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Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.

Obsessive-compulsive disorder

Psychiatry · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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OCD with immediate safety compromise

Suicidal intent, inability to eat or drink, severe skin or chemical injury from rituals, dangerous checking, inability to care for a child or dependent, or loss of reality testing requires urgent intervention beyond routine ERP planning.

Action: Clarify the feared thought, actual desire, intent, preparatory behaviour and ability to resist, while protecting nutrition, wounds and dependants. Arrange same-day crisis, medical or safeguarding assessment when risk is present and avoid repeated reassurance that becomes another compulsion.

Synopsis

Recognise obsessions, overt and mental compulsions and avoidance, assess intrusive harm content without equating thoughts with intent, and sequence exposure and response prevention, SSRIs and specialist care by functional impairment and response.

  • Obsessions are recurrent intrusive thoughts, images or urges experienced as unwanted; compulsions are repetitive behaviours or mental acts performed to reduce distress or prevent a feared event.
  • Ask about hidden rituals, reassurance seeking, checking, avoidance and time consumed because shame often delays disclosure and observable behaviour may underestimate severity.
  • Intrusive violent, sexual or blasphemous content does not by itself indicate desire or dangerousness; assess intent and behaviour without providing endless certainty.
  • Mild impairment: offer low-intensity CBT including ERP up to ten therapist hours; moderate impairment: offer a choice of an SSRI or more intensive CBT with ERP; severe impairment: offer combined SSRI and CBT with ERP.
  • ERP approaches triggers and prevents overt rituals, mental neutralising and reassurance, using collaborative graded tasks and between-session practice.
  • SSRI benefit in OCD may take up to twelve weeks; if a standard dose has not helped enough after four to six weeks and adverse effects are not significant, consider gradual SmPC-aligned increase.
  • Continue an effective SSRI for at least twelve months, then review relapse risk and taper over several weeks rather than stopping abruptly.

Key red flags

A suicide plan, recent attempt, depressive hopelessness or compulsive behaviour that places the person in traffic, near weapons or at other objective danger requires urgent action.

Intrusive harm thoughts are common in OCD and are often ego-dystonic, but expressed intent, pleasure, planning, psychosis or inability to resist must be assessed separately.

Contamination rituals causing dermatitis, burns, dehydration, malnutrition or inability to access essential healthcare require coordinated physical and psychiatric care.

Severe family accommodation, child-care disruption, domestic conflict or inability to meet a dependent person's needs creates safeguarding and treatment urgency.

Investigation priorities

01
Obsessive-compulsive cycle interviewFirst step

Define triggers, intrusions, meaning, distress, rituals, avoidance, relief and functional cost.

Management branches

Mild impairmentBegin low-intensity ERP

OCD causes mild functional impairment and the person can engage with a lower-intensity approach.

  1. Explain the obsession-distress-compulsion-relief cycle and agree one measurable target without offering certainty about the feared outcome.
  2. Offer CBT including ERP with up to ten therapist hours through a suitable structured format and plan repeated between-session practice.
  3. Review symptom and functional outcome and offer an SSRI or more intensive CBT with ERP if engagement is impossible or improvement is inadequate.

Key medicines

Sertraline oralFor licensed adult OCD treatment, start 50 mg by mouth once daily; if needed increase in 50 mg steps at intervals of at least one week to a maximum of 200 mg daily.Actively monitor early anxiety, agitation, akathisia, suicidal thinking and mania, plus bleeding, hyponatraemia, sexual dysfunction and serotonergic interactions; benefit can take longer in OCD and stopping should be gradual.
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE CG31 OCD and BDD recommendationsERP intensity, SSRI sequencing, risk monitoring, continuation and specialist escalation.
  • NHS OCD treatment overviewCurrent UK patient information on ERP, SSRI delay and gradual stopping.
  • Sertraline tablets summary of product characteristicsLicensed adult OCD dose, titration interval, maximum and medicine safety.
  • NICE NG215 dependence and withdrawal recommendationsCollaborative gradual antidepressant reduction and withdrawal management.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateRapid draftClinical stateAwaiting reviewJurisdictionUnited Kingdom