Obsessive-compulsive disorder (OCD) has been defined as a neuropsychiatric condition characterized by recurrent, distressing thoughts and repetitive behaviors or mental rituals that are performed to reduce anxiety. According to the Obsessive Compulsive Foundation, one in 50 American adults has OCD; twice that many have had it at some point in their lives.

An Unrecognized Problem

The Obsessive Compulsive Foundation also notes that, on average, people with OCD see three to four doctors and spend 9 years seeking treatment before they receive a correct diagnosis. It takes an average of 17 years from the time OCD begins for people to obtain appropriate treatment. “OCD tends to be underdiagnosed and undertreated for a number of reasons,” explains Jill N. Fenske, MD. “People with OCD are often secretive about their symptoms. Symptoms are often accompanied by feelings of shame because patients realize the thoughts and behaviors are excessive or unreasonable. This secrecy, along with a lack of recognition of OCD symptoms by physicians, often leads to a long delay in diagnosis and treatment.”

Many primary care physicians (PCPs) and other healthcare providers are unfamiliar with OCD symptoms or are inadequately trained in the provision of appropriate treatments, adds Dr. Fenske. “OCD has a reputation of being difficult to treat, but there are many effective therapies available. As clinicians, it’s imperative to strive for an earlier diagnosis and proper treatment with the right medications or cognitive behavioral therapy (CBT) so that patients can avoid the suffering associated with OCD. A PCP can help by spotting clues regarding the presence of obsessions or compulsions.”

Clinical Recommendations

Dr. Fenske and Thomas L. Schwenk, MD, published a review of practices for diagnosing and treating OCD in the primary care setting in the August 1, 2009 issue of American Family Physician. It describes various subtypes of OCD and their typical presenting features (Figure 1). “OCD presents in different ways, and each individual has a unique cluster of obsessions and compulsions,” says Dr. Fenske. “Recognizing the different OCD subtypes and how they present can have implications for treatment. Some subtypes will respond better to cognitive behavioral therapy (CBT) while others will be better served with medications, perhaps in combination with CBT. By recognizing OCD variances, appropriate treatment courses can be planned accordingly.”

The American Family Physician review also outlines specific key clinical treatment recommendations for practice (Table 2). Important initial steps in facilitating recovery from OCD include making a correct diagnosis and educating patients on the nature of OCD. Treatment is indicated when OCD symptoms cause impaired function or significant distress for patients. First-line therapy should consist of CBT with exposure and response prevention, or pharmacotherapy with an SSRI. “OCD is not a one-size-fits-all disorder, and treatment won’t cure it,” Dr. Fenske says, “but therapies can make a difference by relieving symptoms. Physicians should inform patients on what to expect with treatment and set reasonable goals. CBT and medications for OCD take time to work, and patients should realize that it will likely take several weeks, or sometimes months, before they see results. Physicians need to be supportive and encourage them to stick with treatment plans.”

Special Considerations

Some patients with OCD may be resistant to initial treatment, but research suggests that there are potential second-line options for therapy. “Some investigations have demonstrated that SSRIs can be augmented with an atypical antipsychotic, but in most cases combination therapy with SSRIs and CBT should be tried first,” says Dr. Fenske. “Other treatment augmentations should be explored when these treatments have been ineffective or when patients have failed more than one SSRI. When moving to second-line therapies, initiation of a psychiatry referral is beneficial.” In addition, treatment should be discontinued with caution because OCD is a chronic condition with a high rate of relapse.

Dr. Fenske notes that patients with OCD should be monitored carefully to detect possible comorbid depression, adverse events resulting from medication use, and suicidal ideation. “Even with treatment-resistant OCD,” she says, “there are further treatment options available, but the evidence for such treatments isn’t as robust. Partial hospitalization and residential treatment facilities are options for those with severe treatment-resistant OCD. The key is to identify treatment-resistant OCD as early as possible so that appropriate treatment decisions can be made.”