Psychiatric Evaluation & Medication Management for
Obsessive Compulsive Disorder (OCD)
Dr. Holly Betterly, MD is a Double Board Certified Psychiatrist and member of the International OCD Foundation (IOCDF).
She is dedicated to providing high-quality, evidence-based psychiatric care for OCD, emphasizing treatment options solidly grounded in research.
She is passionate about OCD awareness, especially surrounding its incredible diversity: no two cases of OCD are exactly alike. She considers your unique needs and preferences to develop a treatment plan that is personalized to you as an individual.
It’s important to choose a psychiatrist who is knowledgeable about the diagnosis and treatment of OCD: a recent report estimates that OCD goes undetected by clinicians in 75% of cases.
Dr. Betterly offers:
Comprehensive psychiatric evaluations for the careful diagnosis of OCD, as well as any co-existing mental health conditions.
Thoughtful medication management for OCD, which can help to reduce the symptoms of OCD and alleviate distress and anxiety.
Longer appointments to facilitate thorough evaluations, thoughtful discussion of available treatment options, and plenty of time for questions.
She collaborates with specialized therapists trained in Exposure Response Prevention (ERP), the gold-standard evidence-based therapy modality for OCD. For patients who don’t already have an OCD therapist, Dr. Betterly can provide a list of local & telehealth referrals. For those who are already working with a therapist, she is happy to connect with them to coordinate care with the patient’s permission.
Dr. Betterly is currently accepting new patients. She offers telehealth for patients across Florida, as well as in-person appointments at her office in Weston, FL.
Understanding Obsessive Compulsive Disorder (OCD)
About OCD
Obsessive Compulsive Disorder (OCD) is an extremely misunderstood mental health condition. A 2025 report from the International OCD Foundation (IOCDF) indicates that OCD is severely underdiagnosed, with an estimated 75 percent of those living with OCD going undetected by clinicians. It can take well over a decade to receive a diagnosis of OCD after symptoms first begin!
Why is OCD so misunderstood?
The media and popular culture often inaccurately portray OCD as a simple personality “quirk,” or a preference for cleanliness, symmetry, and organization, which is far from the day-to-day reality for those living with OCD. Many people (including mental health providers!) mistakenly believe that if they aren’t spending their days at the sink washing their hands, they couldn’t possibly have OCD- this can make the diagnosis easy to miss.
Understanding OCD
OCD is a psychiatric disorder characterized by the presence of obsessions (persistent and distressing intrusive thoughts, mental images, or urges) and compulsions (repetitive physical behaviors and/or mental acts). Obsessions bring up intense distress, and compulsions are performed in an attempt to find relief from this distress. Unfortunately, the relief provided by performing compulsions is temporary, and with time the obsessions return, creating a vicious cycle.
Demystifying Obsessions
To better understand the concept of obsessions, consider this. Everyone experiences intrusive thoughts sometimes- things like “what if I left my wallet at home?”. These thoughts pop into our heads involuntarily, and while they may cause some mild distress, we are typically able to brush them off fairly quickly and move along with our day.
In OCD, intrusive thoughts become “sticky” and persistent- they come back again and again. They bring up intense distress, anxiety, and discomfort. They feel urgent, pressing, and important, like something must be done immediately to find certainty and relieve the distress.
It’s also important to note that while many obsessions do show up as thoughts, often in the form of doubts or uncertainty, they can also show up as vivid mental images, as well as physical urges.
Physical (Observable) vs. Mental (Nonobservable) Compulsions
While some compulsions consist of observable physical behaviors, such as counting, checking locks, or handwashing, other compulsions are “invisible”, and can easily slip by undetected- even to those who are experiencing them! We refer to this type of compulsion as mental compulsions, which could include things like mentally replaying an event, reciting a phrase, or reassuring yourself.
Avoidance Behaviors and OCD
In addition to performing compulsions in search of temporary relief from the distress created by obsessions, many people with OCD also find themselves avoiding people, places, objects, or situations that trigger the obsessions (known as avoidance). OCD often latches on to that which matters most to us, and this often means that the avoidance seen in OCD can “steal” those things away from us- things like time spent with friends, family, and beloved hobbies.
How OCD Impacts Lives
The obsessions, compulsions, and avoidance behaviors seen in OCD can severely interfere with one’s daily life and responsibilities, at times consuming hours of one’s day. People living with OCD often experience considerable emotional distress and challenges.
How common is OCD?
If you are living with OCD, you are not alone. OCD is a common mental health condition that impacts about one in forty adults; in other words, between two to three percent of the population. That means that over 8 million adults in the United States are estimated to struggle with OCD during their lifetime.
How is OCD diagnosed?
OCD must be diagnosed by a mental health professional, such as a psychiatrist or a psychologist. The diagnosis is a clinical one, meaning that there is no blood test or imaging that can determine if someone has OCD. The diagnostic process for OCD involves a comprehensive psychiatric evaluation as well as the use of specific instruments and scales.
How is OCD treated?
It’s important to note that OCD is a chronic condition, which means that there is no “cure”- we can’t get rid of it forever in the way that we might get rid of a sinus infection with a course of antibiotics. OCD symptoms may persist throughout one’s life to some extent either with or without treatment, however, the severity of symptoms often fluctuates over time, so there may be periods where symptoms are more or less prominent, often in relation to life stressors.
The good news: there are multiple effective, evidence-based treatment options available for OCD. Specialized forms of evidence-based therapy, such as Exposure Response Prevention, or “ERP”, can help to break the cycle of obsessive thoughts and compulsive behaviors. Prescription medications are also available, and are frequently prescribed in combination with therapy.
The goals of treatment for OCD often involve reducing/eliminating the anxiety and distress brought on by obsessions, and reducing/eliminating performance of compulsions and avoidance behaviors. They also often involve aiming to reduce the amount of time spent occupied by obsessions and engaging in compulsions (for example, aiming for less than 1 hour per day)- giving you time back to live your life. Another important goal is reducing OCD’s interference in important areas of daily life, such as work, school, and relationships, as well as overall day to day functioning.
One can think of medications as a way to “turn down the volume knob” on obsessions- in other words, medications can help to reduce the intensity, persistence, and “stickiness” of obsessions to make them more manageable. Medications can often help to make ERP therapy feel more accessible and approachable.
Common “Thinking Traps” in OCD
There are a number of common thinking traps seen in people living with OCD, including:
Overinflated sense of responsibility
Intolerance of uncertainty
Overestimation of threats
Perfectionism
Belief that thoughts are important, meaningful, and dangerous rather than random
Excess concern about the importance of controlling one’s thoughts
Obsessions
Unwanted, persistent, distressing intrusive thoughts, urges, or mental images which repeatedly enter one’s mind involuntarily.
Often go against one’s personal values and beliefs (ego-dystonic)
Often involve doubt and uncertainty, however the content of the thought itself can be just about anything
Thoughts create intense anxiety, distress, and disgust
Associated distress leads to performing repetitive physical or mental acts, known as compulsions, in an attempt to find certainty and relief from the distress.
Obsessions may also lead to avoidance of people, places, objects, and situations which trigger the obsessions.
Common Obsessions
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Doubts, fears, and uncertainties related to contamination/germs/dirt
Some Examples:
Contracting a rare disease after touching a doorknob
Spreading COVID to loved ones
Poisoning yourself via contact with household cleaners
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Doubts and fears related to causing harm to yourself or others
Some Examples:
Stabbing a loved one
Dropping your newborn baby
Hitting someone with your car
Prescribing the wrong dose of a medication to a patient
Being responsible for a house fire after leaving the stove on
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Doubts and uncertainty surrounding one’s sexual orientation
Some Examples:
Am I actually heterosexual?
What if I’m attracted to men/women?
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Unpleasant, distressing doubts about one’s sexual preferences with respect to pedophilia, incest, animals, etc.
Some Examples:
What if I’m actually attracted to children?
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Unpleasant, distressing doubts related to religion, morality, or right/wrong
Some Examples:
What if I’m a bad person?
What if I’ve committed blasphemy/sacrilege?
What if I’ve accidentally broken the law?
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Need for things to be “just right”/perfect
Some Examples:
What if that email wasn’t phrased correctly?
Could that text be misinterpreted?
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Doubts about one’s relationships or partner
Can involve romantic partner, but doesn’t have to- could also involve family, colleagues, etc.
Some Examples:
Questioning whether one’s partner truly loves them
Questioning whether there partner is “the one,” attractive enough, intelligent enough
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Doubts related to one’s health
Some Examples:
The biopsy result was negative, but what if it was wrong and I actually have cancer?
What if I forgot to tell the doctor about one of my symptoms, and I was misdiagnosed?
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Doubts related to pregnancy/baby
Some Examples:
What if I drop my baby?
What if I hurt my baby?
What if my baby dies of SIDS?
Compulsions
Repetitive physically observable behaviors (i.e., hand washing, ordering, checking, asking for reassurance)
Repetitive non-observable mental acts (i.e., counting, repeating words silently, praying, replaying past events)
Performed in an attempt to find certainty and/or relieve the distress and anxiety brought on by obsessions
Mental acts and repetitive behaviors are not necessarily connected in a realistic way with that which they are designed to prevent. They may be clearly excessive.
Common Observable/Physical Compulsions
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Repetitively and excessively seeking reassurance in an effort to find certainty
May take the form of questions, but can also involve “fishing” statements aimed at eliciting a response.
May involve questions to loved ones, questions on online forums/ social media, questions to AI chatbots, excessive googling, etc.
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Examples may include excessive or ritualized:
Checking locks, stoves, appliances
Checking for mistakes (in work, emails, texts)
Checking that you didn’t harm someone (ex. retracing your driving route to check if you accidentally hit someone)
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Examples may include excessive or ritualized:
Handwashing
Cleaning
Bathing
Sanitizing
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Examples include excessive and repetitive:
Rereading
Rewriting
Redoing a task (ex. folding laundry)
Repeating actions (ex. opening and closing the door 3 times)
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Examples include excessive and repetitive:
"Oversharing” excessive amounts of details to avoid being misunderstood/ leaving something out
“Confessing” to even minor/trivial errors, mistakes, or sins
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Excessively and repetitively touching, tapping, or rubbing, often in a specific, ritualized manner
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Excessive, repetitive, often ritualized ordering
Example:
Lining up the belongings on your nightstand until they are arranged in a very specific, exact pattern
Common Non-Observable/Mental Compulsions
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Repetitively and excessively reassuring oneself
Example:
Thinking “I did lock the door, I remember doing it, I wouldn’t have left it open because…”
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Excessively and repetitively “replaying” past events or situations to check for any mistakes/wrongdoings, to seek certainty, or to find meaning
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Attempting to counteract a “bad” thought by thinking a “good” thought
Example:
After thinking “what if I stab my friend”, thinking “I love my friend”
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Excessively and repetitively “planning”/ imagining potential outcomes to a hypothetical scenario
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Excessive and repetitively mentally reciting prayers. Driven by distress/ego-dystonic, not by religious beliefs/ customs/faith
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Trying to mentally absorb/ hold on to every last detail of a scenario
Example:
Trying to hold on to the image of your stove turned off so that you can be certain you did it
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Mentally checking to see if one is experiencing the “right” bodily sensations or emotions
The Cycle of OCD
How does the Cycle of OCD work?
Obsessions involve persistent, unwanted, intrusive thoughts, mental images, or urges. They often bring up feelings of distress and anxiety. We engage in compulsions in an attempt to relieve the distress brought on by obsessions. The compulsions may provide some temporary relief from anxiety and distress, but this reprieve is short-lived, and with time, the obsessions return.
When we engage in compulsions, we teach our brains that the obsession and its associated discomfort are dangerous, intolerable, and must be dealt with immediately. This strengthens the connection and reinforces the need to engage in the compulsion the next time that the obsession arises- “it worked before, so I need to do it again if I want relief.” This ultimately perpetuates the vicious cycle of OCD.
How do we break the Cycle of OCD?
Exposure and Response Prevention, also known as “ERP”, is a specialized form of therapy used to treat OCD. ERP involves facing the obsessions and their associated distress head-on, resisting the urge to engage in compulsions to alleviate feelings of anxiety.
ERP helps to teach our brains that with time, our anxiety will subside on its own, and that the feared outcomes associated with the obsession are unlikely to occur. It can help us to learn to tolerate uncertainty. ERP is conducted by a trained mental health professional, such as a psychologist.
Medications for OCD
There are many different medication options available for the treatment of Obsessive Compulsive Disorder. A discussion with a board-certified psychiatrist can help you to determine whether medications may be an option for you and your personal health circumstances.
The following information is provided for educational purposes only. It is not intended to substitute for professional medical advice. Always reach out to your doctor with questions about your health.
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The usual first choice category of medication used in treating OCD is Selective Serotonin Reuptake Inhibitors, or SSRIs. There are multiple different SSRIs available, such as sertraline, fluoxetine, paroxetine, fluvoxamine. SSRIs are all equivalent when it comes to treating OCD.
Another medication which is frequently used in treating OCD is clomipramine, a tricyclic antidepressant. Clomipramine has a less favorable side effect profile, so it typically isn’t used as the first choice.
Other medications, such as antipsychotics, are sometimes used as augmentation agents (“add ons”) when first line medications are ineffective alone. The evidence does not support using antipsychotics by themselves to treat OCD.
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SSRIs are a category of medications that are often used as a first-line medication option in the treatment of OCD. They are also frequently used in depression and anxiety- you may hear them referred to as “antidepressants” (although not all antidepressants are SSRIs!).
SSRIs often come in an oral tablet, capsule, or liquid form, and are available in the United States by prescription only. This means that they cannot be purchased over the counter, and should only be taken under the careful supervision of a physician.
Psychiatrists are medical doctors who specialize in the treatment of mental health conditions, with extensive expertise in working with these types of medications.
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SSRIs get their name from their mechanism of action- in other words, how they work. SSRIs selectively inhibit the reuptake of serotonin. But what does that mean, exactly? Let’s break it down.
Serotonin is a neurotransmitter- you can think of it as a chemical messenger in your brain. Serotonin plays many roles, and is involved in mood, emotion, and sleep.
These chemical messengers are involved in the transmission of signals between the cells in your brain, called neurons. You can think of this signal transmission as a method by which the neurons communicate with one another.
To send a chemical message to its neighbor, a neuron releases serotonin into the space between the neurons called the “synaptic cleft”. Once this chemical message has been transmitted to the other neuron, the serotonin is reabsorbed in a process called “reuptake”.
SSRIs work by preventing, or blocking, the reuptake process. This means that rather than being reabsorbed back into the neuron, the serotonin stays put in the synaptic cleft.
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In the United States, the Food and Drug Administration (FDA) has approved four different SSRI medications for the treatment of Obsessive Compulsive Disorder in adults. These medications include:
Sertraline
Fluoxetine
Paroxetine
Fluvoxamine
The medications are listed above by their generic names, however, you may also see these medications referred to by their brand names.
The SSRI category also includes two other medications, citalopram and escitalopram, that may be used on an “off-label” basis for OCD. This means that they have not been approved by the FDA specifically for use in OCD.
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It’s important to note that when we use SSRIs to treat OCD, we use significantly higher doses, and for longer durations, than when using SSRIs to treat depression and anxiety.
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Medications vary significantly in terms of how long they need to take effect and provide symptom relief. Some medications, like antibiotics for infections, get to work right away, and may have you feeling better almost immediately. Unfortunately, this is not the case with SSRIs, which are generally much slower to take effect, especially when we are using them to treat OCD.
While patients may begin to see some improvement in their symptoms over the first few weeks (for example, intrusive thoughts feeling less “sticky” or distressing”), an adequate SSRI trial in OCD is 12 to 16 weeks after reaching the target dose, which is much longer than is required when using SSRIs to treat other conditions, such as depression.
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There is no one “best” SSRI- they are equivalent in terms of their effectiveness in treating OCD. The choice of which SSRI to start out with is individualized, and takes into consideration factors such as patient preferences, other medications that the patient may be taking, and the patient’s other health conditions.
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Like all medications, SSRIs can cause side effects. While some people experience side effects while taking SSRIs, others don’t- people vary significantly in terms of how they respond to a medication. Be wary of genetic tests claiming to predict whether you will or won’t experience side effects- there is no way to predict this with 100% certainty.
SSRIs are often better tolerated than other medications used to treat OCD, which is why they are frequently selected as a first-line option.
A board-certified psychiatrist can provide education about the potential risks and benefits of a specific medication to help you make an informed decision about whether it would be an appropriate choice for you and your unique health circumstances.
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SSRIs vary amongst themselves in terms of potential side effects- no two are exactly alike. It is important to review the prescribing information specific to the particular medication. With that said, some side effects are commonly seen across the SSRI class of medications.
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Some common side effects of SSRIs include (but are not limited to):
Gastrointestinal upset (such as nausea, upset stomach, or diarrhea)
Jitteriness, agitation or increased anxiety
Night Sweats
Jaw Clenching
Headache
Dizziness
Changes in sleep
Changes in appetite, leading to changes in weight
Sexual dysfunction
Discontinuation Syndrome (if an SSRI is stopped abruptly)
Some less common side effects of SSRIs include (but are not limited to):
Increased risk of bleeding/bruising
Suicidal thoughts or behaviors
Serotonin Syndrome
Seizures
Blurred vision
Confusion
The list of side effects can seem pretty intimidating, but it’s important to remember that possibility doesn’t equal probability- in other words, many side effects are quite uncommon, and overall, side effects are far from a guarantee. A psychiatrist can explain what the data shows with respect to the likelihood of side effects occurring.
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Many side effects are time limited, typically occurring only for the first week or so as the body adjusts to the medication, after which they often resolve. A psychiatrist can explain which side effects are usually temporary, and which are more likely to persist as long as you continue taking the medication.
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There are strategies that psychiatrists can utilize to try to reduce the likelihood of certain side effects occurring. These strategies could include things like starting at a lower dose than usual, increasing the dose in smaller increments than usual, and increasing the dose more slowly than usual.
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No, there is no way to predict which SSRI will work best for someone. Sometimes it takes trying multiple medications to find the one that works best for you. Be wary of genetic testing claiming to provide such information. They provide information about how a medication may be broken down by your body, NOT how effective it will be at relieving symptoms.
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Yes- there are multiple OCD medications which are considered to be compatible with pregnancy. A psychiatrist can explain the risks and benefits of available options to facilitate an informed decision. You do not have to choose between your health and your baby’s health!
Trusted OCD Resources
There is so much misinformation out there about OCD- it’s extremely important to make sure that your information is coming from a trusted, evidence-based source.
The following leading professional organizations provide reliable facts and information to help you better understand OCD.
Learn more about OCD
Dr. Holly Betterly is committed to educating her patients about their mental health, encouraging them to play an active role in their psychiatric care. She empowers her patients by sharing the knowledge and expertise that she has gained through over a decade of training.
She maintains a mental health education blog, Better Together, which features articles on timely topics in psychiatry, as well as answers to your mental health questions- straight from a trusted psychiatrist!
Check out some of Dr. Betterly’s latest articles about OCD:
