Obsessive compulsive disorder is characterised by the presence of obsessions and/or compulsions.
It is a relatively common disorder with a wide clinical spectrum. It may significantly impact an individual's daily life and be a cause of profound functional impairment.
NICE reports that anywhere between 1-3% of the UK population are affected. It is characterised by two features:
OCD is a leading cause of global disease burden.
It is estimated that OCD affects 1-3% of the UK population.
It has been observed that childhood OCD affects boys more frequently than girls. After puberty, this appears to reverse. The overall gender balance is roughly equal.
As with many mental health illnesses the aetiology is poorly understood but likely multifactorial.
A number of risk factors have been identified.
Features of OCD may rarely be a symptom secondary to another neurological condition.
The diagnosis of OCD is clinical, classification systems may be used to support this.
Diagnosis of OCD can be challenging. Some patients may feel embarrassed or ashamed by features of the disease and may not wish to discuss their symptoms. Clinicians must pick up on signs and foster an open and honest dialogue.
Those particularly at risk should be screened for:
NICE advise the following questions to help screen for the diagnosis:
The diagnosis is made with clinical judgment and can be helped by either ICD-10 or DSM-V classifications. Below we outline the DSM-V criteria:
A number of conditions closely match and overlap with features of OCD.
OCD treatment often involves psychological therapies and the use of SSRIs.
Once a diagnosis is made, discuss the condition and its management in detail with the patient. Ensure they are aware of the numerous charities and support groups available (see further reading below).
OCD is often a chronic condition, and close follow-up is required. The natural history may feature periods of improvement and periods of worsening symptoms. Some undergo remission and many will find their symptoms improve with treatment and time.
Severity is largely dictated by the distress caused by each individual feature and how it limits their normal function.
In some cases, certain aspects may raise concerns of risk of harm for the patient and to others. Safeguarding concerns must be addressed. Expert opinion should be sought where concern exists.
Consider and assess suicide and self-harm risk. Any patient deemed to be at risk should be discussed immediately with the local specialist mental health services for further assessment and a management plan.
You should be aware that OCD may co-exist with other mental health disorders. Attempt to evaluate and screen for these.
Mild functional impairment: refer for psychological intervention. Low-intensity Cognitive-Behavioural Therapy (CBT) with Exposure and Response Prevention (ERP) is commonly offered. If treatment is inadequate or inappropriate consider the option for moderate functional impairment.
Moderate functional impairment: patients should be offered intensive CBT with ERP or an SSRI. Clomipramine may be used as second-line therapy. If treatment is inadequate or there are concerns regarding the assessment, refer for specialist input.
Severe functional impairment: refer for specialist input. Consider an SSRI (e.g escitalopram) combined with CBT in the interim. Clomipramine may be used as second-line therapy.
Specialist referral should be considered in any patient in whom you have concern. In particular, patients who exhibit marked limitation of normal function should be referred. Refer those at risk of self-harm, neglect or significant co-morbidities. Suicide risk should be assessed and urgently referred (same day) if any concern exists.
A number of mental health charities exist that help provide information and support for patients.
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