Symmetry obsessions

The most common obsessions faced by patients with OCD involve fears of contamination. This fear may focus on germs and infectious diseases, household chemicals, environmental pollutants, or bodily wastes. These contamination obsessions most often result in washing compulsions but may also produce compulsive visits to health care providers. Obsessional doubts (e.g., Did I remember to. .. ) are typically associated with checking compulsions. Another common obsession, need for symmetry and exacmess, leads to compulsive arranging, ordering, or counting. Obsessions may also be aggressive, somatic, or sexual in content. 

Augmentation is called for when there is partial or non-response to the above approaches. Combinations of SSRIs with buspirone, clonazepam, clonidine, inositol, lithium, pindolol, olanzapine, risperidone, trazodone, tryptophan, and venlafaxine have been reported, with limited benefit. To date, only two augmenting agents have been found to be effective in double-blind studies risperidone and pindolol. Augmentation of SSRIs with clomipramine (or vice versa) is a common practice in non-responders however, this combination may lead to a substantial increase in the level of tricyclics in the blood and/or increase the risk of serotonin syndrome. Phenelzine may be helpful in symmetry-related or other atypical obsessions. Electroconvulsive therapy (ECT) should be reserved for severely depressed and suicidal OCD patients. Neurosurgery is the last resort current operations include anterior cingulotomy, anterior capsulotomy, subcaudate tractotomy, and limbic leucotomy. The outcome of such operations is questionable. 

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