What is the difference between the ruminations of depression and the obsessions of OCD?

Morbid preoccupations (sometimes called ruminations) of depression can be mislabeled as obsessional thinking. The depressed patient typically dwells on matters that are meaningful to most people (e.g., one’s accomplishments or other measures of self-worth), but the patient’s perceptions or interpretations of these events and issues are colored by the depressed mood.

In contrast to obsessions, depressed patients usually defend morbid preoccupations as realistic concerns. Another difference is that a depressed patient often is preoccupied with past mistakes and regrets, whereas the person with OCD is more concerned about recent events or averting future harm.

What is the difference between a worry and an obsession?

The worries of generalized anxiety disorder (GAD) can be distinguished from obsessions on the basis of the content and the absence of anxiety-relieving compulsions. The concerns of GAD involve real-life situations (e.g., finances and job or school performance), but the degree of apprehension about them clearly is excessive. In contrast, true obsessions usually reflect unrealistic fears, such as inadvertently poisoning dinner guests.

Can people with OCD also have panic attacks?

Panic attacks can be present in OCD, but an additional diagnosis of panic disorder should not be considered unless the attacks occur out of the blue. Some patients with OCD report the occurrence of panic attacks following exposure to a fearful stimulus, such as a trace of blood encountered by someone with an AIDS obsession. In contrast to panic disorder, the person in this example is not afraid of the panic attack; he or she is fearful of the consequences of contamination.

Is compulsive self-damaging behavior a form of OCD?

There continues to be debate regarding the relationship of “compulsive” self-damaging behaviors to that of the compulsions of OCD. At present, self-mutilation behaviors (e.g., severe nail biting) should not be considered as compulsions when making the diagnosis of OCD. Likewise, behaviors that actually result in physical harm to others are outside the bounds of OCD.

Are people with OCD who have unwanted thoughts about hurting someone at risk of acting on their fears?

If they truly have OCD, the answer is no. Patients with OCD may have unfounded fears about acting on violent and irrational impulses, but they do not act on them. That act of violence represents the most abhorrent idea they can imagine. In evaluating a patient with violent or horrific thoughts, the clinician must decide, based on clinical judgment and the patient’s history, whether these symptoms are obsessions or part of the fantasy life of a potentially violent person. If it is the latter, the patient needs help with maintaining self-control, not reassurance.

What is the difference between having an obsessive-compulsive personality and having OCD?

The relationship between OCD and compulsive traits or personality is the subject of many diagnostic questions. Historically, the psychiatric literature has often blurred the distinction between OCD and obsessive-compulsive personality disorder (OCPD). Psychiatry’s diagnostic system has perpetuated the confusion by selecting very similar diagnostic labels. Although some patients with OCD may have traits listed as criteria for OCPD (particularly perfectionism, preoccupation with details, indecisiveness), most OCD patients do not meet full criteria for OCPD, which also includes restricted expression of feelings, stinginess, and excessive devotion to productivity.

Studies have found that no more than 15 percent of patients with OCD meet full criteria for OCPD. The quintessential OCPD patient is the workaholic draconian supervisor who, at home, shows contempt for displays of tender emotions and insists that the family submit to his will. He does not have insight into his behavior and is not likely to seek psychiatric help on his own. Strictly defined obsessions and compulsions are not present in OCPD. Hoarding behavior is generally regarded as a symptom of OCD although it is listed as a criterion for OCPD. Being detail-oriented, hardworking, and productive is not the same as having OCPD; in fact, these traits are considered advantageous and adaptive in many settings.

When does normal checking end and pathological checking begin?

A diagnosis of OCD is warranted when the symptoms cause marked distress, are time-consuming (take more than an hour a day), or significantly interfere with the person’s functioning. A person who needs to check the door exactly six times before leaving the house but is otherwise free of obsessive-compulsive symptoms may have a compulsive symptom, but does not have OCD. The impairment associated with OCD ranges from mild (little interference in functioning) to extreme (incapacitated).

OCD probably contributed to the death of the billionaire Howard Hughes. Several accounts suggest that Hughes suffered from fears of contamination. He tried to create a germ-free environment that isolated him from contact with the outside world. Instead of performing compulsions himself, he had the means to hire others to perform elaborate rituals on his behalf. Paradoxically, his grooming and self-care deteriorated as more and more routine activities were curtailed. His self-imposed dietary restrictions further hastened the decline in his physical condition. Some severely ill patients with OCD require hospitalization — it can be a life-saving intervention.