In the past, OCD was categorized diagnostically as an anxiety disorder, but in the DSM V it has been separated into its own category. This is largely because research has shown that the genetics of OCD is different from the genetics of other anxiety disorder. OCD is defined as obsessions (intrusive, unwanted and excessive worries) and compulsions (rituals to relieve the anxiety) that are impairing to everyday life. The impairment can be defined by the amount of time spent on the obsessions and compulsions, its effect on preventing a patient from carrying out activities of daily living and work responsibilities, and its effect on alienating important people in the patient’s life. The obsessions and compulsions can involve the following: preoccupation with contamination, cleaning, checking, symmetry and order, preoccupation with sexual, violent or religious thoughts, and hoarding.

The diagnosis of OCD is primarily a clinical one. Two good screening questions to determine if further assessment is indicated are:

1. “Are bothered by unpleasant worries that repeatedly come into your mind about contamination, ordering things, etc?
2. “Are driven to perform certain acts over and over again like checking locks or washing your hands excessively?”

The YBOCs is a good diagnostic tool for delineating specific symptoms and determining the level of severity and the patient’s level of insight. The patient is typically aware that the obsessions and compulsions are irrational and excessive but are compelled to do them anyways. This egodystonic nature of the illness is partly what leads to the suffering from OCD and can lead to an increased risk of suicide.  In rare cases, when patients are not aware that their obsessions and compulsions are irrational and excessive, they are said to have “poor insight” and their OCD is typically more treatment-resistant. These cases can often be difficult to differentiate from true psychotic delusions.

OCD is frequently co-morbid with other anxiety disorders, depressive disorders, and eating disorders in adults and ADHD and tic disorders in children. Treatment options include exposure response prevention (a CBT specifically geared for OCD) and psychotropic medications. ERP involves repeated exposure to situations that trigger the obsessive thoughts and having the patient gradually learn to tolerate the anxiety and resist the urge to perform the compulsions. Medication options include the SSRIs (Prozac, Paxil, Lexapro, Celexa, Zoloft, Luvox) and Anafranil (an older tricyclic antidepressant, used primarily for treatment resistant cases). Medication treatment involves slow titration to avoid worsening the anxiety, and patients often need higher doses for longer periods of time for a full effect. It is important to make sure patients are aware that it can take up to 3 months to get to a full effective dose. Most patients do better with a combination of medication and ERP. There are adjunctive medication options available if full symptom relief is not achieved with an SSRI alone. These include the second-generation antipsychotic medications. Surgery and ECT vs deep brain stimulation can be used for refractory cases.

Given that OCD is more prevalent than previously thought, it is important that first line providers are comfortable with knowing when to assess for OCD and how to pursue with treatment recommendations.

Anxiety is a universal and highly adaptive experience, as it keeps us alert to real life dangers. Excessive and/or chronic anxiety, however, can be problematic as it reduces a person’s ability to function. Timely and effective intervention for anxiety disorders can have a dramatic positive impact on a patient’s life.

Core symptoms: The central psychological features of the anxious patient are feelings of nervousness and thinking that is constricted and dominated by worry. Other features may include ruminations, poor concentration, racing thoughts, panic and feelings of exhaustion. Physical features may include signs of over-arousal such as restlessness, muscle tension, sweating, tremor, pain, dizziness, and others. Some patients present with concern about psychological and emotional symptoms; others may present with predominantly with physical health complaints. Many suffer quietly. Acute and chronic anxiety can have significant negative impact on health conditions.

Multiple Subtypes: Anxiety disorders have many faces and it can be helpful to differentiate among the types.

Social Anxiety Disorder: shyness, embarrassment, physical distress associated with exposure

Obsessive Compulsive Disorder: thinking and action constricted, with distress and impaired functioning

Post-Traumatic Stress Disorder: past trauma exposure with ongoing distress, remembering, distress, arousal

Acute Stress Disorder: recent trauma–distress, arousal

Generalized Anxiety Disorder: pervasive and excessive worrying, typically without clear precipitant or trigger

Panic Disorder: florid episodes of intense anxiety with inter-episode apprehensiveness and anticipation

Adjustment Disorder: anxiety experienced in context of acute stressor which resolves as patient adapts or stressor abates.

Important Questions:

1) Simply asking a patient about their level of emotional distress is an important first step in reaching a diagnosis and developing a collaborative treatment relationship.

2) Is the anxiety acute or is it chronic? Most patients report lifelong challenges with their anxiety symptoms.

3) Are there current life stressors—relationships, job, financial, other? Does the patient have natural supports or others (counselors, clergy, etc.) who can help?

4) Was there prior trauma or abuse? It is best to ask this question openly and directly to see if it could be a factor in the patient’s current symptom profile.

5) Is there a family history of similar problems? If so, what helped them?

6) Is there an underlying medical problem? The list is long but endocrine and other conditions may be of note.

7) Are symptoms being triggered by a medication given for a medical or another psychiatric illness?

8) Is substance abuse a contributing factor or a risk factor?

9) Are there other psychiatric issues—depression, mood problems, personality difficulties, etc.?

Treatment: Optimal treatment often entails a combination of education, psychotherapy and/or medication intervention. Psychotherapy alone can be highly beneficial with a focus on faulty thinking patterns, self-calming strategies, social engagement and other activities. Educational resources may prove useful even without formal therapy referral.

Psychopharmacology: SSRIs and SNRIs are the first line of long term medication treatment for most of the anxiety disorders– use with a low starting dose and slow gradual up-titration, as needed and tolerated. Monitoring symptom progression and side effects is necessary early on, but if treatment is effective, routine follow ups for refills can be done more episodically.

Judicious use of anxiolytic agents such as the benzodiazepines can be an important element in psychopharm management— occasional use of low dose, short acting agents is often quite helpful, but ongoing and increased use of these medications can lead to dependence and other problems. A patient needing to take multiple daily doses of a short acting agent for a sustained period needs attention. In some cases, routine use of longer acting agents may be appropriate, with periodic trials of dose reduction planned.