Obsessive-compulsive disorder (OCD) is a mental health disorder in which obsessions and/or compulsions 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.
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.
History and exam
Key diagnostic factors
- presence of risk factors
- schizotypal personality disorder
- tic disorder
- poor motor coordination
- sensory perceptual difficulties
- difficulties in sequencing of complex motor tasks
Other diagnostic factors
- male sex
- family history of OCD
- PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection)
- male sex (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)
1st investigations to order
- no initial test
Investigations to consider
- structured clinical interview for the DSM (SCID)
- Yale-Brown Obsessive-Compulsive Scale
- clinical global impression (CGI)
mild to moderate symptoms: without comorbid personality disorders or dissociative symptoms
severe symptoms or with comorbid personality disorders or dissociative symptoms
Phillip J. Seibell, MD, FAPA
OCD and Anxiety Psychiatry of Westchester, P.C.
PJS has received honoraria from Slack, Inc., for guest editing an issue on OCD.
Stefano Pallanti, MD, PhD
Professor of Psychiatry
Institute of Neuroscience
SP declares that he has no competing interests. SP is an author of several references cited in this topic.
Silvia Bernardi, MD
New York State Psychiatric Institute
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 topic.
Megan Hughes-Feltenberger, PhD
Assistant Professor of Psychology in Psychiatry
Assistant Director of Education for Psychology
Weill Cornell Medical College
Assistant Attending Psychologist
MHF declares that she has no competing interests.
Eric Hollander, MD
Clinical Professor of Psychiatry and Behavioral Sciences
Compulsive, Impulsive and Autism Spectrum Disorder Program
Albert Einstein College of Medicine
Montefiore Medical Center
EH declares that he has no competing interests.
The authors would like to gratefully acknowledge Dr Ashley Braun, a previous contributor to this topic. AB declares that she has no competing interests.
Juliana Belo Diniz, MD
Department and Institute of Psychiatry
University of Sao Paulo Medical School
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
West London Mental Health NHS Trust
AN declares that he has no competing interests.
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