Obsessive Compulsive Disorder  The three most frequent obsessional behaviors in

descending order are checking, cleaning-washing,

Obsessive compulsive disorder (OCD) is a
derangement in personality that fundamentally presents
with persistent pattern of inflexibility and perfectionism
with obsessive thoughts that impair daily functioning. This
disorder is characterized by orderliness, perseverance,
emotional restriction, indecisiveness and stubbornness.
Epidemiology
o starts at early adulthood, before age 25, with gradual
onset
o lifetime prevalence of OCD is 2-3%
o mean age of onset:: men - 21 years old
women -22 years old
o Men are more commonly affected than women by the
disorder.
o It is most often seen in the oldest children
Pathophysiology
Neurobiological hypothesis
Anatomically involved regions in OCD:
 Caudate nucleus
 Globus pallidus
 Orbitofrontal cortex
Treatment
Decreasing the metabolic activity of the caudate
nucleus is one of the pharmacological concerns in treatment of
obsessive-compulsive disorder.
and counting to a degree that is disruptive for the
individual
 to relieve anxiety and take up more than an hour per
day
 Patients with obsessive-compulsive disorder lack
spontaneity and their mood is often serious
 have formal, stiff, rigid behavior and lack sense of
humor
 their affect is not decreased in intensity or flat but can
be categorized as restricted
 may converse with unusually detailed answers
 are preoccupied with rules, orderliness, neatness,
details, regulations, and achievement of perfection
 capable of performing routine, prolonged work and
does not require changes to which they have an
incapability to adapt
 tend to alienate others, unable to compromise and
insist others to submit to their needs
 making mistakes, are indecisive and ruminate about
making decisions
 may have adequate occupational performance and a
stable marriage, but have few friends
1. Cognitive behavioral psychotherapy
2. Behavioral therapies
3. Medications.

Dosing

DRUGS Usual Therapeutic Dose

(mg/d)
Fluoxetine 20-60
Fluvoxamine 100-300
Paroxetine 20-60
Citalopram 20-60
Sertraline 50-200

Clinical Presentation
 fears of contamination and pathological doubt
PHARMACOTHERAPY

Antidepressant Agents
Drugs Absorp Protein T1/2 Metab Elimination
Binding
Serotonin Specific Reuptake Inhibitors (SSRIs)

Fluoxetine Well-absorbed 95% 1-3 days fluoxetine; 4-16 Norfluoxetine Urine

days
Its metabolite
Fluvoxamine Well-absorbed 80% 15 hours Inactive Urine
Paroxetine Well-absorbed 95% 21 hours glucuronide and sulfate conjugates Urine and feces

Citalopram Well-absorbed low 33 hours Active and inactive Urine as unchanged drug

Sertraline Slowly 98% 26 hours Inactive Urine and feces

absorbed
Tricyclic Antidepressants (TCAs)
CLOMIPRAMINE Readily 21 ho urs desmethylclomipramine Urine
  absorbed Clomipramine; 36 hours for
metabolite
Selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

VENLAFAXINE Readily 27% 5 hours parent drug; 11 hours O-desmethylvenlafaxine Urine as free or
  absorbed for its metabolite conjugated metabolites
DULOXETINE Well-absorbed 96% 8-17 hours Urine and feces

Monoamine Oxidase Inhibitors (MAOIs)

Phenelzine Readily may continue to have effects metabolize in the liver via monoamine oxidase Urine (primarily as
  absorbed 2 wk after stopping therapy (primary pathway) and acetylation (minor pathway) metabolites)
Augmenting Strategies

Lithium Completely 20-24hours; Urine (unchanged drug),

  absorbed 36 hours (elderly) feces, saliva, sweat

DRUG MOA DI ADR USE

Serotonin Specific Reuptake Inhibitors (SSRIs)
(SSRIs include anxiety, nervousness, sweating, nausea, decreased appetite, constipation, diarrhea, dry mouth, somnolence (sleepiness), headache, dizziness,
insomnia, and sexual dysfunction. Withdrawal of an SSRI may result in withdrawal symptoms)
Fluoxetine potent and highly selective Warfarin serious skin rashes, vasculitis, inc BP, seizures depression, bulimia, OCD,
  inhibitor of serotonin Digoxin panic disorder,
(5-HT) re-uptake Clopidogrel premenstrual
dysphoric disorder
(PMDD)
Fluvoxamine Like Fluoxetine Lithium asthenia (weakness), tremor, palpitations, anorexia, OCD
Diltiazem vomiting, flatulence, tremor, agitation, depression, CNS
stimulation, dyspnea, yawn, urinary frequency and
urinary retention

Paroxetine Like fluozetine; limited direct Cyproheptadine weakness, tremor, diaphoresis(excessive sweating), major depression, panic
action at muscarinic Phenytoin vasodilation, chest pain, palpitation, hypertension, disorder with or without
receptors CYP2D6 inhibitors tachycardia, unusual or severe mental/mood changes such agoraphobia, OCD,
and substrates
as agitation, abnormal dreams and thought of suicide, PMDD, dec. anxiety
Lithium
impaired concentration, yawning, amnesia, vertigo,
confusion, chills, rash, pruritus, dysmenorrhoea; anorexia,
dyspepsia, flatulence, abdominal pain, appetite increased,
taste perversion, weight gain, genital disorder, urinary
frequency, UTI, paresthesia, myalgia, back pain, myoclonus,
myopathy, myasthenia, arthralgia, blurred vision, abnormal
vision; tinnitus, respiratory disorder, pharyngitis, sinusitis,

Citalopram Like fluoxetine but with little
or no effect on
noradrenaline, dopamine
and GABA reuptake
Sertraline a potent and selective
inhibitory action on CNS
neuronal reuptake of 5-HT
Tricyclic Antidepressants (TCAs)
CLOMIPRAMINE a potent and selective
inhibitory action on CNS
neuronal reuptake of 5-HT
Selective Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)
VENLAFAXINE selectively inhibits the
  neuronal re-uptake of
serotonin, norepinephrine
and to a lesser extent
dopamine
DULOXETINE potent inhibitor of neuronal
uptake of serotonin and
norepinephrine;weak
inhibitor of dopamine
reuptake
Augmenting Strategies
Lithium unclear but it alters
intraneuronal metabolism of
catecholamines and sodium
transport in neurons and
muscle cells
rhinitis, infection, amount of urine
MAOI therapy increased sweating tremor, fatigue, asthenia, dizziness, OCD, panic disorder and
Warfarin abnormal accommodation, agitation, palpitation, rash, bipolar depressive
pruritus, abnormal vision, increased appetite, anorexia, disorder
apathy, suicide attempt, confusion, yawning, dyspepsia,
vomiting, abdominal pain, flatulence, increased saliva,
weight decrease or increase, postural hypotension,
tachycardia, rhinitis, fatigue, extrapyramidal disorders
Antimuscarinics anorexia, dyspepsia, flatulence, vomiting, increased depression, panic attacks,
Aripiprazole sweating, agitation, dizziness, fatigue, tremor, paraesthesia, OCD, post-traumatic
Warfarin rash, hot flushes and blurred vision stress disorder, social
phobia, and a severe form
of premenstrual syndrome
barbiturates dry mouth, constipation, and urinary retention a second-line drug for
Cimetidine OCD,depression, panic
Guanethidine disorder narcolepsy,
premature ejaculation,
haloperidol
depersonalization disorder
Phenothiazines cataplexy.
MAOIs  
Triptans include nausea, vomiting, anorexia, dry mouth, constipation, Depression, anxiety, social
Linezolid orthostatic hypotension, tremour, sweating, rash, anxiety, anxiety disorder, and
Lithium dizziness, fatigue, headache, syncope, insomnia, panic disorder
Tramadol somnolence, constipation, hyponatraemia, sexual
MAOI dysfunction, dyspepsia, visual disturbances, mydriasis,
Alcohol increased cholesterol concentrations, increased LFT Diabetic neuropathy,
5HT1 receptor Moderate to severe stress
agonists urinary incontinence in
women
MAOIs
Lithium
Tramadol or St
John's wort
carbonic psoriasis, acne and rash Mania, Bipolar disorder,
anhydrase nausea diarrhoea, vertigo, muscle weakness, loss of Recurrent unipolar
inhibitors concentration; tremors; hypothyroidism; wt gain, edema; depression
Chlorpromazine cardiac arrhythmias; exophthalmos; electrolyte disturbances.
Sodium- Fatal: severe neurotoxicity and leucopenia.
containing
preparations
Theophylline
Urea
MAOIs