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Obsessive-compulsive disorder
I Heyman, D Mataix-Cols and N A Fineberg Updated information and services can be found at: References
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I Heyman, D Mataix-Cols, N A Fineberg
Obsessive-compulsive disorder is one of the more common serious mental illnesses. The shame and Summary points
secrecy associated with it, as well as lack of recognition of its characteristic symptoms, can lead to delay in Obsessive-compulsive disorder can occur at any diagnosis and treatment. Effective psychological and age but most often presents for the first time in drug treatments are available for the distressing, time consuming, repetitive thoughts and rituals and the associated functional impairment. This article reviews Long delays in diagnosis often occur, and the shame associated with the disorder may inhibit compulsive disorder and discusses the current best treatment options, as well as directions for the future.
General practitioners should ask specific screening neuropsychology andneuroscience of questions if obsessive-compulsive disorder is suspected We searched for the term “obsessive compulsive disor- der” in electronic databases and referred to published Mild cases may be helped by guided self help; systematic reviews, including the recently published most people with obsessive-compulsive disorder guideline from the National Institute for Health and should be offered cognitive behaviour therapy incorporating exposure and response prevention N A Finebergconsultant psychiatristand visiting professor Who gets it and why does it matter?
Children and adults with obsessive-compulsivedisorder may be offered selective serotonin Obsessive-compulsive disorder occurs throughout the reuptake inhibitor drugs; this should be a second life span, and children as young as 6 or 7 present with the characteristic impairing symptoms (box 1). At the other end of the age range, patients may present for The condition may remit, but can be relapsing or the first time in old age. Most adults with the disorder chronic; people with obsessive-compulsive disorder report onset in childhood or adolescence. The who relapse should have rapid access to services condition can result in considerable disability; for example, children may drop out of education andadults can become housebound. The World Health needed in a range of non-psychiatric healthcare Organization rates obsessive-compulsive disorder as settings, and clinicians need to be confident about one of the top 20 most disabling diseases. If untreated, it generally persists,1 yet effective, evidence basedpsychological and drug treatments are available.
What are the symptoms?
Recent epidemiological studies report prevalence rates of 0.8% in adults and 0.25% in 5-15 year old chil- Obsessions are unwanted ideas, images, or impulses dren,2 3 although earlier studies suggested rates as high that repeatedly enter a person’s mind. Although recog- as 1-3% in adults and 1-2% in children and nised as being self generated, they are experienced as “egodystonic” (out of character, unwanted, and Why do clinicians need to know about it?
Table 1 Non-psychiatrists likely to see patients with
People of all ages with obsessive-compulsive disorder understand the senseless nature of their repetitive, Professional
Reason for consultation
thoughts. This may lead to shame, reluctance to seek help, and poor recognition by health professionals.
Concerns about appearance (body dysmorphic disorder) People with the disorder have long delays in accessing effective treatments—17 years on average in one study.4 They frequently present to non-psychiatrists for OCD associated with Tourette’s syndrome treatment (table 1), and psychiatric symptoms go undetected. Greater awareness of the condition is BMJ VOLUME 333 26 AUGUST 2006
Box 1: Most common symptoms of
Box 2: ICD-10 definition of obsessive-compulsive disorder
obsessive-compulsive disorder
• Either obsessions or compulsions (or both) present on most days for aperiod of at least two weeks Obsessions
• Obsessions (thoughts, images, or ideas) and compulsions share the following features, all of which must be present: Acknowledged as originating in the mind of the patient Repetitive and unpleasant; at least one recognised as excessive or At least one must be unsuccessfully resisted (although resistance may Carrying out the obsessive thought or compulsive act is notintrinsically pleasurable Compulsions
ries about harm, such as being responsible for an accident or the fear of contamination, accompanied by avoidance of situations in which harm or contamination may occur. These obsessions are linked with compulsive behaviours, which may temporarily reduce the associ- ated anxiety, such as excessive checking or cleaning ritu- als. Other common obsessions include a need for symmetry or orderliness, often associated with counting, ordering, and arranging compulsions; unwarrantedfears and images about committing aggressive or sexual acts; and compulsive hoarding. People of all ages, but especially children, may involve family members in their compulsions or persistently demand reassurance. Exces-sive doubt, the need for completeness, shame, andabnormal assessment of risk in the mind of the patient distressing). Compulsions are repetitive stereotyped are thought to underlie most obsessions.
behaviours or mental acts driven by rules that must be Aggressive obsessions are common and must be applied rigidly. They are often intended to neutralise differentiated from violent thoughts occurring in other anxiety provoked by the obsessions (fig 1). They are not disorders, such as urges to hurt people in psychopathy.
inherently enjoyable and do not result in the People with pure obsessive-compulsive disorder worry completion of any useful task. To qualify for the that they might commit an offence but do not carry out diagnosis, the symptoms must be disabling. Even the feared act and spend an excessive amount of time among children, in whom diagnostic criteria allow less and energy resisting and controlling their behaviour to insight, most patients acknowledge the senselessness of avoid the risk of harm. However, obsessive-compulsive the thoughts and behaviours, as well as the wish to be disorder may occur together with other complicating rid of them. Box 2 summarises the ICD-10 (interna- conditions (table 2).5 Screening for and treating these tional classification of diseases, 10th revision) criteria comorbidities is an important part of the management.
Most patients with obsessive-compulsive disorder Can questionnaires help with diagnosis?
experience both obsessions and compulsions (box 1).
Recognition of obsessive-compulsive disorder may Common obsessions include unrealistic distressing wor- require direct questions, as the affected person is oftenreluctant to volunteer symptoms, particularly if thesymptoms are perceived as embarrassing (such as sexual obsessions). People with hoarding symptoms may notsee their hoarding as a problem. The recently launched NICE guideline on the treatment of obsessive-compulsive disorder and body dysmorphic disorder rec-ommends six screening questions (derived from the Zohar-Fineberg obsessive compulsive screen; box 3).6 The obsessive-compulsive disorder cycle. Obsessions are intrusive thoughts (ideas, images, or impulses) that repeatedly enter Table 2 Conditions that commonly occur with
a person’s mind against his or her will. These generate considerable anxiety and are difficult to dismiss. Compulsions or rituals are Condition
Frequency (%)
repetitive acts that are performed in an attempt to reduce the anxietycaused by the obsessions, but the relief is only temporary. Later in the course of obsessive-compulsive disorder, rituals can become more automatic and increase, rather than reduce, the anxiety.
Psychological theories of obsessive-compulsive disorder suggest that ritualising maintains the problem as it prevents habituation to the anxiety and disconfirmation of the patient’s fears. Psychological therapies aim to break this cycle by persuading patients to expose themselves to the feared situations while refraining from performingany rituals; this is known as exposure and response prevention BMJ VOLUME 333 26 AUGUST 2006
Box 3: Quick screen for obsessive-compulsive
disorder6
• Do you wash or clean a lot?
Is there any thought that keeps bothering you that you would like to get rid of but can’t? • Do your daily activities take a long time to finish? Consider an SSRI (with careful monitoring) • Are you concerned about orderliness or symmetry?• Do these problems trouble you? Once the diagnosis has been suggested, the use of Consider use in 8-11 year age group Offer to 12-18 year age group standardised instruments may help to define the Carefully monitor for adverse events, especially at start of treatment symptom profile, estimate severity and impairment,and monitor response to treatment. A short self Consider either (especially if previous good response to): completed questionnaire such as the obsessive compulsive inventory may be used.7 The current best validated instrument is the Yale-Brown obsessive com-pulsive scale (Y-BOCS), which exists in both an adult Treatment options for children and young people with obsessive-compulsive disorder. CBT=cognitive behaviour therapy;ERP=exposure and response prevention; SSRI=selective serotoninreuptake inhibitor. (Adapted from NICE guideline6) What are the treatments and where
should they be accessed?

specialist services for more “difficult to treat” patients.
NICE examined the evidence base supporting the effi- Figures 2 and 3 summarise the treatments for children cacy of all therapies for obsessive-compulsive disorder (and body dysmorphic disorder). In the recently The guideline emphasises the importance of better published guideline, NICE recommends a “stepped recognition of the disorder across the life span and the care” model, with increasing intensity of treatment need for good information and education. A large according to clinical severity and complexity (table 3).6 variety of resources exist, some of which are The intention of the guideline is to encourage evidence summarised in the additional educational resources based treatment to take place at the least intrusive level box. After a diagnosis has been made, the patient and appropriate to a patient’s needs. In some cases, this family need to understand the diagnosis and to be means at the primary care level. At the other end of the helped not to feel blame or shame and the clinician scale, the guideline supports the establishment of needs to instil optimism about recovery. Guided selfhelp may be effective in early or mild obsessive-compulsive disorder, and both computer and paper Unanswered research questions in obsessive-compulsive disorder
self help manuals exist, although fewer options are Nosological status of OCD
• Should OCD be classified as an anxiety disorder?
Do subtypes exist, each with different causes (for example, early onset OCD, OCD with comorbid tics, compulsive hoarding)? • Are hypochondriasis, body dysmorphic disorder, and other “spectrum” disorders variants or completely separate disorders? Causative factors
• What are the precise genetics of OCD? • Might environmental factors such as family environment or streptococcal Management questions
• Would screening, with earlier detection and treatment, improve outcomes?
Offer combined treatment of CBT (+ERP) and SSRI • What is the most effective cognitive behaviour therapy package in termsof intensity and length of treatment and training of therapist?• Offer either: Different SSRI or clomipramine How effective is self help, computer guided therapy, or telephone therapy, compared with conventional face to face therapy?• Does an effective course of cognitive behaviour therapy help to prolong Refer to multidisciplinary team with expertise in OCD remission and prevent relapse?• How effective are combinations of cognitive behaviour therapy and drugs Consider: additional CBT (including ERP) or cognitive therapy, adding antipsychotic to SSRI or clomipramine, combining • What makes some cases treatment resistant? How might treatments bebest modified for these cases? Treatment options for adults with obsessive-compulsive disorder (OCD). CBT=cognitive behaviour therapy; ERP=exposure and response prevention; SSRI=selective serotonin reuptake inhibitor.
(Adapted from NICE guideline6) BMJ VOLUME 333 26 AUGUST 2006
Table 3 NICE stepped care model for obsessive-compulsive disorder (OCD)6
Who is responsible for care?
What is the focus?
Children
Type of OCD
Type of care
Individuals, public organisations, national health service Detect, educate, and discuss treatment options. Signpost voluntary support agencies. Refer if necessary General practitioners, primary care team, Assess, review, and discuss options. For adults: brief individual or group CBT (including ERP) with self help materials, SSRI, or consider combined treatments. Forchildren: guided self help, CBT (including ERP) Management of OCD with comorbidity or poor Assess, review, and discuss options. CBT (including ERP), SSRI, consider alternative SSRI, combined treatments, orclomipramine Management of OCD with significant comorbidity, Reassess and discuss options. As above, and consider more severely impaired functioning and/or OCD with risk to life, severe self neglect, or severe Reassess, discuss options, and care coordination. As above, and consider admission or special living arrangements CAMHS=child and adolescent mental health services; CBT=cognitive behaviour therapy; ERP=exposure and response prevention; NICE=National Institute for Health and Clinical Excellence;SSRI=selective serotonin reuptake inhibitor.
available for the younger age group. NICE paid No evidence exists to support the efficacy of particular attention to patients’ choices in directing psychodynamic psychotherapy in OCD. NICE there- treatment and to the careful estimation of risks and the costs of treating or not treating the disorder.
What happens in cognitive behaviour
therapy?

Additional educational resources
NICE reviewed 17 trials in adults and concluded that Information and self help books for children and adults
cognitive behaviour therapy was an efficacious Wagner A. Up and down the worry hill: a children’s book about obsessive treatment for obsessive-compulsive disorder.6 The best compulsive disorder and its treatment. New York: Lighthouse Press, 2002—Anillustrated book designed to help parents and professionals to explain randomised controlled trials in the younger age group obsessive-compulsive disorder to younger children through the story of showed that delivering cognitive behaviour therapy “Casey,” a young boy with the disorder within a family setting was highly effective.10 Wever C, Phillips N. The secret problem. Sydney: Shrink-Rap Press, 1996—A In both adults and children, the specific psycho- cartoon book that describes obsessive-compulsive disorder in clear and logical technique most strongly associated with good simple language to help children, teenagers, and parents to understand it outcome in studies of cognitive behaviour therapy is Hyman B, Pedrick C. The OCD workbook: your guide to breaking free from obsessive- response rates of up to 85% in patients who complete compulsive disorder. Oakland, CA: New Harbinger Publications, 2005—A self the therapy.11 The patient generates a hierarchy of help manual for adults and older adolescents, which guides the patient throughexposure with response prevention; includes advice for family members feared situations and then practises facing the fear Veale D, Willson R. Overcoming obsessive compulsive disorder. London: Constable (exposure), while monitoring the anxiety and experi- & Robinson, 2005—A self help book suitable for adults and older teenagers encing that it lessens without the need to carry out a Schwartz JM. Brain lock: free yourself from obsessive compulsive behaviour. New ritual (response prevention). Engaging the person by York: Harper Collins, 1997—A self treatment manual suitable for adults and helping them to design a graded programme of expo- sure and response prevention, and working collabora- Information for practitioners
tively on easiest challenges first, is essential. Carefuleducation about mechanisms of anxiety, understand- March J, Mulle K. OCD in children and adolescents: a cognitive-behaviouraltreatment manual. New York: Guilford Press, 1998—A manualised approach ing that repeated exposure leads to reduced anxiety, as to cognitive behavioural therapy, including psychoeducational material and well as reduction in obsessions, is important for success. Practice is needed, as patients will have been Clark DA. Cognitive behavioural therapy for OCD. New York: Guilford Press, reinforcing their behaviours by avoiding feared 2003—Overview of cognitive and behavioural techniques situations or carrying out rituals to deal with their fears Fineberg N, Marazziti D, Stein DJ, eds. Obsessive compulsive disorder: a practical guide. London: Martin Dunitz, 2001 The cognitive model of obsessive-compulsive Websites
disorder emphasises remedying faulty reasoning that South London and Maudsley NHS Trust (www.ocdyouth.info)—Information may have developed with the disorder. Increasingly, on obsessive-compulsive disorder and how to recover, for young people and therapists use cognitive strategies in combination with exposure and response prevention. Cognitive OCD Action (www.ocdaction.org.uk)—National charity in the UK; provides approaches encourage patients to re-evaluate over- valued beliefs about risk or personal responsibility, to Obsessive Compulsive Foundation (www.ocfoundation.org)—US national regain a more realistic perspective, and to carry out “behavioural experiments” to test the validity of their National Institute for Health and Clinical Excellence (www.nice.org.uk/ beliefs.12 Whether the addition of cognitive techniques page.aspx?o = cg031&c = mental)—NICE guideline on obsessive-compulsive significantly improves the efficacy of exposure and response prevention is as yet unclear.
BMJ VOLUME 333 26 AUGUST 2006
studies show equivalent efficacy and better tolerability Patient’s story: teenager with moderately severe
for SSRIs relative to clomipramine.16 Clomipramine obsessive-compulsive disorder
remains a useful option but is usually reserved forpatients in whom trials of SSRIs have been ineffective.
By the time she was 13Y, Chloe had spent almost a year becoming more and The therapeutic response to drug treatment in more disabled by troublesome worries and repetitive behaviours. Chloe was obsessive-compulsive disorder increases gradually over worried that she was “going crazy” and did not tell anyone about her weeks and months; studies show that the benefits symptoms. She had previously been a bubbly, outgoing girl, who wasenthusiastic about school and had many friends. She was now late for continue to accrue for at least six months and probably school every day, and some days she did not go at all. She rarely saw her longer. Patients should be warned that side effects such friends. Her mother noticed unusual behaviours, such as checking. Checks as nausea and agitation tend to emerge early, often included plugs and the gas cooker, her school bag repeatedly in the before the therapeutic response is consolidated, but usu- mornings, and that her pet dogs were each shut in separate rooms of the ally abate. A trial of at least 12 weeks at the maximum house. Chloe was also worried, tearful, and not sleeping well. She was able tolerated dose is advisable before effectiveness is judged.
to explain to her mother that her mind seemed full of terrible, repetitivethoughts that bad things might happen to her dogs or to her family.
Several studies have shown that people with Carrying out the checks or asking repeated questions made it feel like these obsessive-compulsive disorder continue to benefit from long term drug treatment and that a large Chloe saw her general practitioner, who diagnosed obsessive-compulsive number relapse if the drug is discontinued or switched disorder and also wondered if Chloe was depressed. He referred her to to placebo under trial conditions.17 Possibly, patients child and adolescent mental health services. The diagnosis was confirmed, with greater comorbidity are at most risk of relapse.
and Chloe began cognitive behaviour therapy with a nurse therapist, who For at least some cases, therefore, treatment may need worked jointly between the general practitioner and the mental health services. After eight sessions, Chloe had made a few gains, cutting back onsome of her checking. She was still low in mood, not attending school, and Drugs, psychological therapies, or both?
largely housebound, as she thought her dogs would die if she did not checkthem every few minutes.
On the available evidence, for children, adolescents, A referral was made to a specialist obsessive-compulsive disorder service, and adults, psychological and drug treatments seem to where Chloe was reassessed. In a structured interview, Chloe scored in the be equally effective. According to NICE guidance, cog- moderately severe range, and her clinical presentation revealed ongoing nitive behaviour therapy is recommended as the first impairing obsessive-compulsive disorder as well as moderate depression.
line treatment for children and adolescents, because of Chloe and her mother had read about drug treatment and were keen to try the assumption that it has fewer risks than SSRIs.6 For this. Fluoxetine was prescribed (because Chloe had depression as well).
adults, cognitive behaviour therapy or pharmaco- After six weeks on fluoxetine, Chloe’s mood was noticeably improved. Shewas also less anxious and agreed to embark on another course of cognitive therapy can be offered first. Currently, in the United behaviour therapy involving exposure and response prevention. With her Kingdom, provision of evidence based psychological therapist, Chloe worked out a detailed programme of cutting back on time therapies, such as cognitive behaviour therapy, is inad- consuming rituals, challenging the anxious beliefs, and learning to tolerate equate, and expansion of these services is needed.18 some anxiety, while discovering that nothing bad happened if she did not Uncertainty remains as to whether the two forms of carry out her ritual. After 12 sessions of therapy, Chloe had only minimal treatment combined are superior to psychological or symptoms and was back at school and going out with friends.
drug monotherapy. Several studies in adults have Over the next year, Chloe had brief review appointments every three to looked at this; some suggest that addition of drugs four months. She requested an extra appointment during a time whensymptoms threatened to come back, just after she had been mugged near increases the efficacy of cognitive behaviour therapy, her home. A “top-up” session of cognitive behaviour therapy enabled Chloe whereas others show no additional benefit. In a recent to renew her skills and prevent rituals or avoidant behaviour returning.
trial in young people, a placebo pill was compared with Nine months after this, Chloe remained well and wanted to try reducing sertraline alone, cognitive behaviour therapy alone, and stopping her fluoxetine. This was gradually reduced and stopped over and cognitive behaviour therapy plus sertraline. All three months. Chloe has remained well.
three active treatments were better than placebo andnot significantly different from each other.19 Cognitive Do drug treatments work, and who
behaviour therapy, either alone or in combination withdrug treatment, might help to prolong remission and should get them?
prevent relapse on discontinuation of the drug, but this Obsessive-compulsive disorder responds specifically to remains to be tested in long term studies.
drugs that inhibit the synaptic reuptake of serotonin— Do additional treatments help?
that is, the tricyclic antidepressant clomipramine andthe more highly selective serotonin reuptake inhibitors Up to 40% of patients who present to psychiatrists fail (SSRIs). SSRIs are effective at all ages. Both the effect to respond adequately to either cognitive behaviour size and side effect profiles seem to be similar across therapy, drugs, or a combination of the two. Carefulreassessment with detection and treatment of related problems may improve outcomes. For example, young All the SSRIs have been subject to large scale clinical people with developmental difficulties on the autism trials (33 in adults,18 in children).14 15 Dose finding stud- spectrum may be susceptible to obsessive-compulsive ies have been carried out only in adults. Higher doses of disorder as teenagers or young adults, and these SSRIs than those used for depression may be needed to patients may need specifically tailored cognitive behav- effectively treat obsessive-compulsive disorder.
SSRIs have largely superseded clomipramine for Some evidence exists to support various drug strat- treating obsessive-compulsive disorder because of their egies in resistant cases, including increasing the dose of lesser toxicity in overdose and more favourable side the SSRI to the maximum tolerated dose and switching effect profile. This is especially important for children, to an alternative, as response may be idiosyncratic.
in whom cardiac toxicity may be a risk. Head to head SSRI and clomipramine have been combined in some BMJ VOLUME 333 26 AUGUST 2006
studies; this needs careful monitoring and should be The classification of obsessive-compulsive disorder done in a specialist setting. Obsessive-compulsive remains an area of active debate and research, as does disorder does not respond to antipsychotic drugs given the search for causes (see unanswered research as monotherapy. Evidence from children and adults questions box). Identification of meaningful subgroups shows that adding first generation and second genera- may lead to the development of tailored treatments, tion antipsychotics, in low dose, to SSRIs may benefit especially for those patients who do not respond to resistant cases and obsessive-compulsive disorder with comorbid tics.20 This intervention should be initiated Contributors: All authors contributed to the overall planning, by specialists in obsessive-compulsive disorder and drafting, and referencing of the review. IH had particular input monitored closely for effectiveness and side effects.
into child and adolescent OCD and final editing, NAF into adultOCD and psychopharmacology, and DM-C into neurobiologyand psychology of OCD.
Can further research help us?
Competing interests: NAF has done consultancy work for Debate is ongoing about whether obsessive-compulsive Lundbeck, GlaxoSmithKline, Astra-Zeneca, and Bristol-MyersSquibb; is a speakers’ bureau member for Astra-Zeneca and disorder is appropriately classified as an anxiety Wyeth; and has received educational support from Janssen, disorder. Research studies in a range of modalities (neu- Wyeth, and Cephalon. IH and DM-C: none declared.
Skoog G, Skoog I. A 40-year follow up of patients with obsessive- pharmacology) suggest that the disorder has a compulsive disorder. Arch Gen Psychiatry 1999;56:121-7.
heritability and neurobiology distinct from the other Wittchen HU, Jacobi F. Size and burden of mental disorder in Europe: acritical review and appraisal of 27 studies. Eur Neuropsychopharmacol compulsive disorder has a distinct neurobiology, it is Heyman I, Fombonne E, Simmons H, Ford T, Meltzer H, Goodman R.
Prevalence of obsessive-compulsive disorder in the British nationwide highly responsive to psychological treatments that survey of child mental health. Br J Psychiatry 2001;179:324-9.
involve cognitive and behavioural modification of Hollander E, Wong C. Psychosocial functions and economic costs of obsessive compulsive disorder. CNS Spectrums 1998;3(5 suppl 1):48-58.
Piggott TA, L’Heureux F, Dubbert B, Bernstein S, Murphy DL. Obsessive Altered functioning of specific brain regions (basal compulsive disorder: comorbid conditions. J Clin Psychiatry 1994; ganglia and orbitofrontal cortex) is implicated in the National Institute for Health and Clinical Excellence. Obsessive-compulsive disorder. Evidence for this includes high rates of disorder: core interventions in the treatment of obsessive-compulsive disorder and obsessive-compulsive disorder in diseases that affect body dysmorphic disorder. London: NICE, 2005. (Clinical guideline 31.) Huppert JD, Walther MR, Hajcak G, Yadin E, Foa EB, Simpson HB, et al.
these brain regions, such as Tourette’s syndrome, Hunt- The OCI-R: validation of the subscales in a clinical sample. J Anxiety ington’s chorea, and Sydenham’s chorea. A fluctuating Disord 2006 Jun 28; [Epub ahead of print].
Goodman WK, Price LH, Rasmussen SA, Mazure C, Fleischmann RL, form of obsessive-compulsive disorder, tics, or both Gill CL, et al. The Yale-Brown obsessive compulsive scale: development, (paediatric autoimmune neuropsychiatric disorders use and reliability. Arch Gen Psychiatry 1984;46:1006-11.
Scahill L, Riddle MA, McSwiggin-Hardin M, Ort SI, King RA, Goodman associated with streptococcal infection—PANDAS) has WK, et al. Children’s Yale-Brown obsessive compulsive scale: reliability been recently described and is thought to be secondary and validity. J Am Acad Child Adolesc Psychiatry 1997;36:844-52.
10 Barrett P, Healy-Farrell L, March JS. Cognitive-behavioral family to streptococcal infection and mediated by autoanti- treatment of childhood obsessive-compulsive disorder: a controlled trial.
bodies binding to basal ganglia.22 Furthermore, J Am Acad Child Adolesc Psychiatry 2004;43:46-62.
11 Foa EB, Goldstein A. Continuous exposure and complete response pre- research into subtypes, such as compulsive hoarding, vention in the treatment of obsessive-compulsive neurosis. Behav Ther have suggested that neurobiologically distinct forms of obsessive-compulsive disorder may exist.23–25 Research 12 Salkovskis PM. Understanding and treating obsessive-compulsive disorder. Behav Res Ther 1999;37(suppl 1):29-52.
is also needed on early environmental and family risk 13 Fineberg N, Heyman I, Jenkins R, Premkumar P, Veale D, Kendall T, et al.
factors that may, in complex interaction with genes, be Does childhood and adult obsessive compulsive disorder (OCD) respondthe same way to treatment with serotonin reuptake inhibitors (SRIs)? Eur implicated in the genesis of the disorder.
Neuropsychopharmacol 2004;14(suppl 3):S191.
Several disorders seem to be related to obsessive- 14 Fineberg NA, Gale TM. Evidence-based pharmacotherapy of obsessive- compulsive disorder. Int J Neuropsychopharmacol 2005;8:107-29.
compulsive disorder, either by the nature of their 15 Geller DA, Biederman J, Stewart SE, Mullin B, Martin A, Spencer T, et al.
symptoms, which show similarities to obsessions or Which SSRI? A meta-analysis of pharmacotherapy trials in pediatricobsessive-compulsive disorder [see comment]. Am J Psychiatry 2003; compulsions, or by their frequent co-occurrence.
These have been termed obsessive-compulsive disor- 16 Zohar J, Judge R. Paroxetine versus clomipramine in the treatment of obsessive compulsive disorder. Br J Psychiatry 1996;169:468-74.
der spectrum disorders (box 4),26 although whether all 17 Koran LM, Hackett E, Rubin A, Wolkow R, Robinson D. Efficacy of of these disorders are causally related to obsessive- sertraline in the long term treatment of obsessive-compulsive disorder.
Am J Psychiatry 2002;159:89-95.
compulsive disorder is unclear. Hypochondriasis 18 Layard R. The case for psychological treatment centres. BMJ 2006;332:1030-2.
involving a preoccupation with health related fears can 19 Pediatric OCD Treatment Study (POTS) Team. Cognitive-behavior therapy, sertraline, and their combination for children and adolescents be similar to the disorder. Body dysmorphic disorder, with obsessive-compulsive disorder: the pediatric OCD treatment study which involves obsessional thoughts relating to (POTS) randomized controlled trial. JAMA 2004;292:1969-76.
imagined or slight defects in appearance and frequent 20 Bloch MH, Landeros-Weisenberger A, Kelmendi B, Coric V, Bracken MB, Leckman JF. A systematic review: antipsychotic augmentation with treatment checking in the mirror, can also be difficult to refractory obsessive-compulsive disorder. Mol Psychiatry 2006;11:1-11.
distinguish from obsessive-compulsive disorder.
21 Stein DJ. Obsessive-compulsive disorder. Lancet 2002;360:397-405.
22 Swedo SE, Leonard HL, Rapoport JL. The pediatric autoimmune neuro- psychiatric disorders associated with streptococcal infection (PANDAS)subgroup: separating fact from fiction. Pediatrics 2004;113:907-11.
23 Saxena S, Brody AL, Maidment KM, Smith EC, Zohrabi N, Katz E, et al.
Box 4: Conditions related to
Cerebral glucose metabolism in obsessive-compulsive hoarding. Am J obsessive-compulsive disorder26
24 Mataix-Cols D, Wooderson S, Lawrence N, Brammer MJ, Speckens A, Body dysmorphic disorder (dysmorphophobia) Phillips ML. Distinct neural correlates of washing, checking and hoardingsymptom dimensions in obsessive-compulsive disorder. Arch Gen 25 Mataix-Cols D, Rosario-Campos MC, Leckman JF. A multidimensional model of obsessive-compulsive disorder. Am J Psychiatry 2005;162:228-38.
26 Hollander E. Obsessive-compulsive spectrum disorders—an overview.
BMJ VOLUME 333 26 AUGUST 2006

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