GPAtlas🧭 When to suspect
Obsessive-compulsive disorder (OCD) is defined by obsessions and/or compulsions. Most people have both.
• Obsessions – recurrent, intrusive, unwanted thoughts, images or urges that provoke anxiety or distress.
• Compulsions – repetitive behaviours or mental acts performed to neutralise that distress.
The hallmark is a self-perpetuating cycle:
• An intrusion triggers anxiety.
• A compulsion brings brief relief.
• That relief reinforces the behaviour, with avoidance layered on top.
Suspect OCD when symptoms are time-consuming – often more than an hour a day – and cause significant distress or interfere with work, study, relationships or self-care.
OCD affects roughly 1–2% of people. It is frequently concealed through shame and may be missed for years, so ask directly.
Actively case-find in higher-risk groups:
• Depression
• Anxiety
• Substance misuse
• Body dysmorphic disorder (BDD)
• An eating disorder
• Attending dermatology
Ask simple questions such as:
• Whether they wash or check excessively
• Whether an unwanted thought keeps intruding
• Whether everyday tasks take a long time to finish
The two core primary-care skills are to recognise it (because patients hide it) and to match treatment intensity to functional impairment, escalating risk promptly.
| Functional impairment | Typical picture | First-line management |
|---|---|---|
| Mild | • Limited interference • Symptoms occupy relatively little of the day, or the patient prefers a low-intensity approach |
Low-intensity CBT with exposure and response prevention (ERP) – guided self-help, by telephone, or group |
| Moderate | Clear interference with daily functioning | Choice of more intensive CBT with ERP or an SSRI (comparably effective) |
| Severe | • Marked distress and impairment • May be unable to function or housebound |
Combined SSRI plus intensive CBT with ERP |
|
🧠 Clinical pearl • Intrusive thoughts of a violent, sexual or blasphemous nature – harming a loved one, a fear of being a paedophile, distressing religious images – are common, ego-dystonic features of OCD and are not a sign the person will act on them. • These thoughts are routinely misread as risk. • The very distress the thought causes is itself a clue that this is OCD. • Recognise and reassure rather than over-pathologise – while still taking a genuine risk history. |
Source: NICE CG31
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