'I feel like something awful will happen' - managing OCD
Dr Laura Stevenson and Dr Ravindra Belgamwar discuss a common presentation of obsessive compulsive disorder
A 40 year old lady was re-referred to psychiatry services by her GP after presenting with increased symptoms of anxiety. She had first developed difficulties as a teenager but these had remained relatively well-managed until the death of her husband three years ago. Since this time she has struggled with the recurrent unpleasant thought that something untoward would happen to her grandson if she did not perform tasks in certain ways or a repeated number of times. She found this very distressing and recognised the detrimental impact on her day to day functioning. Her mood was negatively affected and she had already been started on an antidepressant by her GP.
Obsessive compulsive disorder is categorised as an anxiety disorder according to the WHO’s International Classification of Diseases-10 (ICD-10).1 As with most mental disorders, its aetiology is multifactorial. The prevalence of OCD in the general population is reported to be 1.6%, with males and females affected equally.2 It commonly presents around the time of early adulthood and as well as being mentally distressing can lead to a significant decline in social functioning. Sufferers do often hide their symptoms, sometimes very effectively, therefore delaying diagnosis and treatment. It is not infrequently seen as a comorbidly with other mental disorders such as depression and substance misuse.
Obsessions and compulsions can occur in isolation but are frequently encountered together.3 Obsessions are defined as repeated, unwanted and intrusive thoughts or images that cause distress. They are often resisted as the suffered recognises their irrationality. Compulsions are repetitive, sometimes ritualistic behaviours that the sufferer feels compelled to do in order to try and alleviate this distress. Compulsions are much more difficult to resist and commonly involve the sufferer performing a mental or physical act.4 There is often a significant level of avoidant behaviour identified where the sufferer will distance themselves from situations likely to precipitate anxiety symptoms.
The most frequently reported obsessions are contamination, fear of harm, and order or symmetry, which are present in 37.8%, 23.6% and 10% of sufferers respectively.5 The most frequently reported compulsive behaviours are checking, cleaning and washing, and repetitive behaviours, which are present in 28.2%, 26.6% and 11.1% respectively.5
In order for a diagnosis of OCD to be made, symptoms should be experienced on most days over a period of at least two weeks and be associated with distress or detriment to functioning.1 The obsessional thoughts should be recognised as the persons own, the thoughts or behaviours must be distressing and repetitive with at least one being irresistible and carrying out a behaviour must not in itself be pleasurable.1 A thorough history of the development and progression of symptoms is imperative, as is an understanding of the sufferer’s personal and social circumstances. Screening those potentially at increased risk, such as anyone already diagnosed with another mental disorder, or those attending with dermatological complaints, especially of the hands, is recommended.
As with all mental disorders, an effective management strategy will involve a determination of the severity of symptoms, including the impact on day to day functioning as well as a comprehensive assessment of risk, with an emphasis on self-harm and suicide.3 For a large proportion of sufferers, treatment initially within the primary care setting with possible support from local Improving Access to Psychological Therapy (IAPT) services is appropriate, and referral to secondary mental health services should be reserved for those individuals who are more severely affected or who have failed to respond adequately.4
The main treatment approaches are psychological therapy and pharmacological.
This involves cognitive behavioural therapy that incorporates work on exposure and response prevention (EPR). This aims to challenge individuals’ thoughts and feelings to effect a change in behaviour. The EPR aspect involves gradually and safely exposing an individual to the situations that they find challenging while enabling them to manage distressing thoughts and feelings (which would usually lead to compulsive behaviours).
The SSRIs are recommended as first line treatment, particularly fluoxetine, with the maximum treatment dose being 60mg.3 Prior to commencing, a full discussion about the risks and benefits of treatment should take place to allow the individual to make an informed choice. Regular monitoring is essential, particularly if there are concerns relating to self-harm or suicidal ideation and the dose should be adjusted according to response and the development of side effects. If effective, treatment should continue at the same dose for at least one year. If response is inadequate after a full trial of an SSRI (at least 12 weeks) then an alternative SSRI or clomipramine should be considered once compliance has been established. Other adjunct therapies should only usually be commenced under the supervision of psychiatry services.
While full recovery is achievable, it is recognised that for many individuals the course of OCD is relapsing and remitting. The use of a comprehensive relapse prevention plan, incorporating identification of early warning signs, may assist both individuals and professionals in acting quickly during times of increased difficulty.
Dr Laura Stevenson is a higher trainee in psychiatry at the North Staffordshire Combined Health Care NHS Trust
Dr Ravindra Belgamwar is a consultant psychiatrist/honorary lecturer at the North Staffordshire Combined Health Care NHS Trust
- Kessler RC, Berglund P, Demler O et. al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry2005;62:593-602.
- Obsessive-compulsive disorder and body dysmorphic disorder: treatment Clinical guideline [CG31] Published date: November 2005. https://www.nice.org.uk/guidance/cg31
- David Veale, Alison Roberts. Clinical review: Obsessive-compulsive disorder. BMJ 2014;348:g2183
- Foa, E. B., Kozak, M. J., Goodman, W. K. et al (1995) DSM-IV Field trial: Obsessive Compulsive Disorder. American Journal of Psychiatry, 152:1, 90-96.