionism over the lifetime) ( American Psychiatric Association, 2013 ).

Along with the identification of the most bothersome symptoms, the clinician should investigate the age of onset of symptoms and the age when a diagnosis of OCD has been determined, because these data can help to predict the prognosis ( Fineberg et al., 2019 ). OCD frequently emerges in childhood, in which group accurate diagnosis is essential for care planning. Paediatric clinicians can ask simple screening questions such as ‘do you ever have unwanted thoughts or worries that won’t go away? Are there things you have to do over and over again, even though you don’t want to or that don’t make sense?’ The formal diagnosis should be made with a structured interview and the nationwide translated versions of the standardized Children’s Y-BOCS (CY-BOCS), which has good reliability ( López-Pina et al., 2015a , b ).

Awareness of other conditions associated with the onset and course of OCD symptoms can also be of help in treatment planning, because OCD frequently follows a chronic course, with most patients reporting residual symptoms, or present an episodic course with long symptom-free periods (Skoog and Skoog, 1999 ). For example, a cross-cultural study has shown an association between reproductive cycle events and the onset (mostly menarche) or exacerbation of OCD during the premenstruum, pregnancy, postpartum and menopause ( Guglielmi et al., 2014 ). Relevant to prevention strategies, exacerbation during or after first pregnancy posed a significant risk to exacerbation in or after a subsequent pregnancy. The underlying factors responsible for triggering exacerbation remain to be understood, especially the role of oestrogen and oxytocin ( Guglielmi et al., 2014 ).

Information on the family history of OCD, tics and other psychiatric disorders and the understanding of OCD among family members and family accommodation are also relevant to treatment-planning and adherence. Evidence shows that successful treatment depends on the reduction of the participation of the family members in the patient’s compulsive behaviours (i.e., reduction of accommodation) ( Gomes et al., 2017 ). Moreover, a recent analysis suggested that children with a family history of OCD have a six times lower response to CBT ( Garcia et al., 2010 ).

Suicidality should be included when assessing people with OCD ( Dell’Osso et al., 2018 ). A recent meta-analysis ( Angelakis et al., 2015 ) found that OCD patients showed relatively increased risk of ‘suicidality’, when compared with healthy controls. In terms of absolute risk, estimates vary. Among 582 patients with OCD, 36% reported lifetime suicidal thoughts, 20% had made suicidal plans, 11% had already attempted suicide and 10% presented with current suicidal thoughts ( Torres et al., 2011 ). In another study of 425 outpatients, recruited by the ICOCS network, 14.6% of the sample reported at least one suicide attempt during their lifetime ( Dell’Osso et al., 2018 ). In the study by Torres et al. (2011 ), comorbid depressive disorder and posttraumatic stress disorder were associated with a range of suicidal behaviours. Sexual/religious symptoms and comorbid substance use disorders were associated with suicidal thoughts and plans, while impulse control disorders were associated with current suicidal thoughts, suicide plans and attempts. In the study of Dell’Osso et al. (2018 ), comorbid tic disorders as well as medical disorders and a previous history of hospitalization were also associated with increased suicidality.

Neuropsychological assessment of patients with OCD suggests that there are deficits across a broad range of domains (Fineberg et al ., 2018a). For example, a recent meta-analysis found that patients with symptoms related to symmetry and orderliness were more likely to have poor performance on memory, visuospatial ability, verbal working memory and cognitive flexibility tests, whereas patients with doubting and checking were more likely to perform poorly on memory and verbal memory tasks ( Bragdon et al., 2018 ). Other meta-analyses have found cognitive flexibility and response inhibition to be impaired in OCD in general (all literature pooled), with medium–large effect sizes ( Lipszyc and Schachar, 2010 ; Chamberlain et al., 2019 ). It must be considered that comorbid neurodevelopmental disorders, such as ASD ( Postorino et al., 2017 ), or ADHD are expected to influence performance on distinct tests, especially but not exclusively in youth.

Behavioural analysis of OCD involves obtaining a history to ascertain the specific situations that provoke obsessions, anxious thoughts or uncomfortable feelings and then separating out the compulsions or anxiolytic behaviours. This is important, as during therapy the patient needs to face up to the anxiety-provoking thoughts or uncomfortable feelings while resisting the urge to ‘put this right’ using compulsive thoughts, behaviours or avoidance. Full descriptions of behavioural analysis are given elsewhere ( Drummond, 2014 ). From a cognitive perspective, there have been several theories about the underlying beliefs that may trigger OCD, such as the failure to challenge underlying beliefs sufficiently ( Emmelkamp et al., 1988 ), inflated responsibility and guilt if compulsions were not acted upon and negative consequences occurred ( Salkovskis, 1985 , 1999 ), or an overinflated idea of danger ( Jones and Menzies, 1998 ) (see section Novel forms of psychotherapy below).

Early intervention in obsessive-compulsive disorder

OCD frequently has an onset early in life ( Fineberg et al., 2019 ). Childhood or adolescent onset accounted for more than 50% of the sample in a recent international multisite report ( Dell’Osso et al., 2016 ). Unfortunately, early onset is all too often not associated with early help-seeking and recognition of the illness. OCD has been consistently associated with a long duration of untreated illness (DUI) – around 7 years on average ( Dell’ Osso et al. , 2019 ) – with this period accounting, in many cases, for more than half of the overall duration of illness ( Albert et al., 2019 ; Dell’ Osso et al. , 2019 ). Longer DUI implies late interventions and poor therapy response, particularly in relation to pharmacological treatment ( Dell’Osso et al., 2010 ; Albert et al., 2019 ). The need for service investment in early intervention for OCD is further highlighted by studies indicating that OCD is among the top 10 most disabling of all disorders, accounting for 2.2% of all years lost to disability ( Ayuso-Mateos, 2006 ), with economic costs to society including those associated with lost productivity, which are long-lasting and profound. It has been estimated that in the USA, over $10 billion dollars per year are spent on treatments for OCD alone ( Hollander et al., 2016 ).

OCD has been traditionally viewed as a secretive illness with some phenotypes (e.g., with sexual, religious or aggressive content) being particularly associated with reluctance to seek help ( Dell’Osso et al., 2015 ). There may also be difficulty detecting the disorder in childhood ( Storch et al., 2014 ). Nonetheless, a greater effort needs to be made at multiple levels (e.g., education, service development and screening of ‘at risk’ individuals) to implement effective strategies for prevention, early diagnosis and intervention. For instance, there have been reports indicating that the earliest symptoms shown by OCD patients belong to the symmetry and ordering dimension ( Kichuk et al., 2013 ) and these may represent a red flag for early detection of subthreshold/early symptoms.

Children of individuals with OCD represent another high-risk group deserving attention and potentially needing preventive interventions. The presence of tic, paediatric acute-onset neuropsychiatric syndrome, obsessive-compulsive personality disorder and impulse control disorders may be indicators of comorbid OCD or herald the subsequent development of OCD ( Fineberg et al., 2019 ). Staging models may also be useful ( Fineberg et al., 2019 ; Fontenelle and Yücel, 2019 ), with four major stages proposed (from stage 0 ‘increased risk, asymptomatic’ to stage 4 ‘severe illness’). However, their clinical utility and applicability remain to be investigated. Interventions such as psychoeducation and reduction of family accommodation represent promising areas for prevention and early intervention when OCD is at its early stages in high-risk groups ( Brakoulias et al., 2018 ). One Australian health service ( Brakoulias, 2018 ) has recently begun using existing early intervention services for psychosis to provide early intervention to patients with OCD ( Brakoulias, 2018 ) (Western Sydney Obsessive-Compulsive and Related Disorders Service).

Cognitive behavioural therapy, selective serotonin reuptake inhibitor or their combination as a first-line treatment for adults with obsessive-compulsive disorder

Pharmacological therapies (SSRIs and the tricyclic clomipramine) ( Zohar et al., 1996 ; Fineberg et al., 2012 ) and psychological therapies (ERP, CBT) ( Abramowitz, 2006 ) are often efficacious in treating OCD in adults. As SSRIs and CBT have been thought to have broadly similar efficacy in acute treatment, current guidelines recommend taking account of patients’ clinical features, needs and preference as well as service availability when choosing a first-line treatment ( Baldwin et al., 2014 ). Monotherapy with CBT involving ERP is particularly recommended as an initial treatment in those with mild–to-moderate OCD, in the absence of severe depression, in those who do not prefer medications and where this form of treatment is accessible, available and preferred by patients (National Institute for Health and Clinical Excellence, 2005a; Koran et al., 2007 ; Katzman et al., 2014 ; Janardhan Reddy et al., 2017 ). In contrast, SSRIs are particularly recommended as a first-line treatment option in more severe OCD, in those who have comorbid depression, in those with previous history of good response to SSRIs, in those who are uncooperative with CBT or in situations where ERP/CBT is not available, accessible or preferred by patients. A combination of CBT involving ERP and SSRIs is often recommended in severe OCD, in the presence comorbid depression and in poor responders to CBT or SSRIs alone (National Institute for Health and Clinical Excellence, 2005b; Skapinakis et al., 2016b ; Hirschtritt et al., 2017 ; Janardhan Reddy et al., 2017 ). In essence, most guidelines recognize SSRIs and CBT involving ERP as first-line monotherapies, but prefer CBT involving ERP over SSRIs.

Several meta-analyses and systematic reviews have demonstrated SSRIs and clomipramine ( Ackerman and Greenland, 2002 ; Soomro et al., 2008 ; Skapinakis et al., 2016b ) and CBT involving ERP to be more effective than placebo (frequently waiting list in CBT trials) in the treatment of OCD ( Gava et al., 2007 ; Rosa-Alcázar et al., 2008 ). Although an earlier meta-analysis suggested superiority of clomipramine over SSRIs ( Ackerman and Greenland, 2002 ), a recent network meta-analysis failed to demonstrate the superiority of clomipramine over SSRIs ( Skapinakis et al., 2016b ). Direct head-to-head comparisons of various medications are few and there seems to be no individual differences in efficacy among SSRIs ( Skapinakis et al., 2016b ), although, of course, they may differ in side effect profiles.

Most studies of CBT involving ERP included symptomatic patients stabilized on antidepressants ( Skapinakis et al., 2016b ). Although the observed effect size of CBT was larger than the SSRIs and clomipramine, this superiority could well be attributed to the additive or synergistic effects of two effective treatment modalities. Therefore, it is not clear whether the efficacy data attributed to CBT with ERP can be generalized to patients who are not taking medication for OCD. The efficacy of CBT as monotherapy still needs to be established clearly in drug-naïve or drug-free patient population for it to be recommended as initial monotherapy in this population.

Some studies suggest that a combination of CBT and an SSRI may be superior to SSRI monotherapy ( Foa et al., 2005 ; Liu et al., 2005 ; Franklin et al., 2011 ; Romanelli et al., 2014 ; Meng et al., 2019 ), exposure monotherapy ( Cottraux et al., 1990 , Fineberg et al., 2018a ) or multimodal CBT ( Hohagen et al., 1998 ). However, it is uncertain whether combining ab-initio CBT and an SSRI is advantageous compared to either treatment used alone ( Albert et al., 2012 ). Confidence in the superiority of the combination of medications and psychotherapy partly stems from the fact that, as described above, most psychotherapy trials are considered variants of combination trials because most patients in these studies were stabilized on SSRI or clomipramine ( Skapinakis et al., 2016b ). Most guidelines and literature recommend a combination of SSRIs and CBT involving ERP in severe OCD, but the recommendation is based on evidence of its efficacy as an augmenting strategy in patients who have clinically significant symptoms despite treatment with medications and not necessarily in severe OCD ( Simpson et al., 2008 , 2013 ). A recent randomized feasibility study that included patients treated in primary care found that although combined treatment with SSRI and ERP was associated with the largest improvement after 16 weeks, SSRI monotherapy was the most efficacious and cost effective treatment after 52 weeks ( Fineberg et al., 2018b ). If replicated, this finding would carry major implications for health services planning, especially where resources are limited, such as lower and middle income countries.

The critical importance of adequate treatment of obsessive-compulsive disorder in children and young people

For children and young people, CBT should always be the first-line approach ( Sánchez-Meca et al., 2014 ; Skapinakis et al., 2016a ), with ERP as core elements ( Lewin et al., 2014 ). ERP is both highly effective and also an acceptable intervention for youth ages 3–8 years with OCD ( Lewin et al., 2014 ). Children with a strong family history of OCD are reported to respond less well to conventional CBT ( Garcia et al., 2010 ), possibly owing to family accommodation of their symptoms. Key adaptations for younger children include extensive parental involvement targeting family accommodation and frequent family meetings while delivering a full course of ERP. According to the study of Sánchez-Meca et al. (2014 ), effect sizes were large for CBT ( d + = 1.742) and combined (medication plus CBT) interventions ( d + = 1.710) and moderate for pharmacological only treatments ( d + = 0.746). Family-based CBT ( Piacentini et al., 2011 ; Freeman et al., 2014 ) is also effective for children and adolescents with OCD, especially when there is a high degree of accommodation. The extant literature also supports CBT when delivered in group settings. More recently, the use of technical devices (smart phones and tablets) using App-delivered CBT seems promising.

Medication is, however, indicated for children and young people when symptoms are more severe, CBT has failed, skilled CBT is unavailable, and there is a comorbid disorder (e.g., depression) that may respond to medication, or when, in the judgement of the parent or clinician, earlier introduction of medicines is clinically indicated. SSRIs have been shown in randomized controlled trials to be well tolerated and effective in youth ( Geller et al., 2004 ; Skarphedinsson et al., 2015 ). Sertraline and fluvoxamine have been approved for children from 6 to 8 years of age. Dosing schedules should include low starting doses, slow titration schedules and maximum recommended doses. Following adequate response and stabilization, treatment should be reviewed after 6–12 months.

In the case of nonresponse or inadequate response, another SSRI should be tried ( Geller et al., 2004 , 2012 ; Locher et al., 2017 ). Treatment with SSRIS in CBT-resistant patients may improve OCD symptoms. Although clomipramine may be effective, it is not recommended as a first-line treatment because of its potential side effects. However, if there are no cardiac contraindications, clomipramine* is also an option in youth but requires electrocardiogram monitoring. In the case of insufficient efficacy of drug treatment with several SSRIs and clomipramine, or in the presence of tic disorder, augmentation with antipsychotics, for example, aripiprazole* or risperidone* in low dosage may be used. Minimal duration on antipsychotics (these medications are not approved or indicated for paediatric use) is encouraged and close monitoring is required.

Relapse prevention

Relapse prevention strategies play an essential role for the optimal clinical management of OCD, considering its frequently chronic course and relapsing nature. Recovery occurs in only about one-fifth of adult cases, while for children, the mean persistence rates for full or subthreshold OCD have been estimated at around 60% ( Maina et al., 2001 ; Stewart et al., 2004 ). Earlier age of OCD onset, increased illness duration, inpatient status, the presence of comorbidities and a positive family history seem to predict greater rates of persistence ( Geller et al., 2003 ; Stewart et al., 2004 ). Furthermore, relapses in OCD are associated not only with considerable distress, significant functional impairment and impairment of quality of life ( Hollander et al., 2010 ) but also with a decreased response to a previous efficacious treatment ( Maina et al., 2001 ).

To date, relapse prevention studies in OCD have mainly investigated SSRIs and clomipramine as the maintenance treatment, with the duration of treatment under placebo-controlled conditions extending up to 12 months. Studies with a longer follow-up period or investigating relapse following CBT are relatively scarce. In the case of adults, the majority of relapse prevention studies have shown an overall superiority of SSRI compared with placebo in preventing relapse ( Fineberg et al., 2007 ) and that discontinuation of maintenance treatment, even after a period of prolonged well-being under SSRI, is associated with a heightened relapse risk. Relapse was particularly prominent in patients with comorbidities, which is the rule rather than the exception in children with OCD. As childhood and adolescence are critical periods for achievement of social, educational and occupational milestones, relapse prevention is particularly relevant for the younger patient population ( Fineberg et al., 2019 ). There has been one randomized controlled relapse prevention study in paediatric OCD, which showed an advantage for paroxetine* over placebo ( Geller et al., 2004 ). As there is no available evidence suggesting a duration of treatment beyond which treatment can be discontinued safely, more recent guidelines emphasized the importance of maintaining medication for at least 12 months to reduce relapse risk ( Baldwin et al., 2014 ).

The clinician’s role in enabling an informed choice about whether or not to discontinue medication at any particular time is challenging, considering the limitations of the available relapse prevention studies. Strategies for safely managing emerging relapse, such as reinstating either ‘booster’ CBT or medication at the first sign of symptoms, do not have established evidence of efficacy. Nevertheless, it is advisable to establish a relapse-management plan, in cooperation with patients and their families based on vigilance for emergent symptoms and rapid access to treatment previously known to be effective. If medication is to be discontinued, this should be done gradually, after a careful explanation of the potential consequences, such as withdrawal symptoms and relapse risk. SSRI tapering over a period of months, rather than weeks, may reduce the risk of withdrawal symptoms ( Horowitz and Taylor, 2019 ).

Treatment-resistant obsessive-compulsive disorder – novel pharmacotherapies tested in adults

After well supported first- and second-line treatments and strategies have been exhausted, some patients will continue to experience impairing OCD symptoms. Next-step treatment strategies may include continuing with the chosen SRI for an extended period of time, switching to another SRI, augmenting the SRI with a second-generation antipsychotic agent* or raising the dose of SRI to the highest tolerated level* ( Fineberg and Craig, 2007 ; Bandelow et al., 2008 ; Fineberg et al., 2012 ; Stein et al., 2012 ).

Although switching to another SRI often is recommended, there is little evidence to support this approach in OCD. When a partial or moderate response has been achieved following the adequate first-line treatment, there is randomized controlled trial (RCT) and meta-analytic evidence to support augmentation with an second-generation antipsychotic ( Brakoulias and Stockings, 2019 ; Dold et al., 2015 ; Stein et al., 2012 ; Zhou et al., 2019 ); however, the use of these agents would be considered off-label. Of these agents, risperidone* is supported by the greatest number of studies, which have generally been positive ( Brakoulias and Stockings, 2019 ). Two RCTs ( Muscatello et al., 2011 ; Sayyah et al., 2012 ), several open-label studies (Connor et al ., 2005; Pessina et al ., 2009; Ak et al ., 2011), and multiple case reports have demonstrated the efficacy in OCD of aripiprazole* as an augmentation agent (Matsunaga et al ., 2011; Higuma et al ., 2012; Hou and Lai, 2014; Ercan et al ., 2015; Akça and Yilmaz, 2016; Patra, 2016; Brakoulias and Stockings, 2019 ). One meta-analysis also found a larger effect size for aripiprazole than for risperidone: Cohen’s d = 1.11 (aripiprazole) versus d = 0.53 (risperidone) (Veale et al ., 2014). Quetiapine* has also been examined as an augmentation agent in OCD, but the evidence is conflicting. Despite several positive studies (Atmaca et al ., 2002; Denys et al ., 2004; Vulink et al ., 2010; Diniz et al ., 2011), negative results have been found in many placebo-controlled trials (Carey et al ., 2005; Kordon et al ., 2008; Fineberg et al ., 2013).

Contrary to the depression literature, a meta-analysis of SSRIs in OCD found that high doses (high end of recommended dosage, not higher than recommended doses) were more effective than medium or low doses in the first-line treatment of OCD ( Bloch et al., 2010 ). Response was more robust for patients with comorbid tics and in individuals who had received more than 12 weeks of maximal SSRI monotherapy ( Bloch et al., 2008 ). However, tolerability is a significant issue as compared with lower doses so that this strategy requires caution in primary care settings ( Stein et al., 2012 ). The Food and Drug Administration in the USA raised a safety warning in 2011 against citalopram doses higher than 40 mg/day due to a modest but probable risk of arrhythmias ( US Food and Drug Administration, 2012 ). However, a more recent meta-analysis identified only 18 cases where electrocardiogram QTc prolongation or torsades de pointes was associated with citalopram at doses between 20 and 60 mg/day. The authors concluded that these cardiac adverse events were infrequent ( Tampi et al., 2015 ).

When an inadequate treatment response persists, less well supported treatment strategies (lacking multiple randomized, controlled trials or meta-analyses) may be considered ( Koran et al., 2007 ; Koran and Simpson, 2013 ), including use of glutamate modulators*, d-amphetamine* or oral morphine sulfate*.

Glutamate modulators such as memantine*, riluzole*, topiramate*, lamotrigine*, N-acetylcysteine* and ketamine* have varying levels of support ( Koran et al., 2007 ; Pittenger et al., 2011 ; Koran and Simpson, 2013 ; Pittenger, 2015 ). Memantine augmentation showed benefit in case studies and open-label trials ( Poyurovsky et al., 2005 ; Pasquini and Biondi, 2006 ; Aboujaoude et al., 2009 ; Feusner et al., 2009 ; Stewart et al., 2010 ; Bakhla et al., 2013 ). In addition, two RCTs of memantine showed exceptionally high response rates (100% in one study), inconsistent with the literature ( Ghaleiha et al., 2013 ; Haghighi et al., 2013 ). Riluzole augmentation showed promise in a case series and open-label trial ( Coric et al., 2003 , 2005 ). Subsequent small controlled studies have been mixed ( Pittenger et al., 2008 ; Emamzadehfard et al., 2016 ). While topiramate augmentation showed promise in case studies and open-label trials ( Rubio et al., 2006 ; Van Ameringen et al., 2006 ; Van Ameringen and Patterson, 2015 ), small RCTs have also produced mixed results ( Mowla et al., 2010 ; Berlin et al., 2011 ; Afshar et al., 2014 ). Lamotrigine augmentation showed mixed results in case reports ( Kumar and Khanna, 2000 ; Uzun, 2010 ; Arrojo-Romero et al., 2013 ; Hussain et al., 2015 ) and benefits in two small RCTs ( Bruno et al., 2012 ; Khalkhali et al., 2016 ). Limited data suggest that N-acetylcysteine is of benefit in some cases of refractory OCD ( Lafleur et al., 2006 ), with mixed data in four RCTs ( Afshar et al., 2012 ; Sarris et al., 2015 ; Paydary et al., 2016 ; Costa et al., 2017 ). N-acetylcysteine is generally well tolerated. A single intravenous dose of ketamine has been reported to be of rapid (in hours) and robust benefit in unmedicated adults with OCD in case report and open-label studies ( Rodriguez et al., 2011 , 2016 ) and a randomized controlled cross-over study ( Rodriguez et al., 2013 ). In an open-label trial of medicated OCD adults with multiple comorbidities, depression improved on ketamine but improvement in OCD symptoms was minimal, and two patients developed new-onset irritability and suicidal ideation ( Bloch et al., 2012 ; Niciu et al., 2013 ). Experience with intranasal ketamine in OCD is very limited ( Adams et al., 2017 ; Rodriguez et al., 2017 ). Ketamine should only be administered at sites with expertise in this approach, with appropriate precautions including monitoring for side effects and screening individuals who have a current or past substance abuse problem ( Sanacora et al., 2017 ).

In two double-blind, placebo-controlled studies, d-amphetamine was superior to placebo in unmedicated OCD adults ( Insel et al., 1983 ; Joffe et al., 1991 ). A subsequent double-blind comparison of SSRI augmentation with d-amphetamine versus high-dose caffeine showed benefit of both drugs ( Koran et al., 2009 ). Oral morphine showed benefit in a case series ( Warneke, 1997 ) and in a double-blind crossover study ( Koran et al., 2005 ) in adults with OCD. Precautions should be taken in the case of both d-amphetamine and morphine to screen out individuals who have current or past substance abuse ( Koran et al., 2007 ).

Other drugs, such as pindolol*, clonazepam*, buspirone*, or lithium*, have been tested, but the results have been mixed and some of the placebo-controlled trials have not found positive results. Some promising results have been found with the 5HT3 antagonist ondansetron* ( Serata et al., 2015 ) and a clinical trial is currently underway ( ClinicalTrials.gov, 2017 ) though a double-blind placebo-controlled trial of low daily dosages of odansetron* (0.5 and 0.75 mg) in a relatively large sample was negative ( ClinicalTrials.gov, 2015 ).

Treatment-resistant obsessive-compulsive disorder – noninvasive neurostimulation

Noninvasive neuromodulatory interventions targeting the corticostriatothalamocortical (CSTC) circuits hold promise as augmenting intervention for treatment-resistant OCD ( Lusicic et al., 2018 ). Repetitive transcranial magnetic stimulation (rTMS)* is the best studied noninvasive modulatory intervention in OCD. rTMS delivered at low-frequency rTMS (≤1 Hz) (LF-rTMS) is thought to inhibit the activity of underlying cortical regions, while high-frequency rTMS, provided at ≥5 Hz, is thought to enhance cortical activity ( Lefaucheur et al., 2014 ). Conventional rTMS, provided through the figure-8 coil, is relatively focal, modulating superficial cortical regions over a depth of around 2 cm ( Lefaucheur et al., 2014 ). LF-rTMS* protocols targeting the supplementary motor area (SMA) have been found to be helpful for OCD in multiple RCTs and meta-analyses ( Mantovani et al., 2010 ; Gomes et al., 2012 ; Hawken et al., 2016 ; Zhou et al., 2017 ; Rehn et al., 2018 ). This effect has been found to last up to 3 months ( Gomes et al., 2012 ). A recent trial demonstrated superior efficacy of this protocol over antipsychotic augmentation in treatment-resistant OCD subjects ( Pallanti et al., 2016 ). However, given recent inconsistent reports on inhibitory rTMS protocols targeting the SMA ( Arumugham et al., 2018 ; Harika-Germaneau et al., 2019 ; Pelissolo et al., 2016 ), there is a need for large multicentre trials to confirm its efficacy at this location.

LF-rTMS targeting the orbitofrontal cortex (OFC)* has also shown promise in small RCTs ( Ruffini et al., 2009 ; Nauczyciel et al., 2014 ). There is a need for larger trials targeting the OFC to confirm its efficacy and tolerability. RCTs targeting the dorsolateral prefrontal cortex have, in contrast – and unlike in major depressive disorder – shown highly inconsistent findings in OCD ( Lusicic et al., 2018 ). A multisite randomized sham-controlled trial found high-frequency deep rTMS, using an H7 coil, over the dorsomedial prefrontal cortex/anterior cingulate cortex to be efficacious and well tolerated in a treatment resistant OCD population ( Carmi et al., 2019 ). This FDA approval and CE (Conformité Européene) certification device for the treatment of resistant OCD. However, considering the cost of this device, there is a need for replication studies confirming the efficacy of the above protocol, which included personalized symptom provocation as an interventional component. Less-expensive deep coils, which have shown promise in targeting the dorsomedial prefrontal cortex in open-label trials on OCD ( Modirrousta et al., 2015 ; Dunlop et al., 2016 ), are yet to be evaluated under controlled conditions.

Transcranial direct current stimulation (tDCS)* involves administration of low-amplitude (1–2 mA) electric current to the brain between a cathode and anode. Anodal tDCS is thought to enhance cortical excitability and cathodal tDCS to have an inhibitory effect ( Rachid, 2019 ). The SMA and OFC are key targets. A randomized sham-controlled trial ( n = 24 treatment-resistant OCD subjects) demonstrated efficacy for anodal tDCS administered over bilateral pre-SMA and cathodal tDCS over right supraorbital regions ( Gowda et al., 2019 ). However, another randomized crossover trial ( n = 12) found clinical improvement with cathodal tDCS over pre-SMA, while anodal tDCS was ineffective ( D’urso et al., 2016 ). Thus, replication studies are needed to determine the optimal stimulation protocol for tDCS over SMA in OCD*. Another randomized sham-controlled trial ( n = 21 treatment-resistant OCD patients) showed efficacy for cathodal tDCS delivered over the OFC and the anode over the right cerebellum, but the effect was not sustained at follow-up ( Bation et al., 2019 ). Other promising results in treatment-resistant OCD for protocols targeting OFC and other cortical regions, such as dorsolateral prefrontal cortex and dorsomedial prefrontal cortex, are found in case reports and small uncontrolled studies and have to be confirmed in well designed trials ( Brunelin et al., 2018 ; Rachid, 2019 ). Furthermore, studies present significant heterogeneity and methodological differences in sample selection criteria, concomitant treatment and tDCS stimulation protocols ( da Silva et al., 2019 ; Rachid, 2019 ). Some authors suggest that overall cathodal tDCS may be better than anodal in treating OCD ( Rapinesi et al., 2019 ).

Currently, there are no RCTs to support the efficacy of electroconvulsive therapy* (ECT) in OCD ( Fontenelle et al., 2015 ). Hence, ECT may be recommended only for acute treatment of comorbid conditions such as depression or psychosis*.

To summarize, LF-rTMS delivered over the SMA (with figure-8 coil) and HF-deep-rTMS over the dorsomedial prefrontal cortex/anterior cingulate cortex (with H7 coil) appear promising interventions in treatment-resistant OCD. There is a pressing need for large replication studies and evaluation of long-term effects/maintenance protocols. The evidence for tDCS is highly preliminary and further exploratory studies are encouraged.

Treatment-resistant obsessive-compulsive disorder – deep brain stimulation and ablative neurosurgery

A significant number (10–40%) of patients do not respond to any available therapy and suffer from severe, enduring symptoms and dysfunction ( Fineberg and Gale, 2005 ; Denys, 2006 ; Gupta et al., 2019 ). For this highly refractory patient group, ablative neurosurgery* and deep brain stimulation* (DBS) remain modalities to be considered. These procedures are usually delivered as an adjunct to existing pharmacological treatments, and CBT is frequently also administered, either during the acute treatment phase or follow-up. DBS is considered an experimental treatment, but has an FDA ‘humanitarian device exemption’ for severe refractory OCD ( US Food and Drug Administration, 2009 ).

Stereotactic neurosurgical procedures for intractable OCD have been available for >50 years ( Miguel et al., 2019 ). The procedures include dorsal anterior cingulotomy and anterior capsulotomy and are reserved for the most severe, treatment nonresponsive patients. A systematic review involving 10 studies and 193 participants suggested both procedures were efficacious ( Brown et al., 2016 ). The authors reported a mean Y-BOCS reduction of 37% for cingulotomy and 57% for capsulotomy. The rates of serious or permanent adverse events were 5.2% in the cingulotomy studies and 21.4% in the capsulotomy studies. Another recent review of publications on anterior capsulotomy spanning over five decades ( Pepper et al., 2019 ) reported ‘significant clinical response’ in 73–90% of patients and ‘remission’ in 24–39% of patients with treatment-resistant OCD.

DBS was investigated as a partially reversible alternative to surgical ablation ( Nuttin et al., 1999 ). The original stimulation target was similar to the site of anterior capsulotomy, that is, ventral capsule/ventral striatum (VC/VS). Three reasonably sized studies have provided evidence in favour of the acute efficacy of DBS in the VC/VS. The first involved 24 patients who were followed up to four years and reported a 37% median improvement in baseline Y-BOCS scores ( Luyten et al., 2016 ). ‘ON’ phases of stimulation were compared with ‘OFF’ phases (no stimulation), demonstrating that improvements were unlikely to represent ‘placebo’ effects. The second study investigated 16 patients, initially as open label, reporting a 46% reduction in baseline Y-BOCS at 8 months as well as a significant difference (25%) in Y-BOCS scores when compared with sham stimulation in a subsequent month-long double-blind phase ( Denys et al., 2010 ). A recent 12-month multicentre study of 30 patients given VC/VS DBS ( Menchón et al., 2019 ) reported a mean reduction of baseline Y-BOCS of 42%. Sixty percent of patients were responded (reduction in baseline Y-BOCS > 40%).

The long-term benefits of VC/VS DBS are less certain. An open-label follow up study of 10 patients ( Greenberg et al., 2006 ) reported a reduction in mean Y-BOCS from 34.67 at baseline (severe) to 22.37 (moderate) at 36 months. In addition, significant improvements in global functioning, depression and anxiety persisted.

The anteromedial subthalamic nucleus (amSTN) has been identified as another promising target for DBS in OCD. Sixteen patients were randomized according to a crossover design to either 3 months active or sham treatment, resulting in a significantly greater reduction in mean Y-BOCS in the stimulation versus sham group (endpoint 19 ± 8 versus 28 ± 7) ( Mallet et al., 2008 ). It remains unclear whether VC/VS holds any advantage over amSTN DBS. A recent ‘mechanism of effect’ study of six OCD patients, in which electrodes were implanted in both these sites, found differential improvements in mood (VC/VS) and cognitive flexibility (amSTN), suggesting that DBS exerts therapeutic effects at these targets via different brain networks ( Tyagi et al., 2019 ).

There have been no head-to-head trials comparing ablative neurosurgery with DBS. A recent review ( Pepper et al., 2015 ) retrospectively evaluated 20 studies of varying methodological quality involving 62 patients who underwent DBS of the VC/VS or the nucleus accumbens and 108 patients who underwent anterior capsulotomy. The capsulotomy group showed a significantly higher (51%) mean reduction in Y-BOCS than the DBS group (40%). No difference in surgical complication rates was observed. Adverse events across both modalities included intracranial haemorrhage (2–5%), persisting postoperative side effects (5–7%), cognitive and personality changes (7–13%) and suicide (1–2%). Weight gain (defined by an increase >10%) was significantly higher in the capsulotomy group (29 versus 3%). In other studies ( Mallet et al., 2008 ; Menchón et al., 2019 ), hypomania after electrode implantation is commonly (6%) reported.

In summary, studies of both DBS and ablative neurosurgery have shown these techniques are clinically effective for this highly refractory and extremely chronically disabled patient group. However, there is as yet insufficient evidence to determine which technique to choose at an individual patient level. Further clarification of the differential effects of ablation and stimulation across the different candidate neural targets, as well as better understanding of the interaction between somatic, pharmacological and psychological interventions, have the potential to advance the field towards a personalized approach. Agreement over standardized patient selection and treatment protocols that would allow clinical outcomes data to be collected and compared across treatment centres, represents an achievable milestone towards this goal ( Menchón et al., 2019 ). Meanwhile, technological innovations, for example, MRI-guided focussed ultrasound, laser interstitial thermal therapy ( Miguel et al., 2019 ), offer potential for safer and more cost-effective surgical approaches.

Future directions for research

Problematic usage of the internet.

Problematic use of the internet (PUI) is an umbrella term for a range of repetitive functionally impairing compulsive behaviours including gambling, gaming, sexual behaviour, shopping, video-streaming or social media use. While advances have been made in defining diagnostic criteria and developing rating scales for some forms of PUI (e.g., Gaming Disorder) ( Király et al., 2015 ), a considerable amount of research is needed to understand better the broad range of PUI phenomena and translate the known behavioural phenotypes into valid and reliable diagnostic criteria and assessment tools, to facilitate the systematic investigation of aetiological factors and brain-based mechanisms, as a platform for the development of preventive and therapeutic interventions ( Fineberg et al., 2018c ).

Significant cross-sectional associations between PUI and OCD symptoms have been found ( Carli et al., 2013 ). For example, in a two-site international online survey, ADHD and social anxiety disorder were associated with high PUI scores in young participants, whereas OCD and generalized anxiety disorder were associated with high PUI scores in older participants ( Ioannidis et al., 2018 ).

Novel digital interventions in obsessive-compulsive disorder

Digital technology offers new opportunities for monitoring and interventions. The extensive use of smartphones and the vast amounts of information they contain has positioned them as a proxy for behavioural and social interactions ( WHO, 2016 ). Harnessing smartphone technology along with smart wearables (e.g., smart watches) is expected to be a valuable source of continuous, objective and reliable data for clinical characterization, behavioural monitoring and treatment support ( Marzano et al., 2015 ). This is true for several disorders, but especially true for obsessive-compulsive problems such as PUI, as the digital media that is directly linked to the disorder is the same one that can accurately monitor the behaviour ( Ferreri et al., 2019 ).

Accordingly, using digital technology along with big data analyses may enable the potential to characterize the ‘digital phenotype’ of the disorder ( Ferreri et al., 2019 ) and to identify those individuals most at risk (e.g., by monitoring online internet usage in comparison with changes in diurnal variation, lack of human contact, lack of geographical movement, restricted circles of friends, etc.). A research avenue in this direction is to use (real time) big data analysis, alongside machine learning algorithms, to establish identifiable OCRD-specific illness patterns and use those real-time results to create an immediate feedback loop with the patient, which could then be used therapeutically by providing direct feedback on their behaviour and progress.

Other forms of active online intervention have become increasingly available for OCRD ( Whiteside et al., 2013 ) and may potentially enhance and facilitate treatment adherence ( Andersson et al., 2014 ; Marzano et al., 2015 ). For example, WhatsApp group interventions, in which the patient reports to their clinician, in real time, their difficulties, daily achievement and progress, enable continual communication, real-time reporting, prompt responses and rapid intervention when needed. In addition, the digital intervention may serve as a platform for continuous monitoring of tasks delivered in face-to-face meetings. Another example of existing digital interventions is the proactive use of webcams and smartphone cameras. Using this domain and with patient’s consent, the clinician has the opportunity to monitor patients in their natural environment. As the digital platform bridges the elapsed time between therapeutic sessions, it overcomes geographical distances and enables therapeutic practice in the patient’s natural environment ( WHO, 2016 ), where symptoms are manifested daily. In addition to enriching the clinical picture by direct observation of symptoms, it confers the general assertive outreach benefits of telemedicine, which can be critical for otherwise difficult to treat socially isolated patients who cannot access help otherwise.

In practice, this approach breaks down the traditional terminology of ‘outpatient’, ‘in-patient’ and ‘day hospitalization’, by allowing real time, objective and continuous monitoring ( WHO, 2016 ). The combination of digital monitoring and online communication produces a form of ‘virtual hospitalization’, enabling comprehensive and intensive treatment by offering continued monitoring and delivery of therapy in the patient’s natural environment, where the OCD usually occurs, and not within the artificial setting of the clinic. While such approaches are still under development, digital tools seem to bear great potential and may change the landscape of treatment in OCRDs, providing potentially cost-effective alternatives to hospitalization or outpatient clinics.

Immunological therapies

Inflammation and release of inflammatory cytokines affect brain circuitry involving both reward and threat-sensitivity, producing potentially adaptive and beneficial behavioural responses ( Raison and Miller, 2013 ). There is growing evidence of dysfunctional immunological function in the pathogenesis of a significant subset of OCD patients. Elevated levels of basal ganglia antibodies have been detected in adult OCD patients’ plasma compared with psychiatric control groups ( Nicholson et al., 2012 ). In addition, significantly increased levels of CSF autoantibodies directed against basal ganglia and thalamus were found among drug-naive OCD patients, and were associated with increased levels of CSF glutamate and glycine, indicating underpinning abnormalities in excitatory neurotransmission and correlating with hyperactivity in the ventral cognitive circuit ( Bhattacharyya et al., 2009 ). Translocator protein distribution volume, a marker of the microglial component of neuroinflammation, was found to be significantly elevated in the CSTC circuit of OCD subjects compared with healthy controls, demonstrating inflammation within the neurocircuitry extending beyond the basal ganglia, and affecting the adult population rather than solely childhood OCD ( Attwells et al., 2017 ).

A common genetic link may explain an excess of some autoimmune comorbidities. For example, in the acute paediatric onset subset of children (PANDAS), there is immunological cross-reactivity with epitopes associated with streptococcal infection expressed on the surface of basal ganglia neurons. About 20% of the mothers of children fulfilling criteria for PANDAS ( Chang et al., 2015 ) had at least one autoimmune disease. Multigenerational studies also show that OCD patients’ relatives are more likely to have an autoimmune disease such as Sjögren’s syndrome, coeliac disease, Guillian Barrè, Crohn’s disease, Hashimotos Thyroiditis, type I diabetes mellitus, ulcerative colitis, multiple sclerosis and psoriasis vulgaris ( Mataix-Cols et al., 2018 ). A subset of patients with PANDAS with motor symptoms demonstrated antineural antibodies against dopamine (D1) receptors as well as elevated antibodies against tubulin, lysoganglioside and higher activation of calmodulin-dependent protein kinase II (Cox et al ., 2015).

Immunomodulatory therapy represents a new field of investigation in OCD. While treatment with antimicrobials has delivered inconsistent results ( Burchi and Pallanti, 2018 ), other immunological modulators, such as celecoxib* ( Shalbafan et al., 2015 ) and nonspecific nonsteroidal anti-inflammatory drugs ( Spartz et al., 2017 ), have produced some positive findings, the latter only in a subset of young people. Thus, evidence of the usefulness of this approach in OCD remains insufficient. Nevertheless, researchers and clinicians should consider genetic and immunological profile differences in the search for precise individualized therapy for OCD.

Novel forms of psychotherapy

Although it may seem logical to try to tackle OCD using cognitive therapy, little evidence suggests that it offers any advantage to graded exposure and self-imposed response prevention ( Tyagi et al., 2010 ; Ougrin, 2011). Poorly applied cognitive therapy, such as that expecting patients to re-evaluate actual dangers, may make some patients with OCD worse. This is because the process of looking for evidence to confirm or refute the obsessions can become incorporated into rituals. Cognitive therapy may also turn out to be less cost-efficient, as it requires more training and supervision for the therapist and usually takes more time in therapy. It is therefore probably best used in situations where there is OCD refractory to ERP therapy ( Drummond and Edwards, 2018 ).

Rational emotive therapy, on the other hand, has been shown to have some possible beneficial effects in OCD ( Emmelkamp et al., 1988 ). Australian researchers have developed danger ideation reduction therapy (DIRT), using rational emotive therapy but with instructions not to undergo exposure for patients with contamination fears; good outcomes in case reports and some small controlled trials have been found ( Jones and Menzies, 1998 ; Krochmalik et al., 2001 ; Maqbool et al., 2017 ). The techniques used in DIRT include cognitive restructuring using rational emotive therapy ( Ellis, 1962 ); filmed interviews with people who work in feared situations; corrective information about the real risks of ‘contamination’ as opposed to the deleterious effects of overzealous hand-washing and attentional focussing whereby patients are taught to focus the mind away from the danger-related intrusive thoughts.

In recent years, the so-called Third Wave Therapies have been used in a number of psychiatric conditions ( Pérez Álvarez, 2012 ). The therapy of this type most commonly used in OCD is mindfulness, which teaches an individual to focus on the world around them rather than their internal dialogue. A recent study demonstrated that both cognitive restructuring and also mindfulness led to a small improvement in Y-BOCS score when compared with waiting list controls. However, the strength of efficacy for both treatments appeared to be less than that generally found with ERP ( Rupp et al., 2019 ). Despite promising results for metacognitive therapy in patients with OCD in case series, a full controlled trial has yet to be performed ( Melchior et al., 2019 ).

Many OCD patients describe their compulsions as habitual, that is, fixed ‘stimulus-response ’acts that, through habit learning, occur automatically in response to a specific environmental trigger. Habit reversal therapy (HRT) ( Azrin and Nunn, 1973 ) is a long-established form of therapy that helps patients alter habitual performance through a variety of behavioural methods. HRT is reported to be efficacious for the treatment of Tourette syndrome and Tic Disorders and has more recently been applied with success in OCRDs such as trichotillomania and skin picking behaviours. However, there remains a scarcity of evidence from controlled trials to support the efficacy of HRT in OCRDs in general and OCD in particular (Lee et al ., 2019a). Emerging neurosciences evidence identifying faulty habit learning in OCD (Fineberg et al ., 2018a) suggests further study of HRT in OCD would be worthwhile.

Pharmacogenetics

Pharmacogenetics or pharmacogenomics define genetic variants that influence either drug metabolism, delivery, affinity to receptors or transporters may contribute to the prediction of drug efficacy or toxicity, promoting precision medicine (Hess et al ., 2015). Because approximately one-quarter of OCD patients do not respond to treatment with either SSRIs or CBT alone, or their combination ( Hirschtritt et al., 2017 ), it has been suggested that pharmacogenetics may contribute to better drug-response prediction and side effect tolerance ( Zai et al., 2014 ).

Currently, several pharmacogenetic approaches using hypothesis-free GWAS have been conducted into the association between candidate genes and drug response in OCD patients ( Di Bella et al., 2002 ; Denys et al., 2007 ; Van Nieuwerburgh et al., 2009 ; Miguita et al., 2011 ; Grünblatt et al., 2014 ; Zai et al., 2014 ; Umehara et al., 2015 ; Mas et al., 2016 ; Qin et al., 2016 ; Umehara et al., 2016 ; Taj et al ., 2018; Lisoway et al., 2018 ; Sina et al., 2018 ; Abdolhosseinzadeh et al., 2019a , b ; Alizadeh et al., 2019 ). The candidate genes investigated belong to: (1) pharmacokinetic regulating genes, such as the CYP450 liver enzymes such as CYP2D6 and CYP2C19; (2) serotonergic systems, such as SLC6A4 and its promoter, HTTLPR, HTR2A, HTR2C, HTR1B and TPH2; (3) glutamatergic systems, such as SLC1A1, DLGAP2, DLGAP2, GRIN2B, GRIK2, SLIT, SLITRK5; (4) dopaminergic systems, such as COMT, MAOA, DRD2 and DRD4 and (5) other systems, such as BDNF, NTRK3, MOG, OLIG2 and DISP1.

Currently, no consensus with sufficiently robust results exists in the pharmacogenetics of OCD, due to the fact that many studies used naturalistic approaches, did not employ double blinded designs or crossed over with the tested drug, used a variety of drugs and doses, as well as used various cutoffs and measures determining response. Although there is still a need systematically to assess the pharmacogenetic link between treatment response (to SSRIs, tricyclics, antipsychotics, clomipramine, etc.) and certain genes, some data are already available, though very limited, on the Internet (e.g., https://www.pharmgkb.org ; Whirl-Carrillo et al., 2012 ) summarizing some findings on pharmacogenetics of some drugs and giving some recommendations aligning with those of the FDA, European Medicine Agency, Pharmaceutical and Medical Devices Agency, Japan and Health Canada (Sante Canada).

Until just 40 years ago, OCD was considered rare, of psychological origin and without effective treatment. Now, all have changed; the finding in the 1970s and 1980s that serotonergic medication (clomipramine, followed by SSRIs) was effective ( Montgomery, 1980 ; Zohar et al., 1987 ; Zohar and Insel, 1987 ) opened the door to great interest in OCD ( Zohar, 2012 ). This led to the development of specific forms of psychological intervention (ERP) which replaced the dynamic approach and to a focus on the serotonergic system in the treatment and pathophysiology of OCD. As a result of neuroscience insights including endophenotype-based approaches (reviewed in Fineberg et al., 2018a ), OCD has been removed from the anxiety disorder grouping in the DSM-5 ( American Psychiatric Association, 2013 ) and ICD-11 ( WHO, 2018 ) and now stands at the head of a new family of OCRDs.

The realization that OCRDs as a group are different from other anxiety disorders has led to significant changes in understanding their impact (the prevalence of OCRD in the population is more than 9%) ( Carmi et al., 2019 , in submission) and to refinement of the treatment approach (e.g., focussing on the urge to perform compulsions and the need for higher doses of serotonergic medication).

This position statement highlights the major changes that have been taking place in the last few years in the field of OCD, in terms of conceptualization, diagnosis, assessment, intervention (with focus on early intervention), strategies for optimizing the efficacy of specific pharmacological intervention (SRI) with specific psychological intervention (ERP), the critical role of treatment of children and young adults and the importance of maintenance of well-being.

As new neuroscience insights are revealed, new therapeutic interventions are being explored (e.g., glutamatergic agents, dopaminergic modulators, etc.). This position statement also covers invasive and noninvasive neuromodulation as experimental interventions, including deep TMS (achieving FDA indication for OCD in 2018) ( US Food and Drug Administration, 2018 ).

Looking to the future, other exciting avenues for investigation include the use of digital tools to monitor (and eventually to diagnose OCRDs), better understanding of links between excessive Internet use and OCRDs, advanced genetic methods and new pharmacological domains (e.g., immunological systems). Indeed, it seems that the future was never so bright for OCRD patients. We trust that this position statement has managed to capture, describe, explain and shed light on many of these developments, including those in the front line of understanding and treatment of OCRD in the future.

Acknowledgements

The authors wish to acknowledge the members of the International College of Obsessive-Compulsive Disorders ( www.ICOCS.org ), who have contributed to the development of this article. With particular thanks for critically reviewing the statement and editing the manuscript, to Rajshekhar Bipeta, Julius Burkauskas, Artemisa Dores, Giacomo Grassi, Donatella Marazziti, Pedro Morgado and Humberto Nicolini. We grateful to the European College of Neuropsychopharmacology (ECNP) Obsessive-Compulsive and Related Disorders Research Network (OCRN) for providing monetary support for the open access article processing charges for this article. We are also grateful to the ECNP OCRN, American College of Neuropsychopharmacology and the World Psychiatric Association Scientific Section for Anxiety and Obsessive-Compulsive and Related Disorders, for providing networking support.

This article refers to studies funded by the National Institute for Health Research (NIHR) RFPB (Grant Reference Number PB-PG-0712-28044, NIHR RfPB PB-PG-1216-20005). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

N.A.F. was supported by a COST Action Grant (CA16207; European Network for Problematic Usage of the Internet; European Cooperation in Science and Technology; www.cost.eu .) and a NIHR grant [NIHR RfPB PB-PG-1216-20005; FEasibility and Acceptability of Transcranial Stimulation in Obsessive-Compulsive Symptoms (FEATSOCS)]. S.R.C. was supported by a Wellcome Trust Clinical Fellowship. E.H. was funded by DOD, and OPD-FDA. E.G. was funded by the University of Zurich.

All authors were involved in drafting the manuscript and agreed to its publication. All authors read and approved their sections of the final version of the manuscript.

Conflicts of interest

N.A.F. declares that in the past 3 years, she had held research or networking grants from the ECNP, UK NIHR, EU H2020, MRC, University of Hertfordshire. In the past 3 years, she had either accepted travel or hospitality expenses or both from the BAP, ECNP, RCPsych, CINP, International Forum of Mood and Anxiety Disorders, World Psychiatric Association and Indian Association for Biological Psychiatry. In the past 3 years, she had received payment from Taylor and Francis and Elsevier for editorial duties. In the past 3 years, she had accepted a paid speaking engagement in a webinar sponsored by Abbott. Previously, she had accepted paid speaking engagements in various industry supported symposia and have recruited patients for various industry-sponsored studies in the field of OCD treatment. She leads an NHS treatment service for OCD. She holds Board membership for various registered charities linked to OCD. She gives expert advice on psychopharmacology to the UK MHRA and NICE. S.W. has received royalties from Thieme, Hogrefe, Kohlhammer, Springer, Beltz in the last 5 years. Her work was supported by the Swiss National Science Foundation (SNF), diff. EU FP7s, HSM Hochspezialisierte Medizin of the Kanton Zurich, Switzerland, Bfarm Germany, ZInEP, Hartmann Müller Stiftung, Olga Mayenfisch, Gertrud Thalmann and Vontobel Fonds in the last 5 years. She received no honoraria from pharmaceutical or other industrial companies in the last 36 months. Outside professional activities and interests are declared under the link of the University of Zurich, https://www.uzh.ch/prof/ssl-dir/interessenbindungen/client/web . V.B. has received lecture honoraria from Lundbeck and Otsuka. V.B. is a clinical investigator in a clinical trial funded by Boeringher Ingelheim and has obtained competitive grant funding from a Pfizer Neuroscience Grant, the Nepean Medical Research Foundation, the University of Sydney, Western Sydney University, Western Sydney Local Health District and the Better Foundation. C.I.R. has served as a consultant for Allergan, BlackThorn Therapeutics, Rugen Therapeutics and Epiodyne, receives research grant support from Biohaven Inc. and a stipend from APA Publishing for her role as Deputy Editor at The American Journal of Psychiatry . J.M.M. has received honoraria and travel grants from Exeltis, Janssen, Servier, AbBiotics and Medtronic in the last 36 months. B.M.D. has received lecture honoraria from Lundbeck, Angelini, Janssen, Neuraxpharma, Arcapharma and Livanova. Y.C.J.R. has received grants from the Department of Biotechnology (DBT) and the Indian Council of Medical Research (ICMR) of the Government of India and is currently involved in a study funded by the National Institute of Mental Health (NIMH), USA. Y.C.J.R. is the lead author of the Indian Psychiatric Society (IPS) Clinical Practice Guidelines for Obsessive-Compulsive Disorder and is also the lead author of the Clinical Practice Guidelines for Cognitive Behaviour Therapies in Anxiety Disorders and Obsessive-Compulsive Related Disorders (in press). D.J.S. has received either research grants or consultancy honoraria from Lundbeck and Sun or both. S.P. declares funding from the National Institute of Mental Health, USA; R21 NCTID NCT03669315. J.Z. received grants and research support from Lundbeck, Servier, Brainsway, Pfizer and the DOD, honoraria and consultation fees from Lundbeck, Roche, Lilly, Servier, Pfizer. S.R.C. consults for Promentis and Ieso Digital Health. S.S.A. has received research funding grant from the Wellcome Trust-DBT India alliance and Indian Council of Medical Research. M.V.A. reports being on the Advisory Boards of Allergan, Almatica, Brainsway, Janssen, Lundbeck, Myriad Neuroscience, Otsuka and Purdue Pharma (Canada); M.V.A. is on the Speaker’s Bureau for Allergan, Lundbeck, Otsuka, Pfizer, Purdue Pharma (Canada) and Takeda; and has received research support from Janssen, Purdue Pharma (Canada), the Canadian Foundation for Innovation and Hamilton Academic Health Sciences Organization (HAHSO). D.A.M.D.G. has received grant or research support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development subcontract with Duke Clinical Research Center Pediatric Trials Network, Biohaven Pharmaceuticals, Neurocrine Biosciences, Nuvelution Pharma, Peace of Mind Foundation, Syneos Health and Teva Pharmaceutical Industries. He has served as a consultant to the Arlington Youth Counseling Center. He has served on the editorial board of Annals of Clinical Psychiatry . He has received honoraria from the Massachusetts Psychiatry Academy and the American Academy of Child and Adolescent Psychiatry. He has held stock options/ownership in Assurex Health and Revolutionary Road. R.G.G.S. receives a productivity grant from the National Council for Scientific and Technological Development, Brazilian Federal Government (CNPq). L.D. declares that she holds small investments in pharmaceutical and biotechnology firms, including AstraZeneca, Bioventic, Hikma Pharmaceutical, International Biotech Trust, Reneuron, Syncona and Yourgene. U.A. has received lecture honoraria from Lundbeck, Angelini, Janssen, Neuraxpharma and Innova Pharma. There are no conflicts of interest for the remaining authors.

Cited Here |
Google Scholar

evidence based; obsessive-compulsive disorder; position statement; treatments

+ Favorites
View in Gallery

Readers Of this Article Also Read

The effect of brexpiprazole (opc-34712) and aripiprazole in adult patients with ..., the efficacy of escitalopram in major depressive disorder: a multicenter..., a trial of quetiapine compared with risperidone in the treatment of first onset ..., differences in the dynamics of serotonin reuptake transporter occupancy may..., olanzapine therapy in anorexia nervosa: psychobiological effects.

Research article
Open access
Published: 17 March 2022

A prospective clinical cohort-based study of the prevalence of OCD, obsessive compulsive and related disorders, and tics in families of patients with OCD

Lior Carmi 1 , 2 ,
Vlasios Brakoulias 3 , 4 ,
Oded Ben Arush 2 ,
Hagit Cohen 5 &
Joseph Zohar 1 , 2

BMC Psychiatry volume 22 , Article number: 190 ( 2022 ) Cite this article

9002 Accesses

12 Citations

2 Altmetric

Metrics details

The lifetime prevalence of obsessive − compulsive disorder (OCD) is currently estimated at 2 − 3% and the prevalence in first-degree family members is estimated to range between 10 and 11%. Separating OCD from other anxiety disorders and including it into the new “obsessive − compulsive and related disorders” (OCRDs) category has had a dramatic impact on the diagnosis, while also contributing to the better understanding of the genetics of these disorders. Indeed, grouping OCD with body dysmorphic disorder (BDD), and body-focused repetitive behaviors such as trichotillomania (hair pulling), onychophagia (nail biting), and excoriation (skin picking) into the same diagnostic family has resulted in a much greater lifetime prevalence (> 9%). These diagnostic changes necessitate an updated epidemiological study, thus motivating this investigation.

The study sample comprised of 457 patient’s cases from an Israeli and an Australian OCD center. Interviews were completed as a part of the intake or during treatment in each of the centers. Prevalence of OCD, OCRDs, tics, and other psychiatric comorbidities in first- and second-degree relatives was assessed by interviewing the OCD patients. Interviews were conducted by at least two researchers (LC, OBA, JZ) and only family information on which the interviewers have reached consensus was considered.

Initial analyses revealed an increase of OCD and OCRD prevalence in first- and second-degree family members as compared to the current literature due to reclassification of these disorders in DSM-5.

The new category of OCRD has changed the landscape of epidemiological studies in OCD. Further and broader studies are needed in order to better understand the lifetime prevalence of OCRD in first- and second-degrees family member.

Peer Review reports

OCD is a global phenomenon, with a substantial similarity across cultures in symptom clusters, gender distribution, age of onset, and comorbidities [ 1 ]. Using the restricted DSM-5 definition (i.e., not including OCD-related disorders), the lifetime prevalence of OCD in the general population was calculated at 2–3% in several studies [ 2 , 3 ]. Those percentages have been confirmed across cultures [ 4 ] and are supported the biological basis of OCD. Although the cultural, economic, and social factors play a role in the presentation of OCD (that is, the content of obsessions and the shape of the compulsions), its prevalence is equally distributed across the globe.

Although several approaches have been used to evaluate the role of heredity in OCD, twin and family studies remain the most common, as they allow comparisons between concordant monozygotic twins and discordant monozygotic twins with OCD, as well as familial aggregation. Based on their literature review, Van Grootheest and colleagues estimated that OCD is inherited in 27% to 47% [ 5 ] while childhood-onset OCD has an even greater genetic component (45–65%) [ 6 , 7 , 8 ]. The role of genetics in OCD has also been investigated by establishing OCD prevalence in family members of OCD patients. Numerous family studies have demonstrated the familial genetic contribution of OCD incidence. While the frequency of OCD and subclinical OCD differed within families across studies, the overall conclusion was that OCD and subclinical OCD are familial [ 9 , 10 , 11 , 12 , 13 , 14 ].

In accordance, relatives of OCD patients are twice as likely to develop OCD than those of healthy subjects, while rates in relatives of children and adolescents with OCD showed a tenfold increase relative to controls [ 15 ]. Furthermore, based on their review and meta-analysis of the genetic epidemiology of OCD, Hettema et al. reported an aggregate odds ratio of 4, supporting the familial aggregation of OCD [ 16 ]. In other studies, OCD prevalence among relatives of affected individuals was significantly higher than either the estimated population prevalence or rate among controls [ 17 , 18 , 19 , 20 ]. Significantly higher percentage of OCD cases was also reported by Grabe and colleagues in relatives of affected individuals based on both clinical and a general population study [ 21 ].

Tourette syndrome (TS) is a childhood-onset, neuropsychiatric disorder defined by multiple waxing and waning motor and phonic tics [ 14 ]. A related diagnosis, chronic tic disorder (CT), is characterized by persistent motor or phonic tics. Community surveys, conducted in various countries over the past twenty years provide estimates of prevalence for TS ranging from 0.5 and 38 cases per 1000 children [ 22 ]. Tourette syndrome/CT and OCD overlap in their phenomenological features, often cluster in families, and co-occur in affected individuals. About 30% of OCD patients have comorbid lifetime tic Disorders [ 23 ], and about 20% of TS/CT patients will suffer from OCD as well [ 24 ].

In DSM-5, OCD was separated from the anxiety disorders and was categorized within a new diagnostic category (denoted as ‘Obsessive–compulsive and related disorders’ or OCRDs), which includes, in addition to OCD, hoarding disorder, body dysmorphic disorder, and body-focused repetitive behaviors such as trichotillomania (hair pulling), onychophagia (nail biting), and excoriation (skin picking) [ 25 ].

Considering this spectrum-oriented view of OCRDs [ 26 ], its cumulative prevalence is estimated to be higher than that of OCD and can reach up to 9.5% [ 25 ]. The diversity of disorders subsumed under this new OCRDs category warrants an epidemiological study that takes these conceptual changes into account.

The study took place between September 2020 – February 2021. Cases of OCD patients from the Israeli Center for OCD and Nepean Hospital, Sydney, Australia were evaluated in this study. Interviews were completed as a part of the intake or during treatment in each of the centers. All patients met the criteria for OCD and scored > 15 on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) [ 27 ].

Diagnostic Procedure

The study was approved by both IRBs; The research Ethics Committee at Chaim Sheba Medical Center (‘International Review Board for human and animal trials’- No. 7204–20-SMC) and the Western Sydney Local Health District Human Research Ethics Committee at Nepean Hospital (‘Human Research Ethics Committee’ No. 2019/ETH01314). All subjects were interviewed by clinicians (psychiatrists or doctorate-level clinical psychologists) who had undergone extensive training in the diagnostic procedure.

In the Israeli cohort, demographic data, OCD domains, presence of other OCRDs or other comorbidities, as well as information on current and past tics was gathered during the interview, which also probed into the presence of OCD or OCRDs, other comorbidities, and current and past tics among family members and relatives. For the purpose of analyses, parents, children, and siblings were considered family members, whereas grandparents, uncles, aunts, cousins, etc. were considered second-degree relatives. In the Australian center, a structured clinical assessment was conducted using Mini Neuropsychiatric Diagnostic Interview, Y-BOCS, Shapiro tic severity scale, and Family history screen. However, patient’s OCRDs comorbidities were not evaluated.

Statistical analysis

Data analysis was performed using the IBM SPSS 25 software. Differences between the OCD sub-groups (i.e., Israeli vs. Australian patients; patients with vs. those without tics; individuals with vs. those without OCRD comorbidity) and the prevalence of OCRDs in the family were evaluated using a chi-squared test for independence (Mantel–Haenszel chi square), with Group (OCD patients with and without tics or OCRDs) as the independent variable and OCRD incidence in the family as the dependent variable. Mean differences in age were analyzed using t-test. The required p -value for significance was corrected (Pc) for the relevant number of comparisons.

The study sample comprised of 457 cases (222 recruited from the Israeli Center for OCD and 235 from Nepean Hospital in Australia). 103 patients were diagnosed with comorbidity, the main comorbidities were depression ( n = 23), Social anxiety ( n = 14), Addiction ( n = 15). No statistically significant differences were found in sex (f/m) distribution (Israeli cohort: 108/114; Australian cohort: 124/111), severity score as measured by Yale-Brown Obsessive Compulsive scale at baseline (YBOCS, Israeli cohort: Mean: 28, SD: 3.3; Australian cohort: Mean: 26, SD: 2.9), or number of patients. The patients in the Israeli cohort were found to be younger (Mean: 25.3 years; SD: 11.6 years) than those in the Australian cohort (Mean: 43.1; SD: 15.8), t (455) = -13.6, p < 0.001.

OCD and OCRD prevalence in family members

Seventy three percent of the entire OCD cohort (335/457) had first- and second-degree family members affected by OCRDs or OCD. The most common disorders were: OCD ( n = 197, 43%), Hoarding ( n = 98, 21%), BDD ( n = 47, 10%). No statistically significant difference was found in the OCRD prevalence in the nuclear families of Israeli and Australian cohorts (147/222 or 66% vs. 145/235 or 62%, p > 0.05). However, higher prevalence of both OCD and OCRDs in the second-degree relatives was noted in the Israeli cohort (30/222, 13%) relative to the Australian cohort (13/235, 6%, χ 2 = 8.5, p = 0.003), as shown in Fig. 1 . (Please see Table 1 for demographical characteristics).

Percentages of OCD or OCRDs in family members. Percentages of OCD or OCRDs in the family of the Israeli ( A ) and Australian ( B ) patients, and general ( C ) cohorts. ** p = 0.003

Tic syndrome was identified in 133 (29%) patients, with significantly higher percentage within the Israeli cohort (105, 47%) relative to the Australian cohort (28, 12%; χ 2 = 69.1, p < 0.0001). In the entire cohort, tic syndrome was identified in 130 (28%) family members (first- and second-degree). However, the prevalence of tics within the family (first- and second-degree) of patients with tics was significantly higher (50%) compared to patients without tics (19%, χ 2 = 44.2, p < 0.001). This pattern was observed when the Israeli (63% vs. 41%, χ 2 = 10.5, p < 0.001) and the Australian (14% vs 6%, χ 2 = 2.7, p < 0.05) cohorts were analyzed separately, as shown in Fig. 2 .

Family’s prevalence of tics of patients with and without tics. Prevalence of tics in family members (first- and second-degree) of patients with and without tics: ( A ) Israeli cohort, ( B ) Australian center. A Overall risk – 51%, risk difference – 22%, risk ratio – 1.5. B Overall risk – 7%, risk difference 8%, risk ratio – 2.4

In addition, OCRD prevalence in the family (first- and second-degree) of patients with tics (χ 2 = 7.1, p = 0.003) and other OCRD comorbidities (χ 2 = 5.9, p = 0.007) was higher compared to patients without tics or OCRD as shown in Fig. 3 .

Family’s prevalence of OCRD of patients with or without tics. Prevalence of OCRD in the family of ( A ) patients with ( n = 133) or without tics ( n = 324) and ( B )*Only within the Israeli cohort, segregated into patients with ( n = 93) and without OCRD comorbidities ( n = 129). A Overall risk – 73% (CI: 69 − 77.1%), risk difference – 12.2% (CI: 4 − 20%), risk ratio – 1.17 (CI: 1 − 1.3). B Overall risk – 79.2% (CI: 73.4 − 84.1%), risk difference – 13.4% (CI: 3.2 − 23.6%), risk ratio – 1.2 (CI: 1 − 1.3)

In accordance with the inclusion of OCD as a part of the OCRD chapter in DSM-5, we evaluated the OCRD prevalence in family members of OCD patients in Israel and Australia. Our analyses revealed that 73% of the cohort had a first- or second-degree family member with an OCRD. Although higher than previous reported prevalence, former studies (focused only on OCD and Tic disorder) have also found a significant genetic contribution both in Tic and Obsessive- compulsive disorders and a shared genetic architecture [ 14 , 28 ].

While the OCRD prevalence within the nuclear family was similar between the sites, the prevalence within second-degree relatives was higher in the Israeli cohort relative to the Australian sample, which can be attributed to the difference in the number of family members in these countries (according to https://data.oecd.org/pop/fertility-rates.htm , fertility in Israel is 3.1 vs 1.7 in Australia). It is also likely due to the younger Israeli cohort, and thus perhaps a greater number of second-degree relatives who are still alive. The discrepancy in findings could also be explained by the differences in the data collection process, as structured interviews were conducted at the Australian site, whereas Israeli patients were subjected to a detailed interview. It should also be noted that the Australian site was located in an area of Sydney where many migrants live and work, to the extent that approximately 50% of the population was born overseas. As a result, patients that were recruited for the study may not have seen their relatives for many years and may not be aware of OCD symptoms or tics in their relatives.

Increased prevalence of tics was also noted in the Israeli cohort relative to the Australian subjects, which could again be ascribed to younger age and differences in data processing methods but also to the higher family aggregation and endogamy [ 29 ]. Specifically, tics tend to affect younger individuals more than older patients [ 30 ], and would thus be more prevalent in the Israeli cohort. It is also worth noting that, in the Australian center, data regarding tics was obtained via structured interviews and self-report questionnaires, while this information was gathered during a clinical interview at the Israeli center. Active assessment and observation for tics in the Israeli cohort may have led to an increased potential for detecting tics, resulting in more accurate prevalence. Indeed, the prevalence of tics within the Israeli cohort (47%) is in line with the results yielded by extant studies (e.g., [ 23 ]).

Nearly 30% of the cohort had a family member that suffered from tic disorder. This is in line with former studies that have shown high prevalence of comorbidity and with comorbidity likeliest to occur in their childhood-onset forms [ 11 , 31 ]. More recent study has shown common neurological basis of both disorders [ 32 ]. Specifically, Converging evidence from animal studies and neuroimaging studies suggests that dysfunction in cortical basal ganglia circuitry mediates tics and compulsive behaviors, supporting a role for shared biological vulnerability [ 33 , 34 ]. Accordingly, the prevalence of tics or OCRD in the family was significantly associated with the patient’s condition and was significantly higher in families of patients that also suffered from tics or OCRD. As this pattern was observed in both Israeli and Australian sample, it may imply a meaningful contribution of genetic loading in OCRD and tic disorder. These results are congruent with the findings yielded by prior family studies in which OCD symptoms were more frequent among family members of patients diagnosed with Tourette’s syndrome (TS) [ 35 ]. Leonard et al. also noted higher TS and tic prevalence in first-degree relatives of children with OCD [ 11 ]. This is also in line with previous studies, that although focused on OCD per se (and not OCRD), have found that genetic factors play an important role in its etiology, particularly in patients with comorbid tic disorder [ 36 , 37 ].

When interpreting these findings, several study limitations should be noted. First, the data collection process was not harmonized across the two centers. Specifically, while the data from the Australian center was collected through validated structured assessments and questionnaires, in the Israeli center, a clinical interview was conducted with the patients. Second, as none of the family members were interviewed, the prevalence reported in this manuscript is based on patient accounts and may relate to OCD symptoms rather than a formal diagnosis. Finally, the time of onset of the disorder (and specifically early onset) is found to be related to Tics comorbidity. However, this data was not assessed in the entire cohort and therefore was not analyzed.

In conclusion, there appear to be high rates of familial prevalence in OCD that are further increased by the presence of tics and OCRD. Further studies are thus required to assess the genetic relationship more accurately between OCD and tic disorder.

Availability of data and materials

All data is available upon request.

Abbreviations

Obsessive compulsive Disorder

Obsessive compulsive and related disorder.

Tourette syndrome

Chronic Tics

Lochner C, Fineberg NA, Zohar J, Van Ameringen M, Juven-Wetzler A, Altamura AC, et al. Comorbidity in obsessive–compulsive disorder (OCD): A report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS). Compr Psychiatry. 2014;55(7):1513–9.

Article Google Scholar

Karno M, Golding JM, Sorenson SB, Burnam MA. The epidemiology of obsessive-compulsive disorder in five US communities. Arch Gen Psychiatry. 1988;45(12):1094–9.

Article CAS Google Scholar

Robins LN, Helzer JE, Weissman MM, Orvaschel H, Gruenberg E, Burke JD, et al. Lifetime prevalence of specific psychiatric disorders in three sites. Arch Gen Psychiatry. 1984;41(10):949–58.

Weissman MM. Cross-national epidemiology of obsessive-compulsive disorder. CNS Spectr. 1998;3(S1):6–9.

Van Grootheest DS, Cath DC, Beekman AT, Boomsma DI. Twin studies on obsessive–compulsive disorder: a review. Twin Res Hum Genet. 2005;8(5):450–8.

Bolton D, Rijsdijk F, Eley TC, O’Connor TG, Briskman J, Perrin S. Normative childhood repetitive routines and obsessive compulsive symptomatology in 6-year-old twins. J Child Psychol Psychiatry. 2009;50(9):1139–46.

Iervolino AC, Rijsdijk FV, Cherkas L, Fullana MA, Mataix-Cols D. A multivariate twin study of obsessive-compulsive symptom dimensions. Arch Gen Psychiatry. 2011;68(6):637–44.

Moore J, Smith GW, Shevlin M, O’Neill FA. Alternative factor models and heritability of the Short Leyton Obsessional Inventory—Children’s Version. J Abnorm Child Psychol. 2010;38(7):921–34.

Chabane N, Delorme R, Millet B, Mouren MC, Leboyer M, Pauls D. Early-onset obsessive-compulsive disorder: a subgroup with a specific clinical and familial pattern? J Child Psychol Psychiatry. 2005;46(8):881–7.

Lenane MC, Swedo SE, Leonard H, Pauls DL, Sceery W, Rapoport JL. Psychiatric disorders in first degree relatives of children and adolescents with obsessive compulsive disorder. J Am Acad Child Adolesc Psychiatry. 1990;29(3):407–12.

Leonard HL, Lenane MC, Swedo SE, Rettew DC, Gershon ES, Rapoport JL. Tics and Tourette’s disorder: a 2-to 7-year follow-up of 54 obsessive-compulsive children. Am J Psychiatry. 1992;149(9):1244–51.

Reddy PS, Reddy YJ, Srinath S, Khanna S, Sheshadri S, Girimaji S. A Family Study of Juvenile Obsessive—Compulsive Disorder. Can J Psychiatry. 2001;46(4):346–51.

Riddle MA, Scahill L, KING R, HARDIN MT, TOWBIN KE, ORT SI, et al. Obsessive compulsive disorder in children and adolescents: phenomenology and family history. J Am Acad Child Adolesc Psychiatry. 1990;29(5):766–72.

Browne HA, Hansen SN, Buxbaum JD, Gair SL, Nissen JB, Nikolajsen KH, et al. Familial Clustering of Tic Disorders and Obsessive-Compulsive Disorder. JAMA Psychiat. 2015;72(4):359–66.

Stewart SE, Pauls DL. The genetics of obsessive-compulsive disorder. Focus. 2010;8(3):350–7.

Hettema JM, Neale MC, Kendler KS. A review and meta-analysis of the genetic epidemiology of anxiety disorders. Am J Psychiatry. 2001;158(10):1568–78.

Albert U, Maina G, Ravizza L, Bogetto F. An exploratory study on obsessive-compulsive disorder with and without a familial component: are there any phenomenological differences? Psychopathology. 2002;35(1):8–16.

D LIPSITZ J, Mannuzza S, Chapman TF, Foa EB, Franklin ME, D GOODWIN R, et al. A direct interview family study of obsessive¿ compulsive disorder. II. Contribution of proband informant information. Psychol Med. 2005;35(11):1623–31.

Fyer AJ, D LIPSITZ J, Mannuzza S, Aronowitz B, Chapman TF. A direct interview family study of obsessive-compulsive disorder. I. Psychol Med. 2005;35(11):1611.

Nestadt G, Samuels J, Riddle M, Bienvenu OJ, Liang K-Y, LaBuda M, et al. A family study of obsessive-compulsive disorder. Arch Gen Psychiatry. 2000;57(4):358–63.

Grabe HJ, Ruhrmann S, Ettelt S, Buhtz F, Hochrein A, Schulze-Rauschenbach S, et al. Familiality of obsessive-compulsive disorder in nonclinical and clinical subjects. Am J Psychiatry. 2006;163(11):1986–92.

Scahill L, Specht M, Page C. The prevalence of tic disorders and clinical characteristics in children. J Obsessive-Compuls Relat Disord. 2014;3(4):394–400.

Richter MA, Summerfeldt LJ, Antony MM, Swinson RP. Obsessive–compulsive spectrum conditions in obsessive-compulsive disorder and other anxiety disorders. Depress Anxiety. 2003;18(3):118–27.

Leckman JF, Walker DE, Goodman WK, Pauls DL, Cohen DJ. “ Just right” perceptions associated with compulsive behavior in Tourette’s syndrome. Am J Psychiatry. 1994;151(5):675–80.

Geddes JR, Andreasen NC. New Oxford textbook of psychiatry: Oxford University Press, USA; 2020, 987–999

Zohar J. From Obsessive-Compulsive Spectrum to Obsessive-Compulsive Disorders: The Cape Town Consensus Statement. CNS spectrums. 2007;12(S3):4

Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, Hill CL, et al. The Yale-Brown obsessive compulsive scale I Development, use, and reliability. Arch Gen Psychiatry. 1989;46(11):1006–11.

Monzani B, Rijsdijk F, Harris J, Mataix-Cols D. The structure of genetic and environmental risk factors for dimensional representations of DSM-5 obsessive-compulsive spectrum disorders. JAMA Psychiat. 2014;71(2):182–9.

Granot-Hershkovitz E, Karasik D, Friedlander Y, Rodriguez-Murillo L, Dorajoo R, Liu J, et al. A study of Kibbutzim in Israel reveals risk factors for cardiometabolic traits and subtle population structure. Eur J Hum Genet. 2018;26(12):1848–58.

Knight T, Steeves T, Day L, Lowerison M, Jette N, Pringsheim T. Prevalence of tic disorders: a systematic review and meta-analysis. Pediatr Neurol. 2012;47(2):77–90.

Frankel M, Cummings JL, Robertson MM, Trimble MR, Hill MA, Benson DF. Obsessions and compulsions in Gilles de la Tourette's syndrome. Neurology. 1986;36(3):378-.

Nordstrom E, Burton F. A transgenic model of comorbid Tourette’s syndrome and obsessive-compulsive disorder circuitry. Mol Psychiatry. 2002;7(6):617–25.

Lewis M, Kim S-J. The pathophysiology of restricted repetitive behavior. J Neurodev Disord. 2009;1(2):114–32.

Muehlmann A, Lewis M. Abnormal repetitive behaviours: shared phenomenology and pathophysiology. J Intellect Disabil Res. 2012;56(5):427–40.

Pauls DL, Alsobrook JP, Goodman W, Rasmussen S, Leckman JF. A family study of obsessive-compulsive disorder. The American journal of psychiatry. 1995

De Mathis MA, Diniz JB, Shavitt RG, Torres AR, Ferrão YA, Fossaluza V, et al. Early onset obsessive-compulsive disorder with and without tics. CNS Spectr. 2009;14(7):362–70.

Brander G, Kuja-Halkola R, Rosenqvist MA, Rück C, Serlachius E, de la Cruz LF, et al. A population-based family clustering study of tic-related obsessive-compulsive disorder. Mol Psychiatry. 2021;26(4):1224–33.

Download references

Acknowledgements

We want to thank Ms. Roni Meir for her help in collecting the data.

Author information

Authors and affiliations.

Chaim Sheba Medical Center, Post Trauma Center, Ramat-Gan, Israel

Lior Carmi & Joseph Zohar

Israeli Center for the Treatment of Obsessive−Compulsive and Related Disorders, Modiin, Israel

Lior Carmi, Oded Ben Arush & Joseph Zohar

Western Sydney Obsessive−Compulsive and Related Disorders Service, Western Sydney Local Health District – Mental Health Services, North Parramatta, Australia

Vlasios Brakoulias

School of Medicine and Translational Health Research Institute, Western Sydney University, Sydney, Australia

Ministry of Health, Anxiety and Stress Research Unit, Faculty of Health Sciences, Beer-Sheva Mental Health Center, Ben-Gurion University of the Negev, Be’er Sheva, Israel

Hagit Cohen

You can also search for this author in PubMed Google Scholar

Contributions

LC, OBA and VB collected the data, LC wrote the first draft of the manuscript; LC and HC analyzed the data, VB and JZ edited the final version of the manuscript. All authors have read and approved the manuscript.

Corresponding author

Correspondence to Joseph Zohar .

Ethics declarations

Ethics approval and consent to participate.

The study was approved by both IRB committees. All patients were written consented to evaluate their clinical files.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Carmi, L., Brakoulias, V., Arush, O.B. et al. A prospective clinical cohort-based study of the prevalence of OCD, obsessive compulsive and related disorders, and tics in families of patients with OCD. BMC Psychiatry 22 , 190 (2022). https://doi.org/10.1186/s12888-022-03807-4

Download citation

Received : 30 September 2021

Accepted : 23 February 2022

Published : 17 March 2022

DOI : https://doi.org/10.1186/s12888-022-03807-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Family members

BMC Psychiatry

ISSN: 1471-244X

General enquiries: [email protected]

Essential Papers on Obsessive-Compulsive Disorder

Information & authors, metrics & citations, view options, information, published in.

Export Citations

If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu .

Format

Citation style
Style

To download the citation to this article, select your reference manager software.

There are no citations for this item

View options

Already a subscriber? Access your subscription through your login credentials or your institution for full access to this article.

Purchase Options

Purchase this article to access the full text.

PPV Articles - American Journal of Psychiatry

Not a subscriber?

Subscribe Now / Learn More

PsychiatryOnline subscription options offer access to the DSM-5-TR ® library, books, journals, CME, and patient resources. This all-in-one virtual library provides psychiatrists and mental health professionals with key resources for diagnosis, treatment, research, and professional development.

Need more help? PsychiatryOnline Customer Service may be reached by emailing [email protected] or by calling 800-368-5777 (in the U.S.) or 703-907-7322 (outside the U.S.).

Share article link

Copying failed.

Next article, request username.

Can't sign in? Forgot your username? Enter your email address below and we will send you your username

If the address matches an existing account you will receive an email with instructions to retrieve your username

Create a new account

Change password, password changed successfully.

Your password has been changed

Reset password

Can't sign in? Forgot your password?

Enter your email address below and we will send you the reset instructions

If the address matches an existing account you will receive an email with instructions to reset your password.

Your Phone has been verified

As described within the American Psychiatric Association (APA)'s Privacy Policy and Terms of Use , this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences. Please read the entire Privacy Policy and Terms of Use. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies.

The Future of Obsessive-Compulsive Spectrum Disorders: A Research Perspective

First Online: 07 February 2021

Cite this chapter

T. Vats 9 ,
N. A. Fineberg 10 , 11 , 12 &
E. Hollander 9

Part of the book series: Current Topics in Behavioral Neurosciences ((CTBN,volume 49))

2772 Accesses

5 Citations

1 Altmetric

Obsessive-compulsive disorder (OCD) sits at the epicenter of a spectrum of related conditions (often referred to as obsessive-compulsive related disorders (OCRD) or obsessive-compulsive spectrum disorders (OCSD)) that can be as disabling as they are varied in presentation. Research in the field now encompasses diverse disciplines ranging from inflammatory mechanisms to computational psychiatry, to neurocognitive endophenotypes to functional imaging to pharmacogenomics to brain stimulation approaches. As these disorders become more clearly elucidated, there is a need to continually re-evaluate the implications of research findings and to incorporate these findings into new treatment approaches that benefit both patients and clinicians. Even the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5) is intended to be flexible and to incorporate validated and reliable biomarkers and neuroscience findings as they become available. This concluding chapter highlights just a few areas of study that promise to influence our understanding of the pathophysiology and clinical practice of OCRD. These include patient-centered outcomes research, the study of developmental brain trajectories in spectrum conditions, robot models of OCRDs, goal-directed versus habit-based behaviors, pharmacogenomics, problematic use of the Internet, and digital interventions. For example, digital medicine may become increasingly useful by identifying patients early on in the course of their illness; providing biomarkers to subtype patients; predicting treatment response; serving as a more proximal outcome measure of treatment response; or providing easily accessible and less costly forms of care. In order to address unmet clinical needs in OCRD, it is helpful to take an interdisciplinary perspective, and the work described in this collection of articles is likely to be invaluable in shaping the future of the field.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save.

Get 10 units per month
Download Article/Chapter or eBook
1 Unit = 1 Article or 1 Chapter
Cancel anytime
Available as PDF
Read on any device
Instant download
Own it forever
Available as EPUB and PDF
Compact, lightweight edition
Dispatched in 3 to 5 business days
Free shipping worldwide - see info
Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Obsessive–compulsive disorder

Toward identifying reproducible brain signatures of obsessive-compulsive profiles: rationale and methods for a new global initiative

Cognitive Behavioral Therapy for Obsessive–Compulsive Disorder: Theory, Assessment, and Treatment

Adams TG, Kelmendi B, Brake CA, Gruner P, Badour CL, Pittenger C (2018) The role of stress in the pathogenesis and maintenance of obsessive-compulsive disorder. Chronic Stress (Thousand Oaks), 2. https://doi.org/10.1177/2470547018758043 . Epub 2018 Mar 4

American Psychiatric Association (2013) Diagnostic and statistical manual of mental disorders (DSM-5). American Psychiatric Pub

Google Scholar

Andersen SL (2016) Commentary on the special issue on the adolescent brain: adolescence, trajectories, and the importance of prevention. Neurosci Biobehav 70:329–333

Article Google Scholar

Brandl EJ, Müller DJ, Richter MA (2012) Pharmacogenetics of obsessive–compulsive disorders. Pharmacogenomics 13(1):71–81. https://doi.org/10.2217/pgs.11.133

Article CAS PubMed Google Scholar

Casey BJ, Heller AS, Gee DG, Cohen AO (2017) Development of the emotional brain. Neurosci Lett. S0304-3940(17):30964–30963

Eisen JL, Sibrava NJ, Boisseau CL, Mancebo MC, Stout RL, Pinto A, Rasmussen SA (2013) Five-year course of obsessive-compulsive disorder: predictors of remission and relapse. J Clin Psychiatry 74(3):233–239

Fineberg NA, Sharma P, Sivakumaran T, Sahakian B, Chamberlain S (2007) Does obsessive compulsive personality disorder belong within the obsessive-compulsive spectrum? CNS Spectrums 12(6):467–482

Fineberg NA, Day GA, de Koenigswarter N, Reghunandanan S, Kolli S, Jefferies-Sewell K, Hranov G, Laws KR (2015) The neuropsychology of obsessive-compulsive personality disorder: a new analysis. CNS Spectr:1–10. [Epub ahead of print]

Fineberg NA, Apergis-Schoute AM, Vaghi MM, Banca P, Gillan CM, Voon V, Chamberlain SR, Cinosi E, Reid J, Shahper S, Bullmore ET, Sahakian BJ, Robbins TW (2018a) Mapping compulsivity in the DSM-5 obsessive compulsive and related disorders: cognitive domains, neural circuitry, and treatment. Int J Neuropsychopharmacol 21(1):42–58. https://doi.org/10.1093/ijnp/pyx088

Fineberg NA, Baldwin DS, Drummond LM, Wyatt S, Hanson J, Gopi S, Kaur S, Reid J, Marwah V, Sachdev RA, Pampaloni I, Shahper S, Varlakova Y, Mpavaenda D, Manson C, O'Leary C, Irvine K, Monji-Patel D, Shodunke A, Dyer T, Dymond A, Barton G, Wellsted D (2018b) Optimal treatment for obsessive compulsive disorder: a randomized controlled feasibility study of the clinical-effectiveness and cost-effectiveness of cognitive-behavioural therapy, selective serotonin reuptake inhibitors and their combination in the management of obsessive compulsive disorder. Int Clin Psychopharmacol 33(6):334–348

Fineberg NA, Demetrovics Z, Stein DJ, Loannidis K, Poetnza MN, Grunblatt E, Brand M, Billeieux J, Carmi L, King DL, Grant JE, Hollander E, Goudriaan A, Pallanti S (2018c) Manifesto for a European research network into problematic usage of the internet. Eur Neuropharmacol 28:1232–1246

Article CAS Google Scholar

Fineberg NA, Dell’Osso B, Albert A, Maina G, Geller D, Carmi L, Sireau N, Walitza S, Grassi G, Pallanti S, Hollander E, Brakoulias V, Menchon JM, Marazziti D, Ioannidis K, Apergis-Schoute A, Stein DJ, Cath DC, Veltman DJ, Van Ameringen M, Fontenelle LF, Shavitt RG, Costa D, Diniz JB, Zohar J (2019) Early intervention for obsessive compulsive disorder: an expert consensus statement. Eur Neuropsychopharmacol 29(4):549–565. https://doi.org/10.1016/j.euroneuro.2019.02.002 . Epub 2019 Feb 14. PMID:30773387

Fineberg NA, Hollander E, Pallanti S, Walitza S, Grünblatt E, Dell’Osso BM, Albert U, Geller DA, Brakoulias V, Janardhan Reddy YC, Arumugham SS, Shavitt RG, Drummond L, Grancini B, De Carlo V, Cinosi E, Chamberlain SR, Ioannidis K, Rodriguez CI, Garg K, Castle D, Van Ameringen M, Stein DJ, Carmi L, Zohar J, Menchon JM (2020) Clinical advances in obsessive-compulsive disorder: a position statement by the international college of obsessive-compulsive spectrum disorders. Int Clin Psychopharmacol 35(4):173–193. https://doi.org/10.1097/YIC.0000000000000314

Article PubMed PubMed Central Google Scholar

Gillan CM, Papmeyer M, Morein-Zamir S, Sahakian BJ, Fineberg NA, Robbins TW, de Wit S (2011) Disruption in the balance between goal-directed behavior and habit learning in obsessive-compulsive disorder. Am J Psychiatry 168(7):718–726

Gillan CM, Morein-Zamir S, Urcelay GP, Sule A, Voon V, Apergis-Schoute AM, Fineberg NA, Sahakian BJ, Robbins TW (2014) Enhanced avoidance habits in obsessive-compulsive disorder. Biol Psychiatry 75(8):631–638. https://doi.org/10.1016/j.biopsych.2013.02.002 . Epub 2013 Mar 16

Gillan CM, Apergis-Schoute AM, Morein-Zamir S, Urcelay GP, Sule A, Fineberg NA, Sahakian BJ, Robbins TW (2015) Functional neuroimaging of avoidance habits in obsessive-compulsive disorder. Am J Psychiatry 172(3):284–293

Gillan CM, Robbins TW, Sahakian BJ, Van den Heuvel OA, Van Wingen G (2016) The role of habit in compulsivity. Eur Neuropsychopharmacol 26(5):828–840

Gillan CM, Fineberg NA, Robbins TW (2017) A trans-diagnostic perspective on obsessive-compulsive disorder. Psychol Med 47(9):1528–1548. https://doi.org/10.1017/S0033291716002786 . Epub 2017 Mar 27. PMID: 28343453; PMCID: PMC5964477

Article CAS PubMed PubMed Central Google Scholar

Hirschtritt ME, Bloch MH, Mathews CA (2017) Obsessive-compulsive disorder: advances in diagnosis and treatment. JAMA 317(13):1358–1367

Hollander E (2019a) Why my OCD went undiagnosed for 25 years. https://elemental.medium.com/c81b26168a12

Hollander E (2019b) Overcoming obsessions and shifting focus 5 ways- break the OCD stigma. https://www.psychologytoday.com/ca/blog/201904

Hollander E, Stein D, Fineberg NA, Legault M (2010) Quality of life outcomes in patients with obsessive-compulsive disorder: relationship to treatment response and symptom relapse. J Clin Psychiatry 71(6):784–792

Hollander E, Nezgovorova V, Citron K (2018) Consumer patient centered study digital treatment. https://adaa.org/learn-from-us/from-the-experts/blogposts/

Ioannidis K, Chamberlain SR, Treder MS, Kiraly F, Leppink EW, Redden SA, Stein DJ, Lochner C, Grant JE (2016) Problematic internet use (PIU): associations with the impulsive-compulsive spectrum. An application of machine learning in psychiatry. J Psychaitr Res 83:94–102. https://doi.org/10.1016/j.jpsychires.2016.08.010 . Epub 2016 Aug 15

Joel D (2006) Current animal models of obsessive compulsive disorder: a critical review. Prog Neuropsychopharmacol Biol Psychiatry 30(3):374–388. https://doi.org/10.1016/j.pnpbp.2005.11.006

Article PubMed Google Scholar

King DL, Chamberlain SR, Carragher N et al (2020) Screening and assessment tools for gaming disorder: a comprehensive systematic review. Clin Psychol Rev. https://doi.org/10.1016/j.cpr.2020.101831

Kristina A. Uban, Megan K. Horton, Joanna Jacobus, Charles Heyser, Wesley K. Thompson, Susan F. Tapert, Pamela A.F. Madden, Elizabeth R. Sowell. Adolescent Brain Cognitive Development Study. Biospecimens and the ABCD study: Rationale, methods of collection, measurement and early data. Dev Cogn Neurosci. 2018 Aug;32:97–106. https://doi.org/10.1016/j.dcn.2018.03.005 . Epub 2018 Mar 16.

Lewis M, Canamero L (2016) Hedonic quality or reward? A study of basic pleasure in homeostasis and decision making of a motivated autonomous robot. Adaptive Behav 24:267–291. https://doi.org/10.1177/1059712316666331

Lewis M, Fineberg NA, Canamero L (2019) A robot model of OC spectrum disorders: design framework, implementation and first experiments. Comput Psychiatry. Accepted for publication, April 2019

Mancebo MC, Grant JE, Pinto A, Eisen JL, Rasmussen SA (2009) Substance use disorders in an obsessive compulsive disorder clinical sample. J Anxiety Disord 23(4):429–435

Marinova Z, Chuang DM, Fineberg N (2017) Glutamate-modulating drugs as a potential therapeutic strategy in obsessive-compulsive disorder. Curr Neuropharmacol. 15(7):977–995. https://doi.org/10.2174/1570159X15666170320104237

Marzano L, Bardill A, Fields B, Herd K, Veale D, Grey N, Moran P (2015) The application of mHealth to mental health: opportunities and challenges. Lancet Psychiatry 2:942–948

Nezgovorova V, Rigby N, Battles J, Krause D, Fineberg NA, Van Ameringen M, Hollander E (2018) Genetic variants of OCD phenotypes and comorbid conditions, ACNP Poster, 2018. The American College of Neuropsychopharmacology, Hollywood, Florida.

Paulus MP, Squeglia LM, Bagot K, Jacobus J, Kuplicki R, Breslin FJ, Bodurka J, Morris AS, Thompson WK, Bartsch H, Tapert SF (2019) Neuroimage. Author manuscript; available in PMC 2019 Apr 29Screen Media Activity and Brain Structure in Youth: Evidence for Diverse Structural Correlation Networks from the ABCD Study. Published in final edited form as: Neuroimage 185:140–153. Published online 2018 Oct 16. https://doi.org/10.1016/j.neuroimage.2018.10.040

Pitman RK (1987) Acybernetic model of obsessive-compulsive psychopathology. Comprehensive Psychiatry 28(4):334–343. https://doi.org/10.1016/0010-440X(87)90070-8

Roncero M, Belloch A, Doron G (2019) Can brief, daily training using a mobile app help change maladaptive beliefs? Crossover randomized controlled trial. JMIR Mhealth Uhealth 7(2):e11443

Skapinakis P, Caldwell DM, Hollingworth W, Bryden P, Fineberg NA, Salkovskis P, Welton N, Baxter H, Kessler D, Churchill R (2016) Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis. Lancet Psychiatry 3:730–739

Skoog G, Skoog I (1999) A 40 year follow up of patients with obsessive compulsive disorder. Arch Gen Psychiatry 56:121–127

Starcevic V, Berle D, Arnáez S, Vismara M, Fineberg NA (2020) The assessment of cyberchondria: instruments for assessing problematic online health-related research. Curr Addict Rep. Published online 30th April 2020. https://doi.org/10.1007/s40429-020-00308-w

Stein DJ, Hermesh H, Eilam D, Segalas C, Zohar J, Menchon J, Nesse RM (2016) Human compulsivity: a perspective from evolutionary medicine. Eur Neuropsychopharmacol. 26(5):869–876. https://doi.org/10.1016/j.euroneuro.2015.12.004 . Epub 2015 Dec 10

Vismara M, Caricasole V, Starcevic V, Cinosi E, Dell’Osso B, Martinotti G, Fineberg NA (2020) Is cyberchondria a new transdiagnostic digital compulsive syndrome? A systematic review of the evidence. Comprehensive Psychiatry 99:152167. https://doi.org/10.1016/j.comppsych.2020.152167 . [Epub ahead of print]

Voon V, Derbyshire K, Rück C, Irvine MA, Worbe Y, Enander J, Schreiber LR, Gillan C, Fineberg NA, Sahakian BJ, Robbins TW, Harrison NA, Wood J, Daw ND, Dayan P, Grant JE, Bullmore ET (2014) Disorders of compulsivity: a common bias towards learning habits. Mol Psychiatry. https://doi.org/10.1038/mp.2014.44 . [Epub ahead of print]

Whiteside S, Ale C, Vickers K, Tiede M, Dammann J (2013) Case examples of enhancing pediatric OCD treatment with a smartphone application. Clin Case Stud 13:80–94

World Health Organization (2016) Monitoring and evaluating digital health interventions: a practical guide to conducting research and assessment. WHO

Zai G, Brandl EJ, Müller DJ, Richter MA, Kennedy JL (2014) Pharmacogenetics of antidepressant treatment in obsessive-compulsive disorder: an update and implications for clinicians. Pharmacogenomics 15(8):1147–1157

Download references

Acknowledgements

This chapter is based upon work from COST Action CA16207 “European Network for Problematic Usage of the Internet”, supported by COST (European Cooperation in Science and Technology) – www.cost.eu .

Dr. Hollander has received grants from Department of Defense (DOD), Orphan Products Division of the Food and Drug Administration (OPD-FDA), Roche, and GW Pharma in the past 3 years.

Dr. Fineberg has, in the past 3 years, held research or networking grants from the ECNP, UK NIHR, EU H2020, MRC, University of Hertfordshire, accepted travel and/or hospitality expenses from the BAP, ECNP, RCPsych, CINP, International Forum of Mood and Anxiety Disorders, World Psychiatric Association, Indian Association for Biological Psychiatry, Sun, received payment from Taylor and Francis and Elsevier for editorial duties, and accepted a paid speaking engagement in a webinar sponsored by Abbott. Previously, she has accepted paid speaking engagements in various industry supported symposia and has recruited patients for various industry sponsored studies in the field of OCD treatment. She leads an NHS treatment service for OCD and holds Board membership for various registered charities linked to OCD. She has given expert advice on psychopharmacology to the UK MHRA and NICE.

Contributors

All authors agreed on the title, scope, and content of the manuscript, contributed to the literature searches, and approved the final manuscript.

Author information

Authors and affiliations.

Autism and Obsessive-Compulsive Spectrum Disorders Program, Psychiatric Research Institute of Montefiore-Einstein, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY, USA

T. Vats & E. Hollander

Center for Clinical and Health Research Services, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK

N. A. Fineberg

Hertfordshire Partnership University NHS Foundation Trust, Rosanne House, Welwyn Garden City, Hertfordshire, UK

University of Cambridge School of Clinical Medicine, Cambridge, UK

You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to E. Hollander .

Editor information

Editors and affiliations.

Centre for Health Services and Clinical Research, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, Hertfordshire, UK

Naomi A. Fineberg

Department of Psychology and Behavioural and Clinical Neuroscience Institute, University of Cambridge, Cambridge, UK

Trevor W. Robbins

Rights and permissions

Reprints and permissions

Copyright information

About this chapter

Vats, T., Fineberg, N.A., Hollander, E. (2021). The Future of Obsessive-Compulsive Spectrum Disorders: A Research Perspective. In: Fineberg, N.A., Robbins, T.W. (eds) The Neurobiology and Treatment of OCD: Accelerating Progress. Current Topics in Behavioral Neurosciences, vol 49. Springer, Cham. https://doi.org/10.1007/7854_2020_208

Download citation

DOI : https://doi.org/10.1007/7854_2020_208

Published : 07 February 2021

Publisher Name : Springer, Cham

Print ISBN : 978-3-030-75392-4

Online ISBN : 978-3-030-75393-1

eBook Packages : Biomedical and Life Sciences Biomedical and Life Sciences (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

Publish with us

Policies and ethics

Find a journal
Track your research

Frontiers in Psychiatry
Mood Disorders
Research Topics

Obsessive-Compulsive Disorder (OCD) Across the Lifespan: Current Diagnostic Challenges and the Search for Personalized Treatment

Total Downloads

Total Views and Downloads

About this Research Topic

Obsessive-Compulsive Disorder (OCD) is one of the most prevalent and disabling neuropsychiatric disorders, with high comorbidity rates and poor response to first-line treatments in about one third of patients. Currently recognized as an early-onset disorder, it may present distinct symptom dimensions, with an ...

Keywords : OCD, obsessive-compulsive disorder, trauma, diagnostic challenges, cognitive markers

Important Note : All contributions to this Research Topic must be within the scope of the section and journal to which they are submitted, as defined in their mission statements. Frontiers reserves the right to guide an out-of-scope manuscript to a more suitable section or journal at any stage of peer review.

Topic Editors

Topic coordinators, recent articles, submission deadlines.

Submission closed.

Participating Journals

Total views.

Demographics

No records found

total views article views downloads topic views

Top countries

Top referring sites, about frontiers research topics.

With their unique mixes of varied contributions from Original Research to Review Articles, Research Topics unify the most influential researchers, the latest key findings and historical advances in a hot research area! Find out more on how to host your own Frontiers Research Topic or contribute to one as an author.

September 7, 2021

A New Way to Understand—and Possibly Treat—OCD

People with the disorder seem to have a more flexible “sense of self”

By Baland Jalal

Gloved hand opening door with paper towel.

Os Tartarouchos Getty Images

Obsessive-compulsive disorder (OCD) has puzzled artists and scientists for centuries. Afflicting one in 50 people, OCD can take several forms, such as compulsively putting things in just the right order or checking if the stove is turned off 10 times in a row. One type of OCD that affects nearly half of those with the condition entails irresistible washing urges. People with this type can spend hours scrubbing their hands in agitation after touching something as trivial as a doorknob even though they know this makes no sense. There is currently a shortage of effective therapies for OCD: 40 percent of patients do not benefit from existing treatments.

A major issue is that today’s treatments are often too stressful. First-line “nonpharmacological therapies” involve telling patients to repeatedly touch things such as toilet seats and then refrain from washing their hands. But recent work by my colleagues and me has found something surprising: people diagnosed with OCD appear to have a more malleable “sense of self,” or brain-based “self-representation” or “body image”—the feeling of being anchored here and now in one’s body—than those without the disorder. This finding suggests new ways to treat OCD and perhaps unexpected insights into how our brain creates a distinction between “self” and “other.”

In our recent experiments, for example, we showed that people with and without OCD responded differently to a well-known illusion. In our first study, a person without OCD watched as an experimenter used a paintbrush to stroke a rubber hand and the subject’s hidden real hand in precise synchrony . This induces the so-called rubber hand illusion: the feeling that a fake hand is your hand. When the experimenter stroked the rubber hand and the real one out of sync, the effect was not induced (or was greatly diminished). This compelling illusion illustrates how your brain creates your body image based on statistical correlations. It’s extremely unlikely for such stroking to be seen on a rubber hand and simultaneously felt on a hidden real one by chance. So your brain concludes, however illogically, that the rubber hand is part of your body.

On supporting science journalism

If you're enjoying this article, consider supporting our award-winning journalism by subscribing . By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today.

After a few minutes of such stroking, we “contaminated” the fake hand (using items such as fake feces). Intriguingly, participants without OCD reported feeling OCD-like disgust, which seemingly arose from the rubber hand. This experiment was later replicated in a large study in Japan , indicating that the finding is robust across cultures. Put differently, beyond feeling like the rubber hand was their own (the standard illusion), the subjects were disgusted by what it was touching.

In a follow-up study my colleague Vilayanur S. Ramachandran of the University of California, San Diego, and I—along with Richard J. McNally, Jason A. Elias and Sriramya Potluri, all then at Harvard University—found that people with OCD felt like the fake hand was theirs even when the experimenter stroked the real and rubber hands out of sync with each other. As noted, the illusion occurs because your brain extracts statistical correlations from sensory inputs: you feel your unseen hand being stroked and see the fake hand being touched the exact same way. The fact that people with OCD experienced a vivid illusion during out of sync stroking suggests they have a more expansive self-representation to the degree that they are willing to seamlessly ignore conflicting sensory inputs— and still accept the rubber hand as their own. Indeed, this is the first study to suggest that OCD involves a more malleable body image⸻in other words, it is the first to indicate that people with the condition construct their sense of self differently than others. Just as in our previous study, inducing the rubber hand illusion and smearing the rubber hand with fake feces provoked disgust—apparently fooling the brain into attributing the disgust to the fake hand.

Taken together, these studies indicate that the “self” is more fluid for people with OCD. Their greater susceptibility to the rubber hand illusion might be explained by dysregulation of chemicals such as dopamine (a feature of OCD). The studies also suggest that once the rubber hand trick is induced, contaminating the fake hand might activate brain modules involved in disgust. The experiments illustrate how seemingly unrelated brain centers—for vision, touch and disgust—may interact in a dynamic fashion to weave together perceptual reality. Indeed, just the right kind of physical stimulation for a few minutes can make someone abandon a lifetime of experience that a rubber hand is not a part of their body. Astonishingly, when presented with this scenario, you will make the perceptual decision that a fake hand is yours and experience bona fide contamination sensations arising from it.

In a related study, Ramachandran and I found that college students with OCD symptoms felt disgust while watching an experimenter contaminate himself and relief while watching him wash his hands—suggesting that highly visceral disgust reactions, as experienced in the context of OCD-like contamination aversion, can ultimately break down the barrier between self and other. Surprisingly, we found that to people with OCD symptoms , it didn’t matter whether they or the experimenter was contaminated—they felt equally disgusted! Participants’ verbal reports about how disgusted they felt were the same both when they touched the contaminant and when they merely watched the experimenter do so. Even more intriguingly, once the participants had contaminated themselves, they reported relief from watching the experimenter washing his own hands. Notably, some participants would dictate how the experimenter should wash his hands, saying things such as “Wash more on this side” or “Pour more water between these fingers.” Echoing these results, we recently found that OCD patients at McLean Hospital in Massachusetts reported experiencing handwashing urges arising from watching an experimenter contaminate himself. They also reported feeling equally disgusted and anxious both when watching an experimenter contaminate himself and when they themselves were contaminated. Finally, once the patients had contaminated themselves, they reported feeling relief—reductions in disgust by 22 percent, equivalent to actual handwashing—from watching the experimenter washing his own hands. Overall, these results are counterintuitive. They demonstrate the elusive interface between mind and body and feelings such as disgust. It may be that contamination feelings in OCD have the potential to override logic and the “self-other” barrier.

Our studies may lead to new treatments for OCD. Traditional therapy has patients touch disgusting things, then shows them that nothing bad happens when they don’t wash their hands. These treatments don’t always work well because patients are too anxious to touch contaminated objects. But what if a rubber hand that feels like the patient’s own is contaminated instead? Indeed, such prolonged contamination of a fake hand should eventually lead to desensitization just like traditional therapy. Unlike standard OCD treatment, this novel rubber hand therapy—which we’ve dubbed “multisensory stimulation therapy”—does not require patients to touch highly aversive “contaminants.” Accordingly, patients who are too frightened to engage in traditional therapy because of the direct skin exposure may be more willing accept this technique.

Likewise the observations that feelings of contamination and relief can arise vicariously may pave the way for new treatments. Watching a video of oneself touching disgusting objects should have a desensitizing effect over time. Similarly, patients could repeatedly watch themselves washing their hands to eradicate washing urges. With our colleagues, Barbara J. Sahakian of the University of Cambridge and I found that people with contamination fears improved their OCD symptoms by simply watching a brief video of themselves touching fake feces or washing their hands on a smartphone a few times daily for a week. OCD is a perplexing condition that blurs the boundary between mind and body, reality and illusion. One may have to fool the brain to overcome the condition—combating one illusion with another.

Baland Jalal is a researcher at Harvard University's department of psychology and a visiting researcher at the department of psychiatry at the University of Cambridge, where he earned his Ph.D. You can follow his work on YouTube and Instagram

Warning: The NCBI web site requires JavaScript to function. more...

An official website of the United States government

The .gov means it's official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Publications
Account settings
Browse Titles

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

StatPearls [Internet].

Obsessive-compulsive disorder.

Hannah Brock ; Abid Rizvi ; Manassa Hany .

Affiliations

Last Update: February 24, 2024 .

Continuing Education Activity

Obsessive-Compulsive Disorder (OCD) is a prevalent psychiatric disorder affecting 1% to 3% of the global population, characterized by intrusive thoughts, known as obsessions, and repetitive actions, or compulsions. These symptoms affect patients not only by consuming a significant portion of their time but also by causing marked distress and functional impairment. The complex etiology of OCD involves cognitive, genetic, and neural factors, making the condition's diagnosis challenging and necessitating the exclusion of other psychiatric conditions that present similarly. Further complicating matters, OCD frequently coexists with other psychiatric disorders, requiring comprehensive identification and treatment for optimal clinical outcomes. While the combination of medication and psychotherapy is generally effective, emerging evidence supports using neuromodulation techniques (eg, deep brain stimulation and transcranial magnetic stimulation) for treatment-resistant cases.

This activity reviews the epidemiology, etiology, clinical presentation, and management of OCD, providing healthcare professionals with the knowledge and tools to improve patient care for this complex and prevalent condition. Emphasizing the importance of prompt recognition for timely diagnosis and intervention, the activity presents evaluation strategies and offers guidelines for differentiating OCD from similar psychiatric disorders. Varying etiologies, clinical presentations, and prognostic factors pertinent to OCD are also reviewed. By participating in this transformative activity, healthcare professionals will augment their clinical expertise and enhance their collaborative capacities, significantly improving patient care in OCD management.

Identify the criteria utilized to diagnose a patient with obsessive-compulsive disorder.
Implement evidence-based treatment plans for patients with obsessive-compulsive disorder.
Assess the diverse etiological factors contributing to obsessive-compulsive disorder.
Implement interprofessional team strategies for improving care coordination and communication to improve outcomes for patients with obsessive-compulsive disorder.
Introduction

Obsessive-compulsive disorder (OCD) is a disabling condition estimated to affect 1% to 3% of individuals throughout their lifetime. [1] [2] This psychiatric disorder is characterized by obsessions and compulsions, which consume a significant amount of time and lead to notable distress and impairment. Obsessions refer to intrusive and repetitive thoughts, urges, or mental images that are challenging to control. These thoughts often lack a clear purpose and are accompanied by distress. [3] Compulsions involve repetitive actions or mental events that individuals with OCD feel compelled to perform to alleviate the distress caused by the obsessions or to prevent a feared consequence from occurring. [3] Additionally, individuals with OCD may also engage in avoidance behaviors of obsession-triggering situations. [2]

OCD is a heterogeneous condition that arises from a complex interplay of genetic and environmental risk factors. [4] Most adults are distressed by the ego-dystonic nature of their obsessions and are aware that their compulsive behaviors are abnormally excessive. Children often have difficulty describing their obsessions. In OCD patients, common obsessions and their associated compulsive behaviors include fear of contamination leading to excessive cleaning, fear of harm linked to repetitive checking of security measures, intrusive, aggressive, or sexual thoughts paired with mental rituals, and a focus on symmetry accompanied by ordering or counting. [5] [6] Though hoarding behaviors are usually specific to hoarding disorder, they can occur in OCD to prevent perceived harm. These behavior sets are consistently observed worldwide, suggesting a degree of commonality in OCD symptom dimensions. OCD can also present with rarer symptoms, including scrupulosity, obsessive jealousy, and musical obsessions. [7] [8] [3]

The understanding of OCD has evolved significantly over time. Historically framed in religious terms as a moral failing or demonic possession, OCD was first medically described by Esquirol. Freud subsequently characterized the condition using the term obsessive neurosis , positing that OCD originated with a regression in the anal phase of psychosexual development. [9] In the third edition of the Diagnostic and Statistical Manual (DSM-III), OCD was grouped with phobias under a single diagnosis. Later, the DSM-IV classified the condition as an anxiety disorder. The DSM-5 has reclassified OCD into the category "Obsessive-Compulsive and Related Disorders," alongside conditions like hoarding and body dysmorphia. This reclassification acknowledges shared characteristics, such as phenomenology, comorbidity, and underlying neurobiological factors. [10] WHO lists OCD as 1 of the 10 most disabling conditions caused by financial loss and decreased quality of life. [11] In The Diagnostic and Statistical Manual of Mental Disorders fifth edition Text Revision (DSM-5 TR), which was published by the American Psychiatric Association (APA) in 2022, OCD sits under the category of o bsessive-compulsive and related disorders where the following subcategories were placed: [3]

Body dysmorphic disorder (BDD)
Hoarding disorder
Trichotillomania
Excoriation (ie, skin-picking) disorder
Substance or medication-induced obsessive-compulsive and related disorder
Obsessive-compulsive and related disorder as a result of another medical condition
Other specified obsessive-compulsive and related disorder
Unspecified obsessive-compulsive and related disorder

The diagnosis of OCD is based on clinical assessment determining whether the DSM-5 TR criteria are met, which specify that either obsessions or compulsions must be present, the behaviors must be time-consuming, taking ≥1 hour per day, and significantly disrupting daily life. [3] (Refer to the History and Physical Examination section for more information on the diagnostic criteria for OCD).

The etiology of OCD is complex, encompassing diverse factors, including cognitive, genetic, molecular, environmental, and neural elements. Evidence from twin studies points to a significant genetic predisposition with an estimated heritability quotient of approximately 48%. [12] [13] However, this estimate is reduced to 35% when maternal effects (eg, prenatal exposure to stress or infection) are considered. [14] However, despite significant efforts through candidate gene association studies, reproducible genetic markers for OCD remain elusive. Many of these studies have focused on neurotransmitter pathways involving serotonin, dopamine, and glutamate without definitive results. [12] Nevertheless, the gene SLC1A1, responsible for encoding the neuronal glutamate transporter EAAT3, has surfaced as a potentially significant candidate. [15] [12]

Recent studies point towards OCD being fundamentally a network-based disorder. [16] The cortico-striato-thalamo-cortical (CSTC) loop has become a pivotal framework for understanding its pathophysiology. [16] The CSTC loop involves a series of interconnected circuits that allow the prefrontal cortex to communicate with subcortical structures (eg, the striatum and the thalamus). This loop has 2 distinct pathways: the direct and the indirect. The direct pathway facilitates behavior initiation, whereas the indirect pathway inhibits or modulates these behaviors. [17] In OCD, hyperactivity in the direct pathway relative to the indirect pathway has been observed. This creates an imbalance that may cause repetitive, intrusive thoughts and compulsive actions. [13] [18] Recent neuroimaging studies indicate heightened connectivity and activation within the CSTC loop in OCD. [13] Furthermore, OCD may occur with other neurological conditions that impact the CSTC circuitry, including Parkinson disease, Sydenham chorea, traumatic brain injury, Tourette syndrome, Huntington disease, and epilepsy. [19] [20]

Early findings of the effectiveness of clomipramine, which has robust serotonin reuptake inhibition observed during treatment, emphasized the role of serotonin in the pathogenesis of OCD. [13] However, this serotonin-centric model has faced scrutiny because other serotonin-modulating agents like buspirone and ondansetron have not proven effective in OCD. [21] [22] Emerging studies point towards the glutaminergic system in the onset and progression of OCD. [13] Pharmacological agents like riluzole and troriluzole, which affect glutaminergic neurotransmission, have shown preliminary benefits. [23] [24] The efficacy of antipsychotic drugs when used for augmentation in OCD suggests dopamine's role in OCD pathology. [25] [13] Imaging studies corroborate this by demonstrating increased dopamine concentrations in the basal ganglia of patients with OCD. Moreover, dopamine agonists can induce OCD-like behaviors in both animals and humans. Interestingly, enhancing cortical dopamine has also shown promise in alleviating OCD symptoms. [26] However, the findings are preliminary and lack direct evidence.

The autoimmune etiology provides another intriguing dimension to OCD, particularly in Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infections (PANDAS) and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS). [27] PANDAS is regarded as a subset of PANS. Unlike OCD, the onset of PANDAS and PANS is often sudden and severe, accompanied by additional symptoms, including handwriting deterioration, emotional lability, and episodic disease courses. These conditions are mediated by autoimmune responses triggered by infection, inflammatory reactions, or other toxins and have parallels with other autoimmune neuropsychiatric disorders (eg, Sydenham chorea). [27] Preliminary research indicates that striatal cholinergic interneurons may be the cellular targets of these autoimmune responses. [28]

Cognitive and learning-based models of OCD posit that maladaptive beliefs fuel obsessional anxiety, leading to compulsive behaviors aimed at mitigating such anxiety. [25] Several cognitive impairments have been identified as contributing to obsessional anxiety, including:

Heightened responsibility
Overemphasis on thoughts
Controlling thoughts
Threat overestimation
Perfectionism
Intolerance of uncertainty

Empirical evidence supports the effectiveness of these models; exposure to obsession-linked stimuli increases anxiety while engaging in compulsive rituals lowers it. [25] Additionally, the learning-based model argues that the underlying learning mechanisms are not inherently pathological. This aligns with the observation that nonclinical populations also experience obsessive-like thoughts without distress. These models have been instrumental in developing psychological therapies for OCD, substantiating their theoretical and practical utility. [29] [25]

Epidemiology

OCD is a leading cause of psychiatric morbidity worldwide, affecting 1% to 3% of the population. Frequently, OCD is associated with comorbid psychiatric conditions. [3] [13] [25] [30] OCD often has onset early in life and generally has a chronic cause. The most common demographic range affected is from ages 18 to 29 years. [3] Interestingly, nearly a quarter of males display symptoms before age 10, whereas the disorder usually emerges during adolescence for females. [3] Additionally, the peripartum and postpartum phases are marked as periods of increased risk for women, with OCD incidence during these times exceeding that in nonpregnant females. [31] Women are also about 1.6 times as likely as men to be affected by the disorder. [32]

A striking 90% of individuals with OCD meet the criteria for at least one additional psychiatric disorder, with anxiety disorders, mood disorders, impulse-control disorders, and substance use disorders being the most prevalent comorbid conditions. [3] Despite the disorder's significant impact, OCD frequently remains both underdiagnosed and undertreated, with only a small fraction of patients receiving appropriate medical care. [3] [33]

Pathophysiology

While OCD is generally considered to stem from a mix of several etiological factors, some instances can be linked explicitly to neurological causes involving the basal ganglia. [12] Detailed evidence supports this from case reports associated with conditions such as Sydenham's chorea and ischemic events. These conditions result in disruptions to basal ganglia regions like the globus pallidus and caudate, leading to obsessive-compulsive behaviors. [13] In research conducted by the Enhancing Neuro Imaging Genetics through Meta-Analysis (ENIGMA) consortium, no marked structural brain differences were discerned between patients with OCD and healthy controls unless factoring in medication status. [34] Postmortem studies, albeit limited, have revealed abnormalities in the orbitofrontal cortex of patients with OCD. [35] Specifically, one such study found evidence for lower excitatory synaptic gene expression in the orbitofrontal cortex of subjects (N=8) when compared with unaffected controls. [35] These studies, however, have limitations, including small sample sizes.

History and Physical

Obsessive-Compulsive Disorder Diagnostic Criteria

In DSM-5 TR, the diagnosis of OCD was based on the following criteria.

Recurrent and persistent thoughts, urges, or images that are experienced at some time during the disturbance are intrusive and unwanted and, in most individuals, cause marked anxiety or distress.
The individual attempts to suppress such thoughts, urges, or images with some other thought or action (ie, by replacing them with a compulsion).
Repetitive behaviors or mental acts 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 aim at reducing anxiety or distress or preventing some dreaded situation; however, these behaviors or mental actions do not connect realistically with what they are designed to or are excessive.
The obsessions are time-consuming or cause clinically significant distress or impairment in social, occupational, or other critical functional areas.
Obsessive-compulsive symptoms do not arise from the physiological effects of a substance (eg, a drug of abuse, a medication) or another medical condition.
The symptoms of another mental disorder do not better explain the disturbance. Differential diagnoses should be considered before an OCD diagnosis is made. (Refer to the Differential Diagnoses section for more information on conditions with clinical features similar to OCD.) These symptoms should not be attributable to other psychiatric or medical disorders. The belief that obsessions lead to compulsions is common; however, the relationship between the conditions is not always straightforward. Theoretically, obsessions and compulsions can occur independently of each other. Patients with OCD typically seek outpatient care and often possess insight into their condition, although exceptions exist in children or severe cases. These individuals usually experience distress due to the ego-dystonic nature of their symptoms.

Clinical Assessment

A thorough medical history and mental status examination are vital in diagnosing the condition, differentiating OCD from other disorders, gauging prognosis, and devising a treatment plan. During the assessment, determining whether the patient is grappling with obsessions, compulsions, or both is critical. Symptoms should also be categorized into the following specific dimensions.

Contamination : cleanliness obsessions and cleaning compulsions
Harmful thoughts : fears of causing harm and compulsive checking
Forbidden thoughts : aggressive, sexual, or religious obsessions with corresponding mental rituals; often suggest a worse prognosis. [3]
Symmetry : compulsions (eg, repeating, ordering, and counting) [3] [25]

Safety assessments are also conducted to look for immediate risks to the patient or others. Screening for comorbid conditions, including depression, bipolar disorder, and other anxiety disorders, should be performed, and the patient's past psychiatric and general medical history should be reviewed. All medications, supplements, and known allergies or sensitivities should be obtained also. Furthermore, clinicians should gather pertinent information on the patient's psychosocial background, including familial relationships, stressors, and educational history. A family history focusing on OCD and other psychiatric conditions is also obtained to provide a holistic view of the patient's health.

Additionally, OCP may have specific nuances in its presentation, such as with postpartum OCD, with which clinicians should be familiar. For instance, some new mothers may experience distressing, obsessive thoughts about harming their baby and may be reluctant to disclose these for fear of judgment or consequences. In such sensitive cases, building rapport and ensuring a confidential and nonjudgmental setting for disclosure becomes paramount. However, the clinician must vigilantly assess the safety of the patient and the child. An individualized treatment plan for each patient should be created using a comprehensive approach.

Mental Status Examination

The mental status examination (MSE) for patients with OCD may differ depending upon the severity of symptoms, specific manifestations of the disorder, and any coexisting conditions. The following are some MSE findings that are common during the clinical assessment.

Appearance and behavior: Patients generally present as well-groomed but exhibit visible anxiety. Manifestations of OCD, such as frequent hand-washing, checking behaviors, or rearrangement of objects, are often observed during the interview and serve as a diagnostic indicator.
Psychomotor activity: Individuals are observed engaging in repetitive actions (eg, tapping, checking, or constantly washing their hands). These behaviors are compulsively performed, even when causing visible distress to the patient.
Speech: While articulation is generally coherent and goal-oriented, intrusive thoughts may periodically disrupt the flow of speech. Depending on the individual, these thoughts may or may not be vocalized during the examination.
Mood and affect: Patients usually report feelings of anxiety or distress, and their emotional expression (ie, affect) appears consistent with these reported experiences, often displaying heightened signs of stress.
Thought content: Obsessive thoughts differ among patients but commonly revolve around themes like contamination, harm to oneself or others, a quest for symmetry, or distressing sexual or religious beliefs. Compulsions to counteract these obsessions are frequently reported.
Thought process: Generally linear and coherent, intrusive, obsessive thoughts intermittently interrupt the thought process. Patients usually acknowledge these thoughts as irrational yet find themselves compelled to respond with corresponding compulsions.
Perceptual abnormalities: Unlike some other psychiatric disorders, hallucinations or illusions are seldom observed in OCD patients.
Cognition: Patients typically remain alert and oriented to time, place, and person. Overall cognitive function is usually preserved, although sometimes compromised by the pervasive nature of the obsessive thoughts.
Insight and judgment: A significant feature in most OCD cases is the preservation of insight. Patients often recognize the irrational nature of their obsessions and compulsions but report feeling powerless to control them. Judgment may specifically falter when resisting the urge to perform compulsive behaviors.

Screening for the correct symptoms of OCD is essential. A common tool is the short OCD screener. At 6 questions long and a sensitivity of 97%, this screening modality is a simple and effective way to identify patients with symptoms of OCD. [36] However, the most widely accepted tool to screen for OCD is the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). [37] The Y-BOCS rates on a scale from 0 to 40, with 40 indicating the most severe symptomatology. [38] This scale requires the patient to rank the following based on severity: [38]

Time occupied by obsessive thoughts and compulsions
Interference of obsessive thoughts
Distress of obsessive thoughts
Resistance against obsessions
Degree of control over obsessive thoughts
Time occupied by compulsive behavior
Interference of compulsive behavior
Distress associated with compulsive behavior
Resistance against compulsive behavior
Degree of control over compulsive behaviors
Treatment / Management

Psychotherapy

Cognitive-behavioral therapy (CBT) is an evidence-based psychotherapeutic intervention for OCD. [39] [40] Within the framework of CBT, exposure and response prevention (ERP) emerges as the most empirically substantiated behavioral technique. ERP entails subjecting patients to stimuli that provoke anxiety while guiding them to abstain from subsequent compulsive behaviors. [41] Various delivery modalities, including individual and group settings, as well as in-person and internet-based formats, have proven effective in treating OCD. [41]

A key determinant of therapeutic efficacy is the patient’s adherence to at-home assignments, most notably those involving home-based ERP exercises. CBT serves as a first-line treatment for OCD, especially when this technique aligns with the patient’s treatment preferences, access to qualified clinicians is available, and no compelling comorbid conditions necessitate pharmacotherapy. Although meta-analyses suggest that CBT often outperforms pharmacological interventions, such conclusions should be drawn cautiously, taking into account variables such as patient selection criteria and baseline severity of OCD symptoms. [3] Emerging research indicates that intensive CBT protocols, often condensed into a brief period and occasionally administered in an inpatient context, hold promise for both initial and advanced treatment of severe OCD cases. [42]

Pharmacotherapy

Selective serotonin reuptake inhibitors (SSRIs) are recommended as the first-line medications due to their proven efficacy, safety, and tolerability. [43] Higher dosages than those used for other anxiety disorders or major depressive disorder are typically prescribed, improving effectiveness but increasing the risk of adverse effects such as gastrointestinal and sexual complications. [44] Therefore, careful assessment of side effects is critical for individual dosage optimization. Uniform effect sizes of commonly used SSRIs have been observed in systematic reviews, yet each SSRI has its adverse effect profile. [45] .

Selection criteria of SSRIs for OCD include prior treatment response, adverse event potential, drug interactions, coexisting medical conditions, and cost and availability of the drug. [3] Treatment guidelines recommend an 8- to 12-week SSRI trial to determine efficacy. However, recent meta-analyses show significant symptom improvement within the first 2 weeks of SSRI treatment. [46] [47] . An open-label fluoxetine study indicated that early symptom reduction within 4 weeks predicted 12-week treatment success. [48] Maintenance treatment is generally advised for at least 12 to 24 months postremission, but longer durations may be needed due to relapse risk upon medication discontinuation. [49]

Clomipramine, a tricyclic antidepressant (TCA), was the first drug to show efficacy in treating OCD. Meta-analyses suggest its higher efficacy compared to SSRIs, but this finding requires caution as early clomipramine studies included fewer treatment-resistant patients. Direct comparisons indicate equivalent efficacy between clomipramine and SSRIs. SSRIs are preferred for long-term treatment due to their superior safety profiles and tolerability than other antidepressants. [3]

Approximately half of patients with OCD fail to respond to first-line treatments. [50] Factors predicting poor response include higher symptom severity, marked functional impairments, specific obsession and compulsion subtypes (eg, sexual, religious, and hoarding), limited insight, high comorbidity rates, and lack of adherence to treatment protocols. [3] Combinatorial strategies involving CBT and SSRIs can be effective for those demonstrating poor response. [3] However, CBT is frequently constrained by availability or patient intolerance to exposure techniques.

Alternative approaches include switching SSRIs, using supratherapeutic doses, or switching to serotonin-noradrenaline reuptake inhibitors. [3] SSRIs may also be augmented with antipsychotics, tricyclic antidepressants (eg, clomipramine), or glutamatergic agents. [51] [52] [3] The combination of fluoxetine and clomipramine outperforms fluoxetine with an antipsychotic. However, the fluoxetine and clomipramine combination carries the risk of elevated blood levels of both drugs, leading to potentially severe adverse events (eg, seizures, cardiac arrhythmias, and serotonergic syndrome). [53] Augmentation with antipsychotics, especially risperidone and aripiprazole, shows some evidence of efficacy; however, only one-third of SSRI-resistant patients experience clinically meaningful improvements, warranting meticulous risk-benefit evaluations. [51] Glutamatergic system modulators (eg, memantine, N-acetylcysteine, lamotrigine, topiramate, riluzole, troriluzole, and ketamine) have been explored as augmentation therapies and have shown some promise. [3] Among these, N-acetylcysteine has the most substantial amount of evidence. [54]

Neuromodulation

In addition to the established treatment options such as Exposure and Response Prevention (ERP), Serotonin Reuptake Inhibitors (SRIs), and antipsychotic augmentation of SRIs, there exists a limited array of other evidence-based alternatives. Nonetheless, several treatment modalities have shown promise for cases refractory to standard interventions.

Transcranial magnetic stimulation : Studies employing repetitive transcranial magnetic stimulation (rTMS) targeted at various brain regions (eg, the dorsolateral prefrontal cortex [dlPFC], dorsomedial prefrontal cortex [dmPFC], and orbitofrontal cortex [OFC]) have yielded mixed outcomes. However, these studies generally support the idea of cortico-striatal hyperactivity as an underlying factor in OCD. [55] Deep transcranial magnetic stimulation (dTMS), which utilizes an H-shaped coil, can reach depths of 3 to 5 cm, targeting midline structures such as the medial prefrontal cortex (mPFC) and anterior cingulate cortex (ACC). These areas are believed to be hyperactive in OCD. [56] Significantly, dTMS has gained US Food and Drug Administration (FDA) approval for the treatment of OCD. [57]
Stereotactic ablation : The introduction of the stereotaxic frame during the last century significantly improved the accuracy of lesion-based treatments for persistent psychiatric disorders. Dorsal anterior cingulotomy and anterior capsulotomy are the most commonly employed ablation methods. The former disrupts the cingulum bundle to sever communication among essential limbic regions, while the latter isolates the anterior limb of the internal capsule to disconnect the OFC and dACC. [58] . Both interventions are designed to regulate hyperactive CSTC circuits, which are believed to underlie OCD. [59] Cingulotomy has shown 41%, whereas capsulotomy had a 54% effectiveness rate. [58]
Deep brain stimulation : Deep brain stimulation (DBS) is a reversible, adjustable treatment for intractable OCD with response rates between 40% and 70%, involving the neurosurgical implantation of an electrode that can activate neighboring neural circuitry. [60] [13] DBS targets the anterior limb of the internal capsule and the ventral striatum (VS). Regulatory endorsements exist, but adoption is limited by cost and required expertise. [13] Electrode placement remains under debate, focusing on deep gray matter structures (eg, VS or nucleus accumbens [NAc], anterior limb of the internal capsule, and subthalamic nucleus [STN]) or white matter pathways connecting the prefrontal cortex to the thalamus. [61] Emerging research challenges the notion of high-frequency DBS as “functional ablation,” pointing to complex therapeutic mechanisms. [13] DBS modulates activity in brain regions linked to OCD, and the degree of modulation correlates with symptom improvement. Different DBS targets may yield specific benefits; ventral capsule (VC) and VS targeting improve comorbid depression, while STN targeting improves cognitive flexibility. [62] Future DBS targeting may be individualized based on clinical or neurobiological measures. [13]
Differential Diagnosis

OCD has symptoms similar to several other psychiatric conditions. Differentiating OCD from these conditions is essential for accurate diagnosis and effective treatment planning, as part of the criteria for OCD diagnosis involves ensuring that the symptoms of another mental disorder do not better explain the disturbance. However, OCD may also occur along with other psychiatric disorders, which can complicate clinical diagnosis. The following are some commonly considered differential diagnoses and the features that can separate from OCD: [3]

Generalized Anxiety Disorders : OCD involves irrational or odd obsessions, distinct from real-life worries found in generalized anxiety disorder. Compulsions are typically present in OCD but not in anxiety disorders.
Specific Phobia : Unlike OCD, fears in specific phobia are circumscribed to particular objects or situations and don't involve rituals or compulsions.
Social Anxiety Disorder : Fears with this condition are related to social interactions, and avoidant behaviors are aimed at reducing social fears rather than neutralizing obsessions.
Major Depressive Disorder : Ruminative thoughts in major depressive disorder (MDD) are mood-congruent and not linked to compulsive behaviors, unlike the intrusive obsessions in OCD.
Body Dysmorphic Disorder: This condition involves obsessions and compulsions related only to physical appearance.
Trichotillomania: Compulsive hair-pulling without the presence of obsessions differentiates trichotillomania from OCD.
Hoarding Disorder: Difficulty in discarding possessions characterizes hoarding disorder; if hoarding is driven by OCD-like obsessions, an OCD diagnosis is given instead.
Eating Disorders : Unlike OCD, the focus of obsessions and compulsions in disorders like anorexia nervosa is on weight and food. Ritualized eating behaviors are associated with eating disorders.
Tic Disorders: Tics and stereotyped movements are generally less complex than compulsions and are not aimed at neutralizing obsessions. A dual diagnosis may be warranted for overlapping symptoms.
Psychotic Disorders: Although some OCD patients may have poor insight or delusional beliefs, they do not exhibit other psychotic symptoms like hallucinations.
Obsessive-compulsive personality disorder : OCD is characterized by intrusive, distressing obsessions and compulsions aimed at alleviating this distress, with individuals often recognizing their symptoms as excessive. In contrast, obsessive-compulsive personality disorder (OCPD) involves a chronic pattern of perfectionism and rigid control, without the presence of obsessions or compulsions, and is often perceived by the individual as rational and desirable.

OCD is a chronic condition characterized by fluctuating periods of symptom exacerbation and remission. Due to this disorder, daily functioning is significantly impaired. Furthermore, OCD is associated with an elevated risk of mortality. [13] [63] Despite the utilization of CBT and SSRIs, a substantial proportion of patients remain unresponsive. Specifically, between 25% and 40% of patients do not experience symptom alleviation when treated with either CBT or SSRIs. [39] [13] Furthermore, only a minority achieve full remission, and approximately half of successfully treated patients continue to manifest residual symptoms.

OCD associated with hoarding symptoms generally results in a more unfavorable prognosis. Clinical data from DSM-IV field trials involving 431 patients revealed that the fear of harm was the most commonly reported obsessive symptom. A significant association between OCD and suicidal tendencies has been confirmed, with contributory factors including coexisting anxiety and depression, as well as a history of suicide attempts. [64] Additionally, the association between OCD and suicidal tendencies remains significant even when controlling for depressive symptoms or mood instability. [65]

Complications

OCD is included in the top 10 disabling disorders by the WHO. Patients with OCD tend to avoid situations that make them uncomfortable, which may lead to decreased social interactions and a poor quality of life. Most who struggle with OCD go undetected for years. If OCD goes untreated, the pattern is harder to break as structural changes to the brain take place. [66] [67] Duration of untreated OCD is associated with worse clinical outcomes. [68] Early intervention is vital.

Consultations

Utilizing cognitive behavioral therapy (CBT) with a focus on exposure and response prevention is the cornerstone of nonpharmacological treatment for OCD. Therefore, seeking consultation with a highly skilled and experienced therapist in administering this specialized form of therapy is crucial. Medical consultations may vary depending on the severity and specific nature of the compulsions exhibited. For instance, if a patient engages in excessive hand-washing, dermatological issues like dermatitis may arise, necessitating consultation with a dermatologist. Comprehensive treatment should address the patient holistically, encompassing psychological symptoms and any resulting medical conditions. Coordination of care with other healthcare clinicians (eg, pediatrics or family medicine) is also vital, especially for monitoring potential side effects of medications, including weight gain and tics.

Deterrence and Patient Education

In OCD, the patient's insight is not lacking. Only 2% to 4% lack insight into their OCD. [69] However, most people do not seek treatment until the disorder has become severely advanced. As most symptoms present during adolescence, clinicians should inform and educate appropriate individuals, including parents, fellow medical personnel, and those in the school systems, about this disorder.

Enhancing Healthcare Team Outcomes

Managing OCD requires an integrated, interprofessional healthcare team to offer patient-focused care, optimize treatment outcomes, ensure patient safety, and maximize team efficiency. The team comprises primary care physicians, psychiatrists, clinical psychologists, occupational therapists, pharmacists, and social workers, each with a distinct but collaborative role. Effective communication among team members is critical for optimal patient care.

Primary care physicians usually serve as the initial point of contact and are responsible for quickly identifying OCD symptoms and referring patients to specialized care. Psychiatrists oversee diagnosis and pharmacotherapy, while clinical psychologists conduct specialized psychometric tests to either confirm or rule out the OCD diagnosis, in addition to providing cognitive behavioral therapy. Clear, open communication among team members enables rapid intervention. Occupational therapists assess the patient's daily functioning, and social workers facilitate access to community resources. Pharmacists play a crucial role in managing medication interactions and ensuring medication adherence, particularly in instances of polypharmacy.

Ethical considerations like obtaining informed consent are paramount, as is aligning care with autonomy, beneficence, and nonmaleficence principles. Shared decision-making is emphasized, placing patient preferences at the center of all treatment decisions. Ongoing education and professional development keep the team updated on best practices in OCD treatment. This interprofessional approach to OCD management prioritizes comprehensive, safe, and high-quality patient care.

Review Questions
Access free multiple choice questions on this topic.
Comment on this article.

Disclosure: Hannah Brock declares no relevant financial relationships with ineligible companies.

Disclosure: Abid Rizvi declares no relevant financial relationships with ineligible companies.

Disclosure: Manassa Hany declares no relevant financial relationships with ineligible companies.

This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ), which permits others to distribute the work, provided that the article is not altered or used commercially. You are not required to obtain permission to distribute this article, provided that you credit the author and journal.

Cite this Page Brock H, Rizvi A, Hany M. Obsessive-Compulsive Disorder. [Updated 2024 Feb 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-.

In this Page

Bulk download.

Bulk download StatPearls data from FTP

Related information

PMC PubMed Central citations
PubMed Links to PubMed

Recent Activity

Obsessive-Compulsive Disorder - StatPearls Obsessive-Compulsive Disorder - StatPearls

Your browsing activity is empty.

Activity recording is turned off.

Turn recording back on

Connect with NLM

National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894

Web Policies FOIA HHS Vulnerability Disclosure

Help Accessibility Careers

COMMENTS

Obsessive-compulsive disorder: Evidence-based treatments and future
Obsessive-compulsive disorder: Evidence-based ...
Obsessive-Compulsive Disorder (OCD): A Comprehensive Review of
Obsessive-Compulsive Disorder (OCD): A Comprehensive ...
Therapies for obsessive-compulsive disorder: Current state of the art
Therapies for obsessive-compulsive disorder: Current state ...
Journal of Obsessive-Compulsive and Related Disorders
Journal of Obsessive-Compulsive and Related Disorders
Cognitive-Behavioral Therapy for Obsessive-Compulsive Disorder ...
Cognitive-behavioral therapy (CBT) remains one of the most effective treatments for obsessive-compulsive disorder (OCD). In this update of a previous article (), we define CBT, review the evidence for the efficacy of CBT for OCD, provide a case example and sample treatment plans, and discuss family factors that affect treatment outcome.In addition, we discuss group and family-based modalities ...
Evidence-Based Assessment of Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) is a neuropsychiatric illness that often develops in childhood, affects 1%-2% of the population, and causes significant impairment across the lifespan. ... this paper reviews commonly used OCD measures that have been examined in research studies to enhance clinicians' abilities to detect and monitor OCD ...
International Group Releases New OCD Treatment Standards
The International Obsessive-Compulsive Disorders Accreditation Task Force (ATF)—a group of more than 60 experts representing 14 nations—has published a comprehensive set of specialty standards for the treatment of obsessive-compulsive disorder (OCD) in children and adults. The task force was created and is overseen by the Canadian Institute ...
Cognitive-Behavioral Treatment of Obsessive-Compulsive Disorder: The
Cognitive-Behavioral Treatment of Obsessive-Compulsive ...
Obsessive-compulsive disorder
Obsessive-compulsive disorder - PMC
Global research on Obsessive Compulsive Disorder and related disorders
1. Introduction. Obsessive Compulsive Disorder (OCD) is characterized by obsessions and compulsions. It is one of the disorder associated with significant disability (Stein et al., 2019), and caregiver burden (Grover and Dutt, 2011).Earlier it was considered to have low prevalence, but over the time, it has been accepted that the prevalence of OCD may be twice that of schizophrenia (Rasmussen ...
Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder
Clinical advances in obsessive-compulsive disorder: a positi ...
advances judged to be of utmost relevance to the treatment of OCD, based on new and emerging evidence from clinical and translational science. Areas covered include refinement in the methods of clinical assessment, the importance of early intervention based on new staging models and the need to provide sustained well-being involving effective relapse prevention. The relative benefits of ...
(PDF) Obsessive-compulsive disorder: Evidence-based treatments and
Telephone: +1-405-9745456 Fax: +1-405-974851. Received: February 17, 2012 Revised: September 14, 2012. Accepted: September 21, 2012. Published online: December 22, 2012. Abstract. Over the past ...
A prospective clinical cohort-based study of the prevalence of OCD
Background The lifetime prevalence of obsessive − compulsive disorder (OCD) is currently estimated at 2 − 3% and the prevalence in first-degree family members is estimated to range between 10 and 11%. Separating OCD from other anxiety disorders and including it into the new "obsessive − compulsive and related disorders" (OCRDs) category has had a dramatic impact on the diagnosis ...
Essential Papers on Obsessive-Compulsive Disorder
Section 2 contains five papers on psychological research. Joseph Sandler and Anandi Hazari present a visionary study of the classification of obsessional character traits and symptoms that employs factor analytic techniques; this approach has recently returned to the fore, promising new insights regarding subtypes of OCD.
Full article: A concentrated approach for treating OCD: a pilot study
Obsessive-compulsive disorder (OCD) affects approximately 1% to 2% of people across the lifespan, more specifically in a recent meta-analysis, Fawcett et al. (Citation 2020) reported current prevalence estimates at 1.1% and lifetime at 1.3%.When not adequately treated, OCD is a chronic condition that results in a poor quality of life (Swain & Behura, Citation 2016) and is associated with ...
Clinical advances in obsessive-compulsive disorder: a position
Clinical and translational research in OCD grows apace, and over the past 10 years has contributed to substantial advances in understanding of the phenomenology, brain-based biology and treatment response, leading to innovations in nosological conceptualizations, therapeutic interventions and services. ... Obsessive-compulsive disorder ...
The Future of Obsessive-Compulsive Spectrum Disorders: A Research
Abstract. Obsessive-compulsive disorder (OCD) sits at the epicenter of a spectrum of related conditions (often referred to as obsessive-compulsive related disorders (OCRD) or obsessive-compulsive spectrum disorders (OCSD)) that can be as disabling as they are varied in presentation. Research in the field now encompasses diverse disciplines ...
Obsessive‐compulsive disorder: Etiology, neuropathology, and cognitive
Obsessive‐compulsive disorder: Etiology, neuropathology ...
Obsessive-Compulsive Disorder (OCD) Across the Lifespan ...
Obsessive-Compulsive Disorder (OCD) is one of the most prevalent and disabling neuropsychiatric disorders, with high comorbidity rates and poor response to first-line treatments in about one third of patients. Currently recognized as an early-onset disorder, it may present distinct symptom dimensions, with an often-chronic course with periods of worsening of symptoms, or, less frequently, an ...
(PDF) Obsessive-compulsive disorder
Obsessive-compulsive disorder (OCD) is characterised by the. presence of obsessions or compulsions, or commonly of both. OCD is the fourth most common mental disorder after. depression, alcohol ...
Obsessive‐compulsive disorder: Etiology, neuropathology, and cognitive
Another aim is to shed light on cognitive deficits in OCD. In sum, research questions include (1) what are the symptoms in OCD; (2) what is the etiology of the disorder and do existing models explain OCD; and (3) what are key cognitive deficits in OCD and do these improve with treatment. ... Discussion paper. Journal of the Royal Society of ...
A New Way to Understand--and Possibly Treat--OCD
A New Way to Understand--and Possibly Treat--OCD
Obsessive-Compulsive Disorder
Obsessive-Compulsive Disorder - StatPearls

Information

Initiatives

Article Menu

JSmol Viewer

1. Introduction

Share and Cite

Article Metrics

Save citation to file

Add to My Bibliography

Conflict of interest statement

Similar articles

Publication types

Related information

Miscellaneous

Secondary Logo

Clinical advances in obsessive-compulsive disorder: a position statement by the International College of Obsessive-Compulsive Spectrum Disorders

Introduction

Global assessment of obsessive-compulsive disorder

Early intervention in obsessive-compulsive disorder

Cognitive behavioural therapy, selective serotonin reuptake inhibitor or their combination as a first-line treatment for adults with obsessive-compulsive disorder

The critical importance of adequate treatment of obsessive-compulsive disorder in children and young people

Relapse prevention

Treatment-resistant obsessive-compulsive disorder – novel pharmacotherapies tested in adults

Treatment-resistant obsessive-compulsive disorder – noninvasive neurostimulation

Treatment-resistant obsessive-compulsive disorder – deep brain stimulation and ablative neurosurgery

Future directions for research

Novel digital interventions in obsessive-compulsive disorder

Immunological therapies

Novel forms of psychotherapy

Pharmacogenetics

Acknowledgements

Conflicts of interest

Readers Of this Article Also Read

A prospective clinical cohort-based study of the prevalence of OCD, obsessive compulsive and related disorders, and tics in families of patients with OCD

Diagnostic Procedure

Statistical analysis

OCD and OCRD prevalence in family members

Availability of data and materials

Abbreviations

Acknowledgements

Author information

Contributions

Corresponding author

Ethics declarations

Consent for publication

Competing interests

Additional information

Rights and permissions

About this article

Share this article

BMC Psychiatry

Essential Papers on Obsessive-Compulsive Disorder

Export Citations

View options

Purchase Options

Not a subscriber?

Share article link

PREVIOUS ARTICLE

Create a new account

Reset password

The Future of Obsessive-Compulsive Spectrum Disorders: A Research Perspective

Cite this chapter

Access this chapter

Similar content being viewed by others

Obsessive–compulsive disorder

Toward identifying reproducible brain signatures of obsessive-compulsive profiles: rationale and methods for a new global initiative

Cognitive Behavioral Therapy for Obsessive–Compulsive Disorder: Theory, Assessment, and Treatment

Acknowledgements

Contributors

Author information

Corresponding author

Editor information

Rights and permissions

Copyright information

About this chapter

Download citation

Share this chapter

Obsessive-Compulsive Disorder (OCD) Across the Lifespan: Current Diagnostic Challenges and the Search for Personalized Treatment

About this Research Topic

Topic Editors