Obsessive compulsive disorder (OCD): Clinical sciences

Obsessive-compulsive disorder, or OCD, is a condition characterized by obsessions and compulsions. Obsessions are recurrent, intrusive thoughts that can manifest as images or urges that cause significant anxiety or distress.

On the other hand, compulsions are ritualized attempts aimed at alleviating the anxiety caused by obsessions. The specific content of obsessions and compulsions varies widely among individuals, with common themes including contamination, concerns about symmetry, or danger. Depending on the severity of the condition and the extent of impairment it causes, OCD can be categorized as mild, moderate, or severe.

When a patient presents with a chief concern suggesting OCD, you should first obtain a focused history and physical examination.

Your patient may report excessive or persistent intrusive thoughts and urges to perform specific tasks, such as excessive hand washing or compulsive checking the locks on doors. On physical examination, you may observe repetitive actions like tapping or touching; skin lesions from repeated behaviors, such as excoriations on the hands; or the use of repetitive words and phrases. If your patient has these findings, suspect OCD.

Your next step is to confirm the diagnosis by assessing the DSM-5 criteria for OCD. To meet the criteria, the patient must have obsessions or compulsions, or both. Obsessions or compulsions are distressing or time-consuming, to the level of interfering with their ability to function well in social or work settings. This interference can manifest as difficulty maintaining relationships, performing job duties, or engaging in daily activities.

Additionally, ensure that their symptoms are not attributable to substances or another medical condition, such as hyperthyroidism. Also, confirm that their symptoms are not more appropriately explained by another mental disorder, such as an anxiety disorder. If these criteria are met, diagnose OCD.

Here’s a high-yield fact! OCD is different from obsessive-compulsive personality disorder, or OCPD. Individuals with OCD experience distressing obsessions and compulsions, whereas those with OCPD are primarily concerned with perfectionism and orderliness. Also, unlike OCD, where behaviors are driven by unwanted obsessions and cause significant distress, individuals with OCPD do not typically feel distressed about their behaviors, as they align with their personal standards of order and control.

Here’s your first clinical pearl to keep in mind! In addition to OCD, DSM-5 describes several related disorders, including hoarding disorder, body dysmorphic disorder, trichotillomania, and excoriation disorder. These OCD-related disorders are characterized by repetitive behaviors or thoughts stemming from specific preoccupations.

Patients with hoarding disorder struggle significantly with discarding possessions, even those that serve no practical purpose. On the other hand, patients with body dysmorphic disorder are consumed by perceived physical imperfections. With trichotillomania, patients have hair loss due to repeatedly pulling their hair out, while patients with excoriation disorder have skin lesions from repeatedly picking or scratching their skin.

Now, once you’ve confirmed OCD, assess the patient’s symptom severity to determine the best treatment options

While there are several validated rating scales for OCD severity, the Yale-Brown Obsessive Compulsive Scale, or Y-BOCS, is one of the most widely used.