- 1 DSM-II
- 2 DSM-III
- 3 DSM-IV
- 3.1 Diagnostic Criteria
- 3.2 Specifier
- 3.3 Differential Diagnosis
- 3.3.1 Anxiety Disorder Due to a General Medical Condition and Substance-Induced Anxiety Disorder
- 3.3.2 Body Dysmorphic Disorder, Specific Phobia, Social Phobia, and Trichotillomania
- 3.3.3 Major Depressive Episode
- 3.3.4 Generalized Anxiety Disorder
- 3.3.5 Hypochondriasis or Specific Phobia
- 3.3.6 Delusional Disorder and Psychotic Disorder Not Otherwise Specified
- 3.3.7 Schizophrenia
- 3.3.8 Tic Disorder and Stereotypic Movement Disorder
- 3.3.9 Eating Disorders, Paraphilias, Pathological Gambling, and Substance-Related Disorders
- 3.3.10 Obsessive-Compulsive Personality Disorder
- 3.3.11 Superstitions and repetitive checking behaviors
- 4 DSM-5
- 4.1 Diagnostic Criteria
- 4.2 Specifiers
- 4.3 Differential Diagnosis
- 4.3.1 Anxiety disorders
- 4.3.2 Major depressive disorder
- 4.3.3 Other obsessive-compulsive and related disorders
- 4.3.4 Eating disorders
- 4.3.5 Tics (in tic disorder) and stereotyped movements
- 4.3.6 Psychotic disorders
- 4.3.7 Other compulsive-like behaviors
- 4.3.8 Obsessive-compulsive personality disorder
In DSM-II, this disorder is called Obsessive compulsive neurosis
This disorder is characterized by the persistent intrusion of unwanted thoughts, urges, or actions that the patient is unable to stop. The thoughts may consist of single words or ideas, ruminations, or trains of thought often perceived by the patient as nonsensical. The actions vary from simple movements to complex rituals such as repeated handwashing. Anxiety and distress are often present either if the patient is prevented from completing his compulsive ritual or if he is concerned about being unable to control it himself.
In DSM-III, this disorder is called Obsessive Compulsive Disorder (or Obsessive Neurosis)
A. Either obsessions or compulsions:
- Obsessions: recurrent, persistent ideas, thoughts, images, or impulses that are ego-dystonic, i.e., they are not experienced as voluntarily produced, but rather as thoughts that invade consciousness and are experienced as senseless or repugnant. Attempts are made to ignore or suppress them.
- Compulsions: repetitive and seemingly purposeful behaviors that are performed according to certain rules or in a stereotyped fashion. The behavior is not an end in itself, but is designed to produce or prevent some future event or situation. However, either the activity is not connected in a realistic way with what it is designed to produce or prevent, or may be clearly excessive. The act is performed with a sense of subjective compulsion coupled with a desire to resist the compulsion (at least initially). The individual generally recognizes the senselessness of the behavior (this may not be true for young children) and does not derive pleasure from carrying out the activity, although it provides a release of tension.
B. The obsessions or compulsions are a significant source of distress to the individual or interfere with social or role functioning.
Some activities, such as eating, sexual behavior (e.g., Paraphilias), gambling, or drinking, when engaged in excessively may be referred to as "compulsive". However, these activities are not true compulsions, because the individual derives pleasure from the particular activity and may wish to resist it only because of its secondary deleterious consequences.
Obsessive brooding, rumination or preoccupation, i.e., excessive and repetitive thinking about real or potentially unpleasant circumstances, or indecisive consideration of alternatives lack the quality of being ego-dystonic, because the individual generally regards the ideation as meaningful, although possibly excessive. Therefore, these are not true obsessions.
In Schizophrenia, stereotyped behavior is common, but can be explained by delusions rather than as being ego-dystonic. Obsessions and compulsions sometimes occur transiently during the prodromal phase of Schizophrenia. In such cases, the diagnosis of Obsessive Compulsive Disorder is not made.
Other mental disorders
Tourette's Disorder, Schizophrenia, Major Depression and, very rarely, Organic Mental Disorder may have obsessions and compulsions as symptoms, but in such instances the diagnosis Obsessive Compulsive Disorder is not made. However, Obsessive Compulsive Disorder may precede the development of a Major Depression, in which case both diagnoses should be recorded.
A. Either obsessions or compulsions:
- Obsessions as defined by (1), (2), (3), and (4):
- recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
- the thoughts, impulses, or images are not simply excessive worries about real-life problems
- the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
- the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insetion)
- Compulsions as defined by (1) and (2):
- repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
- the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive
B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.
C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routing, occupational (or academic) functioning, or usual social activities or relationships.
D. If another mental disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).
E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
- With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable
With Poor Insight
This specifier can be applied when, for most of the time during the current episode, the individual does not recognize that the obsessions or compulsions are excessive or unreasonable.
Obsessive-Compulsive Disorder must be distinguished from Anxiety Disorder Due to a General Medical Condition. The diagnosis is Anxiety Disorder Due to a general Medical Condition when the obsessions or compulsions are judged to be a direct physiological consequence of a specific general medical condition. This determination is based on history, laboratory findings, or physical examination. A Substance-Induced Anxiety Disorder is distinguished from Obsessive-Compulsive Disorder by the fact that a substance (i.e., a drug of abuse, a medication, or exposure to a toxin) is judged to be etiologically related to the obsessions or compulsions.
Recurrent or intrusive thoughts, impulses, images, or behaviors may occur in the context of many other mental disorders. Obsessive-Compulsive Disorder is not diagnosed if the content of the thoughts or the activities is exclusively related to another mental disorder (e.g., preoccupation with appearance in Body Dysmorphic Disorder, preoccupation with a feared object or situation in Specific or Social Phobia, hair pulling in Trichotillomania). An additional diagnosis of Obsessive-Compulsive Disorder may still be warranted if there are obsessions or compulsions whose content is unrelated to the other mental disorder.
In a Major Depressive Episode, persistent brooding about potentially unpleasant circumstances or about possible alternative actions is common and is considered a mood-congruent aspect of depression rather than an obsession. For example, a depressed individual who ruminates that he is worthless would not be considered to have obsessions because such brooding is not ego-dystonic.
Generalized Anxiety Disorder is characterized by excessive worry, but such worries are distinguished from obsessions by the fact that the person experiences them as excessive concerns about real-life circumstances. For example, an excessive concern that one may lose one's job would constitute a worry, not an obsession. In contrast, the content of obsessions does not typically involve real-life problems, and the obsessions are experienced as inappropriate by the individual (e.g., the intrusive distressing idea that "God" is "dog" spelled backward).
If recurrent distressing thoughts are exclusively related to fears of having, or the idea that one has, a serious disease based on misinterpretation of bodily symptoms, then Hypochondriasis should be diagnosed instead of Obsessive-Compulsive Disorder. However, if the concern about having an illness is accompanied by rituals such as excessive washing or checking behavior related to concerns about the illess or about spreading it to other people, then an additional diagnosis of Obsessive-Compulsive Disorder may be indicated. If the major concern is about contracting an illness (rather than having an illness) and no rituals are involved, then a Specific Phobia of illness may be the more appropriate diagnosis.
The ability of individuals to recognize that the obsessions or compulsions are excessive or unreasonable occurs on a continuum. In some individuals with Obsessive-Compulsive Disorder, reality testing may be lost, and the obsession may reach delusional proportions (e.g., the belief that one has caused the death of another person by having willed it). In such cases, the presence of psychotic features may be indicated by an additional diagnosis of Delusional Disorder or Psychotic Disorder Not Otherwise Specified. The specifier With Poor Insight may be useful in those situations that are on the boundary between obsession and delusion (e.g., an individual whose extreme preoccupation with contamination, although exaggerated, is less intense than in a Delusional Disorder and is justified by the fact that germs are indeed ubiquitous).
The ruminative delusional thoughts and bizarre stereotyped behaviors that occurs in Schizophrenia are distinguished from obsessions and compulsions by the fact that they are not ego-dystonic and not subject to reality testing. However, some individuals manifest symptoms of both Obsessive-Compulsive Disorder and Schizophrenia and warrant both diagnoses.
Tics (in Tic Disorder) and stereotyped movements (in Stereotypic Movement Disorder) must be distinguished from compulsions. A tic is a sudden, rapid, recurrent, nonrhythmic stereotyped motor movement or vocalization (e.g., eye blinking, tongue protrusion, throat clearing). A stereotyped movement is a repetitive, seemingly driven nonfunctional motor behavior (e.g., head banging, body rocking, self-biting). In contrast to a compulsion, tics and stereotyped movement are typically less complex and are not aimed at neutralizing an obsession. Some individuals manifest symptoms of both Obsessive-Compulsive Disorder and a Tic Disorder (especially Tourette's Disorder), and both diagnoses may be warranted.
Some activities, such as eating (e.g., Eating Disorders), sexual behavior (e.g., Paraphilias), gambling (e.g., Pathological Gambling), or substance use (e.g., Alcohol Dependence or Abuse), when engaged in excessively, have been referred to as "compulsive." However, these activities are not considered to be compulsions as defined in this manual because the person usually derives pleasure from the activity and may wish to resist it only because of its deleterious consequences.
Although Obsessive-Compulsive Personality Disorder and Obsessive-Compulsive Disorder have similar names, the clinical manifestations of these disorders are quite different. Obsessive-Compulsive Personality Disorder is not characterized by the presence of obsessions or compulsions and instead involves a pervasive pattern of preoccupation with orderliness, perfectionism, and control and must begin by early adulthood. If an individual manifests symptoms of both Obsessive-Compulsive Disorder and Obsessive-Compulsive Personality Disorder, both diagnoses can be given.
Superstitions and repetitive checking behaviors
Superstitions and repetitive checking behaviors are commonly encountered in everyday life. A diagnosis of Obsessive-Compulsive Disorder should be considered only if they are particularly time consuming or result in clinically significant impairment or distress.
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
- Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
- The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
- 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 in response to an obsession or according to rules that must be applied rigidly.
- The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. (Note: Young children may not be able to articulate the aims of these behaviors or mental acts.)
B. The obsessions are time-consuming (e.g., tae more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
D.The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
- With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
- With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
- With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
- Tic-related: The individual has a current or past history of a tic disorder.
Many individuals with obsessive-compulsive disorder (OCD) have dysfunctional beliefs. These beliefs can include an inflated sense of responsibility and the tendency to overestimate threat; perfectionism and intolerance of uncertainty; and over-importance of thoughts (e.g., believing that having a forbidden thought is as bad as acting on it) and the need to control thoughts.
Individuals with OCD vary in the degree of insight they have about the accuracy of the beliefs that underlie their obsessive-compulsive symptoms. Many individuals have good or fair insight (e.g., the individual believes that the house will definitely not, probably will not, or may or may not burn down if the stove is not checked 30 times). Some have poor insight (e.g., the individual believes that the house will probably burn down if the stove is not checked 30 times), and a few (4% or less) have absent insight/delusional beliefs (e.g., the individual is convinced that the house will burn down if the stove is not checked 30 times). Insight can vary within an individual over the course of the illness. Poorer insight has been linked to worse long-term outcome.
Recurrent thoughts, avoidant behaviors, and repetitive requests for reassurance can also occur in anxiety disorders. However, the recurrent thoughts that are present in generalized anxiety disorder (i.e., worries) are usually about real-life concerns, whereas the obsessions of OC usually do not involve real-life concerns and can include content that is odd, irrational, or of a seemingly magical nature; moreover, compulsions are often present and usually linked to the obsessions. Like individuals with OCD, individuals with specific phobia can have a fear reaction to specific objects or situations; however, in specific phobia the feared object is usually much more circumscribed, and rituals are not present. In social anxiety disorder (social phobia), the feared objects or situations are limited to social interactions, and avoidance or reassurance seeking is focused on reducing this social fear.
OCD can be distinguished from the rumination of major depressive disorder, in which thoughts are usually mood-congruent and not necessarily experienced as intrusive or distressing; moreover, ruminations are not linked to compulsions, as is typical in OCD.
In body dysmorphic disorder, the obsessions and compulsions are limited to concerns about physical appearance; and in trichotillomania (hair-pulling disorder), the compulsive behavior is limited to hair pulling in the absence of obsessions. Hoarding disorder symptoms focus exclusively on the persistent difficulty of discarding or parting with possessions, marked distress associated with discarding items, and excessive accumulation of objects. However, if an individual has obsessions that are typical of OCD (e.g., concerns about incompleteness or harm), and these obsessions lead to compulsive hoarding behaviors (e.g., acquiring all objects in a set to attain a sense of completeness or not discarding old newspapers because they may contain information that could prevent harm), a diagnosis of OCD should be given instead.
OCD can be distinguished from anorexia nervosa in that in OCD the obsessions and compulsions are not limited to concerns about weight and food.
Tics (in tic disorder) and stereotyped movements
A tic is a sudden, rapid, recurrent, nonrhythmic motor movement or vocalization (e.g., eye blinking, throat clearing). A stereotyped movement is a repetitive, seemingly driven, nonfunctional motor behavior (e.g., head banging, body rocking, self-biting). Tics and stereotyped movements are typically less complex than compulsions and are not aimed at neutralizing obsessions. However, distinguishing between complex tics and compulsions can be difficult. Whereas compulsions are usually preceded by obsessions, tics are often preceded by premonitory sensory urges. Some individuals have symptoms of both OCD and a tic disorder, in which case both diagnoses may be warranted.
Some individuals with OCD have poor insight or even delusional OCD beliefs. However, they have obsessions and compulsions (distinguishing their condition from delusional disorder) and do not have other features of schizophrenia or schizoaffective disorder (e.g., hallucinations or formal thought disorder).
Other compulsive-like behaviors
Certain behaviors are sometimes described as "compulsive," including sexual behavior (in the case of paraphilias), gambling (i.e., gambling disorder), and substance use (e.g., alcohol use disorder). However, these behaviors differ from the compulsions of OCD in that the person usually derives pleasure from the activity and may with to resist it only because of its deleterious consequences.
Although obsessive-compulsive personality disorder and OCD have similar names, the clinical manifestations of these disorders are quite different. Obsessive-compulsive personality disorder is not characterized by intrusive thoughts, images, or urges or by repetitive behaviors that are performed in response to these intrusions; instead, it involves an enduring and pervasive maladaptive pattern of excessive perfectionism or rigid control. If an individual manifests symptoms of both OCD and obsessive-compulsive personality disorder, both diagnoses can be given.