Obsessive- Compulsive Disorder

Upto early 1980s, OCD was considered as a treatment refractory rare disorder with prevalence of less than 0.5%. But with the observation that Clomipramine is effective in its treatment, clinical interest in OCD started increasing.

The prevalence of OCD and related disorders i.e. Obsessive Compulsive Spectrum Disorder (OCSDs) is about 9%.

Clinical Presentation:

Diagnosis of OCD is based on the presence of either obsessions or compulsions which :

  • cause marked distress
  • are time consuming (more than an hour daily) &
  • significantly interfere with a person’s normal routine & social and occupational activities.


Obsessions are repetitive, intrusive & distressing thoughts, ideas, images or urges that persist despite efforts to suppress, resist or ignore them.


Compulsions are repetitive, stereotyped behaviour or mental acts that are performed in response to obsessions.

***Most Patients with OCD have very good insight. But some patients lack insight & their obsessions are delusional. Such patients may be misdiagnosed as psychotic disorder.

Symptom patterns of OCD:

  1. Contamination/ Cleansing: Obsessions of contamination by dust/germs followed by Compulsions of washing or avoiding contaminated objects (door knobs, electric switches, newspaper etc.). They usually believe that contamination spread from object to object or person to person by slightest contact.
  2. Pathological Doubt/ Checking: Obsessive thoughts of forgetting to lock the door or to turn off the stove followed by repetitive checking. The checking procedure, instead of resolving uncertainty, often contributes to even greater doubt which leads to further checking.
  3. Symmetry/ Ordering: Another Common pattern is the need for symmetry or percision which interferes with task completion & result in pathological slowness. They usually take hours to eat a meal or shave.
  4. Intrusive/ Forbidden Thoughts: These patients complain of intrusive thoughts without noticable compulsions. Patients usually experience thoughts of sexual or aggressive acts. Sometimes, these patients report themselves to the police or confess to a priest.
  5. Causing Harm/ Hurt someone: For example while driving, going back to the relevant spot repeatedly & checking no one was hurt.

Most patients present with multiple Obsessions or Compulsions. The symptoms may shift over time. For example, patients who had washing symptom pattern during childhood may present with checking symptom pattern as an adult.

***Obsessions may not always precede compulsions. Pathological loop may start with the actual urge to perform the compulsion as a habit; while the obsessional component develops later as a secondary phenomenon.

Diagnostic Clues:

  1. OCD is ego dystonic in nature.
  2. History of tics in present or past history.
  3. Family history of Obsessive Compulsive Spectrum Disorders (OCSDs) including Hoarding disorder, Body Dysmorphic Disorder, Trichotillomania (hair pulling), Onychophagia (nail biting) and Excoriation (skin picking).

“NICE” guidelines : Questions to idetify OCD:

  1. Do you wash or clean a lot ?
  2. Do you check things a lot ?
  3. Is there any thought that keeps bothering you that you would like to get rid of but you can’t ?
  4. Do your daily activities take a long time to finish ?
  5. Are you concerned about orderliness or symmetry?
  6. Do these problems trouble you ?


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