Topic Overview
What is obsessive-compulsive disorder (OCD)?
Obsessive-compulsive disorder (OCD) is a type of mental illness that
causes repeated unwanted thoughts. To get rid of the thoughts, a person does
the same tasks over and over. For example, you may fear that everything you
touch has germs on it. So to ease that fear, you wash your hands over and over
again.
OCD is a chronic, or long-term, illness that can take over
your life, hurt your relationships, and limit your ability to work or go to
school.
What causes OCD?
Experts don't know the exact
cause of obsessive-compulsive disorder. Research suggests that there may be a
problem with the way one part of the brain sends information to another part.
Not having enough of a brain chemical called serotonin may help cause the
problem.
Some experts believe that a
problem related to infections, such as
strep throat or
scarlet fever, can suddenly bring on the disorder or
make its symptoms worse in some children.
What are the symptoms?
Symptoms of
obsessive-compulsive disorder tend to come and go over time and range from mild
to severe.
Anxiety is the most common symptom. For example, you
may have an overall sense that something terrible will happen if you don't do a
certain task, such as check again and again to see whether the stove is on. If
you fail to check, you may suddenly feel tense or anxious or have a nagging
sense that you left something undone.
Symptoms of the disorder
include:
- Obsessions. These are
unwanted thoughts, ideas, and impulses that you have again and again. They
won't go away. They get in the way of your normal thoughts and cause anxiety or
fear. The thoughts may be sexual or violent, or they may make you worry about
illness or infection. Examples include:
- A fear of harm to yourself or a loved
one.
- A driving need to do things perfectly or
correctly.
- A fear of getting dirty or infected.
- Compulsions. These are
behaviours that you repeat to try to control the obsessions. Some people have
behaviours that are rigid and structured, while others have very complex
behaviours that change. Examples include:
- Washing, or checking that something has
been done.
- Counting, often while doing another compulsive action,
such as handwashing.
- Repeating things or always moving items to
keep them in perfect order.
- Hoarding.
- Praying.
The obsessions or compulsions usually take up a lot of
time-more than 1 hour a day. They greatly interfere with your normal routine at
work or school, and they affect social activities and relationships.
Sometimes people may understand that their obsessions and compulsions
are not real. But at other times they may not be sure, or they may believe
strongly in their fears.
How is OCD diagnosed?
Your doctor can check for
obsessive-compulsive disorder by asking about your symptoms and your past
health. He or she may also do a physical examination. It's important to talk to your
doctor if you think you have OCD. Many people with the disorder go without
treatment, because they are afraid or embarrassed to talk to a doctor.
How is it treated?
Treatment includes medicines
and counselling. Using both often works best.
Antidepressant
medicines called selective serotonin reuptake inhibitors (SSRIs) are most
commonly used. Examples of these medicines include Prozac and Zoloft. You may
begin to feel better in about 1 to 3 weeks after you start taking medicine. But
it can take as long as 12 weeks to see more improvement. If you have concerns
about your medicine, or if you do not start to feel better by 3 weeks, talk to
your doctor. He or she may increase the dose or change to a different medicine.
Counselling for the disorder includes a type of
cognitive-behavioural therapy called exposure and
response prevention. This therapy slowly increases your contact with the thing
that causes worries or false beliefs. For example, if you were worried about
getting germs from things you touch, you would touch an object you believe has
germs and then not wash your hands afterward. You would keep doing that until
you could do it without feeling anxious. This can be hard at first. But with
the help of a counsellor, this therapy can reduce your symptoms over
time.
Other cognitive therapy may also help change the false
beliefs that lead to OCD behaviours.
Treatment can make your
symptoms less severe. But you may still have some mild symptoms after you begin
treatment.
Frequently Asked Questions
Learning about obsessive-compulsive disorder (OCD): | |
Being diagnosed: | |
Getting treatment: | |
Ongoing concerns: | |
Living with obsessive-compulsive disorder: | |
Cause
Researchers have yet to pinpoint the
exact cause of
obsessive-compulsive disorder (OCD), but brain
abnormalities, genetic (family) influences, and environmental factors are being
studied. Brain scans of people with OCD have shown that they have different
patterns of brain activity than people without OCD and that abnormal
functioning of circuitry within a certain part of the brain (striatum) may
cause the disorder. Abnormalities in other parts of the brain and an imbalance
of brain chemicals, especially serotonin, may also contribute to OCD.1
Some experts believe that a
problem related to infections, such as
strep throat or
scarlet fever, can suddenly bring on the disorder or
make its symptoms worse in some children.
Symptoms
Obsessive-compulsive disorder (OCD) is a chronic or long-term illness, and without treatment,
symptoms typically come and go over time and may significantly interfere with
your ability to work and have a family. Treatment can reduce the severity of
the illness. And although some symptoms may linger after treatment, you should
be able to have an active social life, raise a family, and work.
Anxiety is the most prominent symptom of OCD. For example, you may have
an overall sense that something terrible will happen if you don't follow
through with a particular ritual, such as repeatedly checking to see whether
the stove is on. If you don't perform the ritual, you may have immediate
anxiety or a nagging sense of incompleteness.
Symptoms of OCD
vary with each person and include the following:2
Obsessive thoughts
- Fear of dirt or germs or overconcern about
body smells/secretions or the proper functioning of the
body
- Overconcern with order, neatness, and
exactness
- Fear of thinking bad thoughts or doing something
embarrassing
- Constantly thinking of certain sounds, words, or
numbers, or a preoccupation with counting or checking
- Constant need
for approval or the need to apologize
- Fear that something terrible
will happen or fear of harming yourself or someone else
Compulsive behaviours
- Frequently washing hands, showering, or
brushing teeth or the overuse of items to hide body
smells
- Constantly cleaning, straightening, and ordering certain
objects
- Repeatedly checking zippers and buttons on
clothing
- Checking lights, appliances, or doors again and again to
be sure they are turned off or closed
- Repeating certain physical
activities, such as sitting down and getting up from a
chair
- Hoarding objects, such as newspapers
- Asking the
same question or saying the same thing over and over
- Avoiding
public places or taking extreme measures to prevent harm to yourself or
others
- Religious rituals, such as constant silent praying
It is common for children with OCD to need to repeat
actions until they feel "just right," such as going back and forth through a
door, going up and down stairs, touching things with their right hand and then
their left (symmetrical touch), or rereading or rewriting school
assignments. Children with OCD may not want to go to
school or may be afraid to leave someone they trust.
You may
experience suicidal feelings if you have
depression along with OCD.
Warning signs of suicide include talking about death
or giving away possessions.
What Happens
With
obsessive-compulsive disorder (OCD), you develop
disturbing, obsessive thoughts that cause fear or anxiety. In order to rid
yourself of these thoughts and relieve the fear, you perform rituals, such as
repeated handwashing or checking that something has been done. Unfortunately,
the relief is only temporary. The thoughts return and you repeat the
rituals.
The rituals or behaviours become time-consuming and have a
significant impact on your daily life. If your particular fear involves
unfamiliar situations, it is possible for you to become so obsessed by the
fears that you stop going outside of your home. Quality of life can be
substantially lowered by OCD since it can greatly affect your ability to work
and have relationships.
Many people are too embarrassed by their
symptoms to seek treatment, and they go for years before seeing a doctor.
Symptoms of OCD can be reduced with treatment.
OCD can have a
negative effect on those who care about you. Family members can become angry
and frustrated at the strain the rituals or behaviours put on them. Talk to your
doctor about ways your
family members can help with OCD.
What Increases Your Risk
If you have a parent or
sibling with
obsessive-compulsive disorder (OCD), your chance of
developing OCD is increased.3
Your risk
for developing OCD is greatest from childhood to middle adulthood.3
When To Call a Doctor
It is important to seek treatment
for
obsessive-compulsive disorder (OCD) as soon as you
suspect you have it. Treatment will improve your quality of life as well as
the lives of your loved ones.
If you have OCD (especially with
depression) and are feeling suicidal, or if you know
someone with OCD who is feeling suicidal, call a doctor or
911 right away.
Warning signs of suicide include talking about death
or giving away possessions.
Watchful Waiting
Waiting to treat OCD is not appropriate. OCD
should be treated as soon as you suspect that you or someone you care about has
the disorder.
Who To See
While your family doctor or general practitioner can diagnose, treat, and monitor obsessive-compulsive disorder (OCD), you may need to partner with a health professional who has had specific training in OCD management.
For example, you may be referred to a psychiatrist.
Other health professionals who can provide ongoing
counselling and support for OCD but cannot prescribe medicines include:
To prepare for your appointment, see the topic Making the Most of Your Appointment.
Examinations and Tests
A diagnosis of
obsessive-compulsive disorder (OCD) is based on your
symptoms, medical history, and a physical examination. Your doctor may also
want a
mental health assessment, which is an evaluation of
your emotional functioning and your ability to think, reason, and remember
(cognitive functioning). A mental health assessment may include an examination
of your
nervous system, written or verbal tests, and
laboratory tests (such as blood and urine tests) as well as a review of your
appearance, mood, behaviour, thinking, reasoning, memory, and ability to express
yourself.
Many people with OCD live with the condition for years
before being diagnosed, or they go without treatment because they are afraid or
embarrassed to talk about their symptoms. Answers to three questions
may help your health professional diagnose whether you have OCD:4
- Do you have repeated thoughts that cause
anxiety and that you cannot get rid of no matter how hard you
try?
- Do you wash your hands frequently or keep things extremely
clean and neat?
- Do you excessively check things?
If your doctor suspects you have OCD, he or
she will look for a full range of symptoms that will confirm the diagnosis,
including:5
- Recurrent and persistent thoughts, impulses, or
images that are intrusive and inappropriate, cause anxiety or distress, and are
not simply excessive worries about real-life issues.
- Attempts to
suppress or ignore the thoughts or get rid of them with other thoughts or
actions.
- A recognition that the obsessions are created in your own
mind and don't make sense.
- Repetitive behaviours, such as
handwashing, ordering, praying, or checking that you're driven to do in
response to the obsession. The behaviours are aimed at preventing or reducing
distress or preventing a dreaded event.
For a diagnosis of OCD, the obsessions or compulsions must
be time-consuming (more than 1 hour a day) or greatly interfere with your
normal routine at work or school and affect social activities and
relationships.
Early Detection
Early detection and proper treatment is very
important in improving the course of OCD. This disorder is often a long-lasting
(chronic) condition that will need to be monitored throughout your life.
Treatment Overview
The earlier you seek treatment for
obsessive-compulsive disorder (OCD), the better. Early
treatment of OCD can reduce symptoms and reduce the disruption the illness can
create in your life. Unfortunately, research shows that most people see an
average of 3 to 4 health professionals and spend more than 9 years seeking
treatment for OCD before they are correctly diagnosed.4 Their diagnoses are complicated by their being embarrassed or
secretive about their symptoms and by other conditions they may have along with
OCD, such as depression.
Treatment includes a combination of
professional counselling and medicines.
Initial treatment
Depending on the severity of
your symptoms, your doctor may prescribe only counselling or counselling and an
antidepressant, such as fluoxetine (for example,
Prozac), fluvoxamine (Luvox), or sertraline (Zoloft). For severely ill people
who cannot function in a job or in social situations because of their symptoms,
it is recommended that medicines be tried first before counselling.4
Obsessive-Compulsive Disorder: Should I Take Medicine for OCD?
A type of
cognitive-behavioural therapy called
exposure and response prevention is considered the
most effective type of counselling for
OCD.4 With exposure and
response prevention therapy, you repeatedly expose yourself to an obsession,
such as something you fear is contaminated, and deny yourself the ritual
compulsive act, which in this case would be washing your hands. This therapy is
done with a therapist or on your own with direction from your therapist.
In the beginning of exposure and response prevention therapy, your
therapist may ask you to write a list of your obsessions, rituals
(compulsions), and things that you avoid and then have you rank the amount of
anxiety each of the obsessions causes from highest to lowest. You might begin
exposing yourself to an obsession that causes a moderate amount of anxiety and
then work your way up the list to the obsession that causes the most
anxiety.
Therapists often combine exposure and response prevention
therapy with cognitive-behavioural therapy to help overcome the faulty beliefs
(such as fear of contamination) that lead to OCD behaviours.
Your doctor may first prescribe an antidepressant called
a selective serotonin reuptake inhibitor (SSRI), such as fluoxetine (for
example, Prozac), or a tricyclic antidepressant, such as clomipramine. You may
start to feel better within 1 to 3 weeks of taking an SSRI. But it can take as
many as 12 weeks to see more improvement. If you have questions or concerns
about your medicines, or if you do not notice any improvement by 3 weeks, talk
to your doctor. Your doctor may increase the dosage of your medicine or change
to another SSRI if the first medicine prescribed doesn't help.
Ongoing treatment
Ongoing treatment for
OCD includes monitoring the dosage and effectiveness
of your medicines. Your doctor may want you to stay on one medicine for at
least 10 to 12 weeks before trying a different antidepressant. Although
antidepressants are considered the most effective medicine for OCD, researchers
are studying whether other medicines can be
combined with antidepressants for better results.
If you are in
counselling, your doctor will monitor your progress and, if necessary, modify
the amount or type of counselling you're receiving. Research shows that those
who receive the most counselling have the best results and that longer sessions
(at least 90 minutes) of exposure and response prevention therapy are more
effective for reducing anxiety than short sessions.4
Between 13 and 20 sessions may be needed to relieve symptoms. Your doctor may also advise family members to participate in therapy with you
or on their own.
Treatment if the condition gets worse
Deep brain
stimulation, which uses surgically implanted electrodes in the brain, and
magnetic stimulation of parts of the brain may be tried in rare cases of
OCD when other treatment has not been
successful.
What to Think About
Consistency is important for
both counselling and medicines. People who don't take their medicines regularly
or stop altogether often have their symptoms return (relapse). With
therapy, it is important to work with your doctor to find out when, or if, you
should stop.
If you need help deciding whether to see your doctor,
see some
reasons why people don't get help and how to overcome
them.
Prevention
You cannot prevent
obsessive-compulsive disorder (OCD) from starting. But
the best way to prevent a relapse of OCD symptoms is by staying with your
therapy and taking any medicines exactly as they have been prescribed.
Home Treatment
Taking care of yourself every day is
important in dealing with
obsessive-compulsive disorder (OCD). This includes
taking your medicines as directed every day and doing the homework your
therapist gives you to do at home, such as self-directed exposure and response
prevention exercises. With exposure and response prevention therapy, you
repeatedly expose yourself to an obsession, such as something you fear is
contaminated, and deny yourself the ritual compulsive act, which in this case
would be washing your hands.
It's also important to involve family
members and loved ones in your treatment, especially if your doctor suggested you participate in therapy together. Keeping lines of
communication open may help you deal with relationships that have become
strained during your illness.
Reducing overall stress in your
life, although not proven treatment for OCD symptoms, may help you cope.
Stress- and anxiety-relieving tips include:
- Taking slow, deep breaths.
- Soaking
in a warm bath.
- Listening to soothing music.
- Taking a
walk or doing some other exercise.
- Taking a yoga
class.
- Having a massage or back rub.
- Drinking a warm,
nonalcoholic, non-caffeinated beverage.
Eating a healthy, balanced diet and avoiding certain foods
or drinks may also help you reduce stress.
- Avoid or limit caffeine. Coffee, tea, some soda
pop, and chocolate contain caffeine. Caffeine can make stressful situations
seem more intense. If you drink a lot of caffeine, reduce the amount gradually.
Stopping use of caffeine suddenly can cause headaches and make it hard to
concentrate.
- If you drink alcohol, do so in moderation. If you
are feeling very stressed, you might be turning to alcohol for relief more
often than you realize. If you drink, limit yourself to 2 drinks a day for men
and 1 drink a day for women.
- Make mealtimes calm and relaxed. Try not to skip
meals or eat on the run. Skipping meals can cause your blood sugar to drop,
which will make other stress-related symptoms worse, such as headaches or
stomach tension. make other stress-related symptoms worse, such as headaches or
stomach tension. Eating on the run can cause indigestion. Use mealtime to
relax, enjoy the flavour of your meal, and reflect on your day.
- Avoid eating to relieve stress. Some people turn to
food to comfort themselves when they are under stress. This can lead to
overeating and guilt. If this is a problem for you, try to replace eating with
other actions that relieve stress, like taking a walk, playing with a pet, or
taking a bath.
For more information, see the topic Stress
Management.
Medications
After you are diagnosed with
obsessive-compulsive disorder (OCD), your doctor will
likely prescribe antidepressants known as selective serotonin reuptake
inhibitors (SSRIs), such as fluoxetine (for example, Prozac). Antidepressants
are thought to help balance
neurotransmitters (such as serotonin) in your
brain.
In some cases it takes time to adjust the dosage or find
the right medicine that will work for you. You may start to feel better within
1 to 3 weeks of taking an SSRI. But it can take as many as 12 weeks to see more
improvement. If you have questions or concerns about your medicines, or if you
do not notice any improvement by 3 weeks, talk to your doctor. Your doctor may
increase the dosage of your medicine, change to another SSRI, or use another
medicine known as clomipramine if the medicine first prescribed does not help.
Clomipramine, a tricyclic antidepressant, has been used for years to treat OCD,
but it may have more side effects than SSRIs.
Your doctor may
prescribe other medicines if you have other conditions along with OCD.
Medication Choices
Antidepressants (SSRIs) such as fluoxetine (for
example, Prozac), fluvoxamine (Luvox), and sertraline (Zoloft) are commonly
prescribed to treat OCD. These medicines are taken as tablets or capsules. The
medicine venlafaxine can also help symptoms of OCD. The tricyclic
antidepressant clomipramine (Anafranil) is sometimes used as well.
Antidepressants are used to relieve the obsessive thoughts and subsequent
compulsive behaviours in those who have OCD. By increasing the level of
serotonin in the brain, antidepressants help to regulate the communication
between different parts of the brain.
Other medicines
(such as antipsychotics) are sometimes used to treat OCD.
What to Think About
A person with OCD may also have
other anxiety disorders that complicate treatment and require using other
medicines.
For children and adolescents with OCD, treatment
combining
cognitive-behavioural therapy with antidepressants
(SSRIs), such as sertraline, works better than only taking medicine.
Cognitive-behavioural therapy alone also works well, but it works better if it
is combined with medicine.6
Surgery
In rare cases, deep brain stimulation, which
uses surgically implanted electrodes in the brain, and magnetic stimulation of
parts of the brain are done for severe
obsessive-compulsive disorder (OCD) that does not
respond to other treatments.
Other Treatment
Current research shows
that behaviour therapy can be as effective as medicine for the treatment of
obsessive-compulsive disorder (OCD).4 But you and your doctor will need to decide whether you will
be treated only with therapy or with therapy and medicine.
Types of counselling that have proved effective in treating OCD
include:
- Exposure and response prevention (ERP) therapy, a type of
cognitive-behavioural therapy in which you repeatedly
expose yourself to an obsession, such as something you fear is contaminated,
and deny yourself the ritual compulsive act, which in this case may be washing
your hands.
- Cognitive therapy may also be used to help overcome the
faulty beliefs (such as fear of contamination) that lead to OCD
behaviours.
You and your loved ones may choose to go to
family therapy. During family therapy, the counsellor
teaches the family about the condition, offers them support, and gives them
suggestions on how to help you with OCD. Family therapy may be very important
for other family members who are having difficulty coping with the effects of
your illness.
Other Places To Get Help
Organizations
| International OCD Foundation (IOCDF) |
| P.O. Box 961029 |
| Boston, MA 02196 |
| Phone: | (617) 973-5801 |
| Fax: | (617) 973-5803 |
| Email: | info@ocfoundation.org |
| Web Address: | http://www.ocfoundation.org |
| |
The International OCD Foundation distributes bimonthly newsletters, articles,
videos, and pamphlets with the latest research and resource information for
people who have OCD and their and families. The foundation sponsors membership
conferences and research awards and organizes and promotes OCD-related support
groups. |
|
| Anxiety Disorders Association of
Canada |
| Phone: | 1-888-223-2252 |
| Email: | contactus@anxietycanada.ca |
| Web Address: | www.anxietycanada.ca |
| |
The Anxiety Disorders Association of Canada promotes public and professional awareness of anxiety
disorders, encourages research into the causes of anxiety disorders, and
advocates for improved access to treatment and support for people experiencing
anxiety disorders and their families. |
|
| Canadian Mental Health Association |
| 595 Montreal Road |
| Suite 303 |
| Ottawa, ON K1K 4L2 |
| Phone: | (613) 745-7750 |
| Fax: | (613) 745-5522 |
| Web Address: | www.cmha.ca |
| |
The Canadian Mental Health Association (CMHA) promotes
mental health and focuses on combatting mental health problems and emotional
disorders. The organization offers workshops, pamphlets, newsletters, and other
educational materials as well as contact information for local branches. |
|
References
Citations
- Abramowitz SA, et al. (2009). Obsessive-compulsive disorder. Lancet, 374: 491–499.
- American Psychiatric Association (2000).
Obsessive-compulsive personality disorder. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp.
725–729. Washington, DC: American Psychiatric Association.
- Sadock BJ, Sadock VA (2007). Obsessive-compulsive
disorder. In Kaplan and Sadock's Synopsis of Psychiatry, Behavioral Sciences/Clinical Psychiatry, 10th ed., pp. 604–612.
Philadelphia: Lippincott Williams and Wilkins.
- Jenike MA, (2004). Clinical practice:
Obsessive-compulsive disorder. New England Journal of Medicine, 350(3): 259–265.
- American Psychiatric Association (2000). Obsessive-compulsive
disorder. In Diagnostic and Statistical Manual of Mental Disorders,
4th ed., text rev., pp. 456–463. Washington, DC: American Psychiatric Association.
- The Pediatric OCD Treatment Study (POTS) Team (2004). Cognitive-behavioral therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. Journal of the American Medical Association, 292(16): 1969–1976.
Other Works Consulted
- American Psychiatric Association (2007). Practice guideline for the treatment of patients with obsessive-compulsive disorder. American Psychiatric Association, Arlington, VA. Available online at www.psych.org/psych_pract/treatg/pg/prac_guide.cfm.
- Lewin AB, Piacentini J (2009). Obsessive-compulsive disorder in children. In BJ Sadock, VA Sadock, eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 9th ed., vol. 2, pp. 3671–3678. Philadelphia: Lippincott Williams and Wilkins.
- McClure-Tone EB, Pine DS (2009). Clinical features of Anxiety disorders. In BJ Sadock et al., eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 9th ed., vol. 1, pp. 1844–1856. Philadelphia: Lippincott Williams and Wilkins.
- Sadock BJ, Sadock VA (2007). Obsessive-compulsive
disorder of infancy, childhood, and adolescence. In Kaplan and Sadock's Synopsis of Psychiatry, Behavioral Sciences/Clinical Psychiatry, 10th ed., pp. 1270–1273. Philadelphia: Lippincott Williams
and Wilkins.
- Soomro GM (2009). Obsessive compulsive disorder, search date August 2007. Online version of BMJ Clinical Evidence. Available online: www.clinicalevidence.com.
- Stanley MA, Beidel DC (2009). Behavior therapy. In BJ Sadock, VA Sadock, eds., Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 9th ed., vol. 2, pp. 2781–2804. Philadelphia: Lippincott Williams and Wilkins.
Credits
| By | Healthwise Staff |
|---|
| Primary Medical Reviewer | Kathleen Romito, MD - Family Medicine |
|---|
| Primary Medical Reviewer | Donald Sproule, MD, CM, CCFP, FCFP - Family Medicine |
|---|
| Specialist Medical Reviewer | Lisa S. Weinstock, MD - Psychiatry |
|---|
| Last Revised | November 17, 2010 |
|---|
Abramowitz SA, et al. (2009). Obsessive-compulsive disorder. Lancet, 374: 491–499.
American Psychiatric Association (2000).
Obsessive-compulsive personality disorder. In Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev., pp.
725–729. Washington, DC: American Psychiatric Association.
Sadock BJ, Sadock VA (2007). Obsessive-compulsive
disorder. In Kaplan and Sadock's Synopsis of Psychiatry, Behavioral Sciences/Clinical Psychiatry, 10th ed., pp. 604–612.
Philadelphia: Lippincott Williams and Wilkins.
Jenike MA, (2004). Clinical practice:
Obsessive-compulsive disorder. New England Journal of Medicine, 350(3): 259–265.
American Psychiatric Association (2000). Obsessive-compulsive
disorder. In Diagnostic and Statistical Manual of Mental Disorders,
4th ed., text rev., pp. 456–463. Washington, DC: American Psychiatric Association.
The Pediatric OCD Treatment Study (POTS) Team (2004). Cognitive-behavioral therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study (POTS) randomized controlled trial. Journal of the American Medical Association, 292(16): 1969–1976.
