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

Diagnostic Criteria for Obsessive-Compulsive Disorder (OCD)

The diagnosis of Obsessive-Compulsive Disorder requires the presence of obsessions and/or compulsions that are time-consuming (taking >1 hour per day) or cause clinically significant distress or impairment in functioning. 1

Core Diagnostic Features

Obsessions

• Recurrent and persistent thoughts, urges, or impulses experienced as intrusive and unwanted, causing marked anxiety or distress in most individuals 1
• The individual attempts to ignore, suppress, or neutralize these thoughts with some other thought or action (performing a compulsion) 1

Compulsions

• Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform 1
• Performed in response to an obsession or according to rules that must be applied rigidly 1
• Aimed at preventing/reducing anxiety or distress, or preventing a dreaded event, but are not realistically connected to what they are designed to neutralize or prevent, or are clearly excessive 1

Clinical Significance Criteria

• Obsessions or compulsions must be time-consuming (taking >1 hour per day) 1
• Must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 1

Exclusion Criteria

• Symptoms are not attributable to physiological effects of a substance (drug of abuse, medication) or another medical condition 1
• The disturbance is not better explained by symptoms of another mental disorder 1

Specifiers

Insight Specifiers

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

Other Specifiers

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

Differential Diagnosis

• Normal intrusive thoughts and repetitive behaviors are common but don't meet criteria for OCD unless they are time-consuming (>1 hour daily) or cause significant distress/impairment 1
• Must be distinguished from other obsessive-compulsive related disorders (OCRD) such as:
  • Body dysmorphic disorder (preoccupation with appearance) 1
  • Hoarding disorder (difficulty discarding possessions) 1
  • Trichotillomania (hair-pulling) 1
  • Excoriation disorder (skin-picking) 1
• Differs from generalized anxiety disorder and depression where worries/ruminations are typically about real-life concerns and less irrational/ego-dystonic than in OCD 1
• Must be distinguished from psychotic disorders - individuals with OCD typically maintain insight about their symptoms, though insight may vary 1

Assessment Tools

• Yale-Brown Obsessive Compulsive Scale (Y-BOCS) is the gold standard for measuring OCD symptom severity 2
• Y-BOCS scores ≥28 (or ≥14 if only obsessions or only compulsions are present) indicate severe OCD 1, 2

Special Considerations

• Pediatric cases may present differently - young children may not be able to articulate the aims of their behaviors or mental acts 1
• Pediatric autoimmune neuropsychiatric disorders associated with Streptococcus (PANDAS) represents a subtype characterized by sudden onset of obsessive-compulsive symptoms following streptococcal infection 1, 3
• Neurological conditions affecting the basal ganglia (e.g., Sydenham chorea) can present with obsessive-compulsive symptoms 1

Clinical Pitfalls

• Avoid misdiagnosing OCD with absent insight as a psychotic disorder, which could lead to inappropriate treatment 1
• Be aware that OCD symptoms often fall into specific symptom dimensions that tend to remain stable within individuals 1
• Males are more likely to have early-onset OCD (before puberty) and comorbid tics 1
• Recognize that comorbidities are common - about 90% of OCD patients have comorbid psychiatric diagnoses 4