Obsessive-compulsive disorder
Definition: OCD is characterized by recurrent obsessional thoughts or compulsive acts or, commonly, both, which may cause significant functional impairment and/or distress.
Risk factors
Age
Developmental factors
Family history
Pregnancy and the postnatal period
Differential diagnosis
Diagnosis
Illness anxiety disorder
Delusional disorder
Somatic symptom disorder
Autism spectrum disorder
Body dysmorphic disorder
Hoarding disorder
Obsessive-compulsive personality disorder
Trichotillomania
Substance-induced or medication-induced obsessive compulsie disorder
Excoriation
In children and young people: obsessional thoughts are more likely to include 'magical' or superstitious thinking and Members of the family are almost always involved in a young person's compulsive rituals.
People with OCD may also present in primary care with dermatological symptoms (from excessive washing), genital or anal symptoms (from excessive checking and washing), general stress (for example, from losing a job as a result of repeated lateness or from problems with interpersonal relationships), or doubts about contracting HIV.
Compulsions are repetitive behaviours or mental acts that the person feels driven by their obsession(s) to perform. A compulsion can either be overt and observable by others, or a covert mental act that cannot be observed. Common: repetitive hand washing; checking; ordering, arranging and/or repeating; mental compulsions; memory checking and avoidance of triggers.
Screen those with symptoms of depression, anxiety, alcohol or substance misuse, body dysmorphic disorder, or an eating disorder, and those reporting symptoms of OCD using the following questions: Do you wash or clean a lot? Do you check things a lot? Is there any thought that keeps bothering you that you would like to get rid of, but cannot? Do your daily activities take a long time to finish? Are you concerned about putting things in a special order, or are you upset by mess? Do these problems trouble you?
An obsession is defined as an unwanted intrusive thought, image, or urge that repeatedly enters the person's mind, and that usually causes marked anxiety or distress. Commonly: Contamination from dirt, germs, viruses, bodily fluids, chemicals, sticky substances, dangerous materials; fear of harm; excessive concern with order or symmetry; superstition, fear of 'bad' numbers 'magical' thinking, religious obsessions; 'forbidden' thoughts or images.
The diagnosis can be supported using criteria from the International Classification of Disease (ICD-10) and/or the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
People are often embarrassed and may not disclose symptoms. Direct questions may be required.
Management
For people being managed in primary care, provide written material about the nature of OCD and its treatment options.
Mild functional impairment: Psychological intervention - CBT. If unable to engage or response inadequate treat as for moderate.
Refer for specialist treatment people whose OCD and marked functional impairment are assessed as severe and/or exhibiting/at risk of: self-harm, self-neglect, significant comorbidity, or suicide.
Moderate functional impairment: Offer intesive CBT including ERP or a SSRI.
If the person is exhibiting severe distress and/or functional impairment, co-morbid depression or another mental health disorder, or other concerns have been raised, assess their risk of suicide and self-harm.
Severe functional impairment: Refer to secondary care mental health team for assessment. Consider SSRI and CBT.
Be aware OCD may co-exist with other mental health disorders.
SSRI: Escitalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline are all licensed for the treatment of OCD in adults. Discuss potential for adverse effects and withdrawal symptoms before drug treatment is initiated. Dose for treatment of OCD is higher and a longer duration (at least 12 weeks for an initial response).
Ask about effects on work/school/relationships/social life and quality of life. Gather more information on the initial six questions during diagnosis. Consider use of severity rating scale such as Yale-Brown Obsessive-Compulsive Scale.
Monitoring: be alert for suicidal ideation and assess risk. Monitor progress - including severity, duration of symptoms, degree of distress and functional impairment. Check adherence to treatment and any side effects from medication. If drug effective - advise the person to take it for at least a year. Re-evaluate the frequency required for follow up considering - person's preference, severity, comorbid conditions, change since last review, response to treatment and symptoms during treatment changes.