Elsevier

The Lancet

Volume 360, Issue 9330, 3 August 2002, Pages 397-405
The Lancet

Seminar
Obsessive-compulsive disorder

https://doi.org/10.1016/S0140-6736(02)09620-4Get rights and content

Summary

Obsessive-compulsive disorder is a frequent, chronic, costly, and disabling disorder that presents in several medical settings, but is under-recognised and undertreated. For many years, obsessive-compulsive neurosis was seen as a disorder that provided an important window on the workings of the unconscious mind. Today, obsessive-compulsive disorder is viewed as a good example of a neuropsychiatric disorder, mediated by pathology in specific neuronal circuits, and responsive to specific pharmacotherapeutic and psychotherapeutic interventions. In the future we can expect more precise delineation of the origins of this disorder, with integration of data from neuroanatomical, neurochemical, neuroethological, neurogenetic, and neuroimmunological research.

Section snippets

Symptoms

Obsessive-compulsive disorder is characterised by intrusive thoughts or images (obsessions), which increase anxiety, and by repetitive or ritualistic actions (compulsions), which decrease anxiety. The most recent revision of the diagnostic criteria for obsessive-compulsive disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)4 emphasises that compulsions can be observable behaviours or mental rituals (panel 1).

The most frequent symptoms in obsessive-compulsive disorder

Epidemiology

The Epidemiological Catchment Area study16 provided the first epidemiological data for obsessive-compulsive disorder that were based on a nationally representative sample and reliable diagnostic criteria. Obsessive-compulsive disorder was the fourth most prevalent psychiatric disorder, with a lifetime prevalence of 2·5%.16 Results of a cross-national study1 with similar methods showed that prevalence did not differ by much across many different populations. A review17 of community studies

Neuroanatomy

The earliest indication that obsessive-compulsive disorder is mediated by specific neuronal circuits probably came from work showing an association between postencephalitis parkinsonian and obsessive-compulsive symptoms together with striatal lesions.33 Symptoms of obsessive-compulsive disorder have also been documented in various neurological disorders with striatal involvement, including Tourette's syndrome, Sydenham's chorea, Huntington's disorder, and Parkinson's disorder.34

Conversely,

Pharmacotherapy

Introduction of selective serotonin reuptake inhibitors provided the potential for agents that are not only effective for obsessive-compulsive disorder, but that also have a better safety and tolerability profile than does clomipramine. Indeed, all available serotonin selective reuptake inhibitors are effective and well tolerated in randomised controlled studies of obsessive-compulsive disorder,88 and several are also effective in obsessive-compulsive disorder in children.89 By contrast,

Psychotherapy

Psychoanalytical treatment for obsessive-compulsive neurosis was suggested by Freud,3 and for a long time was thought to be an effective approach to management. However, despite the contribution of investigators in delineation of the characteristics and psychology of obsessive-compulsive disorder, at present, insufficient data support use of psychoanalytical treatment.

Behavioural therapy was the first psychotherapy for which careful empirical support was obtained,100 and is useful in

The spectrum of obsessive-compulsive disorders

Disorders that overlap with obsessive-compulsive disorder are postulated to lie on an obsessive-compulsive disorder spectrum of conditions. Several different approaches to such a spectrum have been formulated.110 Freud postulated that there was a spectrum from obsessive-compulsive personality to obsessive-compulsive neurosis to psychosis. Although this idea is no longer popular, there is still an interest in patients with obsessive-compulsive disorder and poor insight, and in psychotic patients

Recommendation

Although many advances have already been made in treatment of obsessive-compulsive disorder, in the future a better understanding of the pathogenesis of obsessive-compulsive disorder will hopefully lead to further expansion of the present range of treatments, including innovations in psychopharmacology, psychotherapy, and other modalities of intervention.119, 120

Selection criteria and search strategy

I searched Medline up to 2001 for relevant articles using the terms obsession, compulsion, and obsessive-compulsive to aim at objective coverage; but references for this article were chosen more subjectively to illustrate data and themes in description, pathogenesis, pharmacotherapy, and psychotherapy of obsessive-compulsive disorder

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