Half of obsessive-compulsive disorder cases misdiagnosed: vignette-based survey of primary care physicians

Medical settings are the primary mode of care for mental health problems; physicians' abilities with regard to psychiatric diagnosis and treatment recommendations are therefore essential. While misdiagnosis can occur across all psychiatric conditions, the heterogeneous nature of obsessive-compulsive disorder (OCD) may make this condition at an elevated risk for misidentification. The study's aim was to assess primary care physicians' ability to identify OCD.

The study was cross-sectional in design. An online, vignette-based survey was emailed to 1,172 physicians from 5 major medical hospitals in the Greater New York Area. The email included a link to the survey, which consisted of 1 of 8 randomized OCD vignettes; each vignette focused on one of the following common manifestations of OCD: obsessions regarding aggression, contamination, fear of saying things, homosexuality, pedophilia, religion, somatic concerns, or symmetry. Participants provided diagnostic impressions and treatment recommendations for the individual described in the vignette. Data collection took place from December 10, 2012, through January 18, 2013.

Two hundred eight physicians completed the survey. The overall misidentification rate was 50.5%. Vignette type was the strongest predictor of a correct OCD response (Wald χ(2)7 = 40.58; P <.0001). Misidentification rates by vignette were homosexuality (84.6%), aggression (80.0%), saying certain things (73.9%), pedophilia (70.8%), somatic concerns (40.0%), religion (37.5%), contamination (32.3%), and symmetry (3.70%). Participants who misidentified the OCD vignette were less likely to recommend a first-line empirically supported treatment (cognitive-behavioral therapy [CBT] = 46.7%, selective serotonin reuptake inhibitor [SSRI] = 8.6%) compared to participants who correctly identified the OCD vignette (CBT = 66.0%, SSRI = 35.0%). Antipsychotic recommendation rates were elevated among incorrect versus correct responders (12.4% vs 1.9%).

Elevated OCD misdiagnosis rates and the impact of incorrect diagnoses on treatment recommendations highlight the need for greater training regarding OCD symptomatology and empirically supported treatments.