Psychiatry
Obsessive-Compulsive Disorder
강박장애
Chronic disorder with recurrent obsessions and compulsions
- How common
- Lifetime 2–3%
- Typical age
- Adolescence–20s
What is it?
Cortico-striato-thalamo-cortical (CSTC) circuit hyperactivity, serotonin dysfunction, OFC/caudate abnormalities.
Commonly affected: OFC, caudate, ACC, thalamus
How it develops
- Genetic/neuroimmuneSAPAP3, PANDAS (post-strep)
- CSTC hyperactivityOFC-caudate-thalamus loop runaway
- Serotonin dysfunctionHigh-dose SSRI proven effective
- Compulsion reinforcementCompulsions give short relief → vicious cycle
Symptoms
- ObsessionsIntrusive thoughts: contamination, harm, symmetry, morality
- CompulsionsWashing, checking, ordering, counting
- Time-consuming>1 hr/day
- AvoidanceAvoid trigger situations
- Variable insightGood to absent insight (rarely delusional)
How it is examined
- DSM-5 OCDObsessions/compulsions + time-consuming (>1 hr/day) + impairment
- Y-BOCSYale-Brown OCS Scale, 0–40
- Rule out PANDASStrep workup for sudden pediatric onset
Imaging
fMRI: OFC/caudate/ACC hyperactivity.
- OFC hyperactivity
PET: increased caudate metabolism.
- Caudate hypermetabolism
Non-surgical care
- High-dose SSRIFluoxetine 60–80 mg, sertraline 200 mg (4–6 mo trial)
- Clomipramine (TCA)Proven for OCD, more side effects
- Exposure and Response Prevention (ERP)Gold-standard psychotherapy for OCD
- CBTCognitive restructuring + ERP
- Antipsychotic augmentationAripiprazole/risperidone (refractory)
Conservative options are generally tried first. Medications listed here can have side effects — discuss them with your prescriber.
When surgery is considered
Severe refractory OCD (≥2 failed SSRI + ERP)
Procedures that may be discussed
- Deep brain stimulation (VC/VS)
- Intensive inpatient ERP
- rTMS (SMA)
- Rarely: capsulotomy
Outlook
40–60% improve. Chronic waxing/waning. Early treatment crucial.