Obsessive-Compulsive Disorder (OCD)

Obsessions are intrusive, unwanted thoughts, images, or urges that cause distress; compulsions are repetitive behaviors or mental acts done to relieve that distress. OCD is not the same as being tidy or liking order. The cycle is time-consuming and impairing, and people with OCD usually recognize the obsessions as excessive yet feel unable to stop the compulsions.

The strongest evidence is for exposure and response prevention (ERP), a specific form of cognitive behavioral therapy, and for SSRIs. The combination often works best. ERP is the therapy with the most durable benefit and is considered first-line.

Higher SSRI doses than those used for depression are not uncommon in OCD, though they are not always needed; it depends on the case. When higher doses are used, the response can also take longer to appear. Any dose change is made gradually and with monitoring.

ERP gradually and deliberately exposes a person to the thoughts or situations that trigger anxiety while supporting them in not performing the compulsion. Over time the anxiety tends to settle on its own, which weakens the obsession-compulsion cycle. It is done collaboratively and at a pace the person can tolerate.

I start with a full evaluation that distinguishes OCD from conditions it can resemble, then build a plan that usually pairs medication with ERP. When ERP is indicated, I coordinate with a therapist who specializes in it. Medication is managed toward the lowest effective dose that meaningfully reduces symptoms. As with everything in psychiatry, the plan is built case by case.