Obsessive-compulsive disorder: diagnosis

Diagnostic criteria for obsessive-compulsive disorder

A. Presence of obsessions and / or compulsions

Obsessions are continuously repetitive thoughts, impulses or images that at some point in time are perceived as violent and inadequate and cause severe anxiety or anxiety. These thoughts, impulses or images are not just excessive anxiety associated with real problems. A person tries to ignore or suppress these thoughts, impulses or images or to neutralize them with other thoughts or actions. A person realizes that obsessive thoughts, impulses or images are the product of his own mind (rather than being instilled from outside)

Compulsions are repetitive actions or mental acts performed under the influence of obsessions or in accordance with rigidly established rules. These actions or mental acts are carried out in order to prevent or reduce discomfort or prevent some undesirable events or situations. At the same time these actions or mental acts do not have a rational explanation or are clearly redundant

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

C. Obsessions or compulsions cause severe discomfort, take considerable time (more than 1 hour per day) or significantly disrupt the life of the patient

D. In the presence of another disorder related to axis I, the content of obsessions or compulsions is not limited to the intrinsic themes, for example:

• nutritional concerns (eating disorders)
• pulling out of hair (trichotillomania)
• concern with appearance (dysmorphophobia)
• concern about taking medication (eating disorder)
• concern about the possible presence of a serious disease (hypochondria)
• concern with sexual impulses and fantasies (paraphilia)

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

Frequent types of obsessions and compulsions

Obsessions

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

Compulsions

• Excessive actions associated with cleaning or washing
• Excessive checking (eg locks or condition of electrical appliances)
• Excessive actions to restore order or align objects in a certain sequence
• RETAILED ACCOUNT
• Repeated daily activities (for example, passing through the door)
• Collecting or collecting useless items
• Internal ("mental") rituals (for example, uttering meaningless words to themselves to ward off an undesirable image)

[1], [2], [3], [4], [5], [6]

Differential diagnosis of obsessive-compulsive disorder

Before definitive diagnosis of obsessive-compulsive disorder, it is necessary to conduct differential diagnosis with several other common conditions. As already noted, the presence of criticism to its state (at the time of the examination or according to anamnestic data) distinguishes obsessive-compulsive disorder from primary psychotic disorders. Obsessions can be characterized by irrational fears, but, unlike delirium, they are not fixed, unconvincing opinions. To distinguish the obessia from psychotic symptoms, for example, from delusions of influence (when the patient, for example, claims that "someone else sends me telepathic messages"), one should take into account: patients with obsessive-compulsive disorder believe that obsessive thoughts are born in their own head. Obsessions are sometimes mistakenly regarded as auditory hallucinations, when a patient, especially a child, calls them "a voice in my head", but, unlike a psychotic patient, such a patient estimates them as their own thoughts.

There are certain differences in the literature - both popular and special - due to inaccurate use of the terms "obsession" and "compulsion." Previously, clear criteria for obsession and compulsions, necessary for the diagnosis of obsessive-compulsive disorder, were presented. It is especially important to remember that one of the key features of compulsion in obsessive-compulsive disorder is that they do not bring pleasure feelings and at best only alleviate anxiety.

Many patients who seek treatment for "compulsive" food, gambling or masturbation, feel the inability to control their actions and realize the pathological nature of their behavior. But, unlike compulsions, such actions were felt some time ago as bringing pleasure. Similarly, repetitive thoughts of sexual content should be qualified not as obsessions but as supervalued ideas, if the patient either received some sexual satisfaction from these thoughts or tried to obtain from the object of these thoughts the reciprocal feelings. A woman who claims to be haunted by thoughts of a former lover, despite the fact that she understands the need to part with him, definitely does not suffer obsessive-compulsive disorder. In this case, the diagnosis may sound like erotomania (the case depicted in the movie "Death Attraction"), pathological jealousy or simply unrequited love.

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

The anxiety of patients with generalized anxiety disorder (STU) can be distinguished from obsessions by content and the absence of anxiety-facilitating compulsions. The concern of patients with GAD is associated with real life situations (for example, financial situation, professional or school problems), although the degree of experience on this issue is clearly excessive. In contrast, true obsessions usually reflect irrational fears, for example, due to the possibility of unintentional poisoning of guests during a dinner party.

Special difficulties are presented by a differential diagnosis between some complex motor tics and compulsions (for example, repeated touches). By definition, ticks can be distinguished from tick-like compulsions according to the degree of arbitrariness and meaningfulness of movements. For example, when a patient again and again touches a particular object, every time feeling the urge to this action, this should be regarded as compulsion only if the patient performed this action with a conscious desire to neutralize undesirable thoughts or images. Otherwise, this action should be qualified as a complex motor tick.

It is not always possible to draw a clear line between somatic obsessions in obsessive-compulsive disorder and the fears inherent in hypochondria. One of the differences between these disorders, according to DSM-IV, is that patients with hypochondria are concerned that they already have a serious illness, whereas patients with obsessive-compulsive disorder are more likely to fear that they may get sick in the future. However, there are exceptions to this rule. Thus, in some patients who are afraid that they have already fallen ill (for example, AIDS), clinical manifestations, more characteristic for obsessive-compulsive disorder, are noted. 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, ritualized search for enlarged lymph nodes or excessively careful hand washing). Appeals to new doctors or repeated visits to them can not be considered as true compulsions. The presence, at present or in the anamnesis, of other obsessive-compulsive symptoms, not associated with somatic fears, supports the diagnosis of obsessive-compulsive disorder. Unreasonable fears of spreading the disease are also more characteristic of obsessive-compulsive disorder. Finally, the course of hypochondria is more prone to fluctuations than obsessive-compulsive disorder.

Panic attacks can be observed with obsessive-compulsive disorder, but an additional diagnosis of panic disorder should not be exhibited if panic attacks do not occur spontaneously. In some patients with obsessive-compulsive disorder, panic attacks occur under the influence of frightening stimuli - for example, if an attack occurs in a patient with obsessive fear of contracting AIDS if he suddenly sees blood traces. Unlike a patient with panic disorder, such a patient fears not the most panic attack, but rather the consequences of infection.

Discussions continue on the relationship between "compulsive" self-injurious actions and ROC. To date, self-damaging actions (for example, ejection of eyes, severe nipping of nails) should not be considered as compulsions, allowing to diagnose obsessive-compulsive disorder. Similarly, actions that result in physical damage to other persons also do not fit into the clinical framework of OCD. Although patients with OCD may have obsessive fears of an aggressive action, obeying irrational stimuli, they usually do not implement them in practice. When examining a patient with aggressive ideas, the doctor should decide, based on clinical thinking and history, whether these symptoms are obsessions or fantasies of a potentially aggressive person. If these ideas are produced by the patient arbitrarily, then they should not be considered as an obsession.

The relationship between obsessive-compulsive disorder and compulsive personality traits often causes diagnostic problems. From a historical perspective, the distinction between obsessive-compulsive disorder and obsessive-compulsive personality disorder (OCD) in psychiatric literature has always been blurred. DSM-IV creates a nosological confusion between an anxiety disorder related to axis I and a personality disorder related to axis II, offering similar terminology for both states. Although some patients with OCD have personality traits that are characteristic of OCDL-primarily perfectionism (the pursuit of impeccability), jamming on details, indecisiveness-most patients with OCD do not fully meet the criteria of the ACL, which also include stinginess in expressing feelings, stinginess, excessive enthusiasm for work to the detriment of leisure. Studies show that no more than 15% of patients with OCD can be diagnosed with OKLL (Goodman et al., 1994). A typical patient with OCDL is a workaholic and at the same time a strict overseer who despises the home and insists that the family implicitly follow his wishes. Moreover, this person does not show criticism to his behavior and is unlikely to turn to the psychiatrist for help himself. Strictly speaking, the diagnostic criteria of the RCLN do not provide for an obsession and compulsion. Accumulation is usually seen as a symptom of obsessive-compulsive disorder, although it is also referred to as an OCDL criterion. It is important to emphasize that if a person is interested in all the nuances of the work being done, hardworking and hard at work - this does not mean that he has an OKRL. In fact, these personality traits are very useful in many situations, including when teaching medicine.

As part of this discussion, we have followed a conservative approach to the phenomenology of obsessive-compulsive disorder. Because obsessive-compulsive disorder is the area of contact between affective, psychotic and extrapyramidal disorders, it is not surprising that in practice it is not easy for a clinician to identify and qualify a particular disorder. Since standardized diagnostic criteria for mental illnesses must be reliable, their validity should be confirmed by empirical verification.

[7], [8], [9], [10], [11]