History and exam

Key diagnostic factors

common

presence of risk factors

Risk factors strongly associated with OCD include family history of OCD and PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection).

obsessions

Intrusive, unwanted, anxiogenic thoughts that result in marked distress.

Patient typically recognises that these thoughts are irrational.

Common obsessions include fear of contamination, need for symmetry or exactness, fear of causing harm to someone, sexual obsessions, religious obsessions, fear of behaving unacceptably, and fear of making a mistake.​[42]​

Individuals with OCD often avoid people, places, and things that trigger their obsessions.[7]

compulsions

Repetitive behavioural or mental acts that are designed to neutralise the anxiety that results from obsessions.

Compulsions result in a temporary relief of anxiety and are self-reinforcing.

Common behavioural compulsions include cleaning, hand washing, checking, ordering and arranging, hoarding, and seeking reassurance from others.

Common mental compulsions include counting, repeating words silently, ruminating, and attempting to 'neutralise' thoughts.​[42]​

Individuals with OCD often avoid people, places, and things that trigger their compulsions.[7]

A higher frequency of compulsions is related to treatment resistance.[32]

sensory phenomena

Up to 60% of individuals with OCD report sensory phenomena that precede their compulsions.[1]

These include physical sensations, just-right sensations, and feelings of incompleteness.[1]

uncommon

schizotypal personality disorder

Concomitant schizotypal personality disorder is considered a predictor of worse response.[32] May warrant early referral to consultant to tailor therapy.

tic disorder

Up to 30% of those with OCD have a lifelong tic disorder.[1] The presence of a concurrent tic disorder may be associated with more severe OCD symptoms and greater likelihood of treatment resistance.[33] May warrant early referral to consultant to tailor therapy.

poor motor coordination

Results from specific or diffuse brain structural abnormalities.

Has been implicated as a screening tool identifying a potential subgroup of OCD patients with poorer treatment response.[34]

May warrant early referral to consultant to tailor therapy.

sensory perceptual difficulties

Result from specific or diffuse brain structural abnormalities.

Have been implicated as a screening tool identifying a potential subgroup of OCD patients with poorer treatment response.[34]

May warrant early referral to consultant to tailor therapy.

difficulties in sequencing of complex motor tasks

Result from specific or diffuse brain structural abnormalities.

Have been implicated as a screening tool identifying a potential subgroup of OCD patients with poorer treatment response.[34]

May warrant early referral to consultant to tailor therapy.

Other diagnostic factors

common

male sex

Male sex is associated with an earlier onset and chronic course and often predicts poorer response to treatment.[5]

Risk factors

strong

family history of OCD

Genetic factors are important, as monozygotic twins are much more likely to exhibit OCD symptoms than dizygotic twins.[11] First-degree relatives of OCD patients have a higher risk of developing the disorder than the general population.[12]

PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection)

OCD symptoms can be caused or exacerbated by an autoimmune reaction in which antibodies to beta-haemolytic streptococci cross-react with proteins in the basal ganglia.[30]

weak

pregnancy

In one study of 59 female OCD patients, 39% of participants described onset of OCD symptoms during pregnancy.[24]

male sex (earlier onset, more chronic course, treatment resistance)

Male sex is associated with an earlier onset and chronic course and often predicts poorer response to treatment.[5]

Male individuals are also more likely to experience concurrent tic disorders.[7]

higher frequency of compulsions (treatment resistance)

Related to treatment resistance.[32]

early age of onset (treatment resistance)

Related to treatment resistance.[32]

previous hospitalisations for OCD (treatment resistance)

Related to treatment resistance.[32]

schizotypal personality disorder (treatment resistance)

Concomitant schizotypal personality disorder is considered a predictor of worse response.[32] May warrant early referral to consultant to tailor therapy.

tic disorder (treatment resistance)

The presence of a concurrent tic disorder may be associated with more severe OCD symptoms and greater likelihood of treatment resistance.[33] May warrant early referral to consultant to tailor therapy.

Tic disorders are more common in male individuals.[7]

specific or diffuse brain structural abnormalities (treatment resistance)

Patients may have a poorer treatment response.[34] May warrant early referral to consultant to tailor therapy.

Rarely, striatal lesions or head trauma result in the development of OCD.[10]

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