“I know it’s irrational, but I check the locks and wash my hands for hours — it’s taking over my life”

OBSESSIVE-COMPULSIVE DISORDER is defined by OBSESSIONS (recurrent, intrusive, unwanted thoughts, images or urges causing marked anxiety) and COMPULSIONS (repetitive behaviours or mental acts performed to reduce that anxiety or prevent a feared event) that are time-consuming, distressing and impairing, and which the person typically recognises as excessive — a contamination/harm picture with washing/checking and preserved insight is classic. OCD is frequently HIDDEN for years out of shame, so ask sensitively, normalise, validate the disclosure, and explore content, time consumed and impact without judgement — recognising and naming it is itself therapeutic. Distressing or taboo intrusive thoughts (fears of harming others, contamination, blasphemous or sexual themes) are usually EGODYSTONIC — unwanted and abhorrent to the person, and are symptoms, not intent or desire — so say this sensitively (it relieves enormous shame) while still assessing risk appropriately; NICE CG31 advises expert advice where there is real uncertainty about risk. Assess severity and functional impairment, screen for comorbid depression/anxiety, and assess suicidality (OCD carries a real suicide risk through distress/depression), asking directly and agreeing a safety plan rather than a risk label (NICE NG225). Offer EVIDENCE-BASED treatment per NICE CG31: the cornerstone is CBT incorporating EXPOSURE AND RESPONSE PREVENTION (ERP) — facing the trigger without performing the compulsion so anxiety habituates — and/or an SSRI (effective in OCD, often at higher doses and taking longer to work than in depression), within stepped care by functional impairment (mild: low-intensity CBT with ERP, up to 10 therapist hours; moderate: an SSRI or more intensive CBT with ERP, more than 10 therapist hours; severe: combined SSRI and CBT with ERP, usually with secondary care mental health services), continuing an effective SSRI for at least 12 months and considering clomipramine only after at least one adequate SSRI trial; NHS Talking Therapies (self-referral) delivers CBT with ERP. Explain the obsession-compulsion cycle (compulsions relieve anxiety short-term but reinforce it long-term, which ERP breaks). The communication core is destigmatising, validating, instilling HOPE that OCD is common and treatable, and agreeing a collaborative plan.