Diagnostic Formulation: Why Anne Has OCD


Independent practice, Kate Morrison LLC, Sandy, Utah

Key Points

  1. The main components of OCD are obsessions, compulsions, and negative impacts on the client’s life. However, you don’t need both obsessions and compulsions present in order to diagnose OCD.
  2. The main difference between OCD and illness anxiety disorder is that OCD has a broader set of symptoms. Moreover, illness anxiety disorder tends to be more specific, in that the person worries about experiencing symptoms or having an illness.
  3. For the differential diagnosis, it’s also important to rule out anxiety disorders such as GAD and phobias. These conditions don’t usually have the compulsion component as with OCD.
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OCD Diagnosis

Jazmin:  How can clinicians get to an OCD diagnosis?

Dr. Morrison: The main elements you’re looking for are obsessions and compulsions. However, both aren’t needed for a diagnosis.

On Anne’s obsession side, we see an explicit fear of the death of her child. What we’re looking for beyond that fear is how she responds to those obsessions. Does she find them distressing? Does she try to neutralize them in any way? And that’s where you can start to see some of the compulsion side, where she’s engaging in repetitive behaviors to manage or decrease the likelihood of her daughter’s death.

The third part of OCD is to see if those symptoms impact her life. You hear through the case how her obsessions and compulsions negatively impact her relationship with her spouse and her family, as well as her sleep and overall well-being.

Jazmin: We have these three conditions in Anne’s case. The first one is Anne’s obsessions regarding her child being harmed. The second part is the compulsions, where she’s constantly checking that her child is breathing or that she’s safe. And finally, the third part is that her quality of life has decreased in the past year.
However, is the client required to have both the obsessions and the compulsions? Or are there any cases in which we only have one of those?

Dr. Morrison:  According to the DSM, you only need to have obsessions or compulsions. However, I find that most people have both. They usually do some mental or physical activity to manage those obsessions. And often, people don’t always catch the mental compulsions. For Anne, it’s clear that she has some clear external or physical compulsions, but it’s not necessary for the precise diagnosis of OCD.

Differential Diagnosis

Jazmin: Which other clinical conditions should therapists consider when making the differential diagnosis? For example, Anne could also have some symptoms of illness anxiety disorder.

Dr. Morrison: There’s a lot of overlap between OCD and other symptoms. I will preface this by saying I’m not a huge fan of the diagnostic system because it has a lot of flaws. One of them is that there can be an overlap in symptoms. Moreover, there can be problems when we’re looking just at the topography of the behavior, which means we only address how the behavior looks and not how it is or what its function is.

Let’s start with illness anxiety disorder regarding Anne’s case. One of the ways you can distinguish between illness anxiety and OCD is that the first condition tends to be much more specific, where the person worries about experiencing symptoms or having an illness. Even though Anne is concerned about contamination and diseases, her ultimate fear is her daughter’s potential death. Also, in OCD there can be a broader set of symptoms. So you might see fears of disease or death, but there might also be concerns about thoughts of being a pedophile. And so, when you start to see a broader set of fears, that can indicate that it’s more likely to be OCD.

Moreover, to rule out other conditions, we also want to look at the onset of these symptoms. For example, suppose Anne has been through a traumatic event in the past, where she lost a child from SIDS, and her new child is presenting the same signs. In that case, Anne’s obsessions and symptoms are more likely related to PTSD and trauma concerns than OCD, as they started since the traumatic event happened.

Jazmin: The main difference between OCD and illness anxiety disorder is that OCD has a broader set of symptoms. In Anne’s case, it’s not only about the fears of harm or diseases but her daughter’s potential death. Moreover, we need to be looking specifically at each patient and their situation. We don’t only have to guide ourselves by the diagnostic system but also take into account the history of each client.

Dr. Morrison: Another condition we must look for is other forms of anxiety, such as generalized anxiety and phobias. Clients with phobias tend to be specific about one particular fear or object. And generalized anxiety doesn’t always have the compulsion component, but there can be behaviors that look like compulsions. So again, there’s overlap with these conditions, and the treatments we apply for them address similar objectives.

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Diagnostic Formulation: Why Anne Has OCD