Typical presentations captured

• Atypical hoarding causing impairment but not meeting formal diagnostic threshold for hoarding disorder.
• Subthreshold trichotillomania or excoriation disorder with distress/function loss but short duration or partial criteria.
• Obsessive preoccupations (e.g., moral/religious rumination) or ritualised behaviours that do not neatly fit OCD or related categories.
• Unusual presentations such as obsessional slowness or repetitive mental rituals interfering with daily tasks but without overt compulsive acts.

Assessment priorities

1. Clarify phenomenology: content of obsessions, nature of compulsions (overt vs mental), triggers, onset, duration and functional impact.
2. Use validated measures where appropriate (Y‑BOCS, DOCS, MGH scales for hair/picking) to quantify severity and monitor change.
3. Screen for comorbidities: depression, anxiety, tic disorders, neurodevelopmental disorders and substance misuse.
4. Review medications and medical history for secondary causes (medication activation, neuropsychiatric conditions) and obtain collateral history when possible.

Initial management — practical steps

• Validate distress and explain the diagnosis as part of a spectrum; set measurable functional goals (time on rituals, avoidance behaviours) and agree a short‑term plan (4–8 weeks) for low‑intensity interventions.
• Begin low‑intensity CBT elements: psychoeducation, simple behavioural experiments, activity scheduling and stimulus control for body‑focused behaviours.
• Provide habit reversal techniques for hair‑pulling/skin‑picking where applicable and arrange timely follow‑up to judge response and need for escalation.

Evidence‑based treatments to consider

• CBT with ERP: first‑line for OCD; adapt exposures for atypical or subthreshold presentations and focus on reducing avoidance and safety behaviours.
• Habit reversal training (HRT): effective for trichotillomania and skin picking — includes awareness training, competing response and stimulus control.
• Pharmacotherapy: SSRIs at higher (OCD‑effective) doses for persistent or severe symptoms; consider specialist referral for augmentation strategies when response limited.

Practical tips for clinicians

• Document clear care plans with time‑limited goals and safety netting; use brief scales to track progress and justify escalation if needed.
• Engage family/carers in supporting exposure tasks and competing responses where safe and appropriate; provide written guidance and local resources.
• Coordinate between primary care, mental health and specialist OCD services to ensure timely access to CBT‑ERP when indicated.

Typical presentations

• Atypical hoarding behaviours causing functional problems but not meeting full hoarding disorder criteria.
• Subthreshold trichotillomania (hair‑pulling) or excoriation (skin‑picking) with distress but short duration or partial features.
• Obsessional slowness or predominant mental rituals that impair functioning but lack overt compulsions.
• Mixed or overlapping OCRD symptoms that are clinically significant but diagnostically ambiguous.

Assessment checklist

1. Clarify phenomenology: content of obsessions, type of compulsions (overt vs mental), triggers and patterns of avoidance.
2. Timeline and severity: onset, course, time spent on rituals, impact on work/home and prior treatments.
3. Use validated scales where useful (Y‑BOCS, DOCS, MGH scales) and obtain collateral history from family/carers when possible.
4. Screen for comorbidities: depression, anxiety, tic disorders, neurodevelopmental issues and substance use; consider medical/neurological causes for abrupt/atypical onset.

Management principles

• Immediate pragmatic care: validate distress, provide psychoeducation and start low‑intensity behavioural strategies (graded behavioural experiments, stimulus control, habit reversal for body‑focused behaviours).
• First‑line psychological treatment: CBT with ERP adapted to presentation—focus on reducing avoidance and safety behaviours even in atypical cases.
• Pharmacotherapy: SSRIs at OCD‑effective doses for persistent or severe symptoms; consider specialist augmentation strategies for treatment‑resistant cases.
• Coordinate care and set a time‑limited plan (4–8 weeks) for low‑intensity treatment with clear criteria for specialist referral if insufficient improvement.

Practical techniques

• Exposure and Response Prevention (ERP): tailor exposures to the individual’s rituals and avoidance; use imaginal ERP for mental rituals or where in vivo exposure is impractical.
• Habit Reversal Training (HRT): for hair‑pulling and skin‑picking—awareness training, competing response and stimulus control.
• Behavioural experiments and activity scheduling to restore function and reduce checking/neutralising behaviours.

Key takeaways

• Use this diagnosis pragmatically to start timely, evidence‑based care when OCRD symptoms are impairing but diagnostic clarity is lacking.
• Prioritise CBT‑ERP and habit reversal techniques, set measurable short‑term goals and coordinate care with clear follow‑up and escalation criteria.
• Investigate for secondary medical causes in atypical or sudden onset cases and refer to specialist OCD services for treatment‑resistant presentations.