Obsessive compulsive disorder (OCD) is a type of anxiety disorder. Obsessive thoughts result in anxiety which can be temporarily relieved by compulsions.
OCD Cycle
- Individuals with OCD experience obsessive, unwanted thoughts such as worries of harm coming to loved ones, aggressive thoughts, thoughts related to sin/religion, or fears of contamination or germs. This generates anxiety.
- Patients can engage in compulsions, which provides a temporary relief from the anxiety that comes from obsessions.
- For example, patients with contamination obsessions can wash their hands. This provides temporary relief from anxiety, until the obsession returns and the cycle continues.
- The development of OCD is multifactorial in nature. There is evidence of a genetic predisposition to developing the condition alongside dysfunctional activity of neurotransmitters.
Risk Factors
- Family history
- Stressful life events
- Presence of other mental health condition
- Childhood abuse and neglect
Clinical Features
- Excessive unwanted thoughts
- Engaging in compulsions
- Checking e.g. ensuring heat-producing items are turned off
- Reassurance seeking
- Repeating prayers/phrases
- Excessive cleaning
Management
Cognitive behavioural therapy (CBT) and exposure response therapy (ERP) are two key management options for OCD. CBT is used in other mental health conditions such as depression and looks at the interplay between thoughts, mood, and behaviour.
ERP is a type of CBT technique that involves exposure to the patient’s fears, with an attempt to not engage in compulsions e.g. if someone has a contamination obsession, asking them to go 10 minutes without washing their hands. These exposures are graded in nature (you may start with 10 minutes, then go up to 20, 30, 40, and so on). This teaches patients to gradually accept and tolerate the anxiety that comes with not performing compulsions/ritualistic behaviour.
NICE define a low intensity psychological treatment as <10 hours of therapist input for patient. For example, group-based therapies are low intensity as the input per patient is less. Examples of this include:
- Brief individual CBT and ERP with self-help materials or by telephone
- Group CBT and ERP
- Initial management is with a low intensity psychological treatment such as above.
- If this is inadequate, or if the patient has moderate functional impairment from OCD, more intensive CBT/ERP or a course of SSRIs should be offered.
- For patients with severe functional impairment, they should be offered SSRI and CBT/ERP.
- In patients who have not had a response to combined CBT/ERP and SSRI treatment, or an SSRI alone after 12 weeks of treatment, an alternative SSRI or clomipramine should be used.
References
https://www.nice.org.uk/guidance/cg31/chapter/Recommendations#step-1-awareness-and-recognition
