OCD and body-focused repetitive disorders — the AU GP approach

What OCD is — and what it is not

Obsessive-compulsive disorder (OCD) is a mental health condition characterised by two core features: obsessions (recurrent, persistent, intrusive thoughts, urges, or images that are unwanted and cause distress) and compulsions (repetitive behaviours or mental acts performed to neutralise the distress or prevent a feared outcome). To meet diagnostic criteria per DSM-5-TR, these symptoms must consume more than an hour a day or cause meaningful impairment in social, occupational, or daily functioning.

OCD is not a personality trait or a preference for orderliness. Patients with OCD are frequently distressed precisely because they recognise their obsessions as intrusive and not aligned with their values. The person who is distressed by intrusive violent thoughts is not dangerous — they are experiencing a hallmark OCD subtype. This distinction matters clinically because misunderstanding it leads to delayed diagnosis and patients suffering for years in silence.

According to Cochrane reviews and NICE CG31, lifetime prevalence is approximately 2–3 per cent. OCD has a bimodal onset: childhood and adolescence (more common in males, often with tic comorbidity) and early adulthood (more common in females). Mean age at onset is approximately 19; over 80 per cent of cases begin before age 25.

A. Core clinical — the AU general-practice framework

Subtypes and clinical presentation

OCD presents in several overlapping subtypes, each with characteristic obsessional content and compulsive responses:

Contamination and cleaning: fears of germs, disease, or contamination; compulsive washing, cleaning, or avoidance of perceived contaminants.

Harm and checking: fear of causing harm (to self or others through carelessness); repetitive checking of locks, appliances, or driving actions. Patients with harm obsessions are not violent — the egodystonic nature of the obsession is the hallmark.

Symmetry and ordering: distress at asymmetry or a “not-right” feeling; compulsive arranging, ordering, or counting.

Taboo and intrusive thoughts: sexual, religious, or aggressive intrusive thoughts that violate the person’s values; mental neutralising rituals (praying, counting, repeating phrases). Patients typically hide these symptoms out of shame — non-judgemental enquiry is essential. Say directly: “Having these thoughts does not mean you want to act on them — this is a core feature of OCD.”

Hoarding disorder is now classified separately in DSM-5-TR. It has distinct treatment trajectories and generally poorer response to SSRI therapy than OCD; specialised hoarding-focused CBT is first-line.

Assessment in general practice

Screen with direct enquiry: “Do you have unwanted thoughts that keep coming back and upset you? Do you feel compelled to repeat certain behaviours to reduce anxiety?” The Y-BOCS (Yale-Brown Obsessive Compulsive Scale) is the gold-standard severity measure used by mental health clinicians; in general practice, a brief direct screen plus referral threshold assessment is appropriate.

Investigations: OCD is a clinical diagnosis. In a first presentation, consider FBC and TSH (thyroid disease can amplify anxiety), and urine drug screen if atypical or substance use is suspected.

Differentials to consider:

• GAD — worry is reality-based and ego-syntonic; OCD obsessions are intrusive and ego-dystonic
• Autism spectrum disorder — repetitive and restricted behaviours are usually ego-syntonic and not anxiety-driven
• Tic disorders/Tourette syndrome — premonitory urges; comorbid OCD in approximately 30 per cent of Tourette cases
• Psychosis — obsessions retain insight; delusions do not
• ADHD — distractibility and impulsivity overlap but differ phenomenologically

Suicide and self-harm screening is mandatory at every assessment. OCD itself carries elevated risk particularly when associated with body dysmorphic disorder, severe comorbid depression, or treatment-refractory illness. Ask directly. Lifeline 13 11 14, Beyond Blue 1300 22 4636.

The treatment hierarchy

NICE CG31, RANZCP guidelines, and Therapeutic Guidelines align on the following hierarchy:

1. CBT-ERP — first-line for mild OCD; first-line combined with SSRI for moderate-to-severe OCD
2. High-dose SSRI — for all but mild OCD; higher doses than required for depression
3. Combination — CBT-ERP plus SSRI superior to either alone for moderate-to-severe illness
4. Specialist augmentation — clomipramine; antipsychotic augmentation; deep brain stimulation for severe refractory OCD

B. Evidence — CBT-ERP and pharmacotherapy

CBT with Exposure and Response Prevention

Cochrane reviews and NICE CG31 confirm CBT-ERP as the most effective psychological intervention for OCD, with an effect size of approximately 1.0 for symptom reduction. ERP is the behavioural component: deliberate, graduated exposure to obsessional triggers while resisting (preventing) the compulsive response. The anxiety peak reduces progressively with repeated exposures — a process called habituation.

A full course is typically 12–20 weekly sessions with a psychologist trained in OCD-specific ERP. Not all cognitive-behavioural therapists are trained in ERP — ask specifically when referring. Individual therapy is superior to group for OCD.

AU access pathways:

• Mental Health Treatment Plan — GP Mental Health Treatment Plan (items 2715/2717), enabling up to 10 Better Access psychology sessions per year (items 80000–80020)
• Online: This Way Up OCD Program (8-lesson internet-based CBT, free for GP-referred patients) and MindSpot Clinic (free Macquarie University-led iCBT, includes OCD-specific module)
• Paediatric and adolescent access: Headspace centres (ages 12–25) as a first-level entry point

Pharmacotherapy: SSRI dosing for OCD

The critical principle: OCD requires higher SSRI doses than depression, and an 8–12 week trial at maximum tolerated dose before concluding failure.

Per Therapeutic Guidelines and RACGP guidance:

Agent	OCD target dose	PBS status
Fluoxetine	40–80 mg/day	General Schedule
Sertraline	100–200 mg/day	General Schedule
Escitalopram	20 mg/day	General Schedule
Fluvoxamine	200–300 mg/day	Authority Required (Streamlined) for OCD
Paroxetine	40–60 mg/day	General Schedule
Clomipramine	100–250 mg/day	General Schedule (second-line, TCA)

Titrate slowly (every 2–4 weeks) to minimise GI side effects and initial anxiety activation. Response at 8–12 weeks at maximum tolerated dose is the assessment point. When a first SSRI fails, switch to another before concluding pharmacological treatment resistance.

Clomipramine (a tricyclic antidepressant with potent serotonin reuptake inhibition) is second-line — effective but limited by anticholinergic, cardiovascular, and seizure risks. ECG before escalating to high doses (above 150 mg/day). Requires more careful monitoring than SSRIs.

Augmentation for treatment-refractory OCD: low-dose antipsychotics — risperidone 0.5–2 mg or aripiprazole 5–15 mg — added to an SSRI reduce symptoms in treatment-refractory cases per Cochrane meta-analyses. Specialist initiation is appropriate. Deep brain stimulation is available in a small number of specialist centres for severe refractory OCD.

Benzodiazepines have no role as monotherapy in OCD and carry significant tolerance, dependence, and SafeScript monitoring implications. Short-term adjunctive use for acute severe distress is occasionally appropriate; long-term use should be avoided.

C. Body-focused repetitive disorders and body dysmorphic disorder

Trichotillomania (hair pulling disorder)

Trichotillomania involves recurrent, compulsive hair pulling that results in hair loss, with repeated failed attempts to stop. Common affected sites are the scalp, eyebrows, eyelashes, and pubic area. Female:male ratio is approximately 3:1 after puberty; paediatric onset is more equal. Trichophagia — eating the pulled hair — can rarely lead to trichobezoar (a gastrointestinal hair ball), which is a surgical emergency.

Exclude dermatological causes of hair loss (alopecia areata, tinea capitis, telogen effluvium, androgenetic alopecia) via scalp examination and, if uncertain, dermatology referral.

First-line treatment is Habit Reversal Training (HRT) or the Comprehensive Behavioural (ComB) model — accessed via a psychologist trained in BFRDs. N-acetylcysteine 1200–2400 mg/day has small-RCT evidence (Grant and colleagues) as an adjunct; it is not PBS-listed and is available as a supplement at approximately $30–50/month. SSRIs have weak evidence for BFRDs specifically but are a reasonable adjunct if comorbid depression is present.

Excoriation (skin picking) disorder

Compulsive skin picking resulting in skin lesions, with repeated attempts to decrease or stop. Female:male ratio approximately 3:1. Common sites are the face, arms, and hands. Triggered by perceived minor skin imperfections. Comorbid OCD, depression, and anxiety are frequent. Treatment mirrors trichotillomania: HRT, ComB model, and N-acetylcysteine adjunct.

Body dysmorphic disorder (BDD)

BDD is a preoccupation with a perceived physical defect that is not apparent to others or is minor. Repetitive behaviours include mirror-checking, skin picking at the perceived defect, excessive camouflaging with make-up or clothing, seeking reassurance from others, and comparing one’s appearance to others.

BDD is a high-stakes diagnosis:

• Lifetime suicide attempt rate approximately 25 per cent
• Completed suicide rate estimated at 45 times the general population
• Often presents to cosmetic clinics rather than mental health services — always screen for BDD before referring for any cosmetic procedure; cosmetic procedures almost never resolve BDD and frequently worsen distress as the preoccupation shifts to another body part

Treatment: CBT-ERP (tailored for BDD) combined with a high-dose SSRI is the evidence-based approach, per NICE CG31. Suicide risk screening at every contact is mandatory. Psychiatric referral is appropriate for moderate-to-severe BDD.

D. Australian operations

MBS items

• Consultation items 23/36/44 — Level B/C/D consultations; Level C or D is appropriate for full OCD assessment and treatment planning
• Mental Health Treatment Plan — items 2715 (plan preparation) and 2717 (review) — the primary referral pathway for psychology access
• Better Access psychology sessions — items 80000–80020, up to 10 individual sessions per calendar year
• Telehealth psychology — item 81335 (telehealth psychology, where available)
• Psychiatry consultation — items 291/293 for complex, refractory, or paediatric cases, or where BDD with high suicide risk warrants specialist assessment
• GPCCMP — items 965/967 for chronic mental illness with complex comorbidity
• ATSI Health Assessment — item 715: incorporate OCD screening in mental health components

PBS prescribing

• Fluoxetine, sertraline, escitalopram, paroxetine, citalopram — General Schedule (prescribe at higher OCD doses; document clinical indication)
• Fluvoxamine — Authority Required (Streamlined) specifically for OCD
• Clomipramine — General Schedule; monitor for cardiac and anticholinergic effects; ECG at high doses
• Risperidone, aripiprazole — Authority Required for various indications; specialist initiation for augmentation
• Benzodiazepines — General Schedule; SafeScript/RTPM monitoring applies in all states
• N-acetylcysteine — not PBS-listed; OTC supplement

Online and digital access (AU-specific)

• This Way Up — OCD program: 8-lesson internet-CBT developed by St Vincent’s Clinical School, UNSW; free for GP- or psychologist-referred patients; strong evidence base
• MindSpot Clinic: free telephone and online assessment and treatment through Macquarie University; OCD-specific module available
• NOCD and CBT-i Coach: US-developed apps accessible to AU patients as supplementary tools

E. Special populations

Paediatric OCD. OCD onset in childhood and adolescence is common and frequently tic-related. Family-based CBT-ERP — involving parents in reducing accommodation behaviours — is standard of care for under-18s. Parental accommodation (reassurance-giving, ritual participation, avoidance of triggers on behalf of the child) significantly worsens OCD outcomes and is a modifiable behavioural target. Headspace centres provide a youth-friendly general practice entry point.

PANDAS and PANS. Paediatric Acute-onset Neuropsychiatric Syndrome (PANS) — sudden dramatic onset of OCD or tic symptoms with associated neuropsychiatric features (dysphagia, handwriting deterioration, emotional dysregulation) — may follow Group A streptococcal infection (PANDAS) or other triggers. This is a specialist diagnosis; consider it in a child with abrupt-onset severe OCD and refer for specialist evaluation.

Older adults. Late-onset OCD is less common but does occur. Consider medical contributors (thyroid disease, neurological conditions, medication effects). Polypharmacy caution applies for clomipramine and antipsychotic augmentation. Reduced clearance affects SSRI dosing.

Comorbid depression. Comorbid major depression is present in approximately 40 per cent of people with OCD and substantially elevates suicide risk. SSRI treatment addresses both conditions to a degree, though depressive severity may require direct treatment before ERP is feasible. Assess mood at every visit.

Pregnancy and postpartum. Postpartum OCD (typically harm obsessions about the infant) is underrecognised. It is ego-dystonic — the parent is distressed by the intrusive thoughts, not acting on them. Non-judgemental assessment and connection to perinatal mental health services is essential; withholding from help increases risk.

When to escalate

• Moderate-to-severe OCD (Y-BOCS ≥ 16, or significant functional impairment) → psychology referral for CBT-ERP via Mental Health Treatment Plan
• Failed adequate first SSRI trial → second SSRI, then psychiatry referral
• Any BDD diagnosis → immediate suicide risk assessment; psychiatry referral for moderate-to-severe severity
• Paediatric onset with sudden dramatic onset → specialist evaluation for PANS/PANDAS
• Refractory OCD not responding to two SSRI trials plus adequate ERP → psychiatry referral for augmentation or specialist OCD clinic review
• Active suicidal ideation → mental health emergency assessment; Lifeline 13 11 14
• Suspected NSSI (non-suicidal self-injury) or self-harm in context of BDD or severe OCD → urgent mental health review

What this article is and is not

This is general health information drawn from NICE CG31, Therapeutic Guidelines, RANZCP guidelines, Cochrane reviews, and RACGP guidance. It does not constitute personal medical advice and does not establish a doctor–patient relationship. Diagnosis of OCD and related disorders, and decisions about medication and psychological treatment, are made with your own GP and treating mental health clinicians.

For Australian consumer resources: Beyond Blue — OCD, HealthDirect — OCD, This Way Up OCD program, MindSpot Clinic, International OCD Foundation.

For crisis support: Lifeline 13 11 14, Beyond Blue 1300 22 4636, Suicide Call Back Service 1300 659 467.

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Sources cited

1. NICE CG31 — OCD and BDD: treatment (2005, 2024 review)
2. RANZCP — Practice guidelines for OCD
3. Therapeutic Guidelines (eTG) — Obsessive-compulsive disorder
4. RACGP — OCD in general practice (AJGP)
5. Cochrane — SSRIs for OCD; CBT-ERP for OCD
6. This Way Up — OCD program
7. MindSpot Clinic
8. HealthDirect — OCD
9. Beyond Blue — OCD
10. International OCD Foundation
11. APA — DSM-5-TR: OCD and related disorders
12. TLC Foundation for BFRBs