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ACT for OCD: Diagnostic Criteria and Differential Diagnosis

By Kate Morrison, Ph.D.

This video is part of our upcoming online course about ACT for OCD.

Highlights

  • For an OCD diagnosis, the individual needs to show obsessions, compulsions, or both.
  • The obsessions, compulsions, or both need to be interfering with their life.
  • Rule out common conditions: anxiety disorders, delusions, PTSD, suicidal or homicidal ideation, and other medical conditions.
  • Assess the sudden onset of OCD symptoms to rule out medical conditions, such as autoimmune disorders.
  • Separate between true risk of harm and OCD, especially in perinatal OCD.

 

Transcript

Now, looking at the diagnostic criteria for OCD, obsessions and compulsions don’t have to both be present. It can be one or the other.

And with children, they may not be able to identify what the obsession is, or what the intention of their behavior or the repetitive behavior or compulsions, what the purpose of those would be. And so for children, if you’re just seeing repetitive behaviors, that may be sufficient for a diagnosis of OCD.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276. 

And as I mentioned, you will want to rule out 4 other conditions and that includes any effects of a substance or medication or medical conditions. One of the medical conditions is referred to as PANDAS, which is an autoimmune condition that can suddenly bring on symptoms of OCD. And so this is something that you would want to rule out if someone is having a sudden burst in symptoms because OCD tends to be more gradual. And with PANDAS, the onset can be overnight. And so if someone has had an infection recently, then that is something that you’d certainly want them to be assessed for by a medical professional.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276. 

The other things that you will want to rule out—or the things that you specifically want to rule out—are delusions. So, obsessions and delusions can be on the same spectrum and there can be some gray area within those. One thing that can help separate those apart from each other is that the person with obsessions tend to have more insight into the belief and to see that it’s something that’s inconsistent or they don’t believe that that’s actually happening, but it still brings them distress, where on the further end of the delusion spectrum, they may not have that level of insight.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276. 

And there’s not a clear distinction here. Like I said, there can be a gray area, but what’s nice is, when we’re using ACT, that distinction is less important. And we will talk about this in future modules because these are both going to be treated as internal experiences, so it’s okay if there’s that gray area there.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276. 

You’ll also want to rule out anxiety disorders. So, these can include generalized anxiety, health anxiety, social anxiety, and also specific phobias. And so for these, what you want to be looking for is, specifically, those repetitive behaviors. If those are present, it’s a good indicator that it is OCD, also if there are obsessions that cut across a couple of different themes that help separate out from things, like emetophobia or fear of vomiting.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276. 

PTSD and OCD can also look similar. For example, where there’s a lot of overlap between these two can be in moments or situations where the belief is related to a fear of harm. So, if someone has a fear of having someone break into their home and sexually assaulting them, that could be OCD related. But if this person has also had a history of someone breaking into their home and sexually assaulting them, those behaviors might be more related to the traumatic experience that they went through.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276. 

So within OCD, what you see more often is repetitive behaviors or repetitive checking compulsions. And so this could look like someone locks the door to make sure no one can come in at night, but then they’re not quite sure they locked it and they’re staring at it and they can’t quite tell if it’s locked. And so they do it again and then they do it again and then they do it again. And then they go lie down and they are thinking, “I don’t know if I actually locked that.” And they get back up and go check it again. With PTSD, we more often see that they locked it and then that’s usually the end of it.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276.

The other way that you can separate this out is if the symptoms that you’re seeing were present prior to the trauma. That can give some indication that OCD may be present, even if PTSD is also present. And if the intrusive thoughts and the repetitive behaviors, if there are themes of those that are present beyond the trauma theme. So, if they also have fears of contamination in addition to fears of someone coming into their home.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276. 

You’ll also want to rule out when someone has thoughts of harming themselves and thoughts of harming other people, and having these obsessions. You want to rule out if they are having true suicidal or homicidal ideation. Now, this is obviously something that you would want to assess clearly. And when it is an obsession, clients are pretty clear about denying their intention. They find these thoughts to be extremely distressing.

They engage in these elaborate systems and behaviors to block themselves from acting on these thoughts. However, there can be a gray line at times, especially if there is, like, suicidal ideation along with thoughts of obsessive thoughts about harm.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276. 

And so you’ll want to separate these out. But what I really recommend doing is sharing this with them at the beginning of treatment. So I do this when I am discussing my limits to confidentiality and I let them know what conditions would need to be met for me to break our agreement of confidentiality. And I do this because many patients have had poor experiences with sharing with medical professionals that they have these thoughts of harm to their children or harm to other people.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276. 

There are some particularly horrific examples with perinatal OCD where the parents have had thoughts of harm to their infant and have had their child taken away for periods of time—had the cops called on them when they were at their doctor’s office—because the person that they were meeting with just had a lack of awareness about what OCD is.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276. 

And so I share this with them, initially, to say I would need to report something or contact proper authorities if I hear you say, “I’m going to go do this thing when I leave the session” rather than if you’re just having thoughts about these. If you’re having thoughts about it, I’m not concerned about that. That’s something that’s pretty common with OCD. And when you say that to someone, you can see that they’re visibly relaxed when you do that because they are rightly so afraid to share these thoughts with other people because many people don’t understand what OCD is.

References

Abramowitz, J. S., Schwartz, S. A., Moore, K. M., & Luenzmann, K. R. (2003). Obsessive-compulsive symptoms in pregnancy and the puerperium: A review of the literature. Journal of Anxiety Disorders, 17(4), 461–478.

Challacombe, F. L., & Wroe, A. L. (2013). A hidden problem: Consequences of the misdiagnosis of perinatal obsessive-compulsive disorder. British Journal of General Practice, 63(610), 275–276. 

For an OCD diagnosis, the individual will need to be showing obsessions, compulsions, or both of those. And either the obsessions or the compulsions or both need to be interfering with their life in some way. And that can be through how time consuming that they are or can just be leading to problematic issues that occur in their life, and that they cannot be better explained by a medical or other mental health condition.

And some of the other things that you would want to rule out are some common conditions. Those would be anxiety disorders, delusions, PTSD, either suicidal or homicidal ideation, rather than it being obsessions, and other medical conditions that could lead to that.

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