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 – recurrent, intrusive, unwanted thoughts, images or urges that provoke anxiety or distress – and/or compulsions – repetitive behaviours or mental acts performed to neutralise that distress. Most people have both. The hallmark is a self-perpetuating cycle: an intrusion triggers anxiety, a compulsion brings brief relief, and 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. Affecting roughly 1–2% of people, OCD is frequently concealed through shame and may be missed for years, so ask directly. Actively case-find in higher-risk groups – those with depression, anxiety, substance misuse, body dysmorphic disorder (BDD), an eating disorder, or attending dermatology – with simple questions such as whether they wash or check excessively, whether an unwanted thought keeps intruding, or 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 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. They 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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