Obsessive compulsive disorder

Specialties > General practice

Background knowledge 🧠

Definition

Obsessive-compulsive disorder (OCD) is a chronic mental health condition characterized by recurrent, intrusive thoughts (obsessions) and repetitive behaviors or mental acts (compulsions) performed to alleviate anxiety.
Obsessions and compulsions are time-consuming and cause significant distress or impairment in social, occupational, or other important areas of functioning.

Epidemiology

Lifetime prevalence in the UK is approximately 1-2%.
Slightly more common in females, but males tend to have an earlier onset.
Onset typically occurs in late adolescence or early adulthood.
Often underdiagnosed and undertreated.

Aetiology and Pathophysiology

Exact cause is unknown, but involves a combination of genetic, neurobiological, and environmental factors.
Dysregulation of serotonin is implicated; SSRIs are effective treatment.
Structural and functional abnormalities in the cortico-striato-thalamo-cortical (CSTC) circuit.
Family history is a significant risk factor.

Types

OCD can be classified by predominant obsession or compulsion: contamination, symmetry/order, forbidden thoughts, and harm.
Symmetry/order and contamination are the most common subtypes.
Symptoms can vary in severity and may fluctuate over time.
PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections) is a controversial subtype.

Clinical Features 🌡️

Symptoms

Obsessions: intrusive, unwanted thoughts, images, or urges causing marked anxiety (e.g., fear of contamination).
Compulsions: repetitive behaviors or mental acts performed to reduce anxiety (e.g., excessive washing, checking).
Patients often recognize these thoughts and behaviors as irrational, yet feel compelled to perform them.
Avoidance of triggers is common and can lead to significant functional impairment.

Signs

Physical signs may include skin lesions due to excessive washing or hair loss from trichotillomania (compulsion to pull hair).
Behavioral signs include repetitive actions, avoidance behaviors, and distress or frustration when rituals are interrupted.
Co-existing depression or anxiety is common.
Impact on social and occupational functioning often significant.

Investigations 🧪

Tests

Diagnosis is primarily clinical; based on DSM-5 or ICD-11 criteria.
Yale-Brown Obsessive Compulsive Scale (Y-BOCS) can be used to assess severity.
Screening for comorbid conditions, such as depression, anxiety, or substance abuse.
Consider neuroimaging if secondary causes of symptoms are suspected (e.g., brain injury).

Management 🥼

Management

First-line treatment includes cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP).
Selective serotonin reuptake inhibitors (SSRIs) are the pharmacological treatment of choice.
Consider augmentation with antipsychotics if response to SSRIs is inadequate.
Severe or refractory cases may require specialist referral and consideration of neurosurgical options (e.g., deep brain stimulation).
Patient education and involvement in treatment planning is crucial.

Complications

High comorbidity with depression and anxiety disorders.
Increased risk of suicidal ideation and attempts.
Social isolation, relationship difficulties, and occupational impairment.
Physical complications from compulsive behaviors (e.g., dermatitis from washing).

Prognosis

Chronic course with waxing and waning symptoms.
Approximately 40-60% respond well to treatment with CBT and/or SSRIs.
Early treatment and adherence to therapy improve outcomes.
Some patients may experience significant, long-term impairment.
Long-term follow-up is often required.

Key Points

OCD is a common, often debilitating disorder characterized by obsessions and compulsions.
Diagnosis is clinical; severity can be assessed using the Y-BOCS scale.
Management includes CBT with ERP, SSRIs, and potentially augmentation with antipsychotics.
Prognosis varies, with some patients experiencing chronic symptoms despite treatment.
Early intervention and long-term management are crucial for better outcomes.

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