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Diagnosis: The Signs and Symptoms of Obsessive-Compulsive Disorder (OCD)

Matthew D. Jacofsky, Psy.D., Melanie T. Santos, Psy.D., Sony Khemlani-Patel, Ph.D. & Fugen Neziroglu, Ph.D. of the Bio Behavioral Institute, edited by C. E. Zupanick, Psy.D.

hand washingAs the name implies, the obsessive-compulsive disorder (OCD) is the kingpin of the entire category of disorders called obsessive-compulsive and related disorders. Obsessions are repetitive and distressing thoughts, urges, or imagery that are experienced as uncontrollable. Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to obsessions. These obsessions and compulsions are at times consuming (an hour or more per day). They create significant distress and/or interfere with a person's functioning.

Ordinarily, obsessional thoughts, images, or impulses are not about typical, everyday things. Common obsessional themes are:

  • extreme and unrealistic concerns about contamination, and/or need for cleanliness;
  • repeated and excessive doubts, such as wondering if a door was left unlocked, or if a coffee pot was turned off;
  • the need to have things in a precise and particular order or arrangement (with intense distress or distractions if this order or arrangement is disturbed);
  • aggressive or horrific impulses, such as a desire to harm one's child; and
  • disturbing sexual imagery, such as intrusive pornographic imagery.

These are the most common types of obsessions. However, any distressing, repetitive, uncontrollable, and unwanted thought can form an obsession.

Obsessions are not the same as hallucinations, which are a hallmark symptom of several other, rather severe, mental disorders (psychotic disorders). When someone is experiencing a hallucination, they are unaware that what they are experiencing is not real and a creation of their own mind. In contrast, people who experience obsessions recognize that the obsessions are generated by their own mind. This is true, even for people with limited insight.

People with OCD try to ignore or neutralize these intrusive thoughts, images, or impulses. In other words, they attempt to counteract or block these distressing and repetitive thoughts. One way people try to block or neutralize obsessions is with compulsions. Compulsions are recurring behaviors (such as repeatedly checking appliances or repeatedly washing hands) or repetitive mental acts (such as counting or praying) that an individual feels they must do in response to an obsession.

Compulsions serve to avoid or reduce distress. In some cases, a person may believe they must perform compulsive acts in order to prevent something terrible from happening. For example, a person may touch things only after they have all been bleached. They believe they must perform this act in order to prevent disease.

Children's OCD symptoms are similar to adults. However, children may not ask for help. Therefore, it becomes their caregivers' responsibility to identify these symptoms and seek treatment. While an adult may be able to tell you their rationale for the compulsive act ("I'm washing my hands so I don't contract HIV"), a child may not be able to articulate this. Even though children may be unable explain the reason for their compulsive behavior, they may still try to minimize their compulsions in front of others.

The diagnosis of OCD includes an insight specifier to further refine the diagnosis. While it is true that obsessions and compulsions are based on inaccurate or irrational beliefs, people differ in terms of whether they recognize this fact. In other words, some people readily recognize and accept that obsessions and are not sensible. Nonetheless, this insight is insufficient to prevent the obsessions and compulsions. Other people lack this insight. They firmly cling to their distorted beliefs, despite evidence that refutes the validity of such beliefs. This lack of insight is important with respect to treatment. In general, people with poor or absent insight have a poorer prognosis for a full and complete recovery. However, the degree of insight can be quite variable. In one moment, a person may be well aware their beliefs are irrational. Later, when directly faced with a fearful situation, this insight may vanish completely.

There are three insight specifiers: 1) good/fair, 2) poor, or 3) absent/delusional. An insight specifier rates a person's degree of insight about their disorder-related beliefs. For instance, some people realize that checking the locks, dozens of times throughout the day, is unlikely to affect whether or not a burglary occurs. This indicates good/fair insight. Someone else may believe that without this degree of vigilance a burglary is nearly certain to occur. This indicates poor insight. A small minority of people are absolutely convinced a burglary is certain to occur without rigorous checking of locks. These people demonstrate absent/delusional insight.

The presence of absent/delusional insight requires very careful diagnostic evaluation. Delusional thoughts are also a symptom of another category of rather severe disorders, called psychotic disorders. Therefore, is very important that the absent/delusional insight in an OCRD is not misdiagnosed as psychotic disorder merely because of delusional beliefs. Proper diagnosis is essential to receiving the right treatment. For example, the medications used to treat psychotic disorders are very different than for OCRDs. If the symptoms of OCRDs are misdiagnosed as a psychotic disorder, a person might receive the wrong kind of medication.

About 30% of people with OCD will also have a tic disorder at some point in their lives. For this reason, OCD has a tic specifier. This diagnostic distinction is made because people with tic disorder have different presentations of OCD than those who never had a tic disorder. Tic disorder is more common in males with childhood onset OCD (APA, 2013).