Day # 92: Clinical Pearls for Obsessive Compulsive Disorder (OCD)

Welcome back to our current theme of obsessive compulsive disorder (OCD). Up to this point we have covered core features of OCD, diagnostic criteria, epidemiology, risk factors, and pathogenesis. Today we are going to have a discussion on clinical pearls for OCD which will include tips on the clinical interview, validated questionnaires, and differential diagnosis. Let's get started.


Today's Content Level: Intermediate



CLINICAL INTERVIEW


Before we start our discussion it will be helpful to review the symptom criteria for obsessive compulsive disorder (OCD).

  • Presence of obsessions, compulsions, or both.

  • Time consuming (ex: take >1 hour per day) or cause significant distress or impairment (ex: social or occupational).

  • Obsessions = thoughts/urges/images that are recurrent/intrusive/undesired and cause distress/anxiety.

  • Compulsions = repetitive behaviors/mental rituals that the individual feels driven to perform (often in response to obsessions) aimed at preventing or reducing anxiety/distress.


•Keep in mind that the symptoms of OCD are often egodystonic, which means that their feelings/behaviors/symptoms are typically very distressing to them and are in conflict with what the patient wants. Patients with OCD may initially seek help from primary care and other non-psychiatric providers for help with the consequences of compulsions (ex: excessive washing).


Here are some sample questions to give you an idea for how you can screen for OCD symptoms:

  • Do you have repeated unwanted thoughts, images, or urges that are distressing to you?

  • How much of your time is occupied by obsessive thoughts? (YBOC #1)

  • How much do your obsessive thoughts interfere with your work, school, social, or other important role functioning? Is there anything that you don’t do because of them? (YBOC #2)

  • Are there things you feel you must do excessively or thoughts you must think repeatedly to feel comfortable or ease anxiety?

  • How would you feel if prevented from performing your compulsion(s)? How anxious would you become? (YBOC #8)


Other tips on the clinical interview include:

  • Clarify onset/duration of symptoms with patient and family. Remember to screen for obsessions AND compulsions AND the impact on their life.

  • Document if symptoms first occurred during childhood (worse prognosis), if they started acutely after a stressful trigger (better prognosis), and if they have had any symptom free periods after first experiencing symptoms (episodic course has a better prognosis).

  • Determine the specific themes of their obsessions/compulsions. See full discussion here, but common obsessive themes are contamination, doubt/danger, symmetry, violence/sexual, and morality/religion. Common compulsive actions include repetitive hand washing or disinfecting, avoidance, repeated questions, checking (safety), arranging, ordering, counting, touching, and tapping.

  • Screen for how their symptoms are affecting their function to include school/work/social/relationship difficulties, time engaged in obsessive/compulsive activities, poor self care, consequences of compulsions, etc.

  • Does the patient have insight regarding their obsessions/compulsions?

  • Psychiatric review of systems - particular attention to other anxiety disorders (~75%), MDD (~60%), eating disorders, personality disorders, autism spectrum disorder, and ADHD.

  • Substance use - determine if comorbid substance abuse, particularly alcohol.

  • Medical and family history - screen for recent illness and medical co-morbidities including tic disorders.

  • Risk assessment for suicide and aggression - risk/safety assessments covered in full here. Remember that patients with OCD are ten times more likely of dying by suicide than the general population. 1

  • Rating scales: Yale-Brown Obsessive-Compulsive Scale (YBOCS) is the gold standard for baseline OCD symptom severity and is also used to track response to treatment. It is a clinician rated scale and has high internal consistency. The Brief Obsessive–Compulsive Scale (BOCS) is also used.



DIFFERENTIAL DIAGNOSIS


•Before making any psychiatric diagnosis it is important to consider other related disorders and appropriately determine the best fit according to the patients symptoms, biological, psychological, and social factors.


Differential diagnosis:

  • Obsessive-compulsive personality disorder (OCPD): sometimes confused due to similar sounding name and superficial resemblance of symptoms, however they have distinct presentations and are easily distinguished. Individuals with OCPD have traits of perfectionism, obsession with details, and rule preoccupation. In contrast to OCD they do not have intrusive obsessions and compulsions and are not distressed by their symptoms. In other words individuals with OCPD are ego-syntonic, whereas patients with OCD experience their symptoms as ego-dystonic.

  • Depressive disorder: in some cases depression and OCD can be difficult to distinguish because they often co-occur (~60%), and major depression can be associated with "obsessional" ruminations (self-criticism, guilt, failures, worthlessness, regret, pessimism, etc.). There are no compulsions in depressive illness. The two conditions may best be distinguished by their courses, since obsessional thought patterns associated with depression are only found during a depressive episode, whereas true OCD persists despite remission of depression.

  • Generalized anxiety disorder (GAD): in GAD worries/anxiety tend to focus on a host of real-life problems without irrationality and there are not rituals associated with the worries.

  • Psychotic spectrum: grandiose/bizarre/persecutory delusions can lead to obsessive thoughts and compulsive behaviors in some patients with schizophrenia that may resemble an OCD pattern with poor/delusional insight. Keep in mind that patients with OCD can almost always acknowledge the unreasonable nature of their symptoms and psychotic illness are typically associated with other significant features not characteristic of OCD (ex: disorganized speech/behavior, negative symptoms, auditory hallucinations).

  • Posttraumatic stress disorder (PTSD): individuals may experience intrusive thoughts/images/urges that are distressing, however they occur as a result of actual traumatic events, unlike in OCD where future events/consequences are anticipated.

  • Tourette’s syndrome: associated with a pattern of recurrent vocal and motor tics that bears a resemblance to certain compulsions. These tics are often preceded by an urge/impulse that can resemble obsessions. Tics, however, are not in response to obsessional thoughts. Also remember that these conditions are related, and can co-occur in individuals and families. About ~90% of persons with Tourette's disorder have compulsive symptoms, and as many as ~67% meet the diagnostic criteria for OCD. 2

  • Body dysmorphic disorder / Eating disorder: obsessional thoughts and behaviors are restricted to perceived body imperfections, weight, food, and eating.

  • Illness anxiety disorder: can resemble the OCD related theme of contamination/illness, however in illness anxiety disorder the obsessional thoughts and behaviors are restricted to fears of illness and typically arise due to misinterpretation of regular body symptoms. Contrast this with OCD where fear stems from the possibility of external stimuli causing illness (ex: contamination).

  • Paraphilia: some aspects can resemble OCD with sexual images/thoughts, however remember that in paraphilia disorders the individuals will have arousal/pleasure whereas in OCD it is unwanted and will cause anxiety and distress.

  • Medical causes: as discussed previously, sudden onset OCD symptoms can occur in children in the context of infection with group A streptococci or other triggers (viral infections, drugs, or metabolic abnormalities) that trigger an autoimmune neuropsychiatric syndrome (PANDAS; PANS; CANS). A number of other primary medical disorders can produce syndromes that resemble OCD. Examples include Huntington's disease and Sydenham's chorea. New-onset OCD symptoms that develop after age 35 is rare (<15%) and should raise questions about potential neurological contributions.



CONCLUSION


I hope you enjoyed these clinical pearls. Today's lesson was geared towards a beginner/intermediate audience, but I hope all of the readers got something out of today's topic.


Resources for today's post include: Kaplan and Sadock's Synopsis of Psychiatry, DSM-V, First Aid for the Psychiatry Clerkship, and Pocket Psychiatry.















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