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ALL / Psychiatry

Obsessive-compulsive disorder

Obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.

An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person's mind. Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one's mind.

It is thought that 1 to 3% of the population have OCD.

Risk factors
  • family history
  • age: peak onset is between 10-20 years
  • pregnancy/postnatal period
  • history of abuse, bullying, neglect

Management
  • NICE recommend classifying impairment into mild, moderate or severe
    • they recommend the use of the Y-BOCS scale
    • an example of 'severe' OCD would be someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance
  • If functional impairment is mild
    • low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
    • If this is insufficient or can't engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP)
  • If moderate functional impairment
    • offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
    • consider clomipramine (as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated
  • If severe functional impairment
    • refer to the secondary care mental health team for assessment
    • whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider clomipramine as an alternative as above

Notes on treatments
  • ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
  • if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
  • compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response
+PassMedicine Notes

Obsessive-compulsive disorder (OCD) is characterised by the presence of either obsessions or compulsions, but commonly both. The symptoms can cause significant functional impairment and/ or distress.

An obsession is defined as an unwanted intrusive thought, image or urge that repeatedly enters the person's mind. Compulsions are repetitive behaviours or mental acts that the person feels driven to perform. A compulsion can either be overt and observable by others, such as checking that a door is locked, or a covert mental act that cannot be observed, such as repeating a certain phrase in one's mind.

It is thought that 1 to 3% of the population have OCD.

Risk factors
  • family history
  • age: peak onset is between 10-20 years
  • pregnancy/postnatal period
  • history of abuse, bullying, neglect
Management
  • NICE recommend classifying impairment into mild, moderate or severe
    • they recommend the use of the Y-BOCS scale
    • an example of 'severe' OCD would be someone who spends > 3 hours a day on their obsessions/compulsions, has severe interference/distress and has very little control/resistance
  • If functional impairment is mild
    • low-intensity psychological treatments: cognitive behavioural therapy (CBT) including exposure and response prevention (ERP)
    • If this is insufficient or can't engage in psychological therapy, then offer a choice of either a course of an SSRI or more intensive CBT (including ERP)
  • If moderate functional impairment
    • offer a choice of either a course of an SSRI (any SSRI for OCD but fluoxetine specifically for body dysmorphic disorder) or more intensive CBT (including ERP)
    • consider clomipramine (as an alternative first-line drug treatment to an SSRI) if the person prefers clomipramine or has had a previous good response to it, or if an SSRI is contraindicated
  • If severe functional impairment
    • refer to the secondary care mental health team for assessment
    • whilst awaiting assessment - offer combined treatment with an SSRI and CBT (including ERP) or consider clomipramine as an alternative as above
Notes on treatments
  • ERP is a psychological method which involves exposing a patient to an anxiety provoking situation (e.g. for someone with OCD, having dirty hands) and then stopping them engaging in their usual safety behaviour (e.g. washing their hands). This helps them confront their anxiety and the habituation leads to the eventual extinction of the response
  • if treatment with SSRI is effective then continue for at least 12 months to prevent relapse and allow time for improvement
  • compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response


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