28/9/2014 Obsessive-Compulsive Disorder Clinical Presentation

http://emedicine.medscape.com/article/1934139-clinical 1/4
Obsessive-Compulsive Disorder Clinical Presentation
Author: William M Greenberg, MD; Chief Editor: David Bienenfeld, MD more...
Updated: Apr 24, 2014
History
OCD is diagnosed primarily by presentation and history. The age of onset and any history of tics (either current or
past) should be established.
Elements that are covered when obtaining a patients history should also include details relating to the nature and
severity of symptoms.
[30]
Questions regarding the nature and severity of obsessive symptoms
Have you ever been bothered by thoughts that do not make any sense and keep coming back to you even when you
try not to have them?
When you had these thoughts, did you try to get them out of your head? What would you try to do?
Where do you think these thoughts were coming from?
Questions regarding the nature and severity of compulsive symptoms
Has there ever been anything that you had to do over and over again and could not resist doing, such as repeatedly
washing your hands, counting up to a certain number, or checking something several times to make sure you had
done it right?
What behavior did you have to do?
Why did you have to do the repetitive behavior?
How many times would you do it and how long would it take?
Did these thoughts or actions take more time than you think makes sense?
What effect did they have on your life?
Psychiatric review of systems and comorbidities
Individuals with OCD frequently have other psychiatric comorbid disorders, prominently including major depressive
disorder, alcohol and/or substance use disorders, other anxiety disorders, impulse control disorders (eg,
trichotillomania, skin-picking), and Tourette and tic disorders. (Perhaps 40% of individuals with Tourette disorder will
have OCD). Therefore, in taking a psychiatric history, the focus should be on identifying such comorbidities, seeking
to elicit the following:
Mood and anxiety symptoms
Somatoform disorders, especially hypochondriasis and body dysmorphic disorder
Eating disorders
Impulse control disorders, especially kleptomania and trichotillomania
ADHD
Childhood-onset OCD may have a higher rate of comorbidity with Tourette disorder and ADHD.
The co-occurrence of schizophrenia and OCD is problematic for a variety of reasons. Not infrequently, individuals
with schizophrenia do seem to have significant OC symptoms (sometimes, ironically, caused or exacerbated by the
use of the very effective antipsychotic clozapine, whereas adjunctive antipsychotics may lessen treatment-resistant
OC symptoms in those who do not have schizophrenia).
When OC symptoms are present in someone who has schizophrenia, they may meet criteria for a diagnosis of OCD,
but such patients often respond poorly to the usual OCD treatments, and perhaps OCD in schizophrenia has a
different pathophysiology.
Consider the following:
Family history of OCD, Tourette disorder, tics, ADHD, and other psychiatric diagnoses
Current or past substance abuse or dependence
Antecedent infections, especially streptococcal and herpetic infection
Common obsessions include the following:
Contamination
Safety
Doubting one's memory or perception
Scrupulosity (need to do the right thing, fear of committing a transgression, often religious)
Need for order or symmetry
Unwanted, intrusive sexual/aggressive thought
Common compulsions include the following:
Cleaning/washing
Checking (checking locks, stove, iron, safety of children)
Counting/repeating actions a certain number of times or until it "feels right"
Arranging objects
Touching/tapping objects
Hoarding
Confessing/seeking reassurance
List making
28/9/2014 Obsessive-Compulsive Disorder Clinical Presentation
http://emedicine.medscape.com/article/1934139-clinical 2/4
Interpersonal relationships
OCD symptoms can interact negatively with interpersonal relationships, and families can become involved with the
illness in a counterproductive way. For example, a patient with severe doubting obsessions may constantly ask
reassurance for irrational fears from family members or significant others; constantly providing this can inhibit the
patient from making attempts to work on their behavioral disturbances).
Physical Examination
Skin findings in OCD may include the following:
Eczematous eruptions related to excessive washing
Hair loss related to trichotillomania or compulsive hair pulling
Excoriations related to neurodermatitis or compulsive skin picking
Contributor Information and Disclosures
Author
William M Greenberg, MD Medical Director, Mental Health Association of Rockland County; Professor, St
George's University School of Medicine; Private Practice
William M Greenberg, MD is a member of the following medical societies: American Medical Association and
American Psychiatric Association
Disclosure: Nothing to disclose.
Chief Editor
David Bienenfeld, MD Professor, Departments of Psychiatry and Geriatric Medicine, Wright State University,
Boonshoft School of Medicine
David Bienenfeld, MD is a member of the following medical societies: American Medical Association, American
Psychiatric Association, and Association for Academic Psychiatry
Disclosure: Wolters Kluwer Royalty Author
Additional Contributors
Mohammed A Memon, MD Chairman and Attending Geriatric Psychiatrist, Department of Psychiatry,
Spartanburg Regional Medical Center
Mohammed A Memon, MD is a member of the following medical societies: American Association for Geriatric
Psychiatry, American Medical Association, and American Psychiatric Association
Disclosure: Nothing to disclose.
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College
of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Medscape Salary Employment
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