What is a compulsion and how is it treated?

What is a Compulsion?

A compulsion is a repetitive behavior (such as hand washing, ordering, or checking) or mental act (such as praying, counting, or repeating words silently) that a person feels driven to perform in response to an obsession or according to rigid rules, aimed at preventing or reducing anxiety or distress—though these behaviors are not realistically connected to what they are designed to neutralize or are clearly excessive. 1

Core Defining Features

According to DSM-5 diagnostic criteria, compulsions have two essential characteristics 1:

• Repetitive and driven nature: The individual feels compelled to perform these behaviors or mental acts, experiencing an internal sense of being "driven" to complete them 1
• Purpose and disconnect: These acts aim to prevent or reduce anxiety/distress or prevent a dreaded event, but they are either not connected in a realistic way with what they are designed to neutralize or are clearly excessive 1

Common Examples of Compulsions

The most frequently observed compulsions include 1:

• Washing/cleaning in response to contamination concerns
• Checking related to fears of harm to self or others
• Mental rituals (such as praying or counting) in response to intrusive aggressive or sexual thoughts
• Ordering/arranging driven by symmetry concerns

Critical Distinction: Compulsions vs. Impulsive Behaviors

A common pitfall is confusing compulsions with impulsive behaviors—they are fundamentally different. 2

• Compulsions are ego-dystonic: They are performed to reduce anxiety, not to achieve gratification, and patients recognize them as excessive and wish they had more control over them 1, 2
• Impulsive behaviors are ego-syntonic: They provide gratification and are characteristic of conditions like ADHD, bipolar disorder, and substance use disorders—not OCD 2
• DSM-5 explicitly excludes impulse-control disorders from the differential diagnosis of OCD, emphasizing this distinction 1, 2

Clinical Significance for Diagnosis

For compulsions to meet diagnostic criteria for OCD 1:

• They must be time-consuming (taking more than 1 hour per day) OR
• Cause clinically significant distress or impairment in social, occupational, or other important functioning
• They cannot be better explained by substance effects, another medical condition, or another mental disorder 1

How Compulsions Are Treated

First-Line Pharmacotherapy

Initiate treatment with a selective serotonin reuptake inhibitor (SSRI) for 10-12 weeks at adequate doses, as SSRIs have superior safety and tolerability compared to clomipramine while maintaining equivalent efficacy. 3

FDA-approved medications include 4, 5:

• Sertraline: Established efficacy in 12-week trials, with patients experiencing marked reduction in obsessions and compulsions 5
• Clomipramine: Demonstrated 35-42% improvement on the Yale-Brown Obsessive Compulsive Scale in adults and 37% in children/adolescents, with mean reduction of approximately 10 points 4

First-Line Psychotherapy

Cognitive-behavioral therapy in the form of exposure and response prevention (ERP) is a mainstay of treatment alongside medication. 6

• ERP involves exposing patients to anxiety-provoking stimuli while preventing the compulsive response 6
• This approach directly targets the compulsion-obsession cycle 6

Treatment-Resistant Cases

For patients who do not respond to initial SSRI treatment 3, 6:

• Switch to a different SSRI as the first alternative 3
• Add antipsychotic augmentation as the most commonly employed pharmacological strategy 6
• Combine medication with behavioral therapy if not already implemented 3
• Consider neurosurgical procedures (gamma knife radiation, deep brain stimulation) only for severe, treatment-refractory disease that has failed multiple treatments 6