Obsessive-compulsive disorder differential diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Priyanka Kumari, M.B.B.S[2] Sonya Gelfand, Abhishek Reddy, Kiran Singh, M.D. [3]

Overview

The differential diagnosis of obsessive-compulsive disorder (OCD) includes tics, mood and anxiety disorders, and other compulsive behaviors, such as trichotillomania or neurodermatitis.

Differential Diagnosis

• OCD should be differentiated from the following conditions:
  • Anxiety disorders
    • Generalized anxiety disorder (GAD)
    • Social anxiety
  • Eating disorders
    • Anorexia nervosa
  • Major depressive disorder(MDD)
  • Obsessive-compulsive personality disorder
  • Body dysmorphic disorder
  • Autism spectrum disorder
  • Other compulsive-like behaviors
    • Sexual behavior
    • Gambling
    • Substance use
  • Other obsessive-compulsive and related disorders
    • Body dysmorphic disorder
    • Trichotillomania
  • Psychotic disorders
  • Tics (in tic disorder) and stereotyped movements or Tourette syndrome
• People with OCD may be diagnosed with other conditions, such as anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome, compulsive skin picking, body dysmorphic disorder, and trichotillomania.
• There is some research demonstrating a link between drug addiction and obsessive compulsive disorder as well. Many who suffer from OCD suffer from panic attacks. There is a higher risk of drug addiction among those with any anxiety disorder (possibly as a way of coping with the heightened levels of anxiety), but drug addiction among obsessive compulsive patients may serve as a type of compulsive behavior and not just as a coping mechanism.
• Depression is also extremely prevalent among sufferers of OCD. One explanation for the high depression rate among OCD populations was posited by Mineka, Watson, and Clark (1998), who explained that people with OCD (or any other anxiety disorder) may feel depressed because of an "out of control" type of feeling.
• Some cases are thought to be caused at least in part by childhood streptococcal infections and are termed PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections). The streptococcal antibodies become involved in an autoimmune process. Though this idea is not set in stone, if it does prove to be true, there is cause to believe that OCD can to some very small extent be "caught" via exposure to strep throat (just as one may catch a cold). However, if OCD is caused by bacteria, this provides hope that antibiotics may eventually be used to treat or prevent it.
• OCD sufferers are aware that such thoughts and behavior are not rational, but feel bound to comply with them to fend off feelings of panic or dread. Because sufferers are consciously aware of this irrationality but feel helpless to push it away, untreated OCD is often regarded as one of the most vexing and frustrating of the major anxiety disorders. Due to their insight into the abnormal nature of their compulsions, most OCD sufferers will meticulously hide their behaviors from others in order to avoid negative attention. This, combined with the fact that with some sufferers the compulsions are purely mental, gives the disease its often used nickname, "the secret illness".
• Everyone may experience unpleasant thoughts at one time or another, though these are usually warranted concerns that are short-lived and fade after an adequate time period has lapsed. People who suffer with OCD struggle to get any disturbing thoughts out of their mind, often resulting in the inevitable feeling of distress and anxiety.
• Obsessive-compulsive disorder is often confused with the separate condition obsessive compulsive personality disorder. The two are not the same condition, however. OCD is ego dystonic, meaning that the disorder is incompatible with the sufferer's self-concept. Because disorders that are ego dystonic go against an individual's perception of his/herself, they tend to cause much distress. OCPD, on the other hand, is ego syntonic—marked by the individual's acceptance that the characteristics displayed as a result of this disorder are compatible with his/her self-image. Ego syntonic disorders understandably cause no distress. Persons suffering from OCD are often aware that their behavior is not rational and are unhappy about their obsessions but nevertheless feel compelled by them. Persons with OCPD, by contrast, are not aware of anything abnormal about themselves; they will readily explain why their actions are rational, and it is usually impossible to convince them otherwise. Persons with OCD are ridden with anxiety; persons who suffer from OCPD, by contrast, tend to derive pleasure from their obsessions or compulsions. This is a significant difference between these disorders.
• Equally frequently, these rationalizations do not apply to the overall behavior, but to each instance individually; for example, a person compulsively checking their front door may argue that the time taken and stress caused by one more check of the front door is considerably less than the time and stress associated with being robbed, and thus the check is the better option. In practice, after that check, the individual is still not sure, and it is still better in terms of time and stress to do one more check, and this reasoning can continue as long as necessary.
• Some OCD sufferers exhibit what is known as overvalued ideas. In such cases, the person with OCD will truly be uncertain whether the fears that cause them to perform their compulsions are irrational or not. After some discussion, it is possible to convince the individual that their fears may be unfounded. It may be more difficult to do ERP therapy on such patients, because they may be, at least initially, unwilling to cooperate. For this reason OCD has often been likened to a disease of pathological doubt, in which the sufferer, while not usually delusional, is often unable to fully realize what sorts of dreaded events are reasonably possible and which aren't.
• OCD is different from behaviors such as gambling addiction and overeating. People with these disorders typically experience at least some pleasure from their activity, whereas OCD sufferers do not actively want to perform their compulsive tasks, and experience no pleasure from doing so.