Differentiating Obsessions in OCD from Other Conditions
Depressive ruminations. The clinician needs to be able to differentiate obsessions in OCD from the depressive ruminations seen in mood disorders. When asked about constant intrusive thoughts, the depressed person with ruminations will also answer affirmatively. The clinician can usually separate these concepts by asking whether the content of the obsessive thoughts involves negative self-assessment, castigating oneself about the past, or generally about low self-worth—all general symptoms of depressive ruminations. In addition, the person will likely meet other criteria for depression. Also, the clinician should ask the patient whether these thoughts occur only in the context of the other depressive symptoms. This is again evidence for depressive ruminations if they answer affirmatively. It should be noted that OCD (and related conditions) often co-occur with depression and that patients may well meet diagnostic criteria for both depression and an OC related disorder. In these cases, OCD patients will meet criteria for depression (and experience a number of ruminations to do with negative self worth and failure), along with more generalized intrusive thoughts (such as relating to contamination).
Anxious worries. Generally anxious people may also endorse the question of intrusive thoughts. The distinction between general anxiety and OCD, however, is that usually anxiety-related thoughts relate to real-life events such as employment, financial, or relationship issues. In addition, there are no compulsive behaviors that coincide with general anxiety thoughts.
Psychotic ruminations. Although individuals with OCD may intermittently lack insight into their beliefs (e.g., they feel convinced that they can contract HIV from the doorknob), this lack of insight usually fluctuates. In addition, they do not have other psychotic symptoms or other delusional beliefs outside of their obsession. This is unlike schizophrenia, in which the person may have other psychotic symptoms such as hallucinations and there is rarely any insight unless treated.
Weight obsessions. If the person endorses intrusive thoughts, the clinician should ask whether the thoughts are about weight and fear of obesity. The thoughts seen in eating disorders often look very similar to those of OCD. Since treatments for eating disorders and OCD differ, however, making this distinction is important.
Perfectionism. This may be the most difficult topic when the person expresses problems with not meeting a vision of perfection that they feel they should. They will endorse intrusive thoughts but they generally like the thoughts, even though they may feel frustrated with not achieving all they desire. The trait of obsessive perfectionism may be indicative of Obsessive Compulsive Personality Disorder (OCPD). If this trait is endorsed, the clinician should screen for the other symptoms of OCPD. If OCPD is present, these thoughts are unlikely to remit, and it is not even clear that should be the goal. Instead, the goal is most properly conceptualized as reducing the intensity of the thoughts to allow less distress for the person, not to eliminate traits that in fact may be advantageous to some degree.
Severity of the OCD Symptoms
When examining someone with OCD, it is important to establish a baseline severity so that improvement or lack thereof can be assessed in subsequent visits. The clinician could use a standardized severity instrument (e.g., the Yale-Brown Obsessive Compulsive Scale [YBOCS]) which rates the severity of both obsessions and compulsions. In lieu of such an instrument, however, there are some basic questions (based on the YBOCS) that offer important severity information.
- • In general for the past week, how much time in an average day do the obsessions occupy?
- • In general for the past week, how much time in an average day do the compulsive behaviors occupy?
- • Describe how the obsessions and compulsions interfere with your life currently.
- • Describe the distress the obsessions and compulsions currently cause you.
These questions should then be asked at each visit to monitor symptom change.