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Obsessive-Compulsive Disorder: Presentation and Differentials

Until recently obsessive-compulsive disorder (OCD) was considered to be a very rare disorder. However, newer epidemiological studies show OCD to be just as common as panic disorder, and two to three times as common as schizophrenia.

OCD is a chronic psychiatric condition that often emerge in childhood or adolescence and potentially lasts a lifetime. It results in considerable emotional suffering. Yet until recent times, few of those afflicted sought treatment. This is probably because of the common tendency for OCD patients to experience humiliation and shame over symptoms that they generally consider to be “crazy” or “irrational” and thus not to seek out professional help.

It is also likely due,  in part, to the fact that the behavior of people with OCD is often labeled as “quirky” and not attributable to a mental illness.

The major features of this disorder are recurring obsessions (persistent intrusive, troublesome thoughts or urges that are recognized by the patient as senseless that often revolve around themes of germs and filth, symmetry, aggression, sex, and religion) and compulsions (repetitive behaviors or rituals enacted in response to an obsession, such as repeatedly checking to see if doors are locked, excessive hand washing, and counting).

In order to meet the criteria for obsessive-compulsive disorder, the obsessions and compulsions must create significant distress and be time-consuming enough or otherwise interfere with normal routines, work, activities, or relationships (DSM-5). Among the DSM-5 obsessive-compulsive disorders are:

Body dysmorphic disorder (perceived defects in one’s own appearance)

Hoarding disorder (excessive accumulation of items)

Trichotillomania (hair-pulling disorder)

Excoriation (skin picking) disorder

Substance/medication-induced OCD

Other specified and unspecified OCD

Obsessions Largely Relate to Germs, Dirtiness

Although obsessions can take many forms, approximately two-thirds of OCD patients are plagued by obsessions regarding dirtiness, contamination, and germs, with corresponding compulsions such as cleaning and hand washing.

Another 20 percent primarily are worried about safety issues and engage in repetitive checking rituals (checking to see if doors are locked, if the stove is turned off, retracing their routes when driving to make sure they have not accidentally hit a pedestrian).

The remaining patients are concerned with a sense of incompleteness, or lack of order or symmetry, and engage in rituals designed to make their environments just right, religiosity, and sexual behavior.

OCD Patients at Risk for Other Disorders

At the heart of most obsessions and compulsions are two key elements: excessive self-doubt and intense worry regarding the safety of oneself and others. In addition to OCD symptoms, which are a tremendous source of suffering in their own right, two-thirds of OCD patients also experience episodes of major depression. Consequently, OCD patients are at greater risk for substance use disorders and suicide.

Many people will experience occasional obsessions and compulsions, especially when under stress or when they sense some loss of control over the environment or inner emotions. These more minor, transient obsessions and compulsions do not constitute OCD, which in contrast is a chronic and often incapacitating disorder.

For example, a mother who sends her child off to school for the first time may spend the first few days or weeks consumed with thoughts of her child’s safety and well-being. However, over time, her thoughts will diminish as she realizes her child is adjusting well.  This is not OCD, but rather stress-related worry.

Some similarities exist between OCD and obsessive-compulsive personality disorder (OCP); however, there are notable differences. For treatment purposes, it is important to distinguish between OCD and OCP. With OCD the person feels under attack by the obsessions and compulsive rituals; the symptoms are quite painful and ego-­dystonic (in conflict with the person’s self-image).

In contrast, OCP traits (perfectionism, stinginess, emotional rigidity, overdevotion to work) are experienced as a part of oneself, or ­ego-syntonic. These people are often referred to as “anal” or “perfectionistic.” They may jokingly be referred to as “OCD,” but this is not the case.

Some patients are described as suffering from impulse-control disorders (ICD): gambling, overeating, and so on. Although OCD patients subjectively feel seized by an impulse to carry out rituals, notable differences exist between OCD and true ICDs.

Those experiencing impulse-control problems find the actions, such as overeating, to be pleasurable. In contrast, OCD patients never enjoy carrying out rituals (beyond some reduction in anxiety). In fact, they become highly distressed and feel hopeless in that they cannot stop the obsessions or compulsions.

Also, impulse-control patients rarely are riddled with self-doubt or worries about harming others, again in sharp contrast to OCD. Finally, the medication treatments successful in OCD have been shown to be only modestly effective in most forms of impulse-control disorder and not effective at all in individuals with OCP traits.

Anorectics often exhibit a host of obsessions and compulsions (regarding eating, sizes and portions, times for meals, body weight and image) yet two notable differences exist between anorectics and OCD patients.

Obsessive-compulsive disorder patients almost always admit that the worries and rituals are irrational, whereas most anorectics don’t appreciate the irrationality of their acts. Also, medications found to be effective for OCD generally are not effective in the treatment of anorexia nervosa.

*This article is based on Dr. Moore’s latest book “Handbook of Clinical Psychopharmacology for Therapists” published by New Harbinger Press and coauthored by John Preston, John O’Neal, and Mary Talaga.

Preston, J., O’Neal, J., Talaga, M., & Moore, B. A. (in press). Handbook of Clinical Psychopharmacology for Therapists-Ninth Edition.  Oakland, CA: New Harbinger Press.

 

Obsessive-Compulsive Disorder: Presentation and Differentials


Bret Moore, Psy.D.

Dr. Moore is a board-certified clinical psychologist and prescribing psychologist in San Antonio, TX. His recent book Taking Control of Anxiety: Small Steps for Getting the Best of Worry, Stress, and Fear was developed as a self-help guide for people struggling with anxiety and for therapists to use with their patients. Dr. Moore is also coauthor of the Handbook of Clinical Psychopharmacology for Therapists-Ninth Edition and Child and Adolescent Psychopharmacology Made Simple-Fourth Edition.

 

APA Reference
Moore, B. (2020). Obsessive-Compulsive Disorder: Presentation and Differentials. Psych Central. Retrieved on May 28, 2020, from https://pro.psychcentral.com/obsessive-compulsive-disorder-presentation-and-differentials/

 

Scientifically Reviewed
Last updated: 2 May 2020
Last reviewed: By John M. Grohol, Psy.D. on 2 May 2020
Published on PsychCentral.com. All rights reserved.