What symptoms meet the criteria for Obsessive-Compulsive Disorder (OCD)?

Diagnostic Criteria for Obsessive-Compulsive Disorder (OCD)

OCD is characterized by the presence of obsessions and/or compulsions that are time-consuming (taking >1 hour per day), cause significant distress, or impair social, occupational, or other important areas of functioning. 1

Core Diagnostic Features

Obsessions

Obsessions are defined by:

• Recurrent and persistent thoughts, urges, or impulses experienced as intrusive and unwanted
• Causing marked anxiety or distress in most individuals
• Attempts by the individual to ignore, suppress, or neutralize these thoughts with some other thought or action (compulsion) 1

Common obsession themes include:

• Contamination concerns (dirt, germs)
• Harm-related concerns
• Intrusive aggressive, sexual, or religious thoughts
• Symmetry concerns
• Hoarding concerns 1

Compulsions

Compulsions are defined by:

• Repetitive behaviors (e.g., hand washing, checking, ordering) or mental acts (e.g., praying, counting, repeating words silently)
• Performed in response to an obsession or according to rigidly applied rules
• Aimed at preventing/reducing anxiety or distress, or preventing some dreaded event
• Not realistically connected to what they are designed to neutralize or prevent, or are clearly excessive 1

Common compulsions include:

• Washing, showering, cleaning
• Checking
• Mental rituals or praying
• Ordering, straightening, repeating, or counting
• Hoarding behaviors 1

Differential Diagnostic Considerations

The symptoms must NOT be better explained by:

• Physiological effects of substances or medical conditions
• Other mental disorders such as:
  • Generalized anxiety disorder (excessive worries)
  • Body dysmorphic disorder (preoccupation with appearance)
  • Hoarding disorder (difficulty discarding possessions)
  • Trichotillomania (hair-pulling)
  • Excoriation disorder (skin-picking)
  • Stereotypic movement disorder
  • Eating disorders (ritualized eating behavior)
  • Substance-related disorders (preoccupation with substances)
  • Illness anxiety disorder (preoccupation with having an illness)
  • Paraphilic disorders (sexual urges or fantasies)
  • Impulse-control disorders
  • Major depressive disorder (guilty ruminations)
  • Schizophrenia spectrum disorders (thought insertion, delusional preoccupations)
  • Autism spectrum disorder (repetitive patterns of behavior) 1

Clinical Specifiers

Insight Specifiers

• With good or fair insight: Individual recognizes OCD beliefs are definitely or probably not true
• With poor insight: Individual thinks OCD beliefs are probably true
• With absent insight/delusional beliefs: Individual is completely convinced OCD beliefs are true 1

Tic-Related Specifier

• Tic-related: Individual has a current or past history of a tic disorder 1

Symptom Dimensions

Research consistently identifies 4-5 symptom dimensions in OCD:

1. Contamination dimension: Contamination/cleanliness obsessions with cleaning compulsions
2. Harm-related dimension: Thoughts of harm with checking compulsions
3. Unacceptability/forbidden thoughts dimension: Aggressive, sexual, religious obsessions with mental rituals
4. Symmetry dimension: Symmetry obsessions with ordering, repeating, counting compulsions
5. Hoarding dimension: Hoarding concerns with related compulsions 1

Clinical Significance Threshold

For a diagnosis of OCD, symptoms must be:

• Time-consuming (taking more than 1 hour per day), OR
• Cause clinically significant distress, OR
• Result in functional impairment in social, occupational, or other important areas 1, 2

Common Pitfalls in Diagnosis

1. Failure to distinguish from normal rituals: Many people have rituals or superstitions, but these don't qualify as OCD unless they cause significant distress or impairment.

2. Confusing OCD with other disorders: Particularly challenging to differentiate from other obsessive-compulsive related disorders like body dysmorphic disorder or hoarding disorder 3.

3. Missing poor insight presentations: Patients with poor insight may not recognize their symptoms as excessive, which can lead to misdiagnosis as psychotic disorders 1.

4. Overlooking comorbidities: OCD frequently co-occurs with depression and anxiety disorders, which may complicate the clinical picture 4.

5. Not recognizing primarily mental compulsions: Some patients perform mainly mental rituals (counting, praying, reviewing) that may be less obvious than behavioral compulsions 1.

By carefully assessing the presence of obsessions and compulsions, their impact on functioning, and ruling out other potential causes of symptoms, clinicians can accurately diagnose OCD and develop appropriate treatment plans that may include SSRIs and/or cognitive-behavioral therapy with exposure and response prevention 5, 6.