Obsessive compulsive disorder (OCD): Clinical sciences

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Introduction 0:00–0:54

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.

H&P 0:54–4:05

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.

Assess Symptom Severity – Y-BOCS 4:05–5:29

This scale evaluates the severity of both obsessions and compulsions through 10 specific questions, addressing time spent on obsessions, interference with daily life caused by obsessions, distress levels caused by obsessions, resistance against obsessions, control over obsessions, time spent on compulsions, interference caused by compulsions, distress caused by compulsions, resistance to compulsions, and control over compulsions.
Each question is rated on a scale from 0 to 4, resulting in a total score ranging from 0 to 40. The total score ranging from 0 to 7 is categorized as subclinical, indicating minimal impact on daily functioning.
On the other hand, scores of 8 or higher suggest clinically significant symptoms, which can affect the patient's ability to function in social, occupational, or other key areas of life.
Now, let’s look at the different OCD severities. So, if the patient’s Y-BOCS score is 8 to 15, and they have minimal functional impairment, diagnose mild OCD.

Mild OCD 5:29–6:50

Medical treatment may involve clomipramine and selective serotonin reuptake inhibitors, or SSRIs. However, in mild OCD, patients may prefer to avoid medication and try only cognitive behavioral therapy, or CBT.
The most important aspect of CBT for patients with OCD is exposure response prevention, or ERP. This involves facing thoughts, situations, or objects that trigger obsessions, and learning to choose not to engage in compulsive behaviors.
Here’s another clinical pearl! Co-existing mental health and physical conditions should be carefully considered when determining treatment options for mild OCD.
For example, if a patient has an untreated diagnosis of major depressive disorder alongside mild OCD, initiating treatment with an SSRI may be preferable over relying solely on psychotherapy.
Moving on, if the Y-BOCS score falls between 16 and 23, and your patient has moderate functional impairment, you can go ahead and diagnose moderate OCD.

Moderate OCD 6:50–7:24

In this case, first-line treatment involves clomipramine and SSRIs, while second-line options include venlafaxine or mirtazapine.
While some patients can respond to medications alone, there are those who can benefit from augmenting with CBT, especially ERP.
Finally, if the patient’s Y-BOCS score is 24 or greater, and they have severe functional impairment, you can diagnose severe OCD.

Severe OCD 7:24–9:24

As before, first-line treatment involves clomipramine and SSRIs, while second-line medications include second-generation antipsychotic, such as aripiprazole or risperidone.
Patients with severe OCD should also undergo CBT, especially with ERP. Finally, for these patients you can consider transcranial magnetic stimulation or deep brain stimulation.
Here’s a high-yield fact! Clomipramine was the first medication used to treat OCD and is still considered the first-line option along with SSRIs.
Keep in mind that it is a tricyclic antidepressant, so it has a significant anticholinergic side effect profile. However, as long as the side effects can be tolerated, clomipramine should be your first option.
Here’s one last clinical pearl! When you need to prescribe more than one medication for patients with OCD, make sure to discuss the risk of Serotonin Syndrome.
In this condition, medications that elevate serotonin levels cause an excess of serotonin leading to symptoms such as rigid muscles, flushed skin, shaking, tachycardia, excessive sweating, elevated blood pressure, and feelings of disorientation, overheating, and agitation.
Symptoms can range from mild...to severe. Inform the patient that if they experience these symptoms, it is important to seek emergent medical attention for treatment and adjustments to their medication.
Alright, as a quick recap… OCD is diagnosed based on the DSM-5 criteria. After diagnosis, use a validated scale like Y-BOCS to determine severity and the appropriate treatment choice.

Review 9:24–10:05

First-line pharmacological treatment involves clomipramine and SSRIs. Second-line options for moderate OCD include venlafaxine and mirtazapine; while second-line options for severe OCD are second-generation antipsychotics.
Next to pharmacological treatment, patients should receive CBT, and you can consider transcranial magnetic stimulation or deep brain