6 - Obsessions and Compulsions and Obsessive-Compulsive Disorder | Manual of Psychiatric Therapeutics: Practical Psychopharmacology and Psychiatry (Little, Browns Paperback Book Series)

Editors: Shader, Richard I.

Title: Manual of Psychiatric Therapeutics, 3rd Edition

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Obsessions and Compulsions and Obsessive-Compulsive Disorder

Richard I. Shader

As with dissociative experiences and paranoid or suspicious ideation (see Chapter 4), obsessive thoughts and compulsive behaviors are experienced by a broad range of people; as transient symptoms and behaviors, obsessions and compulsions occur in most older children and adults. As enduring traits or as a style of functioning (i.e., obsessive-compulsive personality disorder [OCPD]), such patterns are quite familiar. Obsessions and compulsions in the form of obsessive-compulsive disorder (OCD) may occur in 2% to 3% of the general adult population; a smaller number of children and youth about 1% also have OCD (see Chapter 21). Westphal, who also coined the term agoraphobia (see Chapter 14), first described OCD in the late 19th century. In Europe, the term anancastic reactions is sometimes used to describe patients who feel compelled to think or to act in ways inconsistent with their will or reason.

OCD can be crippling to many patients; it can also be burdensome to their families. Imagine the disruptive effects on family life that are generated by someone who must frequently wash his or her hands or who spends hours trapped by a checking routine.

I. Obsessions and Compulsions: Definitions and Concepts

A. Obsessive Thinking

Obsessive thinking involves the recurrence of undesired or disquieting thoughts, images, or impulses that cannot be dismissed at will (i.e., usually a sense of struggle is present). The affected person knows that the intrusive thoughts originate from within, as opposed to being inserted from the outside as in some patients who have schizophrenia, but he or she typically finds them unacceptable and tries to resist or control them. This effort differentiates obsessives from depressives (see Chapter 18) and paranoids (see Chapter 4), who accept their thoughts and ruminations (i.e., repetitive thoughts that are more volitional and less ego dystonic than obsessional thinking) and who do not try to control them. Not all obsessive thoughts are intrusive or ego alien from the start. Some examples are a young man's obsessive thoughts of love for a particular woman who may or may not know that she is the object of desire or that of preoccupations with song fragments or nonsense words. Typically, however, these thoughts become more intrusive if they truly are obsessional thoughts and not transiently preoccupying concerns or ruminations.

Examples of obsessive thinking include recurrent feelings that one has to return home to check the lock on the door or that one is going to say something inappropriate in public. Obsessive thoughts are often experienced as senseless or untrue, which is a contrast to most delusional thoughts. Six of the following somewhat interrelated themes tend to be dominant: morality or religion; aggression; contamination or dirt; health and illness; orderliness or a need for symmetry; and sex, particularly shameful or degrading acts. These themes may be remembered by the mnemonic MACHOS. All these themes involve harm to oneself or others. Concerns about contamination by dirt, germs, or chemicals are by far the most common.

Obsessions are not simply overvalued ideas. Rarely does an obsessional person focus on just one issue or theme, and most of the time, as noted earlier, such thoughts are experienced as intrusive. Obsessions, therefore, stand in contrast to the isolated preoccupation with thinness (often referred to as being obsessed with thinness) that is not resisted by the patient with anorexia nervosa (see Chapter 8). Of interest is the fact that, for young women with anorexia nervosa to show a pattern of overdoing other things as well, such as studying or exercise, is not uncommon. A similar contrast can be drawn to the transsexual, who is described by some as being obsessed with feeling like a woman trapped

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inside a man's body. These conditions seem more like the fixed body image distortions of the patient with body dysmorphic disorder and delusional disorder, somatic type, (see Chapter 4) than like obsessional preoccupations.

B. Compulsive Acts

These involve repetitive, seemingly purposeful actions and behaviors carried out in a stereotyped manner that often appears to others to be ritual. The four common domains for these actions, which are referred to as the 4 Cs, are as follows: (a) Cleaning, especially handwashing or cleaning one's environment; (b) Checking, or concerns with safety; (c) Clothing, or dressing in a particular sequence or the methodical laying out of clothes; and (d) Counting, often in patterns or aloud. Many readers will remember the following verse: the man from St. Ives with his seven wives and their seven sacks containing seven cats with their seven kits kits, cats, sacks, wives counting can be fun except to a compulsive counter. Counting may be both an obsession and a compulsion (i.e., the mental act of counting is an obsession; counting softly aloud under one's breath is a compulsion). Compulsions are urges; rituals are the observable or external actions or behaviors, although they may be hidden or covert, such as in counting under one's breath. Compulsive acts have in common the theme of incompleteness avoiding harm by doing more. Examples that physicians may recognize include rereading laboratory reports and calling a pharmacy back to see if a prescription was filled out correctly. Compulsive face picking, a combination of cleaning and checking, is typically seen in adolescents and younger adults, particularly in young women.

II. Obsessive-Compulsive Personality Disorder

As was noted earlier, occasional transient obsessional thinking and infrequent or rare compulsive actions are not unusual in many children and adults. On the other hand, when these features are more prominent and they are characteristic of a person's style of dealing with life, the term OCPD applies. These patients often have a degree of compulsive perfectionism or orderliness that is maladaptive and that gets in their way because things have to be done so correctly that they do not get completed. Although this degree of perfectionism or orderliness may have been adaptive or previously pleasing to parents or teachers, the pattern now is self-defeating. Even so, these traits are still not unacceptable to the patient with OCPD.

Other traits of patients with OCPD include rigidity and inflexibility, valuing work over leisure activities, frugality, excessive conscientiousness, indecisiveness, obstinacy, preoccupation with unimportant or trivial levels of detail, hoarding or saving unimportant objects, and a stultifying morality that can verge on or meld into bigotry. Sometimes, these traits lead to manifest behavior that is inordinately slow. Obviously, not all patients have all these traits. When the patterns are less full blown, the patients may seem, at times, to function well; they are punctual, precise, dependable, and conscientious. Indeed these traits, when not excessive, may be seen as virtues or strengths that bolster the self-esteem. Patients with OCPD save money, appear stable in mood, and complete what they start. If I may refer to an old friend for whom punctuality was no less a predicate than existence . ¹

OCPD patients frequently have ups and downs in their symptoms over time. Exacerbations of dysfunctional symptoms and behaviors during and after periods of stress are common. Most patients with OCPD, however, do not go on to develop OCD. Although early studies did suggest that up to 50% of OCD patients had also had preexisting OCPD, many believe that a lower figure of 5% to 10% is more appropriate. Patients with OCPD, if they do decompensate, are more likely to shift into a mood disorder than to move into OCD.

III. Obsessive-Compulsive Disorder

A. Definitions and Concepts

OCD refers to a condition in which patients are plagued by obsessions or compulsions or both. Their obsessions and compulsions, as described earlier,

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are distressing, and they often interfere with relationships, work, and leisure activities. Attempts to contain and control these thoughts and behaviors are usually unsuccessful, and the failed effort itself usually produces increased anxiety.

The etiology of OCD is not known. Genetic factors may be involved. Concordance for OCD is more common in monozygotic twins than is nonconcordance; concordance is not common in dizygotic twins. The rate of OCD in the parents of OCD patients is 5% to 7%, more than double the 2% to 3% rate that is estimated for the general adult population. Overrepresentation of obsessive and compulsive symptoms and traits, often enough to fulfill the criteria for a diagnosis of OCD, is observed in male children and adolescents with Tourette disorder (see Chapter 7). Whether genetic determinants exist for this comorbidity (25% to 35% of male patients with Tourette disorder also meet the criteria for concomitant OCD) is not fully understood; some data suggest a common gene such that boys get Tourette disorder, and girls get OCD.

Neuroanatomic findings in OCD are varied. Some areas, however, seem consistently implicated, but no pattern of involvement is always present. Imaging studies reveal changes in the orbitofrontal cortex, caudate nuclei, thalamus, cingulate gyri, and parietal lobes.

The modal onset for OCD is earlier in males (between the ages of 6 and 15) than it is in females (between the ages of 20 to 29). A sudden onset can occur in adolescence, even with no prior history of symptoms or traits. One-third of OCD patients have an onset of the disorder before the age of 15 years. When OCD has its onset in childhood, it usually is seen between 3 and 15 years of age; boys have an earlier onset than girls. Onset after the age of 40 years is infrequent (less than 10%). That the age of onset is bimodal and that earlier onset is associated with more severe disease seems likely. Approximately 40% of adults place their onset of symptoms in childhood. Typical preonset stresses include pregnancy and childbirth, family deaths, and sexual failures, but 70% have no identifiable stressor that they can associate with the onset. Trichotillomania (compulsive hair pulling) has its onset in adolescence or young adulthood, and it occurs more commonly in women than in men.

OCD has a variable course. Some patients have an intermittent course, whereas others have a chronic course in which the severity waxes and wanes, even with an acute onset. Most patients will not improve spontaneously; fewer than 10% of patients have spontaneous remissions lasting more than 1 year. Severity ranges from mild annoyance to complete incapacitation. Many patients hide their disorder because their obsessions seem so silly, nasty, or horrific and because their ritualistic behavior appears so bizarre that they fear embarrassment, humiliation, or stigmatization should they be discovered. However, even with treatment-related decrements in the manifestations of OCD, about half still have enough dysfunction to qualify for an OCD diagnosis at 40 years after initial diagnosis. Early onset, particularly in males, tends to be linked to a reduction in degree of improvement.

Some patients have mostly obsessional symptoms, and others have mostly compulsions; the latter group tends to do more poorly. Furthermore, patients with more magical, stereotyped, odd, or bizarre obsessive thoughts tend to have poorer outcomes. Two useful scales for assessing OCD patients are the Yale-Brown Obsessive-Compulsive Scale and the Maudsley Obsessive-Compulsive Inventory.

B. Treatment and a Biologic Perspective

Treatment currently emphasizes specific psychopharmacologic and behavioral modalities, with psychosurgery being reserved for an exceedingly small number of severely ill patients who are unresponsive to medications and behavior therapy.

Pharmacotherapy. Clomipramine and all the selective serotonin reuptake inhibitors (SSRIs) marketed in the United States (with the exception of citalopram) are approved by the United States Food and Drug Administration for the treatment of OCD (Table 6.1). Citalopram has shown efficacy in published trials, but it is not currently approved

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for the OCD indication. Occasionally, patients respond well to other agents (e.g., trazodone, monamine oxidase inhibitors, lithium, buspirone). Combinations of this group of proserotonergic agents (e.g., buspirone added to fluoxetine, lithium added to clomipramine, citalopram added to clomipramine), when used for augmentation when a single agent has not proven effective, have also been beneficial to some refractory patients. Most clinicians start with an SSRI and then add in or switch to clomipramine when the response to the SSRI is not sufficient. Clomipramine typically has more adverse effects than the SSRIs.

TABLE 6.1. CURRENT MEDICATIONS FOR THE TREATMENT OF OBSESSIVE-COMPULSIVE DISORDER

Drug	Trade Name	Starting Dose (mg)	Range (mg)	Modal Dose (mg)
Clomipramine^a	Anafranil	25	150 250	150
Fluoxetine^b	Prozac	20	10 80	60
Fluvoxamine^c	Luvox	50	25 300	200
Paroxetine^d	Paxil	10	10 60	40
Sertraline^e	Zoloft	25	25 200	125
Citalopram^f	Celexa	20	10 60	60
^aFor ages 10 yr, may be dosed at 3.0 mg/kg/d up to 200 mg/d. ^bNot approved by United States Food and Drug Administration for children; in the author's experience, some adult patients may tolerate fluoxetine better if it is started at 5 mg/d (dissolving the capsule in water or apple juice). Also available as an oral solution of 20 mg/5 mL. Literature exists to support the use of fluoxetine in children. ^cFor ages 8 yr, start with 25 mg h.s. ^dNot approved by United States Food and Drug Administration for children; also available as an oral suspension of 10 mg/5 mL. ^eFor ages 6 yr, start with 25 mg h.s.; available as an oral concentrate of 20 mg/mL. ^fNot currently approved for obsessive-compulsive disorder; however, literature exists to support its use in both children and adults.

The theoretical value of these proserotonergic agents is supported by the research finding of increased cerebrospinal fluid levels of 5-hydroxyindoleacetic acid, a product of the metabolism of serotonin, in OCD patients. Moreover, metergoline, a serotonin antagonist, can promote relapse in treated patients or worsening in untreated OCD patients. Imaging studies increase glucose utilization (hyperactivity) in orbitofrontal and frontostriatal pathways in some persons who have OCD.

When large groups of OCD patients are treated with SSRIs or clomipramine, from 40% to 80% generally show improvement, with an overall reduction from baseline symptomatology of 25% to 50%. Some do quite well; others do not. No predictors of success exist, and the duration for pharmacotherapy has not been set with OCD. Many patients receiving pharmacotherapy alone relapse fairly promptly when the medication is discontinued. One approach to the duration is to continue pharmacotherapy (in the absence of side effects) until a suitable behavior therapy program can be initiated and is found to be effective. The medication dose is then tapered very gradually. In some refractory patients, augmentation of proserotonergic agents with lithium or low doses of an atypical antipsychotic agent may be beneficial.

For some patients, combining cognitive-behavior therapy (CBT) with medication that modifies serotonergic tone may result in a better outcome than either treatment alone. Some patients fail to comply with behavioral regimens (see section III.B.2). When CBT is not available or when it is ineffective, pharmacotherapy may need to be continued indefinitely,

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with thoughtful monitoring and follow-up to avoid long-term toxicity from drug accumulation.

Cognitive-Behavior Therapy. Effective CBT for OCD requires the following two techniques: exposure and ritual or response prevention. Exposure decreases anxiety and other forms of distress associated with obsessions, whereas response prevention decreases the time involved in a need for rituals. Anxiety management training may provide additional benefit. For children with OCD, family interventions (e.g., psychoeducation, avoiding inadvertent reinforcement of any rituals, habit reversal, behavioral rewards) (see Chapter 21) are useful.

As an example of behavior therapy, consider a patient who fears that, if he raises the toilet seat before he urinates, he may contract a human immunodeficiency virus infection, even in his own home. Being a considerate person, he regularly raises the toilet seat before urinating. Having done so, he can only quell his anxiety by then washing his hands for 5 minutes a ritual that he detests both because of the time that is consumed and the conspicuous nature of the ritual. Exposure therapy has him raise the toilet seat with his hand (instructing the patient to use his hand and to resist the temptation to use his shoe or a paper towel is important), thereby running the risk that he may get a human immunodeficiency virus infection (in reality, the probability of contracting it in this manner is virtually absent). His anxiety level predictably increases with this exposure task, and he is then asked to decrease his washing ritual to 4 minutes. Education and the support of the therapeutic relationship augment the patient's motivation to change and help him to bear the discomfort associated with this treatment approach. With repetition, both the anxiety about raising the toilet seat and the discomfort of reducing the ritual diminish, and the patient learns that he can control his anxiety without ritualizing.

About 25% of patients decline behavior therapy as too time consuming, too frightening, or too stressful. For the 75% who try to comply faithfully, about half will have at least a 70% reduction in the severity of their rituals and obsessions, and an additional 40% will have reductions of 30% to 69%. Sixty percent of patients treated with exposure and response prevention therapy maintain at least moderate gains for up to 6 years in follow-up, a striking contrast to the almost certain and relatively rapid relapse associated with pharmacotherapy alone (e.g., SSRIs or combinations of agents). To maintain the positive benefits from CBT over time, it is essential for patients to continue to practice the cognitive and behavioral strategies that have worked for them.

Relaxation, which is often taught as a technique for the reciprocal inhibition of anxiety, is actually an inert component of CBT. As a coping tactic that helps patients face the things they fear, it may be of indirect benefit. Some patients, by contrast, prefer rapid and complete exposure with no attempts to reduce or minimize anxiety, a technique known as flooding. The level of anxiety experienced, whether low or high, does not correlate with improvement.

Despite long traditions of the use of psychoanalysis, other nonbehavioral psychotherapies, and hypnosis to treat OCD, little nonanecdotal evidence exists to support the efficacy of these treatments when given alone (i.e., without medication or behavioral treatment). Their use should be reserved for those patients with OCD who have failed to respond to treatments that have been established as effective by controlled clinical trials. All patients deserve and benefit from supportive care in which they are provided with an explanation of their disorder, empathy for their emotional pain and suffering, and hope for improvement.

Finally, although scant and sometimes contradictory evidence for the effectiveness of electroconvulsive therapy (see Chapter 24) and anterior cingulate gyrus or limbic leucotomy exists, both have been used in
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severe cases of OCD. The effects of electroconvulsive therapy are at best modest and transitory. Leucotomy, which is reserved for severe or life-threatening self-injurious behaviors and which putatively acts through interruption of the thalamofrontal tracts, appears to produce full remission in a few instances. The use of leucotomy is consistent with the hypothesis that overactivity of the cingulate region (just dorsal to the corpus callosum) is associated with compulsive acts and behaviors. An obvious concern is whether these psychosurgical treatments cause significant decrements in overall mental functioning. Limited data suggest that, although certain frontal lobe functions may be compromised, global cognitive abilities remain comparable with those of nonsurgically treated patients with OCD.

IV. Clinical and Diagnostic Considerations

For a better understanding of this category of disorders, some additional comments are warranted. When obsessions and compulsions appear in their mildest forms, a defensive value may seem apparent. As in displacement, obsessions distract, preoccupy, and shift the focus from other, perhaps less bearable, sources of anxiety or distress. Most people can remember simple ritualistic games from childhood (e.g., avoiding stepping on cracks in the sidewalk, perhaps while reciting step on a crack, break your mother's back ). Rituals may mitigate fears of loss of control or concerns about rage and anger. In addition, one cannot, given the current limitations in knowledge about the pathophysiology of obsessions and compulsions, exclude the possibility that rituals are protective behaviors that have gone awry. Perhaps the ego perceived some subtle deficit in functioning, whether neurologic or otherwise, and instituted actions that were meant to reduce harm (e.g., checking); however, now that behavior is not under appropriate control or internal monitoring (e.g., a perseverative action in the presence of altered frontal lobe functioning). In any case, true OCD patients are in agony. The repetitive nature of their irresistible thoughts and behaviors causes so much suffering that any defensive or protective value, if indeed any exists, is lost. The automatic involuntary nature of these thoughts and actions seems quite tic-like at times. As a clinician who has had considerable experience with patients with varying degrees of obsessions and compulsions, the author is convinced of the clinical and theoretical value of seeing minimal to mild forms (those previously called neurotic ) as separate (i.e., not on a continuum) from OCD. A lack of linearity or a continuum of severity is also supported by the previously mentioned low frequency of OCPD in the histories of patients with OCD.

Finally, a contrast to simple and social phobias (see Chapter 14) seems in order. Phobias, like obsessions and compulsions, curtail freedom. In both, the patient is aware that the disquieting ideas, thoughts, or actions are generated from within and that they are unrealistic. The obsessive, as has been noted earlier, cannot control them. The compulsive would like to stop checking or counting or eating or not eating, but he or she cannot (e.g., Jack Sprat would eat no fat, his wife would eat no lean ). Simply willing oneself to stop, unless one is supported and enabled by a therapist as part of an exposure and response prevention program, typically produces incremental anxiety, at least initially. When an appropriate treatment plan is in place and when the symptoms are still at a level that can be helped by behavior therapy, the initial anxiety increment diminishes with practice, time, and the support of the therapist.

When a patient with simple phobia successfully avoids the feared object (i.e., if Miss Muffet could have avoided the spider all together), no overt anxiety or discomfort is present. Most simple phobias (i.e., phobias involving a specific feared object, situation, or location that can generally be avoided or encountered infrequently) produce little anxiety in everyday living. The patient with a simple phobia usually can be helped with progressive exposure to the fear-provoking stimulus, coupled with relaxation strategies. This is technically referred to as desensitization. The patient with a social phobia, however, cannot readily avoid his or her discomfort that surfaces in gatherings of people and that is linked to feelings of being observed, an expectation of being criticized, or worry about being

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embarrassed or doing something personally embarrassing. The socially phobic patient also has frequent anxiety and distress, but the suffering and disability are seldom as intense as what is felt by the patient with OCD.

Further information for patients and families may be obtained online at http://www.ocfoundation.org/ and http://www.adaa.org/.

ADDITIONAL READING

Angst J. The epidemiology of obsessive compulsive disorder. In: Hollender E, Zohar J, Marazziti D, et al., eds. Current insights in obsessive compulsive disorder. New York: John Wiley & Sons, 1994:93 104.

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Barr LC, Goodman WK, Price LH, et al. The serotonin hypothesis of obsessive compulsive disorder. Implications of pharmacologic challenge studies. J Clin Psychiatry 1992;53:17 28. Bejerot S, Bodlund O. Response to high doses of citalopram in treatment-resistant obsessive-compulsive disorder. Acta Psych Scand 1998;98:423 424.

Clomipramine Collaborative Study Group. Clomipramine in the treatment of patients with obsessive-compulsive disorder. Arch Gen Psychiatry 1991;48:730 738.

Cumming S, Hay P, Lee T, et al. Neuropsychological outcome from psychosurgery for obsessive-compulsive disorder. Austr N Z J Psychiatry 1996;29:293 298.

Degonda M, Wyss M, Angst J. The Zurich study. XIII. Obsessive-compulsive disorders and syndromes in the general population. Eur Arch Clin Neurosci 1993;243:16 22.

Dominguez RA, Jacobson AF, de la Gandara J, et al. Drug response assessed by the modified Maudsley obsessive-compulsive inventory. Psychopharmacol Bull 1989;25:215 218.

Flament MF, Rapoport JL, Berg CJ, et al. Clomipramine treatment of childhood obsessive compulsive disorder: a double-blind controlled study. Arch Gen Psychiatry 1985;42:977 983.

Goodman WK, Price LH, Rasmussen SA, et al. The Yale-Brown obsessive-compulsive scale. I. Development, use, and reliability. Arch Gen Psychiatry 1989;46:1006 1011.

Grados MA, Riddle MA. Pharmacological treatment of childhood obsessive-compulsive disorder: from theory to practice. J Clin Child Psychology 2001;30:67 79.

Greist JH. Treatment of obsessive compulsive disorder. Psychotherapies, drugs, and other somatic treatments. J Clin Psychiatry 1990;51:44 50.

Hewlett WA, Vinogradov S, Agras WS. Clomipramine, clonazepam, and clonidine treatment of obsessive-compulsive disorder. J Clin Psychopharmacol 1992;12:420 430.

Hewlett WA, Vinogradov S, Agras WS. Clonazepam treatment of obsessions and compulsions. J Clin Psychiatry 1990;51:158 161.

Jenike MA, Baer L, Summergrad P, et al. Sertraline in obsessive-compulsive disorder: a double-blind comparison with placebo. Am J Psychiatry 1990;147:923 928.

Jenike MA, Hyman S, Baer L, et al. A controlled trial of fluvoxamine in obsessive-compulsive disorder: implications for a serotonergic theory. Am J Psychiatry 1990;147:1209 1215.

Karno M, Golding JM, Sorenson SB, Burnam MA. The epidemiology of obsessive-compulsive disorder in five US communities. Arch Gen Psychiatry 1988;45:1094 1099.

Kronig MH, Apter J, Asnsi G, et al. Placebo-controlled multicenter study of sertraline treatment for obsessive-compulsive disorder. J Clin Psychopharmacol 1999;19:172 176.

Leonard HL, Swedo SE, Rapoport JL, et al. Treatment of obsessive-compulsive disorder with clomipramine and desipramine in children and adolescents. A double-blind crossover comparison. Arch Gen Psychiatry 1989;46:1088 1092.

Levine R, Hoffman JS, Knepple ED, Kenin M. Long-term fluoxetine treatment of a large number of obsessive-compulsive patients. J Clin Psychopharmacol 1989;9:281 283.

March JS, Biederman J, Wolkow R, et al. Sertraline in children and adolescents with obsessive-compulsive behavior: a multicenter randomized controlled trial. JAMA 1998;280:1752 1756.

McDougle CJ, Goodman WK, Price LH. Dopamine antagonists in tic-related and psychotic spectrum obsessive compulsive disorder. J Clin Psychiatry 1994;55:24 31.

Montgomery SA, Kasper S, Stein DJ, et al. Citalopram 20 mg, 40 mg, 60 mg are all effective and well tolerated compared with placebo in obsessive-compulsive disorder. Int Clin Psychopharmacol 2001;16:75 86.

Murphy DL, Pigott TA. Obsessive-compulsive disorder. Treatment with serotonin-selective uptake inhibitors, azapirones, and other agents. J Clin Psychopharmacol 1990;10:91S 100S.

Perse TL, Greist JH, Jefferson JW, et al. Fluvoxamine treatment of obsessive-compulsive disorder. Am J Psychiatry 1987;144:1543 1548.

Price BH, Baral I, Cosgrove GR, et al. Improvement in severe self-mutilation following limbic leucotomy: a series of 5 cases. J Clin Psychiatry 2001;62:925 932.

Price LH, Heninger GR. Lithium in the treatment of mood disorders. N Engl J Med 1994;331:591 598.

Rasmussen SA, Eisen JL. Epidemiology of obsessive compulsive disorder. J Clin Psychiatry 1990;51:10 13.

Skoog G, Skoog I. A 40-year follow-up of patients with obsessive-compulsive disorder. Arch Gen Psychiatry 1999;56:121 127.

Tippin J, Henn F. Modified leukotomy in the treatment of intractable obsessional neurosis. Am J Psychiatry 1982;139:1601 1603.

Trivedi MH. Functional neuroanatomy of obsessive-compulsive disorder. J Clin Psychiatry 1996;57:26 35.

Turner SM, Jacob RG, Beidel DC, Himmelhoch J. Fluoxetine treatment of obsessive-compulsive disorder. J Clin Psychopharmacol 1985;5:207 212.

Westphal C. Dwangforstellungen. Arch Psych Nervenkr 1878;8:734 750.

Zohar J, Insel TR, Zohar-Kadouch RC, et al. Serotonergic responsivity in obsessive-compulsive disorder: effects of chronic clomipramine treatment. Arch Gen Psychiatry 1988;45:167 172.

¹Tom Stoppard describing Bertrand Russell; Jumpers. New York: Grove Press, 1972:25.