Ep 88 – Obsessive–compulsive disorder

Obsessive–compulsive disorder (OCD) is a prevalent mental health condition characterised by persistent, intrusive thoughts (obsessions) and repetitive behaviours or mental acts (compulsions) aimed at alleviating anxiety. Individuals with OCD often find themselves trapped in a distressing cycle, as compulsions provide only temporary relief, perpetuating the need for repetition. OCD manifests in diverse forms, such as checking, counting or washing rituals, and its severity can range from mild to debilitating. Despite widespread misconceptions, OCD extends beyond a mere desire for order and cleanliness, impacting various aspects of daily life. Genetic, neurological, and environmental factors contribute to its development, and it often emerges in adolescence or early adulthood. In this episode, Dr Roger Henderson provides an overview of OCD, what we should be looking for to help identify patients with this condition, along with guidelines on effective treatments including cognitive behavioural therapy (CBT) and medication.

Key references

1. Veale D and Roberts A. BMJ. 2014;348:g2183. doi: 10.1136/bmj.g2183.
2. NICE. Obsessive-compulsive disorder and body dysmorphic disorder: treatment (CG31). 29 November 2005.
3. Gava I, et al. Cochrane Database Syst Rev. 2007;(2):CD005333. doi: 10.1002/14651858.CD005333.pub2.
4. Soomro GM, et al. Cochrane Database Syst Rev. 2008;2008(1):CD001765. doi: 10.1002/14651858.CD001765.pub3.
5. Del Casale A, et al. Curr Neuropharmacol. 2019;17(8):710-736. doi: 10.2174/1570159X16666180813155017.
6. Addictions and Recovery. Obsessive-Compulsive Test - Yale Brown OCD Scale YBOCS. Accessed 16 January 2024.

Key take-home points

• The WHO ranks OCD as one of the 10 most handicapping conditions by lost income and decreased quality of life.
• The peak age for onset is 15–25 years.
• OCD is characterised by the presence of obsessions or compulsions (often both). Obsessions are unwanted intrusive images, thoughts or urges that repeatedly cross someone’s mind. Compulsions are repetitive rituals, behaviours or mental acts that a person feels driven to do.
• OCD is likely underdiagnosed in practice, affecting up to 3% of adults.
• Obsessions or compulsions must be present for >1 hour/day, not imposed by external influences (originate in the mind) and be unpleasant and repetitive.
• There are multiple differential disorders to OCD.
• When assessing, consider using the Yale-Brown Obsessive-Compulsive Scale to grade severity.
• NICE recommends referring to a specialist multidisciplinary team offering age-appropriate care for management.
• Options include CBT, exposure and response prevention and medication – typically selective serotonin reuptake inhibitors (SSRIs).
• There appear to be no significant differences in efficacy between SSRIs when treating OCD. NICE suggests fluoxetine, citalopram, sertraline, paroxetine or fluvoxamine.
• Around 50% of people with OCD treated with an SSRI have an incomplete response.
• Alternatives to SSRIs include clomipramine and antipsychotics such as aripiprazole.