direct pathophysiological consequence of another medical condition.

Other specified obsessive-compulsive and related disorder (e.g., nail biting, lip biting, cheek
chewing, obsessional jealousy, olfactory reference disorder [olfactory reference syndrome]) and
unspecified obsessive-compulsive and related disorder consist of symptoms that cause clinically
significant distress or impairment that do not meet criteria for a specific obsessive-compulsive
and related disorder in DSM-5 because of atypical presentation or uncertain etiology. These
categories are also used for other specific syndromes that are not listed in Section II and when
insufficient information is available to diagnose the presentation as another obsessive-
compulsive and related disorder.
Those obsessive-compulsive and related disorders that have a cognitive component (i.e.,
OCD, body dysmorphic disorder, and hoarding disorder) include a specifier for

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indicating the individual’s degree of insight with respect to disorder-related beliefs, which
ranges from “good or fair insight” to “poor insight” to “absent insight/delusional beliefs.” Those
individuals whose degree of insight is in the “absent insight/delusional beliefs” range should not
be given an additional diagnosis of a psychotic disorder unless their delusional beliefs involve
content that extends beyond what is characteristic of their obsessive-compulsive and related
disorder (e.g., an individual with body dysmorphic disorder who is convinced that his or her food
has been poisoned).

Obsessive-Compulsive Disorder

Diagnostic Criteria F42.2

A. Presence of obsessions, compulsions, or both:

Obsessions are defined by (1) and (2):
1. 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.
2. 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):
1. 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.
2. 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 or compulsions are time-consuming (e.g., take 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).

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Specify if:
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.
Specify if:
Tic-related: The individual has a current or past history of a tic disorder.

Specifiers
Individuals with obsessive-compulsive disorder (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 definitely will
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.
Up to 30% of individuals with OCD have a lifetime tic disorder. This is most common in
men with onset of OCD in childhood. These individuals tend to differ from those without a
history of tic disorders in the themes of their OCD symptoms, comorbidity, course, and pattern
of familial transmission.

Diagnostic Features
The characteristic symptoms of OCD are the presence of obsessions and compulsions (Criterion
A). Obsessions are repetitive and persistent thoughts (e.g., of contamination), images (e.g., of
violent or horrific scenes), or urges (e.g., to stab someone). Importantly, obsessions are not
pleasurable or experienced as voluntary: they are intrusive and unwanted and cause marked
distress or anxiety in most individuals. The individual attempts to ignore or suppress these
obsessions (e.g., avoiding triggers or using thought suppression) or to neutralize them with
another thought or action (e.g., performing a compulsion). Compulsions (or rituals) are repetitive
behaviors (e.g., washing, checking) or mental acts (e.g., 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. Most individuals with OCD have both obsessions and compulsions.
Obsessions and compulsions are typically thematically related (e.g., thoughts of contamination
associated with washing rituals; thoughts of harm associated with repeated checking).
Individuals often report that they perform compulsions to reduce the distress triggered by
obsessions or to prevent a feared event (e.g., becoming ill). However, these compulsions either
are 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 for hours each day).
Compulsions are not done for pleasure, although individuals may experience temporary relief
from anxiety or distress.
The specific content of obsessions and compulsions varies between individuals. However,
certain themes, or dimensions, are common, including those of cleaning (contamination
obsessions and cleaning compulsions); symmetry (symmetry obsessions and repeating, ordering,
and counting compulsions); forbidden or taboo thoughts (e.g., aggressive, sexual, or religious
obsessions and related compulsions); and harm (e.g., fears of harm to self or others and checking
compulsions). Some individuals also have difficulties discarding and accumulate objects as a
consequence of typical obsessions and

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compulsions (e.g., fears of harming others); such compulsions must be distinguished from
the primary accumulation behaviors seen in hoarding disorder, discussed later in this chapter.
These themes occur across different cultures, are relatively consistent over time in adults with the
disorder, and may be associated with different neural substrates. Importantly, individuals often
have symptoms in more than one dimension.
 Criterion B emphasizes that obsessions and compulsions must be time-consuming (e.g., more
than 1 hour per day) or cause clinically significant distress or impairment to warrant a diagnosis
of OCD. This criterion helps to distinguish the disorder from the occasional intrusive thoughts or
repetitive behaviors that are common in the general population (e.g., double-checking that a door
is locked). The frequency and severity of obsessions and compulsions vary across individuals
with OCD (e.g., some have mild to moderate symptoms, spending 1–3 hours per day obsessing
or doing compulsions, whereas others have nearly constant intrusive thoughts or compulsions
that can be incapacitating).

Associated Features
Sensory phenomena, defined as physical experiences (e.g., physical sensations, just-right
sensations, and feelings of incompleteness) that precede compulsions, are common in OCD. Up
to 60% of individuals with OCD report these phenomena.
Individuals with OCD experience a range of affective responses when confronted with
situations that trigger obsessions and compulsions. For example, many individuals experience
marked anxiety that can include recurrent panic attacks. Others report strong feelings of disgust.
While performing compulsions, some individuals report a distressing sense of “incompleteness”
or uneasiness until things look, feel, or sound “just right.”
It is common for individuals with the disorder to avoid people, places, and things that trigger
obsessions and compulsions. For example, individuals with contamination concerns might avoid
public situations (e.g., restaurants, public restrooms) to reduce exposure to feared contaminants;
individuals with intrusive thoughts about causing harm might avoid social interactions.
Many individuals with 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 overimportance of thoughts (e.g., believing that having a forbidden thought is as
bad as acting on it) and the need to control thoughts. These beliefs, however, are not specific to
OCD. The involvement of family or friends in compulsive rituals, termed accommodation, can
exacerbate or maintain symptoms and is an important target in treatment, especially in children.

Prevalence
The 12-month prevalence of OCD in the United States is 1.2%, with a similar prevalence
internationally (including Canada, Puerto Rico, Germany, Taiwan, Korea, and New Zealand;
1.1%–1.8%). Women are affected at a slightly higher rate than men in adulthood, although men
are more commonly affected in childhood.

Development and Course

In the United States, the mean age at onset of OCD is 19.5 years, and 25% of cases start by age
14 years. Onset after age 35 years is unusual but does occur. Men have an earlier age at onset
than women: nearly 25% of men have onset before age 10 years. The onset of symptoms is
typically gradual; however, acute onset can also occur.
If OCD is untreated, the course is usually chronic, often with waxing and waning symptoms.
Some individuals have an episodic course, and a minority have a deteriorating course. Without
treatment, remission rates in adults are low (e.g., 20% for those reevaluated 40 years later). Onset
in childhood or adolescence can lead to a lifetime of OCD.

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However, 40% of individuals with onset of OCD in childhood or adolescence may

experience remission by early adulthood. The course of OCD is often complicated by the co-
occurrence of other disorders (see section “Comorbidity” for this disorder).
Compulsions are more easily diagnosed in children than obsessions are because compulsions
are usually observable. However, most children have both obsessions and compulsions (as do
most adults). The pattern of symptoms in adults can be stable over time, but it is more variable in
children. Some differences in the content of obsessions and compulsions have been reported
when children and adolescent samples are compared with adult samples. These differences likely
reflect content appropriate to different developmental stages (e.g., higher rates of sexual and
religious obsessions in adolescents than in children; higher rates of harm obsessions [e.g., fears
of catastrophic events, such as death or illness to self or loved ones] in children and adolescents
than in adults).

Risk and Prognostic Factors

Temperamental. Greater internalizing symptoms, higher negative emotionality, and behavioral
inhibition in childhood are possible temperamental risk factors.
Environmental. Different environmental factors may increase the risk for OCD. These include
adverse perinatal events, premature birth, maternal tobacco use during pregnancy, physical and
sexual abuse in childhood, and other stressful or traumatic events. Some children may develop
the sudden onset of obsessive-compulsive symptoms, which has been associated with different
environmental factors, including various infectious agents and a postinfectious autoimmune
syndrome.
Genetic and physiological. The rate of OCD among first-degree relatives of adults with OCD is
approximately two times that among first-degree relatives of those without the disorder;
however, among first-degree relatives of individuals with onset of OCD in childhood or
adolescence, the rate is increased 10-fold. Familial transmission is due in part to genetic factors
(e.g., a concordance rate of 0.57 for monozygotic vs. 0.22 for dizygotic twins). Twin studies
suggest that additive genetic effects account for ~40% of the variance in obsessive-compulsive
symptoms. Dysfunction in the orbitofrontal cortex, anterior cingulate cortex, and striatum have
been most strongly implicated; alterations in frontolimbic, frontoparietal, and cerebellar
networks have also been reported.

Culture-Related Diagnostic Issues

OCD occurs across the world. There is substantial similarity across cultures in the gender
distribution, age at onset, and comorbidity of OCD. Moreover, around the globe, there is a
similar symptom structure involving cleaning, symmetry, hoarding, taboo thoughts, and fear of
harm. However, regional variation in symptom expression exists, and cultural factors may shape
the content of obsessions and compulsions. For example, obsessions related to sexual content
may be reported less frequently in some religious and cultural groups, and obsessions related to
violence and aggression may be more common in settings with higher prevalence of urban
violence. Attributions of OCD symptoms vary cross-culturally, including physical, social,
spiritual, and supernatural causes; specific compulsions and help-seeking options may be
reinforced by these cultural attributions.

Sex- and Gender-Related Diagnostic Issues

Men have an earlier age at onset of OCD than women, often in childhood, and are more likely to
have comorbid tic disorders. Onset in girls is more typically in adolescence; among adults, OCD
is slightly more common in women than in men. Gender differences in the pattern of symptom
dimensions have been reported, with, for example, women more likely to have symptoms in the
cleaning dimension and men more likely to have

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symptoms in the forbidden thoughts and symmetry dimensions. Onset or exacerbation of OCD,
as well as symptoms that can interfere with the mother-infant relationship (e.g., aggressive
obsessions such as intrusive violent thoughts of harming the infant, leading to avoidance of the
infant), has been reported in the peripartum period. Some women also report exacerbation of
OCD symptoms premenstrually.

Association With Suicidal Thoughts or Behavior

A systematic literature review of suicidal ideation and suicide attempts in clinical samples with
OCD from multiple countries found a mean rate of lifetime suicide attempts of 14.2%, a mean
rate of lifetime suicidal ideation of 44.1%, and a mean rate of current suicidal ideation of 25.9%.
Predictors of greater suicide risk were severity of OCD, the symptom dimension of unacceptable
thoughts, severity of comorbid depressive and anxiety symptoms, and past history of suicidality.
Another international systematic review of 48 studies found a moderate to high significant
association between suicidal ideation/suicide attempts and OCD.
A cross-sectional study of 582 outpatients with OCD from Brazil found that 36% reported
lifetime suicidal thoughts, 20% had made suicide plans, 11% had already attempted suicide, and
10% presented with current suicidal thoughts. The sexual/religious dimension of OCD and
comorbid substance use disorders were associated with suicidal thoughts and suicide plans,
impulse-control disorders were associated with current suicidal thoughts and with suicide plans
and attempts, and lifetime comorbid major depressive disorder and posttraumatic stress disorder
(PTSD) were associated with all aspects of suicidal behaviors.
In a study using Swedish national registry data involving 36,788 individuals with OCD and
matched general population control subjects, individuals with OCD had a higher risk of suicide
death (OR = 9.8) and suicide attempt (OR = 5.5), and the increased risk for both outcomes
remained substantial even after adjusting for psychiatric comorbidities. Comorbid personality or
substance use disorder increased suicide risk, whereas female gender, higher parental education,
and a comorbid anxiety disorder were protective factors.

Functional Consequences of Obsessive-Compulsive Disorder

OCD is associated with reduced quality of life as well as high levels of social and occupational
impairment. Impairment occurs across many different domains of life and is associated with
symptom severity. Impairment can be caused by the time spent obsessing and performing
compulsions. Avoidance of situations that can trigger obsessions or compulsions can also
severely impair functioning. In addition, specific symptoms can create specific obstacles. For
example, obsessions about harm can make relationships with family and friends feel hazardous;
the result can be avoidance of these relationships. Obsessions about symmetry can derail the
timely completion of school or work projects because the project never feels “just right,”
potentially resulting in school failure or job loss. Health consequences can also occur. For
example, individuals with contamination concerns may avoid doctors’ offices and hospitals (e.g.,
because of fears of exposure to germs) or develop dermatological problems (e.g., skin lesions
due to excessive washing). Sometimes the symptoms of the disorder interfere with its own
treatment (e.g., when medications are considered contaminated). When the disorder starts in
childhood or adolescence, individuals may experience developmental difficulties. For example,
adolescents may avoid socializing with peers; young adults may struggle when they leave home
to live independently. The result can be few significant relationships outside the family and a
lack of autonomy and financial independence from their family of origin. In addition, some
individuals with OCD try to impose rules and prohibitions on family members because of their
obsessions

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(e.g., no one in the family can have visitors to the house for fear of contamination), and this can
lead to family dysfunction.

Differential Diagnosis
Anxiety disorders. 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 OCD usually do not involve real-life concerns and can include content that is odd,
irrational, or of a seemingly magical nature; moreover, compulsions are usually 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,
the feared objects or situations are limited to social interactions or performance situations, and
avoidance or reassurance seeking is focused on reducing feelings of embarrassment.
Major depressive disorder. OCD needs to 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.
Other obsessive-compulsive and related disorders. 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 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 accumulation (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.
Eating disorders. 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.
Psychotic disorders. 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 disorganized speech). For individuals whose OCD symptoms warrant the
“with absent insight/delusional beliefs” specifier, these symptoms should not be diagnosed as a
psychotic 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

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from the compulsions of OCD in that the person usually derives pleasure from the activity and
may wish to resist it only because of its deleterious consequences.
Obsessive-compulsive personality disorder. 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 intrusive symptoms;
instead, it involves an enduring and pervasive maladaptive pattern of excessive perfectionism
and rigid control. If an individual manifests symptoms of both OCD and obsessive-compulsive
personality disorder, both diagnoses can be given.

Comorbidity
Individuals with OCD often have other psychopathology. Many adults with the disorder in the
United States have a lifetime diagnosis of an anxiety disorder (76%; e.g., panic disorder, social
anxiety disorder, generalized anxiety disorder, specific phobia) or a depressive or bipolar
disorder (63% for any depressive or bipolar disorder, with the most common being major
depressive disorder [41%]); a lifetime diagnosis of an impulse-control disorder (56%) or a
substance use disorder (39%) is also common. Onset of OCD is usually later than for most
comorbid anxiety disorders (with the exception of separation anxiety disorder) and PTSD but
often precedes that of depressive disorders. In a study of 214 treatment-seeking adults in the
United States with DSM-IV OCD at intake, comorbid obsessive-compulsive personality disorder
was found in 23%–32% of individuals followed longitudinally.
Up to 30% of individuals with OCD also have a lifetime tic disorder. A comorbid tic disorder
is most common in men with onset of OCD in childhood. These individuals tend to differ from
those without a history of tic disorders in the themes of their OCD symptoms, comorbidity,
course, and pattern of familial transmission. A triad of OCD, tic disorder, and attention-
deficit/hyperactivity disorder can also be seen in children.
Several obsessive-compulsive and related disorders, including body dysmorphic disorder,
trichotillomania, and excoriation (skin-picking) disorder, also occur more frequently in
individuals with OCD than in those without OCD.
OCD is also much more common in individuals with certain other disorders than would be
expected based on its prevalence in the general population; when one of those other disorders is
diagnosed, the individual should be assessed for OCD as well. For example, in individuals with
schizophrenia or schizoaffective disorder, the prevalence of OCD is approximately 12%. Rates
of OCD are also elevated in bipolar disorder; eating disorders, such as anorexia nervosa and
bulimia nervosa; body dysmorphic disorder; and Tourette’s disorder.

Body Dysmorphic Disorder

Diagnostic Criteria F45.22

A. Preoccupation with one or more perceived defects or flaws in physical

appearance that are not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed
repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking,
reassurance seeking) or mental acts (e.g., comparing his or her appearance with
that of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning.

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D. The appearance preoccupation is not better explained by concerns with body fat
or weight in an individual whose symptoms meet diagnostic criteria for an eating
disorder.
Specify if:
With muscle dysmorphia: The individual is preoccupied with the idea that his
or her body build is too small or insufficiently muscular. This specifier is used
even if the individual is preoccupied with other body areas, which is often the
case.