Obsessive-Compulsive Disorder in Adults E-Book

Jonathan S. Abramowitz

• Herausgeber: Hogrefe Publishing
• Kategorie: Geisteswissenschaft
• Serie: Advances in Psychotherapy - Evidence-Based Practice
• Sprache: Englisch

Seitenzahl: 277

Veröffentlichungsjahr: 2025

Beschreibung

An updated edition of the popular guide to successfully assessing and treating adults with OCD - Compact and current overview of science and practice - Details the best treatment approaches - Includes downloadable tools for clinical use The new edition of this concise and popular guide delivers up-to-date, hands-on guidance on the assessment and treatment of obsessive-compulsive disorder (OCD), offering a framework for understanding and helping people with this complex and challenging condition. Written by leading experts in the field, this book unpacks the intricacies of diagnosing OCD and explores models that explain the onset, development, and persistence of the disorder as well as its various manifestations. Using case studies and examples throughout, the authors detail the most evidence-based therapeutic approaches, emphasizing two techniques that have proven most effective in clinical practice: exposure and response prevention. Methods such as optimizing inhibitory learning, using acceptance and commitment therapy, and techniques for working with couples and families affected by OCD are also integrated to address the disorder's core symptoms and collateral effects. Further sections explore multicultural issues, less common forms of OCD (e.g., relationship obsessions), and in-person vs. virtual treatment. Printable tools and worksheets in the appendices provide invaluable resources allowing for immediate use in practice. This is essential reading for clinical psychologists, therapists, psychiatrists, counselors, and students engaged in treating OCD.

Leseprobe

Cover for EPUB

Advances in Psychotherapy – Evidence-Based Practice, Volume 31

Obsessive-Compulsive Disorder in Adults

2nd edition

Jonathan S. Abramowitz

Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, NC

Ryan J. Jacoby

Massachusetts General Hospital, Harvard Medical School, Boston, MA

About the Authors

Jonathan S. Abramowitz, PhD, is Professor and Director of the Clinical Psychology Doctoral Program at the University of North Carolina (UNC) at Chapel Hill. He is also a North Carolina licensed psychologist with a diplomate from the American Board of Professional Psychology. Dr. Abramowitz is an international expert on anxiety and OCD and has published 20 books and over 350 research articles and book chapters. He is the founder and former editor of the Journal of Obsessive-Compulsive and Related Disorders. Dr. Abramowitz has served as President of the Association for Behavioral and Cognitive Therapies.

Ryan J. Jacoby, PhD, is Assistant Director of the Center for OCD and Related Disorders in the Department of Psychiatry at the Massachusetts General Hospital in Boston and Assistant Professor at Harvard Medical School. Her clinical and research interests are focused on the nature and treatment of OCD and related disorders, and she has authored over 40 scientific publications on these topics. She has received funding for her work from the National Institute of Mental Health and the International OCD Foundation and serves on the editorial board of several academic journals.

Advances in Psychotherapy – Evidence-Based Practice

Series Editor

Danny Wedding, PhD, MPH, Professor Emeritus, University of Missouri–Saint Louis, MO

Associate Editors

Jonathan S. Comer, PhD, Professor of Psychology and Psychiatry, Director of Mental Health Interventions and Technology (MINT) Program, Center for Children and Families, Florida International University, Miami, FL

Kenneth E. Freedland, PhD, Professor of Psychiatry and Psychology, Washington University School of Medicine, St. Louis, MO

J. Kim Penberthy, PhD, ABPP, Professor of Psychiatry & Neurobehavioral Sciences, University of Virginia, Charlottesville, VA

Linda C. Sobell, PhD, ABPP, Professor, Center for Psychological Studies, Nova Southeastern University, Ft. Lauderdale, FL

The basic objective of this series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice – and to do so in a reader-friendly manner. Each book in the series is both a compact “how-to” reference on a particular disorder for use by professional clinicians in their daily work and an ideal educational resource for students as well as for practice-oriented continuing education.

The most important feature of the books is that they are practical and easy to use: All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical “pearls,” marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

Continuing Education Credits

Psychologists and other healthcare providers may earn five continuing education credits for reading the books in the Advances in Psychotherapy series and taking a multiple-choice exam. This continuing education program is a partnership of Hogrefe Publishing and the National Register of Health Service Psychologists. Details are available at https://www.hogrefe.com/us/cenatreg

The National Register of Health Service Psychologists is approved by the American Psychological Association to sponsor continuing education for psychologists. The National Register maintains responsibility for this program and its content.

Library of Congress Cataloging in Publication information for the print version of this book is available via the Library of Congress Marc Database under the Library of Congress Control Number 2025945064

Library and Archives Canada Cataloguing in Publication

Title: Obsessive-compulsive disorder in adults / Jonathan S. Abramowitz, Department of Psychology

and Neuroscience, University of North Carolina at Chapel Hill, NC, Ryan J. Jacoby, Massachusetts

General Hospital, Harvard Medical School, Boston, MA.

Names: Abramowitz, Jonathan S., author. | Jacoby, Ryan J., author.

Series: Advances in psychotherapy--evidence-based practice ; v. 31.

Description: 2nd edition. | Series statement: Advances in psychotherapy--evidence-based practice ;

volume 31 | Includes bibliographical references.

Identifiers: Canadiana (print) 20250257289 | Canadiana (ebook) 20250265435 | ISBN 9780889376076

(softcover) | ISBN 9781616766078 (PDF) | ISBN 9781613346075 (EPUB)

Subjects: LCSH: Obsessive-compulsive disorder. | LCSH: Obsessive-compulsive disorder—Treatment. |

LCSH: Obsessive-compulsive disorder—Case studies. | LCSH: Evidence-based psychiatry. | LCGFT:

Case studies.

Classification: LCC RC533 .A29 2025 | DDC 616.85/227—dc23

© 2026 by Hogrefe Publishing. All rights, including for text and data mining (TDM), Artificial Intelligence (AI) training, and similar technologies, are reserved.

www.hogrefe.com

The authors and publisher have made every effort to ensure that the information contained in this text is in accord with the current state of scientific knowledge, recommendations, and practice at the time of publication. In spite of this diligence, errors cannot be completely excluded. Also, due to changing regulations and continuing research, information may become outdated at any point. The authors and publisher disclaim any responsibility for any consequences which may follow from the use of information presented in this book.

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Format: EPUB

ISBN 978-0-88937-607-6 (print) • ISBN 978-1-61676-607-8 (PDF) • ISBN 978-1-61334-607-5 (EPUB)

https://doi.org/10.1027/00607-000

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Dedication

To our parents: Ferne and Leslie Abramowitz; Doug and Jennie Jacoby.

viiAcknowledgments

We are indebted to a large group of people, including series editor Danny Wedding and Robert Dimbleby of Hogrefe, for their invaluable guidance and suggestions. The pages of this book echo with the clinical wisdom we have acquired through direct and indirect learning from masters of the science and art of psychological theory and intervention, including Joanna Arch, Donald Baucom, David A. Clark, Michelle Craske, Edna Foa, Martin Franklin, Michael Kozak, Jack Rachman, Paul Salkovskis, and Michael Twohig.

We dedicate this book to our clients and research participants who come to us seeking help and, in the face of uncertainty, find the courage to approach what they fear and give up their compulsive behaviors so that they can achieve a better quality of life. They believe in us, confide in us, challenge us, and educate us.

Übersicht

Cover

Titel

About the authors

Impressum

Dedication

Inhaltsverzeichnis

Preface

Inhalt

8 Appendix: Tools and Resources

ixContents

Obsessive-Compulsive Disorder in Adults

Acknowledgments

Preface

1  

Description

1.1  

Terminology

1.2  

Definition

1.2.1  

Avoidance

1.2.2  

Insight

1.2.3  

Tics

1.2.4  

OCD From an Interpersonal Perspective

1.3  

Epidemiology

1.4  

Course and Prognosis

1.5  

Differential Diagnoses

1.5.1  

Generalized Anxiety Disorder

1.5.2  

Depression

1.5.3  

Tics and Tourette’s Syndrome

1.5.4  

Psychotic Disorders (e.g., Schizophrenia)

1.5.5  

Impulsive Behavior and Habit Disorders

1.5.6  

Obsessive-Compulsive Personality Disorder

1.5.7  

Illness Anxiety Disorder

1.5.8  

Body Dysmorphic Disorder

1.5.9  

Hoarding Disorder

1.6  

Comorbidity Rates

1.7  

Diagnostic Procedures and Documentation

1.7.1  

Screening

1.7.2  

Structured Diagnostic Interviews

1.7.3  

Semistructured Symptom Interviews

1.7.4  

Self-Report Inventories

1.7.5  

Documenting Changes in Symptom Levels

2  

Theories and Models

2.1  

Biological Theories

2.1.1  

Neurotransmitter Theories

2.1.2  

Neuroanatomical Theories

2.2  

Psychological Theories

2.2.1  

Learning Theory

2.2.2  

Cognitive Deficit Models

2.2.3  

Contemporary Cognitive-Behavioral Models

Normalizing Effects

3  

Diagnosis and Treatment Indications

3.1  

Form Versus Function

3.2  

The Diagnostic Assessment

3.3  

Identifying the Appropriate Treatment

3.4  

Factors That Influence Treatment Decisions

3.4.1  

Age

3.4.2  

Sex and Gender

3.4.3  

Ethnic and Racial Background

3.4.4  

Educational Level and Cognitive Impairments

3.4.5  

Client Preference

3.4.6  

Clinical Presentation

3.4.7  

OCD Symptom Theme

3.4.8  

Interpersonal Factors

3.4.9  

Insight

3.4.10  

Comorbidity

3.4.11  

Treatment History

3.5  

Presenting the Recommendation for ERP

4  

Treatment

4.1  

Methods of Treatment

4.1.1  

Functional Assessment

4.1.2  

Self-Monitoring

4.1.3  

Psychoeducation

4.1.4  

Using Cognitive Therapy Techniques

4.1.5  

Using Acceptance-Based Strategies

4.1.6  

Planning for Exposure and Response Prevention

4.1.7  

Implementing Exposure and Response Prevention

Importance of Therapeutic Alliance

4.1.8  

Ending Treatment

4.2  

Mechanisms of Action

4.3  

Efficacy and Prognosis

4.4  

Variations and Combinations of Methods

4.4.1  

Variants of ERP Treatment Procedures

4.4.2  

Combining Medication and ERP

4.4.3  

Involving Significant Others in Treatment

4.4.4  

In-Person Versus Virtual Treatment Delivery

4.5  

Problems in Carrying Out the Treatment

4.5.1  

Negative Reactions to the Cognitive Behavioral Model

4.5.2  

Nonadherence

4.5.3  

Arguments

4.5.4  

Persistent Family Accommodation of OCD Symptoms

4.5.5  

Therapist’s Inclination to Challenge the Obsession

4.5.6  

Hijacking Psychoeducational and Cognitive Interventions

4.5.7  

Using Exposure to Control Anxiety

4.5.8  

Intolerable Anxiety Levels During Exposure

4.5.9  

Absence of Anxiety During Exposure

4.5.10  

Therapist Discomfort With Conducting Exposure Exercises

4.5.11  

Clients Asking Therapists for Reassurance

4.5.12  

Reluctance to Share Intrusive Thoughts

4.5.13  

Considering a Higher Level of Care

4.6  

Multicultural Issues

4.6.1  

International Presentations of OCD

4.6.2  

Justice-Based Treatment of OCD

5  

Case Vignettes

6  

Further Reading

7  

References

8 Appendix: Tools and Resources

List of Figures

Figure 1  Cognitive-behavioral conceptual model of OCD.

List of Tables

Table 1  Clinical Breakdown of Scores on the Y-BOCS Severity Scale (based on Storch et al., 2015)

Table 2  Summary of Maintenance Processes in OCD

Table 3  Domains of Pathogenic Beliefs in OCD

Table 4  Types of Safety Behaviors Observed in OCD

Table 5  Common OCD symptom presentations

Table 6  Medications With Demonstrated Efficacy for Treating OCD

Table 7   Components of Exposure Sessions

Table 8  Priya’s Exposure List (With SUDS)

Table 9  Armando’s Exposure List (With SUDS)

Table 10  Stephanie’s Exposure List (With SUDS)

Table 11  Greg’s Exposure List (With SUDS)

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xiiiPreface

This book describes the conceptualization, assessment, and psychological treatment of obsessive-compulsive disorder (OCD) in adults, using empirically supported cognitive behavior therapy (CBT) interventions. The centerpiece of this approach is exposure and response prevention (ERP), a well-studied tandem of CBT techniques derived from learning theory accounts of OCD. The delivery of ERP is also informed by the fields of cognitive therapy, acceptance and commitment therapy (ACT), couples therapy, and inhibitory learning. We assume the reader will have basic knowledge and training in the delivery of psychotherapeutic interventions, yet not necessarily be a specialist in OCD. This book is for mental health professionals and trainees wishing to learn therapeutic strategies for managing OCD effectively in day-to-day clinical practice.

The book is divided into five chapters. The first describes the clinical phenomenon of OCD differentiating it from other problems with similar characteristics and outlining scientifically based diagnostic and assessment procedures. Chapter 2 reviews leading theoretical approaches to the development and maintenance of OCD, and their treatment implications. In Chapter 3, we present a framework for conducting an initial assessment of OCD and for deciding whether a particular client is a candidate for the treatment program in this volume. Methods for explaining the diagnosis of OCD and introducing the treatment program to clients are incorporated. Chapter 4 presents the details of how to conduct effective ERP for OCD. There are numerous case examples and transcripts of in-session dialogs to illustrate the treatment procedures. All case examples are based on composites of clients and our clinical experiences but do not represent any specific individual. The chapter also reviews the scientific evidence for the efficacy of this program and discusses how to identify and surmount a number of common obstacles to successful outcomes. Finally, Chapter 5 includes a series of case examples describing the treatment of various sorts of OCD symptoms (contamination concerns, fears of responsibility for harm, etc.). A variety of forms and client handouts for use in treatment appear in the book’s Appendix.

OCD is a highly heterogeneous problem. Some clients experience fears of germs and contamination, while others have recurring, unwanted anxiety-evoking ideas of acting in ways that are wholly inconsistent with their values or character (e.g., using racial slurs or deliberately running into pedestrians while driving). Still others experience senseless but distressing doubts about unsolvable or existential questions (e.g., “how do I know I’m really in love,” “what if my existence is just a dream?”). It is rare to see two individuals with completely overlapping symptoms. Thus, we provide a multicomponent approach that guides the clinician in structuring treatment to meet individual clients’ needs. In this book you will find practical clinical information and illustrations, along with supporting didactic materials for both you and your clients.

1 1  Description

1.1  Terminology

Obsessive-compulsive disorder (OCD) has traditionally been considered an anxiety-related disorder. In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision (DSM-5-TR; American Psychiatric Association [APA], 2022), it became the flagship diagnosis of the obsessive-compulsive and related disorders (OCRDs), a category of conditions with putatively overlapping features (see Section 1.5).

1.2  Definition

OCD is defined in the DSM-5-TR by the presence of obsessions and compulsions that are time-consuming, typically taking up an hour or more each day, and cause significant distress or impairment in social, occupational, or other important areas of functioning. Obsessions are repetitive and persistent thoughts, images, or doubts that are experienced as intrusive and unwanted, cause distress such as anxiety, shame, guilt, or doubt, and are not simply worries about real-life problems (e.g., unlike in generalized anxiety disorder). Individuals with obsessions typically attempt to ignore, suppress, or neutralize them with other thoughts or actions.

Although highly specific to the individual, obsessions typically concern the following themes: aggression and violence, responsibility for causing physical or emotional harm (e.g., by making a mistake), contamination, sex, religion, the need for exactness or completeness, and serious illnesses (e.g., cancer). Most people diagnosed with OCD experience multiple types of obsessions. Examples of common and uncommon obsessions appear in Box 1.

Compulsions are repetitive behaviors (e.g., handwashing) or mental acts (e.g., counting, praying) that a person feels driven to perform in response to an obsession or according to rigid rules. These actions are intended to prevent or reduce distress or prevent some dreaded event but are excessive or not realistically connected to the feared outcomes.

As with obsessions, rituals are highly individualized. Examples of behavioral (overt) rituals include repetitious handwashing, checking (e.g., locks, the stove), and repeating routine actions (e.g., going through doorways). 2Examples of mental rituals include excessive prayer, repeating special phrases or numbers to oneself to neutralize obsessional fear, and mentally analyzing intrusive thoughts. Box 2 presents examples of some common and uncommon compulsive rituals.

People with OCD vary in their level of insight, ranging from good or fair to poor or absent, and this may fluctuate over time or depending on the specific obsessional theme. In some cases, OCD can co-occur with tics, in which distressing somatic sensations – such as physical discomfort – are temporarily relieved by movements or vocalizations.

Box 1 Examples of Common and Uncommon Obsessions

Common obsessions

The idea that one is contaminated from dirt, germs, animals, body fluids, bodily waste, or household chemicals

Doubts that one is (or may become) responsible for harm, bad luck, or other misfortunes such as fires, burglaries, awful mistakes, and injuries (e.g., car accidents)

Unacceptable sexual ideas (e.g., of molesting a child)

Unwanted violent impulses (e.g., to attack a helpless person)

Unwanted sacrilegious thoughts (e.g., of desecrating a place of worship)

Need for order, symmetry, completeness

Fears of certain numbers (e.g., 13, 666), colors (e.g., red), or words (e.g., murder)

Uncommon obsessions

Fear of having an abortion without realizing it

Fear that not being able to remember events fully means they didn’t occur

Fear of that one’s mind is contaminated by thoughts of unethical situations

Fear of contamination from a geographic region

Distressing preoccupations with bodily processes (e.g., breathing, blinking, swallowing, eye contact)

Existential preoccupations about the meaning of life or one’s own existence (e.g., “Am I real?”)

Box 2 Examples of Common and Uncommon Compulsive Rituals

Common rituals

Washing one’s hands 40 times per day or taking multiple (lengthy) showers

Repeatedly cleaning objects or vacuuming the floor

Returning several times to check that the door is locked

Placing items in the “correct” order to achieve “balance”

Retracing one’s steps

Rereading or rewriting things to prevent mistakes

Calling relatives or “experts” to ask for reassurance

3Thinking the word “healthy” to counteract hearing the word “cancer”

Repeated and excessive confessing of one’s “sins”

Repeating a prayer until it is said perfectly

Uncommon rituals

Having to touch (with equal force) the right side of one’s body after being touched on the left side

Having to look at certain points in space in a specified way

Having to mentally rearrange letters in sentences to spell out comforting words

Having to blink in a way that feels “just right”

Excessive list making or digital cataloging of information

1.2.1  Avoidance

People with OCD often use avoidance behaviors as a strategy for evading situations, objects, or thoughts that trigger obsessions or provoke anxiety. Avoidance functions as a coping mechanism aimed at reducing or controlling discomfort or preventing perceived harm associated with obsessions. Avoidance can be overt (e.g., refraining from using public restrooms) or more subtle (e.g., procrastination, distraction).

1.2.2  Insight

People with OCD show a range of insight into the validity of their obsessions and compulsions – some acknowledge that their obsessions are unrealistic (i.e., acknowledging that their feared consequences are unlikely to occur and that they perform their compulsions because “it’s better to be safe than sorry” or simply because it reduces their distress), while others are more firmly convinced (approaching delusional intensity) that their symptoms are rational. To accommodate this parameter of OCD, the DSM-5-TR includes specifiers to denote whether the person has (a) good or fair, (b) poor, or (c) no insight into the senselessness of their OCD symptoms. Often, the degree of insight varies within a person across time, situations, and across types of obsessions. For example, someone might have good insight into the senselessness of their obsessional thoughts about violence yet have poor insight regarding fears of contamination from chemicals.

1.2.3  Tics

DSM-5-TR also includes a specifier to distinguish between people with OCD with and without tics (or a history of a tic disorder). Whereas in OCD, obsessions lead to a negative emotional (affective) state such as anxiety or fear, tics are characterized by a distressing sensory (somatic) state such as physical 4discomfort in specific body parts (e.g., face) or a diffuse psychological distress or tension (e.g., “in my head”). This sensory discomfort is then relieved by motor responses (e.g., head twitching, eye blinking). (More details regarding differential diagnosis of OCD vs. tics/Tourette’s disorder are reviewed in Section 1.5.3)

1.2.4  OCD From an Interpersonal Perspective

The previous description highlights the experience of OCD from the individual’s perspective. Yet OCD commonly has an interpersonal component that may negatively impact close relationships, such as that with a parent, sibling, spouse, or romantic partner (Abramowitz et al., 2013). This component may be manifested in two ways. First, a partner or spouse (or other close friend or relative) might inadvertently be drawn to help with or accommodate the performing of compulsive rituals and avoidance behavior out of a desire to show care or concern for the individual with OCD (e.g., to help reduce anxiety). Second, OCD symptoms may lead to arguments and other forms of conflict within these relationships.

Symptom Accommodation

Accommodation occurs when a loved one (a) participates in the client’s rituals (e.g., answers reassurance-seeking questions, performs cleaning and checking behaviors for the client), (b) helps with avoidance strategies (e.g., avoids places deemed “contaminated” by the client), or (c) helps to resolve or minimize problems that have resulted from the client’s OCD symptoms (e.g. making excuses for the person’s behavior, supplying money for special soaps). Accommodation might occur at the request (or demand) of the individual with OCD or it might be voluntary and based on the desire to show care and concern by reducing the distress of the individual with OCD. The following vignette illustrates accommodation:

Avery adores her dog, Sadie, a gentle golden retriever who has been her loyal companion for years. Recently, Avery has been plagued by intrusive thoughts of accidentally harming Sadie. These thoughts terrify her, leading her to avoid activities like cooking, where she fears a knife might slip and hurt Sadie. She refuses to watch movies or shows that depict violence and insists on rearranging her furniture to avoid any accidental collisions that could harm her pet. Avery’s partner, Cameron, does everything possible to ensure that sharp objects are safely stored away, avoids discussing any potentially upsetting topics related to pets, and even rearranges their daily routines to minimize any perceived risks to Sadie. Cameron reassures Avery constantly, reminding her that he would do anything to protect both her and their beloved dog. Despite Cameron’s loving support, Avery’s obsessive fears continue to cause her significant distress, making everyday tasks and interactions challenging as she strives to keep Sadie safe from harm.

5Accommodation can be subtle or overt (and extreme) and is observed in distressed and nondistressed relationships. Even if there is no obvious distress, accommodation creates a relationship “system” that fits with the OCD symptoms to perpetuate the problem. For example, accommodation might decrease a client’s incentive to engage in treatment that would require a great deal of effort and change the status quo. It might also be the chief way in which loved ones have learned to show affection for the person with OCD. Not surprisingly, accommodation is related to more severe OCD symptoms and poorer long-term treatment outcome (Jacoby et al., 2021). Accordingly, reducing accommodation is an important target in treatment.

Relationship Conflict

Relationships in which one person has OCD are often characterized by interdependency, unassertiveness, and avoidant communication patterns that foster conflict. Typically, OCD symptoms and interpersonal distress influence each other (rather than one exclusively leading to the other). For example, a father’s contentious relationship with his adult daughter with OCD might contribute to anxiety and uncertainty that increases the daughter’s obsessional doubting. Her compulsive reassurance seeking and overly cautious behavior might also lead to frequent disagreements and conflicts with her father.

1.3  Epidemiology

OCD has a 1-year prevalence of 1.2% and a lifetime prevalence of 2.3% in the adult population (this is equivalent to about 1 in 40 adults; Ruscio et al., 2010). The disorder affects women slightly more often than men, and the age of onset, although earlier for males, is around 19 years on average.

Most individuals experience OCD symptoms for several years before receiving proper diagnosis and treatment. Factors contributing to the underrecognition of OCD include the reluctance of clients to disclose their sometimes embarrassing symptoms (see Section 4.5.12), the failure of professionals to screen for obsessions and compulsions during routine examinations (see Section 1.7.1), and difficulties with differential diagnoses (see Section 1.5).

1.4  Course and Prognosis

OCD symptoms typically develop gradually. An exception is the abrupt onset sometimes observed during pregnancy or postpartum. Another putative exception is pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), which involves the abrupt onset or worsening of OCD and/or tics among children following such an infection (Swedo, 2002). The modal age of onset of OCD ranges between 6–15 years in males 6and 20–29 years in females. Generally, OCD has a low rate of spontaneous remission. Left untreated, the disorder runs a chronic and deteriorating course, although symptoms may wax and wane in severity over time (often dependent upon levels of psychosocial stress).

1.5  Differential Diagnoses

In clinical practice, OCD can be difficult to differentiate from a number of problems with deceptively similar symptom patterns. Moreover, the terms “obsessive” and “compulsive” are often used indiscriminately to refer to phenomena that are not clinical obsessions and compulsions as defined by the DSM-5-TR. This section highlights key differences between the symptoms of OCD and those of several other disorders.

1.5.1  Generalized Anxiety Disorder

Anxious apprehension and repetitive thoughts are present in both OCD and generalized anxiety disorder (GAD). However, worries in GAD concern real-life problems (e.g., losing one’s job, finances, relationships) and are typically in line with the individual’s sense of self (i.e., ego-syntonic). On the other hand, obsessions in OCD often contain senseless or bizarre content that is ego-dystonic (i.e., not in line with one’s sense of self). For example, rather than generally worrying about losing one’s job (as in GAD), a client with OCD may be worried about sending something offensive or inappropriate in a work email by mistake that they would never normally write. Obsessions in OCD also often focus on personalized responsibility. For example, rather than generally worrying about the safety of loved ones as in GAD (e.g., “what if my husband gets in a car accident driving to work”), a client with OCD might think “what if I suddenly swerve the car when I’m driving and hit a pedestrian.” Moreover, the content of worries in GAD may shift frequently, whereas the content of obsessional fears is generally stable over time.

1.5.2  Depression

OCD and depression both involve repetitive negative thoughts. However, depressive ruminations are generalized, pessimistic ideas about the self, world, or future (e.g., “no one likes me”) with frequent shifts in content. Unlike obsessions, ruminations are not strongly resisted, and they do not elicit avoidance or compulsive rituals. Obsessions, on the other hand, are thoughts, ideas, and images that involve fears of specific disastrous consequences, with infrequent shifts in content.

7Sometimes it can be challenging to distinguish an unwanted intrusive thought about self-harm from suicidal thoughts. Some helpful questions to ask clients include: (a) are the thoughts of harm ego-dystonic (i.e., the exact opposite of what the person wants to do; more likely OCD); (b) do the thoughts come up randomly (e.g., the person is walking down the street, and all of a sudden they have a thought of stepping in front of oncoming traffic; more likely OCD) or are they mood-congruent (i.e., do they come up when the person is feeling most depressed; more likely depression); (c) does the person feel anxious when thoughts of harm come up (more likely OCD) or do they feel a sense of comfort in thinking about ways they can kill themselves (more likely depression); (d) does the person express any intent to act on the thoughts (which would be a risk factor and also more likely indicative of depression). In summary, clients with OCD most commonly will say these thoughts come up randomly and are the exact opposite of anything they would want to do. They make clients feel anxious or fearful (e.g., wondering what these thoughts mean), and they do not want to do anything to act on them.

1.5.3  Tics and Tourette’s Syndrome

Both OCD and Tourette’s syndrome (TS) involve stereotyped or repetitive movements. However, tics (as in TS) are spontaneous acts evoked by a sensory urge. They serve to reduce sensory tension rather than as an escape from obsessive fear. In contrast, compulsions in OCD are deliberate acts evoked by affective distress and the urge to reduce fear.

1.5.4  Psychotic Disorders (e.g., Schizophrenia)

Both OCD and psychotic disorders involve senseless and fixed thoughts and beliefs that may evoke distress. In fact, these thoughts can be conceptualized as occurring on a spectrum, with delusions seen in psychotic disorders being on the extreme end of conviction and most bizarre. For example, a client with OCD may fear that they will accidentally cheat on an exam without meaning to whereas one with psychotic delusions may be convinced that their professor is watching them through the webcam of their computer to catch them cheating on a take-home exam. Additionally, obsessions are typically inconsistent with the client’s sense of self (i.e., ego-dystonic), whereas delusions, on the other hand, are integrated into a client’s belief system. Furthermore, any repetitive behaviors seen in schizophrenia are in harmony with the delusional beliefs (e.g., repeatedly checking the window to confirm one is being spied on) rather than being an attempt to neutralize unwanted obsessions, and clients with schizophrenia view these behaviors as justified (rather than senseless or excessive). Schizophrenia is also accompanied by other negative symptoms of thought disorders (e.g., loosening associations) that are not present in OCD.

81.5.5  Impulsive Behavior and Habit Disorders

Excessive and repetitive behaviors might be present in both OCD and in disorders characterized by impulse control difficulties, such as pathological gambling, pathological shopping and/or buying, body-focused repetitive behaviors