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
• Certain psychiatric conditions are diagnosed alongside OCD including; Anorexia nervosa, social anxiety disorder, bulimia nervosa, Tourette syndrome, compulsive skin picking, body dysmorphic disorder, and trichotillomania.
• There is some evidence of a link between drug addiction and obsessive compulsive disorder, according to some studies. Panic attacks are common among OCD sufferers. Although those with any anxiety disorder are at a higher risk of drug addiction (possibly as a coping mechanism for the increased levels of anxiety), drug addiction in obsessive compulsive patients may be a type of compulsive behavior rather than a coping mechanism.
• OCD sufferers are also more likely to suffer from depression. Mineka, Watson, and Clark (1998) proposed one explanation for the high rate of depression in OCD populations, stating that people with OCD (or any other anxiety disorder) may feel depressed due to a "out of control" type of feeling.
• PANDAS refers to childhood streptococcal infections (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections) could be responsible for some cases of OCD. Antibodies to streptococcal bacteria become involved in an autoimmune reaction. Though this theory is not conclusive, if it proves to be correct, there is reason to believe that OCD can be "caught" to some extent through strep throat exposure (just as one may catch a cold). If OCD is caused by bacteria, however, there is hope that antibiotics will be used to treat or prevent it in the future.
• OCD sufferers are aware that their thoughts and behaviors are irrational, but they feel compelled to follow them in order to avoid panic or dread. Untreated OCD is often regarded as one of the most vexing and frustrating of the major anxiety disorders because sufferers are consciously aware of their irrationality but powerless to push it away. Most OCD sufferers will hide their behaviors from others to avoid negative attention because they understand the abnormal nature of their compulsions. This, combined with the fact that the compulsions in some sufferers are entirely mental, has earned the disease the moniker "the secret illness."
• Everyone has unpleasant thoughts at some point in their lives, but these are usually justified concerns that disappear after a reasonable amount of time has passed. People with OCD find it difficult to get any disturbing thoughts out of their heads, which often leads to feelings of distress and anxiety[6]
• 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. Obsessive-compulsive disorder is frequently confused with obsessive compulsive personality disorder, which is a separate condition. However, the two are not the same condition. The former is ego dystonic, which means it is incompatible with the sufferer's self-concept. Ego dystonic disorders cause a great deal of distress because they go against a person's perception of himself. OCPD, on the other hand, is ego syntonic, which means that the individual accepts that the symptoms of the disorder are compatible with his or her self-image. Ego syntonic disorders, for the most part, are not distressing. People with OCD are often aware that their behavior is irrational, and they are unhappy with their obsessions, but they still feel compelled to follow them. Persons with OCPD, on the other hand, are unaware of anything abnormal about themselves; they will readily explain why their actions are rational, and convincing them otherwise is usually impossible. People with OCD are anxious; people with OCPD, on the other hand, enjoy their obsessions or compulsions. This is a significant distinction between these conditions.
• 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.