Diagnosis and Management of Obsessive Compulsive Disorder in Primary Care

Diagnosis and Management of OCD in primary care

“It's a thousand tiny impulses, building on one another. First you decide it's a good idea to check the oatmeal bin for bugs. Next you're going through all the canisters, and before you know it, you're wearing a hazmat suit and examining the frosted flakes for ground-up glass. When the disease is full-blown, sufferers are firmly entrenched in the neural loops that make them repeat thoughts and actions over and over. In other words, your brain keeps getting back in line for the same carnival ride it didn't enjoy in the first place.”

Devil in the Details: Scenes from an Obsessive Girlhood – by Jennifer Traig

Obsessive Compulsive Disorder (OCD) is characterised by unwanted and distressing thoughts (obsessions) which the sufferer responds to by repeating certain mental or physical acts (compulsions). OCD is chronic and relatively common condition, with a lifetime prevalence of 2.5%.

Symptoms are time-consuming, distressing and significantly reduce quality of life (to an equivalent degree as in schizophrenia)[i].  Unfortunately, it is also undertreated. Individuals with OCD often go for over a decade without being diagnosed[ii]- they frequently have a sense of shame around their symptoms which leads them to delay seeking help for many years. They also risk being misdiagnosed if they do not have classical OCD symptoms[iii] (see the textbox below).

There are other challenges in treating this disorder. It can occasionally be difficult to differentiate OCD from other types of mental disorders and at times the picture can be complicated by psychiatric comorbidities. Additionally, commonly used pharmacotherapy and psychotherapy requires some specific adaptations for OCD treatment.

OCD subtypes misidentified in Primary Care

• In a survey of GPs over 50% of vignettes of common OCD subtypes were misdiagnosed
• OCD obsessions involving aggression, homosexuality and paedophilia most likely to be misidentified
• Obsessions regarding religion, hygiene/contamination and symmetry were correctly identified as OCD

Assessment and Diagnosis

Patients with OCD may complain specifically about their OCD symptoms however in other cases they may complain more vaguely about anxiety or low mood. Additionally, OCD can be mistaken (both by the patient or physician) for another mental health difficulty. Obsessions can be mistaken for psychosis, and mental compulsions can be difficult to recognise due to the lack of observable characteristic behaviour. Therefore, it is useful to quickly screen for OCD when a patient presents with emotional or psychiatric symptoms.

Screening questions for OCD

1. Are you experiencing any upsetting thoughts, images or impulses, which keep repeating even though you try not to think about them? (Screening for obsessions)
2. Do you ever feel driven to repeat certain acts over and over- to reduce your anxiety or to prevent something bad from happening? (Screening for compulsions)
3. How much time does this take? Is it interfering in your life or causing you a lot of distress? (severity- do they meet criteria for diagnosis; see panel)

The symptoms should then be explored. Obsessions are unwanted, unpleasant, intrusive and ego dystonic thoughts, images or urges.  They are often unsuccessfully resisted by the patient. Obsessions cause distress or anxiety- which the patient then attempts to reduce by performing a compulsion. Compulsions can be overt (eg: handwashing, checking) or covert (eg: thinking a good thought). It is important to note that it is not necessary that the patient have both obsessions and compulsions to make a diagnosis of OCD-although usually both are present.

Common obsessions and compulsions to ask about

• Contamination obsession- fear of becoming contaminated or spreading contamination to others → washing/cleaning compulsions
• Pathological doubt- often also fearing responsibility for accident/disaster → checking compulsions
• Violent/sexual obsessions-frequently mental images/impulses → mental rituals, avoidance, reassurance seeking
• Religious obsessions-thoughts about being against God → praying, studying bible
• Fear of losing control eg: saying something inappropriate → avoiding others
• Superstition- fears of certain “bad” numbers, colours, actions → counting, undoing, redoing
• Symmetry-needing to do things in a balanced or exact fashion → Ordering and arranging
• Somatic obsessions- hyperawareness of bodily functions→ mental checking, rumination

Rating scales- YBOCS

Although it is not essential to use a rating scale when assessing OCD in primary care, they can be very useful in determining severity and as a prompt to cover the range of OCD symptoms. The Yale-Brown Obsessive Compulsive Scale (YBOCS) is a symptom checklist and severity rating scale; which is available both as an observer rated and as a self-assessment scale.  It is the gold standard OCD rating scale and can be used to measure a change in symptom severity over time.

Differentiating OCD from other mental health difficulties and comorbidities[iv]

Other Obsessive-Compulsive and Related Disorders: OCD was separated from the anxiety disorders in DSM-5 and placed in the new category: “Obsessive-Compulsive and Related Disorders”(OCRDs). These conditions are generally characterised by specific types of preoccupations or repetitive behaviours, and there is significant overlap with OCD.

• In body dysmorphic disorder there is distress caused by a perceived defect(s) in appearance, resulting in repetitive behaviours (such as checking appearance, time-consuming grooming behaviours, seeking reassurance).
• In hoarding disorder, the fear is that if an item is discarded it might be needed at a later date-this leads to a problematic accumulation of useless items.
• In trichotillomania and excoriation disorder, the focus is on repetitive hair pulling or skin picking and there are no associated obsessions.

Generalised Anxiety Disorder: the worries or recurring thoughts of GAD are primarily concerned with realistic or everyday concerns; obsessions in OCD more unusual and unrealistic in their themes. Worries and obsessions are also experienced differently. Worry is something that you “do” in order to problem solve- whereas obsessions “happen”-they intrude into consciousness fully formed.

Phobic Disorders: In phobias, there is usually very little distress in the absence of the feared situation. There is also an absence of rituals.

Major Depressive Disorder: Depression is commonly comorbid with OCD. Depressive rumination may be differentiated from obsessions in that ruminations are generally mood-congruent, ego-syntonic and not usually experienced as intrusive. Also, obsessions tend trigger anxiety and doubt; whereas depressive ruminations trigger dysphoria and hopelessness.

Eating Disorders: preoccupations are focused on food, weight or body image and the fear is of weight gain. The thoughts in eating disorders are ego-syntonic and the behaviours are purposeful.

Illness Anxiety Disorder: This is characterized by recurring thoughts that are exclusively related to fear of currently having a serious disease.

Tic Disorders: Tics are sudden, rapid, recurrent, non-rhythmic behaviours such as blinking, touching, grimacing or sniffing, and are not triggered by obsessions.

Psychotic Disorders: Although people with OCD may have poor insight or even be delusional with regard to the obsessions, they will not have hallucinations or formal thought disorder.

Obsessive Compulsive Personality Disorders: Also known as anakastic personality disorder, this is often what people are referring to when describing themselves as “so OCD.” It is characterised by traits of perfectionism, over-control (both interpersonally and mentally), excessive conscientiousness and rigidity. The traits in OCDP are ego-syntonic, as opposed to OCD obsessions and compulsions which are egodystonic.

Approaches to management

Therapy

• CBT/ERP
• Self help and support groups

ERP-CBT is the most effective treatment for OCD. ERP is a structured form of CBT where, in a graded fashion, the patient is exposed to triggers for their obsessions and instructed not to perform the related compulsions.  In addition to the behavioural component of the therapy; the patient will also learn to challenge unhelpful cognitions- such as assumptions about the significance of their thoughts and negative core beliefs.  Non-specific counselling and analytical psychotherapy are not effective in treating OCD.

Medication

Patients benefit from being informed of the delay in experiencing the positive effects of medication. Psychotherapy options should also be discussed, given the often self-sustaining nature of OCD and modest response rates to medication.

Selective serotonin reuptake inhibitors (SSRIs) and clomipramine are currently recommended as first-line agents for drug treatment of OCD. According to current evidence, effective SSRIs include escitalopram, fluvoxamine, fluoxetine, paroxetine and sertraline. Compared with other anxiety disorders, OCD tends to have lower response rates to medication and somewhat higher doses of these drugs tend to be used. Higher doses are associated with greater efficacy in some, but not all, studies. 

It is generally recommended that an SSRI should be continued at maximum tolerated doses for at least 12 weeks before efficacy can be determined. It is also generally recommended that successful treatment with SSRIs should be maintained at the maximal effective dose for at least 12 months. However, because of the generally chronic nature of OCD; most patients should be offered indefinite treatment to control symptoms and prevent relapse.

For short term reduction of anxiety and distress, benzodiazapines are often used. However, because OCD is a chronic condition, they are generally not recommended. This is because of the risk of dependency. Low dose atypical antipsychotics (eg: Olanzapine 2.5mg or Quetiapine 12.5mg) ar preferable as they have also been shown to have some benefit in terms of reduction in OCD symptoms.

When to refer to secondary psychiatric service

Despite the efficacy of SSRIs and clomipramine in many patients with OCD, approximately half of those treated show no or partial symptom improvement following treatment with a first-line drug. There is ongoing research into effective second-line strategies and referral on to a specialist psychiatrist is recommended.

Second-line strategies, often employed in specialist practice, include high-dose treatment with serotonergic agents (sometimes above British National Formulary (BNF) recommendations), switching/combining antidepressants, and augmentation with antipsychotics. Other strategies such as glutamatergic agents, gabapentin, valproate, ondansetrone and cyproterone acetate require further evaluation and may have a role to play in future treatment. 

The majority of patients with OCD are treated successfully within primary care. A GP with knowledge and understanding has the potential to make a very significant impact on the life of a patient with OCD.

References

[1] Quality of life in obsessive-compulsive disorder: impact of the disorder and of treatment. Subramaniam M1, Soh P, Vaingankar JA, Picco L, Chong SA 2013 May;27(5):367-83. doi: 10.1007/s40263-013-0056-z.
[1] The Brown Longitudinal Obsessive Compulsive Study. Pinto A, Mancebo MC, Eisen JL, et al.  J Clin Psychiatry. 2006;67(5):703–711.
[1] Half of obsessive-compulsive disorder cases misdiagnosed: vignette-based survey of primary care physicians. Glazier K1, Swing M, McGinn LK. J Clin Psychiatry. 2015 Jun;76(6):e761-7. doi: 10.4088/JCP.14m09110.
[1] Obsessive-Compulsive Disorder. London, UK: NICE; 2005.
[1] American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013.
[1] The Yale-Brown Obsessive Compulsive Scale. Goodman, W.K., Price, L.H., Rasmussen, S.A. et al. Arch Gen Psychiatry 46:1006-1011,1989
[1] Ruscio AM, Stein DJ, Chiu WT, Kessler RC. The epidemiology of obsessive-compulsive disorder in the National Comorbidity Survey Replication. Mol Psychiatry. 2010;15(1):53–63
[1] Obsessive-Compulsive Disorder in Children and Adolescents. S Walitza et al.Dtsch Arztebl Int. 2011 Mar; 108(11): 173–179.
[1] Namouz-Haddad S, Nulman I. Safety of treatment of obsessive compulsive disorder in pregnancy and puerperium. Can Fam Physician. 2014;60(2):133–136.
[1] Obsessive Compulsive Disorder- Theory, Research and Treatment- Wiley Series in Clinical Psychology 2003.
[1] Ost L et al., Cognitive behavioural treatments of obsessive-compulsive disorder: a systematic review and meta-analysis of studies published 1993-2014. Clinical Psychology Reviews. 2015
[1]Obsessive-Compulsive Disorder: Advances in Diagnosis and Treatment. Hirschtritt et al.  JAMA. 2017 Apr 4;317(13):1358-1367. doi: 10.1001/jama.2017.2200.
[i] Quality of life in obsessive-compulsive disorder: impact of the disorder and of treatment. Subramaniam M1, Soh P, Vaingankar JA, Picco L, Chong SA 2013 May;27(5):367-83. doi: 10.1007/s40263-013-0056-z.
[ii] The Brown Longitudinal Obsessive Compulsive Study. Pinto A, Mancebo MC, Eisen JL, et al.  J Clin Psychiatry. 2006;67(5):703–711.
[iii] Half of obsessive-compulsive disorder cases misdiagnosed: vignette-based survey of primary care physicians. Glazier K1, Swing M, McGinn LK. J Clin Psychiatry. 2015 Jun;76(6):e761-7. doi: 10.4088/JCP.14m09110.
[iv] Obsessive Compulsive Disorder- Theory, Research and Treatment- Wiley Series in Clinical Psychology 2003.