Diagnostic Features
The essential features of Obsessive-Compulsive Disorder are recurrent obsessions or compulsions (Criterion A) that are severe enough to be time consuming (i.e., they take more than 1 hour a day) or cause marked distress or significant impairment (Criterion C). At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable (Criterion B). If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (Criterion D). 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 (Criterion E).

Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. The intrusive and inappropriate quality of the obsessions has been referred to as “ego-dystonic.” This refers to the individual’s sense that the content of the obsession is alien, not within his or her own control, and not the kind of thought that he or she would expect to have. However, the individual is able to recognize that the obsessions are the product of his or her own mind and are not imposed from without (as in thought insertion).

The most common obsessions are repeated thoughts about contamination (e.g., becoming contaminated by shaking hands), repeated doubts (e.g., wondering whether one has performed some act such as having hurt someone in a traffic accident or having left a door unlocked), a need to have things in a particular order (e.g., intense distress when objects are disordered or asymmetrical), aggressive or horrific impulses (e.g., to hurt one’s child or to shout an obscenity in church), and sexual imagery (e.g., a recurrent pornographic image). The thoughts, impulses, or images are not simply excessive worries about real-life problems (e.g., concerns about current ongoing difficulties in life, such as financial, work, or school problems) and are unlikely to be related to a real-life problem.

The individual with obsessions usually attempts to ignore or suppress such thoughts or impulses or to neutralize them with some other thought or action (i.e., a compulsion). For example, an individual plagued by doubts about having turned off the stove attempts to neutralize them by repeatedly checking to ensure that it is off.

Compulsions are repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification. In most cases, the person feels driven to perform the compulsion to reduce the distress that accompanies an obsession or to prevent some dreaded event or situation. For example, individuals with obsessions about being contaminated may reduce their mental distress by washing their hands until their skin is raw; individuals distressed by obsessions about having left a door unlocked may be driven to check the lock every few minutes; individuals distressed by unwanted blasphemous thoughts may find relief in counting to 10 backward and forward 100 times for each thought. In some cases, individuals perform rigid or stereotyped acts according to idiosyncratically elaborated rules without being able to indicate why they are doing them. By definition, compulsions are either clearly excessive or are not connected in a realistic way with what they are designed to neutralize or prevent. The most common compulsions involve washing and cleaning, counting, checking, requesting or demanding assurances, repeating actions, and ordering.

By definition, adults with Obsessive-Compulsive Disorder have at some point recognized that the obsessions or compulsions are excessive or unreasonable. This requirement does not apply to children because they may lack sufficient cognitive awareness to make this judgment. However, even in adults there is a broad range of insight into the reasonableness of the obsessions or compulsions. Some individuals are uncertain about the reasonableness of their obsessions or compulsions, and any given individual’s insight may vary across times and situations. For example, the person may recognize a contamination compulsion as unreasonable when discussing it in a “safe situation” (e.g., in the therapist’s office), but not when forced to handle money. At those times when the individual recognizes that the obsessions and compulsions are unreasonable, he or she may desire or attempt to resist them. When attempting to resist a compulsion, the individual may have a sense of mounting anxiety or tension that is often relieved by yielding to the compulsion. In the course of the disorder, after repeated failure to resist the obsessions or compulsions, the individual may give in to them, no longer experience a desire to resist them, and may incorporate the compulsions into his or her daily routines.

The obsessions or compulsions must cause marked distress, be time consuming (take more than 1 hour per day), or significantly interfere with the individual’s normal routine, occupational functioning, or usual social activities or relationships with others. Obsessions or compulsions can displace useful and satisfying behavior and can be highly disruptive to overall functioning. Because obsessive intrusions can be distracting, they frequently result in inefficient performance of cognitive tasks that require concentration, such as reading or computation. In addition, many individuals avoid objects or situations that provoke obsessions or compulsions. Such avoidance can become extensive and can severely restrict general functioning.

Specifier
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.

Associated Features and Disorders

Associated descriptive features and mental disorders. Frequently there is avoidance of situations that involve the content of the obsessions, such as dirt or contamination. For example, a person with obsessions about dirt may avoid public restrooms or shaking hands with strangers. Hypochondriacal concerns are common, with repeated visits to physicians to seek reassurance. Guilt, a pathological sense of responsibility, and sleep disturbances may be present. There may be excessive use of alcohol or of sedative, hypnotic, or anxiolytic medications. Performing compulsions may become a major life activity, leading to serious marital, occupational, or social disability. Pervasive avoidance may leave an individual housebound.

In adults, Obsessive-Compulsive Disorder may be associated with Major Depressive Disorder, some other Anxiety Disorders (i.e., Specific Phobia, Social Phobia, Panic Disorder, Generalized Anxiety Disorder), Eating Disorders, and some Personality Disorders (i.e., Obsessive-Compulsive Personality Disorder, Avoidant Personality Disorder, Dependent Personality Disorder). In children, it may also be associated with Learning Disorders and Disruptive Behavior Disorders. There is a high incidence of Obsessive-Compulsive Disorder in children and adults with Tourette’s Disorder, with estimates ranging from approximately 35% to 50%. The incidence of Tourette’s Disorder in Obsessive-Compulsive Disorder is lower, with estimates ranging between 5% and 7%. Between 20% and 30% of individuals with Obsessive-Compulsive Disorder have reported current or past tics.

Associated laboratory findings. No laboratory findings have been identified that are diagnostic of Obsessive-Compulsive Disorder. However, a variety of laboratory findings have been noted to be abnormal in groups of individuals with Obsessive-Compulsive Disorder relative to control subjects. There is some evidence that some serotonin agonists given acutely cause increased symptoms in some individuals with the disorder. Individuals with the disorder may exhibit increased autonomic activity when confronted in the laboratory with circumstances that trigger an obsession. Physiological reactivity decreases after the performance of compulsions.

Associated physical examination findings and general medical conditions. Dermatological problems caused by excessive washing with water or caustic cleaning agents may be observed.

Specific Culture, Age, and Gender Features
Culturally prescribed ritual behavior is not in itself indicative of Obsessive-Compulsive Disorder unless it exceeds cultural norms, occurs at times and places judged inappropriate by others of the same culture, and interferes with social role functioning. Although cultural factors may not lead to Obsessive-Compulsive Disorder per se, religious and cultural beliefs may influence the themes of obsessions and compulsions (e.g., Orthodox Jews with religious compulsions may have symptoms focusing on dietary practices). Important life transitions and mourning may lead to an intensification of ritual behavior that may appear to be an obsession to a clinician who is not familiar with the cultural context.

Presentations of Obsessive-Compulsive Disorder in children are generally similar to those in adulthood. Washing, checking, and ordering rituals are particularly common in children. Children generally do not request help, and the symptoms may not be ego-dystonic. More often the problem is identified by parents, who bring the child in for treatment. Gradual declines in schoolwork secondary to impaired ability to concentrate have been reported. Like adults, children are more prone to engage in rituals at home than in front of peers, teachers, or strangers. For a small subset of children, Obsessive-Compulsive Disorder may be associated with Group A beta-hemolytic streptococcal infection (e.g., scarlet fever and “strep throat”). This form of Obsessive-Compulsive Disorder is characterized by prepubertal onset, associated neurological abnormalities (e.g., choreiform movements and motoric hyperactivity) and an abrupt onset of symptoms or an episodic course in which exacerbations are temporally related to the streptococcal infections. Older adults tend to show more obsessions concerning morality and washing rituals compared with other types of symptoms.

In adults, this disorder is equally common in males and females. However, in childhood-onset Obsessive-Compulsive Disorder, the disorder is more common in boys than in girls.

Prevalence
Community studies have estimated a lifetime prevalence of 2.5% and a 1-year prevalence of 0.5%-2.1% in adults. However, methodological problems with the assessment tool used raise the possibility that the true prevalence rates are much lower. Community studies of children and adolescents have estimated a lifetime prevalence of 1%-2.3% and a 1-year prevalence of 0.7%. Research indicates that prevalence rates of Obsessive-Compulsive Disorder are similar in many different cultures around the world.

Course
Although Obsessive-Compulsive Disorder usually begins in adolescence or early adulthood, it may begin in childhood. Modal age at onset is earlier in males than in females: between ages 6 and 15 years for males and between ages 20 and 29 years for females. For the most part, onset is gradual, but acute onset has been noted in some cases. The majority of individuals have a chronic waxing and waning course, with exacerbation of symptoms that may be related to stress. About 15% show progressive deterioration in occupational and social functioning. About 5% have an episodic course with minimal or no symptoms between episodes.

Familial Pattern
The concordance rate for Obsessive-Compulsive Disorder is higher for monozygotic twins than it is for dizygotic twins. The rate of Obsessive-Compulsive Disorder in first-degree biological relatives of individuals with Obsessive-Compulsive Disorder and in first-degree biological relatives of individuals with Tourette’s Disorder is higher than that in the general population.

Differential Diagnosis
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 illness 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 occur 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 movements 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 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.

Diagnostic criteria for Obsessive-Compulsive Disorder

A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):
(1) 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
(2) the thoughts, impulses, or images are not simply excessive worries about real-life problems
(3) the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action
(4) 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 insertion)
Compulsions as defined by (1) and (2):
(1) 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
(2) 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 routine, occupational (or academic) functioning, or usual social activities or relationships.
D. If another Axis I 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.

Specify if:

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