Is a patient's excessive worry about people-pleasing and making amends indicative of obsessive-compulsive disorder (OCD) or anxiety?

Distinguishing People-Pleasing Worry from OCD

This presentation is more consistent with generalized anxiety or relationship anxiety rather than OCD, unless the patient performs specific, repetitive mental or behavioral rituals to neutralize intrusive, unwanted thoughts about upsetting others.

Core Diagnostic Framework

The critical distinction hinges on whether compulsions are present and whether the thoughts are truly ego-dystonic obsessions versus ego-syntonic worries 1, 2.

Key Questions to Establish OCD vs. Anxiety

Assess the nature of the thoughts:

• OCD obsessions are recurrent, persistent, intrusive thoughts experienced as unwanted and anxiety-provoking that the individual actively attempts to suppress or neutralize 1, 3
• Anxiety worries are ego-syntonic concerns that feel like natural extensions of the person's personality and values, even if excessive 2

Evaluate for compulsions (the defining feature):

• Does the patient perform repetitive behaviors or mental acts (counting, praying, repeating words silently, confessing, reassurance-seeking) in response to these thoughts? 1, 3
• Are these behaviors performed rigidly according to rules that must be applied, aimed at preventing or reducing anxiety about upsetting others? 1
• Does the patient recognize these behaviors as excessive or unreasonable but feel driven to perform them anyway? 1

Assess the time burden and functional impairment:

• Do the obsessions or compulsions consume more than 1 hour per day? 1
• Do they cause clinically significant distress or impairment in social, occupational, or other important areas of functioning? 1

Clinical Presentation Patterns

If This is OCD (Less Likely Based on Description)

The patient would exhibit the "harm-related" or "unacceptability" symptom dimension 1:

• Intrusive thoughts about having harmed others through social interactions that feel threatening and unwanted 1, 3
• Mental rituals (reviewing conversations repeatedly, mentally checking for mistakes) or behavioral compulsions (excessive apologizing, confessing) performed to neutralize the obsessive fear 1
• Reassurance-seeking that provides only short-lived relief, performed repeatedly in rigid patterns 3

If This is Anxiety (More Likely Based on Description)

The patient would show:

• Worries about relationships and social acceptance that feel like genuine concerns rather than intrusive threats 2
• Rumination that is ego-syntonic (comfortable, part of their thought process) rather than ego-dystonic 3
• No rigid, repetitive compulsive rituals performed to neutralize specific obsessive fears 2
• Worries driven by genuine uncertainty and desire for connection rather than compulsive neutralization 3

Structured Assessment Approach

Ask these specific diagnostic questions:

1. "Do these thoughts about upsetting people feel like they're intruding against your will, or are they concerns you naturally have about your relationships?" 3

2. "When you worry about making up for something, do you feel driven to perform specific actions (like apologizing a certain number of times, confessing in a particular way, or mentally reviewing the interaction repeatedly) to reduce your anxiety?" 1, 3

3. "Do these thoughts cause you to feel like something terrible will happen if you don't perform certain behaviors?" 1

4. "Do you recognize these worries as excessive or unreasonable, but feel unable to stop them?" 2

Use standardized instruments:

• The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) can quantify OCD severity, with scores ≥14 indicating clinically significant OCD requiring treatment 3, 2
• The Structured Clinical Interview for DSM-5 (SCID-5) or Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5) can confirm diagnosis 2

Common Pitfalls to Avoid

Do not confuse excessive worry with obsessions:

• Generalized anxiety disorder worries are ego-syntonic and lack compulsive rituals, whereas OCD obsessions are ego-dystonic with driven compulsions 2
• The presence or absence of compulsions is the key differentiator 1, 2

Recognize that both conditions can coexist:

• Anxiety disorders co-occur with OCD in approximately 90% of individuals with lifetime OCD 2
• Both diagnoses can be made when obsessions/compulsions are distinct from anxiety symptoms and each causes independent functional impairment 2

Treatment Implications

If OCD is confirmed:

• Initiate Cognitive Behavioral Therapy with Exposure and Response Prevention (ERP) as first-line treatment 3, 4
• Consider sertraline 50 mg daily as first-line SSRI pharmacotherapy for moderate-to-severe symptoms 3, 4
• Focus on preventing reassurance-seeking compulsions and mental rituals 3

If anxiety disorder is diagnosed:

• Treatment may include SSRIs at standard anxiety doses, cognitive-behavioral therapy focused on anxiety management, and addressing underlying relationship security concerns 3
• The approach differs fundamentally from OCD treatment as it does not require exposure and response prevention 3