I Heyman, D Mataix-Cols and N A Fineberg
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Obsessive-compulsive disorder I Heyman, D Mataix-Cols, N A Fineberg
Obsessive-compulsive disorder is one of the more
common serious mental illnesses. The shame and
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 professorWho 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 (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
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?
• 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 practicalguide. London: Martin Dunitz, 2001
The cognitive model of obsessive-compulsive
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
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
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13 Fineberg N, Heyman I, Jenkins R, Premkumar P, Veale D, Kendall T, et al.
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14 Fineberg NA, Gale TM. Evidence-based pharmacotherapy of obsessive-
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15 Geller DA, Biederman J, Stewart SE, Mullin B, Martin A, Spencer T, et al.
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16 Zohar J, Judge R. Paroxetine versus clomipramine in the treatment of
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17 Koran LM, Hackett E, Rubin A, Wolkow R, Robinson D. Efficacy of
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18 Layard R. The case for psychological treatment centres. BMJ 2006;332:1030-2.
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19 Pediatric OCD Treatment Study (POTS) Team. Cognitive-behavior
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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
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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-
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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 Jobsessive-compulsive disorder26
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