Obsessive-Compulsive Disorder (DSM-IV-R)

DIAGNOSTIC CRITERIA FOR OBSESSIVE-COMPULSIVE DISORDER

  1. 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 somet ime 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
  1. 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.
  2. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour per day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.
  3. If another 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 a Body Dysmorphic Disorder, etc.).
  4. 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.

DIAGNOSTIC FEATURES

The essential features of Obsessive-Compulsive Disorder 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.

 

ASSOCIATED FEATURES AND DISORDERS

Frequently there is avoidance of situations that involve the content of the obsessions, such as dirt or contamination.  For example, a person with obsession 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 pahtological 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, Eating Disorders, or Personality Disorders. In children, it may also be associated with Learning Disorders and Disruptive Behavior Disorders. 

 

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 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.

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.

 

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 for males and between ages 20 and 29 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.

The treatment of OCD usually involves:

  1. Use of SSRI (Selective Serotonin Reuptake Inhibitor)
  2. CBT (Cognitive Behavioral Therapy)