Obsessive–compulsive disorder

Abstract

Obsessive–compulsive disorder (OCD) is a highly prevalent and chronic condition that is associated with substantial global disability. OCD is the key example of the ‘obsessive–compulsive and related disorders’, a group of conditions which are now classified together in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the International Classification of Diseases, 11th Revision, and which are often underdiagnosed and undertreated. In addition, OCD is an important example of a neuropsychiatric disorder in which rigorous research on phenomenology, psychobiology, pharmacotherapy and psychotherapy has contributed to better recognition, assessment and outcomes. Although OCD is a relatively homogenous disorder with similar symptom dimensions globally, individualized assessment of symptoms, the degree of insight, and the extent of comorbidity is needed. Several neurobiological mechanisms underlying OCD have been identified, including specific brain circuits that underpin OCD. In addition, laboratory models have demonstrated how cellular and molecular dysfunction underpins repetitive stereotyped behaviours, and the genetic architecture of OCD is increasingly understood. Effective treatments for OCD include serotonin reuptake inhibitors and cognitive–behavioural therapy, and neurosurgery for those with intractable symptoms. Integration of global mental health and translational neuroscience approaches could further advance knowledge on OCD and improve clinical outcomes.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

Fig. 1: Obsessive–compulsive and related disorders.
Fig. 2: OCD symptom dimensions.
Fig. 3: Comorbidities of OCD.
Fig. 4: Circuits involved in OCD.
Fig. 5: Lifespan changes related to disease stage — brain changes as a cause and consequence of OCD.
Fig. 6: OCD treatment algorithm.
Fig. 7: Targets for treatment.

References

  1. 1.

    Robbins, T. W., Vaghi, M. M. & Banca, P. Obsessive-compulsive disorder: puzzles and prospects. Neuron 102, 27–47 (2019).

  2. 2.

    Mataix-Cols, D., do Rosario-Campos, M. C. & Leckman, J. F. A. Multidimensional model of obsessive-compulsive disorder. Am. J. Psychiatry 162, 228–238 (2005).

  3. 3.

    Bloch, M. H., Landeros-Weisenberger, A., Rosario, M. C., Pittenger, C. & Leckman, J. F. Meta-analysis of the symptom structure of obsessive-compulsive disorder. Am. J. Psychiatry 165, 1532–1542 (2008).

  4. 4.

    Taylor, S. et al. Musical obsessions: a comprehensive review of neglected clinical phenomena. J. Anxiety Disord. 28, 580–589 (2014).

  5. 5.

    Stein, D. J., Hollander, E. & Josephson, S. C. Serotonin reuptake blockers for the treatment of obsessional jealousy. J. Clin. Psychiatry 55, 30–33 (1994).

  6. 6.

    Greenberg, D. & Huppert, J. D. Scrupulosity: a unique subtype of obsessive-compulsive disorder. Curr. Psychiatry Rep. 12, 282–289 (2010).

  7. 7.

    Phillips, K. A. et al. Should an obsessive-compulsive spectrum grouping of disorders be included in DSM-V? Depress. Anxiety 27, 528–555 (2010). This review provides the rationale for the DSM-5 decision to include a new chapter on OCRDs.

  8. 8.

    Stein, D. J. et al. The classification of obsessive–compulsive and related disorders in the ICD-11. J. Affect. Disord. 190, 663–674 (2016).

  9. 9.

    Bienvenu, O. J. et al. The relationship of obsessive–compulsive disorder to possible spectrum disorders: results from a family study. Biol. Psychiatry 48, 287–293 (2000).

  10. 10.

    Monzani, B., Rijsdijk, F., Harris, J. & Mataix-Cols, D. The structure of genetic and environmental risk factors for dimensional representations of DSM-5 obsessive-compulsive spectrum disorders. JAMA Psychiatry 71, 182–189 (2014).

  11. 11.

    Karno, M. The epidemiology of obsessive-compulsive disorder in five US communities. Arch. Gen. Psychiatry 45, 1094 (1988).

  12. 12.

    Baxter, A. J., Vos, T., Scott, K. M., Ferrari, A. J. & Whiteford, H. A. The global burden of anxiety disorders in 2010. Psychol. Med. 44, 2363–2374 (2014). This systematic review provides the foundation for estimations of the global burden of anxiety and related disorders.

  13. 13.

    Fontenelle, L. F., Mendlowicz, M. V. & Versiani, M. The descriptive epidemiology of obsessive–compulsive disorder. Prog. Neuropsychopharmacol. Biol. Psychiatry 30, 327–337 (2006).

  14. 14.

    Ruscio, A. M., Stein, D. J., Chiu, W. T. & Kessler, R. C. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol. Psychiatry 15, 53–63 (2008). This community survey provides data on the prevalence and comorbidity of OCD in the general population.

  15. 15.

    Fontenelle, L. F. & Hasler, G. The analytical epidemiology of obsessive–compulsive disorder: risk factors and correlates. Prog. Neuropsychopharmacol. Biol. Psychiatry 32, 1–15 (2008).

  16. 16.

    Russell, E. J., Fawcett, J. M. & Mazmanian, D. Risk of obsessive-compulsive disorder in pregnant and postpartum women. J. Clin. Psychiatry 74, 377–385 (2013).

  17. 17.

    Sharma, E., Thennarasu, K. & Reddy, Y. C. J. Long-term outcome of obsessive-compulsive disorder in adults. J. Clin. Psychiatry 75, 1019–1027 (2014).

  18. 18.

    Lewis-Fernández, R. et al. Culture and the anxiety disorders: recommendations for DSM-V. Depress. Anxiety 27, 212–229 (2010).

  19. 19.

    Isomura, K. et al. Metabolic and cardiovascular complications in obsessive-compulsive disorder: a total population, sibling comparison study with long-term follow-up. Biol. Psychiatry 84, 324–331 (2018).

  20. 20.

    Meier, S. M. et al. Mortality among persons with obsessive-compulsive disorder in Denmark. JAMA Psychiatry 73, 268–274 (2016).

  21. 21.

    Nelson, E. & Rice, J. Stability of diagnosis of obsessive-compulsive disorder in the Epidemiologic Catchment Area study. Am. J. Psychiatry 154, 826–831 (1997).

  22. 22.

    Weissman, M. M. et al. The cross national epidemiology of obsessive compulsive disorder. The Cross National Collaborative Group. J. Clin. Psychiatry 55, 5–10 (1994).

  23. 23.

    Stein, D. J., Scott, K. M., de Jonge, P. & Kessler, R. C. Epidemiology of anxiety disorders: from surveys to nosology and back. Dialogues Clin. Neurosci. 19, 127–136 (2017).

  24. 24.

    Taylor, S. Etiology of obsessions and compulsions: a meta-analysis and narrative review of twin studies. Clin. Psychol. Rev. 31, 1361–1372 (2011).

  25. 25.

    Leckman, J. F. et al. Obsessive-compulsive disorder: a review of the diagnostic criteria and possible subtypes and dimensional specifiers for DSM-V. Depress. Anxiety 27, 507–527 (2010).

  26. 26.

    Taylor, S. Molecular genetics of obsessive–compulsive disorder: a comprehensive meta-analysis of genetic association studies. Mol. Psychiatry 18, 799–805 (2012).

  27. 27.

    Taylor, S. Disorder-specific genetic factors in obsessive-compulsive disorder: a comprehensive meta-analysis. Am. J. Med. Genet. B Neuropsychiatr. Genet. 171, 325–332 (2015).

  28. 28.

    International Obsessive Compulsive Disorder Foundation Genetics Collaborative (IOCDF-GC) & OCD Collaborative Genetics Association Studies (OCGAS). Revealing the complex genetic architecture of obsessive–compulsive disorder using meta-analysis. Mol. Psychiatry 23, 1181–1188 (2017). This paper comprises the largest analysis of genome-wide association studies in OCD.

  29. 29.

    McGrath, L. M. et al. Copy number variation in obsessive-compulsive disorder and Tourette syndrome: a cross-disorder study. J. Am. Acad. Child Adolesc. Psychiatry 53, 910–919 (2014).

  30. 30.

    Brander, G., Pérez-Vigil, A., Larsson, H. & Mataix-Cols, D. Systematic review of environmental risk factors for obsessive-compulsive disorder: a proposed roadmap from association to causation. Neurosci. Biobehav. Rev. 65, 36–62 (2016).

  31. 31.

    Dykshoorn, K. L. Trauma-related obsessive–compulsive disorder: a review. Health Psychol. Behav. Med. 2, 517–528 (2014).

  32. 32.

    Miller, M. L. & Brock, R. L. The effect of trauma on the severity of obsessive-compulsive spectrum symptoms: a meta-analysis. J. Anxiety Disord. 47, 29–44 (2017).

  33. 33.

    Mufford, M. S. et al. Neuroimaging genomics in psychiatry—a translational approach. Genome Med. 9, 102 (2017).

  34. 34.

    Wolpe, J. The systematic desensitization treatment of neuroses. J. Nerv. Ment. Dis. 132, 189–203 (1961).

  35. 35.

    Rachman, S., Hodgson, R. & Marks, I. M. The treatment of chronic obsessive-compulsive neurosis. Behav. Res. Ther. 9, 237–247 (1971).

  36. 36.

    Rachman, S. Obsessional ruminations. Behav. Res. Ther. 9, 229–235 (1971).

  37. 37.

    Salkovskis, P. M. Obsessional-compulsive problems: a cognitive-behavioural analysis. Behav. Res. Ther. 23, 571–583 (1985).

  38. 38.

    Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T. & Vervliet, B. Maximizing exposure therapy: an inhibitory learning approach. Behav. Res. Ther. 58, 10–23 (2014).

  39. 39.

    Jacoby, R. J. & Abramowitz, J. S. Inhibitory learning approaches to exposure therapy: a critical review and translation to obsessive-compulsive disorder. Clin. Psychol. Rev. 49, 28–40 (2016).

  40. 40.

    Obsessive Compulsive Cognitions Working Group. Cognitive assessment of obsessive-compulsive disorder. Behav. Res. Ther. 35, 667–681 (1997).

  41. 41.

    Stein, D. J., Goodman, W. K. & Rauch, S. L. The cognitive-affective neuroscience of obsessive-compulsive disorder. Curr. Psychiatry Rep. 2, 341–346 (2000).

  42. 42.

    Benzina, N., Mallet, L., Burguière, E., N’Diaye, K. & Pelissolo, A. Cognitive dysfunction in obsessive-compulsive disorder. Curr. Psychiatry Rep. 18, 80 (2016).

  43. 43.

    Wood, J. & Ahmari, S. E. A. Framework for understanding the emerging role of corticolimbic-ventral striatal networks in OCD-associated repetitive behaviors. Front. Syst. Neurosci. 9, 171 (2015).

  44. 44.

    Burguière, E., Monteiro, P., Mallet, L., Feng, G. & Graybiel, A. M. Striatal circuits, habits, and implications for obsessive–compulsive disorder. Curr. Opin. Neurobiol. 30, 59–65 (2015).

  45. 45.

    Kalueff, A. V. et al. Neurobiology of rodent self-grooming and its value for translational neuroscience. Nat. Rev. Neurosci. 17, 45–59 (2015).

  46. 46.

    Baxter, L. R. Caudate glucose metabolic rate changes with both drug and behavior therapy for obsessive-compulsive disorder. Arch. Gen. Psychiatry 49, 681 (1992).

  47. 47.

    Kwon, J. S., Jang, J. H., Choi, J.-S. & Kang, D.-H. Neuroimaging in obsessive–compulsive disorder. Expert Rev. Neurother. 9, 255–269 (2009).

  48. 48.

    van den Heuvel, O. A. et al. Brain circuitry of compulsivity. Eur. Neuropsychopharmacol. 26, 810–827 (2016).

  49. 49.

    van Velzen, L. S., Vriend, C., de Wit, S. J. & van den Heuvel, O. A. Response inhibition and interference control in obsessive-compulsive spectrum disorders. Front. Hum. Neurosci. 8, 419 (2014).

  50. 50.

    Rotge, J.-Y. et al. Provocation of obsessive-compulsive symptoms: a quantitative voxel-based meta-analysis of functional neuroimaging studies. J. Psychiatry Neurosci. 33, 405–412 (2008).

  51. 51.

    Thorsen, A. L. et al. Emotional processing in obsessive-compulsive disorder: a systematic review and meta-analysis of 25 functional neuroimaging studies. Biol. Psychiatry Cogn. Neurosci. Neuroimaging 3, 563–571 (2018).

  52. 52.

    Del Casale, A. et al. Executive functions in obsessive–compulsive disorder: an activation likelihood estimate meta-analysis of fMRI studies. World J. Biol. Psychiatry 17, 378–393 (2015).

  53. 53.

    Eng, G. K., Sim, K. & Chen, S.-H. A. Meta-analytic investigations of structural grey matter, executive domain-related functional activations, and white matter diffusivity in obsessive compulsive disorder: an integrative review. Neurosci. Biobehav. Rev. 52, 233–257 (2015).

  54. 54.

    Gillan, C. M., Robbins, T. W., Sahakian, B. J., van den Heuvel, O. A. & van Wingen, G. The role of habit in compulsivity. Eur. Neuropsychopharmacol. 26, 828–840 (2016).

  55. 55.

    Rasgon, A. et al. Neural correlates of affective and non-affective cognition in obsessive compulsive disorder: a meta-analysis of functional imaging studies. Eur. Psychiatry 46, 25–32 (2017).

  56. 56.

    Williams, L. M. Precision psychiatry: a neural circuit taxonomy for depression and anxiety. Lancet Psychiatry 3, 472–480 (2016).

  57. 57.

    Sprooten, E. et al. Addressing reverse inference in psychiatric neuroimaging: meta-analyses of task-related brain activation in common mental disorders. Hum. Brain Mapp. 38, 1846–1864 (2017).

  58. 58.

    Fineberg, N. A. et al. Mapping compulsivity in the DSM-5 obsessive compulsive and related disorders: cognitive domains, neural circuitry, and treatment. Int. J. Neuropsychopharmacol. 21, 42–58 (2017).

  59. 59.

    Carlisi, C. O. et al. Shared and disorder-specific neurocomputational mechanisms of decision-making in autism spectrum disorder and obsessive-compulsive disorder. Cereb. Cortex 27, 5804–5816 (2017).

  60. 60.

    Norman, L. J. et al. Neural dysfunction during temporal discounting in paediatric attention-deficit/hyperactivity disorder and obsessive-compulsive disorder. Psychiatry Res. Neuroimaging 269, 97–105 (2017).

  61. 61.

    Fan, S. et al. Trans-diagnostic comparison of response inhibition in Tourette’s disorder and obsessive-compulsive disorder. World J. Biol. Psychiatry 19, 527–537 (2017).

  62. 62.

    Norman, L. J. et al. Structural and functional brain abnormalities in attention-deficit/hyperactivity disorder and obsessive-compulsive disorder. JAMA Psychiatry 73, 815 (2016).

  63. 63.

    Pujol, J. et al. Mapping structural brain alterations in obsessive-compulsive disorder. Arch. Gen. Psychiatry 61, 720 (2004).

  64. 64.

    van den Heuvel, O. A. et al. The major symptom dimensions of obsessive-compulsive disorder are mediated by partially distinct neural systems. Brain 132, 853–868 (2008).

  65. 65.

    Radua, J. & Mataix-Cols, D. Voxel-wise meta-analysis of grey matter changes in obsessive–compulsive disorder. Br. J. Psychiatry 195, 393–402 (2009).

  66. 66.

    Radua, J., van den Heuvel, O. A., Surguladze, S. & Mataix-Cols, D. Meta-analytical comparison of voxel-based morphometry studies in obsessive-compulsive disorder versus other anxiety disorders. Arch. Gen. Psychiatry 67, 701–711 (2010).

  67. 67.

    de Wit, S. J. et al. Multicenter voxel-based morphometry mega-analysis of structural brain scans in obsessive-compulsive disorder. Am. J. Psychiatry 171, 340–349 (2014).

  68. 68.

    Fouche, J.-P. et al. Cortical thickness in obsessive–compulsive disorder: multisite mega-analysis of 780 brain scans from six centres. Br. J. Psychiatry 210, 67–74 (2017).

  69. 69.

    Subirà, M. et al. Structural covariance of neostriatal and limbic regions in patients with obsessive–compulsive disorder. J. Psychiatry Neurosci. 41, 115–123 (2016).

  70. 70.

    Thompson, P. M. et al. ENIGMA and the individual: predicting factors that affect the brain in 35 countries worldwide. NeuroImage 145, 389–408 (2017).

  71. 71.

    Boedhoe, P. S. W. et al. Distinct subcortical volume alterations in pediatric and adult OCD: a worldwide meta- and mega-analysis. Am. J. Psychiatry 174, 60–69 (2017).

  72. 72.

    Goodkind, M. et al. Identification of a common neurobiological substrate for mental illness. JAMA Psychiatry 72, 305–315 (2015).

  73. 73.

    Boedhoe, P. S. W. et al. Cortical abnormalities associated with pediatric and adult obsessive-compulsive disorder: findings from the ENIGMA Obsessive-Compulsive Disorder Working Group. Am. J. Psychiatry 175, 453–462 (2018). Together with Boedhoe et al. (2017), this paper comprises the largest brain imaging study of OCD.

  74. 74.

    Radua, J. et al. Multimodal voxel-based meta-analysis of white matter abnormalities in obsessive–compulsive disorder. Neuropsychopharmacology 39, 1547–1557 (2014).

  75. 75.

    Jenkins, L. M. et al. Shared white matter alterations across emotional disorders: a voxel-based meta-analysis of fractional anisotropy. Neuroimage Clin. 12, 1022–1034 (2016).

  76. 76.

    Bandelow, B. et al. Biological markers for anxiety disorders, OCD and PTSD: a consensus statement. Part II: neurochemistry, neurophysiology and neurocognition. World J. Biol. Psychiatry 18, 162–214 (2016).

  77. 77.

    Kim, E. et al. Altered serotonin transporter binding potential in patients with obsessive-compulsive disorder under escitalopram treatment: [11C]DASB PET study. Psychol. Med. 46, 357–366 (2015).

  78. 78.

    Nikolaus, S., Antke, C., Beu, M. & Müller, H.-W. Cortical GABA, striatal dopamine and midbrain serotonin as the key players in compulsive and anxiety disorders — results from in vivo imaging studies. Rev. Neurosci. 21, 119–139 (2010).

  79. 79.

    Goodman, W. K. et al. Beyond the serotonin hypothesis: a role for dopamine in some forms of obsessive compulsive disorder? J. Clin. Psychiatry 51, 36–43 (1990).

  80. 80.

    Olver, J. S. et al. Dopamine D1 receptor binding in the anterior cingulate cortex of patients with obsessive–compulsive disorder. Psychiatry Res. 183, 85–88 (2010).

  81. 81.

    Ducasse, D. et al. D2 and D3 dopamine receptor affinity predicts effectiveness of antipsychotic drugs in obsessive-compulsive disorders: a metaregression analysis. Psychopharmacology 231, 3765–3770 (2014).

  82. 82.

    Brennan, B. P., Rauch, S. L., Jensen, J. E. & Pope, H. G. A. Critical review of magnetic resonance spectroscopy studies of obsessive-compulsive disorder. Biol. Psychiatry 73, 24–31 (2013).

  83. 83.

    Bhattacharyya, S. et al. Anti-brain autoantibodies and altered excitatory neurotransmitters in obsessive–compulsive disorder. Neuropsychopharmacology 34, 2489–2496 (2009).

  84. 84.

    Stewart, S. E. et al. Meta-analysis of association between obsessive-compulsive disorder and the 3ʹ region of neuronal glutamate transporter gene SLC1A1. Am. J. Med. Genet. B Neuropsychiatr. Genet. 162, 367–379 (2013).

  85. 85.

    Burguiere, E., Monteiro, P., Feng, G. & Graybiel, A. M. Optogenetic stimulation of lateral orbitofronto-striatal pathway suppresses compulsive behaviors. Science 340, 1243–1246 (2013). This paper demonstrates the value of basic neuroscience research in shedding light on OCD.

  86. 86.

    Kariuki-Nyuthe, C., Gomez-Mancilla, B. & Stein, D. J. Obsessive compulsive disorder and the glutamatergic system. Curr. Opin. Psychiatry 27, 32–37 (2014).

  87. 87.

    Turna, J., Grosman Kaplan, K., Anglin, R. & Van Ameringen, M. “What’s bugging the gut in OCD?” A review of the gut microbiome in obsessive-compulsive disorder. Depress. Anxiety 33, 171–178 (2015).

  88. 88.

    Renna, M. E., O’Toole, M. S., Spaeth, P. E., Lekander, M. & Mennin, D. S. The association between anxiety, traumatic stress, and obsessive-compulsive disorders and chronic inflammation: a systematic review and meta-analysis. Depress. Anxiety 35, 1081–1094 (2018).

  89. 89.

    Fineberg, N. A. et al. Probing compulsive and impulsive behaviors, from animal models to endophenotypes: a narrative review. Neuropsychopharmacology 35, 591–604 (2009).

  90. 90.

    Mataix-Cols, D. et al. Symptom stability in adult obsessive-compulsive disorder: data from a naturalistic two-year follow-up study. Am. J. Psychiatry 159, 263–268 (2002).

  91. 91.

    Lochner, C. et al. Gender in obsessive–compulsive disorder: clinical and genetic findings. Eur. Neuropsychopharmacol. 14, 105–113 (2004).

  92. 92.

    Torresan, R. C. et al. Symptom dimensions, clinical course and comorbidity in men and women with obsessive-compulsive disorder. Psychiatry Res. 209, 186–195 (2013).

  93. 93.

    Rapp, A. M., Bergman, R. L., Piacentini, J. & Mcguire, J. F. Evidence-based assessment of obsessive–compulsive disorder. J. Cent. Nerv. Syst. Dis. 8, 13–29 (2016).

  94. 94.

    du Toit, P. L., van Kradenburg, J., Niehaus, D. & Stein, D. J. Comparison of obsessive-compulsive disorder patients with and without comorbid putative obsessive-compulsive spectrum disorders using a structured clinical interview. Compr. Psychiatry 42, 291–300 (2001).

  95. 95.

    Goodman, W. K. et al. The Yale-Brown Obsessive Compulsive Scale. I. Development, use, and reliability. Arch. Gen. Psychiatry 46, 1006–1011 (1989). The Y-BOCS remains the gold standard measure for assessing symptom severity in OCD.

  96. 96.

    Rosario-Campos, M. C. et al. The Dimensional Yale–Brown Obsessive–Compulsive Scale (DY-BOCS): an instrument for assessing obsessive–compulsive symptom dimensions. Mol. Psychiatry 11, 495–504 (2006).

  97. 97.

    Storch, E. A. et al. Florida obsessive-compulsive inventory: development, reliability, and validity. J. Clin. Psychol. 63, 851–859 (2007).

  98. 98.

    Rosario, M. C. et al. Validation of the University of São Paulo Sensory Phenomena Scale: initial psychometric properties. CNS Spectr. 14, 315–323 (2009).

  99. 99.

    Eisen, J. L. et al. The Brown Assessment of Beliefs Scale: reliability and validity. Am. J. Psychiatry 155, 102–108 (1998).

  100. 100.

    Albert, U., Baffa, A. & Maina, G. Family accommodation in adult obsessive–compulsive disorder: clinical perspectives. Psychol. Res. Behav. Manag. 10, 293–304 (2017).

  101. 101.

    Brakoulias, V., Perkes, I. E. & Tsalamanios, E. A call for prevention and early intervention in obsessive-compulsive disorder. Early Interv. Psychiatry 12, 572–577 (2017).

  102. 102.

    Fineberg, N. A. et al. Early intervention for obsessive compulsive disorder: an expert consensus statement. Eur. Neuropsychopharmacol. 29, 549–565 (2019).

  103. 103.

    Sarris, J., Camfield, D. & Berk, M. Complementary medicine, self-help, and lifestyle interventions for obsessive compulsive disorder (OCD) and the OCD spectrum: a systematic review. J. Affect. Disord. 138, 213–221 (2012).

  104. 104.

    Amerio, A., Odone, A., Marchesi, C. & Ghaemi, S. N. Treatment of comorbid bipolar disorder and obsessive–compulsive disorder: a systematic review. J. Affect. Disord. 166, 258–263 (2014).

  105. 105.

    McGuire, J. F. et al. A meta-analysis of cognitive behavior therapy and medication for child obsessive-compulsive disorder: moderators of treatment efficacy, response, and remission. Depress. Anxiety 32, 580–593 (2015).

  106. 106.

    Dell’Osso, B. et al. Obsessive-compulsive disorder in the elderly: a report from the International College of Obsessive-Compulsive Spectrum Disorders (ICOCS). Eur. Psychiatry 45, 36–40 (2017).

  107. 107.

    Skapinakis, P. et al. A systematic review of the clinical effectiveness and cost-effectiveness of pharmacological and psychological interventions for the management of obsessive–compulsive disorder in children/adolescents and adults. Health Technol. Assess. 20, 1–392 (2016).

  108. 108.

    Meyer, E. et al. Adding motivational interviewing and thought mapping to cognitive-behavioral group therapy: results from a randomized clinical trial. Braz. J. Psychiatry 32, 20–29 (2010).

  109. 109.

    Simpson, H. B. et al. Challenges using motivational interviewing as an adjunct to exposure therapy for obsessive-compulsive disorder. Behav. Res. Ther. 48, 941–948 (2010).

  110. 110.

    Öst, L.-G., Havnen, A., Hansen, B. & Kvale, G. Cognitive behavioral treatments of obsessive-compulsive disorder. A systematic review and meta-analysis of studies published 1993–2014. Clin. Psychol. Rev. 40, 156–169 (2015).

  111. 111.

    Öst, L.-G., Riise, E. N., Wergeland, G. J., Hansen, B. & Kvale, G. Cognitive behavioral and pharmacological treatments of OCD in children: a systematic review and meta-analysis. J. Anxiety Disord. 43, 58–69 (2016).

  112. 112.

    Huppert, J. D. & Franklin, M. E. Cognitive behavioral therapy for obsessive-compulsive disorder: an update. Curr. Psychiatry Rep. 7, 268–273 (2005).

  113. 113.

    Hirschtritt, M. E., Bloch, M. H. & Mathews, C. A. Obsessive-compulsive disorder. JAMA 317, 1358 (2017).

  114. 114.

    Wootton, B. M. Remote cognitive–behavior therapy for obsessive–compulsive symptoms: a meta-analysis. Clin. Psychol. Rev. 43, 103–113 (2016).

  115. 115.

    Rogers, M. A., Lemmen, K., Kramer, R., Mann, J. & Chopra, V. Internet-delivered health interventions that work: systematic review of meta-analyses and evaluation of website availability. J. Med. Internet Res. 19, e90 (2017).

  116. 116.

    Wheaton, M. G. et al. Patient adherence and treatment outcome with exposure and response prevention for OCD: which components of adherence matter and who becomes well? Behav. Res. Ther. 85, 6–12 (2016).

  117. 117.

    Pinto, A., Liebowitz, M. R., Foa, E. B. & Simpson, H. B. Obsessive compulsive personality disorder as a predictor of exposure and ritual prevention outcome for obsessive compulsive disorder. Behav. Res. Ther. 49, 453–458 (2011).

  118. 118.

    Skapinakis, P. et al. Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis. Lancet Psychiatry 3, 730–739 (2016).

  119. 119.

    Kvale, G. et al. Successfully treating 90 patients with obsessive compulsive disorder in eight days: the Bergen 4-day treatment. BMC Psychiatry 18, 323 (2018).

  120. 120.

    Soomro, G. M., Altman, D. G., Rajagopal, S. & Oakley Browne, M. Selective serotonin re-uptake inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). Cochrane Database Syst. Rev. 1, CD001765 (2008).

  121. 121.

    Bloch, M. H., McGuire, J., Landeros-Weisenberger, A., Leckman, J. F. & Pittenger, C. Meta-analysis of the dose-response relationship of SSRI in obsessive-compulsive disorder. Mol. Psychiatry 15, 850–855 (2009).

  122. 122.

    Stein, D. J., Wreford Andersen, E., Tonnoir, B. & Fineberg, N. Escitalopram in obsessive–compulsive disorder: a randomized, placebo-controlled, paroxetine-referenced, fixed-dose, 24-week study. Curr. Med. Res. Opin. 23, 701–711 (2007).

  123. 123.

    Koran, L. M. et al. Practice guideline for the treatment of patients with obsessive-compulsive disorder. Am. J. Psychiatry 164, 5–53 (2007).

  124. 124.

    Murphy, D. L. et al. Obsessive—compulsive disorder as a 5-HT subsystem-related behavioural disorder. Br. J. Psychiatry 155, 15–24 (1989).

  125. 125.

    Karabanow, O. Double-blind controlled study in phobias and obsessions. J. Int. Med. Res. 5 (Suppl. 5), 42–48 (1977).

  126. 126.

    López-Ibor, J. J. et al. Double-blind comparison of fluoxetine versus clomipramine in the treatment of obsessive compulsive disorder. Eur. Neuropsychopharmacol. 6, 111–118 (1996).

  127. 127.

    Zohar, J. & Judge, R. Paroxetine versus clomipramine in the treatment of obsessive–compulsive disorder. Br. J. Psychiatry 169, 468–474 (1996).

  128. 128.

    Bisserbe, J., Lane, R. & Flament, M. A double-blind comparison of sertraline and clomipramine in outpatients with obsessive-compulsive disorder. Eur. Psychiatry 12, 82–93 (1997).

  129. 129.

    Bandelow, B. et al. Guidelines for the pharmacological treatment of anxiety disorders, obsessive–compulsive disorder and posttraumatic stress disorder in primary care. Int. J. Psychiatry Clin. Pract. 16, 77–84 (2012).

  130. 130.

    Issari, Y., Jakubovski, E., Bartley, C. A., Pittenger, C. & Bloch, M. H. Early onset of response with selective serotonin reuptake inhibitors in obsessive-compulsive disorder. J. Clin. Psychiatry 77, e605–e611 (2016).

  131. 131.

    Varigonda, A. L., Jakubovski, E. & Bloch, M. H. Systematic review and meta-analysis: early treatment responses of selective serotonin reuptake inhibitors and clomipramine in pediatric obsessive-compulsive disorder. J. Am. Acad. Child Adolesc. Psychiatry 55, 851–859 (2016).

  132. 132.

    da Conceição Costa, D. L. et al. Can early improvement be an indicator of treatment response in obsessive-compulsive disorder? Implications for early-treatment decision-making. J. Psychiatr. Res. 47, 1700–1707 (2013).

  133. 133.

    Greist, J. H. et al. WCA recommendations for the long-term treatment of obsessive-compulsive disorder in adults. CNS Spectr. 8, 7–16 (2003).

  134. 134.

    Batelaan, N. M. et al. Risk of relapse after antidepressant discontinuation in anxiety disorders, obsessive-compulsive disorder, and post-traumatic stress disorder: systematic review and meta-analysis of relapse prevention trials. BMJ 358, j3927 (2017).

  135. 135.

    Erzegovesi, S. et al. Clinical predictors of drug response in obsessive-compulsive disorder. J. Clin. Psychopharmacol. 21, 488–492 (2001).

  136. 136.

    Ravizza, L., Barzega, G., Bellino, S., Bogetto, F. & Maina, G. Predictors of drug treatment response in obsessive-compulsive disorder. J. Clin. Psychiatry 56, 368–373 (1995).

  137. 137.

    Belotto-Silva, C. et al. Group cognitive-behavioral therapy versus selective serotonin reuptake inhibitors for obsessive-compulsive disorder: a practical clinical trial. J. Anxiety Disord. 26, 25–31 (2012).

  138. 138.

    Simpson, H. B. et al. Cognitive-behavioral therapy versus risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry 70, 1190–1199 (2013). This randomized controlled trial informs current approaches to the management of treatment-resistant OCD.

  139. 139.

    Cavanagh, K. Geographic inequity in the availability of cognitive behavioural therapy in England and Wales: a 10-year update. Behav. Cogn. Psychother. 42, 497–501 (2013).

  140. 140.

    Zhou, D.-D. et al. Augmentation agents to serotonin reuptake inhibitors for treatment-resistant obsessive-compulsive disorder: a network meta-analysis. Prog. Neuropsychopharmacol. Biol. Psychiatry 90, 277–287 (2019).

  141. 141.

    Dougherty, D. D. et al. Open-label study of high (30 mg) and moderate (20 mg) dose escitalopram for the treatment of obsessive–compulsive disorder. Int. Clin. Psychopharmacol. 24, 306–311 (2009).

  142. 142.

    Ninan, P. T. et al. High-dose sertraline strategy for nonresponders to acute treatment for obsessive-compulsive disorder. J. Clin. Psychiatry 67, 15–22 (2006).

  143. 143.

    Pampaloni, I. et al. High-dose selective serotonin reuptake inhibitors in OCD: a systematic retrospective case notes survey. J. Psychopharmacol. 24, 1439–1445 (2009).

  144. 144.

    Albert, U., Aguglia, E., Maina, G. & Bogetto, F. Venlafaxine versus clomipramine in the treatment of obsessive-compulsive disorder. J. Clin. Psychiatry 63, 1004–1009 (2002).

  145. 145.

    Denys, D., van Megen, H. J. G. M., van der Wee, N. & Westenberg, H. G. M. A. Double-blind switch study of paroxetine and venlafaxine in obsessive-compulsive disorder. J. Clin. Psychiatry 65, 37–43 (2004).

  146. 146.

    Yeh, Y.-W. et al. High-dose duloxetine for treatment-resistant obsessive-compulsive disorder. Clin. Neuropharmacol. 32, 174–176 (2009).

  147. 147.

    Dougherty, D. D. et al. Open-label study of duloxetine for the treatment of obsessive-compulsive disorder. Int. J. Neuropsychopharmacol. 18, pyu062 (2015).

  148. 148.

    Bandelow, B. et al. World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for the pharmacological treatment of anxiety, obsessive-compulsive and post-traumatic stress disorders – first revision. World J. Biol. Psychiatry 9, 248–312 (2008).

  149. 149.

    Bloch, M. H. et al. A systematic review: antipsychotic augmentation with treatment refractory obsessive-compulsive disorder. Mol. Psychiatry 11, 622–632 (2006).

  150. 150.

    Albert, U. et al. Role and clinical implications of atypical antipsychotics in anxiety disorders, obsessive-compulsive disorder, trauma-related, and somatic symptom disorders. Int. Clin. Psychopharmacol. 31, 249–258 (2016).

  151. 151.

    Dold, M., Aigner, M., Lanzenberger, R. & Kasper, S. Antipsychotic augmentation of serotonin reuptake inhibitors in treatment-resistant obsessive-compulsive disorder: an update meta-analysis of double-blind, randomized, placebo-controlled trials. Int. J. Neuropsychopharmacol. 18, pyv047 (2015).

  152. 152.

    Diniz, J. B. et al. A double-blind, randomized, controlled trial of fluoxetine plus quetiapine or clomipramine versus fluoxetine plus placebo for obsessive-compulsive disorder. J. Clin. Psychopharmacol. 31, 763–768 (2011).

  153. 153.

    Pittenger, C. Glutamatergic agents for OCD and related disorders. Curr. Treat. Options Psychiatry 2, 271–283 (2015).

  154. 154.

    Popli, A. P. Interactions of serotonin reuptake inhibitors with tricyclic antidepressants. Arch. Gen. Psychiatry 51, 666 (1994).

  155. 155.

    Matsunaga, H. et al. A long-term trial of the effectiveness and safety of atypical antipsychotic agents in augmenting SSRI-refractory obsessive-compulsive disorder. J. Clin. Psychiatry 70, 863–868 (2009).

  156. 156.

    Fineberg, N. A. et al. Obsessive–compulsive disorder (OCD): practical strategies for pharmacological and somatic treatment in adults. Psychiatry Res. 227, 114–125 (2015).

  157. 157.

    Rodriguez, C. I., Levinson, A., Zwerling, J., Vermes, D. & Simpson, H. B. Open-label trial on the effects of memantine in adults with obsessive-compulsive disorder after a single ketamine infusion. J. Clin. Psychiatry 77, 688–689 (2016).

  158. 158.

    Costa, D. L. C. et al. Randomized, double-blind, placebo-controlled trial of N-acetylcysteine augmentation for treatment-resistant obsessive-compulsive disorder. J. Clin. Psychiatry 78, e766–e773 (2017).

  159. 159.

    Afshar, H. et al. N-Acetylcysteine add-on treatment in refractory obsessive-compulsive disorder. J. Clin. Psychopharmacol. 32, 797–803 (2012).

  160. 160.

    Paydary, K. et al. N-Acetylcysteine augmentation therapy for moderate-to-severe obsessive-compulsive disorder: randomized, double-blind, placebo-controlled trial. J. Clin. Pharm. Ther. 41, 214–219 (2016).

  161. 161.

    Sarris, J. et al. N-Acetylcysteine (NAC) in the treatment of obsessive-compulsive disorder: a 16-week, double-blind, randomised, placebo-controlled study. CNS Drugs 29, 801–809 (2015).

  162. 162.

    Ghanizadeh, A. et al. Efficacy of N-acetylcysteine augmentation on obsessive compulsive disorder: a multicenter randomized double blind placebo controlled clinical trial. Iran J. Psychiatry 12, 134–141 (2017).

  163. 163.

    Kishi, T., Matsuda, Y. & Iwata, N. Combination therapy of serotonin reuptake inhibitors and memantine for obsessive–compulsive disorder: a meta-analysis of double-blind, randomized, placebo-controlled trials. J. Alzheimers Dis. 64, 43–48 (2018).

  164. 164.

    Senço, N. M. et al. Transcranial direct current stimulation in obsessive–compulsive disorder: emerging clinical evidence and considerations for optimal montage of electrodes. Expert Rev. Med. Devices 12, 381–391 (2015).

  165. 165.

    Rehn, S., Eslick, G. D. & Brakoulias, V. A. Meta-analysis of the effectiveness of different cortical targets used in repetitive transcranial magnetic stimulation (rTMS) for the treatment of obsessive-compulsive disorder (OCD). Psychiatr. Q. 89, 645–665 (2018).

  166. 166.

    Lefaucheur, J.-P. et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin. Neurophysiol. 125, 2150–2206 (2014).

  167. 167.

    Berlim, M. T., Neufeld, N. H. & Van den Eynde, F. Repetitive transcranial magnetic stimulation (rTMS) for obsessive–compulsive disorder (OCD): an exploratory meta-analysis of randomized and sham-controlled trials. J. Psychiatr. Res. 47, 999–1006 (2013).

  168. 168.

    Zhou, D.-D., Wang, W., Wang, G.-M., Li, D.-Q. & Kuang, L. An updated meta-analysis: short-term therapeutic effects of repeated transcranial magnetic stimulation in treating obsessive-compulsive disorder. J. Affect. Disord. 215, 187–196 (2017).

  169. 169.

    Luis Lujan, J. Tracking the mechanisms of deep brain stimulation for neuropsychiatric disorders. Front. Biosci. 13, 5892–5904 (2008).

  170. 170.

    Garnaat, S. L. et al. Who qualifies for deep brain stimulation for OCD? Data from a naturalistic clinical sample. J. Neuropsychiatry Clin. Neurosci. 26, 81–86 (2014).

  171. 171.

    Alonso, P. et al. Deep brain stimulation for obsessive-compulsive disorder: a meta-analysis of treatment outcome and predictors of response. PLOS ONE 10, e0133591 (2015).

  172. 172.

    Hamani, C. et al. Deep brain stimulation for obsessive-compulsive disorder. Neurosurgery 75, 327–333 (2014).

  173. 173.

    Coenen, V. A. et al. The medial forebrain bundle as a target for deep brain stimulation for obsessive-compulsive disorder. CNS Spectr. 22, 282–289 (2016).

  174. 174.

    Greenberg, B. D., Rauch, S. L. & Haber, S. N. Invasive circuitry-based neurotherapeutics: stereotactic ablation and deep brain stimulation for OCD. Neuropsychopharmacology 35, 317–336 (2009).

  175. 175.

    Jung, H. H. et al. Bilateral thermal capsulotomy with MR-guided focused ultrasound for patients with treatment-refractory obsessive-compulsive disorder: a proof-of-concept study. Mol. Psychiatry 20, 1205–1211 (2014).

  176. 176.

    Miguel, E. C. et al. Evolution of gamma knife capsulotomy for intractable obsessive-compulsive disorder. Mol. Psychiatry 24, 218–240 (2018).

  177. 177.

    Lopes, A. C. et al. Gamma ventral capsulotomy for obsessive-compulsive disorder: a randomized clinical trial. JAMA Psychiatry 71, 1066–1076 (2014).

  178. 178.

    Shannahoff-Khalsa, D. S. et al. Randomized controlled trial of yogic meditation techniques for patients with obsessive-compulsive disorder. CNS Spectr. 4, 34–47 (1999).

  179. 179.

    Key, B. L., Rowa, K., Bieling, P., McCabe, R. & Pawluk, E. J. Mindfulness-based cognitive therapy as an augmentation treatment for obsessive-compulsive disorder. Clin. Psychol. Psychother. 24, 1109–1120 (2017).

  180. 180.

    Kumar, A., Sharma, M., Narayanaswamy, J., Kandavel, T. & Janardhan Reddy, Y. Efficacy of mindfulness-integrated cognitive behavior therapy in patients with predominant obsessions. Indian J. Psychiatry 58, 366 (2016).

  181. 181.

    Rector, N. A., Richter, M. A., Lerman, B. & Regev, R. A. Pilot test of the additive benefits of physical exercise to CBT for OCD. Cogn. Behav. Ther. 44, 328–340 (2015).

  182. 182.

    Abrantes, A. M. et al. A pilot randomized controlled trial of aerobic exercise as an adjunct to OCD treatment. Gen. Hosp. Psychiatry 49, 51–55 (2017).

  183. 183.

    Zhang, Z.-J., Wang, X.-Y., Tan, Q.-R., Jin, G.-X. & Yao, S.-M. Electroacupuncture for refractory obsessive-compulsive disorder. J. Nerv. Ment. Dis. 197, 619–622 (2009).

  184. 184.

    Subramaniam, M., Soh, P., Vaingankar, J. A., Picco, L. & Chong, S. A. Quality of life in obsessive-compulsive disorder: impact of the disorder and of treatment. CNS Drugs 27, 367–383 (2013).

  185. 185.

    Macy, A. S. et al. Quality of life in obsessive compulsive disorder. CNS Spectr. 18, 21–33 (2013).

  186. 186.

    Coluccia, A. et al. Adult obsessive–compulsive disorder and quality of life outcomes: a systematic review and meta-analysis. Asian J. Psychiatry 22, 41–52 (2016).

  187. 187.

    Coluccia, A., Ferretti, F., Fagiolini, A. & Pozza, A. Quality of life in children and adolescents with obsessive–compulsive disorder: a systematic review and meta-analysis. Neuropsychiatr. Dis. Treat. 13, 597–608 (2017).

  188. 188.

    Farris, S. G., McLean, C. P., Van Meter, P. E., Simpson, H. B. & Foa, E. B. Treatment response, symptom remission, and wellness in obsessive-compulsive disorder. J. Clin. Psychiatry 74, 685–690 (2013).

  189. 189.

    Cicek, E., Cicek, I. E., Kayhan, F., Uguz, F. & Kaya, N. Quality of life, family burden and associated factors in relatives with obsessive–compulsive disorder. Gen. Hosp. Psychiatry 35, 253–258 (2013).

  190. 190.

    Grover, S. & Dutt, A. Perceived burden and quality of life of caregivers in obsessive-compulsive disorder. Psychiatry Clin. Neurosci. 65, 416–422 (2011).

  191. 191.

    Hollander, E., Stein, D. J., Fineberg, N. A., Marteau, F. & Legault, M. Quality of life outcomes in patients with obsessive-compulsive disorder. J. Clin. Psychiatry 71, 784–792 (2010).

  192. 192.

    Srivastava, S., Bhatia, M. S., Thawani, R. & Jhanjee, A. Quality of life in patients with obsessive compulsive disorder: a longitudinal study from India. Asian J. Psychiatry 4, 178–182 (2011).

  193. 193.

    Hauschildt, M., Jelinek, L., Randjbar, S., Hottenrott, B. & Moritz, S. Generic and illness-specific quality of life in obsessive-compulsive disorder. Behav. Cogn. Psychother. 38, 417–436 (2010).

  194. 194.

    Van Ameringen, M., Turna, J., Khalesi, Z., Pullia, K. & Patterson, B. There is an app for that! The current state of mobile applications (apps) for DSM-5 obsessive-compulsive disorder, posttraumatic stress disorder, anxiety and mood disorders. Depress. Anxiety 34, 526–539 (2017).

  195. 195.

    Thorsen, A. L., van den Heuvel, O. A., Hansen, B. & Kvale, G. Neuroimaging of psychotherapy for obsessive–compulsive disorder: a systematic review. Psychiatry Res. 233, 306–313 (2015).

  196. 196.

    Dougherty, D. D. et al. Neuroscientifically informed formulation and treatment planning for patients with obsessive-compulsive disorder. JAMA Psychiatry 75, 1081–1087 (2018).

  197. 197.

    Stein, D. J. et al. Global mental health and neuroscience: potential synergies. Lancet Psychiatry 2, 178–185 (2015).

  198. 198.

    Stein, D. Obsessive-compulsive disorder and global mental health. Indian J. Psychiatry 61, 4 (2019).

  199. 199.

    Cheyette, S. R. & Cummings, J. L. Encephalitis lethargica: lessons for contemporary neuropsychiatry. J. Neuropsychiatry Clin. Neurosci. 7, 125–134 (1995).

  200. 200.

    Laplane, D. Obsessive-compulsive disorders caused by basal ganglia diseases [French]. Rev. Neurol. 150, 594–598 (1994).

  201. 201.

    Khanna, S. Obsessive-compulsive disorder: is there a frontal lobe dysfunction? Biol. Psychiatry 24, 602–613 (1988).

  202. 202.

    Swedo, S. E. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS). Mol. Psychiatry 7, S24–S25 (2002). This paper introduces the construct of paediatric autoimmune neuropsychiatric disorders associated with Streptococcus (PANDAS).

  203. 203.

    Swedo, S. E. et al. High prevalence of obsessive-compulsive symptoms in patients with Sydenham’s chorea. Am. J. Psychiatry 146, 246–249 (1989).

  204. 204.

    Hounie, A. G. et al. Obsessive-compulsive spectrum disorders in rheumatic fever with and without Sydenham’s chorea. J. Clin. Psychiatry 65, 994–999 (2004).

  205. 205.

    Chang, K. et al. Clinical evaluation of youth with pediatric acute-onset neuropsychiatric syndrome (PANS): recommendations from the 2013 PANS Consensus Conference. J. Child Adolesc. Psychopharmacol. 25, 3–13 (2015).

  206. 206.

    Thienemann, M. et al. Clinical management of pediatric acute-onset neuropsychiatric syndrome: part I — psychiatric and behavioral interventions. J. Child Adolesc. Psychopharmacol. 27, 566–573 (2017).

  207. 207.

    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) (American Psychiatric Press, 2013).

  208. 208.

    Prado, H. S. et al. Sensory phenomena in obsessive-compulsive disorder and tic disorders: a review of the literature. CNS Spectr. 13, 425–432 (2008).

Download references

Author information

Introduction (D.J.S.); Epidemiology (D.J.S.); Mechanisms/pathophysiology (O.A.v.d.H.); Diagnosis, screening and prevention (C.L.); Management (E.C.M., D.L.C.C., R.G.S.); Quality of life (Y.C.J.R.); Outlook (H.B.S.); Overview of Primer (D.J.S.).

Correspondence to Dan J. Stein.

Ethics declarations

Competing interests

D.J.S. has received research grants and/or consultancy honoraria from Lundbeck and Sun, and is also on the scientific advisory board of the TLC Foundation for Body-Focused Repetitive Behaviours, the Anxiety and Depression Association of America (ADAA), and the South African Depression and Anxiety Support Group. D.L.C.C. has received consultancy honoraria from Pfizer and Libbs, and a scholarship from Fundação de Amparo à Pesquisa do Estado de Sao Paulo (Sao Paulo State Foundation for Research Support). E.C.M. has received a productivity grant from the Brazilian National Council for Scientific and Technological Development. Y.C.J.R. has been involved in a study on bipolar disorder, supported by GlaxoSmithKline, and is also lead author on clinical guidelines on OCD produced by the Indian Psychiatric Society. R.G.S. has received consultancy honoraria from Lundbeck, and she receives a productivity grant from the Brazilian National Council for Scientific and Technological Development. H.B.S. has received research grants from Biohaven Pharmaceuticals and royalties from UpToDate, Inc. and Cambridge University Press. She is also on the Board of Directors and the Scientific Advisory Board of ADAA, and is an Associate Editor at JAMA Psychiatry. All other authors declare no competing interests.

Additional information

Peer review information

Nature Reviews Disease Primers thanks D. Marazziti, D. Tolin, J. Piacentini, and the other, anonymous, reviewer(s), for their contribution to the peer review of this work.

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Related links

Astoc St: www.astocst.com.br

International OCD Foundation: https://iocdf.org/

OCD Action: http://www.ocdaction.org.uk

South African Depression and Anxiety Group: www.sadag.org

Supplementary information

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark