Internet Mental Health

OBSESSIVE-COMPULSIVE DISORDER





Internet Mental Health Quality of Life Scale (Client Version)

Internet Mental Health Quality of Life Scale (Therapist Version)

Big 5 Factors Of Mental Illness And Code For This Disorder
(The "6th Big Factor" of Mental Health, "Physical Health", Is Coded Normal or Green)

  • Had obsessions (anxiety-provoking, repetitive, unwanted thoughts) or compulsions (obsession-relieving, repetitive rituals).

  • This caused significant distress or disability.

  • Not due to a medical or substance use disorder.

Prediction

    Is episodic or continuous for years:
    • 80% have chronic waxing and waning course; made worse by stress
    • 15% have progressive deterioration in occupational and social functioning
    • 5% have an episodic course with minimal or no symptoms between episodes

Problems

Occupational-Economic Problems:

  • Causes significant impairment in academic, occupational and/or social functioning.

Negative Emotions (Negative Emotion):

  • Recurrent obsessional thoughts or compulsive acts

  • The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause significant distress or impairment in social, occupational, or other important areas of functioning

Medical:
  • Not due to a medical or substance use disorder.

  • 35%-50% of adults with Tourette's Disorder have OCD, but only 6% of people with OCD have Tourette's Disorder

  • 20%-30% of adults with OCD have current or past tics

  • Hands may be red from excessive washing or use of caustic cleaning agents


Fear, Generalized Anxiety, Phobia, Panic, Obsession, and Compulsion

Fearful avoidance is part of our instinctual "flight" response to adversity.

Our ancestors learned to fear dangerous things (e.g., snakes), and this harm avoidance saved their lives.

However, fear can spiral out of control. For example, an individual can develop a phobia to snakes in which the fear becomes excessive. This phobia can develop into an obsession in which the individual spends much of the time thinking about snakes, and how to avoid them. The obsession can develop into a compulsion in which the individual spends much of the time doing superstitious, compulsive, ritual behaviors aimed at avoiding snakes.

There are stages in the escalation of fear:

  • Normal Fear:
    Fear is normal if it is in proportion to the actual danger posed by the specific object or situation, and this fear doesn't cause significant distress or disability.

  • Generalized Anxiety:
    Fear can become excessive, and generalized with excessive anxiety and worry about a number of objects or situations. This anxiety is often associated with avoidance of the feared objects or situations and irritability. Individuals with obsessive-compulsive disorder have an increased risk of developing generalized anxiety disorder.

  • Phobia:
    Fear can become excessive, and specifically attached to specific objects or situations (e.g., fear of flying). This phobic fear is out of proportion to the actual danger posed by these feared objects or situations, and the individual desperately tries to avoid whatever triggers the phobia. This phobic fear causes significant distress or disability. Individuals with obsessive-compulsive disorder have an increased risk of developing social anxiety disorder (social phobia) and specific phobias.

  • Panic:
    Phobic individuals can develop a full-blown panic attack if exposed to whatever triggers their phobia. In panic disorder, individuals experience panic attacks that occur spontaneously, and that are not triggered by any phobic stimulus. Individuals with obsessive-compulsive disorder have an increased risk of developing panic disorder.

  • Obsession:
    If the individual develops persistent, unwanted thoughts about the phobia; this is defined as an obsession. An obsession is an unwanted, recurrent, persistent, fear-provoking intrusive thought. In obsessive-compulsive disorder, these obsessional thoughts are involuntary and often repugnant. They are almost invariably distressing and the individual often tries, unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts. Obsessions are a core feature of obsessive-compulsive disorder.

  • Compulsion:
    If the individual develops a superstitious ritual aimed at reducing the anxiety associated with the obsession; this is defined as a compulsion. A compulsion is a fear-relieving avoidance behavior. The individual feels driven to perform these compulsions. Some of these superstitious rituals may spawn other, illogically related compulsions (e.g., "I must avoid stepping on sidewalk cracks because that will injure my mother"). Such irrationality is the hallmark of superstitious learning. Compulsive rituals in obsessive-compulsive disorder are not enjoyable, nor do they result in the completion of inherently useful tasks. Their function is fearful avoidance - to prevent some objectively unlikely event which the individual fears might otherwise occur. Usually, superstitious rituals are recognized by the individual as pointless or ineffectual. Anxiety is almost invariably present. If these superstitious rituals are resisted the anxiety gets worse. Compulsions are a core feature of obsessive-compulsive disorder.



Back to top


Click Here For Free Diagnosis

Limitations of Self-Diagnosis

Self-diagnosis of this disorder is often inaccurate. Accurate diagnosis of this disorder requires assessment by a qualified practitioner trained in psychiatric diagnosis and evidence-based treatment.

However, if no such professional is available, our free computerized diagnosis is usually accurate when completed by an informant who knows the patient well. Computerized diagnosis is less accurate when done by patients (because they often lack insight).

Example Of Our Computer Generated Diagnostic Assessment

Obsessive-Compulsive Disorder 300.3

This diagnosis is based on the following findings:
  • Had obsessions (persistent, intrusive, inappropriate thoughts) (still present)
  • Obsessions were not simply excessive worries about real-life problems
  • Obsessions were unwanted and resisted
  • Obsessions weren't imposed from without (as in thought insertion)
  • Had compulsions (persistent, intrusive, inappropriate rituals) (still present)
  • Compulsions were aimed at reducing distress or preventing some dreaded harm
  • Obsessions or compulsions were recognized as being excessive or unreasonable
  • Obsessions or compulsions caused clinically significant distress or disability (still present)
  • Obsessions or compulsions were not symptoms of another mental disorder
  • Obsessions or compulsions were not due to a general medical condition
  • Obsessions or compulsions were not due to substance use or other treatment

TREATMENT GOALS:

  • Goal: prevent obsessions (persistent, intrusive, inappropriate thoughts).

  • Goal: prevent compulsions (persistent, intrusive, inappropriate rituals).


Back to top


Obsessive-Compulsive Disorder F42 - ICD10 Description, World Health Organization

The essential feature is recurrent obsessional thoughts or compulsive acts. Obsessional thoughts are ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form. They are almost invariably distressing and the patient often tries, unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur. Usually, this behavior is recognized by the patient as pointless or ineffectual and repeated attempts are made to resist. Anxiety is almost invariably present. If compulsive acts are resisted the anxiety gets worse.
Obsessive-Compulsive Disorder - Diagnostic Criteria, American Psychiatric Association

An individual diagnosed with obsessive-compulsive disorder needs to meet all of the following criteria:

  • Presence of obsessions, compulsions, or both:

    Obsessions are defined by both of the following:

    • Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety and distress.

    • The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).

    Compulsions are defined by both of the following:

    • Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silentl) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

    • The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note. Young children may not bbe able to articulate the aims of these behaviors or mental acts.

  • The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause significant distress or impairment in social, occupational, or other important areas of functioning.

  • The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.

  • The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania (hair-pulling disorder); skin picking, as in excoriation [skin picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupations with substances or gambling, as in substance-related and addictive disorders; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).

Back to top


Diagnostic Features

Obsessive-compulsive disorder (OCD) is often a severe anxiety disorder that affects approximately 2% of the population. This disorder is characterized by: (a) obsessions (unwanted, disturbing, and intrusive thoughts, images, or impulses that are generally seen by the patient as excessive, irrational, and ego-alien), and (b) compulsions (repetitive behaviors and mental acts that neutralize obsessions and reduce emotional distress). These obsessions and/or compulsions are time consuming (take more than 1 hour per day), or cause marked distress or life impairment.

Complications

Compulsive, repetitive behavior is seen throughout nature (e.g., birds have repetitive songs and mating rituals). Animals can be quickly taught "superstitious behavior" (e.g., only giving a bird food when it lifts one wing results in the bird learning to walk around with one wing always elevated). Humans also have a high propensity to acquire unwanted, repetitive, "superstitious" thoughts (obsessions) and behaviors (compulsions). Individuals with obsessions try desperately to suppress them by performing a compulsion (e.g., contamination obsessions lead to hand-washing compulsions). The obsession is unwanted and unpleasant, and the compulsion is performed to reduce the unpleasantness associated with the obsession. Compulsions are not done for pleasure. Some individuals with this disorder compulsively hoard objects, and fill their homes with objects they can not discard. When confronted with situations that trigger obsessions and compulsions, individuals with this disorder experience marked anxiety, disgust, or even panic attacks. Situations that trigger obsessions and compulsions are avoided (e.g., restaurants, public restrooms, public transportation, social gatherings). There is a striking similarity in the presentation of OCD throughout the world. It usually involves cleaning, symmetry (putting everything in its proper place), hoarding, taboo thoughts, or fear of harm. OCD can cause severe social and occupational impairment.

Comorbidity

The majority (76%) of individuals with OCD have an Anxiety Disorder (e.g., Panic Disorder, Social Anxiety Disorder, Generalized Anxiety Disorder, Specific Phobia), and 63% have a Depressive or Bipolar Disorder. Up to one-third of individuals with OCD also have Obsessive-Compulsive Personality Disorder. Surprisingly, up to 30% of individuals with OCD have a tic disorder. The combination of OCD, tic disorder, and Attention Deficit - Hyperactivity Disorder occurs in children. Tourette's Disorder, Trichotillomania (hair-pulling disorder), Excoriation (skin-picking) Disorder are also comorbid with OCD. Rates of OCD are elevated in Schizophrenia or Schizoaffective Disorder (12%), Eating Disorders, Body Dysmorphic Disorder, and Oppositional Defiant Disorder.

Associated Laboratory Findings

No laboratory test has been found to be diagnostic of this disorder.

Prevalence

The 1-year prevalence rate of OCD is 1.2%, with women in adulthood slightly more likely to develop this disorder than men.

Course

One-quarter of OCD cases start by age 14, and the mean age at onset in America is 19.5 years. Onset after 35 is unusual. OCD develops earlier in males than females. Nearly 25% of males have onset before age 10. Onset is usually gradual (but sudden onset does occur, especially after infections). In adulthood, untreated OCD has a chronic course with only a 20% recovery rate after 40 years. However, 40% of individuals with onset of OCD in childhood or adolescence recover by early adulthood.

Familial Pattern

First-degree relatives of adults with OCD are twice as likely than normal to have OCD. However, first-degree relatives of individuals with onset of OCD in childhood or adolescence are 10-times more likely than normal to have OCD. Research is showing that dysfunction in the orbitofrontal cortex, anterior cingulate cortex, and striatum is strongly implicated in OCD.

Effective Therapies

The average amount of time that lapses between onset of symptoms and appropriate treatment is 17 years. Yet the sooner OCD is treated, the better the outcome.

Behavioural or cognitive-behavior therapy alone appears to be an effective treatment for OCD in children, adolescents and adults. It is as effective as medication alone and may lead to better outcomes when combined with medication compared to medication alone. There is a lack of research on the long-term effectiveness of psychological treatments.

Individuals with OCD receiving SSRI antidepressants are nearly twice as likely as those receiving placebo to achieve clinical response (defined as a 25% or more reduction in symptoms). SSRI medications are similar in their effectiveness, but differ in their adverse effects. 40 - 60% of all patients with OCD respond to serotonin reuptake inhibitors.

There is some evidence that adding quetiapine or risperidone to antidepressants increases efficacy, but this must be weighed against less tolerability.

Ineffective therapies

Vitamins and dietary supplements are ineffective for this disorder. There is a lack of evidence for the effectiveness of benzodiazepines, transcranial magnetic stimulation or meditation therapy in the treatment of OCD.

A Dangerous Cult


Back to top


Videos



Stories

Rating Scales


Back to top


Treatment Guidelines

Treatment

Summary Of Practice guideline for the treatment of patients with obsessive-compulsive disorder. - American Psychiatric Association (2007)

Rating Scheme for the Strength of the Recommendations

Each recommendation is identified as falling into one of three categories of endorsement, indicated by a bracketed Roman numeral following the statement. The three categories represent varying levels of clinical confidence:

  • [I] Recommended with substantial clinical confidence.

  • [II] Recommended with moderate clinical confidence.

  • [III] May be recommended on the basis of individual circumstances.

Major Recommendations

  1. Psychiatric Management

    Obsessive-compulsive disorder (OCD) seen in clinical practice is usually a chronic illness with a waxing and waning course. Treatment is indicated when OCD symptoms interfere with functioning or cause significant distress [I]. Psychiatric management consists of an array of therapeutic actions that may be offered to all patients with OCD during the course of their illness at an intensity consistent with the individual patient's needs, capacities, and desires [I]. It is important to coordinate the patient's care with physicians treating co-occurring medical conditions, other clinicians, and social agencies such as schools and vocational rehabilitation programs [I]. When OCD is of disabling severity, the psychiatrist may need to write on the patient's behalf to government agencies that control access to disability income, publicly financed health care, or government-supported housing; or to tax authorities, courts, schools, or employers [I]. OCD patients who are parents of young children may want advice regarding the genetic risk of OCD. It is important for clinicians to explain to such patients that the available data indicate an increased but modest risk of OCD in the children of affected individuals; patients wanting more information may be referred to a genetic counselor [I].

    1. Establishing a Therapeutic Alliance

      Establishing and maintaining a strong therapeutic alliance is important so that treatment may be jointly, and therefore more effectively, planned and implemented [I]. Steps toward this end include tailoring one's communication style to the patient's needs and capacities, explaining symptoms in understandable terms, and being both encouraging and comforting [I]. The excessive doubting that is characteristic of OCD may require special approaches to building the alliance, including allowing the patient extra time to consider treatment decisions and repeating explanations (a limited number of times) [I]. In building the therapeutic alliance, the psychiatrist should also consider how the patient feels and acts toward him or her as well as what the patient wants and expects from treatment [I].

    1. Assessing the Patient's Symptoms

      In assessing the patient's symptoms with the aim of establishing a diagnosis using Diagnostic and Statistical Manual of Mental Disorders, Text Revision IV (DSM-IV-TR) criteria, it is important to differentiate the obsessions, compulsions, and rituals of OCD from similar symptoms found in other disorders, including depressive ruminations, the worries of generalized anxiety disorder, the intrusive thoughts and images of posttraumatic stress disorder, and schizophrenic and manic delusions [I].

    1. Using Rating Scales

      The psychiatrist should consider rating the baseline severity of OCD symptoms and co-occurring conditions and their effects on the patient's functioning, using a scale such as the 10-item Yale-Brown Obsessive Compulsive Scale (Y-BOCS), since this provides a way to measure response to treatment [I]. If a rating scale is not used, it is helpful to document the patient's estimate of the number of hours per day spent obsessing and performing compulsive behaviors, and the degree of effort applied to trying to escape the obsessions and to resisting the behaviors [I]. Recording actively avoided items or situations also provides a useful baseline against which change can be measured [I]. Scales may also be utilized to rate other symptoms, such as depression or degree of disability.

    1. Enhancing the Safety of the Patient and Others

      The psychiatrist should evaluate the safety of the patient and others [I]. This entails assessing the patient's potential for self-injury or suicide, since individuals with OCD alone or with a lifetime history of any co-occurring disorder have a higher suicide attempt rate than do individuals in the general population. Although acting on aggressive impulses or thoughts has not been reported in OCD, and patients rarely resort to violence when others interfere with their performing their compulsive rituals, it remains important to inquire about past aggressive behavior. OCD patients who fear loss of control may engage in extensive avoidance rituals in an effort to contain their symptoms.

      The psychiatrist should understand that individuals with OCD are not immune to co-occurring disorders that may increase the likelihood of suicidal or aggressive behavior. When such co-occurring conditions are present, it is important to arrange treatments that will enhance the safety of the patient and others [I].

      Because OCD symptoms can also interfere with parenting, the clinician may have to work with the unaffected parent or social agencies to mitigate the effects of OCD symptoms on the patient's children [II].

    1. Completing the Psychiatric Assessment

      In completing the psychiatric assessment, the psychiatrist will usually consider all the elements of the traditional medical evaluation [I]. With regard to co-occurring conditions, the psychiatrist should pay particular attention to past or current evidence of depression, given its frequency and association with suicidal ideation and behaviors [I]. Exploration for co-occurring bipolar disorder and family history of bipolar disorder is also important in view of the risk of precipitating hypomania or mania with anti-OCD medications [I]. Other anxiety disorders are common in OCD patients, as are tic disorders, and may complicate treatment planning. Other disorders that may be more common and may complicate treatment planning include impulse-control disorders, anorexia nervosa, bulimia nervosa, alcohol use disorders, and Attention Deficit - Hyperactivity Disorder. Past histories of panic attacks, mood swings, and substance abuse or dependence are also relevant [I].

      It is important to document the patient's course of symptoms and treatment history, including psychiatric hospitalizations and trials of medications (with details on treatment adequacy, dose, duration, response, and side effects) and psychotherapies (with details on the nature, extent, and response to all trials) [I].

      The psychiatrist should also assess the patient's developmental, psychosocial, and sociocultural history, including his or her primary support group and sociocultural supports, potential psychosocial stressors, educational and occupational history (including military history), sexual history, and capacity to navigate developmental transitions and achieve stable and gratifying familial and social relationships [I]. In addition, the psychiatrist should evaluate how OCD has interfered with academic and vocational achievement as well as familial, social, and sexual relationships [I]. Having evaluated the symptoms and their effects on well-being, functioning, and quality of life, the psychiatrist should assess the role of the patient's social supports in facilitating treatment and in maintaining or exacerbating symptoms [I].

      The psychiatrist should consider whether the OCD is a manifestation of a general medical condition [I]; document current medical conditions, relevant hospitalizations, and any history of head trauma, loss of consciousness, or seizures [I]; and record the presence and severity of somatic or psychological symptoms that could be confused with medication side effects [I]. Current medications and doses, including hormonal therapies, herbal or "natural" remedies, vitamins, and other over-the-counter medications, should be reviewed to assess the potential for pharmacokinetic and pharmacodynamic interactions with psychotropic drugs [I]. Allergies or sensitivities to medications should be recorded [I]. A mental status examination, including an evaluation of insight and judgment, should be performed to systematically collect and record data related to the patient's signs and symptoms of illness during the interview [I].

    1. Establishing Goals for Treatment

      Clinical recovery and full remission, if they occur, do not occur rapidly. Thus, ongoing goals of treatment include decreasing symptom frequency and severity, improving the patient's functioning, and helping the patient to improve his or her quality of life [I]. Treatment goals also include enhancing the patient's ability to cooperate with care despite the frightening cognitions generated by OCD, minimizing any adverse effects of treatment (e.g., medication side effects), helping the patient develop coping strategies for stressors, and educating the patient and family regarding the disorder and its treatment [I].

    1. Establishing the Appropriate Setting for Treatment

      The appropriate treatment setting may be the hospital, a residential treatment or partial hospitalization program, home-based treatment, or outpatient care. Treatment should generally be provided in the least restrictive setting that is both safe and effective [I].

    1. Enhancing Treatment Adherence

      To enhance treatment adherence, the psychiatrist should consider factors related to the illness, the patient, the physician, the patient-physician relationship, the treatment, and the social or environmental milieu [I]. Because the patient's beliefs about the nature of the illness and its treatments will influence adherence, providing patient and family education may enhance adherence [II]. Many patients with OCD benefit from educational materials and access to support groups provided by the Obsessive Compulsive Foundation (www.ocfoundation.org ). When a patient has insufficient motivation to participate effectively in treatment, motivational interviewing or other psychosocial interventions designed to enhance readiness for change may be helpful [II]. Because medications used to treat OCD have side effects, particularly at high doses, adherence may be enhanced by informing the patient about any likely side effects, responding quickly to side effect concerns, and scheduling follow-up appointments soon after starting or changing medications [I]. In describing cognitive-behavioral therapy (CBT), it is helpful to advise that it involves confronting feared thoughts and situations, though at a tolerable rate [I]. Practical issues such as treatment cost, insurance coverage, and transportation may need to be addressed. When a patient with OCD refuses or prematurely discontinues treatment, the clinician may wish to recommend that family members and others negatively affected by the OCD seek therapy to help develop strategies to mitigate the effect of the patient's OCD on their lives and to encourage the patient to obtain treatment [II].

  1. Choosing an Initial Treatment Modality

    In choosing a treatment approach, the clinician should consider the patient's motivation and ability to comply with pharmacotherapy and psychotherapy [I]. CBT and serotonin reuptake inhibitors (SRIs) are recommended as safe and effective first-line treatments for OCD [I]. Whether to utilize CBT, an SRI, or combined treatment will depend on factors that include the nature and severity of the patient's symptoms, the nature of any co-occurring psychiatric and medical conditions and their treatments, the availability of CBT, and the patient's past treatment history, current medications, capacities, and preferences. CBT alone, consisting of exposure and response prevention, is recommended as initial treatment for a patient who is not too depressed, anxious, or severely ill to cooperate with this treatment modality, or who prefers not to take medications and is willing to do the work that CBT requires [II]. An SRI alone is recommended for a patient who is not able to cooperate with CBT, has previously responded well to a given drug, or prefers treatment with an SRI alone [II]. Combined treatment should be considered for patients with an unsatisfactory response to monotherapy [II], for those with co-occurring psychiatric conditions for which SRIs are effective [I], and for those who wish to limit the duration of SRI treatment [II]. In the latter instance, uncontrolled follow-up studies suggest that CBT may delay or mitigate relapse when SRI treatment is discontinued [II]. Combined treatment or treatment with an SRI alone may also be considered in patients with severe OCD, since the medication may diminish symptom severity sufficiently to allow the patient to engage in CBT [II].

    Deciding whether to start or stop a psychotropic drug during pregnancy or breast-feeding requires making a risk-benefit calculation with the patient and her significant other; this process may be enhanced by providing clear information, seeking consultation from an obstetrician, and providing counseling over several sessions to help the patient come to terms with the uncertainty of the risks [I].

  1. Choosing a Specific Pharmacological Treatment

    Clomipramine, fluoxetine, fluvoxamine, paroxetine, and sertraline, which are approved by the U.S. Food and Drug Administration (FDA) for treatment of OCD, are recommended pharmacological agents [I]. Although meta-analyses of placebo-controlled trials suggest greater efficacy for clomipramine than for fluoxetine, fluvoxamine, and sertraline, the results of head-to-head trials comparing clomipramine and selective serotonin reuptake inhibitors (SSRIs) directly do not support this impression. Because the SSRIs have a less troublesome side-effect profile than clomipramine, an SSRI is preferred for a first medication trial [I]. Although all SSRIs (including citalopram and escitalopram) appear to be equally effective, individual patients may respond well to one medication and not to another. In choosing among the SSRIs, the psychiatrist should consider the safety and acceptability of particular side effects for the patient, including any applicable FDA warnings, potential drug interactions, past treatment response, and the presence of co-occurring general medical conditions [I].

  1. Choosing a Specific Form of Psychotherapy

    CBT that relies primarily on behavioral techniques such as exposure and response prevention (ERP) is recommended because it has the best evidentiary support [I]. Some data support the use of CBT that focuses on cognitive techniques [II]. There are no controlled studies that demonstrate effectiveness of dynamic psychotherapy or psychoanalysis in dealing with the core symptoms of OCD. Psychodynamic psychotherapy may still be useful in helping patients overcome their resistance to accepting a recommended treatment by illuminating their reasons for wanting to stay as they are (e.g., best adaptation, secondary gains) [III]. It may also be useful in addressing the interpersonal consequences of the OCD symptoms [II]. Motivational interviewing may also help overcome resistance to treatment [III]. Family therapy may reduce inter-family tensions that are exacerbating the patient's symptoms or ameliorate the family's collusion with symptoms [III].

  1. Implementing a Treatment Plan

    When treatment is initiated, the patient's motivation and adherence may be challenged by factors such as treatment cost and medication side effects. It is essential for the psychiatrist to employ strategies to enhance adherence, as described above in Section 1.h [I].

    1. Implementing Pharmacotherapy

      For most patients, the starting dose is that recommended by the manufacturer [I]. Patients who are worried about medication side effects can have their medication started at lower doses, since many SSRIs are available in liquid form or in pills that can be split [I]. Most patients will not experience substantial improvement until 4 to 6 weeks after starting medication, and some who will ultimately respond will experience little improvement for as many as 10 to 12 weeks. Medication doses may be titrated up weekly in increments recommended by the manufacturer during the first month of treatment [II], or when little or no symptom improvement is seen within 4 weeks of starting medication, the dose may be increased weekly or biweekly to the maximum dose comfortably tolerated and indicated [II]. This maximum dose may exceed the manufacturer's recommended maximum dose in some cases [III]. The treatment trial is then continued at this dosage for at least 6 weeks [II]. Since available trial data suggest that higher SSRI doses produce a somewhat higher response rate and a somewhat greater magnitude of symptom relief, such doses should be considered when treatment response is inadequate [II]. Higher doses may also be appropriate for patients who have had little response to treatment and are tolerating a medication well [I]. If higher doses are prescribed, the patient should be closely monitored for side effects, including the serotonin syndrome [I]. Experience with pharmacotherapy in the elderly indicates that lower starting doses of medication and a more gradual approach to dose increase are often advisable [I]. Medication side effects should be inquired about and actively managed [I]. Useful strategies to manage medication side effects include gradual initial dose titration to minimize gastrointestinal distress [I], addition of a sleep-promoting agent to minimize insomnia [I], modest doses of modafinil to minimize fatigue or sleepiness [III], and use of a low-dose anticholinergic agent to minimize sweating [III]. Sexual side effects may be minimized by reducing the dose [II], waiting for symptoms to remit [II], trying a once-weekly, one-day "drug holiday" before sexual activity [II], switching to another SSRI [II], or adding a pharmacological agent such as bupropion [II].

      The frequency of follow-up visits after a new pharmacotherapy is initiated may vary from a few days to two weeks. The indicated frequency will depend on the severity of the patient's symptoms, the complexities introduced by co-occurring conditions, whether suicidal ideation is present, and the likelihood of troubling side effects [I].

    1. Implementing Cognitive-Behavioral Therapies

      Cognitive-behavioral therapies have been delivered in individual, group, and family therapy sessions, with session length varying from less than 1 hour to 2 hours. One group has explored a computer-based approach coupled with a touch-tone telephone system accessible 24 hours a day. CBT sessions should be scheduled at least once weekly [I]. Five ERP sessions per week may be more effective than once-weekly sessions but are not necessarily more effective than twice-weekly sessions [II]. The number of treatment sessions, their length, and the duration of an adequate trial have not been established, but expert consensus recommends 13 to 20 weekly sessions for most patients [I]. Clinicians should consider booster sessions for more severely ill patients, for patients who have relapsed in the past, and for patients who show signs of early relapse [II]. When resources for CBT are not available, the psychiatrist can suggest and supervise the use of self-help treatment guides and recommend support groups such as those accessible through the Obsessive Compulsive Foundation [III] (see the Appendix in the original guideline document).

    1. Changing Treatments and Pursuing Sequential Treatment Trials

      First treatments rarely produce freedom from all OCD symptoms. When a good response is not achieved after 13 to 20 weeks of weekly outpatient CBT, 3 weeks of daily CBT, or 8 to 12 weeks of SRI treatment (including 4 to 6 weeks at the highest comfortably tolerated dose), the psychiatrist should decide with the patient when, whether, and how to alter the treatment [I]. This decision will depend on the degree of suffering and disability the patient wishes to accept. However, it is important to consider that illness can bring secondary gains and that depressed mood can diminish hopefulness; the psychiatrist may have to address issues such as these when patients are not well motivated to pursue further treatments despite limited improvement [I].

      When initial treatment is unsatisfactory, the psychiatrist should first consider the possible contribution of several factors: interference by co-occurring conditions, inadequate patient adherence to treatment, the presence of psychosocial stressors, the level of family members' accommodation to the obsessive-compulsive symptoms, and an inability to tolerate an adequate trial of psychotherapy or the maximum recommended drug doses [I].

      When no interfering factor can be identified, augmentation strategies may be preferred to switching strategies in patients who have a partial response to the initial treatment [II]. The psychiatrist should first consider augmentation of SRIs with trials of different antipsychotic medications or with CBT consisting of ERP, or augmentation of CBT with an SRI [II]. Combined SRI and CBT treatment may be provided when the patient has a co-occurring disorder that is SRI-responsive [I] or has a partial response to monotherapy [II]. Combined SRI and CBT treatment may also reduce the chance of relapse when medication is discontinued [II]. Another option in the case of partial response to ERP therapy is to increase the intensity of treatment (e.g., from weekly to daily sessions) [III]. Some evidence suggests that adding cognitive therapy to ERP may enhance the results, but this remains to be established [III].

      Patients who do not respond to their first SRI may have their medication switched to a different SRI [I]. A switch to venlafaxine is less likely to produce an adequate response [II]. For patients who have not benefitted from their first SSRI trial, a switch to mirtazapine can also be considered [III]. The available evidence does not allow one to predict the chance of response to switching medications. SRI nonresponders, like partial responders, have responded to augmentation with antipsychotic medications [II] or CBT [II].

      After first- and second-line treatments and well-supported augmentation strategies have been exhausted, less well-supported treatment strategies may be considered [III]. These include augmenting SSRIs with clomipramine, buspirone, pindolol, riluzole, or once-weekly oral morphine sulfate [III]. However, morphine sulfate should be avoided in patients with contraindications to opiate administration, and appropriate precautions and documentation should occur. If clomipramine is added, appropriate precautions should be utilized with regard to preventing potential cardiac and central nervous system side effects [I]. Less well-supported monotherapies to consider include D-amphetamine [III], tramadol [III], monoamine oxidase inhibitors (MAOIs) [III], ondansetron [III], transcranial magnetic stimulation (TMS) [III], and deep brain stimulation (DBS) [III]. Intensive residential treatment or partial hospitalization may be helpful for patients with severe treatment-resistant OCD [II]. Ablative neurosurgery for severe and very treatment-refractory OCD is rarely indicated and, along with deep brain stimulation, should be performed only at sites with expertise in both OCD and these treatment approaches [III].

  1. Discontinuing Active Treatment

    Successful medication treatment should be continued for 1 to 2 years before considering a gradual taper by decrements of 10% to 25% every 1 to 2 months while observing for symptom return or exacerbation [I]. Successful ERP should be followed by monthly booster sessions for 3 to 6 months, or more intensively if response has been only partial [II]. In medication discontinuation trials, rates of relapse or trial discontinuation for insufficient clinical response are substantial but vary widely because of major methodological differences across studies. Thus, discontinuation of pharmacotherapy should be carefully considered, and for most patients, continued treatment of some form is recommended [II]. The data suggest that CBT consisting of ERP may have more durable effects than some SRIs after discontinuation, but the observed differences in relapse rates could be explained by other factors.

  • The nature, assessment, and treatment of obsessive-compulsive disorder. (2012) Obsessive-compulsive disorder (OCD) is an anxiety disorder that affects between 1% to 2% of individuals and causes considerable impairment and disability. Although > 50% of individuals experience symptom onset in childhood, symptoms can continue to develop throughout adulthood. Accurate and timely assessment of clinical presentation is critical to limit impairment and improve prognosis. Presently, there are 2 empirically supported treatments available for OCD in children and adults, namely cognitive-behavioral therapy and pharmacotherapy with serotonin reuptake inhibitors.
  • Deep brain stimulation for intractable psychiatric disorders. (2012) Deep brain stimulation (DBS) has virtually replaced ablative neurosurgery for use in medication-refractory movement disorders. DBS is now being studied in severe psychiatric conditions, such as treatment-resistant depression (TRD) and intractable obsessive-compulsive disorder (OCD). Effects of DBS have been reported in ~100 cases of OCD and ~50 cases of TRD for seven (five common) anatomic targets. Although these published reports differ with respect to study design and methodology, the overall response rate appears to exceed 50% in OCD for some DBS targets. DBS was generally well tolerated in both OCD and TRD, but some unique, target- and stimulation-specific adverse effects were observed (e.g., hypomania).
  • Safety and efficacy of repetitive transcranial magnetic stimulation in the treatment of obsessive-compulsive disorder: a review. (2012) Promising findings regarding rTMS efficacy appeared for two structures based on recent controlled studies: the supplementary motor area and the orbitofrontal cortex. On the other hand, rTMS of the dorsolateral prefrontal cortex is not significantly effective when compared to sham rTMS.
  • Evidence-based pharmacotherapy and other somatic treatment approaches for obsessive-compulsive disorder: state of the art (2011) Meta-analyses of the randomized controlled trials (RCT) in obsessive-compulsive disorder (OCD) have clearly demonstrated that selective serotonin reuptake inhibitors (SSRIs) are the medication treatment of choice, while cognitive behavioural therapy (CBT) with exposure and response prevention is the psychotherapy of choice in OCD. Several guidelines emphasized that SSRIs are the first choice of medication in OCD. It has been noted that these agents may need to be given at a higher dose, and for a longer duration, than is usually the case in disorders such as depression. In the management of refractory patients, medication history should be carefully reviewed and adherence to the recommendations of the guideline established. Antipsychotics (risperidone, quetiapine, haloperidol) are currently the pharmacotherapy augmentation strategy of choice. In those OCD patients who fail to respond to a range of SSRIs and augmentation strategies combined with CBT, more unusual interventions (including deep brain stimulation) can be considered.
  • Diversity of obsessive-compulsive disorder and pharmacotherapy associated with obsessive-compulsive spectrum disorders (2011) Serotonin reuptake inhibitors (SRI) are effective in the treatment of obsessive-compulsive disorder (OCD). The response rate for SRI is approximately 50% and refractory OCD may exist. The effect of antipsychotics augmentation therapy has been established for this kind of patients. However, OCD is clinically and biologically heterogeneous neuropsychiatric disease and it will affect the response of pharmacotherapy. Several subtypes of OCD have been identified. Early onset OCD and hoarding symptoms dominant patients with OCD tend to resist SRI treatment. Antipsychotics augmentation with SRI is much effective for OCD with tic disorders. SRI is effective for patients with body dysmorphic disorder (BDD) in preoccupation with body appearance or sensation subgroup.
  • Do it yourself? Self-help and online therapy for people with obsessive-compulsive disorder. (2011) The current review identifies self-help, which is based on evidence-based concepts, as a promising clinical tool for the treatment of OCD. The current literature suggests that self-help can be a facilitator and aid to standard face-to-face interventions, rather than a rival.
  • Efficacy of antipsychotic augmentation therapy in treatment-resistant obsessive-compulsive disorder: a meta-analysis of double-blind, randomised, placebo-controlled trials (2011) Only 40 - 60 % of all patients with obsessive-compulsive disorder (OCD) respond to serotonin reuptake inhibitors (SRIs). Therefore, the evaluation of additive treatment in the presence of treatment resistance has high clinical relevance. All double-blind, randomised, placebo-controlled trials that evaluated the efficacy of a combination therapy of SRIs and antipsychotics in treatment-resistant OCD were identified by systematic literature searches and combined in a meta-analysis. After the augmentation, significantly more subjects in the intervention groups (SRI + antipsychotic) fulfilled the response criterion (reduction in the Yale-Brown obsessive compulsive scale [Y-BOCS] = 35 %) than in the control groups (SRI + placebo) (relative risk = 2.16). The subgroup analysis showed significant efficacy only for risperidone.
  • Pharmacological management of treatment-resistant obsessive-compulsive disorder. (2011) We review up-to-date evidence focusing on strategies for treatment-resistant OCD, including increasing the dose of SSRI, switching to another SSRI, augmentation with antipsychotics, and the use of serotonin noradrenaline (norepinephrine) reuptake inhibitors (SNRIs) and monoamine oxidase inhibitors (MAOIs).
  • Obsessive-compulsive disorder in children and adolescents. (2011) Early-onset obsessive-compulsive disorder (OCD) is one of the more common mental illnesses of children and adolescents, with prevalence of 1% to 3%. Its manifestations often lead to severe impairment and to conflict in the family. Obsessive-compulsive manifestations are of many types and cause severe impairment. Comorbid mental disturbances are present in as many as 70% of patients. The disease takes a chronic course in more than 40% of patients. Cognitive behavioral therapy is the treatment of first choice, followed by combination pharmacotherapy including selective serotonin reuptake inhibitors (SSRI) and then by SSRI alone.
  • Cognitive-behavioral therapy for obsessive-compulsive disorder in children and adolescents. (2011) Cognitive-behavioral therapy (CBT), now widely recognized as the gold standard intervention for childhood OCD, relies on exposure and response prevention, and also includes psychoeducation, creation of a symptom hierarchy, imaginal exposures, cognitive interventions, and a contingency management system.
  • Pharmacotherapy of compulsive hoarding. (2011) SRIs appear to be as effective for compulsive hoarders as for nonhoarding OCD patients. Symptom improvement from pharmacotherapy of compulsive hoarding appears to be at least as great as that resulting from cognitive-behavioral therapy (CBT). However, the combination of pharmacotherapy and CBT for compulsive hoarding is likely more effective than either treatment alone.
  • Psychotherapy for obsessive-compulsive disorder: what is evidence based?. (2011) Cognitive behavioural therapy with exposure and response prevention (CBT) is the most thoroughly investigated and most effective intervention, leading to a clinically significant symptom reduction in 60-70% of the patients. Correctly applied, this treatment can be equally effective as its combination with pharmacological management.


Back to top



Self-Help Resources For Panic Disorder






Afternoon Meditation (Learn How To Have Healthy Relationships)





Life Satisfaction Scale (Video)





Healthy Social Behavior Scale (Video)





Mental Health Scale (Video)




Click Here For More Self-Help



Back to top




    "In physical science a first essential step in the direction of learning any subject is to find principles of numerical reckoning and practicable methods for measuring some quality connected with it. I often say that when you can measure what you are speaking about and express it in numbers you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meagre and unsatisfactory kind: it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the stage of science, whatever the matter may be."

    Lord Kelvin (1824 – 1907)

  • The best summary on bad research is given by Laura Arnold in this TEDx lecture. If you read nothing else about research, you owe it to yourself to watch this short video - it is excellent!

  • Canadian researchers who commit scientific fraud are protected by privacy laws: There are criminals in every community - even in the scientific research community (especially if a lot of money is at stake). Criminal researchers can hide their fraud behind outdated privacy laws.

  • The power of asking "what if?"

  • The active placebo effect: 2300 years ago, the Greek Stoic philosophers taught that it is not the objective event, but our subjective judgment about the event, that determines our behavior. The active placebo effect bears witness to this ancient wisdom.

  • Criteria For High Quality Research Studies

    • It is troubling that a recent study found that two-thirds of important psychological research studies couldn't be replicated. High quality research must meet the following criteria:

    • Randomized Controlled Trial:
      Ask: Was the trial randomized? Was the randomization procedure described and was it appropriate? The best research design is to have research subjects randomly assigned to an experimental or control group. It is essential that confounding factors be controlled for by having a control group or comparator condition (no intervention, placebo, care as usual etc.).

    • Representative Sample:
      Ask: Do the research subjects represent a normal cross-section of the population being studied? Many psychological research studies using university students are flawed because their subjects are not representative of the normal population since they are all W.E.I.R.D. (White, Educated, Intelligent, Rich, and living in a Democracy).

    • Single Blind Trial:
      Ask: Was the treatment allocation concealed? It is essential that the research subjects are kept "blind" as to whether they are in the experimental or control group (in order to control for any placebo effects).

    • Double Blind Trial (Better Than Single Blind Trial):
      Ask: Were blind outcome assessments conducted? In a double blind study, neither the research subjects nor the outcome assessors know if the research subject is in the experimental or control group. This controls for both the placebo effect and assessor bias.

    • Baseline Comparability:
      Ask: Were groups similar at baseline on prognostic indicators? The experimental and control groups must be shown to be comparable at the beginning of the study.

    • Confounding Factors:
      Ask: Were there factors, that weren't controlled for, that could have seriously distorted the study's results? For example, research studies on the effectiveness of mindfulness cognitive therapy in preventing depressive relapse forgot to control for whether the research subjects were also simultaneously receiving antidepressant medication or other psychological treatments for depression.

    • Intervention Integrity:
      Ask: Was the research study protocal strictly followed? The research subjects must be shown to be compliant (e.g., taking their pills, attending therapy) and the therapists must be shown to be reliably delivering the intervention (e.g., staying on the research protocol).

    • Statistical analysis:
      Ask: Was a statistical power calculation described? The study should discuss its statistical power analysis; that is whether the study size is large enough to statistically detect a difference between the experimental and control group (should it occur) and usually this requires at least 50 research subjects in the study.

      Ask: Are the results both statistically significant and clinically significant? Many medical research findings are statistically significant (with a p-value <0.05), but they are not clinically significant because the difference between the experimental and control groups is too small to be clinically relevant.

      For example, the effect of a new drug may be found to be 2% better than placebo. Statistically (if the sample size was large enough) this 2% difference could be statistically significant (with a p-value <0.05). However, clinicians would say that this 2% difference is not clinically significant (i.e., that it was too small to really make any difference).

      Statistically, the best way to test for clinical significance is to test for effect size (i.e., the size of the difference between two groups rather than confounding this with statistical probability).

      When the outcome of interest is a dichotomous variable, the commonly used measures of effect size include the odds ratio (OR), the relative risk (RR), and the risk difference (RD).

      When the outcome is a continuous variable, then the effect size is commonly represented as either the mean difference (MD) or the standardised mean difference (SMD) .

      The MD is the difference in the means of the treatment group and the control group, while the SMD is the MD divided by the standard deviation (SD), derived from either or both of the groups. Depending on how this SD is calculated, the SMD has several versions such, as Cohen's d, Glass's Δ, and Hedges' g.

        Clinical Significance: With Standard Mean Difference, the general rule of thumb is that a score of 0 to 0.25 indicates small to no effect, 0.25-0.50 a mild benefit, 0.5-1 a moderate to large benefit, and above 1.0 a huge benefit. It is a convention that a SMD of 0.5 or larger is a standard threshold for clinically meaningful benefit.

      The statistical summary should report what percentage of the total variance of the dependent variable (e.g., outcome) can be explained by the independent variable (e.g., intervention).

      In clinical studies, the study should report the number needed to treat for an additional beneficial outcome (NNTB), and the number needed to treat for an additional harmful outcome (NNTH).

        Number Needed To Benefit (NNTB): This is defined as the number of patients that need to be treated for one of them to benefit compared with a control in a clinical trial. (It is defined as the inverse of the absolute risk reduction.) Note: Statistically, the NNTB depends on which control group is used for comparison - e.g., active treatment vs. placebo treatment, or active treatment vs. no treatment.

        Number Needed To Harm (NNTH): This is defined as the number of patients that need to be treated for one of them to be harmed compared with a control in a clinical trial. (It is defined as the inverse of the absolute increase in risk of harm.)

        Tomlinson found “an NNTB of 5 or less was probably associated with a meaningful health benefit,” while “an NNTB of 15 or more was quite certain to be associated with at most a small net health benefit.”

      Ask: Does the researcher accept full responsibility for the study's statistical analysis? The researcher should not just hand over the study's raw data to a corporation (that may have $1,000 million invested in the study) to do the statistical analysis.

    • Completeness of follow-up data:
      Ask: Was the number of withdrawals or dropouts in each group mentioned, and were reasons given for these withdrawals or dropouts? Less than 20% of the research subjects should drop out of the study. The intervention effect should persist over an adequate length of time.

    • Handling of missing data:
      Ask: Was the statistical analysis conducted on the intention-to-treat sample? There must be use of intention-to-treat analysis (as opposed to a completers-only analysis). In this way, all of the research subjects that started the study are included in the final statistical analysis. A completers-only analysis would disregard those research subjects that dropped out.

    • Replication of Findings:
      Ask: Can other researchers replicate this study's results? The research study's methodology should be clearly described so that the study can be easily replicated. The researcher's raw data should be available to other researchers to review (in order to detect errors or fraud).

    • Fraud:
      Ask: Is there a suspicion of fraud? In a research study, examine the independent and dependent variables that are always measured as a positive whole number (e.g., a variable measured on a 5-point Likert-type scale ranging from "1 = definitely false to 5 = definitely true" etc.). For each of these variables, look at their sample size (n), mean (M) and standard deviation (SD) before they undergo statistical analysis. There is a high suspicion of fraud in a study's statistics:

      • If the M is mathematically impossible (online calculator): This is one of the easiest ways to mathematically detect fraud. The mean (M) is defined as "the sum (Sum) of the values of each observation divided by the total number (n) of observations". So: M = Sum/n. Thus: (Sum) = (M) multiplied by (n). We know that, if a variable is always measured as a positive whole number, the sum of these observations always has to be a whole number. For these variables to test for fraud: calculate (M) multiplied by (n). This calculates the Sum which MUST be a positive whole number. If the calculated Sum isn't a positive whole number; the reported mean (M) is mathematically impossible - thus the researcher either cooked the data or made a mistake. A recent study of 260 research papers published in highly reputable psychological journals found that 1 in 2 of these research papers reported at least one impossible value, and 1 in 5 of these research papers reported multiple impossible values. When the authors of the 21 worst offending research papers were asked for their raw data (so that its reliability could be checked) - 57% angrily refused. Yet such release of raw data to other researchers is required by most scientific journals. (Here is an example of a research paper filled with mathematically impossible means.)

      • If the SD is mathematically impossible (online calculator): When researchers fraudulently "cook" their data, they may accidently give their data a mean and standard deviation that is mathematically impossible.

      • If the SD/M is very small (i.e., the variable's standard deviation is very small compared to the mean suggesting data smoothing).

      • If the SD's are almost identical (i.e., the variables have different means but almost identical standard deviations).

      • If the 4th digit of the values of the variables aren't uniformly distributed - since each should occur 10% of the time (Benford's Law).

      • If the researcher is legally prevented from publishing negative findings about a drug or therapy because that would violate the "nondisclosure of trade secrets" clause in the research contract (i.e., it is a "trade secret" that the drug or therapy is ineffective - hence this can not be "disclosed"). Approximately half of all registered clinical trials fail to publish their results.

      • If the researcher refuses to release his raw data to fellow researchers (so that they can check its validity). In order to be published in most scientific journals, a researcher must promise to share his raw data with fellow researchers. Thus a researcher's refusal to do so is almost a sure indicator of fraud.

      • If the research study's data contradicts the study's own conclusions - surprisingly, this often occurs.

  • Calling Bullshit In The Age of Big Data - "Bullshit is language, statistical figures, data graphics, and other forms of presentation intended to persuade by impressing and overwhelming a reader or listener, with a blatant disregard for truth and logical coherence." Reading the syllabus of this university course should be required reading for every student of mental health. This syllabus is absolutely fantastic!

  • Statistical Methods in Psychology Journals: Guidelines and Explanations - American Psychologist 1999

  • Not All Scientific Studies Are Created Equal - video

  • The efficacy of psychological, educational, and behavioral treatment

  • Estimating the reproducibility of psychological science

  • Psychologists grapple with validity of research

  • Industry sponsorship and research outcome (Review) - Cochrane Library

  • 'We've been deceived': Many clinical trial results are never published - (text and video)

  • Junk science misleading doctors and researchers

  • Junk science under spotlight after controversial firm buys Canadian journals

  • Medicine with a side of mysticism: Top hospitals promote unproven therapies - Are some doctors becoming modern witchdoctors?

  • When Evidence Says No, But Doctors Say Yes


Research Topics

Obsessive-Compulsive Disorder - Latest Research (2016-2017)

Cochrane Review (The best evidence-based, standardized reviews available)

Strong evidence of effectiveness:
  • Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD) (2009) (This review summarises all the available evidence for one class of antidepressant drugs, the selective serotonin re-uptake inhibitors (SSRIs) (including citalopram, fluoxetine, fluvoxamine, paroxetine and sertraline) compared to placebo in the treatment of OCD in adults. The review included 17 studies (3097 participants), and showed that SSRIs were effective in reducing the symptoms of OCD. Based on 13 studies (2697 participants), the review showed that people receiving SSRIs were nearly twice as likely as those receiving placebo to achieve clinical response (defined as a 25% or more reduction in symptoms). Indirect comparisons of effectiveness suggested that although individual SSRI drugs were similar in their effectiveness, they differed in terms of their adverse effects. The most common adverse effect reported by participants was nausea.)

Some evidence of effectiveness:
  • Second-generation antipsychotic drugs for obsessive compulsive disorder (2010) (This review found some trials comparing the effects of adding second-generation antipsychotic drugs or placebo to antidepressants in obsessive compulsive disorder (OCD). There were only 11 trials on three second-generation antipsychotic drugs (olanzapine, quetiapine and risperidone). The available data of the effects of olanzapine in OCD are too limited to draw any conclusions. There is some evidence that adding quetiapine or risperidone to antidepressants increases efficacy, but this must be weighed against less tolerability and limited data.)
  • Behavioural and cognitive-behavioural therapy for obsessive-compulsive disorder (OCD) in children and adolescents (2010) (This review identified eight randomised controlled trials involving 343 participants, evaluating the benefits of behavioural and cognitive-behavioural therapy. The results show that, compared to a wait-list or pill placebo, BT/CBT is an effective treatment for reducing OCD symptoms and lowering the risk of having OCD after treatment. Based on three studies that directly compared BT/CBT with medication, there was no current evidence to suggest that either BT/CBT or medication was superior to the other. When combined with medication, BT/CBT produces better outcomes than medication alone. Although based on a small number of studies, these findings provide support for the value of BT/CBT in the treatment of children and adolescents with OCD.)
  • Psychological treatments compared with treatment as usual for obsessive compulsive disorder (2009) (We found eight studies, which together suggested that cognitive and/or behavioural treatments were better than treatment as usual conditions at reducing clinical symptoms. Baseline OCD severity and depressive symptom level predicted the degree of response. However, the conclusions were based on a small number of randomised controlled trials with small sample sizes. There were no trials of other forms of psychological treatment such as psychodynamic therapy and client-centred therapy, and a lack of available evidence for the long-term effectiveness of psychological treatments.)

Not yet possible to draw any definite conclusions due to insufficient evidence:
Note: The Cochrane Reviews are the best in psychiatry, but they do not cover all psychiatric topics. Thus it is essential that you also read Research Review Articles.

Back to top



Which Behavioral Dimensions Are Involved?

Research has shown that there are 5 major dimensions (the "Big 5 Factors") of personality disorders and other mental disorders. There are two free online personality tests that assess your personality in terms of the "Big 5 dimensions of personality". Although not computerized online, the Big Five Inventory (BFI) is a 44-item test often used in personality research.

This website uses these 5 major dimensions of human behavior to describe all mental disorders. (This website adds one more dimension, "Physical Health", but our discussion will focus on the first 5 major dimensions.)

These major dimensions of human behavior seem to represent the major dimensions whereby our early evolutionary ancestors chose their hunting companions or spouse. To maximize their chance for survival, our ancestors wanted companions who were agreeable, conscientious, intelligent, sociable, emotionally stable, and physically healthy.

    Dimensions of Human Behavior That Are Impaired in Obsessive-Compulsive Disorder

    THE POSITIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THE NEGATIVE SIDE OF THE "BIG 5" PERSONALITY DIMENSIONS THIS DISORDER
    Agreeableness Antagonism       Agreeableness
    Conscientiousness Disinhibition       Conscientiousness
    Intellect Decreased Intellect       Intellect
    Sociability (Extraversion) Detachment       Sociability (Extraversion)
    Emotional Stability Negative Emotion       Negative Emotion

The 5 Major Dimensions of Mental Illness

The Big 5 Factors or dimensions of mental illness each has a healthy side and an unhealthy side. Thus the Big 5 Factors are: (1) Agreeableness vs. Antagonism, (2) Conscientiousness vs. Disinhibition, (3) Intellect vs. Decreased Intellect, (4) Sociability (Extraversion) vs. Detachment (Introversion), and (5) Emotional Stability vs. Negative Emotion.

The Following Will Only Discuss The Dimensions of Mental Illness That Are Abnormal In This Disorder

The problems that are diagnostic of this disorder are highlighted in   Pink  . Other problems that are often seen in this disorder are highlighted in   Yellow  .



Treatment Goals for Individuals With Negative Emotion

EMOTIONAL STABILITY VS. NEGATIVE EMOTION
.
EMOTIONAL STABILITY
.
Description: Emotional Stability is synonymous with being calm and emotionally stable. The Emotional Stability dimension measures the behaviors that are central to the concept of COURAGE - having calm composure and endurance when confronting adversity. High emotional stability is associated with better: longevity, leadership, job [team] performance, and marital success. (This dimension appears to measure the behaviors that differentiate safety from danger.)
Descriptors: Calm, even-tempered, peaceful, confident
Language Characteristics: Pleasure talk, agreement, compliment, low verbal productivity, few repetitions, neutral content, calm, few self-references, many short silent pauses, few long silent pauses, many tentative words, few aquiescence, little exaggeration, less frustration, low concreteness.
"I am relaxed, and I handle stress well."
"I am emotionally stable, and not easily upset."
"I remain calm in tense situations."
"I rarely get irritated."
"I keep my emotions under control."
"I rarely lose my composure."
"I am not easily annoyed."
"I seldom feel blue."
"I feel comfortable with myself."
"I rarely feel depressed."
"I am not embarrassed easily."
.
NEGATIVE EMOTION
.
Description: Degree to which people experience persistent anxiety or depression and are easily upset. (This could be thought of as high threat sensitivity or low stress tolerance.)
Descriptors: Emotionally unstable, anxious, separation-insecure, depressed, self-conscious, oversensitive, vulnerable.
Language Characteristics: Problem talk, dissatisfaction, high verbal productivity, many repetitions, polarised content, stressed, many self-references, few short silent pauses, many long silent pauses, few tentative words, more aquiescence, many self references, exaggeration, frustration, high concreteness.
Research: Lower scores on Emotional Stability are associated with unhappiness, dysfunctional relationships, and mental health problems. *MRI research found that Low Emotional Stability (= Negative Emotion or Neuroticism) was associated with increased volume of brain regions associated with threat, punishment, and negative emotions.
.
* Emotional Instability:
"I get emotional easily, often for very little reason."
"I get emotional over every little thing."
"My emotions are unpredictable."
"I never know where my emotions will go from moment to moment."
"I am a highly emotional person."
"I have much stronger emotional reactions than almost everyone else."
"My emotions sometimes change for no good reason."
"I get angry easily."
"I get upset easily."
"I change my mood a lot."
"I am a person whose moods go up and down easily."
"I get easily agitated."
"I can be stirred up easily."
.
* Anxiety:
"I worry about almost everything."
"I'm always fearful or on edge about bad things that might happen."
"I always expect the worst to happen."
"I am a very anxious person."
"I get very nervous when I think about the future."
"I often worry that something bad will happen due to mistakes I made in the past."
"I am filled with doubts about things."
"I feel threatened easily."
"I am afraid of many things."
.
* Separation Insecurity:
"I fear being alone in life more than anything else."
"I can't stand being left alone, even for a few hours."
"I’d rather be in a bad relationship than be alone."
"I'll do just about anything to keep someone from abandoning me."
"I dread being without someone to love me."
.
* Submissiveness:
"I usually do what others think I should do."
"I do what other people tell me to do."
"I change what I do depending on what others want."
.
* Perseveration:
"I get stuck on one way of doing things, even when it's clear it won't work."
"I get stuck on things a lot."
"It is hard for me to shift from one activity to another."
"I get fixated on certain things and can’t stop."
"I feel compelled to go on with things even when it makes little sense to do so."
"I keep approaching things the same way, even when it isn’t working."
.
* Depressed Mood:
"I have no worth as a person."
"Everything seems pointless to me."
"I often feel like a failure."
"The world would be better off if I were dead."
"The future looks really hopeless to me."
"I often feel just miserable."
"I'm very dissatisfied with myself."
"I often feel like nothing I do really matters."
"I know I'll commit suicide sooner or later."
"I talk about suicide a lot."
"I feel guilty much of the time."
"I'm so ashamed by how I've let people down in lots of little ways."
"I am easily discouraged."
"I become overwhelmed by events."
.
("Emotional Stability vs. Negative Emotion" modified from "PID-5" by Kreuger RF, Derringer J, Markon KE, Watson D, Skodol AE and Between facets and domains: 10 aspects of the Big Five)
*MRI Research: Testing predictions from personality neuroscience. Brain structure and the big five.


Back to top


Internet Mental Health © 1995-2018 Phillip W. Long, M.D.