Diagnosis and Management of Obsessive-Compulsive Disorder in the Primary Care Setting

Afi M. Semenya; Prakhya Bhatnagar

AFI M. SEMENYA, MD, MPH, AND PRAKHYA BHATNAGAR, MD

Am Fam Physician. 2024;110(4):385-392

This clinical content conforms to AAFP criteria for CME.

Author disclosure: No relevant financial relationships.

Obsessive-compulsive disorder is a common neuropsychiatric disorder that is often underdiagnosed or misdiagnosed. It is characterized by obsessions, which are intrusive and include unwanted thoughts, images, or urges that cause marked anxiety or distress. Obsessions also drive patients to engage in repetitive actions or thoughts, known as compulsions. The condition has a high prevalence of comorbid disorders and can be associated with functional impairment. Early recognition and treatment can lead to improved outcomes, and complete remission is possible. Validated tools, such as the Yale-Brown Obsessive-Compulsive Scale, are effective in diagnosing and monitoring obsessive-compulsive disorder and determining the severity of the condition. Severity varies among cases, and proper diagnosis and education about this condition are important for determining a treatment plan, which can include psychotherapy, pharmacotherapy, or both. Exposure and response prevention is the most effective form of psychotherapy, and selective serotonin reuptake inhibitors are the most effective pharmacotherapy. If monotherapy is not effective, psychotherapy and pharmacotherapy can be combined. Treatment of obsessive-compulsive disorder is typically recommended for at least 12 months for maintenance and prevention of relapse. In patients requiring augmentation, higher-risk or novel adjunctive treatments or investigational therapies should be managed by an experienced multidisciplinary team.

Obsessive-compulsive disorder (OCD) is a common disabling neuropsychiatric disorder often managed in primary care. OCD is well known for the classic dyad of obsessions and compulsions. Obsessions are repetitive, time consuming, and involve life-disrupting thoughts, images, or urges that lead to anxiety and distress. Compulsions are behaviors or thoughts that an individual performs to reduce the anxiety and distress caused by obsessions; examples include washing, counting, and praying.¹

Clinical recommendation	Evidence rating	Comments
Early detection and treatment are key to reducing the burden of OCD.^4–6	C	Consensus guidelines, usual practice, and disease-oriented evidence
Validated tools are effective in diagnosing, monitoring, and determining severity of OCD.^14–16	C	Consensus guidelines, randomized controlled trial, and an evaluation study
Exposure and response prevention is the most effective form of psychotherapy for treatment of OCD.^3,8,14	C	Expert opinion and consensus guidelines
Selective serotonin reuptake inhibitors are first-line pharmacotherapy for OCD.^3,14,27	A	Expert opinion, systematic review with multiple randomized controlled trials, and consensus guidelines

The four primary dimensions of common obsessions and compulsions are contamination and cleaning; worry about accidental harm, leading to repeated checking; seeking symmetry and ordering; and unacceptable thoughts and mental rituals.² There may be variations among these dimensions based on the patient's age, sex, and culture. For example, children and adolescents more commonly experience fears regarding death or illness.³

Health care professionals do not always recognize the diverse presentations of OCD, which often delays diagnosis. Early detection and treatment are key to reducing the burden of the condition.^4–6

EPIDEMIOLOGY

OCD is the fourth most common psychiatric disorder.⁷ It responds well to appropriate treatment, but relapse can occur. The lifetime prevalence in the United States is 1% to 3%.^8,9 OCD manifests in a bimodal fashion; most cases occur before the onset of puberty or in early adulthood, which is known as late-onset OCD. The average age of onset is 19.5 years, and it can take up to an average of 17 years to receive adequate treatment after symptom onset.^4,9,10 Early diagnosis is critical because research has found that a shorter duration of untreated illness is associated with a higher likelihood of response to treatment and remission.⁵

DIAGNOSIS

Patients with OCD may report general feelings of anxiety or depression. They may allude to intrusive thoughts or repetitive behaviors indirectly due to a fear of embarrassment and stigma. Avoidance of certain things, excessive concerns about health, and repetitive reassurance-seeking behaviors are common.^6,11 OCD is often misdiagnosed as anxiety, depression, attention-deficit/hyperactivity disorder, autism, psychotic disorder, or Tourette syndrome. However, these conditions can also co-occur with OCD, making a clear diagnosis challenging. Table 1 discusses overlapping features of these diagnoses.^3,11

Condition	Similar symptoms	Differentiating characteristics
Attention-deficit/hyperactivity disorder	Inattention and lack of focus; patient can appear distracted; need to do things “just right” or in a “complete” manner	People with attention-deficit/hyperactivity disorder have problems with attention and focus and may procrastinate, whereas people with OCD exhibit mental rituals or obsessive thoughts that may interfere with attention and focus
Anxiety	Worrying that can mimic obsessive thinking	Anxiety is usually related to real-life concerns, such as finances, health, and loved ones, whereas worrying related to OCD can seem irrational
Autism	Repetitive, self-soothing behaviors can mimic repetitive urges to perform an action until it is done “just right” Social isolation can mimic persistent deficits in social interactions	Patients with autism may not recognize their repetitive behaviors as being outside perceived norms, whereas patients with OCD view these behaviors as excessive and unreasonable Social skills are preserved in OCD
Depression	Ruminations can mimic obsessions	Ruminations typically center around a depressed theme (negative self-assessment or guilt due to perceived inadequacies)
Psychotic disorder	Delusional beliefs can appear to be irrational beliefs or thoughts	Patients with OCD can typically recognize that their thoughts are irrational
Tourette syndrome	Motor or vocal tics that can look like repetitive behavior	Tics are involuntary, whereas repetitive behaviors in OCD are typically voluntary for the need to get something “just right”

Comorbid conditions, including anxiety disorders, post-traumatic stress disorder, substance use disorders, and impulse control disorders, occur in 90% of patients with OCD.⁹ Notably, obsessive-compulsive personality disorder is a separate condition from OCD and is not characterized by compulsions or obsessions; it is a pattern of behaviors that focus on perfectionism and sense of control.^12,13 However, OCD and obsessive-compulsive personality disorder can co-occur.¹³ Family physicians should consider psychiatric referral if there is any diagnostic uncertainty.

Validated tools are effective in diagnosing and monitoring OCD and determining the severity of the condition.^14–16 The Yale-Brown Obsessive-Compulsive Scale contains a detailed checklist of obsessions and compulsions and is a standard scale for measuring severity.¹⁴ It is often used to measure the progression and maintenance of the disorder after diagnosis. Each of the 10 items is scored from 0 to 4, and the sum is an index of overall severity. An index value of 0 to 7 is considered subclinical, and a value of 24 to 31 is severe.¹⁷ The scale is long, which may limit its use in the primary care setting. The Obsessive-Compulsive Inventory–Revised and the Florida Obsessive Compulsive Inventory are commonly used self-reported inventories that are more succinct and therefore more useful in a primary care setting.^18,19

These tools can help establish the diagnosis and determine the severity of OCD, but many physicians may still find them cumbersome to implement in a busy practice. The National Institute for Health and Care Excellence has created a list of screening questions that can aid in diagnosis and are quick to implement in the primary care setting (Table 2).¹¹ If a patient answers affirmatively to any of these questions and the symptom causes distress, a diagnostic interview or patient symptom inventory should be administered to delineate OCD from common misdiagnoses. The patient interview should include a focused psychiatric evaluation to assess symptoms, severity, daily function, presence of co-occurring conditions, and the safety of the patient and others. Diagnostic criteria for OCD are presented in Table 3.¹²

Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; as in excoriation [skin picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder.

Specify if:

With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.

With poor insight: The individual thinks obsessive-compulsive beliefs are probably true.

With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive beliefs are true.

Specify if:

Tic-related: The individual has a current or past history of tic disorder.

Suicide risk is high in patients with OCD, and patients may be reluctant to report suicidal ideation. Thus, clinician assessment should include asking about suicidal ideation, plans, and any history of suicide attempts. Patients with comorbidities such as depression or substance use disorder have an even higher risk of suicide.²⁰

TREATMENT

Once OCD is diagnosed, physicians should facilitate extensive education and support for the patient and family. Patients should be educated about the chronicity of the disease and the availability of evidence-based behavior and pharmacologic therapies. These therapies can take weeks or months to demonstrate improvement; therefore, adherence is essential.

Patients often experience partial response to treatment and require augmentation strategies. Figure 1 is an algorithm for the treatment of OCD.^11,21

Psychotherapy

Exposure and response prevention (ERP), a type of cognitive behavior therapy (CBT), is the most effective form of psychotherapy for treatment of OCD.^3,8,14 ERP entails controlled, repeated, and prolonged exposures to obsession-triggering situations or stimuli while the patient is instructed to refrain from responding with compulsive behavior. The patient can then develop strategies to experience the situation and reduce the anxiety surrounding it.

Traditional CBT, on the other hand, helps patients reduce anxiety and compulsion by identifying and challenging unrealistic beliefs and cognitive distortions. For example, the therapist will ask the patient to perform an action they are fearful of and keep a log of how often the fearful action led to an undesirable outcome. Traditional CBT focuses on identifying and reevaluating beliefs, whereas ERP focuses on exposure-based anxiety reduction.³

Psychotherapy can be delivered in person, via telephone, or online with similar effectiveness in an individual or group setting.^22–24 Therapy should initially be delivered weekly or twice weekly for at least 12 weeks. For maintenance, therapy should be delivered monthly for 3 to 6 months. In randomized controlled studies, 60% to 85% of people noted reduction in symptoms with ERP, and maintenance was noted for up to 5 years after discontinuation of treatment.^3,25 Similarly, 60% to 80% of patients experienced reduction in symptoms with CBT, but premature discontinuation was more common compared with those who participated in ERP.³ Availability, cost, time commitment, and patient motivation may limit the usefulness of these modalities.

Acceptance and commitment therapy may help reduce symptoms of OCD and increase rates of adherence to behavioral changes.²⁶ The goal of acceptance and commitment therapy is to enable patients to accept and change their relationship with negative emotions, feelings, thoughts, and sensations by engaging in value-driven behavior.

Pharmacologic Treatment

Selective serotonin reuptake inhibitors (SSRIs) are first-line pharmacotherapy.^3,14,27 The U.S. Food and Drug Administration (FDA) has approved fluoxetine, fluvoxamine, paroxetine, and sertraline for the treatment of OCD.^3,28 Higher-than-usual doses of SSRIs are often needed; therefore, it is important to closely monitor for serotonin syndrome. Early signs include anxiety, diarrhea, dizziness, dry mouth, drowsiness, tremor, diaphoresis, and insomnia.

Citalopram and escitalopram are other SSRIs that can be used for treatment of OCD but have not been approved by the FDA for this indication. Due to an increased risk of QT prolongation, a daily dosage of more than 40 mg is not recommended. In patients with certain comorbidities, such as anxiety- or stress-related disorders, escitalopram and paroxetine have been shown to be more effective than sertraline.²⁹ Ongoing research involving drug-drug comparisons is needed to determine which drugs can effectively treat specific symptom dimensions of OCD.

Clomipramine is the only tricyclic antidepressant that is FDA approved for the treatment of OCD. Due to an increased risk of arrhythmias, cardiac toxicity, and seizures, it is not typically a first-line treatment and requires close monitoring. It should be started at a low dosage and gradually titrated to minimize adverse effects. Common anticholinergic adverse effects include dry mouth, constipation, blurred vision, urinary retention, orthostatic hypotension, weight gain, and sedation.²¹

A 6- to 12-week course of a medication using an adequate treatment dosage is regarded as an adequate trial of assessment. Medication should be started at a low dosage with monitoring for adverse effects or intolerability. The dosage can be increased after a week if the patient is not experiencing any intolerable adverse effects.²⁷ Subsequent dosage changes are commonly assessed at a 4- to 6-week interval. For patients whose symptoms respond to medication, treatment should be continued for at least 1 to 2 years with a gradual taper to help prevent relapse.²⁸ If relapse occurs, the medication should be titrated back up to the target dosage and continued indefinitely.³⁰

Table 4 summarized pharmacotherapies for OCD.^3,21 Clinicians can consider initiation of any one of these medications; if no improvement occurs after an adequate trial, patients can be referred to a psychiatry team

Medication	Starting daily dosage	Target daily dosage	Adverse effects
First-line
Fluoxetine	20 mg	40 to 80 mg	Common effects^*
Fluvoxamine	50 mg	200 to 300 mg	Common effects^*
Paroxetine	20 mg	40 to 60 mg	Common effects^*
Sertraline	50 mg	100 to 200 mg	Common effects^*
Second-line
Citalopram†	20 mg	20 to 40 mg	Common effects^*
			The U.S. Food and Drug Administration recommends not exceeding a daily dosage of 40 mg due to increased risk of QTc prolongation Patients older than 60 years or taking concurrent cytochrome P450 inhibitors (e.g., cimetidine) should not exceed 20 mg per day
Clomipramine	25 mg	150 to 250 mg	Cardiac toxicity, arrhythmias, seizures, dry mouth, constipation, blurred vision, urinary retention, orthostatic hypotension, weight gain, and sedation; may increase suicidal thoughts, especially when starting therapy or changing dosage
Escitalopram†	10 mg	20 to 40 mg	Common effects^*

Combined Treatment

Psychotherapy is considered as effective, if not more, than pharmacotherapy, but combination therapy should be considered when symptoms do not improve with either monotherapy.^14,27 Notably, combination therapy is considered superior to pharmacotherapy alone but not to psychotherapy alone.²¹ Patients receiving both ERP and SSRI treatment should be able to discontinue their SSRI without any clinical worsening at effective completion of ERP treatment. However, abrupt discontinuation of SSRIs can exacerbate symptoms, and a careful taper is recommended. Further research is underway to investigate individual factors that impact SSRI taper.³¹

Other Therapies

Emerging evidence suggests that mindfulness-based interventions are effective adjunct treatments for OCD. Mindfulness can enable patients to reduce their obsessive-compulsive symptoms by practicing nonjudgmental awareness and purposeful observation as intrusive and undesirable thoughts occur, thereby minimizing the significance attached to those thoughts.³²

Although evidence is limited, some studies show effectiveness of venlafaxine (a serotonin-norepinephrine reuptake inhibitor), neuroleptic agents (topiramate, lamotrigine, pregabalin, and gabapentin), or mirtazapine (an alpha₂-antagonist) for OCD.²¹ Other medications under investigation for the treatment of OCD are ketamine, riluzole, memantine, celecoxib, and ondansetron.^33–41

Investigational therapies can be considered as last resort options. These include deep brain stimulation, which modulates the frontobasal ganglia-thalamic circuits, and neuroablation techniques such as anterior capsulotomy using radiofrequency ablation and stereotactic ablation.^42–44 Evidence regarding the effectiveness and safety of deep brain stimulation is limited; it is used in research for chronic, severe, and treatment-resistant OCD.⁴³

Patients requiring adjunctive treatment or investigational therapies should be managed by an experienced multidisciplinary team consisting of a psychiatrist, neuropsychiatrist, clinical psychologist, neurologist, and neurosurgeon.

SPECIAL POPULATIONS

Pregnant and Postpartum Patients

Clinical symptoms of OCD tend to vary from pregnancy to postpartum stages. Intrusive thoughts during pregnancy often focus on fetal well-being with compensatory rituals. These can range from excessive monitoring of fetal heart tones to frequent physician appointments. Postpartum intrusive thoughts may focus on harm to the infant and result in avoidance of contact. CBT is an effective and preferred treatment modality during pregnancy and postpartum.⁴⁵ SSRIs should be considered for patients who do not have significant improvement with psychotherapy. Due to its low presence in breast milk, sertraline is the preferred medication for lactating patients who have not previously taken an SSRI.⁴⁶

Children

ERP is the preferred treatment for children and should be continued for 12 weeks. If response to treatment is inadequate, longer-term ERP is recommended before considering SSRIs.⁴⁷ Family involvement is crucial for successful outcomes, and ERP should be adapted to suit the developmental age of the child.²⁸ SSRIs can be considered for children older than 8 years once a full trial of ERP involving the family has been completed. Fluvoxamine, fluoxetine, and sertraline are the recommended SSRIs in children.⁴⁸ Children treated with SSRIs should be monitored closely to assess for the risk of suicide.⁴⁹

Abrupt onset of obsessive-compulsive symptoms may raise concern for pediatric autoimmune neuropsychiatric disorders, pediatric acute-onset neuropsychiatric syndrome, and childhood acute neuropsychiatric symptoms, but these are beyond the scope of this review.^50,51

This article updates previous articles on this topic by Fenske and Petersen¹¹; Fenske and Schwenk⁵²; and Eddy and Walbroehl.⁵³

Data Sources: An Essential Evidence Plus evidence summary report for OCD was used, which included POEMs, the Cochrane database, systematic reviews, and practice guidelines. A less restrictive PubMed search was also completed using the key terms obsessive-compulsive disorder and OCD. We also critically reviewed studies that used patient categories such as age, race, and/or gender. The search included meta-analyses, randomized controlled trials, BMJ Clinical Evidence, and JAMA Clinical Review within the past 10 years. A targeted search was also conducted to research specific topics, such as the course of illness, treatment modalities, demographics, and special populations. Search dates: September through November 2023, March through May 2024, and August 2024.

This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

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