Differentials
Obsessive-compulsive personality disorder (OCPD)
SIGNS / SYMPTOMS
OCPD is more common among males; it is characterised by a preoccupation with orderliness, details, rules, organisation, or schedules, to the degree that the point of the activity is lost.
Perfectionism, hoarding, workaholism, and mental and interpersonal control occur at the expense of flexibility, openness, and efficiency.
There is an absence of obsessions and compulsions in OCPD. The condition may involve discomfort if things are sensed not to have been done completely.[51]
The greater discomfort (alterations in anxiety or affect) associated with obsessive-compulsive disorder (OCD) seems to be the clinical factor that best distinguishes between the two disorders.
Insight into behaviour or symptoms is usually absent.
INVESTIGATIONS
History is used to distinguish OCPD from OCD.
Assessment of OCPD may be conducted through structured interviews for diagnosis such as the Structured Clinical Interview for DSM-II (SCID-II), the Diagnostic Interview for Personality Disorders (DIPD), and the Structured Interview for DSM-III Personality Disorders (SIDP).[52][53]
Clinically, the ego-dystonic nature of obsessions may also distinguish obsessions from the ego-syntonic traits of OCPD.
Body dysmorphic disorder (BDD)
SIGNS / SYMPTOMS
Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.[2] Excessive repetitive behaviours or mental acts are performed in response to this preoccupation.[2]
INVESTIGATIONS
Separate diagnosis of obsessive-compulsive disorder (OCD) should be made only if the obsessions or compulsions are not restricted to concerns about appearance.[2]
Somatic symptom disorder
SIGNS / SYMPTOMS
Excessive thoughts, feelings, or behaviours related to somatic symptoms or associated health concerns.[2]
INVESTIGATIONS
Recurrent ideas about somatic symptoms or illness are less intrusive than in obsessive-compulsive disorder (OCD), and individuals do not perform the associated repetitive behaviours aimed at reducing anxiety that occur in OCD.[2]
Illness anxiety disorder (hypochondriasis)
SIGNS / SYMPTOMS
A preoccupation with having or acquiring serious illness. The individual performs excessive health-related behaviours, such as repeatedly checking for signs of illness, or demonstrates maladaptive avoidance, such as avoiding medical appointments.[2]
INVESTIGATIONS
Preoccupations in illness anxiety disorder are focused on having a disease, whereas in obsessive-compulsive disorder (OCD), the thoughts are intrusive and are usually focused on fears of getting a disease in the future. Individuals with OCD will likely have other concerns in addition to those about contracting disease.[2]
Delusional disorder
SIGNS / SYMPTOMS
A false belief that is firmly sustained and based on incorrect inference about reality; compulsions may be absent.[54]
INVESTIGATIONS
Obsessive-compulsive disorder (OCD) can share features with delusional disorders, such as magical thinking; in fact, it has also been conceptualised by cognitive theories as a form of belief disorder similar to a delusion or an overvalued idea that is a product of distorted reasoning processes.[55]
Severe social phobia
SIGNS / SYMPTOMS
Severe social phobia can mimic the anxiety related to obsessive-compulsive disorder (OCD).
INVESTIGATIONS
None.
Panic disorder
SIGNS / SYMPTOMS
Panic disorder can mimic the anxiety related to obsessive-compulsive disorder (OCD).
INVESTIGATIONS
None.
Autism spectrum disorder
SIGNS / SYMPTOMS
Autism spectrum disorder presents with impaired social communication and social interaction with restricted and repetitive patterns of behaviour, interests, or activities.
Symptoms are present in the early developmental period and are not better explained by intellectual development disorder or global developmental delay.[2]
INVESTIGATIONS
In obsessive-compulsive disorder (OCD), compulsions are typically performed in response to intrusive thoughts about contamination, organisation, or sexual or religious themes. In autism spectrum disorder, repetitive behaviours classically include more stereotyped motor behaviours or insistence on routines, which may be perceived as pleasurable and reinforcing.[2]
Hoarding disorder
SIGNS / SYMPTOMS
Hoarding disorder is characterised by a persistent difficulty in discarding or parting with possessions, regardless of actual value, because of a perceived need to save items and distress associated with discarding them.[2]
INVESTIGATIONS
In obsessive-compulsive disorder (OCD), excessive acquisition is usually not present. If it is present, accumulated items are typically more unusual, such as fingernail cuttings and hair. Accumulation of these sorts of items is very uncommon in hoarding disorder.
A dual diagnosis of OCD and hoarding disorder may be made if severe hoarding appears concurrently with other typical symptoms of OCD but is judged to be independent from these symptoms.[2]
Trichotillomania (hair-pulling disorder)
SIGNS / SYMPTOMS
Trichotillomania is recurrent pulling out of one’s hair, resulting in hair loss.[2]
INVESTIGATIONS
A diagnosis of trichotillomania should be not given in an individual with obsessive-compulsive disorder (OCD) and symmetry concerns, i.e., if an individual pulls out hairs as part of their symmetry rituals.[2]
Excoriation (skin-picking) disorder
SIGNS / SYMPTOMS
Excoriation is recurrent picking at one’s own skin, resulting in skin lesions.[2]
INVESTIGATIONS
A diagnosis of excoriation disorder should not be given in an individual with obsessive-compulsive disorder (OCD) if excessive washing compulsions, in response to contamination obsessions, lead to skin lesions.[2]
Substance-/drug-induced obsessive-compulsive or related disorder
SIGNS / SYMPTOMS
Symptoms of an obsessive-compulsive or related disorder, such as obsessions, compulsions, skin picking, and hair pulling predominate. Symptoms are attributable to the effects of a drug (or a drug of abuse), and develop during or soon after substance intoxication or withdrawal or after exposure to the substance. The substance must be capable of reproducing symptoms.[2]
INVESTIGATIONS
Substance/drug-induced obsessive-compulsive and related disorder arises only in association with intoxication, whereas a primary obsessive-compulsive and related disorder may precede the onset of substance/drug use.[2]
Schizophrenia and other psychotic disorders
SIGNS / SYMPTOMS
Negative symptoms and psychotic symptoms such as hallucinations, grossly disorganised behaviour, and disorganised thinking are not symptoms of body dysmorphic disorder (BDD). Psychotic-like symptoms that may occur as a symptom of BDD should not be diagnosed as a psychotic disorder. Such symptoms include complete conviction that the person looks abnormal or ugly, and delusions of reference (the conviction that other people take special notice of the person in a negative way because of how they look).[54]
INVESTIGATIONS
No differentiating test is available. Use the DSM-5-TR diagnostic criteria to distinguish between BDD and other disorders. This can be done by clinical interview or the use of the Structured Clinical Interview for DSM-5 (SCID-5).
Paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS)/Paediatric acute-onset neuropsychiatric syndrome (PANS)
SIGNS / SYMPTOMS
Abrupt and dramatic onset (<72 hours) of new obsessive-compulsive symptoms or severely restricted food intake, with similarly severe and acute onset of at least two concurrent cognitive, behavioural, or neurological symptoms.
Presentation is typically from age 3 years to the beginning of puberty.
Symptoms have a relapsing-remitting and episodic course.
INVESTIGATIONS
Clinical diagnosis. Other diagnoses such as Sydenham chorea, systemic lupus erythematosus, or autoimmune encephalitis, should be ruled out first.
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