Takeaway
To accurately diagnose OCD, clinicians must move beyond general inquiries about "unwanted thoughts" and instead ask specific, sensitive questions about the diverse ways obsessions and compulsions can manifest. Effective treatment often includes a combination of medication and psychotherapy—specifically Exposure and Response Prevention (ERP).
Lifelong Learning in Clinical Excellence | February 18, 2025 | 3 min read
By Ghida Kassir, MD, University of Toronto, Canada
This is Part 2 of a two-part series on obsessive-compulsive disorder (OCD). Read Part 1 here: “Educating patients about OCD.”
Screening
It’s crucial to go beyond general questions when screening for OCD. Many individuals with OCD feel embarrassed by their obsessions and compulsions. This results in internalized stigma and hesitation to disclose symptoms. Asking general questions like “Do you experience unwanted thoughts?” may not elicit accurate responses, especially when the obsessions or compulsions are culturally or morally unacceptable, such as sexual, violent, or religious obsessions, for example. By providing specific examples such as “Do you experience any unwanted sexual thoughts, images, or behaviors?” or “Do you have any intrusive thoughts related to religion or spirituality?” healthcare professionals can encourage open and honest communication.
Furthermore, creating a safe and nonjudgmental environment is paramount for effective screening. Patients need to feel comfortable disclosing highly personal and potentially shameful information. Clinicians must practice active listening, and convey empathy and reassurance that their experiences are valid and understood within the context of OCD. It’s also essential to emphasize that OCD is a treatable condition, and that seeking help is a sign of strength, not weakness.
Many individuals with OCD have suffered in silence for years, believing they are uniquely flawed. By normalizing their experiences and offering hope for recovery, clinicians can empower patients to engage in treatment and begin the journey toward managing symptoms and reclaiming their lives. Building this rapport and trust from the outset is fundamental to obtaining an accurate picture of the patient’s struggles and ultimately providing the most effective care. This might involve taking the time to explain the neurobiological underpinnings of OCD in simple terms, dispelling common myths about the disorder, and offering resources for further learning and support. Ultimately, a compassionate and informed approach to screening can be the first step toward breaking the cycle of secrecy and suffering that often accompanies OCD.
Diagnosing
It’s important to remember that compulsions can manifest as mental acts, such as excessive reassurance or repetitive counting or reciting, and can often be missed. Utilizing a detailed checklist like the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) can be valuable in identifying a wide range of OCD symptoms, ensuring a comprehensive assessment, accurate diagnosis, and appropriate treatment. This detailed tool probes for a wide range of obsessions and compulsions, including those that may be less common or obvious and difficult to identify through general questioning. This not only improves the accuracy of diagnosis but also helps patients understand that their specific experiences are recognized as legitimate symptoms of OCD and helps in a way “normalize” the abnormal.
Treatment
Discussing evidence-based treatments for OCD with patients is also necessary. Many patients believe they’re forever stuck with their intrusive thoughts and compulsive behaviors which elicits severe suffering and feelings of hopelessness. Pharmacotherapy is a valuable tool in managing OCD symptoms, however, it’s important to set realistic expectations. Informing patients that medications need time to work and that a “magic pill” unfortunately doesn’t exist is essential.
It’s equally important to emphasize that a combination of medication and psychotherapy, specifically Exposure and Response Prevention (ERP), yields the most significant results and lasting improvements. In a rather simplistic explanation, ERP involves gradually exposing individuals to their obsessions while preventing them from engaging in their usual compulsive rituals. Acknowledging that ERP will be challenging, especially in the beginning, and that anxiety levels may actually increase during the early stages of treatment helps set expectations. This is a normal part of the process as the brain learns to tolerate anxiety without resorting to compulsive behaviors. It’s vital that individuals engage in ERP with an experienced and specialized mental health professional. By gradually confronting fears and resisting the urge to engage in compulsions, individuals can break the cycle of OCD and regain some control over their lives.
Finally, it’s important to avoid “feeding the OCD.” Patients’ families and even healthcare professionals sometimes reinforce the OCD without even recognizing it. While well intentioned, actions like excessive reassurance or accommodating compulsions can inadvertently strengthen OCD symptoms and are therefore countertherapeutic. By understanding these dynamics, professionals and families can learn to provide support in a way that’s both compassionate and helpful.
OCD is a complex mental health condition and is often underdiagnosed or misdiagnosed due to its different presentations. By understanding its core features, recognizing common presentations, thoroughly screening for its symptoms and providing effective treatment, healthcare professionals can significantly improve the quality of care for individuals with OCD and their caregivers.
This piece expresses the views solely of the author. It does not represent the views of any organization, including Johns Hopkins Medicine.