Obsessive-compulsive disorder

OCD shows up across many case types, often as the diagnosis you must separate from generalized worry, perfectionism, or psychosis, and the exam rewards knowing that exposure and response prevention (ERP) is the first-line psychotherapy.

Criteria at exam depth. The client has obsessions, compulsions, or both. Obsessions are recurrent, intrusive, unwanted thoughts, urges, or images that cause marked anxiety or distress, which the client tries to ignore, suppress, or neutralize. Compulsions are repetitive behaviors (washing, checking, ordering) or mental acts (counting, praying, repeating words) the client feels driven to perform in response to an obsession or by rigid rules, aimed at reducing distress or preventing a feared outcome, but either not realistically connected to that outcome or clearly excessive. The symptoms are time-consuming (more than 1 hour a day) or cause clinically significant distress or impairment, are not caused by a substance or medical condition, and are not better explained by another disorder. Specifiers: insight (good or fair, poor, or absent insight/delusional beliefs) and tic-related (current or past tic disorder).

Hinge differentials.

• Generalized anxiety disorder: worries are about real-life concerns and are not paired with ritualized neutralizing; OCD obsessions are typically ego-dystonic and drive rituals.
• Obsessive-compulsive personality disorder: a lifelong, ego-syntonic pattern of perfectionism and control without true obsessions or compulsions; both can co-occur.
• Psychotic disorder: an OCD client with absent insight still has OCD-themed beliefs and no other psychotic features such as hallucinations or disorganization.
• Illness anxiety disorder: fear of having a disease, rather than contamination rituals or intrusive images.
• Hoarding, BDD, trichotillomania: related disorders with a narrower focus (discarding, appearance, hair pulling).

On the NCMHCE. Use a structured measure such as the Y-BOCS to rate severity and track progress. Psychoeducate on the OCD cycle: obsession raises anxiety, the compulsion brings short-term relief, and that relief reinforces the cycle. First-line psychotherapy is CBT with ERP: a fear hierarchy, graded exposure, and blocking rituals and reassurance-seeking, with family members coached to reduce accommodation. Refer to a prescriber when severity or poor response warrants; SSRIs are the usual medication class. Screen for depression and suicidal ideation, and for tics. Sudden onset in a child after an infection warrants medical referral. Respect cultural and religious practice; scrupulosity is distinguished from normative faith by distress and ritual rigidity.

Clinical Pearl: OCD = ego-dystonic obsessions plus neutralizing rituals that take more than an hour a day or impair; OCPD = ego-syntonic perfectionism without rituals. Treat with ERP, and never give reassurance as a ritual.