Obsessive-compulsive disorder - Diagnosis

Diagnostic criteria for obsessive-compulsive disorder

A. Presence of obsessions and/or compulsions

Obsessions are persistently recurring thoughts, impulses, or images that are experienced at some point in time as violent and inappropriate and that cause marked anxiety or worry. These thoughts, impulses, or images are not simply excessive worry about real problems. The person tries to ignore or suppress these thoughts, impulses, or images, or to neutralize them with other thoughts or actions. The person is aware that the obsessive thoughts, impulses, or images are a product of his or her own mind (and are not imposed on him or her by an outside source).

Compulsions are repetitive actions or mental acts performed under the influence of obsessions or in accordance with strictly established rules. These actions or mental acts are performed with the aim of preventing or reducing discomfort or preventing some undesirable events or situations. At the same time, these actions or mental acts have no rational explanation or are clearly excessive.

B. At a certain stage in the development of the disease, the person realizes that the obsessions or compulsions are excessive or irrational

B. Obsessions or compulsions cause significant discomfort, take up a significant amount of time (more than 1 hour a day) or significantly disrupt the patient's life.

D. In the presence of another Axis I disorder, the content of obsessions or compulsions is not limited to their specific themes, such as:

• preoccupation with food (eating disorders)
• hair pulling (trichotillomania)
• preoccupation with appearance (dysmorphophobia)
• preoccupation with taking drugs (substance use disorder)
• concern about the possible presence of a serious illness (hypochondria)
• preoccupation with sexual impulses and fantasies (paraphilia)

E. The disorder is not caused by direct physiological action of exogenous substances or by a general disease

Common Types of Obsessions and Compulsions

Obsessions

• Fear of contamination or infection
• Fear of possible catastrophic events, such as fire, illness, or death
• Fear of harming oneself or others
• Hypertrophied need for order and symmetry
• Individually unacceptable thoughts of sexual or religious content
• Superstitious fears

Compulsions

• Excessive actions involving cleaning or washing
• Excessive checking (e.g. of locks or the condition of electrical appliances)
• Excessive actions to tidy up or arrange things in a certain order
• Ritualized account
• Repetitive everyday activities (eg walking through a door)
• Collecting or gathering useless items
• Internal ("mental") rituals (for example, silently saying meaningless words to drive away an unwanted image)

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Differential diagnosis of obsessive-compulsive disorder

Before a definitive diagnosis of obsessive-compulsive disorder can be made, it is necessary to differentiate it from several other common conditions. As noted, the presence of criticism of one's condition (at the time of examination or based on anamnestic data) distinguishes obsessive-compulsive disorder from primary psychotic disorders. Obsessions may be characterized by irrational fears, but, unlike delusions, they are not fixed, unconvincing opinions. To distinguish obsessions from psychotic symptoms, such as delusions of influence (when the patient, for example, claims that "someone else is sending me telepathic messages"), it should be taken into account that patients with obsessive-compulsive disorder believe that obsessive thoughts are born in their own heads. Obsessions are sometimes mistakenly regarded as auditory hallucinations when the patient, especially a child, calls them "a voice in my head," but, unlike a psychotic patient, such a patient evaluates them as his own thoughts.

There are some discrepancies in the literature, both popular and specialized, due to the imprecise use of the terms "obsession" and "compulsion". Clear criteria for obsession and compulsion necessary for diagnosing obsessive-compulsive disorder were given earlier. It is especially important to remember that one of the key features of compulsions in obsessive-compulsive disorder is that they do not bring a sense of pleasure and, at best, only relieve anxiety.

Many patients who seek treatment for compulsive eating, gambling or masturbation feel unable to control their actions and are aware of the pathological nature of their behavior. But, unlike compulsions, such actions were previously felt to bring pleasure. Similarly, recurring thoughts of a sexual nature should not be classified as obsessions, but as overvalued ideas - if the patient either received some sexual satisfaction from these thoughts or tried to get reciprocal feelings from the object of these thoughts. A woman who claims to be haunted by thoughts of a former lover, despite the fact that she understands the need to break up with him, certainly does not suffer from obsessive-compulsive disorder. In this case, the diagnosis may sound like erotomania (the case depicted in the movie "Deadly Attraction"), pathological jealousy or simply unrequited love.

Painful experiences in depression, sometimes called "depressive chewing gum," may be mistakenly classified as obsessive thoughts. However, a patient with depression usually dwells on issues that worry most people (for example, personal dignity or other aspects of self-esteem), but the perception and interpretation of these events or issues is colored by the depressive background of mood. Unlike obsessions, painful experiences are usually defined by the patient as real problems. Another difference is that patients with depression are often preoccupied with past mistakes and remorse for them, while patients with obsessive-compulsive disorder are more likely to be preoccupied with recent events or premonitions of upcoming dangers.

The worries of patients with generalized anxiety disorder (GAD) can be distinguished from obsessions by their content and the absence of anxiety-relieving compulsions. The worries of patients with GAD are related to real-life situations (e.g., financial situation, professional or school problems), although the degree of worry about them is clearly excessive. In contrast, true obsessions usually reflect irrational fears, such as the possibility of inadvertently poisoning guests at a dinner party.

Particularly difficult is the differential diagnosis between some complex motor tics and compulsions (e.g., repetitive touching). By definition, tics can be distinguished from tic-like compulsions by the degree of voluntariness and meaningfulness of the movements. For example, when a patient repeatedly touches a certain object, each time feeling the urge to do so, this should be assessed as a compulsion only if the patient performed this action with a conscious desire to neutralize unwanted thoughts or images. Otherwise, this action should be classified as a complex motor tic.

It is not always possible to draw a clear line between the somatic obsessions of obsessive-compulsive disorder and the fears characteristic of hypochondria. One of the differences between these disorders, according to DSM-IV, is that patients with hypochondria are concerned about already suffering from a serious illness, while patients with obsessive-compulsive disorder are more likely to fear that they may become ill in the future. However, there are exceptions to this rule. Thus, some patients who fear that they have already become ill (for example, with AIDS) have clinical manifestations more characteristic of obsessive-compulsive disorder. Therefore, in order to diagnose obsessive-compulsive disorder in such cases, it is necessary to take into account additional signs, in particular, the presence of multiple compulsions (for example, a ritualized search for enlarged lymph nodes or excessively thorough hand washing). Seeking new doctors or repeat visits to them cannot be considered true compulsions. The presence of other obsessive-compulsive symptoms not associated with somatic concerns at present or in the anamnesis supports the diagnosis of obsessive-compulsive disorder. Unreasonable fears of the spread of the disease are also more characteristic of obsessive-compulsive disorder. Finally, the course of hypochondria is more subject to fluctuations than obsessive-compulsive disorder.

Panic attacks may be seen in obsessive-compulsive disorder, but the additional diagnosis of panic disorder should not be made unless panic attacks occur spontaneously. Some patients with obsessive-compulsive disorder have panic attacks triggered by feared stimuli - for example, if an attack occurs in a patient with an obsessive fear of contracting AIDS if he unexpectedly sees traces of blood. Unlike a patient with panic disorder, such a patient fears not the panic attack itself, but rather the consequences of infection.

There is ongoing debate about the relationship between "compulsive" self-injurious behaviors and OCD. At present, self-injurious behaviors (e.g., eye gouging, severe nail biting) should not be considered compulsions that would allow a diagnosis of obsessive-compulsive disorder. Similarly, behaviors that result in physical injury to others do not fit into the clinical framework of OCD. Although patients with OCD may have obsessive fears of committing an aggressive act in obedience to irrational stimuli, they usually do not carry them out in practice. When assessing a patient with aggressive ideas, the clinician must decide, based on clinical reasoning and the anamnesis, whether these symptoms are obsessions or fantasies of a potentially aggressive personality. If the patient produces these ideas voluntarily, they should not be considered obsessions.

The relationship between obsessive-compulsive disorder and compulsive personality traits often causes diagnostic problems. Historically, the distinction between obsessive-compulsive disorder and obsessive-compulsive personality disorder (OCPD) has always been blurred in the psychiatric literature. DSM-IV creates nosological confusion between Axis I anxiety disorder and Axis II personality disorder by offering similar terminology for both conditions. Although some patients with OCD have personality traits characteristic of OCPD - especially perfectionism (the desire for perfection), fixation on details, indecisiveness - most patients with OCD do not fully meet the criteria for OCPD, which also include stinginess in expressing feelings, miserliness, excessive preoccupation with work at the expense of leisure. Research shows that no more than 15% of patients with OCD can be diagnosed with OCPD (Goodman et al., 1994). The typical patient with OCPD is a workaholic and at the same time a strict taskmaster who despises sentimentality at home and insists that the family follow his wishes without question. Moreover, this person does not criticize his behavior and is unlikely to voluntarily seek help from a psychiatrist. Strictly speaking, the diagnostic criteria for OCPD do not include obsession and compulsion. Hoarding is usually considered a symptom of obsessive-compulsive disorder, although it is also mentioned as a criterion for OCPD. It is important to emphasize that if a person is interested in all the nuances of the work he does, is hardworking and persistent, this does not mean that he has OCPD. In fact, these personality traits are very useful in many situations, including medical training.

In this discussion, we have taken a conservative approach to the phenomenology of obsessive-compulsive disorder. Since obsessive-compulsive disorder represents the intersection of affective, psychotic, and extrapyramidal disorders, it is not surprising that in practice the clinician may have difficulty defining and classifying the disorder. Since standardized diagnostic criteria for mental illness must be reliable, their validity must be supported by empirical testing.

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