CLINICAL REVIEW Obsessive-compulsive disorder Follow the link from the online version of this article to obtain certi ed continuing 1 2 1 medical education credits David Veale, Alison Roberts 5 6 1Centre for Anxiety Disorders Obsessive-compulsive disorder (OCD) is characterised by 5-15 year olds. They have a similar presentation to adults. and Trauma, South London and the presence of obsessions or compulsions, or commonly The differences reflect developmental stages (for example, Maudsley NHS Foundation Trust, of both. OCD is the fourth most common mental disorder more sexual and religious obsessions in adolescents than London SE5 8AZ, UK 2Anxiety Disorders Residential Unit, after depression, alcohol/substance misuse, and social in children and more fears of death of a parent for young 6 South London and Maudsley NHS phobia, with a lifetime prevalence in community surveys people than for adults). Rarely, children may develop a Foundation Trust and Institute of of 1.6%.1 The severity of OCD differs markedly from one sudden onset of obsessive-compulsive symptoms with an Psychiatry, King’s College London person to another. People are often able to hide their OCD, episodic course and the presence of motor tics, hyperac- Correspondence to: D Veale [email protected] even from their own family, although it can cause problems tivity, or choreiform movements. This is associated with Cite this as: BMJ 2014;348:g2183 in relationships and interfere with the ability to study or various infectious agents and other environmental factors doi: 10.1136/bmj.g2183 work. Health consequences can also occur: fear of contami- in several case series of children with OCD.7 nation can, for example, prevent the accessing of appro- bmj.com priate health services or lead to dermatitis from excessive What are obsessions and compulsions? Previous articles in this washing. When the disorder starts in childhood or adoles- An obsession is defined as an unwanted intrusive thought, series cence, young people may avoid socialising with peers or doubt, image, or urge that repeatedly enters the mind. Ж Modern management become unable to live independently. The World Health Obsessions are distressing and ego-dystonic (that is, they of splenic trauma Organization ranks OCD as one of the 10 most handicap- are repugnant or inconsistent with the person’s values). (BMJ 2014;348:g1864) ping conditions by lost income and decreased quality of The person usually regards the intrusions as unreason- Ж Fungal nail infection: life.2 This clinical review summarises the evidence on how able or excessive and tries to resist them. A minority of diagnosis and to recognise, assess, and manage people with OCD. obsessions are regarded as overvalued ideas and, rarely, management delusions.8 Obsessions do not concern day to day worries, (BMJ 2014;348:g1800) Who gets OCD? which occur in generalised anxiety disorder; perceived Ж Endometriosis OCD occurs all over the world, although cultural factors defects in appearance, which occur in body dysmorphic (BMJ 2014;348:g1752) may shape the content. (For example, religious obsessions disorder; or fear of having a serious disease, which occurs are more common in some communities.) The sex ratio in in health anxiety. Ж Management of 1 sickle cell disease in the epidemiological surveys across the world is equal, but more Compulsions are repetitive behaviours or mental acts women have compulsive washing, and more men have sex- that a person feels driven to perform in response to an community ual obsessions, magical numbers, or obsessional slowness. obsession. They are largely involuntary and are seldom (BMJ 2014;348:g1765) The mean age of onset is late adolescence for men and resisted. A compulsion can take the form of either an overt Ж Coeliac disease the early 20s for women. However, OCD can also present action observable by others (such as checking that a door (BMJ 2014;348:g1561) in older people, either after a long history of the condi- is locked) or a covert mental act that cannot be observed tion hitherto undiagnosed or with symptoms that are (such as repeating a certain phrase in the mind). Covert or more recent in onset. OCD occurs with a point prevalence mental compulsions are generally more difficult to resist or of about 1% of the population.3 4 Children and adolescents monitor than overt ones, as they are “portable” and easier can also have OCD, with a prevalence of about 0.25% in to perform. The table lists common obsessions and com- pulsions. A compulsion in OCD is not in itself pleasurable, SUMMARY POINTS which differentiates it from impulsive acts such as shop- The World Health Organization ranks obsessive-compulsive disorder (OCD) as one of the 10 ping, gambling, or paraphilias that are associated with most handicapping conditions by lost income and decreased quality of life immediate gratification. OCD occurs across all ages but most commonly presents in young people The term “ritual” is synonymous with compulsion but Shame often prevents people with OCD seeking help and causes delays in effective usually refers to motor acts. “Rumination” in OCD refers treatment to mental acts repeated endlessly in response to intrusive Non-specialists should ask screening questions if OCD is suspected ideas and doubts. The term “pure O” is sometimes used OCD is a treatable condition—children and adults should initially be offered cognitive by patients to describe ruminations without observable behavioural therapy compulsions. To warrant a diagnosis of OCD, obsessions For moderate to severe OCD in children and adults, selective serotonin reuptake inhibitors and compulsions must be time consuming (for example, may also be offered more than one hour a day) or cause significant distress or functional impairment (see box).9 10 Hoarding is a compul- SOURCES AND SELECTION CRITERIA sion in OCD, but “hoarding disorder” is now planned to be We referred to published systematic reviews, including the treatment guideline from the a separate diagnosis in ICD-11 (international classifica- National Institute for Health and Care Excellence (2005) and the obsessive compulsive tion of diseases, 11th revision). It refers to the excessive disorder evidence update (2013). We identified reviews by searches for “compulsive acquisition and marked difficulty in discarding of items, behavior”, “obsessive-compulsive disorder”, “obsessive behavior”, “compulsions”, regardless of their actual value, leading to significant dis- “obsessions”, “obsessive compulsive neurosis”, “scrupulosity”, “symmetry”, “recur$ adj tress or handicap. obsession$”, “recurr$ adj thought$”, “symmetr$ or count$ or arrang$ or order$ or wash$ or Although tics may be mistaken for compulsions, they repeat$ or hoard$ or clean$ or check$ (adj compulsi$)” can be differentiated by the focal uncomfortable somatic BMJ | 12 APRIL 2014 | VOLUME 348 31 CLINICAL REVIEW sensations that precede and are relieved by the tic. Motor that they have OCD or feel too ashamed and stigmatised tics vary from simple abrupt movements to more complex to seek help. They may present to a general practitioner and apparently purposive behaviours (such as clapping with dermatological symptoms (from excessive washing), or touching an object). Phonic or vocal tics range from genital or anal symptoms (from excessive checking and simple throat clearing sounds to more complex vocalisa- washing), general stress (for example, from losing a job tions in speech. The behaviour is considered a compul- as a result of repeated lateness), or doubts about contract- sion rather than a tic if it is performed a certain number ing HIV. of times or in a certain order or at a particular time of day, Other themes concern intrusions about sexuality, blas- is done in response to an obsession, and is intended to phemy, morality, or mistakes. OCD is more difficult to reduce anxiety or prevent harm. However, the boundaries recognise when the compulsions are covert or stigmatis- between a complex tic and a tic-like compulsion can be ing. Observers may notice simply that the person seems blurred.11 preoccupied or anxious or takes a long time to respond to questions. They would not be able to see the person trying How can we identify and diagnose obsessive-compulsive mentally to replace unacceptable sexual thoughts with symptoms? “safe” or “correct” thoughts, praying, or trying to reassure Simple screening questions for OCD take only a few min- him or herself that a particular action is safe. Thus OCD is utes and may indicate a need for onward referral. Guidance often hidden, as patients believe that their own intrusive from the National Institute for Health and Care Excellence thoughts or images are too shameful. They may refuse to (NICE)12 suggests that the following questions can be used reveal the content of their intrusive thoughts to a health clinically to help to diagnose OCD when the symptoms are professional, owing to the fear of being misunderstood significantly distressing or interfering in a person’s life: or being reported to social services. Generalists may not • Do you wash or clean a lot? need to know the exact content of intrusive thoughts, and • Do you check things a lot? reassuring a person with OCD that having unacceptable or • Is there any thought that keeps bothering you that you senseless thoughts is extremely normal may be sufficient would like to get rid of but cannot? before onward referral. • Do your daily activities take a long time to finish? Health visitors or social workers may, however, raise • Are you concerned about putting things in a special concerns about whether sexual or violent thoughts might order or are you very upset by mess? mean that a person with OCD is dangerous. Each case • Do these problems trouble you? needs to be assessed individually, but no recorded cases If a person responds affirmatively to one of the above exist of people with OCD acting on their thoughts.