Obsessive-compulsive disorder

Essential (Required) Features:

• Presence of persistent obsessions and/or compulsions.
• Obsessions are repetitive and persistent thoughts (e.g., of contamination), images (e.g., of violent scenes), or impulses/urges (e.g., to stab someone) that are experienced as intrusive and unwanted, and are commonly associated with anxiety. The individual typically attempts to ignore or suppress obsessions or to neutralize them by performing compulsions.
• Compulsions are repetitive behaviours or rituals, including repetitive mental acts, that the individual feels driven to perform in response to an obsession, according to rigid rules, or to achieve a sense of ‘completeness’. Examples of overt behaviours include repetitive washing, checking, and ordering of objects. Examples of analogous mental acts include mentally repeating specific phrases in order to prevent negative outcomes, reviewing a memory to make sure that one has caused no harm, and mentally counting objects. Compulsions are either not connected in a realistic way to the feared event (e.g., arranging items symmetrically to prevent harm to a loved one) or are clearly excessive (e.g., showering daily for hours to prevent illness).
• Obsessions and compulsions are time-consuming (e.g., take more than 1 hour per day) or result in significant distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. If functioning is maintained, it is only through significant additional effort.
• The symptoms or behaviours are not a manifestation of another medical condition (e.g., basal ganglia ischemic stroke) and are not due to the effects of a substance or medication on the central nervous system (e.g., amphetamine), including withdrawal effects.

Insight specifiers:

Individuals with Obsessive-Compulsive Disorder vary in the degree of insight they have about the accuracy of the beliefs that underlie their obsessive-compulsive symptoms. Although many can acknowledge that their thoughts or behaviours are untrue or excessive, some cannot, and the beliefs of a small minority of individuals with Obsessive-Compulsive Disorder may at times appear to be delusional in the degree of conviction or fixity with which these beliefs are held (e.g., an individual is convinced that she will become seriously ill if she does not maintain her washing rituals). Insight may vary substantially even over short periods of time, for example depending on the level of current anxiety or distress, and should be assessed with respect to a time period that is sufficient to allow for such fluctuation (e.g., a few days or a week). The degree of insight that an individual exhibits in the context of Obsessive-Compulsive Disorder can be specified as follows:

6B20.0 Obsessive-Compulsive Disorder with fair to good insight

• Much of the time, the individual is able to entertain the possibility that their disorder-specific beliefs may not be true and they are willing to accept an alternative explanation for their experience. This specifier level may still be applied if, at circumscribed times (e.g., when highly anxious), the individual demonstrates no insight.

6B20.1 Obsessive-Compulsive Disorder with poor to absent insight

• Most or all of the time, the individual is convinced that the disorder-specific beliefs are true and they cannot accept an alternative explanation for their experience. The lack of insight exhibited by the individual does not vary markedly as a function of anxiety level.

6B20.Z Obsessive-Compulsive Disorder, unspecified

Additional Clinical Features:

• The content of obsessions and compulsions varies among individuals and can be grouped into different themes or symptom dimensions, including: cleaning (i.e., contamination obsessions and cleaning compulsions); symmetry (i.e., symmetry obsessions and repeating, ordering, and counting compulsions); forbidden or taboo thoughts (e.g., aggressive, sexual, and religious obsessions) and related compulsions. Some individuals have difficulties discarding objects and accumulate (i.e., hoard) them as a consequence of typical obsessions, such as fears of harming others (see Boundary with Other Obsessive-Compulsive or Related Disorders, under Hoarding Disorder). Individuals usually manifest symptoms on more than one dimension.
• Although compulsions are not done for pleasure, their performance may result in temporary relief from anxiety or distress or a temporary sense of completeness.
• Individuals with Obsessive-Compulsive Disorder experience a range of affect when confronted with situations that trigger obsessions and compulsions. These affects can include marked anxiety or panic attacks, strong feelings of disgust, or a distressing sense of ‘incompleteness’ or uneasiness until things look, feel, or sound ‘just right’.
• Individuals with Obsessive-Compulsive Disorder often avoid people, places, and things that trigger obsessions and compulsions.
• Common beliefs in Obsessive-Compulsive Disorder include an inflated sense of responsibility, overestimation of threat, perfectionism, intolerance of uncertainty, and overvaluation of the power of thoughts (e.g., believing that having a forbidden thought is as bad as acting on it).
• The severity of Obsessive-Compulsive Disorder symptomatology varies such that some individuals spend a few hours per day obsessing or engaging in compulsions, whereas others have near constant intrusive thoughts or compulsions that can be incapacitating.
• When both obsessions and compulsions are present there is typically a discernible relationship between them in content or temporal sequence. Compulsions are most often performed in response to obsessions (e.g., excessive hand washing due to fear of contamination). However, in some individuals with Obsessive-Compulsive Disorder, particularly during the initial phase of the disorder, compulsions may precede the manifestation of obsessions. For example, an individual begins to feel that he must be afraid of an accidental fire because he repeatedly checks the gas knob on the stove or an individual concludes that she must be afraid of contamination based on the evidence of her repeated hand washing. Understanding the relationship between obsessions and compulsions can assist in intervention selection and treatment planning.

Boundary with Normality (Threshold):

• Intrusive thoughts, images, and impulses/urges as well as repetitive behaviours are common in the general population (e.g., thoughts of harming a loved one, double-checking that the door is locked). Obsessive-Compulsive Disorder should only be diagnosed when obsessions and compulsions are time-consuming (e.g., take more than 1 hour per day) or cause significant distress or result in functional impairment.
• Developmentally normative preoccupations (e.g., worrying about interacting with strangers in young children) and rituals (e.g., skipping over cracks in a sidewalk) should not be attributed to a presumptive diagnosis of Obsessive-Compulsive Disorder and are differentiated from obsessions and compulsions characteristic of Obsessive-Compulsive Disorder because they are transient, age-appropriate, not time-consuming (e.g., taking more than hour per day), and do not result in significant distress or impairment.

Course Features:

• Obsessive-Compulsive Disorder typically has an age of onset in the late teens and early twenties, with late onset (i.e., after age 35) being less common. In cases of late onset, there is often a history of chronic sub-clinical symptoms.
• Onset of Obsessive-Compulsive Disorder symptoms is often gradual. Sudden or late onset, in particular, should prompt additional assessment to differentiate Obsessive-Compulsive Disorder from other medical conditions (e.g., basal ganglia ischemic stroke) that may better explain the symptoms.
• Many adults with Obsessive-Compulsive Disorder (30%-50%) report a childhood onset of symptoms. For those with onset during childhood or adolescence, 40% may experience a remission of symptoms by early adulthood.
• Obsessive-Compulsive Disorder in adults is generally considered a chronic condition with waxing and waning of symptoms. Some experience an episodic course and a minority experience a worsening course.

Developmental Presentations:

• Onset before age 10 is more common among males (approximately 25%), whereas adolescent onset is more likely among females. Younger age of onset is associated with greater genetic loading and poorer outcomes due to interference of symptoms with achieving developmental milestones (e.g., forming peer relationships, acquiring academic skills). Although childhood-onset Obsessive-Compulsive Disorder typically follows a chronic course, particularly if left untreated, symptoms tend to wax and wane and many (approximately 40%) experience full remission by early adulthood. Among the elderly, the prevalence of Obsessive-Compulsive Disorder is slightly higher among men than women.
• Although precipitous onset of Obsessive-Compulsive Disorder symptoms in children and adolescents has been reported, often attributed to Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS), development of symptoms is typically gradual.
• The content and type of obsessions and compulsions varies across the lifespan. Children and adolescents are more likely to report obsessions centred upon bad things happening to their loved ones (e.g., parents) whereas adolescents and adults are more likely to report religious or sexual obsessions. Among children and adolescents, females are more likely to report symptoms centred upon contamination or cleaning whereas males are more like those of a sexual-religious or aggressive nature. It may be easier to assess for the presence of compulsions in children because their level of cognitive development may preclude verbalizing content of obsessions.
• Among children and adolescents, the course of Obsessive-Compulsive Disorder is frequently complicated by the co-occurrence of other mental disorders, the presence of which may affect identification of Obsessive-Compulsive Disorder among youth. Up to 30% of all individuals with Obsessive-Compulsive Disorder will also experience Tourette Syndrome or another primary tic disorder during their lifetime. Co-occurring tics are more common among males with childhood-onset Obsessive-Compulsive Disorder. Children and adolescents are also more likely than adults to present with a combination of Obsessive-Compulsive Disorder, a primary tic disorder and/or Attention Deficit Hyperactivity Disorder. Body Dysmorphic Disorder or Hoarding Disorder often co-occur among adolescents with Obsessive-Compulsive Disorder. Approximately half of elderly patients with Obsessive-Compulsive Disorder exhibit ordering, hoarding and checking behaviours, which may also reflect symptoms of Personality Disorder with anankastic traits.

Culture-Related Features:

• Similar types of Obsessive-Compulsivity Disorder symptoms (e.g., concerns with contamination) are present cross-culturally, but cultural variation exists in the salience and prevalence of certain themes of content of obsessions and compulsions. For example, aggressive obsessions have been found to predominate in Brazil and religious/scrupulosity concerns in Middle Eastern settings. In addition, scrupulosity obsessions may be more distressing among individuals of certain faith groups that emphasize ritual exactitude or the sinful nature of certain kinds of thoughts. The influence of culture may lead to the adoption of specific themes, such as fear of contamination by HIV/AIDS, obsessions about kashrut (dietary restrictions) observances among Jews, or about being in a state of uncleanliness (Napak) among Muslims. Distinguishing religious compulsions from zealous but normative religious practice may require the help of religious experts aware of local norms.
• Etiological attributions may vary across social groups, including biological, psychological, social, and supernatural or spiritual explanations. These attributions may also shape the specific obsessions, such as concerns about being deserving of punishment as the result of a transgression or the object of sorcery, witchcraft, or the evil eye. In some cultural groups, compulsions may be reinforced by the belief that such acts ward off evil spirits or have another spiritual function.
• Help seeking and clinical disclosure are less likely when the obsessions or compulsions are considered by the individual to be culturally taboo.

Sex- and/or Gender-Related Features:

• Males are more likely to experience Obsessive-Compulsive Disorder during childhood, with approximately 25% experiencing onset before age 10. During adulthood, prevalence is higher for females.
• Males are more likely to experience co-occurring primary tic disorders.
• Gender differences in the specific content of obsessions and compulsions have been reported whereby females are more likely to report cleaning and contamination related themes and males are more likely to report symmetry related themes and taboo intrusive thoughts (e.g., violent impulses, sacrilegious images).
• Onset or exacerbation of Obsessive-Compulsive Disorder has been reported during the peripartum period.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Hypochondriasis (Health Anxiety Disorder): Hypochondriasis is characterized by persistent preoccupation or fear about the possibility of having one or more serious, progressive or life-threatening illnesses. Although obsessions in Obsessive-Compulsive Disorder may be health-related, when these occur they tend to be focused more on potential contamination than on the undiagnosed symptoms of a particular illness and to be accompanied by a history of other obsessions that are not health-related.
• Boundary with other Obsessive-Compulsive or Related Disorders: Recurrent thoughts and repetitive behaviours occur in other Obsessive-Compulsive or Related Disorders but the foci of apprehension and form of repetitive behaviours are distinct for each diagnostic entity. In Body Dysmorphic Disorder, the intrusive thoughts and repetitive behaviours are limited to concerns about physical appearance. In Trichotillomania or Excoriation Disorder, the repetitive behaviours are limited to hair pulling or skin picking, respectively, in the absence of obsessions. Hoarding Disorder symptoms include excessive accumulation or difficulty discarding possessions and marked distress related to discarding items. Hoarding behaviour can be symptomatic of Obsessive-Compulsive Disorder, but in contrast to Hoarding Disorder it is undertaken with the goal of neutralizing or reducing concomitant distress and anxiety arising from obsessional content such as aggressive (e.g., fear of harming others), sexual/religious (e.g., fear of committing blasphemous or disrespectful acts), contamination (e.g., fear of spreading infectious diseases), or symmetry/ordering (e.g., feeling of incompleteness) themes. However, Obsessive-Compulsive or Related Disorders can co-occur, and multiple diagnoses from this grouping may be assigned if warranted.
• Boundary with Autism Spectrum Disorder: Persistent repetitive thoughts, images, or impulses/urges (i.e., obsessions) and/or repetitive behaviours (i.e., compulsions) characteristic of Obsessive-Compulsive Disorder may be difficult to distinguish from restricted, repetitive, and inflexible patterns of behaviour, interests, or activities that are characteristic of Autism Spectrum Disorder. However, unlike those with Autism Spectrum Disorder, individuals with Obsessive-Compulsive Disorder feel driven to perform repetitive behaviours in response to an obsession, according to rigid rules, to reduce anxiety, or to achieve a sense of ‘completeness’. Obsessive-Compulsive Disorder can also be distinguished from Autism Spectrum Disorder because difficulties in initiating and sustaining social communication and reciprocal social interactions are not features of Obsessive-Compulsive Disorder.
• Boundary with Stereotyped Movement Disorder: A stereotyped movement is a repetitive, seemingly driven non-functional motor behaviour (e.g., head banging, body rocking, self-biting). These movements are typically less complex than compulsions and are not aimed at neutralizing obsessions.
• Boundary with Delusional Disorder and other Primary Psychotic Disorders: Some individuals with Obsessive-Compulsive Disorder lack insight about the irrationality of their thoughts and behaviours to such an extent that convictions of the veracity of their obsessions as well as the strength of beliefs regarding the connection between compulsions and obsessions may at times appear to be delusional in the degree of conviction and fixity with which these beliefs are held (see Insight specifiers, page __). If these beliefs are restricted to fear or conviction that intrusive thoughts, images, or impulses/urges are true or that compulsions are realistically connected to obsessional content in an individual without a history of other delusions, that is, these beliefs occur entirely in the context of symptomatic episodes of Obsessive-Compulsive Disorder and are fully consistent with the other clinical features of the disorder, Obsessive-Compulsive Disorder should be diagnosed instead of Delusional Disorder. Individuals with Obsessive-Compulsive Disorder do not exhibit other features of psychosis (e.g., hallucinations or formal thought disorder).
• Boundary with Depressive Disorders: Differentiating rumination that occurs in the context of Depressive Disorders from obsessions and compulsive mental acts characteristic of Obsessive-Compulsive Disorder is challenging. Nonetheless, it may be helpful to consider that ruminations are typically congruent with negative affect and reflect depressive cognition (e.g., self-criticism, guilt, failure, regret, pessimism, hopelessness). Unlike obsessions, ruminations are not typically experienced as intrusive, nor are they linked to compulsive behaviours. In contrast to ruminations, compulsive mental acts are typically performed with the intention of reducing distress or perceived risk of harm. Individuals with Depressive Disorders experience low mood or a lack of interest in pleasurable activities, which are not diagnostic features of Obsessive-Compulsive Disorder. However, Obsessive-Compulsive Disorder and Depressive Disorders often co-occur, and both diagnoses may be assigned if the full diagnostic requirements are met.
• Boundary with Anxiety or Fear-Related Disorders: Recurrent thoughts, avoidance behaviours, and requests for reassurance commonly observed in Obsessive-Compulsive Disorder also occur in Anxiety or Fear-Related Disorders. In contrast to Anxiety or Fear-Related Disorders, however, obsessions in Obsessive-Compulsive Disorder are experienced as intrusive, can involve content that is odd or irrational (e.g., intrusive images of harming a friend), and are typically accompanied by compulsions. Obsessive-Compulsive Disorder is further differentiated by not being characterized by the same foci of apprehension that characterize Anxiety or Fear-Related Disorders. For example, in Generalized Anxiety Disorder, the recurrent thoughts or worries are focused on negative events that could possibly occur in different aspects of everyday life (e.g., work, finances, health, family). In Social Anxiety Disorder, symptoms are in response to feared social situations (e.g., speaking in public, initiating a conversation) and concerns about being negatively evaluated by others. In Specific Phobia, symptoms are limited to one or a few circumscribed phobic objects or situations (e.g., fear and avoidance of animals) and concerns are about the perceived harm that could arise if exposed to these stimuli (e.g., being bitten by an animal).
• Boundary with Panic Disorder: Panic Disorder is characterized by recurrent, unexpected panic attacks. Some individuals with Obsessive-Compulsive Disorder experience panic attacks that are triggered by feared stimuli associated with obsessions and compulsions or if the individual is prevented from enacting neutralizing compulsions. If an individual with Obsessive-Compulsive Disorder experiences panic attacks exclusively in relation to obsessions or compulsions without the presence of unexpected panic attacks, an additional diagnosis of Panic Disorder is not warranted. However, unexpected panic attacks are also present and all other diagnostic requirements are met, both diagnoses may be assigned.
• Boundary with Post-Traumatic Stress Disorder: In Post-Traumatic Stress Disorder, symptoms are limited to stimuli associated with or that serve as reminders of a traumatic event (e.g., fear and avoidance of a place where an individual was assaulted) and the intrusive thoughts and images are associated with the traumatic event.
• Boundary with Eating Disorders: Obsessive-Compulsive Disorder can be distinguished from Anorexia Nervosa, Bulimia Nervosa, and Binge-Eating Disorder because obsessions and compulsions are not limited to concerns about being or becoming overweight and are not accompanied by body image distortions.
• Boundary with Disorders Due to Substance Use and Impulse Control Disorders: A variety of behaviours may be described by lay people and sometimes by health professionals as ‘compulsive’, including sexual behaviour, gambling, and substance use. Compulsions characteristic of Obsessive-Compulsive Disorder, are differentiated from these behaviours in that they typically lack a rational motivation and are rarely reported to be pleasurable, though they may reduce anxiety or distress. Behaviours such as sexual behaviour, gambling, and substance abuse are also not typically preceded by intrusive unwanted thoughts characteristic of obsessions, although they are often preceded by thoughts about engaging in the relevant behaviour.
• Boundary with Primary Tics or Tic Disorders including Tourette Syndrome: A tic is a sudden, rapid, recurrent, non-rhythmic motor movement or vocalization (e.g., eye blinking, throat clearing). Obsessive-Compulsive Disorder can be differentiated from Tic Disorders because unlike compulsions, tics appear unintentional in nature and clearly utilize a discrete muscle group. However, it can be difficult to distinguish between complex tics and compulsions associated with Obsessive-Compulsive Disorder. Although tics (both complex and simple) are preceded by premonitory sensory urges, which diminish as tics occur, tics are not aimed at neutralizing antecedent cognitions (e.g., obsessions) or reducing anxiety. Many individuals exhibit symptoms of both Obsessive-Compulsive Disorder and primary tic disorders, in particular, Tourette Syndrome, and both diagnoses may be assigned if the diagnostic requirements for each are met.
• Boundary with Personality Disorder with prominent anankastic features: Personality Disorder with prominent anankastic features involves an enduring and pervasive maladaptive pattern of excessive perfectionism and rigid control. Individuals with Personality Disorder with prominent anankastic features do not experience intrusive thoughts, images, or impulses/urges characteristic of Obsessive-Compulsive Disorder or engage in repetitive behaviours response to these intrusive thoughts. If diagnostic requirements for both Obsessive-Compulsive Disorder and a Personality Disorder with prominent anankastic features are met, both diagnoses may be assigned.