Obsessive-Compulsive Disorder (OCD)
This patient meets diagnostic criteria for Obsessive-Compulsive Disorder (OCD), specifically the checking subtype, characterized by repetitive checking compulsions (locks and appliances) and intense distress when unable to perform these rituals.
Diagnostic Criteria
The presentation clearly fulfills DSM-5 criteria for OCD 1:
- Compulsions present: Repetitive checking behaviors (locks and appliances) that the patient feels driven to perform
- Clinically significant distress: Intense distress when unable to perform these rituals
- Time-consuming or impairing: The behaviors cause substantial functional impairment
The checking dimension is one of the most common symptom presentations in OCD, specifically involving concerns about harm to self or others paired with checking behaviors 1. Checking is the most frequently reported compulsion in OCD, affecting approximately 80% of individuals with the disorder 2.
Key Diagnostic Considerations
Distinguishing from Normal Behavior
While double-checking locks is common in the general population, a diagnosis of OCD requires that these behaviors are time-consuming (taking more than 1 hour per day) and cause substantial distress or functional impairment 1. The "intense distress" when unable to perform rituals is the critical distinguishing feature here.
Differential Diagnosis to Rule Out
Generalized Anxiety Disorder (GAD): Worries in GAD are typically about real-life concerns and tend to be less irrational than OCD obsessions. Crucially, compulsions are not typically seen in GAD 1. This patient's repetitive checking behaviors clearly indicate compulsions, not simple worry.
Depression: While ruminations occur in depression, they focus on real-life concerns and lack the compulsive behavioral component 1.
Psychotic Disorder: This is a critical pitfall to avoid. The patient likely has good or fair insight (recognizing the checking is excessive), which distinguishes OCD from psychosis. Patients with OCD and absent insight/delusional beliefs should still be diagnosed with OCD, not a psychotic disorder 1.
Assessment Approach
Conduct a detailed psychiatric history focusing on:
- Specific obsessions: What thoughts drive the checking? (e.g., fear of burglary, fire, harm to others)
- Time spent: How many hours per day on checking rituals?
- Functional impairment: Impact on work, relationships, daily activities
- Insight level: Does the patient recognize the checking is excessive?
- Comorbidities: Screen for depression, other anxiety disorders, tic disorders
Use the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) to assess symptom severity and establish a baseline for treatment monitoring 1. This is the gold standard severity measure.
Clinical Significance
OCD has a lifetime prevalence of 2-3% and is associated with substantial disability 1. Early recognition and treatment lead to improved outcomes, and complete remission is possible 3. The checking subtype specifically involves increased repetition of functional activity and differs behaviorally from other OCD subtypes like cleaning 4.
Common Pitfalls to Avoid
- Do not misdiagnose as psychosis if the patient has poor insight—use the DSM-5 insight specifier instead 1
- Do not dismiss as "normal worry"—the presence of compulsions and marked distress distinguishes OCD 1
- Do not overlook comorbidities—OCD has high rates of comorbid depression and anxiety disorders that require concurrent treatment 3