Obsessive-Compulsive Disorder (OCD)

🔍 When to Suspect

Recurrent, intrusive thoughts (obsessions) causing distress, leading to repetitive behaviours (compulsions) that are time-consuming (>1 hr/day)

From the full topic in The Ocean Library: Obsessive-Compulsive Disorder (OCD)

🧭 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

---