Clinical Screening for Obsessive-Compulsive and Related Disorders

Article excerpt

Abstract: Background: Obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD) and other OCD-related disorders (OCDs) are frequently overlooked during medical or even psychiatric evaluation. Individuals with affective disorders, anxiety disorders, eating disorders, alcohol abuse and schizophrenia are commonly affected. Increased prevalence of OCDs is also reported to occur in certain secondary health-care settings. Better identification and treatment of OCDs are increasingly recognized as important public health priorities. Method: In this narrative review we consider the arguments for the use of screening strategies for OCD in clinical practice, paying particular attention to pragmatic issues such as the shortage of suitable screening instruments and areas of medical practice where screening might most profitably be exercised. Results: Arguments for screening in fields where affected individuals congregate appear persuasive, although evidence that screening produces clinical and social benefits by reducing morbidity is still lacking. Conclusion: Confirmation of health-care settings attracting high concentrations of OCD and BDD and evaluation of specific screening instruments and their utility in reducing the burden of disease are important areas for future research. Further evaluation of the validity and reliability of specific screening tools across different clinical populations is required.

Introduction

Obsessive-compulsive disorder (OCD) is a common, lifespan disorder ( 1 ). Community surveys have consistently identified a lifetime prevalence ranging between 1 -2% (2, 3), but the illness is poorly recognized and only a minority of cases receive timely treatment (4). Untreated OCD usually runs a chronic, lifelong course, fluctuating in intensity but rarely disappearing. In a seminal follow-up study spanning several decades, Skoog and Skoog (5) reported only a small number of cases had become symptom-free. Comorbidity between OCD and other mental disorders such as depression, anxiety, drug and alcohol abuse and eating disorders is common, and OCD is often missed or misdiagnosed (6). Clinical studies indicate considerable psychosocial morbidity is associated with OCD compared to other illnesses (7) and because OCD frequently manifests itself in childhood or adolescence, the potential lifetime consequences are great. Although some evidence suggests the time lag between onset of symptoms and correct diagnosis may be shortening (8), individuals with OCD are still reported to wait on average 17 years before correct treatment is initiated (9). Children with OCD may be particularly poorly recognized (10). The World Health Organisation recently ranked OCD within the twenty leading causes of medical disability. Given the substantial socioeconomic costs associated with untreated OCD, estimated in one American study as 6% of the total cost associated with mental illness (11), and the development of cost-effective therapies that can be offered in primary or secondary medical care settings, better recognition and treatment of the disorder is now recognized as a major public health objective (12).

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (13), for a diagnosis of OCD, obsessions (persistent ideas, thoughts, impulses or images that inappropriately intrude into awareness and cause distress or anxiety) or compulsions (repetitive unwanted behaviors or mental acts the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification) must be present, recognized as unreasonable or excessive, and associated with distress, time consumption (more than an hour per day), and interference with the individual's usual social, work or personal function. A substantial lifetime comorbidity between OCD and other mental disorders has been identified, including depression which develops in approximately two-thirds of cases presenting for treatment, specific phobia (22%), social anxiety disorder (social phobia) (18%), eating disorders (17%), alcohol dependence (14%), panic disorder (12%) and Tourette's syndrome (7%) (14). …