Obsessive–compulsive disorder

Diagnostic framework #

Characterize intrusive, unwanted thoughts/images/urges and repetitive behaviors or mental acts performed to reduce distress or prevent feared outcomes. Document time, distress, impairment and insight. Distinguish the syndrome from ordinary preferences for order or a single unwelcome thought.

Targeted clinical assessment #

Map a representative trigger–obsession–distress–ritual sequence. Ask directly about mental reviewing, praying, counting, reassurance, avoidance and accommodation. Establish depression, tics, autism, psychosis and self-harm separately; quantify impact with a consistent version of Y-BOCS when helpful.

Differential diagnosis #

Differential diagnosis — clinical reference
Alternative	Discriminator
Psychosis	Clarify ownership, conviction, broader symptoms and whether behavior neutralizes an unwanted thought.
GAD	Worry across everyday domains versus obsessional intrusions and ritualized neutralizing.
Personality traits	Enduring preferences/perfectionism alone do not establish OCD.
Body dysmorphic or related disorder	Identify the primary feared defect and associated repetitive behaviors.

Indicated investigations #

Indicated investigations — clinical reference
Context	Assessment
Typical presentation	No blood test establishes OCD; investigate physical symptoms or unusual neurological findings as indicated.
Before an SSRI	Interactions, mood-switch history and medicine-specific medical risks.
Complex or refractory presentation	Revisit neurological, substance and diagnostic alternatives before escalation.

Treatment sequence #

View treatment map

Psychological treatment
CBT with ERP: graded exposure while reducing overt/covert neutralizing responses.
Medicine option
An SSRI with a sufficiently long, tolerated trial; discuss that benefit is slower than immediate anxiolysis.
Greater impairment
Consider combined SSRI and ERP.
Persistent illness
Verify both trial quality and actual ERP participation before specialist medication or intensive-therapy options.

Treatment sequence — clinical reference
Treatment situation	Approach
Psychological treatment	CBT with ERP: graded exposure while reducing overt/covert neutralizing responses.
Medicine option	An SSRI with a sufficiently long, tolerated trial; discuss that benefit is slower than immediate anxiolysis.
Greater impairment	Consider combined SSRI and ERP.
Persistent illness	Verify both trial quality and actual ERP participation before specialist medication or intensive-therapy options.

Doses & prescribing #

Each prescribing record identifies its population and source jurisdiction; international labeling does not establish Indian approval. The clinician selects treatment after assessment.

Prescribing reference

Sertraline

Adult obsessive–compulsive disorder

Adults · Immediate-release tablets · Oral · United States product labeling

Starting dose: 50 mg once daily.
Titration: Subsequent increases of 25–50 mg/day no more often than weekly, according to response and tolerability.
Treatment range / target: 50–200 mg/day.
Maximum / limits: 200 mg/day.
Trial & duration: Condition-specific trial and continuation guidance below.
Monitoring: Activation, mood switch, suicidality, gastrointestinal/sexual effects; sodium when indicated.
Population & organ-function adjustments: Mild hepatic impairment: half starting and maximum doses; moderate/severe hepatic impairment: not recommended.
Important cautions: Avoid MAOIs and pimozide; reconcile serotonergic and bleeding-related interactions.

Nonresponse & escalation #

After 4–6 weeks at a standard SSRI dose without adequate improvement and without limiting adverse effects, NICE supports gradual dose increase within the product instructions. Review a full approximately 12-week course and adherence before a switch; assess the quality of ERP and family accommodation. Specialist options include another SSRI, clomipramine and carefully selected augmentation.

Maintenance & discontinuation #

Continue an effective SSRI for at least 12 months under NICE guidance, then review illness duration, previous relapse and residual symptoms. Reduce gradually with monitoring; maintain exposure practice and a plan for the return of rituals.

Special populations & comorbidity #

Poor insight, severe depression, active psychosis or bipolar illness, substance use and major family conflict can impair ERP participation and need concurrent management. Adapt explanations and exposure tasks to communication/developmental needs. Adult doses must not be applied to children.

Follow-up #

Track time occupied, distress, avoidance, ritual resistance, accommodation and function, alongside adverse effects and activation during dose changes. Improvement in distress without reduced ritual behavior may leave substantial disability.

Clinical pitfalls #

Reassurance can function as a compulsion. Exposure is collaborative and planned; it is not forcing an unprepared person into distress. Do not repeatedly seek certainty that an intrusive thought will never occur again.

Assessment tools #

Yale–Brown Obsessive Compulsive Scale (Y-BOCS)Yale–Brown Obsessive Compulsive Scale-II (Y-BOCS-II)Obsessive-Compulsive Inventory-Revised (OCI-R)

Sertraline reference ↗

Open assessment flowchart ↗

Choose the instrument for its intended purpose; interpretation accompanies the linked tool.

Patient discussion #

Open a plain-language explanation

Having an intrusive thought does not mean wanting it to happen. Treatment helps change the response to the thought and reduce rituals.

Obsessive–compulsive disorder

Clinical essentials #