diagnosis phenomenological and psychological understanding of the DOC
Diagnostic Evaluation
Obsessive compulsive disorder is included in the DSM-IV (APA, 1994) within the category of anxiety disorders, along with panic disorder, phobias, the post-traumatic stress disorder and generalized anxiety disorder (check on DSM-IV).
The diagnostic criteria suggested by the DSM-IV consider five points:
A. obsessions or compulsions

Ossessioni come definite da 1), 2), 3) e 4):
1) pensieri, impulsi o immagini ricorrenti e persistenti, vissuti, in qualche momento nel corso del disturbo, come intrusivi e inappropriati, e che causano ansia o disagio marcati
2) i pensieri, gli impulsi o le immagini non sono semplicemente eccessive preoccupazioni per i problemi della vita reale
3) la persona tenta di ignorare o di sopprimere tali pensieri, impulsi o immagini, o di neutralizzarli con altri pensieri o azioni
4) la persona riconosce che i pensieri, gli impulsi, o le immagini ossessivi sono un prodotto della propria mente (e non imposti dall’esterno come nell’inserzione del pensiero).

Compulsions as defined by 1) and 2):
1) repetitive behaviors (eg. Hand washing, ordering, checking) or mental acts (eg. Praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation, however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.
B. In qualche momento nel corso del disturbo la persona ha riconosciuto che le ossessioni o le compulsioni sono eccessive o irragionevoli. Nota. Questo non si applica ai bambini.
C.  Le ossessioni o le compulsioni causano disagio marcato, fanno consumare tempo (più di un’ora al giorno), o interferiscono significativamente con le normali abitudini della persona, con il funzionamento lavorativo (o scolastico) o con le attività o relazioni sociali usuali.
D.  Se è presente un altro disturbo sull’Asse I, il contenuto delle ossessioni o delle compulsioni non è limitato ad esso (per es. preoccupation with food in the presence of an eating disorder, hair pulling in the presence of trichotillomania, concern about the substances in the Substance Use Disorder, etc.)
E. The disturbance is not due to the direct physiological effects of a substance (eg. A drug of abuse or a medication) or a general medical condition.



The DSM also stresses the need to specify if the patient has poor insight, or if most of the time during the episode attuale, la persona non riconosce che le ossessioni e le compulsioni sono eccessive o irragionevoli.
Per una diagnosi positiva è necessario che tutti i criteri siano presenti.
Il DSM-IV definisce le ossessioni come pensieri egodistonici ricorrenti, riferendosi alla loro qualità intrusiva ed inappropriata e riconducendole alla sensazione dell’individuo che il contenuto delle ossessioni sia estraneo e non sia sotto il proprio controllo, pur riconoscendo che sono il prodotto della sua mente e non vengono imposte dall’esterno.
Alcune tra le ossessioni più frequenti riguardano la contaminazione (per es. essere contaminati quando si stringe la mano a qualcuno), dubbi ripetitivi (Eg. Whether it was properly made a gesture, you understand a word or phrase that they have damaged someone driving), aggressive impulses (eg. Assault or kill someone, as a vehicle of infection, shouting obscenities in church) the need to arrange objects in a certain order and / or symmetry, sexual fantasies (eg. recurrent pornographic images), various obsessions, such as fear of saying the wrong things, doubt that some items are perfectly superimposed and so on. The amount of the content of obsessions is almost endless. From the standpoint of psychological treatment is not relevant to the content of these obsessions.
Compulsions are mental acts or repetitive behaviors, ritualized and more or less intentional, carried out according to certain rules applied rigidly, put in place to prevent or reduce anxiety and discomfort. In most cases occur in response to an obsession in order to neutralize the discomfort associated with it or preventing some dreaded event. Are performed with a feeling of subjective compulsion that, at least initially, is related to the desire to oppose it. The most frequent compulsions
the clean one's own person or object, the closing of doors, windows, gas, every few minutes, repeat frasi, pensieri o il contare per allontanare pensieri blasfemi involontari, mettere in ordine, ossessioni varie, come non calpestare righe sul pavimento, attraversare una soglia un certo numero di volte, richiedere o pretendere rassicurazioni.
E’ necessario rilevare una differenza tra i criteri diagnostici proposti dal DSM-IV e l’ICD-10: quest’ultimo distingue ossessioni e compulsioni in base al fatto che si tratti di pensieri, idee o immagini (ossessioni) oppure atti (compulsioni), mentre il DSM-IV li distingue in base al fatto che l’idea o il pensiero causi o riduca l’ansia. Quindi nel DSM-IV possono essere presenti compulsioni ideative, che sarebbero considerate ossessioni nell’ICD-10. In addition, the ICD-10 provides for a minimum duration of symptoms of at least 2 weeks.
The clinical manifestations of obsessions and compulsions can take many different forms and can coexist in the same subject, different expressions symptoms. These tend to change over time, often without a specific progression. The symptomatology is identical in both adults and children and no symptoms related specifically to age (Friedlander et al., 2005).
The choice of obsession or compulsion reflects the intellectual and psycho-social subject and is due to cultural aspects and the medical and scientific knowledge of a specific era or culture. However, the type of obsession or compulsion does not change or favors a form of clinical intervention, let alone allows us to understand the source of the disturbance (Savron, 1998).
As we have seen, the DSM-IV provides, among the diagnostic features of obsessive-compulsive, or compulsions, or obsessions, being recognized as excessive or unreasonable by the subject. However, we must specify that these requirements do not apply to children, since they may lack sufficient cognitive awareness to make a critical assessment. In adults it is still found some variability of insight about the reasonableness of the obsessions or compulsions, that may change in different periods or situazioni.Il DSM-IV-10 el'ICD pose the same level diagnostic obsessive thoughts and compulsive acts. However, from a phenomenological analysis (Burgy, 2005) shows that the foregoing acts obsessive compulsive thoughts and anxiety is an affective reaction secondary obsessive idea. Clinical results, both in psychoanalysis, both behavioral therapies, confirm this observation.
In this sense it is possible to apply a distinction between the phenomenon of obsessive primary (obsession) and the phenomenon of secondary obsessive (compulsion), both necessary for a positive diagnosis. The compulsive act, from a psychopathological point of view, DOC is not specific and is not necessarily a result of obsessive idea, why not have the same diagnostic value of obsessive thought. If we considered only the compulsive act, as a symptom of obsessive-compulsive disorder, can we come to an erroneous diagnosis. Only through analysis of the primary phenomenon (obsession) is possible to reach a correct diagnosis of DOC and exclude pseudo-obsessive phenomena.
nosographic During the development, namely the DSM-III (APA, 1980) the disorder has been put into the category of anxiety disorders, overcoming the tradition of diagnosis of obsessive-compulsive. Today, the term neurosis in nosography Modern almost disappeared. This choice is based on the assumption that the primary function of an obsession or compulsion is to regulate anxiety. Gabbard (1994) states that, although in line with recent biological studies, this classification suggests a concept of anxiety as a disease rather than as a symptom caused by an unconscious conflict and invites the clinician to a psychodynamic approach to understand, however, the unconscious reasons anxiety. This method however does not apply to our centers as we found out that it is not the "unconscious reason" or the cause of anxiety to be understood as the psycho-physiological processes of maintaining the disorder in the here-and-now ovvero quei processi bio-psico-sociali che potrebbero portare ad una cronicizzazione del problema anziché alla sua soluzione.
Attualmente, comunque, al di là della disputa sulla collocazione del disturbo nella sfera ansiosa o affettiva, vi sono aspetti che definiscono strutturalmente il DOC, pur nella variabilità di espressione sintomatologica.
Per quanto riguarda il nostro gruppo di studio e ricerca attualmente utilizziamo il DSM-IV-TR come strumento di valtuazione diagnostica di tipo fenomenologico ed associamo a tale diagnosi una complessa valutazione del funzionamento globale della paziente all’interno del proprio contesto di vita.
Epidemiologia
Fino a non molto tempo fa il disturbo was considered relatively rare, with data estimated incidence in the general population around 0.05%. However, recent epidemiological studies indicate that OCD affects 2 to 3% of the population with a prevalence of 1 in one year, 5% -2.1%, representing the fourth most common complaint in the United States (Savron, 1998 ). A similar prevalence rate is estimated in adolescents and children. The recognition that the disorder is more common in childhood than previously thought, paved the way for retrospective studies that showed that about 80% of adult patients developed the first symptoms before age 18 (Friedlander et al. , 2005). It affects so pressochè uguale uomini e donne. Nella distribuzione non emerge alcuna differenza razziale.
Familiarità
L’incidenza del DOC nei familiari inferiore al 10%, una percentuale superiore rispetto alla popolazione generale. Tratti ossessivi di personalità sono stati riscontrati in oltre il 40% dei casi in genitori di soggetti con DOC (Savron, 1998). La concordanza per il disturbo è più alta nei gemelli omozigoti che dizigoti. La frequenza del DOC è più alta nei consanguinei di primo grado affetti da disturbo di Tourette.
Esordio e Decorso
L’esordio del DOC è generalmente antecedente ai 30 anni (74%), only a very small percentage of patients the first symptoms develop after age 40. Several studies indicate that there is a bimodal distribution of age of onset, with peaks in early adolescence (12-14 years) and early adulthood (20-22 years). The typical age of onset is earlier in males than in females and men develop more severe symptoms. It also seems that children with early onset (before 7 years) are more often male and have a family member with OCD (Friedlander et al., 2005).
The onset is gradual, but in many cases it was noticed an acute onset.
Usually the disorder begins with an occasional sense of unease in the face of objects o situazioni, reali o immaginate, e le prime strategie messe in atto per ridurlo sono l’evitamento dell’oggetto o della situazione che lo scatena, o il tentativo di ignorare i sintomi, considerandoli normali atti della vita quotidiana. Questi tentativi non riducono la sensazione di malessere, che, al contrario, aumenta e l’unica fonte di sollievo temporaneo è data dall’esecuzione di atti o rituali preventivi, senza eliminare definitivamente il problema. Nel corso del tempo le manifestazioni dei sintomi diventano sempre più evidenti, sia per il soggetto che per i familiari, ed emerge la consapevolezza della difficoltà di controllarli, fino a non provare più il desiderio di resistervi ed includere le compulsioni nelle their daily routine.
The course of the disorder is usually chronic, and the severity of symptoms can fluctuate over time, with periods of partial remission, or with an intermittent pattern.
In children, there was an interesting fact: after two years, about two-thirds of children diagnosed as obsessive no longer have the disorder, without resorting to any treatment (Savron, 1998).
Patients with this condition who turn to a specialist mental disorders are still few and, in most cases, seek treatment only after long years of suffering (7.5).
The data of our clinical interventions, however, seem to suggest that through the new possibility of non-pharmacological psychological treatment can reduce the disabling symptoms and make up quickly and without risk of relapse the patient to a significant improvement in the situation.
Differential Diagnosis
symptoms similar to obsessive-compulsive disorder manifests itself in many other mental disorders, in which however we do not find the overall characteristics of the disorder, where these are present, the diagnosis is based that the causes are traceable and specific (organic causes, intoxication, etc.).
The DOC then must be distinguished from anxiety disorder due to a general medical condition (or obsessions Compulsions are believed to be a physiological consequence of the medical condition), the Substance-induced Anxiety Disorder (the substance is considered to be etiologically related to the obsessions or compulsions).
not diagnosed if the DOC content of the thoughts and activities is tied exclusively to another mental disorder (Disorder Body dimorphism, Specific Phobia or Social, trichotillomania), or recurrent thoughts concerning specifically the fear of having a disease (Hypochondriasis), or counter, without the involvement of rituals (Specific Phobia). In these cases, if the concern is related to or performed rituals of verification, can be given the additional diagnosis of DOC.
episode Major Depressive ruminations can be found on specific thoughts, obsessions but are not considered because the subject does not recognize them as thoughts, excessive or unreasonable. In Generalized Anxiety Disorder are excessive worry, but related to facts of real life. On the contrary, a diagnosis of DOC, obsessions are experienced by the subject as ego-dystonic and their content does not relate to real life problems.
sometimes obsessive thoughts might be confused with the delusions found in schizophrenia, but in these cases are not perceived as inappropriate, nor be subject to assessment of reality. The specification "with poor insight" can be useful in those situations the border between obsession and delusion.
The Tic Disorder and stereotyped movements differs from DOC because the motor acts are less complex and not intended to neutralize an obsessive thought.
It is distinguished from other behaviors excessively repeated (as in cases of Dependency, Eating Disorders, Paraphilias, pathological gambling) because the actions are considered pleasant, while compulsions are unpleasantly repetitive.
Finally, we distinguish the DOC from Obsessive-Compulsive Personality: despite the similarity of clinical manifestations, the obsessive compulsive personality is characterized by the presence of obsessions or compulsions, as a pervasive pattern of concern for order and control.
In the differential diagnosis must be taken into consideration by organic diseases, which can induce a clinical apparently agreeing with the DOC: temporal lobe epilepsy, which produces repetition of gestures, but linked to a feeling of disorientation and depersonalization of the subject, very different from ' obsessional distress, traumatic brain injury and poisoning, but in such cases is always detectable onset of the episode and there is no ego-dystonic.
Comorbidity
The DOC often occurs in distinct comorbidity with other disorders, which may be incurred before, simultaneously or subsequently to the DOC.
It is a high incidence rate of DOC in patients with Tourette's Disorder (30% to 50%), while the percentage of Tourette disorder in patients with OCD seems lower (5-7%). Overall, the two disorders may submit an expression very similar symptoms, especially in the case of involuntary, intrusive, ego-dystonic behavior, fluctuation of symptoms, but there are specific characteristics that set it apart. Mainly
awareness of the disorder and the need to make a move to relieve internal stress, in patients with Tourette's, is very different from the malaise described by DOC.
E’ piuttosto comune l’associazione di DOC con il Disturbo Depressivo Maggiore. La presenza di sintomi depressivi in pazienti affetti da DOC è compresa tra il 13% ed 75% e la depressione risulta la codiagnosi più frequente. Nella maggior parte dei casi la sintomatologia depressiva insorge successivamente al DOC. Solo nel 30% dei quadri depressivi associati al DOC si può parlare di Episodio Depressivo Maggiore, dal momento che in genere la Depressione tende ad assumere le caratteristiche di una demoralizzazione secondaria, senza anedonia, riduzione dell’attenzione, propositi autolesivi. Sintomi ossessivo-compulsivi in pazienti depressi vengono riportati con una percentuale che va dal 6% al 38%.
La presenza di sintomi anxiety disorder or obsessive-compuilsivo is significant (75%) and is also a frequent sintomatogia obsessive anxiety disorders. The disorder is the most common simple phobia (17%) (oasis blue).
may be associated with Obsessive-Compulsive Personality Disorder (5-10%) or other traits and personality disorders (40%) (oasis blue).
Finally, we found an incidence ranging from 13% to 33% of DOC in patients with eating disorders.
The specialist must consider that there are some characteristics conducted in patients with OCD, consequential to the disorder itself: hypochondriacal concerns are common, with frequent medical visits in cerca di rassicurazioni; possono esservi disturbi del sonno e abuso di alcool o farmaci sedativi.
In sede diagnostica è importante che siano identificati i diversi disturbi che possono presentarsi in comorbilità con il DOC e la successione di insorgenza, al fine di individuare un intervento terapeutico differenziato.
Nella nostra casistica clinica abbiamo notato spesso sintomi di tipo ossessivo anche in pazienti con disturbo schizotipico di personalità.



  Dott.ssa Sara Reggimenti



:
Reggimenti, S.  (2006)
Il disturbo ossessivo-compulsivo. Comprensione e Diagnosi
SRM Psicologia Rivista (www.psyreview.org). Roma, 20 maggio 2006.



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