Obsessive-compulsive disorder

Last reviewed: April 2019

Last updated: December 2018

Summary

Obsessions and/or compulsions that cause marked distress, are time consuming (take more than 1 hour per day), or interfere substantially with the person's normal routine, occupational or academic functioning, or usual social activities or relationships.

If the content of the obsessions or compulsions is limited to the scope of another psychiatric disorder, such as an obsession with food in the context of an eating disorder, then an additional diagnosis of OCD should not be made.

The Yale-Brown Obsessive-Compulsive Scale is useful in grading severity initially and following trials of therapy.

Patients tend to seek treatment from 3 to 4 doctors and spend on average around 9 years in treatment before a correct diagnosis is made. The average amount of time that lapses between onset of symptoms and appropriate treatment is 17 years.

Cognitive behavioural therapy in the form of exposure and response prevention, alone or in combination with a selective serotonin-reuptake inhibitor (SSRI) or clomipramine, is a first-line therapy.

While controlled trials with SSRIs have demonstrated a selective efficacy in OCD, up to 40% to 60% of patients do not have a satisfactory outcome.

Definition

Obsessive-compulsive disorder (OCD) is a frequently debilitating and often severe anxiety disorder that affects approximately 2% of the population. OCD is characterised by: (a) obsessions, defined as unwanted, disturbing, and intrusive thoughts, images, or impulses that are generally seen by the patient as excessive, irrational, and ego-alien; and (b) compulsions, defined as repetitive behaviours and mental acts that neutralise obsessions and reduce emotional distress. OCD causes significant distress and impairment in daily functioning and can have a substantial effect on the sufferer's quality of life. [1]

History and exam

Key diagnostic factors

presence of risk factors
obsessions
compulsions
schizotypal personality disorder
tic disorder
poor motor coordination
sensory perceptual difficulties
difficulties in sequencing of complex motor tasks

Full details

Other diagnostic factors

male gender

Full details

Risk factors

FHx of OCD
PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection)
pregnancy
male gender (earlier onset, more chronic course, treatment resistance)
higher frequency of compulsions (treatment resistance)
early age of onset (treatment resistance)
previous hospitalisations for OCD (treatment resistance)
schizotypal personality disorder (treatment resistance)
tic disorder (treatment resistance)
specific or diffuse brain structural abnormalities (treatment resistance)

Full details

Diagnostic investigations

1st investigations to order

no initial test

Full details

Investigations to consider

structured clinical interview for the DSM (SCID)
Yale-Brown Obsessive-Compulsive Scale
clinical global impression (CGI)

Full details

Treatment algorithm

ACUTE

mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms

severe symptoms or with comorbid personality disorders or dissociative symptoms

Contributors

Authors VIEW ALL 

Phillip J. Seibell, MD, FAPA

OCD and Anxiety Psychiatry of Westchester, P.C.

Hawthorne

Disclosures

PJS has received honoraria from Slack, Inc., for guest editing an issue on OCD.

Stefano Pallanti, MD, PhD

Professor of Psychiatry

Institute of Neuroscience

Florence

Italy

Disclosures

SP declares that he has no competing interests. SP is an author of several references cited in this monograph.

Silvia Bernardi, MD

Project Manager

New York State Psychiatric Institute

Columbia University

New York

Disclosures

SB receives research sponsorship from NYSPI, APA, and the Brain & Behavior Research Foundation. SB is also a board member of the New York council on Problem Gambling. SB is an author of a reference cited in this monograph.

Megan Hughes-Feltenberger, PhD

Assistant Professor of Psychology in Psychiatry

Assistant Director of Education for Psychology

Weill Cornell Medical College

Assistant Attending Psychologist

NewYork-Presbyterian Hospital

New York

Disclosures

MHF declares that she has no competing interests.

Eric Hollander, MD

Clinical Professor of Psychiatry and Behavioral Sciences

Director

Compulsive, Impulsive and Autism Spectrum Disorder Program

Albert Einstein College of Medicine

Montefiore Medical Center

New York

Disclosures

EH declares that he has no competing interests.

Acknowledgements

The authors would like to gratefully acknowledge Dr Ashley Braun, a previous contributor to this monograph. AB declares that she has no competing interests.

Peer reviewers VIEW ALL 

Juliana Belo Diniz, MD

Psychiatrist

Department and Institute of Psychiatry

Clinical Hospital

University of Sao Paulo Medical School

Sao Paulo

Brazil

Disclosures

JBD declares that she has no competing interests.

Amit Nigam, MBBS, MRCPsych

Specialist Registrar in Forensic Psychiatry and Honorary Research Worker

National OCD Service

Queen Elizabeth II Hospital

Welwyn Garden City

Forensic Psychiatrist

West London Mental Health NHS Trust

London

Disclosures

AN declares that he has no competing interests.

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Obsessive-compulsive disorder

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms

severe symptoms or with comorbid personality disorders or dissociative symptoms

Contributors

Authors VIEW ALL 

Phillip J. Seibell, MD, FAPA

Disclosures

Stefano Pallanti, MD, PhD

Disclosures

Silvia Bernardi, MD

Disclosures

Megan Hughes-Feltenberger, PhD

Disclosures

Eric Hollander, MD

Disclosures

Acknowledgements

Peer reviewers VIEW ALL 

Juliana Belo Diniz, MD

Disclosures

Amit Nigam, MBBS, MRCPsych

Disclosures

Differentials

Guidelines

Patient leaflets

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