Obsessive–compulsive disorder

Presentation and immediate needs

Unwanted intrusive thoughts, images or urges and repetitive behaviours or mental rituals can occupy time and cause substantial distress or impairment.

Begin assessment → History, examination and context

History, examination and context

Ask about mental rituals, reassurance, avoidance, insight, family accommodation and time occupied. Distinguish an unwanted harm obsession from intent while assessing actual intent and behaviour separately.

Consider the branch → Intrusive unwanted thoughts linked to rituals or avoidance?

Intrusive unwanted thoughts linked to rituals or avoidance?

Use clinical findings and collateral. Uncertainty needs clarification, not a default negative answer.

Yes / concerning features → Priority assessment; No / not established → Formulation and care discussion; Uncertain / not assessed → Obtain the missing information

Priority assessment

Explore the obsession–compulsion cycle, insight and actual intent separately.

After appropriate assessment → Formulation and care discussion

Obtain the missing information

Review the examination, timeline, relevant investigations and consented collateral. Escalate urgent concerns while uncertainty is resolved.

Reassess the branch → Intrusive unwanted thoughts linked to rituals or avoidance?

Formulation and care discussion

Discuss OCD-specific CBT with exposure and response prevention and indication-specific medicine options. Address accommodation collaboratively and assess the adequacy of previous treatment.

Agree follow-up → Reassess and follow up

Reassess and follow up

Review rituals, avoidance, distress and functioning rather than reassurance alone. Match treatment intensity to complexity and response.