What are the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria for obsessive-compulsive disorder (OCD)?

DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder

The DSM-5 criteria for obsessive-compulsive disorder (OCD) require 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

• OCD is characterized by the presence of obsessions and/or compulsions 2, 1

• Obsessions are defined as:

  • Recurrent and persistent thoughts, urges, or impulses experienced as intrusive and unwanted 1
  • 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 are defined as:

  • Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) 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 1
  • Not realistically connected to what they are designed to neutralize or prevent, or are clearly excessive 1

Clinical Significance Criteria

• The obsessions or compulsions must be time-consuming (taking >1 hour per day) 2, 1
• Must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 2, 1

Exclusion Criteria

• The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., drug of abuse, medication) or another medical condition 2, 1
• The disturbance is not better explained by symptoms of another mental disorder 2

Specifiers

The DSM-5 includes two types of specifiers for OCD:

Insight Specifiers:

• With good or fair insight: the individual recognizes that OCD beliefs are definitely or probably not true, or that they may or may not be true 2, 1
• With poor insight: the individual thinks OCD beliefs are probably true 2, 1
• With absent insight/delusional beliefs: the individual is completely convinced that OCD beliefs are true 2, 1

Tic-Related Specifier:

• Tic-related: the individual has a current or past history of a tic disorder 2, 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 2, 1
• Must be distinguished from other obsessive-compulsive related disorders (OCRDs) such as:
  • Body dysmorphic disorder (preoccupation with appearance) 2, 3
  • Hoarding disorder (difficulty discarding possessions) 2, 3
  • Trichotillomania (hair-pulling disorder) 2, 3
  • Excoriation disorder (skin-picking) 2, 3
• Differs from generalized anxiety disorder and depression where worries/ruminations are typically about real-life concerns and are less irrational/ego-dystonic than in OCD 2, 1
• Must be distinguished from psychotic disorders - individuals with OCD typically maintain some level of insight about their symptoms, though insight may vary 1, 4

Special Considerations

• Pediatric cases may present differently - young children may not be able to articulate the aims of their behaviors or mental acts 2, 5
• Males are more likely to have early-onset OCD (before puberty) and comorbid tics 2, 5
• OCD symptoms often fall into specific symptom dimensions (e.g., contamination/cleaning, harm/checking, symmetry/ordering) that tend to remain stable within individuals 2, 5

Clinical Pitfalls to Avoid

• Misdiagnosing OCD with absent insight as a psychotic disorder, which could lead to inappropriate treatment 2, 1
• Failing to distinguish OCD from normal developmental rituals in children 5
• Overlooking that OCD symptoms must be time-consuming (>1 hour daily) or cause significant distress/impairment for diagnosis 2, 1
• Not recognizing that OCD is now classified under "Obsessive-Compulsive and Related Disorders" in DSM-5, rather than as an anxiety disorder 3, 6