Obsessive-Compulsive Spectrum Disorders
There are a number of disorders that don't technically meet the Diagnostic and Statistical Manual
of Mental Disorders (DSM-5) diagnostic criteria for obsessive-compulsive disorder (OCD), yet
they have very similar symptoms The DSM-5 has a whole chapter dedicated to these similar
disorders entitled "Obsessive-Compulsive Related Disorders" also known as obsessive-
compulsive spectrum disorders. The obsessive-compulsive spectrum includes different clusters of
symptoms that are similar to, but not exactly the same as, OCD symptoms. Often (but not always)
the only difference between OCD and a given obsessive-compulsive spectrum disorder is the
specific focus of the obsessions and/or compulsions.
Here are the disorders the DSM-5 includes in the chapter regarding obsessive-compulsive related
disorders.
1. Obsessive-Compulsive Disorder
2. Body Dysmorphic Disorder
3. Hoarding Disorder
4. Trichotillomania (Hair-Pulling Disorder)
5. Excoriation (Skin-Picking) Disorder
6. Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
7. Obsessive-Compulsive and Related Disorder Due to Another Medical Condition
8. Other Specified Obsessive-Compulsive and Related Disorder
9. Unspecified Obsessive-Compulsive and Related Disorder
Diagnostic Criteria of Obsessive-Compulsive Disorder
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).
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.
Diagnostic Criteria of Body Dysmorphic Disorder
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.
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.
Specify if:
Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., “I look ugly” or “I
look deformed”).
With good or fair insight: The individual recognizes that the body dysmorphic disorder
beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks that the body dysmorphic disorder beliefs are
probably true.
With absent insight/delusional beliefs: The individual is completely convinced that the
body dysmorphic disorder beliefs are true.
Diagnostic Criteria of Hoarding Disorder
A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
B. This difficulty is due to a perceived need to save the items and to distress associated with
discarding them.
C. The difficulty discarding possessions results in the accumulation of possessions that
congest and clutter active living areas and substantially compromises their intended use. If
living areas are uncluttered, it is only because of the interventions of third parties (e.g.,
family members, cleaners, authorities).
D. The hoarding causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning (including maintaining a safe environment for self
and others).
E. The hoarding is not attributable to another medical condition (e.g., brain injury,
cerebrovascular disease, Prader-Willi syndrome).
F. The hoarding is not better explained by the symptoms of another mental disorder (e.g.,
obsessions in obsessive-compulsive disorder, decreased energy in major depressive
disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in
major neurocognitive disorder, restricted interests in autism spectrum disorder).
Specify if:
With excessive acquisition: If difficulty discarding possessions is accompanied by
excessive acquisition of items that are not needed or for which there is no available space.
Specify if:
With good or fair insight: The individual recognizes that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are
problematic.
With poor insight: The individual is mostly convinced that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are
not problematic despite evidence to the contrary.
With absent insight/delusional beliefs: The individual is completely convinced that
hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or
excessive acquisition) are not problematic despite evidence to the contrary.
Diagnostic Criteria of Trichotillomania (Hair-Pulling Disorder)
A. Recurrent pulling out of one’s hair, resulting in hair loss.
B. Repeated attempts to decrease or stop hair pulling.
C. The hair pulling causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a
dermatological condition).
E. The hair pulling is not better explained by the symptoms of another mental disorder (e.g.,
attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).
Diagnostic Criteria of Excoriation (Skin-Picking) Disorder
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or impairment in social, occupational,
or other important areas of functioning.
D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine)
or another medical condition (e.g., scabies).
E. The skin picking is not better explained by symptoms of another mental disorder (e.g.,
delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived
defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic
movement disorder, or intention to harm oneself in non-suicidal self-injury).
Diagnostic Criteria Substance/Medication-Induced of Obsessive-Compulsive and Related
Disorder
A. Obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors,
or other symptoms characteristic of the obsessive-compulsive and related disorders
predominate in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings of both
(1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or
withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.
C. The disturbance is not better explained by an obsessive-compulsive and related disorder that
is not substance/medication-induced. Such evidence of an independent obsessive- compulsive
and related disorder could include the following:
The symptoms precede the onset of the substance/medication use; the symptoms persist for
a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or
severe intoxication; or there is other evidence suggesting the existence of an independent
non-substance/medication-induced obsessive-compulsive and related disorder (e.g., a
history of recurrent non-substance/medication related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
Note: This diagnosis should be made in addition to a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture
and are sufficiently severe to warrant clinical attention.
Diagnostic Criteria of Obsessive-Compulsive and Related Disorder Due to Another Medical
Condition
A. Obsessions, compulsions, preoccupations with appearance, hoarding, skin picking hair
pulling, other body-focused repetitive behaviors, or other symptoms characteristic of
obsessive-compulsive and related disorder predominate in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the
disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
Specify if:
With obsessive-compulsive disorder-like symptoms: If obsessive-compulsive disorder-
like symptoms predominate in the clinical presentation.
With appearance preoccupations: If preoccupation with perceived appearance defects
or flaws predominates in the clinical presentation.
With hoarding symptoms: If hoarding predominates in the clinical presentation.
With hair-pulling symptoms: If hair pulling predominates in the clinical presentation.
With skin-picking symptoms: If skin picking predominates in the clinical presentation.
Other Specified Obsessive-Compulsive and Related Disorder
This category applies to presentations in which symptoms characteristic of an obsessive-
compulsive and related disorder that cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning predominate but do not meet the full criteria
for any of the disorders in the obsessive-compulsive and related disorders diagnostic class. The
other specified obsessive-compulsive and related disorder category is used in situations in which
the clinician chooses to communicate the specific reason that the presentation does not meet the
criteria for any specific obsessive-compulsive and related disorder. This is done by recording
“other specified obsessive-compulsive and related disorder” followed by the specific reason (e.g.,
“body-focused repetitive behavior disorder”).
Examples of presentations that can be specified using the “other specified” designation include the
following:
1. Body dysmorphic-like disorder with actual flaws: This is similar to body dysmorphic
disorder except that the defects or flaws in physical appearance are clearly observable by others
(i.e., they are more noticeable than “slight”). In such cases, the preoccupation with these flaws
is clearly excessive and causes significant impairment or distress.
2. Body dysmorphic-like disorder without repetitive behaviors: Presentations that meet body
dysmorphic disorder except that the individual has not performed repetitive behaviors or mental
acts in response to the appearance concerns.
3. Body-focused repetitive behavior disorder: This is characterized by recurrent body focused
repetitive behaviors (e.g., nail biting, lip biting, and cheek chewing) and repeated attempts to
decrease or stop the behaviors. These symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning and are not better
explained by trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder,
stereotypic movement disorder, or non-suicidal self-injury.
4. Obsessional jealousy: This is characterized by non-delusional preoccupation with a partner’s
perceived infidelity. The preoccupations may lead to repetitive behaviors or mental acts in
response to the infidelity concerns; they cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning; and they are not better explained
by another mental disorder such as delusional disorder, jealous type, or paranoid personality
disorder.
5. Shubo-kyofu: A variant of taijin kyofusho that is similar to body dysmorphic disorder and is
characterized by excessive fear of having a bodily deformity.
6. Koro: Related to dhat syndrome, an episode of sudden and intense anxiety that the penis (or
the vulva and nipples in females) will recede into the body, possibly leading to death.
7. Jikoshu-kyofu: A variant of taijin kyofusho (see “Glossary of Cultural Concepts of Distress”
in the Appendix) characterized by fear of having an offensive body odor (also termed olfactory
reference syndrome).
Unspecified Obsessive-Compulsive and Related Disorder
This category applies to presentations in which symptoms characteristic of an obsessive
compulsive and related disorder that cause clinically significant distress or impairment in social,
occupational, or other important areas of functioning predominate but do not meet the full criteria
for any of the disorders in the obsessive-compulsive and related disorders diagnostic class. The
unspecified obsessive-compulsive and related disorder category is used in situations in which the
clinician chooses not to specify the reason that the criteria are not met for a specific obsessive-
compulsive and related disorder, and includes presentations in which there is insufficient
information to make a more specific diagnosis (e.g., in emergency room settings).
