History and exam

Key diagnostic factors

common

obsessions

Obsessions are defined as intrusive, unwanted, anxiogenic thoughts that result in marked distress.

The patient typically recognizes that these thoughts are irrational.

Common obsessions include fear of contamination, need for symmetry or exactness, fear of causing harm to someone, sexual obsessions, religious obsessions, fear of behaving unacceptably, and fear of making a mistake.​[50]

Individuals with obsessive-compulsive disorder (OCD) often avoid people, places, and things that trigger their obsessions.[7]

compulsions

Compulsions are defined as repetitive behavioral or mental acts that are designed to neutralize the anxiety that results from obsessions.

Compulsions result in a temporary relief of anxiety and are self-reinforcing.

Common behavioral compulsions include cleaning, hand washing, checking, ordering and arranging, and seeking reassurance from others.

Common mental compulsions include counting, repeating words silently, ruminating, and attempting to "neutralize" thoughts.​[50]

Individuals with obsessive-compulsive disorder (OCD) often avoid people, places, and things that trigger their compulsions.[7]

A higher frequency of compulsions is related to treatment resistance.[38]

sensory phenomena

Up to 60% of individuals with obsessive-compulsive disorder (OCD) report sensory phenomena that precede their compulsions.[2]

These include physical sensations, just-right sensations, and feelings of incompleteness.[2]

uncommon

schizotypal personality disorder

Concomitant schizotypal personality disorder is considered a predictor of worse response.[38] May warrant early referral to a specialist to tailor therapy.

tic disorder

Up to 30% of those with obsessive-compulsive disorder (OCD) have a lifelong tic disorder.[2] The presence of a concurrent tic disorder may be associated with more severe OCD symptoms and a greater likelihood of treatment resistance.[39] It may warrant early referral to a specialist to tailor therapy.

poor motor coordination

Poor motor coordination results from specific or diffuse brain structural abnormalities.

It has been implicated as a screening tool, identifying a potential subgroup of patients with obsessive-compulsive disorder (OCD) with poorer treatment response.[40]

It may warrant early referral to a specialist to tailor therapy.

sensory perceptual difficulties

Sensory perceptual difficulties result from specific or diffuse brain structural abnormalities.

They have been implicated as a screening tool, identifying a potential subgroup of patients with obsessive-compulsive disorder (OCD) who have a poorer treatment response.[40]

Sensory perceptual difficulties may warrant early referral to a specialist to tailor therapy.

difficulties in sequencing of complex motor tasks

Difficulties in sequencing of complex motor tasks result from specific or diffuse brain structural abnormalities.

They have been implicated as a screening tool, identifying a potential subgroup of patients with obsessive-compulsive disorder (OCD) who have a poorer treatment response.[40]

Difficulties in sequencing of complex motor tasks may warrant early referral to a specialist to tailor therapy.

Other diagnostic factors

common

male sex

Male sex is associated with an earlier onset and a more chronic course and often predicts poorer response to treatment.[5]

Risk factors

strong

family history of obsessive-compulsive disorder (OCD)

Genetic factors are important, as monozygotic twins are much more likely to exhibit OCD symptoms than dizygotic twins.[11] First-degree relatives of patients with OCD have a higher risk of developing the disorder than the general population.[12]

PANDAS/PANS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection/pediatric acute-onset neuropsychiatric syndrome)

Obsessive-compulsive disorder (OCD) symptoms can be caused or exacerbated by an autoimmune reaction in which antibodies to beta-hemolytic streptococci cross-react with proteins in the basal ganglia; this phenomenon has been termed PANDAS.[36] More recently, another subset of patients was identified with a symptom complex similar to PANDAS but with evidence of infectious agents other than streptococcus, such as mycoplasma, mononucleosis, Lyme disease, and the H1N1 flu virus, and the term PANS was introduced.[37]​​

weak

pregnancy

In one study of 59 female patients with obsessive-compulsive disorder (OCD), 39% of participants described the onset of OCD symptoms during pregnancy.[24]

male sex (earlier onset, more chronic course, treatment resistance)

Male sex is associated with an earlier onset and a more chronic course of obsessive-compulsive disorder (OCD) and often predicts a poorer response to treatment.[5]

Male individuals are also more likely to experience concurrent tic disorders.[7]

higher frequency of compulsions (treatment resistance)

A higher frequency of compulsions is related to treatment resistance.[38]

early age of onset (treatment resistance)

A lower age at onset of obsessive-compulsive disorder (OCD) is related to treatment resistance.[38]

previous hospitalizations for obsessive-compulsive disorder (OCD [treatment resistance])

A history of previous hospitalizations for OCD is related to treatment resistance.[38]

schizotypal personality disorder (treatment resistance)

Concomitant schizotypal personality disorder is considered a predictor of worse response and may warrant early referral to a specialist to tailor therapy.[38]

tic disorder (treatment resistance)

The presence of a concurrent tic disorder may be associated with more severe obsessive-compulsive disorder (OCD) symptoms and a greater likelihood of treatment resistance.[39] It may warrant early referral to a specialist to tailor therapy.

Tic disorders are more common in male individuals.[7]

specific or diffuse brain structural abnormalities (treatment resistance)

Patients with neurologic soft-sign abnormalities may have a poorer treatment response, which may warrant early referral to a specialist to tailor therapy.[40]

Rarely, striatal lesions or head trauma result in the development of obsessive-compulsive disorder (OCD).[10]

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