Obsessive-Compulsive Disorder Diagnosis

  • Diagnosis

    Obsessive-compulsive disorder (OCD) is a psychiatric disease characterized by obsessions, repetitive (usually unpleasant) thoughts and compulsions, and ritualistic behaviors. Obsessive-compulsive disorder (OCD) usually starts in childhood or early adulthood. It is characterized by anxiety-provoking thoughts, images, or ideas (obsessions) and/or ritualistic behaviors such as counting, repeated checking, or handwashing (compulsions). People with OCD engage in compulsive behaviors to try to rid themselves of disturbing obsessive thoughts.

    Symptoms can usually be brought under control with medications or behavioral therapy. Even with appropriate treatment, most people with the disorder experience symptoms that wax and wane throughout life.

    OCD is the fourth most common psychiatric disorder after phobias, substance abuse, and major depression. In the US, 1% to 2% of the population suffers from OCD. Most people experience their first symptoms around age 20. Few people have an initial episode of OCD after the age of 35.

    While the exact cause of OCD is unknown, in some cases genetics may be involved. If you have a close relative with OCD, you are more likely to develop OCD yourself Table 01.

    Table 1.  Possible Causes of OCD

    Genetics
    Infection (e.g. streptococcal infection, von Economo's encephalitis, Sydenham's chorea)
    Lesions in specific areas of the brain
    Oversensitive or malfunctioning brain circuits
    Head trauma (occasionally)
    Brain tumor (in rare cases)
    Drug effects
    Anxiety
    Issues of control, aggression, and sexuality resulting from excessively strict parenting

    A small percentage of children develop OCD after a streptococcal infection. Sometimes after a streptococcal infection, a child's immune system will attack normal healthy cells (autoimmune response). It is thought that this response causes OCD symptoms. An episode of OCD that begins this way may disappear within a few months, or may persist longer.

    People with OCD have abnormal levels of brain chemicals and abnormal activity in certain areas of the brain Figure 01. Certain areas of the brain that are associated with anxiety, habit formation, and skill learning (called the limbic lobe, the caudate nucleus, and the orbital frontal cortex) are abnormal in people with OCD.

    In addition, levels of the brain chemical serotonin are thought to be responsible for OCD. Most medications used to treat OCD have an effect on serotonin levels.

    Some theories point to psychological reasons for OCD.

    Click to enlarge: Areas of Abnormal Brain Activity in OCD

    Figure 01. Areas of Abnormal Brain Activity in OCD

    People with OCD have obsessions and/or compulsions Table 02. If you have OCD, you will have obsessions, compulsions, or both. Obsessions and compulsions are unpleasant, and are usually accompanied by high levels of anxiety. Obsessions are ideas, thoughts, and images that occur over and over. Common examples include fears of contamination by germs, fear that loved ones will be harmed, or worries that things are not in order.

    Compulsions are behaviors that people perform in order to get rid of their obsessions. These may manifest as frequent handwashing, repeatedly checking to make sure that doors are locked, or mental exercises such as habitual counting, praying, or repeating special phrases.

    Table 2.  Common Obsessions and Compulsions

    Type Characteristics Percent of cases
    Obsessions
    Contamination Incessant worries about dirt, germs, and contagion 37.8%
    Fear of harming yourself or others Recurrent thoughts that something has not been done properly, even when you know it has 23.6%
    Symmetry Feelings that certain things must always be in a certain place, position, or order 10.0%
    Somatic Worries about the shapes of body parts or about bodily functions 7.2%
    Religious Blasphemous thoughts or concern about right and wrong 5.9%
    Sexual Unwanted or repulsive thoughts about sexual acts 5.5%
    Hoarding Urge to collect objects that have no inherent or sentimental value 4.8%
    Unacceptable urges Often of a violent nature 4.3%
    Miscellaneous ? 1.0%
    Compulsions
    Checking rituals Checking locks, doors, appliances, or other objects 28.2%
    Washing/cleaning rituals Excessive handwashing, showering, bathing, toothbrushing, grooming, or household cleaning 26.6%
    Miscellaneous compulsions e.g., compulsion to perform a task very slowly 11.8%
    Repeating Touching certain objects, going in and out of a door, putting clothes on and taking them off 11.1%
    Mental rituals Repetitive thoughts regarding obsessions, such as silently praying or counting in one's head 10.9%
    Ordering Placing objects in a certain position 5.7%
    Hoarding/collecting Acquiring and collecting objects that have no inherent or sentimental value 3.5%
    Counting ? 2.1%

    Adults with OCD usually realize that their thoughts or behaviors are irrational or excessive. Most adults with OCD are aware that their obsessions and compulsions are extreme and unrealistic. This feature often distinguishes people with OCD from those who are psychotic and cannot differentiate fantasy from reality. People with OCD are usually ashamed of their problem, realize that their fears and behaviors are irrational, and try to hide their symptoms from others.

    Obsessions or compulsions are time-consuming, or significantly interfere with normal daily life. Activities associated with obsessions and compulsions take up more than one hour a day, or significantly interfere with work, social activities, relationships, or a normal daily routine.

    Other psychiatric conditions have symptoms similar to those of OCD, but are different in important ways. People with depression, generalized anxiety disorder, and hypochondria also have obsessive thoughts. However, unlike individuals with OCD, they usually do not consider their worries to be absurd or unreasonable, and have no rituals to attempt to block such thoughts.

    People with anorexia nervosa may have obsessions with they know are unreasonable, and may also have rituals surrounding eating. However, because these symptoms are specific only to this one issue, anorexia nervosa is not considered to be a generalized problem like OCD.

    Obsessive-compulsive personality disorder is another disorder that has overlapping traits with OCD. People with this personality disorder tend to be workaholics, and are preoccupied with orderliness, rules, and perfectionism. They need orderliness and exactness in every aspect of their life, and usually do not have the insight to recognize that they may have a problem.

    Younger people are more at risk for OCD. OCD usually first appears during childhood or young adulthood. Boys usually get OCD earlier than girls. The average age for boys is between 6 and 15 years of age. Girls usually begin having symptoms in puberty. Both sexes frequently have their first episode in their early twenties.

    Your doctor will ask you questions about your health history, perform a physical exam, and may ask you to fill out a standard questionnaire. It is important that you tell your doctor about all of your symptoms.People with OCD are often aware that their obsessions and compulsions are irrational, but are reluctant to admit having them because they are ashamed, or are fearful of being labeled as crazy. Therefore, people sometimes go for years before being diagnosed or treated appropriately.

    One tool sometimes used during diagnosis is the Yale-Brown Obsessive Compulsive Scale and Symptom Checklist, which is a questionnaire designed to diagnose and evaluate the severity of your OCD.

    Your doctor will also look for physical signs of OCD that may reflect nervous tics. For example, your doctor might look for bald patches or dry and chafed skin that suggests excessive handwashing.

  • Prevention and Screening

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