Diagnostic Criteria for Obsessive-Compulsive Disorder (OCD)
According to DSM-5 diagnostic criteria, OCD is diagnosed when a patient presents with obsessions, compulsions, or both, that are time-consuming (taking >1 hour per day) or cause significant distress or functional impairment. 1
Core Diagnostic Features
Obsessions
- Definition: Recurrent, persistent thoughts, urges, or images experienced as intrusive and unwanted, causing marked anxiety or distress
- Key characteristic: The individual attempts to ignore, suppress, or neutralize these thoughts with another thought or action (compulsion)
Compulsions
- Definition: Repetitive behaviors (e.g., hand washing, checking) or mental acts (e.g., praying, counting) performed in response to an obsession or according to rigid rules
- Key characteristic: These behaviors aim to reduce anxiety or prevent a dreaded event but are excessive or not realistically connected to what they're designed to prevent
Diagnostic Requirements
- Symptoms must cause significant distress or impairment in functioning
- Symptoms must be time-consuming (>1 hour daily)
- Symptoms cannot be better explained by another mental disorder
- Symptoms are not attributable to substance effects or another medical condition
Common Symptom Patterns
| Obsession Type | Associated Compulsions |
|---|---|
| Contamination concerns | Cleaning/washing rituals |
| Harm/danger concerns | Checking behaviors |
| Symmetry concerns | Ordering/arranging behaviors |
| Intrusive aggressive/sexual thoughts | Mental rituals |
Differential Diagnosis
OCD must be distinguished from:
- 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/fantasies)
- Impulse control disorders
- Major depression with rumination
Medical Considerations
Certain neurological conditions can cause OCD-like symptoms:
- Basal ganglia lesions
- Frontal lobe lesions
- Sydenham chorea
- Neuroacanthocytosis
- PANDAS/PANS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) 1
Treatment Options
First-line Pharmacotherapy
First-line Psychotherapy
- Cognitive-Behavioral Therapy with Exposure and Response Prevention (CBT-ERP) is the most effective psychotherapeutic approach 5
- Involves gradual exposure to feared stimuli while preventing compulsive responses
- Typically requires 12-16 sessions
Treatment-Resistant OCD
For patients who don't respond adequately to first-line treatments:
- Augmentation with antipsychotics
- Combination of medication and CBT-ERP
- Higher doses of SRIs
- For severe, treatment-refractory cases: neurosurgical procedures, deep brain stimulation, or transcranial magnetic stimulation may be considered 5
Clinical Pearls and Pitfalls
- OCD affects 1-3% of the population and typically begins during adolescence or early adulthood 6
- Patients often delay seeking treatment due to shame about their symptoms
- The full therapeutic effect of medication may take 4-12 weeks to manifest
- Regular reassessment is necessary to determine ongoing treatment needs
- Long-term maintenance treatment is often required as OCD tends to be chronic
- Comorbidities are common and should be assessed, particularly depression, anxiety disorders, and personality disorders 7
- OCD is now classified within the "Obsessive-Compulsive and Related Disorders" grouping in diagnostic systems, reflecting shared features with conditions like body dysmorphic disorder and hoarding disorder 8
Remember that early diagnosis and appropriate treatment significantly improve long-term outcomes and quality of life for patients with OCD.