OCD: Beware Misdiagnosis

Diagnosing a mental health patient with a precise clinical disorder can be a difficult undertaking, and some types of mental disorders are particularly easily confused with others. In most situations, allowing concurrent diagnoses of different clinical disorders ' and even being generally over-inclusive in identifying a patient's different disorders ' is not harmful to the patient. In the case of the diagnosis of “obsessive compulsive disorder” (OCD), however, a misdiagnosis may send the patient down the wrong treatment path entirely. Such misdiagnoses can be particularly prevalent where OCD patients are abusing substances in an effort to self-medicate. But no matter the difficulties, misdiagnosed patients may have a viable claim for medical malpractice, so knowing the common diagnostic pitfalls is helpful.

Making the Diagnosis

There is a description of each type of clinical disorder in the DSM V, the most recently released version of the Diagnostic and Statistical Manual used by psychiatrists to diagnose clinical disorders. Unfortunately, many of the disorders have overlapping criteria. In fact, the manual states that “there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries.”

Obsessive Compulsive Disorder is diagnosed when a patient has either recurrent “obsessions” or “compulsions.” Obsessions are types of uncontrollable thoughts ' like thinking you left the stove on. Compulsions are types of uncontrollable actions that patient needs to take, such as repeated checking to make sure the stove is off.'

The DSM defines obsessions as “recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress. The DSM defines compulsions as “repetitive behaviors (e.g., hand washing) or mental acts (e.g., 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.”

Currently, there are very good treatment options for patients diagnosed with OCD. There are classes of SSRI (selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitors) medications that appear to slow down the obsessive thoughts and prevent obsessive thoughts from leading to compulsive behavior. Many people who begin SSRI therapy can find near complete relief from symptoms of OCD. Unfortunately, OCD can be a tricky diagnosis to make. The DSM V has recently changed the diagnostic criteria in an effort to better identify OCD and its related disorders, such as Body Dysmorphic Disorder and Hoarding Disorder.'

One key part of the OCD diagnosis is that the obsessions are not supposed to be “simply excessive worries about real-life problems.” This can be a hard criterion to apply where the patient is an otherwise high-functioning individual with a lot of real-life responsibilities (such as a doctor, lawyer or banker). These high-functioning individuals may have important real-life worries that may make excessive worrying or checking behavior look like “simply excessive worries about real-life problems.” For example, in one recent medical malpractice case, a client had OCD that manifested in his repeated checking of paperwork to make sure he hadn't missed anything. To all the world, he looked like a very careful and conscientious professional, not a patient suffering from OCD.

Are We Treating the Right Condition?

Unfortunately, many substances that are subject to abuse are actually good treatments for OCD. Anything that depresses the central nervous system, such as opioid medication or alcohol, can have a dampening effect on the obsessive thoughts of the OCD patient. In fact, opioid medication was once prescribed to treat OCD, despite the obvious potential for addiction. This being the case, many OCD patients discover these substances on their own and may have been self-medicating for years before they are seen by a psychiatrist. This self-medication can sometimes lead to the patient being misdiagnosed with Substance Abuse Disorder, and the underlying OCD diagnosis can be missed.'

There is a potential danger to the patient with a misdiagnosis of Substance Abuse Disorder. First, the treatment for that disorder is relatively rigid. It typically involves some version of a 12-step treatment program, on either an inpatient or an outpatient basis. These programs are extremely effective at treating addicts, but not necessarily OCD sufferers. For example, the first part of such programs involves admitting that one is an addict; the second, obviously, is refraining from consuming intoxicating substances. For someone suffering from OCD, however, this might actually lead to an exacerbation of OCD symptoms because the obsessive thoughts will return when the central nervous system depressants are withdrawn.

In addition, once the patient successfully completes a substance abuse rehabilitation program, he or she may still have unaddressed OCD issues. This makes it highly likely that the patient will relapse unless proper drug therapy for OCD can be instituted after rehabilitation. Sending a patient out into the world with undiagnosed OCD, with its potential for relapse into abusive drugs, can expose the health care practitioner to suits for malpractice.”

Conclusion

Obviously, the correct diagnosis is important in all areas of medicine, and for all diseases and conditions, but some health issues are easier to misdiagnose than others. When this is the case, extra care must be taken ' especially when, as with OCD and substance abuse, the treatment for the one condition is contraindicated for the condition that is “missed.”

Sean McElligott, a member of this newsletter's Board of Editors, is a member of Koskoff, Koskoff & Bieder. P.C., Bridgeport, CT.

Diagnosing a mental health patient with a precise clinical disorder can be a difficult undertaking, and some types of mental disorders are particularly easily confused with others. In most situations, allowing concurrent diagnoses of different clinical disorders ' and even being generally over-inclusive in identifying a patient's different disorders ' is not harmful to the patient. In the case of the diagnosis of “obsessive compulsive disorder” (OCD), however, a misdiagnosis may send the patient down the wrong treatment path entirely. Such misdiagnoses can be particularly prevalent where OCD patients are abusing substances in an effort to self-medicate. But no matter the difficulties, misdiagnosed patients may have a viable claim for medical malpractice, so knowing the common diagnostic pitfalls is helpful.

Making the Diagnosis

There is a description of each type of clinical disorder in the DSM V, the most recently released version of the Diagnostic and Statistical Manual used by psychiatrists to diagnose clinical disorders. Unfortunately, many of the disorders have overlapping criteria. In fact, the manual states that “there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries.”

Obsessive Compulsive Disorder is diagnosed when a patient has either recurrent “obsessions” or “compulsions.” Obsessions are types of uncontrollable thoughts ' like thinking you left the stove on. Compulsions are types of uncontrollable actions that patient needs to take, such as repeated checking to make sure the stove is off.'

The DSM defines obsessions as “recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress. The DSM defines compulsions as “repetitive behaviors (e.g., hand washing) or mental acts (e.g., 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.”

Currently, there are very good treatment options for patients diagnosed with OCD. There are classes of SSRI (selective serotonin re-uptake inhibitors or serotonin-specific reuptake inhibitors) medications that appear to slow down the obsessive thoughts and prevent obsessive thoughts from leading to compulsive behavior. Many people who begin SSRI therapy can find near complete relief from symptoms of OCD. Unfortunately, OCD can be a tricky diagnosis to make. The DSM V has recently changed the diagnostic criteria in an effort to better identify OCD and its related disorders, such as Body Dysmorphic Disorder and Hoarding Disorder.'

One key part of the OCD diagnosis is that the obsessions are not supposed to be “simply excessive worries about real-life problems.” This can be a hard criterion to apply where the patient is an otherwise high-functioning individual with a lot of real-life responsibilities (such as a doctor, lawyer or banker). These high-functioning individuals may have important real-life worries that may make excessive worrying or checking behavior look like “simply excessive worries about real-life problems.” For example, in one recent medical malpractice case, a client had OCD that manifested in his repeated checking of paperwork to make sure he hadn't missed anything. To all the world, he looked like a very careful and conscientious professional, not a patient suffering from OCD.

Are We Treating the Right Condition?

Unfortunately, many substances that are subject to abuse are actually good treatments for OCD. Anything that depresses the central nervous system, such as opioid medication or alcohol, can have a dampening effect on the obsessive thoughts of the OCD patient. In fact, opioid medication was once prescribed to treat OCD, despite the obvious potential for addiction. This being the case, many OCD patients discover these substances on their own and may have been self-medicating for years before they are seen by a psychiatrist. This self-medication can sometimes lead to the patient being misdiagnosed with Substance Abuse Disorder, and the underlying OCD diagnosis can be missed.'

There is a potential danger to the patient with a misdiagnosis of Substance Abuse Disorder. First, the treatment for that disorder is relatively rigid. It typically involves some version of a 12-step treatment program, on either an inpatient or an outpatient basis. These programs are extremely effective at treating addicts, but not necessarily OCD sufferers. For example, the first part of such programs involves admitting that one is an addict; the second, obviously, is refraining from consuming intoxicating substances. For someone suffering from OCD, however, this might actually lead to an exacerbation of OCD symptoms because the obsessive thoughts will return when the central nervous system depressants are withdrawn.

In addition, once the patient successfully completes a substance abuse rehabilitation program, he or she may still have unaddressed OCD issues. This makes it highly likely that the patient will relapse unless proper drug therapy for OCD can be instituted after rehabilitation. Sending a patient out into the world with undiagnosed OCD, with its potential for relapse into abusive drugs, can expose the health care practitioner to suits for malpractice.”

Conclusion

Obviously, the correct diagnosis is important in all areas of medicine, and for all diseases and conditions, but some health issues are easier to misdiagnose than others. When this is the case, extra care must be taken ' especially when, as with OCD and substance abuse, the treatment for the one condition is contraindicated for the condition that is “missed.”

Sean McElligott, a member of this newsletter's Board of Editors, is a member of Koskoff, Koskoff & Bieder. P.C., Bridgeport, CT.