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Diagnosis and Management of Obsessive-Compulsive Disorder in the Primary Care Setting

Afi M. Semenya, MD, MPH
Prakhya Bhatnagar, MD

American Family Physician. 2024;110(4):385-392.

Author disclosure: No relevant financial relationships.

This clinical content conforms to AAFP criteria for CME.

Obsessive-compulsive disorder is a common neuropsychiatric disorder that is often underdiagnosed or misdiagnosed. It is characterized by obsessions, which are intrusive and include unwanted thoughts, images, or urges that cause marked anxiety or distress. Obsessions also drive patients to engage in repetitive actions or thoughts, known as compulsions. The condition has a high prevalence of comorbid disorders and can be associated with functional impairment. Early recognition and treatment can lead to improved outcomes, and complete remission is possible. Validated tools, such as the Yale-Brown Obsessive-Compulsive Scale, are effective in diagnosing and monitoring obsessive-compulsive disorder and determining the severity of the condition. Severity varies among cases, and proper diagnosis and education about this condition are important for determining a treatment plan, which can include psychotherapy, pharmacotherapy, or both. Exposure and response prevention is the most effective form of psychotherapy, and selective serotonin reuptake inhibitors are the most effective pharmacotherapy. If monotherapy is not effective, psychotherapy and pharmacotherapy can be combined. Treatment of obsessive-compulsive disorder is typically recommended for at least 12 months for maintenance and prevention of relapse. In patients requiring augmentation, higher-risk or novel adjunctive treatments or investigational therapies should be managed by an experienced multidisciplinary team.

Obsessive-compulsive disorder (OCD) is a common disabling neuropsychiatric disorder often managed in primary care. OCD is well known for the classic dyad of obsessions and compulsions. Obsessions are repetitive, time consuming, and involve life-disrupting thoughts, images, or urges that lead to anxiety and distress. Compulsions are behaviors or thoughts that an individual performs to reduce the anxiety and distress caused by obsessions; examples include washing, counting, and praying.1

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating Comments
Early detection and treatment are key to reducing the burden of OCD.4–6 C Consensus guidelines, usual practice, and disease-oriented evidence
Validated tools are effective in diagnosing, monitoring, and determining severity of OCD.14–16 C Consensus guidelines, randomized controlled trial, and an evaluation study
Exposure and response prevention is the most effective form of psychotherapy for treatment of OCD.3,8,14 C Expert opinion and consensus guidelines
Selective serotonin reuptake inhibitors are first-line pharmacotherapy for OCD.3,14,27 A Expert opinion, systematic review with multiple randomized controlled trials, and consensus guidelines

OCD = obsessive-compulsive disorder.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The four primary dimensions of common obsessions and compulsions are contamination and cleaning; worry about accidental harm, leading to repeated checking; seeking symmetry and ordering; and unacceptable thoughts and mental rituals.2 There may be variations among these dimensions based on the patient's age, sex, and culture. For example, children and adolescents more commonly experience fears regarding death or illness.3

AFI M. SEMENYA, MD, MPH, is core faculty at the Tristar Nashville (Tenn.) Family Medicine Residency Program and an assistant professor in the Department of Family Medicine at Boston (Mass.) University Chobanian and Avedisian School of Medicine.

PRAKHYA BHATNAGAR, MD, is core faculty at the Tristar Nashville Family Medicine Residency Program.

Address correspondence to Afi M. Semenya, MD, MPH, at afi.semenya@hcahealthcare.com.

Author disclosure: No relevant financial relationships.

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