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When hoarding disorder is suspected, it is important to assess for other psychiatric disorders that may affect the presentation and treatment of symptoms. Find out more in this quiz.

Mini Quiz: Hoarding Disorder in the Elderly

SPECIAL REPORT: OCD AND RELATED DISORDERS

OCD manifests as recurrent and persistent obsessive thoughts, and/or repetitive compulsive behaviors. The disorder affects about 2% of the population, with incidence peaks in both pre-adolescent children, and young adults.

 Anxiety disorders are the most common emotional difficulty for children, and in the in the US, 7.1% of children (aged 3-17 years) have been diagnosed with an anxiety disorder.

 This number increases when considering lifetime prevalence, and up to one-third of the population will suffer from an anxiety disorder at some point.

 OCD and anxiety disorders present differently from child to child, and it can be challenging to distinguish between the various anxiety disorders and OCD. While anxiety disorders and OCD are often comorbid, and have overlapping symptoms, there are some key distinguishing factors that lead to diagnostic clarity.

 Differentiating between these attributes can guide treatment choices and goals for OCD as well as non-OCD anxiety disorders.

In 2013, DSM-5 separated OCD from anxiety disorders by creating a distinct category of Obsessive Compulsive and Related Disorders. While the diagnostic criteria spell out differences between the categories, phenotypically, the presentations of OCD and anxiety disorders, such as social anxiety disorder and specific phobias, can appear very similar.

DSM defines obsessions as “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 or distress.” This marked anxiety or distress leads to an urge to complete compulsions. Patients often come in describing that they are “obsessing,” or having persistent thoughts, yet, these descriptions do not necessarily indicate the presence of OCD and may be indicative of ruminations or fears more consistent with an anxiety disorder.

Two helpful considerations when determining whether recurrent thoughts are obsessions as defined within the framework of OCD are the source of the threat and the nature of the thoughts as well as presence or absence of compulsive behaviors.

The Source of Threat and Nature of the Thoughts

. The source of threat can help distinguish between the various anxiety disorders. According to DSM, the presence or absence of “non-real-life concerns” or content that is “odd, irrational, or of a seemingly magical nature” can often indicate OCD. DSM-5 added the possibility that an individual may not recognize that the beliefs are possibly untrue, and in this case, there is a specifier “with absent insight/delusional beliefs.”

. There are instances in which the obsessions are about something rational; however, in these cases, there are often rituals or compulsions that are not rational responses to the thought. While DSM 5 does not require that the individual recognize that the behaviors are irrational, the criteria still clearly states “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.”

Max is terrified of vomiting. He avoids being near sick people and runs away when he hears that someone in his class has been ill.

Sarah is also terrified of vomiting. She engages in excessive and ritualized hand washing to prevent illness, and her hands are chapped and raw as a result. She counts the number of seconds she washes to make sure she feels that she has completed her cleaning task.

In a specific phobia, there may be recurrent thoughts about a specific topic or item. It may appear that these are “obsessions.” In both of these examples, we can consider that the source of threat-illness and vomiting-is the same. This is not a nonâreal-life concern and the content is not odd, irrational, or of a seemingly magical nature. With Max, rituals are not present, and instead we see significant avoidance. Only Sarah presents with compulsions, which are not connected in a fully realistic way with the prevention of illness.

We can extend this example to other anxiety disorders: in a case of social anxiety disorder, the source of threat is judgement and evaluation from others. A person may have recurrent thoughts about this but typically engages in avoidance of these situations rather than in compulsive behaviors that are disconnected with the fear. In generalized anxiety disorder, a person is likely to have recurrent and persistent thoughts about a variety of things, yet these are categorized as ruminations. If the person has compulsions, then this may warrant a separate diagnosis of OCD (

Jamie is having recurring thoughts about harming herself and others. She is terrified to go near knives, for fear that she will hurt someone. She is extremely distressed about these thoughts and seeks reassurance to confirm that she has not hurt anyone from her mother multiple times a day.

Danielle has suffered from OCD symptoms for years. She is now presenting with significant symptoms of depression and is having thoughts about harming herself. She is distressed about the fact that she is having suicidal ideation and hates that she is having so much trouble finding a reason to live.

Both Jamie and Danielle present with thoughts about harming themselves, and in both cases, these thoughts are distressing. The differential that we are considering is whether these thoughts are intrusive thoughts consistent with OCD, or true suicidal ideation.

Intrusive thoughts are unwanted thoughts that a person does not agree with.

 The thoughts are most often incongruent and antithetical to the person’s values and true beliefs. Jamie is having thoughts about harming others even though she absolutely does not want to, and she is even horrified by the thought. A person may have thoughts about sexual interest in children, even though he or she are not interested in children sexually. These are intrusive thoughts, and the obsession and source of threat is “does the fact that I am having a thought mean something about me?” or “does the fact that I am having a thought mean something about my desires and what I may do in the future?”

The thoughts are taken as truth and are often interpreted as holding significant meaning about the individual. With intrusive thoughts, a person often does not understand why they are having these thoughts. The thoughts are ego-dystonic, and often the opposite of the individual’s desires.

In contrast, Danielle is distressed about her thoughts of harming herself, but she is further distressed because she has some ego-syntonic desire to harm herself. Fears may also be ego-syntonic. A fear of being stabbed by an intruder is consistent with what a person wants: a desire to prevent being stabbed. In many cases, this would be categorized as a fear, and may be consistent with a phobia or anxiety disorder.

In Jamie’s case, we would provide psychoeducation about intrusive thoughts and OCD, and then proceed to exposure and response prevention. We would have her face her obsession that her thoughts are meaningful by purposely thinking about harming people, while preventing any reassurance seeking and avoidance. We would also have her hold knives while thinking these thoughts. This would allow her to see that her thoughts are not dangerous, and do not reflect who she is or who she will become. She will learn that she can think the thought, and still not harm anyone. For Danielle, despite her significant history of OCD, we would address her primary concern of depression and suicidal ideation.

Ben has a life-threatening allergy to nuts and is terrified of having a severe allergic reaction. Upon further assessment, Ben explains that he has stopped eating at restaurants, even when they are nut-free, and checks food labels multiple times, even on products that he has previously eaten. His mother discloses that, a few years ago, he washed his hands five times before each meal.

When it remains unclear whether a presentation is OCD or an anxiety disorder, it may be helpful to assess for other compulsive behaviors, past or present. Ben presents with fear of an allergic reaction, which could be a specific phobia. Upon further assessment, you find out that there are current checking behaviors that are irrational. Even if these were not present, the history of hand-washing compulsions is a strong indicator that Ben’s symptom presentation is likely consistent with a diagnosis of OCD (

When considering a course of treatment, it is helpful to conceptualize OCD separately from anxiety disorders, from both psychotherapeutic and medication perspectives. Anxiety disorders are treated with cognitive behavioral therapy (CBT), which includes exposure, facing fears and anxiety provoking situations. With anxiety disorders, this exercise revolves around facing the fears themselves. When treating OCD, this treatment element is part of exposure and response prevention.

Preventing a compulsion or compensatory behavior is essential. If a person completes exposures, but later engages in the compensatory behaviors, rituals, or compulsions, the individual learns that they are only okay because they completed the compensatory behavior. The impact of the exposure is diminished, and this reinforces the 

, rather than reducing it. For example, if a patient has OCD with contamination concerns, and he practices touching the floor throughout his session, but then goes home and scrubs his hands for 30 minutes, he only learns that he was able to tolerate the exposure because he was able to complete a compulsion. Treatment for OCD must include both the exposure AND the response prevention.

The first-line medications for both OCD and anxiety disorders are SSRIs. Additionally, for both OCD and anxiety disorders there is strong evidence for a 

of SSRIs and CBT as the most effective treatment.

 However, despite strong evidence of the effectiveness of SSRIs in the treatment of anxiety, the only FDA-approved medication for childhood anxiety disorders is the SNRI, duloxetine for treating generalized anxiety disorder.

for the use of alternative medications including venlafaxine, buspirone, mirtazapine, tricyclic antidepressant, and benzodiazepine among others, is less compelling or negative.

This is not the case for OCD; fluoxetine, sertraline, fluvoxamine, and clomipramine are all FDA-approved for the treatment of pediatric OCD giving clinicians numerous options before considering off-label treatments. When treating OCD with medication there are two additional major differences. OCD often requires high doses of SSRIs, doses that are not usually necessary for anxiety disorders. Moreover, OCD may take longer to respond to medications than anxiety disorders and so clinicians must prepare their patients for this and understand this before deciding to further titrate a patient’s dose of medication.

Differential diagnosis is also critical to medical decision-making as certain comorbid disorders (eg, tic disorders) may affect the choice and response to medications. For example, patients with co-occurring tic disorders and OCD may benefit more from off-label augmentation with an atypical antipsychotic than patients who do not have a tic disorder.

While it may be challenging to differentiate between OCD and other anxiety disorders, using a multi-informant assessment and understanding the content of a patient’s fears is a fundamental start to outlining an effective treatment plan. It is also important to consider that given the high comorbity between anxiety disorders and OCD, if a patient meets full criteria for both OCD and an anxiety disorder both diagnoses should be given.

Treatment approaches for anxiety disorders emphasize aspects of exposure treatment, and it is essential to include response prevention in the treatment of OCD. Maintaining an openness to the source of threat and presence of less typical symptoms as you assess and build rapport with a patient can aid in diagnostic clarity and provide a foundation to flexibly adapt treatment approaches.

 is Assistant Professor of Psychology in Clinical Psychiatry, and Director, Pediatric OCD, Anxiety, and Tic Disorders Program; 

 is Postdoctoral Fellow of Psychology in Psychiatry, and 

 is Assistant Professor of Clinical Psychiatry, Vice Chair for Child and Adolescent Psychiatry, and Vice Chair, Faculty Practice, Weill Cornell Medicine, New York, NY. The authors report no conflicts of interest concerning the subject matter of this article.

1. Walitza S, Melfsen S, Jans T, et al. Obsessive-compulsive disorder in children and adolescents. 

2. Bitsko R, Holbrook J, Ghandour R, et al. Epidemiology and impact of health care provider diagnosed anxiety and depression among US children. 

3. Bandelow B, Michaelis S. Epidemiology of anxiety disorders in the 21st century. 

4. Goodwin GM. The overlap between anxiety, depression, and obsessive-compulsive disorder. 

5. Rachman S. Part I: unwanted intrusive cognitions. 

6. Walkup JT, Albano AM, Piacentini J, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. 

7. The Pediatric OCD Treatment Study (POTS) Team. Cognitive behavior therapy, sertraline, and their combination for children and adolescents with obsessive compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. 

8. Mohatt J, Bennett SM, Walkup JT. Treatment of separation, generalized, and social anxiety disorders in youth. 

Psychopharmacologic treatment of children and adolescents with anxiety disorders

While it may be challenging to differentiate between OCD and other anxiety disorders, using a multi-informant assessment and understanding the content of a patient’s fears is a fundamental start to outlining an effective treatment plan.

Is It OCD or an Anxiety Disorder? Considerations for Differential Diagnosis and Treatment

, which is notoriously disabling, OCD causes similar degrees of serious impairment in social relationships and daily living, but we often do not consider OCD in this light because effective treatments are available. However, up to half of patients do not respond to first-line treatments and traditional pharmacological approaches are often associated with difficult adverse effects. In fact, even when patients do “respond,” it is rare to see true symptom remission.

, which often measure the percentage of “responders” and “remitters,” many OCD studies only measure “responders” and “partial responders.” For these reasons, it is essential to develop a more effective treatment algorithm that can help patients who do not respond to first-line options.

OCD is characterized by uncontrollable, recurring thoughts or images (obsessions) accompanied by the urge to repeat specific behaviors (compulsions) to alleviate these intrusive thoughts. Effective treatments reduce symptoms and help patients cope with the anxiety surrounding these obsessions and compulsions. The 

 implemented an OCD treatment algorithm that designates a specific type of cognitive behavioral therapy (CBT)-exposure-response prevention (ERP)-and SSRIs as first-line treatments [

ERP involves patients working with their therapist to actively expose themselves in increasing degrees to the very things that elicit their fears. The process reduces anxiety surrounding the various triggers that induce the obsessive thoughts and compulsions. This form of CBT is effective in patients who complete a full course of treatment; however, some patients may have difficulty fully committing to the therapy as it can be extremely anxiety inducing. Ultimately, 45% of OCD patients either quit ERP because of the difficult treatment process or fail to respond to this treatment to a satisfactory degree.

 One option is to introduce a pharmacological treatment in parallel with ERP.

The first pharmacological option for patients with OCD is an SSRI. SSRIs are effective in about 50% to 70% of patients.

 However, because their effects are not localized only to OCD brain regions, they can have significant negative adverse effects in other parts of the body. Further exacerbating this issue is the fact that patients with OCD often require higher doses of SSRIs than those effective in treating depression. Research has shown that increasing the dose of  SSRIs in this manner can lead to increased adverse effects, which can often be severe enough that patients choose to stop their medications.

 Moreover, because we do not fully understand how SSRIs work in the brain to reduce OCD symptoms, we have not yet found methods for predicting who will respond to the treatment in any reliable, affordable, or clinically feasible way.

After non-response to ERP and/or initial doses of SSRIs, psychiatrists have only a few validated options. Clinicians will often escalate the dose of SSRIs, try multiple different SSRIs, or switch to or add clomipramine, an older, but sometimes more effective SRI, but which unfortunately can often have more serious adverse effects. Next, atypical antipsychotics such as risperidone or aripiprazole are added to the patients’ treatment regimen. Again, the adverse effects associated with adding an antipsychotic are often worse than those associated with treatment with an SSRI alone. This process of escalating doses and testing different medications and combinations can often take several months to years.

When these options are exhausted, the next option in the treatment algorithm is surgical implantation of a deep brain stimulator (DBS) or a procedure known as a ventral capsulotomy, which creates a lesion in part of the brain implicated in OCD.

 While surgery has been proven effective in treatment-resistant patients, there are risks, costs, and complications associated with the procedures.

Furthermore, brain surgery can be particularly anxiety-provoking for patients with severe OCD, and many are not willing to proceed with surgery. This leaves clinicians in a difficult position, and other non-invasive treatment options are needed. Fortunately, a non-invasive treatment was cleared by the FDA, offering psychiatrists another neurocircuitry-based tool with far fewer risks compared with surgical options.

The FDA approved deep transcranial magnetic stimulation (dTMS); dTMS works by directing electromagnetic fields that generate excitation or inhibition of neurons deep inside the brain. It is completely noninvasive and performed in an outpatient setting, with no need for hospital gowns or anesthesia. Patients receive stimulation through a helmet with a built-in magnetic coil (

Treatment is well tolerated, usually with only mild discomfort due to sensations on the scalp sometimes described as feeling like a woodpecker tapping on the head; however, with increasing treatments, the scalp desensitizes to this sensation, and most patients report it to be less bothersome with each treatment.

Unlike SSRIs, this treatment is localized, more precisely targeting specific brain regions-the medial prefrontal cortex and the anterior cingulate cortex (

 This localized specificity means that the rest of the body is spared adverse effects.

Clinical trial results show that daily dTMS treatment for a 6-week period results in a statistically significant 30% reduction in symptom severity as measured by the Yale-Brown Obsessive-Compulsive Scale.

 This magnitude of response is on par with responses seen in SSRI treatment; however, dTMS may achieve these results faster. Many SSRI studies demonstrate similar responses but only after 8 to 12 weeks.

At the 10-week follow up, the response rate to dTMS increased further. This increase demonstrated a positive treatment effect over time, even once the stimulation had ceased. Overall, 38.1% of patients in the dTMS group showed a response, compared with 11.1% of patients in the sham treatment group.

 Adverse effects were limited; the most frequent adverse reaction was headache, which resolved shortly after treatment.

This clinical trial was especially unique, because prior to each treatment session, OCD symptoms were provoked in each patient. This provocation of symptoms was personalized, based on a fear hierarchy created between patients and their clinician before the start of treatment. For example, immediately before undergoing dTMS treatment, patients with obsessions related to contamination fears may have been presented with a dirty sponge to touch, or perhaps they brought triggering items from home.

This idea of provoking symptoms and activating trigger-specific circuity stems from earlier studies in posttraumatic stress disorder, addiction, and smoking cessation that have shown greater improvement in groups that had provocation protocols.

 The sham group also received the brief exposure or provocation protocol but did not see the same results.

Many patients who have experienced minimal relief from their symptoms with pharmacological treatment and/or therapy are able to function at a significantly higher level following dTMS treatment. This comes without adverse effects, and the benefits are sometimes quicker than pharmacologic approaches. These results are promising; however, it remains to be seen how this treatment is integrated into clinical practices more broadly: dTMS may not work in some patients and do wonders in others. We do not yet know how to predict patient response.

Patients who respond often describe feeling that they have more choice over their behaviors, that obsessions are more muted, and that they feel they can resist the compulsions more successfully. Patients who previously struggled to progress in ERP sometimes report feeling they are now able to make new progress or progress at a faster pace. This anecdotal evidence is exciting, especially to those who believe in ERP as the cornerstone of OCD treatment.

In a population that often struggles with treatment resistance, any additional treatment that is complementary to ERP and SSRIs without increasing the adverse effect burden and decreasing the quality of life is worth incorporating into the OCD treatment algorithm. It makes sense to place dTMS into the algorithm between pharmacological approaches and surgery (

Moving forward, after a specific time at which pharmacological and therapy approaches have failed to help patients to a sufficient degree, dTMS approaches should be considered and potentially integrated into the treatment plan. For particularly severe patients, it might even be considered sooner, in conjunction with both medications and therapy.

Deep TMS is quite safe, with minimal overall risk and few significant or persistent adverse effects. Risk of seizure is often discussed with patients. However, this is rare, with less than 1% of patients in depression studies from the past 10 years who experience seizures.14 In the trial that achieved FDA clearance for OCD, no patients had seizures.

The biggest downside to TMS is that it is usually administered as a daily treatment, 5 days per week, for about 4 to 6 weeks. Treatment itself, depending on the parameters used, is only about 15 to 20 minutes. Without anesthesia and cognitive adverse effects, patients are often able to come in for treatment early in the morning, on a lunch break, or between classes. Nonetheless, it is a daily commitment. This could change in the future: data for 

, which involves treating patients multiple times a day for fewer overall days, are showing that it may be similarly effective for
	depression as traditional TMS.

While OCD is considered treatable, not all patients respond to therapy or medication. Even when patients do respond, it is rare to see full remission of symptoms. Fortunately, new research is ongoing, and as there is more understanding of the neurobiology underlying OCD, additional treatment options become available and should be thoughtfully integrated into the treatment algorithm. One such option is dTMS.

As a noninvasive treatment with few adverse effects, dTMS may be a good option for patients who have not responded to first- or second-line therapies. Additional data are needed, but the potential of dTMS to enhance or augment other modalities is exciting. Similarly, as dTMS is integrated into clinical practice, clinicians will be better able to identify the variables in OCD that are more receptive to dTMS treatment and in which patients it will be most successful. It will be interesting to see how this option works in clinical practice and in the broader population outside of clinical trials.

A further point of note: this treatment offers greater possibility for collaboration between behavioral therapists and psychiatrists. Together we should brainstorm new protocols and study designs, utilizing dTMS to further enhance each of our own already validated treatments.

This article was originally posted on September 13, 2019, and has since been updated. -Ed

 is Assistant Clinical Professor, Department of Psychiatry, UCSF School of Medicine, and Director, OCD Program, TMS Health Solutions, San Francisco, CA. He reports that he is employed by TMS Health Solutons, an insurance-based, group psychiatric private practice that offers rTMS and dTMS as one of many various treatment modalities.

1. Hollander E, Doernberg E, Shavitt R, et al. 

The cost and impact of compulsivity: a research perspective

. 2016;26:800-809. 2. Whittal ML, Thordarson DS, McLean PD. Treatment of obsessive–compulsive disorder: cognitive behavior therapy vs exposure and response prevention. 

3. Jenike MA. Obsessive-compulsive disorder. 

4. Pallanti S, Hollander E, Bienstock C, et al. Treatment non-response in OCD: methodological issues and operational definitions. 

5. Bloch MH, McGuire J, Landeros-Weisenberger A, et al. 

Meta-analysis of the dose-response relationship of SSRI in obsessive-compulsive disorder

6. Pittenger C, Bloch MH. Pharmacological treatment of obsessive-compulsive disorder. 

7. Janardhan Reddy YC, Sundar AS, Narayanaswamy JC, Math SB. Clinical practice guidelines for obsessive- compulsive disorder. 

8. Jung HH, Kim SJ, Roh D, et al. Bilateral thermal capsulotomy with MR-guided focused ultrasound for patients with treatment-refractory obsessive-compulsive disorder: a proof-of-concept study. 

9. Dougherty DD, Brennan BP, Stewart SE, et al. 

Neuroscientifically informed formulation and treatment planning for patients with obsessive-compulsive disorder: a review

10. Tendler A, Zohar J, Carmi L, et al. Deep TMS of the medial prefrontal and anterior cingulate cortices for OCD: a double-blinded multi-center study. 

11. Soomro GM, Altman DG, Rajagopal S, Browne MO. Selective serotonin reuptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder. 

12. Dinur-Klein L, Dannon P, Hadar A, et al. Smoking cessation induced by deep repetitive transcranial magnetic stimulation of the prefrontal and insular cortices: a prospective, randomized controlled trial. 

13. Isserles M, Shalev AY, Roth Y, et al. Effectiveness of deep transcranial magnetic stimulation combined with a brief exposure procedure in post-traumatic stress disorder: a pilot study. 

14. Perera T, George MS, Grammer G, et al. The clinical TMS society consensus review and treatment recommendations for TMS therapy for major depressive disorder. 

15. Sonmez AI, Camsari DD, Nandakumar AL, et al. 

Accelerated TMS for depression: a systematic review and meta-analysis

16. Hirschtritt ME, Bloch MH, Mathews CA. Obsessive- compulsive disorder: advances in diagnosis and treatment. 

As our understanding of the neurobiology of OCD grows, additional treatment options become available and should be thoughtfully integrated into the treatment algorithm. One such option is dTMS.

Integrating Deep Transcranial Magnetic Stimulation Into the OCD Treatment Algorithm

As psychiatrists we must remember that comorbidities is often the rule, not the exception. This is especially true for obsessive and compulsive disorder (OCD). Not only is this important from a diagnostic point of view, but treatment may need to be pharmacologically as well as behaviorally diverse to treat all the co-existing conditions.

The articles in this Special Report address some of the more common comorbidities: bipolar disorder; Tourette syndrome; and anxiety disorders, such as panic disorder, generalized anxiety disorder, simple phobia, and specific phobia, especially in an adolescent population. In discussing bipolar disorder, the point is made that treating the mania may be enough and that adding a serotonin reuptake inhibitor could worsen mood symptoms, particularly mania. In treating Tourette syndrome, special attention should be given to Comprehensive Behavioral Intervention for tics before considering the addition of neuroleptics or the newer alpha-2 adrenergic agonist in the separate treatment of the tics in addition to the OCD.

With the article by Andrea Aguglia, MD, PhD, and colleagues, we are reminded that the brain is connected to the rest of the body. Comorbid general medical problems such as diabetes, hypertension, and obesity may be related to OCD treatment or precipitated by environmental stressors as a result of living with the disorder. Some of these environmental stressors include living lonely isolated lives and engaging in unhealthy behaviors, such as alcohol use and smoking, to deal with the anxiety related to OCD symptoms.

Pregnancy is another type of stress that cannot be overlooked as a cause or exacerbation of OCD. Erika L. Nurmi, MD, PhD, and Carol A Mathews, MD, address postpartum OCD and make some specific recommendations for treatment during and after pregnancy. In particular, they note physiological and psychodynamic issues around breastfeeding. For example, new mothers may obsess about harming the newborn from exposure in utero or in breast milk because of the OCD medications they are taking.

Meanwhile, Jon E. Grant, MD, and Samuel R. Chamberlain, MD, provide hope in what we have learned most recently about the neurobiology of OCD but also challenges for us to fill in the blanks about what we still do not know. They make note of newer regions outside of the orbital frontal loop that might be part of the neurophysiology of OCD.

Although there is still more to say and learn, together these articles provide up-to-date information that clinicians can turn to when making treatment decisions for OCD, its comorbidities and related disorders.

Dr Pato is Co-Director, Institute for Genomic Health (IGH) and Professor and Vice Chair for Research, Department of Psychiatry, SUNY Downstate, Brooklyn, NY. She reports no conflicts of interest concerning the subject matter of this Special Report.

As psychiatrists we must remember that comorbidities is often the rule, not the exception. This is especially true for obsessive and compulsive disorder (OCD).

Clinician Perspectives on Psychiatric and General Medical Comorbidities

“Andrea,” a 28 year old is 6 months postpartum. She presents to the psychiatric department (ED) seeking help for anxiety. She notes that she was reluctant to come to the ED because of fear of being judged, yet ultimately came because her husband has noticed that she is spending less and less time with the baby and he is becoming increasingly worried about her.

Andrea reports that she has been having thoughts of drowning her child since she was 1 month postpartum. She has been avoiding washing dishes for fear that she will spray the water on her baby and cause her harm. She does not want to harm her child, and reports these thoughts are scary and distressing, but she cannot get the drowning images out of her head. The thoughts are frequent and can persist for up to 4 or 5 hours every day. She is so worried that she will act on these thoughts that she has been asking her mother or her partner to bathe her daughter, and she is relieved not to have to do it herself. Aside from adapting to life with a newborn, she reports no other major current stressors and appreciates the support from her husband and her parents.

On psychiatric review of symptoms, she does not endorse current mood symptoms. She has a history of depression; in her first year of college she was treated with fluoxetine and completed a course of cognitive behavioral therapy, after which the symptoms resolved. She stopped fluoxetine 6 months later and has felt well since then.

She has no history of harming herself or others and no other psychiatric history, including no history of obsessive compulsive disorder. She reports significant anxiety and feeling on edge often because of the thoughts of drowning her baby. Aside from recent non-complicated vaginal delivery, her medical history is also significant for hypothyroidism, for which she continues to take levothyroxine.

Perinatal (ie, pregnancy or in the year after birth) obsessive-compulsive disorder (OCD) is common, with a prevalence of 2% during pregnancy and 2.5% in the postpartum period.

 In perinatal OCD, the onset of OCD symptoms is during pregnancy or the postpartum period. Subthreshold OCD symptoms that can involve intrusive thoughts about harming the newborn or fetus also are prevalent, and prior research reports that 49% to 69% of women have such thoughts during the perinatal period.

OCD in the general population often differs from OCD that presents in the perinatal period. In perinatal OCD, most obsessions involve the fetus or newborn, and the obsessions are often accompanied by intrusive thoughts and fears of harming the newborn. Compulsions often manifest as avoidance of the newborn or things related to their obsessions (eg, water, in the Andrea’s case).

 Similarly, women who develop OCD during pregnancy tend to have contamination obsessions and rituals such as washing and cleaning. To meet the diagnostic criteria for OCD, the symptoms need to be severe enough to cause impairment.

When the onset of OCD symptoms occurs postpartum, it tends to occur rapidly, usually beginning within 4 weeks postpartum. Symptoms can also start during pregnancy, although usually the onset is more gradual if occurring during the prenatal period as compared to during the postpartum period.

Risk factors for perinatal OCD include personal history of depression, primiparity, obsessive-compulsive personality disorder, avoidant personality disorder, obstetric complications during pregnancy or delivery, and somatic illness. Family history of mood and substance use disorders are more common than family history of obsessive-compulsive disorder in women with perinatal OCD.

Many women with perinatal OCD are hesitant to disclose symptoms to medical providers due to stigma and concerns about child protective services. It is important to approach women using an empathic strength-based approach and to ask specifically about intrusive thoughts. Women may prefer to discuss intrusive thoughts in general without revealing specific details. Asking how they are managing the thoughts can help facilitate the assessment, because women may be more comfortable discussing it when approached in this manner. For example, stating “This sounds so stressful and scary, how are you managing to spend time with your baby with all this happening?” instead of “Why have you not been spending time with your baby?”

Women with OCD are at low risk of acting on intrusive thoughts because, as in Andrea’s case, the thoughts of harming their newborns are ego dystonic and scare women, thus they have no intention of harming their newborn. Given this, referral to child protective services or referral the psychiatric emergency room is not usually necessary. If done inappropriately, such referrals can be perceived as punitive by women and their families, exacerbating OCD symptoms and creating barriers for participating in outpatient mental health treatment.

Women with postpartum OCD often have obsessional thoughts around harming their child, which can be scary for both the patient and their health care provider(s). As previously noted, patients with OCD do not typically act on their intrusive thoughts. It is important to differentiate intrusive thoughts of harming the infant that are part of OCD or depression versus thoughts of harm secondary to postpartum psychosis (

). Postpartum psychosis is ego syntonic and often is associated with hallucinations, delusions, and negative symptoms of psychosis such as disorganization and changes in mood that are not seen in OCD.

 Postpartum psychosis is rare but is considered a psychiatric emergency and occurs most frequently in women with bipolar disorder.

Women with perinatal OCD are at higher risk of depression, especially significant when intrusive thoughts about hurting the newborn are present. Many women with perinatal OCD also develop depression, and obsessions are common within perinatal depression as well.

After a full assessment, the psychiatrist in the ED diagnoses perinatal OCD. The psychiatrist provides psychoeducation and reassures Andrea that the risks of harming her baby are low and that what she is having are intrusive thoughts that are common in OCD. The psychiatrist talks to Andrea about various treatment options, including exposure response prevention therapy (a type of cognitive behavioral therapy) and medication options. Andrea is eager to start exposure response prevention therapy.

Andrea, however, is much more cautious about medications, despite her severe symptoms, because she is currently breastfeeding. She reports she has talked to friends who were told that medications were too risky throughout the perinatal period and when breastfeeding and would like to know more about the risks and benefits of medications prior to starting one. She said that she has several friends who were told that they needed to stop their medications immediately after getting pregnant and could not start them again until after they finished breastfeeding, and she worries about the risks.

A patient-centered approach is important for the treatment of OCD, and both the provider and patient should feel comfortable with the plan. Cognitive behavioral therapy either alone or with selective serotonin reuptake inhibitor (SSRI) medications is effective and should be offered. SSRIs alone can also be effective. In cases of treatment-resistant OCD in the perinatal period, when treatment with SSRI medication or serotonin norepinephrine reuptake inhibitors (SNRIs) has not been effective, augmentation with quetiapine also has been shown to be effective.

When leveraging pharmacotherapy, it is important to discuss the risks and benefits of the medications during the perinatal period, which includes potential effects to the fetus if the woman is pregnant and effects in postpartum if the woman is breastfeeding. When discussing medications, it also is important to discuss the risks of untreated perinatal OCD, which carries risk in itself. Stress and anxiety in pregnancy can lead to distress for the mother and can lead to changes in fetal and infant development. Perinatal OCD has been associated with negative consequences on social support, infant development, and mothering.

During pregnancy, antidepressants are an evidence-based treatment option and are not considered major teratogens.

 When considering medications in the postnatal period, if a woman is breastfeeding, it is important to also discuss that breastfeeding is considered generally safe with low blood levels of SSRIs passed through the breastmilk.

 When considering a medication, it is important to consider what has and has not been helpful to the woman in the past to avoid multiple exposures and medication trials. There are many databases that can be helpful for information on medications during the perinatal period for patients and clinicians who have more questions, including databases such as MotherToBaby,

Given its prevalence and it negative impact when left untreated, it is imperative to recognize, assess, and treat perinatal OCD using a strength-based approach. Doing so carries the potential to improve maternal and child outcomes and have a transgenerational impact.

Dr Kucherer is Assistant Professor of Psychiatry at the University of Pittsburgh Medical Center, Western Psychiatric Hospital. Dr. Byatt is Associate Professor of Psychiatry at University of Massachusetts Medical School. Dr Kucherer has nothing to disclose regarding the subject matter of this piece. Dr Byatt has served on the Medscape Steering Committee on Clinical Advances in Postpartum Depression. She has received honoraria from Medscape and Miller Medical Communications. She has served on Advisory Boards for Sage Therapeutics, and is a Council Member of the Gerson Lehrman Group. She also has served as a consultant for Ovia Health, Sage Therapeutics or their agents, and has received speaking honoraria from Sage Therapeutics.

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Anales De PsicologÃ­a/Annals of Psychology

3. Buchholz, JL, Hellberg, SN, & Abramowitz, JS. Phenomenology of perinatal obsessive-compulsive disorder. In Biomarkers of Postpartum Psychiatric Disorders. 

4. Sharma, V, & Sommerdyk, C. Obsessive–compulsive disorder in the postpartum period: diagnosis, differential diagnosis and management. 

5. Challacombe, FL., Bavetta, M, DeGiorgio, S. Intrusive thoughts in perinatal obsessive-compulsive disorder. 

6. Lewis KJ, Di Florio A, Forty L, et al. Mania triggered by sleep loss and risk of postpartum psychosis in women with bipolar disorder. 

7. Marchesi C, Ossola P, Amerio A, et al. Clinical management of perinatal anxiety disorders: A systematic review. 

8. Collardeau F, Corbyn B, Abramowitz J, et al. Maternal unwanted and intrusive thoughts of infant-related harm, obsessive-compulsive disorder and depression in the perinatal period: study protocol. 

9. Payne JL. Psychopharmacology in pregnancy and breastfeeding. 

10. Organization of Teratology Information Specialists. MotherToBaby Fact sheets. 

https://mothertobaby.org/fact-sheets-parent/

11. National Library of Medicine (US). Drugs and Lactation Database (LactMed). 

12. Reproductive Toxicology Center. Reprotox. 

OCD in the general population often differs from OCD that presents in the perinatal period. It is imperative to recognize, assess, and treat perinatal OCD to improve maternal and child outcomes and have a transgenerational impact.

When Baby and OCD Are on Board Assessment and Treatment Issues

The key features of obsessive-compulsive-disorder (OCD) are obsessions and compulsions; in most cases of severe symptomatology, avoidance behaviors also are present. Anxiety is a secondary but very pervasive manifestation of OCD. The onset of OCD is typically in late childhood, early adolescence, or early adulthood. The pathophysiology of OCD is uncertain, largely because of the 

of manifestations and the high rates of comorbidity (anxiety, depressive or bipolar disorder). Furthermore, OCD symptoms can be quite difficult to recognize; intrusive thoughts and behaviors that are the primary features of the disease are internally driven. Not understanding what is happening, patients tend to be ashamed and suffer in silence, often resulting in a period of 8 to 10 years of untreated illness and long-term negative outcomes.

First-line treatment of OCD consists of cognitive behavioral therapy with exposure and prevention of response often in combination with selective serotonin reuptake inhibitors plus clomipramine. These treatment approaches usually guarantee symptom reduction and remission in at least 60% to 70% of cases. Quite often, they are used together 

 if symptoms are mild to moderate. International guidelines suggest the use of pharmacological treatment at maximum tolerated doses for at least 8 to 12 weeks, but clinicians should wait even longer to evaluate the potential improvement of symptoms.

For patients who do not achieve remission after a trial of adequate dosage and duration, a switch to another SSRI or clomipramine is recommended. If there is partial response, consider augmenting with a first-generation (eg, haloperidol) or second-generation antipsychotic (eg, risperidone, aripiprazole, olanzapine).

According to the National Comorbidity Survey Replication (NCS-R), 68% of patients in the US subjects with a psychiatric disorder have at least one co-occurring general medical condition (GMC). In addition, in those with primarily a GMC, 29% report to have a comorbid psychiatric disorder.

question has been widely examined in patients with schizophrenia or bipolar disorder as well as unipolar depression. Metabolic syndrome (primarily abdominal obesity, dyslipidemia, type II diabetes mellitus) and cardiovascular conditions (primarily hypertension) are the most common co-occurring medical condition, with cumulative incidences at age 47 of 56.2% versus 34.4% in the general population.

Medical comorbidities in OCD and other anxiety disorders have been insufficiently studied; researchers have only started to pay attention to this in the past few years.

 As in other psychiatric disorders, pharmacological treatment and unhealthy lifestyles play a leading role in causing these problems. OCD patients often conduct lonely lives, reduce their physical 

, and engage in drinking or smoking to control their symptoms.

Inherited factors such as hypothalamic pituitary adrenal (HPA) axis dysregulation have been considered for a long time as being responsible for altering metabolic profiles. Although a recent study ruled out shared genetic and environmental factors because family members of patients with OCD had the same metabolic and cardiovascular risk as the general population, patients with OCD have a 45% increased risk for any metabolic or cardiovascular complications.

Cardiovascular issues and antidepressants

 is higher in individuals suffering with depression. Some antidepressants, if given at full dose (eg, citalopram), can cause QT prolongation, resulting in an increased risk of arrhythmia. As demonstrated by a recent study, SSRIs would not be associated with an increased risk for arrhythmias, stroke, or transient ischemic attack in adults. Fluoxetine seems to reduce the hazard of a myocardial infraction.

Reduced physical activity and unhealthy food consumption determine obesity, which is one of the main risk factors for altered metabolic profiles in psychiatric patients. Apart from lifestyle causes, pharmacological treatments (ie, second-generation antipsychotics, antidepressants with high H

 affinity receptor, and mood stabilizers) are responsible for the weight gain that often reduce treatment adherence and determine relapses. Although they are commonly prescribed, only a few studies examined the relationship between antidepressants and weight change.

Tricyclics can determine weight gain through anticholinergic activity while SSRIs seem to lead to weight loss rather than weight gain, at least at the beginning of treatment. This effect could be due to the first improvement of depressive symptoms as well as the activation of the melanocortin system by an increase in serotonin levels. However, as treatment continues, 

 The reason is mostly unknown and not completely understood; it also could be produced by the physiological return to pre-illness weight, after a long period of appetite loss.

The most common metabolic risk factors are diabetes mellitus and insulin resistance. Chronic stress may result in decreased insulin sensitivity, even when there is no weight gain. It is unclear how it happens, most likely the association is multifactorial. A dysfunctional HPA axis may have a role on two levels:

1. At a behavioral level altered appetite, sleep disturbances and reduced activity may result in impaired glucose metabolism.

2. At a molecular level, neuroendocrine and inflammatory responses could develop diabetes mellitus.

Dyslipidemia is another important risk factor that contributes to mortality and morbidity in OCD patients. Relevant associations were discovered relating to the use of SSRIs and higher cholesterol level, increased triglyceride, and reduced high-density lipoprotein cholesterol (HDL-c). Second-generation antipsychotics also make a significant impact on eating behaviors and energy balance. Metabolism centers located in the central nervous system 

 balance the need for energy and the seeking of reward. At the peripheral level, all is ruled by connections between muscles, liver, pancreas, adipose tissue, and neuroendocrine organs. Neurotransmitter receptors, the main target of antipsychotic drugs, play a fundamental role in metabolism regulation. Bullet-receptor interaction can both protect and harm metabolism. Different second-generation antipsychotics can (at different levels) determine diabetes, obesity, and lipid profile alterations; pharmacodynamic profiles can only partially explain this difference.

Plot twist: are therapies the main problem?

A recent Swedish population-based study showed unexpected results: a higher dose of SSRIs and longer treatment duration were correlated with a lower risk of metabolic or cardiovascular problems. This evidence can be explained in many ways, including better disease control, appropriate pharmacological treatment, and unhealthy habits (smoking, unhealthy diet). Full doses of SSRIs could prevent secondary depression; comorbidity can be as high as 80%, but most prevalence rates are around 25% and 50%, considering OCD. Moreover, better symptom control could reduce anxiety, which plays a key role in causing metabolic and cardiovascular alterations.

Both depression and OCD have an impact on glycemic control, which is exacerbated with high anxiety with consequent hyperglycemia via activation of autonomic responses and triggering the HPA axis. Hyperglycemia can also lead to anxiety in different ways. By increasing cortisol secretion, altering heart rate, and modifying skin conductance levels it can lead to stress-like arousal patterns pervasive in psychiatric patients.

Patients affected by diabetes mellitus type II, if not well informed on their condition and not trained to deal with it, can develop secondary OCD. They may become obsessed by glycemic control, run unnecessarily frequent blood tests, and live with exaggerated concerns about the condition. Too many alterations of insulin doses can lead to even poorer glycemic control and higher manifestations of OC symptoms.

Physical well-being results in better quality of life and is associated with lower anxiety levels lowering the risk of a diabetes diagnosis. Mental well-being is linked to lower anxiety and depression, but not to metabolic disease duration or control. Planning psychological intervention for diabetes patients that are targeted on psychological health can result in better self-management and better health outcomes.

When comorbidity occurs, the impairment caused by the psychiatric disease reduces the ability to deal with the medical condition. Deficits in frontal-striatal function have been seen with OCD.

 The integrity of these structures and their connections play a key role in the affective, cognitive, and motor flexibility needed for actions that are goal-directed. Therefore, for OCD patients it could be much more difficult to focus on necessary behaviors to control the metabolic symptoms.

Patients with OCD as well as those affected by bipolar disorder and schizophrenia have an increased risk for comorbid medical illness. The presence of medical illness is probably multifactorial and can lead to a longer duration of untreated illness with a negative impact on the course of illness. Clinicians should keep in mind that the primary aim should always be to achieve symptom remission as the minimum effective dosage. Moreover, assessing the risk to benefit ratio in treatment planning will help in decision making for the best therapeutic strategies, resulting in reduced risk for relapse, better symptom control, and fewer adverse effects.

 is Researcher and Psychiatrist, Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), Section of Psychiatry, University of Genoa, Genoa, Italy; IRCCS Ospedale Policlinico San Martino, Genoa, Italy

is Resident in Psychiatry, DINOGMI, Section of Psychiatry, University of Genoa, and IRCCS Ospedale Policlinico San Martino; 

 is Researcher and Psychiatrist DINOGMI, Section of Psychiatry, University of Genoa; IRCCS Ospedale Policlinico San Martino; and Mood Disorders Program, Tufts Medical Center, Boston, MA. 

 is Associate Professor, DINOGMI, Section of Psychiatry, University of Genoa, and IRCCS Ospedale Policlinico San Martino. 

OCD symptoms can be quite difficult to recognize. Not understanding what is happening, patients tend to be ashamed and suffer in silence, often resulting in a period of 8 to 10 years of untreated illness and long-term negative outcomes.

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