Understanding Obsessive-Compulsive Disorder (OCD) and its Treatment
Psychiatry • Psychotherapy • OCD Services
Understanding Obsessive‑Compulsive Disorder (OCD) and Its Treatment
OCD is a common, often chronic disorder characterised by distressing intrusive thoughts (obsessions) and repetitive behaviours or mental acts (compulsions) performed to reduce anxiety. Evidence‑based treatments (CBT with Exposure and Response Prevention, and SSRIs) produce substantial improvement for most patients when delivered properly.
Core features
- Obsessions: recurrent, intrusive thoughts, images, or urges that cause marked anxiety or distress.
- Compulsions: repetitive behaviours or mental acts performed in response to obsessions or rigid rules (e.g., checking, washing, counting, mental rituals).
- Obsessions/compulsions are time‑consuming (often >1 hour/day), cause significant distress, and impair functioning.
- Symptoms recognised as excessive or unreasonable by many sufferers (insight varies), though some have poor insight or delusional beliefs.
Common symptom dimensions
- Contamination & washing
- Symmetry, ordering & arranging
- Forbidden/taboo thoughts (aggressive, sexual, religious) & mental rituals
- Checking & harm avoidance
- Hoarding (now separate disorder but often overlaps)
Assessment checklist
- Detailed history: onset, course, symptom content, time spent, triggers, avoidance, insight, prior treatments and response.
- Use validated scales: Y‑BOCS (clinician), Obsessive‑Compulsive Inventory (OCI‑R) for monitoring severity.
- Assess comorbidity: depression, anxiety, tic disorders, ADHD, substance use, and suicidality.
- Screen for secondary causes (neurological disorders, medications, substance‑induced syndromes) in atypical or abrupt onset.
First‑line psychological treatment — CBT with ERP
- Exposure and Response Prevention (ERP): graded exposure to feared stimuli or thoughts while preventing compulsive responses — typically weekly sessions plus intensive homework; highly effective.
- ERP can be delivered in different formats: individual, group, intensive day‑treatment, and via digital/telehealth modalities when traditional access limited.
- Key elements: collaborative formulation, hierarchy building, imaginal and in‑vivo exposures, response prevention, and relapse prevention planning.
Pharmacotherapy
- First‑line: SSRIs at higher doses than for depression (sertraline, fluoxetine, fluvoxamine, paroxetine, escitalopram) — allow 10–12 weeks at adequate dose before judging response.
- Clomipramine: a tricyclic with strong serotonergic action; effective but less well tolerated — use when SSRIs ineffective or as specialist option.
- Augmentation: antipsychotic augmentation (risperidone, aripiprazole, haloperidol) for treatment‑resistant OCD, especially with comorbid tics or poor response to combined SSRI+ERP. Specialist supervision required.
Treatment planning & sequencing
- Offer CBT‑ERP as first‑line; when unavailable or refused, start SSRI and continue to offer therapy. Combined SSRI+ERP can be more effective for some patients.
- Monitor with Y‑BOCS/OCI‑R and functional outcomes; set measurable goals (time spent, distress, behavioural targets).
- Consider intensive ERP (daily or multi‑day programmes) for severe or treatment‑refractory cases where resources allow.
Special populations & considerations
- Children & adolescents: CBT‑ERP adapted developmentally with family involvement; SSRIs used cautiously with child/adolescent psychiatry input.
- Pregnancy & lactation: balance risks and benefits—prefer CBT when possible; if medication needed, choose SSRIs with obstetric/psychiatric collaboration.
- Tic‑related OCD: higher likelihood of antipsychotic augmentation and different response patterns—coordinate with neurology/psychiatry.
When to escalate / red flags
- Severe functional impairment (unable to work/attend school), high suicidal ideation, psychotic symptoms, severe comorbidity or medical complications—urgent specialist referral.
- Poor response after adequate trials of ERP and two SSRIs (with/without clomipramine) — consider specialist services for augmentation strategies, intensive ERP, or neuromodulation (rTMS, DBS in extremely refractory cases).
Case vignette
Patient: A., 29, presents with 3 years of intrusive thoughts about causing harm and checking rituals taking 2–3 hours/day, causing work impairment and depression. Management: detailed assessment (Y‑BOCS 30), start weekly CBT‑ERP with hierarchy targeting checking, commence sertraline 150 mg/day due to severity and comorbid depression, monitor response regularly. After 12 weeks A. showed reduced rituals and improved functioning; continue ERP and review medication over next 9–12 months with taper planning when stable.
தமிழில் — சுருக்கம்
OCD என்பது மீண்டும் மீண்டும் வருகிற intrusive எண்ணங்கள் மற்றும் அவற்றை ஈர்க்கும் repetitive நடத்தைகளை கொண்ட ஒரு நிலை. முதன்மை சிகிச்சை CBT‑ERP மற்றும் உயர் இரத்தத்திற்கு SSRIs ஆகும்; கடுமையான அல்லது எதிர்ப்பு உள்ள வழிகளில் நிபுணர் உதவி தேவை.
Practical tips for clinicians
- Use collaborative formulation and measurable behavioural targets; give patients clear rationale for ERP and normalise short‑term anxiety increases during exposures.
- Encourage treatment adherence (homework exposures), involve family to support but not accommodate compulsions, and provide relapse prevention planning.
- Document treatment trials carefully (dose, duration) before labeling treatment resistance — consult specialist OCD services early when complex.
Key takeaways
- OCD is treatable — first‑line therapies are CBT with ERP and SSRIs at OCD‑effective doses; combine treatments for severe cases.
- Early, structured ERP with homework and measurement (Y‑BOCS) improves outcomes; escalate to specialist care for treatment resistance or severe comorbidity.
- Coordinate care, set clear goals, and provide family psychoeducation to reduce accommodation and support recovery.