OCD: You Are Probably Missing it
Because it’s not all handwashing and light switches
DISCLAIMER
The content provided in this Substack post is for entertainment and informational purposes only and is not intended to serve as medical advice. The views and opinions expressed herein are those of the writer and should not be taken as definitive or authoritative. Readers should not rely solely on the information provided in this post to make decisions about patient care. Instead, use this content as a starting point for further research and consult a qualified healthcare professional before making any changes to treatment or medication regimens.
Before getting into today’s post, quick update! I’m testing out a new psych-specific auto scribe. I’m hopeful it continues to proves useful over the next days and if so, I will line up a deal for subscribers & share details in a few days. Stay tuned, ideally this becomes the first of many partnerships that actually bring value to our readers. With that said, back to our regularly scheduled programming….
Let’s be honest, often have you diagnosed OCD in the past month?
In inpatient psychiatry, it’s likely rare. In outpatient settings, maybe a bit more frequent. But either way, most psych providers (even good ones) miss it more often than they catch it. Not because we’re careless, but because we’ve been trained to spot stereotypes that don’t reflect most cases.
OCD isn’t always the person washing their hands 50 times a day, or the teenager flipping the light switches on and off before bed. Those cases exist, but they’re often a minority. Most OCD is subtler, messier, and harder to spot.
If you’re not asking the right questions or looking beyond anxiety, you might be missing it.
The Reality of OCD (Beyond the Stereotypes)
Your patients may not volunteer this, but here’s what OCD often sounds like:
• “I keep worrying I hit someone with my car, so I drive back to check the road.”
• “I get intrusive thoughts about harming my child, so I avoid being alone with them.”
• “I replay conversations in my head for hours to make sure I didn’t offend anyone.”
That’s OCD.
No soap. No obsessive tidiness. Just intrusive thoughts, which are unwanted, distressing ideas that spark anxiety, and compulsions, which can be physical, like checking, or mental, like repeating phrases in their head.
And yeah, patients often know these thoughts are irrational, but that doesn’t stop the cycle. The distress comes from being stuck in a loop of doubt and the urge to fix it.
DSM-5 Criteria
Sure you can memorize the DSM-5 (you should!)
• Presence of obsessions (intrusive thoughts), compulsions (repetitive behaviors or mental acts), or both.
• Symptoms are time-consuming (more than 1 hour per day) or cause significant distress or impairment.
• Not better explained by substances, medical conditions, or another mental disorder.
But in real life? Patients don’t walk in quoting the diagnostic criteria. They might describe anxiety, stress, or vague avoidance. To catch OCD, you need to dig deeper.
How to Spot OCD in Real Life
Here’s how to recognize OCD when it’s hiding in plain sight:
1. Listen for Persistent Doubt. OCD thrives on “what if.” If a patient says, “I just need to be sure” or fixates on unlikely scenarios, such as “What if I’m a bad person?”, consider OCD.
2. Ask About Mental Compulsions. Physical rituals like handwashing are obvious, but mental rituals, like silently counting or neutralizing a bad thought, are more common. Ask: “Do you ever do something in your head to feel less anxious or undo a thought?”
3. Notice Specific Avoidance. Avoiding driving, holding sharp objects, or watching certain movies due to intrusive thoughts isn’t typical generalized anxiety disorder. It’s often OCD. Look for patterns that seem overly specific or irrational.
If you’re not probing for these signs, you might mislabel OCD as anxiety and miss the chance for targeted treatment.
Treatment: Get It Right the First Time
When you diagnose OCD, avoid these common pitfalls:
1. SSRIs: Higher Doses, Thoughtful Titration. OCD often requires higher SSRI doses than depression or generalized anxiety disorder. Evidence-based targets include:
• Fluoxetine 40 to 80 mg per day
• Sertraline 150 to 200 mg per day
• Fluvoxamine 200 to 300 mg per day Start low, titrate carefully, and monitor for side effects. Improvement may take 8 to 12 weeks at therapeutic doses.
1. ERP is Non-Negotiable. Exposure and Response Prevention (ERP), a specialized form of cognitive behavioral therapy, is the gold-standard psychotherapy for OCD. It outperforms general cognitive behavioral therapy or talk therapy. Refer patients to ERP-trained therapists or platforms like NOCD, which offer virtual ERP.
2. Treatment-Resistant Cases? Consider Augmentation. For partial responders:
• Add low-dose clomipramine, a tricyclic antidepressant with strong evidence for OCD.
• Consider low-dose antipsychotics like aripiprazole for agitation or stuckness.
• Memantine (10 mg twice daily) has emerging but limited evidence; use cautiously.
• Transcranial magnetic stimulation is FDA-approved for OCD and may help treatment-resistant cases. Consult a specialist for eligibility.
Explaining OCD to Patients
When patients say, “But I don’t wash my hands,” try this:
“OCD isn’t about being neat. It’s your brain getting stuck in a loop: an intrusive thought pops up, it feels overwhelming, and you feel compelled to do something, physically or mentally, to make it go away, even if it doesn’t make sense.”
This reframe helps patients understand their symptoms and engage in treatment.
Final Takeaway
If a patient with anxiety isn’t improving with standard treatments or avoids specific situations in ways that seem unusual, dig for OCD. Ask about intrusive thoughts, mental rituals, and doubt-driven behaviors.
By looking beyond the stereotypes, you’ll uncover cases of OCD that might otherwise slip through the cracks and get your patients the help they need.