Obsessive-compulsive disorder

Obsessive-Compulsive Disorder (OCD) is a chronic psychiatric disorder characterized by the presence of obsessions, compulsions, or both, which cause significant distress and interfere with daily functioning.

Obsessions are recurrent, intrusive, and unwanted thoughts, urges, or images that generate anxiety or discomfort. Compulsions are repetitive behaviours or mental acts performed in response to obsessions or according to rigid rules, aimed at reducing anxiety or preventing feared outcomes.

Common examples include excessive hand washing, repeated checking, counting rituals, ordering behaviours, or mental repetition of words or prayers. Patients usually recognize that these thoughts or behaviours are excessive or irrational, making the condition highly distressing.

Risk Factors

• Family history of OCD or anxiety disorders

• Genetic susceptibility

• Childhood trauma or abuse

• Neurobiological abnormalities involving serotonin pathways

• History of anxiety or depressive disorders

• Stressful life events

• Perfectionistic personality traits

• Pediatric autoimmune neuropsychiatric disorders (rare cases)

• Early onset anxiety disorders

Signs and Symptoms

Obsessions

• Fear of contamination or germs

• Fear of harming self or others

• Excessive doubts (e.g., doors unlocked, appliances left on)

• Need for symmetry or exactness

• Intrusive aggressive, sexual, or religious thoughts

• Persistent unwanted mental images

Compulsions

• Excessive hand washing or cleaning

• Repeated checking behaviours

• Ordering or arranging objects repeatedly

• Counting rituals

• Repeating words silently

• Seeking constant reassurance

Associated Features

• Anxiety symptoms

• Avoidance behaviours

• Time-consuming rituals (>1 hour daily)

• Social or occupational impairment

• Shame or embarrassment about symptoms

Diagnostic Criteria

Diagnosis is clinical and requires:

• Presence of obsessions and/or compulsions

• Pattern of repetitive behaviours

• Associated anxiety or distress

• Recognition that symptoms are excessive (in most adults)

• Symptoms consuming significant time or impairing functioning

• Symptoms not attributable to substance use or another medical condition

Investigations

There are no specific laboratory tests for OCD.

Investigations aim to exclude alternative causes:

Clinical Assessment

• Detailed psychiatric history

• Mental status examination

• Functional impairment assessment

• Suicide risk assessment

Screening Tools

• Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

• Anxiety and depression screening scales

Medical Evaluation (When Indicated)

• Thyroid function tests

• Neurological assessment

• Substance use screening

Management

Management requires a combined psychological and pharmacological approach.

Goals include:

• Reduction of obsessive thoughts

• Control of compulsive behaviours

• Improvement of daily functioning

• Prevention of relapse

Non-Pharmacological Management

Psychoeducation

• Explanation of illness nature

• Normalization of symptoms

• Treatment adherence counselling

• Family education

Psychotherapy (First-Line Treatment)

• Cognitive Behavioural Therapy (CBT)

• Exposure and Response Prevention (ERP) therapy

• Behaviour therapy techniques

• Stress management strategies

ERP is considered the gold standard psychological treatment for OCD.

Pharmacological Management

Selective Serotonin Reuptake Inhibitors (SSRIs) are first-line medications.

Fluoxetine

• Initial dose: 20 mg orally daily

• Increase to 40 mg daily after 4–8 weeks if partial or no response and well tolerated

OR Citalopram

• Initial dose: 20 mg orally daily

• Increase to 40 mg daily after 4–8 weeks if required

Treatment Principles

• Higher doses may be required compared to depression treatment

• Adequate therapeutic trial: 8–12 weeks

• Continue treatment for at least 12 months after improvement

• Gradual tapering recommended to prevent relapse

Treatment-Resistant OCD

If response is inadequate:

• Optimize SSRI dose

• Switch SSRI

• Combine medication with CBT

• Psychiatric specialist referral

Complications

• Major depressive disorder

• Social isolation

• Occupational impairment

• Substance misuse

• Suicide risk in severe cases

• Poor quality of life

Prevention

• Early identification of anxiety symptoms

• Prompt psychological intervention

• Stress management education

• Family awareness and support

• Long-term follow-up care

• Relapse prevention strategies

Prognosis

OCD typically follows a chronic course but responds well to combined psychotherapy and pharmacotherapy. Early treatment significantly improves long-term functional outcomes.

Patient Education

• OCD is a treatable medical condition

• Thoughts are symptoms of illness, not personal weakness

• Avoid reinforcing compulsive rituals

• Medication and therapy require time to work

• Consistent treatment reduces relapse risk