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

Diagnosing Obsessive-Compulsive Disorder

OCD diagnosis requires the presence of obsessions (recurrent, intrusive, ego-dystonic thoughts/images/impulses) and/or compulsions (repetitive behaviors or mental acts performed in response to obsessions) that cause marked distress, consume significant time (>1 hour/day), or substantially interfere with social or occupational functioning. 1

Core Diagnostic Criteria

The diagnosis is clinical and based on DSM criteria, requiring:

• Obsessions: Recurrent, persistent ideas, thoughts, images, or impulses that are ego-dystonic and unwanted 2
• Compulsions: Repetitive, purposeful, intentional behaviors performed in response to an obsession or in a stereotyped fashion, recognized by the person as excessive or unreasonable 2
• Functional impairment: Symptoms must cause marked distress, be time-consuming (typically >1 hour/day), or significantly interfere with social/occupational functioning 3, 2

Common Symptom Dimensions

OCD symptoms cluster into specific dimensions that are remarkably consistent across cultures: 1

• Contamination concerns with subsequent cleaning/washing rituals 1
• Harm-related obsessions with subsequent checking compulsions 1
• Symmetry/ordering concerns with arranging/ordering compulsions 1

Structured Assessment Tools

Use the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) or Children's Y-BOCS (CY-BOCS) to quantify symptom severity: 1, 3

• Y-BOCS is the gold standard clinician-rated scale measuring time spent on obsessions/compulsions, distress levels, and functional interference independent of symptom content 3
• Clinical threshold: Symptoms consuming >1 hour/day or causing significant distress/impairment 3
• Treatment response: ≥35% reduction in Y-BOCS score indicates clinically meaningful improvement 3, 2

Alternative brief assessment:

• Florida Obsessive-Compulsive Inventory (FOCI): Shorter symptom checklist with only 5 severity items, included as dimensional rating scale in DSM-5 1

For comprehensive diagnostic interviews:

• Structured Clinical Interview for DSM (SCID) or Mini International Neuropsychiatric Interview (MINI 7.0) revised for DSM-5 1

Critical Differential Diagnoses

Distinguish OCD from related conditions that may present similarly:

• Schizotypal Personality Disorder: Look for pervasive referential ideas, magical thinking across situations (not just rituals), and social/interpersonal deficits beyond OCD avoidance 4
• Social Anxiety Disorder with OCD: Differentiate realistic fear of social judgment from true referential thinking; these can be comorbid 4
• Other OCRDs: Body dysmorphic disorder, hoarding disorder, Tourette syndrome require separate assessment as they are frequently missed in standard OCD screening 1

Comorbidity Assessment

Screen for common comorbidities as 90% of OCD patients meet criteria for another lifetime disorder: 1

• Most common: Anxiety disorders (79.2% precede OCD), mood disorders (equal likelihood of preceding/following OCD), impulse-control disorders, substance use disorders 1
• Tic disorders and other OCRDs commonly co-occur 1
• Family accommodation: Assess whether family members provide reassurance, assist with avoidance, or participate in rituals, as this reinforces symptoms 1, 3

Clinical Pitfalls to Avoid

Patients often delay seeking treatment by nearly 10 years due to shame and stigma: 5

• Directly ask about specific symptom dimensions (contamination, harm, symmetry) rather than waiting for disclosure 1
• Distinguish ego-dystonic obsessions from psychotic delusions: OCD patients recognize their thoughts as excessive/unreasonable (though insight varies) 2
• Assess insight level: Poor insight requires motivational interviewing techniques and may predict treatment resistance 1
• Evaluate sensory phenomena: Some patients perform compulsions driven by "not just right" feelings rather than anxiety reduction 1

Severity and Functional Impact

Quantify impairment using standardized measures: 1

• 65.3% of 12-month OCD cases report severe role impairment on the Sheehan Disability Scale 1
• Average of 45.7 days out of role per year in affected individuals 1
• Increased mortality has been documented in OCD populations 1

Age-Specific Considerations

OCD typically begins early in life with distinct patterns: 1

• Males: Nearly 25% have onset before age 10 1
• Females: Onset typically during adolescence, though peripartum/postpartum precipitation occurs 1
• Peak risk: Ages 18-29 years for lifetime onset 1
• Children/adolescents: Use CY-BOCS for assessment; symptom dimensions similar to adults 1

Treatment Implications of Diagnosis

Once diagnosis is confirmed, initiate evidence-based treatment without delay: 1, 5

• First-line psychotherapy: Cognitive-behavioral therapy with exposure and response prevention (ERP) is most effective 1, 5
• First-line pharmacotherapy: SSRIs (fluoxetine, sertraline) or clomipramine at higher doses than used for depression 2, 6, 7, 5
• Treatment duration: 10-12 week adequate trial required before assessing response 2, 6, 7
• Maintenance: OCD is chronic; responders require long-term treatment with periodic reassessment 2, 6, 7