What are the diagnostic criteria and steps for Obsessive-Compulsive Disorder (OCD)?

Diagnosing Obsessive-Compulsive Disorder (OCD)

A diagnosis of OCD requires the presence of time-consuming obsessions and compulsions (taking more than 1 hour per day) that cause substantial distress or functional impairment. 1

Diagnostic Criteria

OCD is characterized by:

1. Obsessions: Recurrent, persistent, and intrusive thoughts, urges, or images that cause anxiety or distress
2. Compulsions: Repetitive behaviors or mental acts performed in response to obsessions to reduce anxiety or prevent harm
3. Time consumption: Symptoms must take up more than 1 hour per day
4. Distress/Impairment: Must cause significant distress or functional impairment
5. Not attributable: Symptoms not better explained by another mental disorder or substance use

Diagnostic Assessment Process

Step 1: Comprehensive Psychiatric History and Mental Status Examination

• Focus on identifying obsessive-compulsive symptoms, their severity, and impact on functioning
• Determine onset, course, and previous treatments
• Assess for common symptom dimensions:
  • Contamination concerns with cleaning rituals
  • Harm concerns with checking behaviors
  • Symmetry concerns with ordering behaviors 1

Step 2: Structured Diagnostic Interviews

Use one of these validated diagnostic instruments:

• Structured Clinical Interview for DSM-5 (SCID-5) - gold standard for adults 1
• Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5) - available for both adults and children 1
• Mini International Neuropsychiatric Interview (MINI version 7.0) - shorter alternative for both adults and children 1
• Structured Clinical Interview for Obsessive-Compulsive Spectrum Disorders (SCID-OCSD) - specialized for OCD and related disorders 2

Step 3: Symptom Severity Assessment

Administer one of these validated severity measures:

• Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) - gold standard for adults 1

  • Includes symptom checklist and severity scale
  • Available in self-report format
  • Score ≥ 14 indicates at least moderate severity 2

• Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) - for pediatric patients 1

• Dimensional Yale-Brown Obsessive-Compulsive Scale (DY-BOCS) - for detailed assessment of symptom dimensions 1

• Florida Obsessive-Compulsive Inventory (FOCI) - shorter alternative with symptom checklist and five severity items 1

Step 4: Assessment of Related Factors

Evaluate:

• Insight: Determine if patient has good/fair insight, poor insight, or absent insight/delusional beliefs 1
• Presence of tics: Current or past history of tic disorders 1
• Family accommodation: Assess how family members may facilitate OCD symptoms 1
• Functional impairment: Evaluate impact on relationships, work/school, and daily activities 1

Step 5: Differential Diagnosis

Rule out conditions with similar presentations:

• Other Obsessive-Compulsive Related Disorders (OCRDs):

  • Body dysmorphic disorder
  • Hoarding disorder
  • Trichotillomania
  • Excoriation disorder 1

• Anxiety disorders: Especially generalized anxiety disorder (focuses on real-life concerns, less irrational, lacks compulsions) 1

• Depression: Ruminations are typically about real-life concerns, less ego-dystonic 1

• Psychotic disorders: Distinguish OCD with poor/absent insight from schizophrenia spectrum disorders 1

• Substance-related disorders: Often have ego-syntonic, gratifying components 1

Common Pitfalls in OCD Diagnosis

1. Delayed diagnosis: On average, diagnosis is delayed by almost 10 years due to lack of recognition and stigma 3

2. Misdiagnosis: Patients with poor insight may be misdiagnosed with psychotic disorders 1

3. Overlooking comorbidities: 90% of OCD patients have comorbid conditions, especially anxiety disorders, mood disorders, and impulse-control disorders 1

4. Confusing normal intrusive thoughts with OCD: Normal intrusive thoughts don't cause significant distress or impairment requiring time-consuming rituals 1

5. Missing pediatric OCD: Early-onset OCD (before puberty) is more common in males and often associated with tics 1

Clinical Pearls

• OCD affects 1-3% of the population but is underdiagnosed and undertreated 4, 3
• Only 30.9% of severe OCD cases receive appropriate treatment 1
• Early intervention significantly improves quality of life and reduces functional disability 3
• Males are more likely to have early-onset OCD (before puberty) with comorbid tics 1
• OCD symptoms are remarkably consistent across different cultures and regions 1

By following this structured diagnostic approach, clinicians can accurately identify OCD, assess its severity, and initiate appropriate treatment to improve morbidity, mortality, and quality of life outcomes.