Sections

Presentation

History

OCD is diagnosed primarily by presentation and history. The age of onset and any history of tics (either current or past) should be established.

Elements that are covered when obtaining a patient’s history should also include details relating to the nature and severity of symptoms.^[32]

Questions regarding the nature and severity of obsessive symptoms

Have you ever been bothered by thoughts that do not make any sense and keep coming back to you even when you try not to have them?

When you had these thoughts, did you try to get them out of your head? What would you try to do?

Where do you think these thoughts were coming from?

Questions regarding the nature and severity of compulsive symptoms

Has there ever been anything that you had to do over and over again and could not resist doing, such as repeatedly washing your hands, counting up to a certain number, or checking something several times to make sure you had done it right?

What behavior did you have to do?

Why did you have to do the repetitive behavior?

How many times would you do it and how long would it take?

Did these thoughts or actions take more time than you think makes sense?

What effect did they have on your life?

Psychiatric review of systems and comorbidities

Individuals with OCD frequently have other psychiatric comorbid disorders, prominently including major depressive disorder, alcohol and/or substance use disorders, other anxiety disorders, impulse control disorders (eg, trichotillomania, skin-picking), and Tourette and tic disorders. (Perhaps 40% of individuals with Tourette disorder will have OCD). Therefore, in taking a psychiatric history, the focus should be on identifying such comorbidities, seeking to elicit the following:

Mood and anxiety symptoms
Somatoform disorders, especially hypochondriasis and body dysmorphic disorder
Eating disorders
Impulse control disorders, especially kleptomania and trichotillomania
ADHD

Childhood-onset OCD may have a higher rate of comorbidity with Tourette disorder and ADHD.

The co-occurrence of schizophrenia and OCD is problematic for a variety of reasons. Not infrequently, individuals with schizophrenia do seem to have significant OC symptoms (sometimes, ironically, caused or exacerbated by the use of the very effective antipsychotic clozapine, whereas adjunctive antipsychotics may lessen treatment-resistant OC symptoms in those who do not have schizophrenia).

When OC symptoms are present in someone who has schizophrenia, they may meet criteria for a diagnosis of OCD, but such patients often respond poorly to the usual OCD treatments, and perhaps OCD in schizophrenia has a different pathophysiology.

Consider the following:

Family history of OCD, Tourette disorder, tics, ADHD, and other psychiatric diagnoses
Current or past substance abuse or dependence
Antecedent infections, especially streptococcal and herpetic infection

Common obsessions include the following:

Contamination
Safety
Doubting one's memory or perception
Scrupulosity (need to do the right thing, fear of committing a transgression, often religious)
Need for order or symmetry
Unwanted, intrusive sexual/aggressive thought

Common compulsions include the following:

Cleaning/washing
Checking (checking locks, stove, iron, safety of children)
Counting/repeating actions a certain number of times or until it "feels right"
Arranging objects
Touching/tapping objects
Hoarding
Confessing/seeking reassurance
List making

Interpersonal relationships

OCD symptoms can interact negatively with interpersonal relationships, and families can become involved with the illness in a counterproductive way. For example, a patient with severe doubting obsessions may constantly ask reassurance for irrational fears from family members or significant others; constantly providing this can inhibit the patient from making attempts to work on their behavioral disturbances).

Physical Examination

Skin findings in OCD may include the following:

Eczematous eruptions related to excessive washing
Hair loss related to trichotillomania or compulsive hair pulling
Excoriations related to neurodermatitis or compulsive skin picking

Differential Diagnoses

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Obsessions	Commonly Associated Compulsions
Fear of contamination	Washing, cleaning
Need for symmetry, precise arranging	Ordering, arranging, balancing, straightening until "just right"
Unwanted sexual or aggressive thoughts or images	Checking, praying, “undoing” actions, asking for reassurance
Doubts (eg, gas jets off, doors locked)	Repeated checking behaviors
Concerns about throwing away something valuable	Hoarding

Obsessive-Compulsive Disorder Clinical Presentation

History

Questions regarding the nature and severity of obsessive symptoms

Questions regarding the nature and severity of compulsive symptoms

Psychiatric review of systems and comorbidities

Interpersonal relationships

Physical Examination

References

Tables

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