Disease Description (Causes and Symptoms)
- Definition summary: A disorder in the anxiety-disorder spectrum in which certain thoughts (obsessions) or behaviors (compulsions) are repeatedly experienced or performed against the person's will, interfering with daily life.
- Causes and pathophysiology: The exact cause is unclear, but genetic, biological, and environmental factors are thought to act in combination. Neuroimaging and medication studies have found that specific neural circuits in the brain (the prefrontal cortex–basal ganglia–thalamic circuit) and abnormalities in the serotonin system may be involved.
- Main symptoms:
- Obsessions: Unwanted intrusive thoughts (related to contamination, violence, sex, religion, etc.) repeatedly come to mind and cause anxiety.
- Compulsions: Behaviors intended to temporarily relieve anxiety, such as handwashing, repeated checking, arranging and organizing, or specific ritualistic actions.
- Symptom characteristics: Although compulsions provide temporary relief, they increase anxiety and time consumption in the long term, causing functional impairment.
- Diagnostic criteria (clinical indicators): Obsessive-compulsive disorder should be suspected when a person spends an average of at least 1 hour per day on obsessive-compulsive symptoms or experiences significant impairment in social, occupational, academic, or interpersonal functioning.
Treatment Methods
- Standard treatment
- Cognitive behavioral therapy (especially exposure and response prevention: ERP): The patient is gradually exposed to anxiety-provoking stimuli and trained to suppress compulsive behaviors (responses), thereby promoting symptom relief. This is one of the primary recommended treatments.
- Medication: Serotonergic antidepressants (SSRIs: fluoxetine, sertraline, fluvoxamine, paroxetine, etc.) and the non-selective agent clomipramine (TCA) are effective. Some effects are generally observed within 4–6 weeks, while the full effect may take up to 8–16 weeks. Because medication response and side effects vary between individuals, ongoing follow-up and adjustment are necessary.
- Medication-related considerations
- Although treatment effects vary between individuals, approximately 50–75% of patients may improve with medication treatment.
- Because the risk of relapse is high when medication is discontinued, long-term maintenance therapy may be required.
- The side effects of SSRIs/clomipramine (sexual dysfunction, gastrointestinal symptoms, sleep disturbances, sedation, anticholinergic effects, etc.) should be explained and managed.
- Treatment of refractory cases
- For cases that do not respond to medication or behavioral therapy (approximately 20–30%), surgical interventions (partial disconnection of portions of the frontal lobe or limbic system, such as partial cingulotomy) or deep brain stimulation (DBS) may be considered. The response rate to surgical treatment is limited (improvement has been reported in approximately 30–40% of cases), so careful selection is necessary.
- Lifestyle management and supportive approaches
- Stress management, regular sleep and exercise, and avoidance of alcohol and substance misuse.
- Family education and family support and environmental adjustment (excessive assistance or accommodating behaviors may contribute to maintaining symptoms).
- Complications and precautions
- If left untreated, depression, other anxiety disorders, eating problems, substance misuse, and functional impairment (occupational or academic difficulties and social isolation) may occur.
- In children and adolescents, comorbid conditions such as tic disorders may affect the treatment plan.
Outpatient Visit Checklist (Examples of Items to Prepare and Medical History Questions)
- Items to prepare
- A list of currently used medications (including prescriptions, OTC medications, and herbal medicines) and the times they are taken
- History of previous medication and psychotherapy (medication names, effects, side effects, and reasons for discontinuation)
- A record of major symptoms (when symptoms began, types and frequency of symptoms, time spent per day), aggravating and relieving factors
- Comorbid conditions (depression, anxiety disorders, tics, autism spectrum disorder, etc.) and family history
- Information about any self-harm or suicidal thoughts
- Examples of questions the clinician may ask during the outpatient visit
- When the symptoms began and how they have progressed
- Specific effects of obsessions/compulsions on daily life (work, school, interpersonal relationships)
- Recent medication use and expectations regarding treatment
- Stressors and alcohol or substance use
Examples of General Questions to Ask the Doctor
- How long will it take for the expected effects to appear when taking this medication (or receiving this treatment)?
- What are the main side effects of the medication, and how should they be managed if they occur?
- Is there a risk of relapse if I stop taking the medication? How long is maintenance treatment recommended?
- How will ERP or other psychotherapy be conducted, and how many sessions will be needed?
- What are the indications and risks of surgical treatment (or invasive treatment)?
- How should treatment be adjusted during pregnancy or breastfeeding, or when planning a pregnancy?
Examples of Disease-Specific Questions
- How will my compulsive behaviors (e.g., repeated checking/handwashing) specifically be addressed through exposure and response prevention in ERP?
- My symptoms began in childhood and are accompanied by tics (or autism spectrum disorder). How will the choice or sequence of medications and treatments differ?