OCD stands for Obsessive Compulsive Disorder. Many people mistake OCD for other psychological traits such as Autism. Let us debunk a few of those. OCD is a combination of Obsessive and Compulsive traits that are either beyond the control of the individual or very difficult to resist.
Here, obsessive describes a thought or idea that seems to intrude upon the person’s mind and seems like it comes from elsewhere. It is not a pleasant thought or idea; and compulsive describes actions or rituals taken that are repetitive and perceived to prevent an unlikely or disconnected event, generally of a catastrophic nature. As mentioned before, it is a disorder because the thought intrusion and the requirement to do the action interfere in one’s life.
Diagnostic Criteria
There are two major systems for describing the differential diagnostic criteria for OCD, the USA based DSM and the United Nations, World Health Organisation based ICD.
It is important to recognise that differential diagnostic criteria allow one to hopefully pinpoint that the symptoms before the diagnostician are indeed this condition, and not some other similar looking condition. Hence the need for the minimum features for inclusion, and the aspects that exclude the person from this diagnosis.
In this case, the two most important elements are the inclusion of both an obsession and a compulsion that lead to sufficient intrusion into normal daily function that they are a disorder. Often misdiagnosis is due to one of these features not being included, or the diagnostician mistaking this someone’s presentation for this condition when it is one of the conditions listed in “Not Actually OCD“.
DSM V TR
The Diagnostic and Statistical Manual, version 5 Text Revision, is the manual for how to diagnose various mental health and neurological conditions released by the USA.
DSM TR Diagnostic Criteria [Criteria]
Disorder Class: Obsessive-Compulsive and Related Disorders
Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
- Recurrent and persistent thoughts, urges or images that are experienced, at some time during the disturbance, as intrusive, unwanted, and that in most individuals cause marked anxiety or distress.
- The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
- Repetitive behaviors (e.g., hand washing, ordering checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to the rules that must be applied rigidly.
- The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation. However, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
The obsessions or compulsions are time consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possession, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder); stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
The disturbance is not due to the direct physiological effects of a substance (e.g., drug of abuse, a medication) or a general medical condition.
Specify if:
- With good or fair insight: The individual recognizes that obsessive-compulsive beliefs are definitely or probably not true or that they may or may not be true.
- With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
Specify if:
- Tic related: The individual has a current or past history of a tic disorder.
Differential Diagnosis:
Obsessive-compulsive disorder must be distinguished from:
- Anxiety disorder due to a general medical condition.
- Substance-induced anxiety disorder
Recurrent or intrusive thoughts, impulses, images or behaviours may occur in the context of many other mental disorders. OCD is not diagnosed if the thoughts or activities is exclusively related to another disorder, such as
- Body dysmorphic disorder
- Specific or social phobia
- Hair pulling in trichotillomania
Worries or ruminations are mood-congruent and aspects of the condition and are not ego-dystonic in
- Major depressive episode
Worries are related to real-life circumstances in
- Generalised anxiety disorder
Distressing thoughts are exclusively related to fears based on misinterpretation of bodily symptoms in:
- Hypochondriasis
Ruminative delusional thoughts and stereotyped behaviours differ from obsessions and compulsions because they are not ego-dystonic and not subject to reality testing in:
- Schizophrenia
Movements are typically less complex and are not aimed at neutralising an obsession in:
- Tic disorder
- Stereotypic movement disorder
Activities are not considered to be compulsions because pleasure is usually derived in:
- Eating disorder
- Paraphilia
- Pathological gambling
- Alcohol dependence or abuse
Condition is not characterised by the presence of obsessions and compulsions and instead involves a pervasive pattern of preoccupation with orderliness and cleanliness and must begin by early adulthood in:
- Obsessive compulsive personality disorder
An additional diagnosis of OCD may be warranted if there are obsessions or compulsions not related to the other mental disorder.
Summary:
ICD 10
The ICD is the International Classification of Diseases, compiled and released by the World Health Organisation. OCD is considered in the category of “other anxiety disorders”.
ICD 10 Diagnostic Criteria [Click to expand]
ICD Code: F42. The essential feature [of OCD] is recurrent obsessional thoughts or compulsive acts. Obsessional thoughts are ideas, images, or impulses that enter the patient’s mind again and again in a stereotyped form. They are almost invariably distressing and the patient often tries, unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur. Usually, this behaviour is recognized by the patient as pointless or ineffectual and repeated attempts are made to resist. Anxiety is almost invariably present. If compulsive acts are resisted the anxiety gets worse.
Inclusive (same condition)
- Anankastic neurosis
- Obsessive-compulsive neurosis
Exclusive (different condition)
- obsessive-compulsive personality (disorder) (F60.5)
This traps for names that mean the same thing, and names that seem like they might be the same, but aren’t.
Obsessional thoughts:
- Distressing ideas, images, or impulses that enter a person’s mind repeatedly. Often violent, obscene, or perceived to be senseless, the person finds these ideas difficult to resist.
Compulsive acts or rituals:
- Stereotyped behaviours that are not enjoyable that are repeated over and over and are perceived to prevent an unlikely event that is in reality unlikely to occur. The person often recognises that the behaviour is ineffectual and makes attempts to resist it, but is unable to.
- Obsessional symptoms or compulsive acts or both must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities.
- Obsessional symptoms should have the following characteristics:
a. they must be recognised as the individual’s own thoughts or impulses.
b. there must be at least one thought or act that is still resisted unsuccessfully, even though others may be present which the sufferer no longer resists.
c. the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense).
d. the thoughts, images, or impulses must be unpleasantly repetitive.
Differential Diagnosis:
Differentiating between obsessive-compulsive disorder and a depressive disorder may be difficult because the two types of symptoms frequently occur together.
In an acute episode, presence should be given to the symptoms that developed first; when both types are present but neither predominates, it is usually best to regard the depression as primary.
In chronic disorders, the symptoms that most frequently persist in the absence of the other should be given priority.
Occasional panic attacks or mild phobic symptoms are no bar to the diagnosis.
However, obsessional symptoms developing in the presence of schizophrenia, Tourette’s syndrome, or organic mental disorder should be regarded as part of these conditions.
Although obsessional thoughts and compulsive acts commonly coexist, it is useful to be able to specify one set of symptoms as predominant in some individuals, since they may respond to different treatments.
Commentary on the Diagnostic Criteria
Not Actually OCD
- Sense of Correctness / Preference for Pattern
- A person who can’t stand a tile being out of place in the bathroom, for example, or some other broken pattern has a keen Sense of Correctness or Sense of Pattern. While a Sense of Correctness is common in with Autistic people, it is not exclusive to Autistic people, and is quite helpful when accuracy is needed in your job. It is not OCD.
- Hyperfixation on an interest
- Someone who hyperfixates on a particular interest, or person, or object, can seem obsessive, but this is not OCD either. Again, this is not uncommon with Autistic people, and again this character trait is not exclusive to Autistic people.
- Ritualistic Behaviour
- Ritualistic behaviour is a trait in common with OCD, but is not exclusive to OCD. Consider people who follow a particular religion that has specific set of rituals involved, or someone who just really likes the milk poured in their coffee first, not second, or maybe the other way around. Familiar patterns are commonly found with Autistic people, and again are not exclusive to Autistic people.
- Autism
- I have mentioned Autism a few times in connection to OCD. That is because in my experience, Autistic people are frequently mistaken for having OCD. While it is possible to be Autistic and have OCD, the OCD diagnosis has to be carefully done by not assuming a sense of correctness, fixation on details or comfort in patterns/rituals means OCD.
OCD is a combination of Obsessive and Compulsive traits that are either beyond the control of the individual or very difficult to resist. Here, obsessive describes a thought or idea that seems to intrude upon the person’s mind and seems like it comes from elsewhere. It is not a pleasant thought or idea; and compulsive describes actions or rituals taken that are repetitive and perceived to prevent an unlikely or disconnected event, generally of a catastrophic nature. As mentioned before, it is a disorder because the thought intrusion and the requirement to do the action interfere in one’s life.
OCD is a cousin to Anxiety, in that the pressure you feel to do your behaviour has a strong anxiety component to it. The person will feel very anxious about the future catastrophe and extreme anxiety and fear in the absence of doing the ritual that staves it off, or if the ritual is incomplete or no longer effective.
Some OCD is a learned behaviour, where a person fears an outcome that is generally beyond their control. They perform some kind of unusual action and in so doing, find a feeling of relief. As the fearful outcome has not actually been effected by this relieving action, the anxiety mounts again, so the action is repeated again with a soothing outcome. This cycle repeats and the training of the behaviour becomes stronger.
Treatments
Most OCD has a neurological component and some medications are quite effective at relieving the symptoms. Generally a combination of talking therapies to address the specific symptoms and behaviours is helpful and medication to relieve the neurological aspect is key.