What other conditions are associated with OCD?

Depression is a common consequence of OCD. About 75% of patients with OCD report that they have suffered from symptoms of depression, including feeling sad, hopeless, irritable, cranky; having trouble concentrating or making simple decisions; unable to enjoy favorite activities; problems sleeping; changes in appetite or weight; decreased sex drive; and suicidal thoughts. Sometimes patients with OCD do not seek treatment until depression becomes overwhelming. The development of depression is usually secondary to having obsessive-compulsive symptoms.

Several lines of evidence suggest a relationship between OCD and the childhood-onset disorder, Tourette’s Syndrome (TS). Both multiple motor and one or motor tics need to be present to make a diagnosis of TS. About 50% of patients with TS develop obsessive-compulsive symptoms during the course of their illness. One of the most dramatic and distressing symptoms of TS is involuntary cursing (coprolalia). Interestingly, some people with pure OCD worry about blurting out obscenities but never actually do. Studies that have looked at the families of people with TS have found a much higher rate of OCD than would be expected in the general population.

OC-Spectrum Disorders

Some conditions have been referred to as Obsessive-Compulsive (OC)-Spectrum Disorders on the basis of clinical similarities to OCD (i.e., recurrent disturbing ideas and/or irresistible urges), higher than expected co-occurrence with OCD, and favorable response to SRIs (the medications that tend work in OCD). Two of the most frequently mentioned OC-Spectrum Disorders are Body Dysmorphic Disorder and Trichotillomania.

The central feature of Body Dysmorphic Disorder (BDD) is a preoccupation with an imagined or inconsequential defect in physical appearance. The clinical characteristics of BDD and OCD are similar in many respects. Both disorders are characterized by recurrent, disturbing, and intrusive thoughts. In the case of OCD, the content may involve a variety of different subjects (e.g., contamination or fear of acting on unwanted impulses). The concerns of BDD, by definition, always involve a minor or imagined physical abnormality. The most frequent concerns relate to the face and head (e.g., nose size, facial shape, and skin texture, wrinkles, or blemishes); less frequently, other aspects of the body are the focus of attention (e.g., breast asymmetry and foot size). BDD is often accompanied by repeated checking (e.g., examining the imagined defect in the mirror) or touching; behaviors that are very similar to those found in classic OCD. Instead of engaging in checking rituals, some patients with BDD may endeavor to avoid all reminders of their flawed appearance by removing mirrors and covering all reflective surfaces in their home.

In contrast to OCD, patients with BDD usually are convinced that their irrational preoccupations are justifiable. However, when presented with contradictory evidence (e.g., graphs showing that one's measured head size is within normal limits), a BDD patient will acknowledge that there is no objective support for the concern. Thus, the overvalued ideas of BDD fall somewhere between obsessions and delusions with respect to how strongly false beliefs are held to be valid.

The key features of trichotillomania are 1) recurrent hair pulling; 2) mounting tension preceding the act; and 3) pleasure or relief accompanying the act. The sites most often affected are the scalp, eyebrows, eyelashes, extremities, and pubic hair. Some patients eat their hair (trichotillophagia). The bald spots can be obvious and may require wigs or extensive makeup to camouflage. Rather than feeling gratification following hair-pulling, patients are more likely to experience regret over the disfigurement or frustration with their loss of self-control.

Although hair-pulling can occur during periods of heightened stress, patients seem most vulnerable during times of idleness like while watching TV, reading, or driving home from work. This observation has led to the suggestion that trichotillomania is better characterized as a habit disorder than as an impulse control disorder. The behavior therapy technique (habit reversal) that seems most beneficial for treating trichotillomania was originally developed for maladaptive habits. Some authors have proposed that pathological grooming is the common thread running between trichotillomania, compulsive nail-biting (onychophagia), and some forms of OCD.

Despite similarities between trichotillomania and OCD, the differences between these conditions are equally noteworthy. While early reports of trichotillomania emphasized its co-occurrence with OCD and favorable response to SRIs, later studies indicate that trichotillomania often exists in isolation and that medication treatment often fails. In contrast to OCD, many more women than men are affected. The hypothesis that OCD and trichotillomania are mediated by shared brain pathways was called into question after brain imaging studies revealed differences between the two disorders.

How do you distinguish OCD from other conditions?

Much of the confusion regarding the differences between OCD and other conditions stems from the many different uses of the words obsession and compulsion. To be true symptoms of OCD, obsessions and compulsions are strictly defined as:

• OBSESSIONS are unwelcome and distressing ideas, thoughts, images or impulses that repeatedly enter your mind. They may seem to occur against your will. They may be repugnant to you, you may recognize them as senseless, and they may not fit your personality or value system.

• COMPULSIONS are behaviors or acts that you feel driven to perform even though you may recognize them as senseless or excessive. At times, you may try to resist doing them but this may prove difficult. You may experience anxiety that does not diminish until the behavior is completed.

A key point to remember is that the compulsions of OCD are not considered inherently pleasurable: at best, they relieve anxiety.

As a contrasting clinical example, although patients seeking treatment for "compulsive" eating, gambling or masturbating may feel unable to control behaviors they acknowledge as deleterious, at some time in the past, these acts were experienced as gratifying. By the same token, sexual "obsessions" are relabeled as preoccupations when it is evident that the person either derives some sexual satisfaction from these thoughts or the object of these thoughts is coveted. A woman who says she's "obsessed" with an ex-boyfriend even though she knows she should let him alone is probably not suffering from OCD.

The presence of insight distinguishes OCD from a psychotic illness, such as schizophrenia (although some people with schizophrenia also have obsessive-compulsive symptoms). Patients with psychosis actually lose touch with reality and their perceptions may become distorted. Obsessions may involve unrealistic fears, but unlike delusions, they are not fixed, unshakable false beliefs. The symptoms of OCD may be bizarre, but the patient recognizes their absurdity. Occasionally, an obsession can be misdiagnosed as an auditory hallucination when the patient, especially a child, refers to it as "the voice in my head" even though it's recognized as his/her own thoughts.

Distinguishing between certain complex motor tics and certain compulsions (e.g., repetitive touching) can be a problem. By convention, tics are distinguished from "tic-like" compulsions (e.g., compulsive touching or blinking) based on whether the patient attaches a purpose or meaning to the behavior. For example, if a patient feels an urge to repeatedly touch an object, this would be classified as a compulsion only if it was preceded by a need to neutralize an unwanted thought or image; otherwise it would be labeled a complex motor tic. Tics are often identified by "the company that they keep": if a complex motor act is accompanied by clear-cut tics (e.g., head jerks), it is most likely a tic itself.