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Obsessive compulsive
disorder (OCD) -
clinical presentation
History and
examination
Consider differential
diagnoses
Diagnosis of obsessive
compulsive disorder
(OCD)
Review first-line
therapy
Review
Consider referral to
specialist treatment
service
Refer to specialist
treatment service
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
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1 Background information
Quick info:
Scope:
assessment and management of obsessive compulsive disorder (OCD), in primary and secondary care
pharmacological and non-pharmacological treatments
treatments in adults with special considerations in children and adolescents, the elderly, and in pregnant and breastfeeding
women
Out of scope:
body dysmorphmic disorder (BDD)
related pathways include:
depression
anxiety
self harm
adverse effects of antipsychotic treatments
Definition:
OCD is defined as the presence of obsessional thoughts or compulsive acts, or most commonly, both.
obsessions are recurring thoughts, images or impulses that leads to marked anxiety.
compulsions are repetitive behaviours or mental acts guided by obsessions or following certain rules, to try and reduce distress
or prevent imagined negative events
Prevalence:
estimates vary between 0.8-3% in adults, and 0.25-2% in children and adolescents [1]
Prognosis:
untreated OCD can often persist; approximately 48% of people continue to have OCD 30 years after diagnosis [1]
Complications:
OCD can have severe effects on the quality of life and the ability for sufferers to study or work
References:
[1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008.
[2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder.
Washington DC: American Psychiatric Association (APA); 2007.
[3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE).
Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic
disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RC-
PSYCH); 2005.
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
This care map was published by International. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
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http://eng.mapofmedicine.com/evidence/map/obsessive_compulsive_disorder_ocd_1.html
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
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the associated behaviours checking and cleaning rituals are the most common; others include order, hoarding, superstitious
behaviours and counting
effects on patient's psychosocial functioning:
effect on their daily life and employment or schooling
hazards to physical health (due to hoarding objects or repetitive washing)
for co-morbid conditions such as depression, drug abuse, risk of self harm and suicide
effects on the family including carer and/or dependent children
Obsessions may include (most to least common):
contamination from dirt, germs, viruses, bodily fluids, chemicals, sticky or dangerous substances
fear of causing harm to self or others by acts of omission, eg door locks are not secure
perfectionism
excessive attention to order or symmetry
obsession with body or physical symptoms
religious, sacrilegious or blasphemous thoughts
sexual thoughts, eg paedophilia
desire to hoard worn out or useless possessions
violent or aggressive thoughts
magical or superstitious thoughts (in children)
Compulsions may include (most to least common):
checking, eg gas, taps, locks
decontamination, cleaning, and washing
repetition of acts
mental compulsions eg repetition of special words or prayers
ordering, symmetry, exactness
hoarding or collecting
counting
limitation of function (eg prevents social contact) and may cause anxiety and distress
insight at some point during course of disorder, the person recognises and tries to resist obsessions and compulsions
Asking the following questions may aid diagnosis:
do you check things a lot?
do you wash a lot?
do your daily activities take a long time to complete?
do you always need to put things in a special order?
It may also be helpful to get the patient to document an estimate of how long they spend obsessing or performing compulsive acts.
This information was drawn from the following references:
[1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008.
[2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder.
Washington DC: American Psychiatric Association (APA); 2007.
[3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE).
Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic
disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RC-
PSYCH); 2005.
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
This care map was published by International. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
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http://eng.mapofmedicine.com/evidence/map/obsessive_compulsive_disorder_ocd_1.html
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
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[3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE).
Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic
disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RC-
PSYCH); 2005.
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
This care map was published by International. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
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reserve pharmacological treatment only for those children where psychological treatment has been unsuccessful
consider dosages carefully in relation to age and size
carefully monitor for adverse side effects
SSRI's have been shown to be effective in reducing overall symptom severity [7]
elderly:
check for drug interactions
lower dosage due to reduced metabolism
pregnancy and breastfeeding:
avoid drugs if possible
consider potential risks and benefits of any pharmacological treatment
fluoxetine should be used as first-line drug in pregnancy, but should not be used in breastfeeding
References:
[1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008.
[2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder.
Washington DC: American Psychiatric Association (APA); 2007.
[3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE).
Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic
disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RC-
PSYCH); 2005.
[4] Munoz-Solomando A, Kendall T, Whittington CJ. Cognitive behavioural therapy for children and adolescents. Curr Opin
Psychiatry 2008; 21(4):332-337.
[5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders:
recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96.
[6] Choi YJ. Efficacy of treatments for patients with obsessive-compulsive disorder: a systematic review. J Am Acad Nurse Pract
2009; 21: 207-13.
[7] Ipser JC, Stein DJ, Hawkridge S et al. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database
Syst Rev 2009; CD005170.
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
This care map was published by International. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
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Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
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[2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder.
Washington DC: American Psychiatric Association (APA); 2007.
[3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE).
Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic
disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RC-
PSYCH); 2005.
[5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders:
recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96.
[6] Choi YJ. Efficacy of treatments for patients with obsessive-compulsive disorder: a systematic review. J Am Acad Nurse Pract
2009; 21: 207-13.
[7] Ipser JC, Stein DJ, Hawkridge S et al. Pharmacotherapy for anxiety disorders in children and adolescents. Cochrane Database
Syst Rev 2009; CD005170.
23 First-line therapies
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
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Quick info:
Severe obsessive compulsive disorder (OCD) is usually managed by a combination of cognitive behavioural therapy (CBT) and drug
therapy [1,2,3].
There are several factors to consider at each stage of treatment, including [2]:
patient's motivation
severity of symptoms
suicide risk
other co-existing psychiatric or medical disorders
drug side effects
past treatment history
whether women are at childbearing age
elderly patients
References:
[1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008.
[2] Koran LM, Hanna GL, Hollander E. Practice guideline for the treatment of patients with obsessive-compulsive disorder.
Washington DC: American Psychiatric Association (APA); 2007.
[3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE).
Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic
disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RC-
PSYCH); 2005.
25 Drug therapy
Quick info:
First-line drug treatment should involve selective serotonin re-uptake inhibitors (SSRI), eg fluoxetine, as these can alleviate
symptoms and improve quality of life. Consider [3,5]:
a trial for 12 weeks, as drugs may not show a response before this (if patient responds, continue drugs after 12 week trial)
trials should be up to the maximum tolerated dose there is often a dose response relationship in obsessive compulsive
disorder (OCD)
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
This care map was published by International. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
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http://eng.mapofmedicine.com/evidence/map/obsessive_compulsive_disorder_ocd_1.html
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
This care map was published by International. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
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30 Review
Quick info:
If a patient has taken maintenance medication for 1 year without relapse, and has been fully functioning for 12 weeks, consider need
for continued treatment. Factors favouring more prolonged treatment include [3]:
longer and more severe illness
continuing symptoms
greater number of previous relapses
co-morbidities
poor social support
ongoing psychosocial problems
Do not stop medications abruptly in order to minimise discontinuation or withdrawal symptoms; taper medications over a few weeks
and monitor for relapse [3,5].
Patients, family and carers should be advised that [1]:
there is a risk of relapse even after successful treatment and recovery
they should seek help as soon as possible if symptoms recur
If a patient fails to respond to appropriate interventions, consider [10]:
intensive cognitive behavioural therapy (CBT); or
cognitive therapy
References:
[1] Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne: CKS; 2008.
[3] National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical Excellence (NICE).
Obsessive Compulsive Disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic
disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal College of Psychiatrists (RC-
PSYCH); 2005.
[5] Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety disorders:
recommendations from the British Association for Psychopharmacology. J Psychopharmacol 2005; 19: 567-96.
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
This care map was published by International. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
For terms of use please see our Terms and Conditions http://mapofmedicine.com/map/legal Page 12 of
16
http://eng.mapofmedicine.com/evidence/map/obsessive_compulsive_disorder_ocd_1.html
[10] Map of Medicine (MoM) Clinical Editorial team, and independent reviewers invited by Map of Medicine. London: MoM; 2010.
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
This care map was published by International. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
For terms of use please see our Terms and Conditions http://mapofmedicine.com/map/legal Page 13 of
16
http://eng.mapofmedicine.com/evidence/map/obsessive_compulsive_disorder_ocd_1.html
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
This care map was published by International. A printed version of this document is not controlled so may not be up-to-date with the latest clinical information.
For terms of use please see our Terms and Conditions http://mapofmedicine.com/map/legal Page 14 of
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http://eng.mapofmedicine.com/evidence/map/obsessive_compulsive_disorder_ocd_1.html
Key Dates
Published: 29-Jul-2010, by International
Valid until: 29-Feb-2012
Accreditations
The care map is accredited by:
The Chief Knowledge Officer of the NHS:
Disclaimer
References
This is a list of all the references that have passed critical appraisal for use in the care map Obsessive compulsive disorder (OCD)
ID Reference
1 Clinical Knowledge Summaries (CKS). Obsessive-compulsive disorder. Version 1.0. Newcastle upon Tyne:
CKS; 2008.
http://www.cks.nhs.uk/obsessive_compulsive_disorder#350948001
2 Koran LM, Hanna GL, Hollander E et al. Practice guideline for the treatment of patients with obsessive-
compulsive disorder. Washington, DC: American Psychiatric Association (APA); 2007.
http://www.psychiatryonline.com/pracGuide/loadGuidelinePdf.aspx?file=OCDPracticeGuidelineFinal0
5-04-07
3 National Collaborating Centre for Mental Health (NCCMH), National Institute for Health and Clinical
Excellence (NICE). Core interventions in the treatment of obsessive-compulsive disorder and body
dysmorphic disorder. Clinical guideline 31. London: The British Psychological Society (BPS) and The Royal
College of Psychiatrists; 2005.
http://www.nice.org.uk/nicemedia/pdf/cg031fullguideline.pdf
4 Munoz-Solomando A, Kendall T, Whittington CJ. Cognitive behavioural therapy for children and
adolescents. Curr Opin Psychiatry 2008; 21: 332-7.
http://www.ncbi.nlm.nih.gov/pubmed/18520736
5 Baldwin DS, Anderson IM, Nutt DJ. Evidence-based guidelines for the pharmacological treatment of anxiety
disorders: recommendations from the British Association for Psychopharmacology. J Psychopharmacol
2005; 19: 567-96.
http://www.bap.org.uk/pdfs/Anxiety_Disorder_Guidelines.pdf
6 Choi YJ. Efficacy of treatments for patients with obsessive-compulsive disorder: a systematic review. J Am
Acad Nurse Pract 2009; 21: 207-13.
http://www.ncbi.nlm.nih.gov/pubmed/19366379
7 Ipser JC, Stein DJ, Hawkridge S et al. Pharmacotherapy for anxiety disorders in children and adolescents.
Cochrane Database Syst Rev 2009;
http://www.ncbi.nlm.nih.gov/pubmed/19588367
8 Jonsson H, Hougaard E. Group cognitive behavioural therapy for obsessive-compulsive disorder: a
systematic review and meta-analysis. Acta Psychiatr Scand 2009; 119: 98-106.
http://www.ncbi.nlm.nih.gov/pubmed/18822090
9 Bloch MH, McGuire J, Landeros-Weisenberger A et al. Meta-analysis of the dose-response relationship of
SSRI in obsessive-compulsive disorder. Mol Psychiatry 2009; [Epub ahead of print]:
http://www.ncbi.nlm.nih.gov/pubmed/19468281
10 Map of Medicine (MoM) Clinical Editorial team,and independent reviewers invited by MoM. London: MoM;
2010.
Disclaimers
The Chief Knowledge Officer of the NHS
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
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It is not the function of the Chief Knowledge Officer of the NHS to substitute for the role of the clinician, but to support the clinician
in enabling access to know-how and knowledge. Users of the Map of Medicine are therefore urged to use their own professional
judgement to ensure that the patient receives the best possible care. Whilst reasonable efforts have been made to ensure the
accuracy of the information on this online clinical knowledge resource, we cannot guarantee its correctness or completeness. The
information on the Map of Medicine is subject to change and we cannot guarantee that it is up-to-date.
Published: 29-Jul-2010 Valid until: 29-Feb-2012 Map of Medicine Ltd All rights reserved
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