Course and Prognosis

If OCD is untreated, the course is usually chronic, often with waxing and waning symptoms. Some individuals have an episodic course, and a minority of patients have a deteriorating course. Without treatment, remission rates in adults are low (e.g., 20% for those re-evaluated 40 years later); however, up to 40% of individuals with onset of OCD in childhood or adolescence may experience remission by early adulthood.

The pattern of symptoms in adults can be stable over time, but symptoms are much more variable in children. Differences in the content of obsessions and compulsions between children and adults likely reflect content appropriate to different developmental stages

(e.g., higher rates of sexual and religious obsessions in adolescents than in children; higher rates of harm obsessions [e.g., fears of catastrophic events, such as death or illness to self or loved ones] in children and adolescents than in adults).

Differential Diagnosis

Several other conditions can appear with obsessive thoughts and therefore need to be considered when making the diagnosis. OCD is also frequently misdiagnosed (see Table 3.1).

Tic Disorder: A tic is a sudden, rapid, recurrent, non-rhythmic motor movement or vocalization (e.g., eye blinking, throat clearing). Tics are typically less complex than compulsions and are not aimed at neutralizing obsessions. Distinguishing between complex tics and compulsions can be difficult. Whereas compulsions are usually preceded by obsessions, tics are often preceded by premonitory sensory urges. Some individuals have symptoms of both OCD and a Tic Disorder, in which case both diagnoses may be warranted.

Stereotypic Movement Disorder (SMD): Stereotypic Movement Disorder (SMD) involves repetitive engagement in motor activities, including head banging, body rocking, self-biting, and hand waving that begin in the early developmental period. Oftentimes these compulsive behaviors are associated with developmental delays although they also occur in young typically developing children. Stereotypic Movement Disorders are differentiated from OCD in that they are fixed, localized, and purposeless (i.e., they are not done in response to an obsessional thought).

Psychotic Disorders: Some individuals with OCD have poor insight or even delusional OCD beliefs. This is not the same as a psychotic disorder or schizophrenia. People with OCD have obsessions and compulsions (distinguishing their condition from delusional disorder) and do not have other features of schizophrenia or schizoaffective disorder (e.g., hallucinations or formal thought disorder). Many people with OCD, however, have been incorrectly diagnosed and treated for psychotic disorders.

Generalized Anxiety Disorder: Recurrent thoughts, avoidant behaviors, and repetitive requests for reassurance can also occur in anxiety disorders. The recurrent thoughts that are present in generalized anxiety disorder (i.e., worries) are usually about real-life concerns, whereas the obsessions of OCD usually do not involve real-life concerns and can include content that is odd, irrational, or of a seemingly magical nature. In addition, compulsions are often present and usually linked to the obsessions.

Specific Phobia: Like individuals with OCD, individuals with specific phobia can have a fear reaction to specific objects or situations (e.g., heights, flying, spiders). In specific phobia, however, the feared object is usually much more circumscribed, and rituals (i.e., compulsions) are not present.

Social Anxiety Disorder: In social anxiety disorder, the feared objects or situations are limited to social interactions, and avoidance or reassurance seeking is focused on reducing this social fear.

Anorexia Nervosa: OCD can be distinguished from anorexia nervosa in that in OCD the obsessions and compulsions are not limited to concerns about weight and food.

Bipolar disorder: Although bipolar disorder appears to be a rare co-morbidity in patients with OCD (2% current rate), when present, it poses a therapeutic dilemma. Specifically, agents (including SRIs) documented to be helpful in the treatment of OCD also have the risk of exacerbating mood symptoms and precipitating mania. Lithium, anti-epileptics, or atypical antipsychotics may therefore be needed to counteract the activating effects of SRIs required to treat OCD. From a drug interaction perspective, SRIs and antipsychotic medications are generally safe to co-prescribe.

Body Dysmorphic Disorder: Body Dysmorphic Disorder, a preoccupation with a slight or imagined defect in appearance, co-occurs with OCD at the rate of approximately 15%. When present, Body Dysmorphic Disorder co-morbidity has been associated with greater depressive symptoms and more illicit drug use. Although Body Dysmorphic Disorder is not associated with more severe OCD, the fact that patients with both disorders have more severe depressive

TABLE 3.1 Frequent Misdiagnoses in Patients with OCD

Misdiagnosis

Reason for Misdiagnosis

Depression

Depression often coexists with OCD (25%-30%) and the depression is diagnosed but the OCD missed

Social Phobia or avoidant personality disorder

Because social anxiety is a common consequence of OCD (40%), OCD is often misdiagnosed as Social Phobia or avoidant personality disorder

Agoraphobia

Some patients with OCD are housebound and these patients can be misdiagnosed with agoraphobia

Psychotic

disorder

Because the beliefs associated with OCD can be of delusional intensity, some patients are diagnosed with a psychotic disorder

Compulsive sexual behavior or pedophilia

OCD patients who suffer from sexual obsessions will describe intrusive thoughts about sexual activities, sometimes with children. Clinicians unfamiliar with the “taboo” obsessive subtype of OCD will often misdiagnose these patients with sexual addiction or pedophilia

Substance Use Disorder

Chemical dependency in OCD patients is often a response to untreated OCD. Because certain psychoactive substances, such as opiates, may be enticing for individuals with OCD as they may potentially alleviate obsessional symptoms, patients with OCD may develop a Substance Use Disorder. The Substance Use Disorder is then usually diagnosed instead of the underlying OCD

Obsessive

Compulsive

Personality

Disorder

Focusing on the behavior, such as perfectionism or list-making, without assessing whether it is ego-syntonic or dystonic or whether it involves the need for order, symmetry, and arranging may result in misdiagnosis of OCD as OCPD

TABLE 3.1 Continued

Misdiagnosis

Reason for Misdiagnosis

Attention

Deficit

Hyperactivity

Disorder

OCD patients with “incompleteness” or “just right” symptoms often display low motivation, repeating rituals, which often resemble procrastination, and difficulties with attention and focus

symptoms and are more likely to use drugs means that treatment strategies need to focus on these related aspects of care.

 
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