Obsessive-compulsive disorder (OCD) is a common psychiatric disorder with a 12-month prevalence of 1.2% in the United States and internationally.1 Like other psychiatric disorders, patients with OCD present more often to primary care than specialty settings.2 Despite high distress and impairment levels, individuals with OCD are often undiagnosed and do not receive evidence-based care.3,4 This can be particularly problematic in fast-paced primary care settings due to high medical utilization and increased costs associated with OCD.5
A time-consuming disorder associated with distress
OCD is characterized by obsessive thoughts and/or compulsions.1
Obsessions are repeated, unwanted, distressing thoughts or images (eg, of being contaminated by dirt/germs, fears of causing harm to others without wanting to). Individuals with OCD attempt to avoid these thoughts by suppressing or neutralizing them.
Compulsions are mental or behavioral rituals that the individual feels compelled to perform to reduce distress or prevent a feared consequence (eg, hand-washing, checking locks, counting). Compulsions are not reasonable safety efforts, but are instead out-of-proportion reactions to the situation.
Onset of OCD usually occurs by young adulthood, but may be present in children. Pregnancy and postpartum periods may be associated with increased risk for symptoms.6 The course is typically chronic if left untreated, although symptoms can occur episodically.1
Intrusive thoughts and compulsive behaviors are surprisingly common in the general population. One study found that most individuals in a non-clinical sample reported having occasional intrusive thoughts such as whether they may have accidentally left the stove on, running their car off the road, or engaging in a “disgusting” sex act.7 With OCD, however, obsessions and compulsions are time-consuming and associated with distress and/or impairment.1
For example, an individual with OCD may restrict their diet due to fears of handling foods that other people may have touched or may limit contact with people for fear they will lose control and act violently. This is partly the result of overestimating the significance of the thoughts.8 Individuals with OCD may believe that the thoughts mean something negative about them (eg, that they are immoral) or could lead to serious consequences (eg, thinking about a car accident makes it more likely to occur).
Distinguishing features of OCD
OCD is commonly misdiagnosed,9 which may contribute to the long duration of untreated illness (average 17 years).10 In one study, primary care providers were given vignettes describing OCD symptoms; half of these cases were misidentified.9 Certain types of obsessions (eg, aggression, fear of saying certain things, homosexuality, pedophilia) were misdiagnosed 70% to 85% of the time.9
Although OCD shares characteristics with other disorders, several features can help family physicians correctly identify OCD. Fears associated with OCD are usually not about everyday concerns or worries. For example, a patient with social anxiety disorder may report fear of embarrassing themselves in public, whereas a patient with OCD may report fear that they will lose control and do something outlandish such as start swearing loudly.
Additionally, obsessions and compulsions in OCD are not exclusively tied to a traumatic experience as in posttraumatic stress disorder. Someone with OCD who has harm-related or sexual obsessions (eg, homosexuality) will report that this is not consistent with their interests and desires. Furthermore, a small subset of people with OCD may have poor insight, meaning they have low self-awareness of the nature of their obsessions or compulsions, but they do not experience psychotic symptoms.