Obsessive-compulsive disorder (obsessive-compulsive disorder)

Always wash your hands, check ten times to see if the door is locked - stressful compulsive actions and thoughts are typical symptoms of an obsessive-compulsive disorder

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Obsessive-Compulsive Disorder - Briefly Explained

Obsessive-compulsive disorder (obsessive-compulsive disorder) is a common mental disorder. Those affected have to repeatedly follow certain actions or trains of thought, although these are usually perceived as nonsensical or stressful. Such compulsions can affect one's entire life. Why obsessive-compulsive disorder develops is not yet fully understood. Psychological and organic factors seem to work together. The diagnosis is made based on the typical symptoms. The main therapy options are cognitive behavioral therapy, but also medication - a combination of the two methods is also used. The treatment usually helps to reduce the obsessive-compulsive symptoms to a tolerable level, but they usually cannot be completely banished. But there is a significant improvement in the quality of life.

What is Obsessive Compulsive Disorder?

Obsessive-compulsive disorder is characterized by repetitive unwanted thoughts and / or actions. Those affected mostly know about the nonsense, but are not in a position to forego the ritualized actions that have a short-term relief. A distinction is made between compulsive actions, obsessive thoughts and compulsive impulses. Frequent obsessive-compulsive disorders are washing, control or order compulsions.

The transition from "normal behavior" to obsessive-compulsive disorder is fluid: Most people know the feeling of wanting to double-check whether you have actually switched off the iron. If someone has an obsessive-compulsive disorder, this need becomes an unrepressible compulsion. The person concerned cannot help but to control again and again - or to carry out certain actions or to pursue stereotypical lines of thought.

Obsessive-compulsive disorder is the fourth most common mental disorder. Around two to three percent of all adults in Germany will suffer from more or less pronounced obsessive-compulsive disorder in the course of their lives. However, it is estimated that the actual number of sick people is higher. Because those affected often only see a doctor when the obsessive-compulsive disorder significantly interferes with everyday life. The first obsessive-compulsive symptoms often appear in childhood and adolescence. The incidence in children and adolescents is around one to three percent. 85 percent of the time, the disease occurs before the age of 30, and onset after the age of 40 is rare. In adulthood, women seem to have a somewhat higher risk of developing the disease, whereas in children, the male gender is more likely to be affected.

What is an obsessive-compulsive personality?

The obsessive-compulsive personality must be differentiated from obsessive-compulsive disorder: Here it is less the person affected who suffers, but rather those around him. People with an obsessive personality are often perceived as pedantic, neat, tidy and in love with rules. However, those affected do not experience their character traits as exaggerated and their compulsiveness as meaningless. Therefore, they are seldom willing to seek treatment for it.

This is where the crucial difference lies. People with obsessive-compulsive disorder usually know that their compulsions are futile, at least at the beginning of the compulsions. However, they are not able to suppress this in the long term and therefore often suffer extremely from the increased expenditure of time, the accompanying fears and the limitations of everyday life as a result of their compulsions.

Eight to 29 percent of people with obsessive-compulsive disorder also have obsessive-compulsive personality disorder.

Symptoms: how are obsessive-compulsive disorder manifested?

How are compulsive acts and compulsive rituals expressed?

A person concerned feels an inner compulsion to have to perform certain actions - although he knows that they are nonsensical or at least strongly exaggerated. For example, he checks ten times in a row whether the front door is locked - even though he knows that he has closed the door. Nevertheless, he has to repeat the action in a stereotypical manner until he finally feels reasonably safe. Doctors speak of compulsory control.

Compulsive acts usually follow self-defined "rules". They are therefore also called compulsory rituals. For example, someone affected touches each hotplate individually in a precisely defined sequence in order to feel whether the hotplates are all cold - i.e. whether the hob is really off. Often you have to count and repeat the whole process. This ultimately creates a complex ritual that "must" be followed exactly. If "errors" occur, it has to start over. Otherwise - this is how it feels to the person affected - there is a risk of a self-inflicted catastrophe.

Most often, such compulsions relate to issues such as order, cleanliness, control, or neatness. Affected people fear, for example, of becoming terminally ill (for example from HIV) or of causing irreparable damage. In the case of compulsory washing, for example, those affected feel the urge to wash their hands over and over again or to shower for hours.

If those affected try to suppress the actions, fear or tension arise, and many also experience a feeling of disgust. The compulsive actions serve to reduce these unpleasant feelings in the short term and to regain more security.

In the long term, however, constraints lead to even greater uncertainty. Often they severely restrict life. Because those affected avoid more and more situations that could trigger compulsions. For example, a person with compulsory control no longer uses his stove at all in the further course of the disease so that after it has been used, he does not have to check whether it is switched off.

What are obsessive-compulsive thoughts?

Obsessive thoughts are ideas, conceptions or impulses that impose themselves against the will of the person concerned. They are experienced as very uncomfortable or distressing. For example, the bad thought suddenly comes to mind of injuring or even killing someone close to you. For example, a driver thinks he might hit a pedestrian on the side of the road. A mother thinks she could suffocate her beloved baby with the pillow.

An extreme form of doubt (pathological doubt), the overestimation of personal influence or one's own responsibility and the loss of confidence in one's own perception ("Have I really turned off the stove?", "Do I have someone right now?" immorally touched? "). It is not uncommon for connections to be made between actions or events which, according to "common sense", cannot be related, for example averting a fate through a certain number of repetitions or a certain arrangement of objects (magical thinking).

Such thoughts trigger feelings of fear and shame and often lead to avoidance behavior: those affected try to avoid situations in which such thoughts occur. There is usually no risk that the person concerned will actually carry out the feared action. On the contrary: These thoughts, which often concern aggressive, sexual or blasphemous content, are mostly alien to those affected and are more a result of perfectionism and excessive moral standards. The often extremely shameful and threatening quality of these thoughts (for example: "I could be a pedophile") is often responsible for the fact that many affected people only trust their caregivers or professional help and receive help after many years of uncertainty and withdrawal.

Mental rituals

In addition to obsessive thoughts, there are also mental rituals: They serve those affected to "neutralize" obsessive thoughts again. An example: First, an aggressive or blasphemous obsession comes to mind. As a consequence, a prayer "must" be said internally so that the fear and tension subside. For example, some patients "have" to recite certain formulas to prevent misfortune from happening to relatives.

Compulsions to brood, on the other hand, are typical of severe depression. Those affected think for hours about the same content - for example previous mistakes or money worries. This ruminating tends to subside as the depression is treated and resolved.

Compulsions are felt to be nonsensical

An essential symptom of compulsions: those affected know that their compulsive actions or obsessive thoughts are actually nonsensical. They are not perceived as pleasant. They impose themselves. Those affected experience their own actions as absurd, exaggerated, unnecessary, strange and disturbing.

However, if they try to refrain from an obsession, they experience an uncomfortable and growing feeling of fear, tension and restlessness. Ultimately, they have to do the action when they really don't want to. The intellect says "everything is okay", but the feeling of security does not want to set in ("not-just-right feeling"). Many people worry that they are gradually losing control of their thoughts and actions.

Those affected usually have Not the feeling that the constraints come from outside, that is, were imposed by the environment. The compulsions are experienced as "self-made", that is, as one's own thoughts and belonging to one's own person.

Compulsions can dominate everyday life

A pronounced compulsion can significantly affect everyday life. In extreme cases, for example, patients are no longer able to leave the house or do a regular job. They spend the whole day indulging in their compulsions or thoughts.

Many do not know that there is a disease behind their symptoms. Instead of asking a doctor for advice, feel ashamed of their nonsensical behavior and try to hide their problems.

Most of the time, however, compulsions do not improve on their own - on the contrary. Often they spread to more and more situations in life, taking up more and more time. It is more difficult to maintain work and social contacts. Family members and friends often react with incomprehension.

Special features in children and adolescents

According to a widespread opinion, affected children and adolescents, unlike adults with obsessive-compulsive disorder, are more likely to lack insight into the nonsense and resistance to compulsions. More recent studies seem to refute this. However, massive family impairments very often occur, and family members are included in the coercive system. As a rule, children and adolescents with compulsions do not seek treatment independently and less often voluntarily, often only under pressure from desperate parents and family members. As a result of obsessive-compulsive disorders that are specifically diagnosed and treated earlier, often only after years, there is a significantly increased risk of sustained impairment of social, emotional and academic development.

Case studies on obsessive-compulsive disorder

Example 1:

A 32-year-old woman, mother of one child, reports that she had always been very tidy as a child and paid more attention to cleanliness. After the birth of her child at the age of 28, strong fears arose that she could harm her child with bacteria. There were strong washing and cleaning compulsions (like washing hands 100 times a day, constant changing of clothes). Everyday life was also influenced by constant monitoring. Possible "sources of infection", such as playgrounds, were avoided or checked to see whether there was dog feces somewhere when going for a walk. She has not been able to practice her job as a doctor's assistant for years because the job had increased fears of coming into contact with germs and bacteria. As a result, she was then unable to work. Her daughter was also involved in the compulsive acts, so that her everyday life was severely impaired and she suffered from her mother's constraints. The daughter also had to clean herself excessively, and many situations (for example going to the playground) were avoided.

Example 2:

A 23-year-old student who is rather shy and fearful reports that she has had OCD for 12 years. At that time she was very afraid of not making the transition to high school and learned too much for fear of disappointing her parents otherwise. She also suffered from compulsory rituals. She was only allowed to enter rooms with her right foot first, otherwise she could get poor academic results. In the course of the following years, various compulsions, especially when washing and showering, arose. She has to shower 3 hours a day and wash her hands 30 times, the number 3 is a magic number. She cannot touch things that other people have already held in their hands. If this happens anyway, she has to practice her washing rituals. The fears are so strong that they can no longer go to university, no longer drive a car or use any means of transport. Almost the entire everyday life is determined by the constraints. As a result of the compulsions, she has become very depressed, feels worthless, useless and helpless.

Example 3:

A 23-year-old student reports that he has had compulsions since he was 11. At that time, his father suddenly died. With the transfer to high school, the first compulsions with magical thinking and repetition compulsions began. For example, he was no longer able to write certain letters as this could lead to an accident. In the years that followed, the constraints were always strongly pronounced. After another death in the family, the obsessive-compulsive illness worsened.

He currently suffers from various compulsions to control and magical thinking. He is afraid that if he does not practice certain rituals, other people could die. When driving a car, the thought arises that someone might have run over them so that they no longer drive the car.

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Causes: what causes obsessive-compulsive disorder?

What exactly causes obsessive-compulsive disorder has not been fully researched. Hereditary predisposition obviously plays a role, as well as psychological and biological factors. In addition, the individual "brain chemistry" seems to have a decisive influence. Mostly an interaction of several factors is necessary, which are individually different.

Brain messenger substances out of balance?

A disturbance in the balance of neurotransmitters is also discussed as a cause of obsessive-compulsive disorder. Neurotransmitters are messenger substances that transmit signals between nerve cells. There are different types of neurotransmitters. Serotonin and dopamine are particularly interesting for the activities in the brain that occur in obsessive-compulsive disorder. Both messenger substances also play a role in depression and are jointly responsible for mood, impulsivity, sexuality and anxiety, among other things.

Imaging procedures (MRT and PET examinations) showed a change in certain areas of the brain in those affected, but the extent to which these changes are the cause or consequence of the disease cannot be said with certainty.

The causes may also be found in disorders of the so-called basal ganglia in the brain. They are located in the right and left hemispheres below the cerebral cortex and, among other things, control movement sequences. If their function is disturbed, the interaction between a movement impulse and the associated movement may no longer work properly.

Hereditary factors play a role

A hereditary factor appears to increase the risk of obsessive-compulsive disorder. Obsessive-compulsive disorder is more common in families. In addition, results from twin studies suggest that genetic causes play an important role. In twin studies, identical twins are compared with dizygotic twins with regard to differences in their risk of disease. In this way, it is possible to find out what proportion genetic and environmental factors have on the development of diseases.

Environmental factors

Serious traumatic experiences, such as sexual assault or experiences of violence that are associated with intense fear and disgust, can also play a role in the development of obsessive-compulsive symptoms. In addition, compulsions can develop as a result of neurological brain injuries, strokes, or traumatic brain injuries. Recent studies show that in some of those affected, infections in childhood, especially streptococci, are a possible trigger. Large registry studies from Scandinavia showed that children with a positive strep test were at higher risk of developing compulsions or tics later than if they had a negative strep test.

According to the latest findings, severe childhood infections and autoimmune diseases generally play a causal role in that they can increase the risk of mental illnesses and obsessive-compulsive disorder.
In some studies, the birth of a child has also been shown to be the trigger for an obsessive-compulsive disorder.

Psychological causes

Experts assume that certain factors in upbringing or personal learning experiences contribute to the development of compulsions. These include, for example, excessive toilet training and an anxious parenting style. People with coercion also frequently report early physical and emotional neglect and early loss of caregivers, for example an early death of a parent. For many of those affected, fear of separation and loss play a role, especially in the case of compulsions to collect (pathological hoarding, in English "hoarding disorder").

High performance expectations and great severity can make people insecure and cause those affected to be very strict with themselves later in life, becoming perfectionist in order to avoid mistakes. A lack of experience of security and affection can lead to a lack of skills in dealing with negative thoughts and feelings, which is characteristic of many obsessive-compulsive disorders, combined with a reduced tolerance for unpleasant thoughts and feelings. Therefore, adults with obsessive-compulsive disorder very often display anxious, insecure and perfectionist traits.

How do the compulsions develop?

Experts assume that learning mechanisms (conditioning) are of central importance when compulsions arise: An originally neutral stimulus - for example dirt - is coupled with a very unpleasant experience that is associated with fear and tension. This link is called classical conditioning.

Later, the sight or the idea of ​​dirt creates fear and tension. Those affected learn to relieve internal tension by washing and cleaning and to feel better for a short time (negative reinforcement). But the relief only lasts until the next stimulus. In the long term, compulsive acts will become more and more frequent and complex, and doubts and uncertainty will increasingly determine everyday life.

Diagnosis: How is Obsessive Compulsive Disorder diagnosed?

In a detailed discussion, the doctor inquires about the exact symptoms and asks about your personal medical history.

Obsessive-compulsive disorder is when compulsive acts and / or obsessive-compulsive thoughts are so pronounced that they affect the life of those affected. It is then advisable to contact a specialist in psychiatry and psychotherapy, a specialist in psychosomatic medicine and psychotherapy or a licensed psychological psychotherapist. He can check the diagnosis. Is it really an obsessive-compulsive disorder? Or are the obsessive-compulsive symptoms signs of another mental disorder?

The following characteristics are typical of obsessive-compulsive disorder:

  • The compulsions and thoughts or impulses have been occurring for at least two weeks, and most days thereof.
  • The compulsions are perceived as tormenting and / or pointless.
  • Everyday life is affected by the compulsions.
  • Obsessive thoughts and impulses are assigned to one's own person, so they are not experienced as "foreign" or "made from outside".
  • Resistance / failure will lead to inner restlessness and fear.

Certain questionnaires (Yale-Brown Obsessive-Compulsive Scale, Y-BOCS) are used to ask about symptoms of obsessive-compulsive thinking and compulsive behavior.

A thorough physical exam is important. Because sometimes organic causes are responsible for the symptoms observed. For example, compulsions occur more frequently in certain neurological diseases. Sometimes an EEG examination or magnetic resonance imaging (MRI) of the skull is necessary to rule out other diseases.

The specialist or psychotherapist must differentiate between other diseases

The specialist or licensed psychotherapist will try to rule out other psychological disorders as the cause, for example a personality disorder. Schizophrenia or depression can also sometimes resemble and be confused with obsessive-compulsive disorder.

Obsessive-compulsive symptoms often occur in both diseases. The main difference to obsessive-compulsive disorder, however, lies in the perception of obsession: The obsessive-compulsive thoughts are perceived as stressful in depression and schizophrenia, but usually not as superfluous or pointless as in an obsessive-compulsive disorder. Mental illnesses such as depression or an anxiety disorder can occur together with obsessive-compulsive disorder.

Comorbidities in obsessive-compulsive disorder (comorbidity):

  • Anxiety disorder
  • Mood swings, especially depression
  • obsessive-compulsive personality disorder (see above)
  • Tic disorder
  • schizophrenia
  • Eating disorder
  • Tourette syndrome

Background information - Obsessive-compulsive spectrum disorder

Obsessive-compulsive spectrum disorders are a range of mental disorders that have in common the repetitive nature of actions and the inability to suppress inappropriate impulses or behaviors.

Obsessive-compulsive spectrum disorders include, for example, compulsive scratching of the skin ("skin picking") or compulsive pulling out of hair ("trichotillomania"). The pathological hoarding and collecting ("Messie Syndrome") and pathological preoccupation with one's own body image ("body dysmorphic disorder") as well as one's own health ("hypochondriacal disorder") will be counted as compulsive spectrum disorders in the future nomenclature. Neuropsychiatric diseases such as tic disorders or Tourette's syndrome are also part of the compulsive spectrum.

Therapy: How is Obsessive Compulsive Disorder Treated?

The therapy for obsessive-compulsive disorder is individual and depends on the severity and type of the disorder. Psychotherapeutic (behavioral) treatment and drug therapy come into question. Often both are combined.

The involvement of the family is mandatory for children and young people. Even with adult OCDs, the involvement of partners and family members is usually useful or even necessary.

Most effective therapy: cognitive behavioral therapy

The most effective form of treatment is cognitive behavioral therapy (CBT) with

Therapeutically accompanied exposure (triggering stimulus or thought is presented) and reaction management ("how did I react to it?", "how could I still react?"). This form of therapy is particularly helpful when the compulsive actions are in the foreground and at the same time there is no other severe mental disorder such as severe depressive symptoms, psychosis or post-traumatic stress disorder.

How does cognitive behavioral therapy work? Put simply, with the support of a therapist, the person affected exposes himself step by step to precisely those stimuli or situations that usually trigger his compulsions (exposure). In doing so, the patient learns alternative ways (reaction management) of dealing with the feelings (emotions) that arise and experiences a review of the beliefs and fears involved in maintaining the compulsions (for example, the fear that the emotions triggered could not be endured or could never go away) . This requires a great deal of cooperation from the patient. He has to make a conscious choice to experience even more fear and tension temporarily. It makes no sense if he is forced to do so or to participate for the sake of his therapist. Because the patient must later implement the exercises independently in his everyday life.

Direct therapist support is often difficult here. The Internet can then provide a remedy by providing the patient with professional video support (Internet-based therapy).

Intensive preparation with a precise behavior analysis is a prerequisite for cognitive behavioral therapy. Therapist and patient examine in which situations the compulsions occur and with which thoughts and feelings they are associated. In the further course of the specific treatment of obsessive-compulsive disorder, the person concerned learns to understand what function the obsessions have for him.

Newer therapy methods: mindfulness-based and metacognitive therapy

In the classic and scientifically best proven cognitive behavioral therapy (CBT), the following strategies are in the foreground (see above):

- Uncovering and confrontation with the triggering stimuli (exposure of compulsions)

- Reduction (reduction) of compulsive acts

- Processing of faulty thoughts and beliefs

In contrast, acceptance-based therapy methods primarily aim to promote an accepting action in relation to unpleasant thoughts and feelings (emotions).

Mindfulness-based exercises (mindfulness therapy) from the field of Acceptance Commitment Therapy (ACT) and Mindfulness-based Stress Reduction (MBSR) have also proven themselves in the treatment of obsessive-compulsive disorder. For example, those affected are instructed to adopt an accepting and present-day attitude towards their obsessive thoughts. Very often the result of the therapy shows a significantly improved tolerance of those affected towards their unpleasant thoughts and feelings. These are now accepted as a natural part of life.

Metacognitive therapy is another method specifically used in the treatment of compulsions. The focus here is on the central importance of (faulty) beliefs about the ability to be influenced and the consequences of one's own thoughts ("meta" thoughts). In everyday behavior experiments and exposures, one's own thoughts are checked. For example, obsessive-compulsive thoughts are often associated with the belief that one's own thoughts can be threatening and should therefore be controlled, suppressed, or avoided. Practical exercises accordingly focus on checking and correcting these often erroneous beliefs.

Scientific studies have so far not been able to show any superiority of these newer therapy methods instead of or in addition to classic strategies of cognitive behavioral therapy. However, promising clinical experience shows that an exposure treatment of compulsions supplemented by mindfulness-based exercises and strategies of metacognitive therapy can lead to an overall improved attention and emotion regulation, a calmer posture in everyday life as well as an improvement in mood and better sleep in relation to compulsion.

Therapy with drugs

Drugs from the group of antidepressants (selective serotonin reuptake inhibitors - SSRI and non-selective serotonin reuptake inhibitors - clomipramine) can reduce compulsions. The active ingredients strengthen the effect of the messenger substance serotonin in the brain. They are prescribed for depression, but are also used for obsessive-compulsive disorder, usually in higher doses. The dosage is determined by the attending physician.

Symptoms decrease in almost half of the patients treated with SSRIs. The overall effect is only moderately pronounced. However, the effect only occurs after six to eight weeks. If the drugs help, they are usually prescribed for a year or two.

The earlier belief that serotonin reuptake inhibitors are not addictive needs to be questioned recently. There is no fear of addictive behavior in relation to the use of antidepressants, but withdrawal symptoms can occur over weeks or even months and even possible so-called rebound phenomena (the latter has not yet been adequately researched). Rebound phenomena are a temporary increase in symptoms, which can even go beyond the extent before the start of treatment. When stopping the medication, it should definitely be done very carefully and in small steps over a longer period of time. When it comes to side effects, a distinction must be made between those that occur at the beginning: these include, for example, nausea and vomiting, diarrhea, sleep disorders, loss of appetite and restlessness. With long-term use, these side effects are usually no longer relevant or at least subside. Decreased sexual functions (such as decreased libido, erectile dysfunction and ejaculation disorders) are very common. Weight gain is also more common than previously thought. Based on these new findings, greater attention should be paid to using psychotherapy for obsessive-compulsive disorder and only using SSRIs when psychotherapy is not sufficiently effective or is not available. The non-selective serotonin reuptake inhibitor clomipramine has a similar spectrum of side effects as SSRIs, but causes other side effects such as dry mouth. Patients should seek detailed advice from their doctor on the effects and possible side effects.

The chances of success of the treatment are different. Obsessive-compulsive disorder often cannot be completely eliminated. Most of the time, however, the compulsions can be reduced to a more tolerable level. Overall, this can lead to a significant improvement in the quality of life.

Support groups

In self-help groups, patients and their relatives have the opportunity to exchange ideas with other affected persons. They can find support and help each other. The German Society for Obsessive Compulsive Diseases e.V .: http://www.zwaenge.de/therapie/frameset_therapie.htm, for example, provides information, addresses and current literature recommendations

Treatment options: outpatient or inpatient therapy?

Anyone who is affected by obsessive-compulsive disorder should inform themselves about the clinical picture, because only a knowledge and understanding that compulsions are pathological phenomena can have a very relieving effect. If you are affected, we wish and hope that reading this information will help you. Anyone who would like to find out more about this can now access a large number of good guides that have been written by experts.

If this is not enough, that is, life is clearly impaired by the compulsions, therapy is recommended. The therapy of choice is cognitive behavioral therapy. Basically, outpatient therapy should be attempted first. It would be best here if the therapist (behavior therapy) has a lot of experience in treating obsessive-compulsive disorder. If you want to get information on this, you can contact the German Society for Obsessive Compulsive Diseases e.V., which can give you recommendations for therapists.

If this is not enough, inpatient or partial inpatient treatment is recommended. More intensive psychotherapy for obsessive-compulsive disorder can be offered as part of inpatient or partial inpatient treatment. Here, too, it is recommended to choose a clinic with a corresponding focus on obsessive-compulsive disorder, which is also provided by the German Society for Obsessive-Compulsive Diseases e.V.can be requested.

Prof. Dr. Ulrich Voderholzer

© W & B / private

Consulting expert:

Professor Dr. Ulrich Voderholzer is the medical director and chief physician of the Medical-Psychosomatic Clinic Roseneck in Prien am Chiemsee and an expert on obsessive-compulsive disorders, sleep disorders and depression. He is a member of the German Society for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN), board member of the Scientific Advisory Board of the German Society for Obsessive Compulsive Diseases (DGZ) and has published numerous publications.

Swell:

  • Neurologists and Psychiatrists on the Net, What are Obsessive Compulsive Disorders ?; https://www.neurologen-und-psychiater-im-netz.org/psychiatrie-psychosomatik-psychotherapie/ Disease / Zwangs Krankungen/was-sind-zwangs Krankungen/ (accessed January 7, 2019)
  • German Society of Obsessive Compulsive Diseases e.V; http://www.zwaenge.de/ (accessed on January 7, 2019)
  • H. Blair Simpson, Obsessive-compulsive disorder in adults: Epidemiology, pathogenesis, clinical manifestations, course, and diagnosis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (accessed January 8, 2019)
  • H. Blair Simpson, Pharmacotherapy for obsessive-compulsive disorder in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com (accessed January 8, 2019)

Important NOTE:
This article contains general information only and should not be used for self-diagnosis or self-treatment. He can not substitute a visit at the doctor. Unfortunately, our experts cannot answer individual questions.