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

Diagnostic Criteria for Obsessive-Compulsive Disorder (OCD)

OCD is diagnosed when a patient has obsessions and/or compulsions that consume more than 1 hour per day or cause clinically significant distress or functional impairment, provided these symptoms are not better explained by substance use, medical conditions, or other psychiatric disorders. 1

Core Diagnostic Requirements

Obsessions Must Meet These Features:

• Recurrent, persistent, intrusive thoughts, urges, or images that are experienced as unwanted and cause marked anxiety or distress 1, 2
• The individual attempts to ignore, suppress, or neutralize these thoughts with another thought or action (typically by performing a compulsion) 1
• These are not simply excessive worries about real-life problems—they are ego-dystonic (experienced as inconsistent with one's self) and often involve themes of contamination, harm, symmetry, or forbidden thoughts 1, 3

Compulsions Must Meet These Features:

• Repetitive behaviors (hand washing, ordering, checking) or mental acts (praying, counting, repeating words silently) that the person feels driven to perform 1
• These behaviors are performed in response to an obsession or according to rigid rules 1
• They aim to prevent or reduce anxiety/distress or prevent a dreaded event, but are either not realistically connected to what they're designed to neutralize or are clearly excessive 1

Time and Impairment Thresholds

• Symptoms must be time-consuming, taking more than 1 hour per day 1, 4
• Must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning 1

Mandatory Exclusion Criteria

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

Insight Specifiers (Must Be Documented)

• Good or fair insight: Patient recognizes OCD beliefs are definitely or probably not true, or may or may not be true 1
• Poor insight: Patient thinks OCD beliefs are probably true 1
• Absent insight/delusional beliefs: Patient is completely convinced OCD beliefs are true 1
• Note that absent insight does not make this a psychotic disorder—avoid this common misdiagnosis that leads to inappropriate treatment 1

Critical Differential Diagnoses

Distinguishing from Autism Spectrum Disorder:

• Ask: "Do these thoughts feel like they're intruding against your will, or are they topics you enjoy thinking about?" 3
• OCD rumination is ego-dystonic (unwanted, anxiety-provoking), while autism-related repetitive thoughts are ego-syntonic (comfortable, part of routine) 3
• OCD may secondarily impair social functioning, but does not cause primary social-communication deficits seen in autism 3

Distinguishing from Generalized Anxiety Disorder:

• GAD worries are typically about real-life concerns and less irrational than OCD obsessions 1
• OCD thoughts are more ego-dystonic than GAD worries 1

Distinguishing from Normal Intrusive Thoughts:

• Normal intrusive thoughts and repetitive behaviors don't meet criteria unless they consume >1 hour daily or cause significant distress/impairment 1

Distinguishing from Other Obsessive-Compulsive Related Disorders:

• Must differentiate from body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder 1

Severity Assessment

• Use the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) as the gold standard for measuring symptom severity 1, 3
• Y-BOCS scores ≥28 (or ≥14 if only obsessions or only compulsions present) indicate severe OCD 1

Special Populations

Pediatric Considerations:

• Young children may not articulate the aims of their behaviors or mental acts 1
• Males are more likely to have early-onset OCD (before puberty) and comorbid tics 1
• PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus) presents with sudden onset of obsessive-compulsive symptoms following streptococcal infection, though the American Heart Association considers this "a yet-unproven hypothesis" 1, 5

Medical Conditions to Consider:

• Neurological conditions affecting the basal ganglia (e.g., Sydenham chorea) can present with obsessive-compulsive symptoms 1

Common Clinical Pitfalls

• Do not misdiagnose OCD with absent insight as a psychotic disorder—this leads to inappropriate antipsychotic monotherapy instead of OCD-specific treatment 1
• Recognize that OCD symptoms often fall into specific symptom dimensions (contamination, harm, symmetry, forbidden thoughts) that remain stable within individuals 1
• Be aware that significant comorbidity exists with depression, anxiety disorders, and personality disorders 6