Obsessive-Compulsive Disorder Issues Pertinent to Women

‘The prevalence of OCD is approximately equal between men and women, but females have a slightly later onset - in their teens or twenties…’

Obsessive-compulsive disorder (OCD) is a psychiatric condition first described 100 years ago [1]. The pathognomic features of the disorder are persistent, intrusive, senseless thoughts and impulses (obsessions) and repetitive, intentional behaviors (compulsions). Patients with the disorder recognize that their thoughts and behaviors are excessive and unreasonable and they struggle to resist them. The lifetime prevalence of OCD is estimated to be 1–3%, based on population-based surveys conducted in many communities both nationally and internationally [2,3]. Although the disorder affects individuals of all ages, the period of greatest risk is from childhood to early adulthood [4,5]. Patients experience a chronic or episodic course with exacerbations that can substantially impair social, occupational and academic functioning; according to the WHO, OCD is among the ten most disabling medical conditions worldwide [6]. Moreover, the burden placed on, and stresses experienced by, family members are considerable [7]. Medications and behavior therapy can control symptoms, but the course is chronic or relapsing in most cases, and cure is rare.

The causes for OCD are unknown. The strongest known risk factor is genetics, as demonstrated by both family and twin studies [8–12]. Heritability has been estimated from these studies to be in the order of 80%. A neuroimmunologic hypothesis is under study, which posits that an acute syndrome may emerge in children as a poststreptococcal infection event (pediatric autoimmune veuropsychiatric disorders associated with streptococcal infection, PANDAS) [13]. There is strong evidence that the pathophysiology involves the cortico-striato pallido-thalamic circuitry [14,15], based on a considerable body of neuroimaging and cognitive neuroscience research in this area [16].

Although the phenomenological form of obsessions and compulsions are particularly stereotypic, there is considerable diversity in their content, ranging from contamination, sexual, religious and aggressive concerns through compulsive hoarding, checking, ordering and counting. There have been inconsistent reports that women are more affected by some more than other symptoms. While all symptoms are extremely bothersome, some are more unique to women. Examples from my practice, among many more, include: fears that everyday physical contact with one's child may (irrationally) be construed as sexually abusive, concerns that inadvertently one may have poisoned one's child; and that one will overlook serious maladies among the common complaints of one's child.

‘The therapeutic management of patients with OCD consists of behavioral therapy … and/or medication.’

The prevalence of OCD is approximately equal between men and women, but females have a slightly later onset – in their teens or twenties – although, individuals with a family history of the condition tend to have an earlier age-at-onset. There may be a second, smaller peak of incidence among women in later life [5]. A genetic segregation study suggests that there is a higher penetrance among women with this condition with a dominant or codominant pattern of inheritance [17].

Genetic linkage and association studies have found several genomic regions and genes as possible susceptibility loci [18]. Among these, a region on chromosome 11 [19] and the gene SLC1A1 [20,21] – a glutamate transporter gene – are more likely to confer susceptibility to men than women; these findings suggest that there are possibly other genetic variants, as yet undetermined, which increase susceptibility in women.

The therapeutic management of patients with OCD consists of behavioral therapy (exposure and response prevention) and/or medication. Both are frequently, but not always, effective [22]. The first-line medications consist of any of the selective serotonin-reuptake inhibitors (SSRIs). These medications may need to be dosed higher than is typical for treatment of depression, and a longer duration of treatment (8–10 weeks) may be required in order to assess response. There are reports of differential response to medication between the sexes, but these findings require confirmation and are not considered in the routine treatment of patients.

‘It is not uncommon for either the first-onset or a severe exacerbation of the condition to occur during pregnancy or in the postpartum period.’

There are several issues that need to be specifically considered for the clinical management of women with OCD. Although there is waxing and waning of symptoms in all people with OCD, frequent exacerbation of symptoms in the premenstrual period of the female cycle are not uncommon. This may be particularly severe, and in that case, an increase in medication dose during that period may be warranted, and often helpful.

It is not uncommon for either the first-onset or a severe exacerbation of the condition to occur during pregnancy or in the postpartum period. Furthermore, women who have experienced this exacerbation, and their physicians, may face the dilemma of how best to manage the condition during pregnancy. Without doubt, behavioral management is the safest approach. However, in many instances medication may be necessary. Greene states that “while patients and physicians alike would prefer it if there were clear lines separating ‘risk’ and ‘no risk”’ [23], this is not the case with SSRIs; but that any increased risk of congenital abnormalities are likely to be “small in terms of absolute risks” [24]. Nevertheless, good practice involves an in-depth discussion regarding risks and alternatives with the patient and significant other, including the other physicians involved in her care. If medications are used during pregnancy, the choice of medication ought to be based on the most current information; for example, paroxetine may be avoided. An additional concern is the risk of persistent pulmonary hypertension of the newborn in patients taking SSRIs in the later stages of the third trimester [25]. One should be cautious about the use of medication during breastfeeding; certain medications should be avoided, such as fluoxetine, and others (e.g., sertraline) are less of a concern [26,27].

Weight gain secondary to SSRIs should also be addressed. The possibility of it occurring ought to be raised prior to initiating therapy. In addition to encouraging appropriate dietary measures and exercise, efforts may be needed to maintain a low dose of medication where possible. It is occasionally successful to employ alternate SSRIs if weight gain emerges as a problem.

Sexual side effects, anorgasmia or reduced libido often prompts patients to forego treatment. Occasionally, this difficulty subsides with time or reduced SSRI dosage. Different SSRIs may, in individual cases, be helpful; sometimes the addition of other medications, such as buproprion or mirtazapine, is ameliorative.

Family and marital relationships are often strained because of the behavior of the patient; either the disturbing nature of the symptoms themselves or the inability of the patient to fulfill domestic or occupational roles. This is addressed in several ways. Primarily, education of the family with respect to the nature of the condition is crucial. This involves both an explanation that the behavior is not voluntary and has a biological basis, and discouraging the family from reinforcing the behavior by supporting the irrational obsessions, such as participating in a ‘cleaning’ ritual or reassuring the patient excessively.

Finally, because of the familial nature of the disorder, patients often are concerned about passing on the condition to offspring. Genetic counseling is less straightforward than for Mendelian disorders (OCD probably has a complex pattern of inheritance); nevertheless, councilors are more and more able to advise about complex genetic disorders.

In conclusion, I believe that practitioners have paid insufficient attention to the specific management of OCD in women. As described above, there are several clinical concerns unique to women, and these should be addressed directly. More importantly, I believe that research should focus directly on aspects of treatment and etiology in both sexes separately. My prediction is that we will detect syndromic differences between the sexes that will hasten etiologic discovery and ultimately require different practices in the clinical management of men and women.