OCD involves intrusive, unwanted thoughts and repetitive behaviors or mental rituals performed to relieve the anxiety they cause. It is treated with SSRIs at higher doses than for depression, exposure and response prevention (ERP) therapy, or both. For OCD that does not respond, Deep TMS is FDA-cleared and antipsychotic augmentation is an option. Most patients improve within six months.
Stedfast Psychiatry treats OCD with the three approaches that have the best evidence: higher-dose SSRIs, exposure and response prevention therapy, and, for people who have not responded to those, Deep TMS, which has been FDA-cleared for OCD since 2018 and is available at our Palm Beach Gardens office. OCD is often misdiagnosed for years; an accurate diagnosis is the first step.
Symptoms of OCD
- Intrusive thoughts, images or urges that feel unwanted and cause distress
- Fear of contamination, germs or illness
- Fear of harming yourself or others, or of being responsible for harm
- Unwanted sexual, violent or blasphemous thoughts
- Need for symmetry, order or things feeling 'just right'
- Excessive washing, cleaning, checking, counting or arranging
- Mental rituals such as reviewing, praying or repeating phrases
- Repeatedly seeking reassurance from others
- Avoiding situations that trigger the thoughts
- Rituals taking more than an hour a day or interfering with life
Causes and risk factors
OCD is partly genetic; having a first-degree relative with OCD raises risk several times over, and heritability is higher when onset is in childhood. Brain imaging consistently shows overactivity in a loop connecting the orbitofrontal cortex, anterior cingulate cortex, striatum and thalamus, the circuit that normally flags errors and drives corrective action. Serotonin and glutamate signaling in that circuit are involved, which is why SSRIs help and why TMS targeting the medial prefrontal and anterior cingulate cortex works. Stressful life events, pregnancy and the postpartum period can trigger onset in vulnerable people. A small subset of children develop sudden-onset OCD after streptococcal or other infections (PANDAS/PANS).
About 1.2 percent of US adults had OCD in the past year, and 2.3 percent will have it at some point in their lives.
Source: NIMH, National Comorbidity Survey Replication
About half of adults with OCD have serious impairment, and the average delay between symptom onset and treatment is many years.
Source: NIMH
Deep TMS for OCD received FDA clearance in 2018; in the pivotal multicenter trial, 38 percent of patients responded to active treatment versus 11 percent on sham.
Source: Carmi et al., American Journal of Psychiatry, 2019
Exposure and response prevention produces clinically significant improvement in roughly 50 to 60 percent of patients who complete treatment.
Source: American Psychiatric Association Practice Guideline for OCD
How we diagnose it at Stedfast Psychiatry
We diagnose OCD with a structured clinical interview and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), which measures the time, distress, interference and control associated with obsessions and compulsions and is repeated to track progress. We screen for the conditions that commonly accompany or mimic OCD: depression, generalized anxiety, tic disorders, body dysmorphic disorder, hoarding, eating disorders, autism spectrum disorder and, importantly, psychosis, since insight in OCD can be poor. We take a careful history of onset, themes, family history and prior treatment including SSRI doses and duration, since many patients have had trials that were too low or too short to count. In children with abrupt onset we consider PANDAS/PANS and coordinate with pediatrics.
Treatment options
Medication management
SSRIs are first-line for OCD and typically need higher doses and longer trials than for depression: fluoxetine up to 80 mg, sertraline up to 200 mg, fluvoxamine up to 300 mg, escitalopram up to 40 mg, or paroxetine up to 60 mg. We increase the dose gradually and allow 10 to 12 weeks at the target dose before judging response. Clomipramine, a tricyclic, is somewhat more effective but has more side effects and is used when SSRIs fail. When response is partial, adding a low dose of an atypical antipsychotic such as aripiprazole or risperidone helps about a third of patients, particularly those with tics. Monitoring includes side effects, EKG for clomipramine, and metabolic labs for antipsychotics. Medication is usually continued for one to two years after response and tapered slowly, if at all.
Psychotherapy
Exposure and response prevention (ERP) is the most effective psychological treatment for OCD and the standard of care. You and the therapist build a ladder of feared situations, approach them deliberately, and resist the compulsion until the anxiety falls on its own. Over 12 to 20 sessions the brain learns that the feared outcome does not happen and that anxiety is tolerable. General talk therapy and reassurance do not work for OCD and can reinforce it. ERP combined with an SSRI produces the best results for moderate to severe OCD, and ERP skills reduce relapse after medication is tapered.
Interventional options
Deep TMS (BrainsWay) was FDA-cleared for OCD in 2018, the first device clearance for the condition. The H7 coil stimulates the medial prefrontal and anterior cingulate cortex, and sessions include a brief personalized symptom provocation so the circuit is active during stimulation. A standard course is 29 sessions over about six weeks, offered at our Palm Beach Gardens office. In the pivotal trial, 38 percent of patients receiving active treatment had a clinically meaningful response compared with 11 percent on sham. Deep TMS is also cleared for major depressive disorder, anxious depression and smoking cessation, which matters because many OCD patients also have depression. Spravato is FDA-approved for treatment-resistant depression and MDD with suicidal ideation in adults 18 and older, not for OCD, and is considered only when those depression criteria are met.
What to expect
Your first visit is a 60-minute evaluation that includes the Y-BOCS. If OCD is diagnosed, you leave with a plan for medication, ERP, or both, and an honest timeline. Medication follow-ups are at three to four weeks initially, then monthly as the dose increases, then every two to three months. Most follow-ups and ERP sessions can be done by telehealth from anywhere in Florida or South Carolina; ERP by video has the advantage of practicing exposures in the real environment where symptoms occur. Deep TMS requires daily weekday visits to Palm Beach Gardens for about six weeks.
When to seek help
Seek help when obsessions or compulsions take more than an hour a day, cause significant distress, or interfere with work, school, relationships or daily routines. Do not wait because the thoughts feel embarrassing; harm, sexual and religious obsessions are common OCD themes and do not mean you will act on them. If OCD has led to depression and thoughts of suicide, call or text 988 or go to the nearest emergency room.
Common OCD subtypes
OCD takes many forms, and the theme does not change the treatment. Contamination OCD involves fear of germs, chemicals or illness with washing and avoidance. Checking OCD centers on doubt about locks, appliances or having caused harm. Harm OCD involves intrusive thoughts of hurting others or oneself, with mental reviewing and avoidance of knives or driving. Sexual orientation and pedophilia-themed OCD, relationship OCD and religious scrupulosity are common and badly underdiagnosed because patients are ashamed to describe them. Symmetry and 'just right' OCD involves arranging and repeating until a feeling of completeness arrives. Pure obsessional OCD has compulsions that are mostly mental, which makes it easy to miss.
OCD versus related conditions
Several conditions share features with OCD and are grouped with it in DSM-5-TR. Body dysmorphic disorder focuses on perceived flaws in appearance. Hoarding disorder involves difficulty discarding possessions. Trichotillomania and skin picking are body-focused repetitive behaviors. Obsessive-compulsive personality disorder is a different condition: a rigid, perfectionistic style without true obsessions or compulsions. Generalized anxiety produces worry about real-life problems rather than intrusive, bizarre-feeling thoughts. Psychosis is distinguished by the loss of insight and the presence of delusions or hallucinations, although OCD with poor insight can be a gray area that needs careful evaluation. Tic disorders co-occur with OCD in about a third of childhood-onset cases and shift medication choices.
What makes OCD worse and what helps
Reassurance from family members, accommodation of rituals and avoidance all feed OCD, which is why we involve family in treatment. Stress, poor sleep, alcohol and stimulants increase symptom intensity. Regular exercise, consistent sleep and practicing ERP exposures between sessions speed recovery. Mindfulness techniques that teach you to observe a thought without engaging it complement ERP. Support groups through the International OCD Foundation connect patients and families with others who understand the condition.
Prognosis
Untreated OCD tends to be chronic, with symptoms that wax and wane but rarely disappear. With proper treatment, most people achieve substantial improvement: Y-BOCS scores typically fall by 35 to 50 percent or more with combined SSRI and ERP, which translates into reclaiming hours each day. Full remission occurs in a meaningful minority, and partial remission with good function is the common outcome. Those who have not responded to two SSRI trials and ERP now have Deep TMS as an FDA-cleared next step, and for the most severe cases, neurosurgical options exist at academic centers. The outlook today is markedly better than it was a generation ago.
Frequently asked questions
What is the best treatment for OCD?
Exposure and response prevention therapy is the single most effective treatment, and an SSRI at a high enough dose is the best medication. For moderate to severe OCD, the combination works better than either alone. If both have been tried properly without enough improvement, Deep TMS (FDA-cleared for OCD) or augmenting the SSRI with a low-dose antipsychotic are the next steps. We will tell you which stage you are at and what comes next.
Why does my SSRI dose for OCD seem so high?
OCD responds to higher SSRI doses than depression does, and it takes longer: 10 to 12 weeks at the target dose before we can judge response. Fluoxetine 60 to 80 mg or sertraline 150 to 200 mg are typical OCD doses. Many people who think an SSRI failed them were never on an adequate dose for long enough. These doses are safe with monitoring, and side effects usually settle after the first few weeks at each step.
Does TMS work for OCD?
Deep TMS with the BrainsWay H7 coil is FDA-cleared for OCD based on a multicenter randomized trial in which 38 percent of patients responded versus 11 percent with sham treatment, with benefits persisting at one-month follow-up. It is intended for people who have not responded adequately to medication and therapy. The course is 29 sessions over about six weeks at our Palm Beach Gardens office, and most insurance plans now cover it for OCD with documentation.
How long does OCD treatment take?
ERP is typically 12 to 20 sessions over three to five months, and many people see meaningful change by the midpoint. Medication takes 10 to 12 weeks at full dose to show its effect and is continued for one to two years after response. Deep TMS is about six weeks. OCD tends to be chronic, but with treatment most people reduce symptoms to a level that no longer runs their life, and ERP skills help you handle flare-ups on your own.
Can OCD be treated through telehealth?
Yes. Medication management works well by video, and ERP delivered by telehealth has results comparable to in-person therapy in clinical studies. Video sessions let the therapist guide exposures in your actual home, car or workplace, where the triggers live, which is often more effective than practicing in an office. We see patients throughout Florida and South Carolina. Deep TMS requires in-person visits at Palm Beach Gardens for the six-week course.
Is OCD treatment covered by insurance?
Yes. We accept most major commercial plans and Medicare; visits are billed as specialist mental health visits with your usual copay, and our self-pay rate for a new evaluation is $185. SSRIs are inexpensive generics. ERP is covered as outpatient psychotherapy. Deep TMS for OCD is covered by many plans after documented medication and therapy trials; we handle the prior authorization.
Will I act on my intrusive thoughts?
No. Intrusive thoughts about harm, sex or blasphemy in OCD are ego-dystonic: they are the opposite of what you want, which is why they cause such distress. People with OCD do not act on these thoughts; the disorder is defined by the fear of them, not the desire. Telling a clinician about them is safe and is the beginning of effective treatment. We hear these themes every week.
How is OCD treated in children?
Pediatric OCD affects about one in 200 children and responds to the same core treatments: family-based ERP and, when needed, SSRIs such as sertraline or fluoxetine, which are FDA-approved for pediatric OCD. Parents learn to stop accommodating rituals, which is a key part of treatment. Sudden overnight onset with other neurological symptoms prompts evaluation for PANDAS/PANS. Our child and adolescent providers treat OCD at all ages.
Where to get treatment for obsessive-compulsive disorder
Evaluation and treatment for obsessive-compulsive disorder is available at every Stedfast Psychiatry office and by video across Florida and South Carolina.
Related conditions
If you are thinking about harming yourself, call or text 988 now, or go to the nearest emergency room. This page is educational and does not replace an evaluation. Clinical content reviewed by Dr. David Husted, board-certified psychiatrist.