Panda’s Top Tip 🐼
As well as observable compulsions, always asked about ‘unseen’ mental compulsions e.g. counting, reviewing a memory.
Key Knowledge
What is Obsessive Compulsive Disorder (OCD)?
OCD is a mental health disorder defined by the presence of obsessions and compulsions.
Obsessions: recurrent, intrusive, and unwanted thoughts, images, or urges that cause marked anxiety or distress.
Compulsions: repetitive behaviours or mental acts (e.g. checking, washing, counting) that the individual feels driven to perform, either in response to an obsession or according to rigidly applied rules, to prevent or reduce anxiety, avert a dreaded event or situation, or achieve a sense of ‘completeness’.
The content of obsessions and compulsions can be grouped into themes e.g. contamination, symmetry, forbidden or taboo thoughts, hoarding (to neutralise distress from an obsession).
As well as thoughts and actions, individuals with OCD experience a range of affects e.g. anxiety/panic, disgust, sense of ‘incompleteness’.
ICD-11 specifies that for OCD (6B20)
● Either obsessions, compulsions, or both must be present
● They are time-consuming (e.g. take more than 1 hour per day) or result in significant impairment. Functioning may be maintained but with considerable effort.
Differential Diagnosis for OCD
Delusional/ other primary psychotic disorder
● In OCD, the individual will recognise their actions as their own (not imposed). However, they may vary in the extent to which they recognise their disorder specific beliefs as excessive or unreasonable. At times they may be delusional in the degree of conviction. ICD-11 includes an ‘insight’ specifier for this.
Health Anxiety Disorder
● In OCD, health-related obsessions tend to be more focused on contamination than undiagnosed symptoms of a particular illness. Often there are also non-health related obsessions.
Body Dysmorphic Disorder
● Intrusive thoughts and repetitive behaviours are limited to concerns about physical appearance.
Hoarding Disorder
● Accumulation due to distress discarding objects (not to neutralize anxiety from other obsessional content e.g. contamination, symmetry).
Autism Spectrum Disorder
● Compulsions may be difficult to distinguish from restricted, repetitive, and inflexible patterns of behaviour in autism, however difficulties in initiating and sustaining social communication and reciprocal social interactions are not features of OCD.
Depression
● Unlike obsessions, ruminations are not typically experienced as intrusive, nor are they linked to compulsive behaviours.
Other Anxiety Disorders
● In OCD, obsessions are often ‘odd’ and are accompanied by compulsions, unlikely in other anxiety disorders.
Impulsive control disorders e.g. gambling
● Compulsions characteristic of OCD typically lack a rational motivation and are rarely reported to be pleasurable.
Personality disorder with anankastic features
● Associated with a pervasive maladaptive pattern of excessive perfectionism and rigid control but not intrusive thoughts/images/urges or repetitive actions
Risk Assessment in OCD
As with every risk assessment, you must consider risk to self, to others and from others. However some specific risks to consider in OCD include those related to compulsions:
Risk to self:
Excessive washing, use of chemical detergents, exhaustion from lengthy compulsions
Thoughts of harm to self (some intrusive thoughts e.g. of a sexual nature can cause overwhelming shame)
Communication Tips
● Validate their distress and the need to find a way to cope, e.g. “It’s natural and understandable to find ways to cope with distressing thoughts, but your behaviour is now reinforcing the problem, trapping you in a vicious cycle”
● Provide hope by explaining OCD is treatable
CASC Practice Scenarios
Scenario 1: OCD History Taking & Risk Assessment
Candidate Instructions
You are working in a community mental health team. You are scheduled to see Mr. Oliver Tran, a 34-year-old primary school teacher, for a follow-up appointment. Mr. Tran was recently placed on medical leave due to exhaustion.
Take a history and assess risk.
Actor Instructions
You are Mr Oliver Tran, a 37-year-old primary school teacher. You are a highly organized, meticulous, and responsible person, and you take immense pride in your job. You are also a single dad to a seven-year-old daughter, and your need for control and order has always been part of your personality. You present as calm and polite but are clearly exhausted.
Your obsessive-compulsive symptoms began subtly about a year ago with a nagging thought that you might have forgotten to lock the back door at night and an associated worry that someone would break in to the house. This happened after you read a news story about a violent robbery at night in your town.
This escalated into a need to repeatedly check all the doors and windows every morning before you leave and every evening before bed. Your checking rituals consume at least two to three hours a day. You have to touch each lock and handle multiple times in a very specific sequence, and if you get interrupted or miss a step, you have to start all over again.
You’ve even tried to hide the checking from your daughter so as not to worry her, completing checks when she is having breakfast and after her bedtime. However, the time spent on checking is becoming exhausting. You are now so sleep-deprived that your performance at work has suffered, and you have been placed on medical leave.
You have no other mental health concerns. Your sister has a diagnosed anxiety disorder. You have no medical conditions and do not drink or use drugs. You are very worried about your job and being able to be a good father to your daughter. You are keen to get your life back but also maintain that some of your checking behaviour is rationale, as you want to protect your daughter from danger.
If asked about potential triggers or important events, you might mention that around the time you read about the robbery, your partner left and you have been the primary caregiver for your daughter since.
Feedback for Scenario 1
Knowledge & Clinical Skills
A good candidate will:
● Systematically explore the core symptoms of obsession and compulsion, including mental acts, and quantify the amount of time taken each day
● Ask about possible triggers
● Ask about impact on functioning (work, family, social)
● Conduct a thorough risk assessment including risk to others (e.g. daughter)
Communication
A good candidate will:
● Build rapport with open questions
● Sensitively explore risk to self and others
● Validate anxiety associated with distressing thoughts about a break in, but explain that the compulsive checking has become part of a ‘vicious cycle’
Example phrases:
“Has this affected your ability to care for your daughter in anyway, for example, has she been late to school?”
“It is understandable that since you are worried about your daughter’s safety, you would want to make sure the house is secure. However, the time spent checking and performing rituals is trapping you in a vicious cycle of anxiety, causing you to become exhausted and likely impacting on your parenting, ”
Scenario 2: Example Video
Actor Instructions:
You are working in a busy psychiatric outpatient department. You are scheduled to see Mr. Oliver Tran, a 34-year-old primary school teacher, for a follow-up appointment. Mr. Tran was recently placed on medical leave due to his intense need to repeatedly check that his doors and windows are locked, which can take hours each evening. Your consultant has diagnosed obsessive-compulsive disorder (OCD) after an initial assessment. He has returned to clinic today to discuss the diagnosis and learn about potential treatment options.
Please explain the diagnosis of OCD and outline the treatment options for this disorder. You do not need to take a history or assess risk.
Authors/Reviewers
Dr Damir Rafi is a psychiatry speciality registrar in forensics, currently working in London.
Dr Sarah Barber is a Psychiatry Registrar, currently taking time out of clinical work to complete a PhD in psychiatric epidemiology.
References and Resources
1. World Health Organization (2022). ICD-11: International classification of diseases (11th revision).
Disclaimer:
This article is intended for use as a learning resource for doctors training in Psychiatry in the UK. It is not intended for patients. If you are looking for information about mental health conditions, please visit www.rcpsych.ac.uk/mental-health to find readable, user-friendly and evidence-based information on mental health problems, treatments and other topics written by qualified psychiatrists, with help from patients and carers. If you are looking for help for a mental health condition, please visit https://www.mind.org.uk/ for information about where help is available.
The article was written by UK doctors and cross-checked against various published sources (see Reference list). We endeavour to keep information up to date, but it should not be relied on for clinical decision making. Consult local guidelines and senior colleagues whenever you are not sure.
Related Articles:
PTSD Diagnosis & History Taking: https://psychpanda.com/ptsd/
Depression History Taking: https://psychpanda.com/depression/
Understanding & Assessing Delusions: https://psychpanda.com/delusions/