Obsessive compulsive disorder

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Definition

Obsessive compulsive disorder is an anxiety-related disorder and one of the six most common mental health conditions in the UK (National Institute for Health and Care Excellence, 2024). Obsessive compulsive disorder comprises three main components:

Obsessions consisting of unwanted and intrusive thoughts, images or urges
Emotional response, such as anxiety, fear and distress
Compulsions which are repetitive, ritualistic acts or behaviours that temporarily reduce anxiety (National Institute for Health and Care Excellence, 2024)

Obsessive compulsive disorder affects around 1 in 50 people in the UK (Royal College of Psychiatrists, 2019), and is seen equally in men and women and across all socioeconomic backgrounds (Stein et al, 2019). Obsessive compulsive disorder commonly emerges in adolescence to early adulthood (National Institute for Health and Care Excellence, 2024). The disorder has been rated as one of the top 20 most debilitating conditions (National Institute for Health and Care Excellence, 2024). The symptoms can cause significant impairment to daily functioning and can be enduring; however, with the right treatment and support, recovery can be achieved and maintained for many people (Stein et al, 2019).

Symptoms

The symptoms of obsessive compulsive disorder lie on a spectrum of severity, from mild to severe (World Health Organization, 2019). The essential symptoms are repetitive obsessional thoughts, images, impulses or compulsions which are repetitive actions or behaviours. Additional symptoms include:

anxiety
distress
avoiding people or triggering situations
significant and time-consuming preoccupation with thoughts and behaviours
significant impact on personal and social functioning (World Health Organization, 2019)

People with obsessive compulsive disorder can present with either obsessions or compulsions, but most commonly a combination of the two (World Health Organization, 2019). Obsessive compulsive disorder does not simply involve being tidy and orderly, the obsessive thoughts are distressing or repulsive and cause significant levels of anxiety (National Institute for Health and Care Excellence, 2024). To manage their emotional response, people engage in compulsive behaviours which follow rigid rules that are not enjoyable or useful. Their purpose is to avoid an unlikely, unwanted scenario, often involving the person or others coming to harm, or to achieve a sense of completeness. The compulsions provide short-term relief, but also maintain the cycle, as any attempt to resist the compulsions heightens the anxiety and distress (World Health Organization, 2019).

Common obsessions include:

contamination fears
forbidden/taboo thoughts, such as sexual or harm-related
superstitious or magical thinking
symmetry and order
collecting and hoarding (World Health Organization, 2019)

Common compulsions include:

hand washing
checking rituals
cleaning, ordering and arranging items
counting, often involving special numbers
repeating special words or prayers (World Health Organization, 2019)

Obsessive compulsive disorder can follow a chronic or episodic course, and relapses are associated with periods of increased stress (Fineberg et al, 2020).

Aetiology

Although the exact cause of obsessive compulsive disorder is not known, there are multiple neurobiological, genetic and environmental factors associated with the disorder (Shapiro, 2020).

Genetics

Twin studies have found a strong genetic link in people with obsessive compulsive disorder (Stein et al, 2019). Genes associated with serotonin, dopamine and adrenaline pathways have been implicated, affecting learning, thoughts, memory processing, mood and stress responses. However, further research is needed to fully understand the genetic influences on the disorder (Stein et al, 2019).

Neurobiological

Neuroimaging has highlighted functional and structural abnormalities in people with obsessive compulsive disorder. Reduced volume is seen in the striatum, orbitofrontal cortex and hippocampus, which relate to habit formation, decision making, memory processing and reward-orientated behaviours (Jalal et al, 2023). Structural anomalies in the pallidum, associated with motivation and reward, and the amygdala, associated with anxiety and fear responses, have been found and correlate with increased symptom severity and duration (Zhang et al, 2019).

Neurochemical

Neurochemical imbalances in the cortico–striato–thalamo–cortical (CSTC) circuits are evident in people with obsessive compulsive disorder (Jalal et al, 2023). This causes hyperactivity and hypoactivity in different areas associated with cognitive processing, habit formation, response inhibition, reward and motivation (Jalal et al, 2023).

Psychosocial

There is limited research into the environmental risk factors associated with obsessive compulsive disorder (Brander et al, 2016). Some contributory factors include:

adverse childhood experiences
trauma
a family environment with rigid rules, high levels of guilt, blame
critical or perfectionist parenting styles (Shapiro, 2020)

Responsibility and perceived threat are important aetiological factors. Anxious and avoidant parenting can lead to overestimating threat, preventing the child from taking any responsibility or risks (Barcaccia et al, 2015). Conversely, the child may develop an increased sense of responsibility for the safety and protection of others and believe that mistakes can have catastrophic consequences (Barcaccia et al, 2015).

Psychological theories

Although the cognitive and behavioural theories around obsessive compulsive disorder are now decades old, they continue to form the basis for psychological interventions (Shapiro, 2020). Experiencing intrusive thoughts at times is normal, but people with obsessive compulsive disorder can misinterpret these thoughts as having special meaning or high importance. The negative emotional response that follows leads to the person developing avoidance behaviours. These behaviours are then negatively reinforced, through repeated action, leading to the development of obsessive compulsive disorder (Shapiro, 2020).

Diagnosis

Diagnosing obsessive compulsive disorder requires careful and holistic assessment of the symptoms, their severity, duration and impact on functioning (National Institute for Health and Care Excellence, 2024). Accurate assessment is crucial in determining the appropriate level of treatment required (Fineberg et al, 2020) and should involve the person’s family where possible (National Institute for Health and Care Excellence, 2020).

Rating scales are not necessary for diagnosis (National Institute for Health and Care Excellence, 2020). However, the Yale-Brown Obsessive-Compulsive Scale is seen as the gold standard for assessing symptoms, severity and measuring treatment response (Fineberg et al, 2020). People with obsessive compulsive disorder often feel ashamed about their symptoms, especially where taboo and harm-based thoughts are present, which can lead to delays in seeking support (National Institute for Health and Care Excellence, 2020). People with obsessive compulsive disorder benefit from early intervention, as treatment delays are associated with poorer outcomes (Fineberg et al, 2020).

Diagnosis is based on the above clinical symptoms. In addition, there must be:

A degree of insight that the obsessive thoughts are a product of their own mind
The obsessions and compulsions must be time consuming, causing significant levels of distress and disruption in day-to-day functioning
The symptoms must not be a result of any other mental health condition (National Institute for Health and Care Excellence, 2020)

Differential diagnoses and co-morbidities can affect treatment planning and outcomes (Fineberg et al, 2020). Around 90% of people with obsessive compulsive disorder meet the criteria for a comorbidity, commonly including:

problem alcohol and substance use
mood and anxiety disorders
eating disorders
impulse disorders, such as attention deficit hyperactivity disorder (Pampaloni et al, 2022)

Comorbid mood, anxiety and eating disorders are associated with higher risk of self-harm or suicide (Pampaloni et al, 2022). Comorbidities and psychosocial factors that influence risk must be considered when undertaking a risk assessment (National Institute for Health and Care Excellence, 2020).

Differential diagnoses include:

obsessive compulsive personality disorder
depressive disorders
anxiety disorders
psychotic disorders
autistic spectrum disorders
obsessive compulsive related disorders, such as body dysmorphia

Women are particularly vulnerable to new onset or exacerbation of obsessive compulsive disorder symptoms during pregnancy, post-partum and the menopause. This requires careful monitoring, especially where there have been previous episodes of the disorder (Fineberg et al, 2020).

Management

The National Institute for Health and Care Excellence (2020) guidelines recommend a stepped-care approach to treatment depending on:

the severity of symptoms
level of impairment
previous treatment response

When considering medication, a risk assessment is advised, especially where there are comorbid conditions, as selective serotonin reuptake inhibitors can potentially increase risks in the initial period of prescription (National Institute for Health and Care Excellence, 2024). Suicidal behaviours associated with selective serotonin reuptake inhibitor use are more common in people aged under 25 years (National Institute for Health and Care Excellence, 2024). Higher doses are required and for longer periods, typically 12 weeks, to achieve a therapeutic response. Medication should be continued for at least 12 months to prevent any potential relapse (National Institute for Health and Care Excellence, 2020).

Mild symptoms

These symptoms are treated by low intensity psychological therapy (less than 10 hours per week) via self-help, telephone or in a group, including:

Cognitive-behavioural therapy – a skills-based therapy aimed at understanding the link between thoughts and behaviours
Exposure and response prevention – gradually exposes the person to fear-provoking situations and supports them to manage their emotional responses and resist compulsive behaviours (National Institute for Health and Care Excellence, 2024)

Moderate symptoms

These symptoms are treated using either a selective serotonin reuptake inhibitor, intensive cognitive behavioural therapy or exposure and response prevention, for more than 10 hours per week (National Institute for Health and Care Excellence, 2024). First choice selective serotonin reuptake inhibitors are fluoxetine, fluvoxamine, paroxetine, sertraline or citalopram. If there is an inadequate response after 12 weeks, then an alternative selective serotonin reuptake inhibitor or clomipramine (a tricyclic antidepressant) should be trialled (National Institute for Health and Care Excellence, 2024).

Severe symptoms

Around 50% of people with obsessive compulsive disorder do not respond to first-line treatments (Stein et al, 2019). Risk factors include:

being male
having more severe symptoms
greater functional impairment
higher rate of comorbid conditions (Stein et al, 2019)

Where symptoms prevent the person from leaving their home, reasonable adjustments for care delivery must be made (National Institute for Health and Care Excellence, 2020). If there has been a poor response to selective serotonin reuptake inhibitors and clomipramine alone or in combination with intensive cognitive behavioural therapy, then augmentation with an antipsychotic medication or buspirone, a medication used to treat anxiety, should be considered. Aripiprazole or risperidone can also be beneficial (Fineberg et al, 2020).

Treatment resistant obsessive compulsive disorder

Around 10–40% of people with obsessive compulsive disorder do not respond to any of the above treatments (Fineberg et al, 2020). Inpatient services can be considered where there are prominent debilitating symptoms, functional impairment, extreme distress and risk of harm (National Institute for Health and Care Excellence, 2020).

Neurosurgery is not broadly recommended, but if this is requested by the patient, the National Institute for Health and Care Excellence (2020) have set out guidance for clinicians on this option. Neurosurgery consists of creating lesions in the brain areas that are associated with the symptoms of obsessive compulsive disorder, but carries a risk of permanent adverse effects (Fineberg et al, 2020).

Psychoeducation

Education for the patient and families, where appropriate, should include information in suitable formats on the symptoms, cause and treatment options along with signposting to appropriate support groups (National Institute for Health and Care Excellence, 2020). When families are provided with education to reduce how they accommodate the person’s compulsive behaviours, treatment is more successful (Stein et al, 2019).

NMC proficiencies

Nursing and Midwifery Council: standards of proficiency for registered nurses

Part 1: Procedures for assessing people’s needs for person-centred care

1. Use evidence-based, best practice approaches to take a history, observe, recognise and accurately assess people of all ages

Part 2: Procedures for the planning, provision and management of person-centred nursing care

3. Use evidence-based, best practice approaches for meeting needs for care and support with rest, sleep, comfort and the maintenance of dignity, accurately assessing the person’s capacity for independence and self-care and initiating appropriate interventions

11. Procedural competencies required for best practice, evidence-based medicines administration and optimisation

Resources

Barcaccia B, Tenore K, Mancini F. Early childhood experiences shaping vulnerability to Obsessive-Compulsive Disorder. Clin Neuropsychiatry. 2015;12(6):141-147

Brander G, Pérez-Vigil A, Larsson H, Mataix-Cols D. Systematic review of environmental risk factors for obsessive-compulsive disorder: a proposed roadmap from association to causation. Neurosci Biobehav Rev. 2016;65:36-62. http://doi.org/10.1016/j.neubiorev.2016.03.011

Fineberg NA, Hollander E, Pallanti S et al. Clinical advances in obsessive-compulsive disorder: a position statement by the International College of Obsessive-Compulsive Spectrum Disorders. Int Clin Psychopharmacol. 2020;35(4):173-193. http://doi.org/10.1097/YIC.0000000000000314

Jalal B, Chamberlain SR, Sahakian BJ. Obsessive-compulsive disorder: etiology, neuropathology, and cognitive dysfunction. Brain Behav. 2023;13(6):e3000. http://doi.org/10.1002/brb3.3000

National Institute for Health and Care Excellence. Obsessive compulsive disorder: core interventions in the treatment of obsessive compulsive disorder and body dysmorphic disorder. 2020. https://www.nice.org.uk/guidance/cg31/evidence/full-guideline-pdf-194883373 (accessed 31 July 2024)

National Institute for Health and Care Excellence. Obsessive-compulsive disorder. 2024. https://cks.nice.org.uk/topics/obsessive-compulsive-disorder/ (accessed 31 July 2024)

Pampaloni I, Marriott S, Pessina E et al. The global assessment of OCD. Compr Psychiatry. 2022;118:152342. http://doi.org/10.1016/j.comppsych.2022.152342

Royal College of Psychiatrists. Obsessive-compulsive disorder. 2019. https://www.rcpsych.ac.uk/mental-health/mental-illnesses-and-mental-health-problems/obsessive-compulsive-disorder (accessed 31 July 2024)

Shapiro L. Obsessive compulsive disorder: elements, history, treatments and research. London: Bloomsbury Academic; 2020

Stein DJ, Costa DLC, Lochner C et al. Obsessive-compulsive disorder. Nat Rev Dis Primers. 2019;5(1):52. http://doi.org/10.1038/s41572-019-0102-3

World Health Organization. ICD-10: international statistical classification of diseases and related health problems. 2019. https://icd.who.int/browse10/2019/en (accessed 31 July 2024)

Zhang L, Hu X, Li H et al. Characteristic alteration of subcortical nuclei shape in medication-free patients with obsessive-compulsive disorder. Neuroimage Clin. 2019;24:102040. http://doi.org/10.1016/j.nicl.2019.102040

Obsessive compulsive disorder

Katie Loader