DSM 5 Criteria for OCD

What is obsessive compulsive disorder (OCD)?

Obsessive-compulsive disorder (OCD) is a mental disorder that impacts millions globally. OCD is defined by patterns of uncontrollable, recurrent thoughts (obsessions) and behaviors (compulsions) that the individual feels the urge to repeat over and over. These obsessions and compulsions are time-consuming and often significantly disrupt the individual’s daily activities and social interactions.

The experience is far from the occasional worry or ritualistic behavior that people without the disorder experience. For someone with OCD, ordinary objects and common situations can become triggers for their obsessions. These obsessions are not simply concerns or worries about real-life problems but are often exaggerated fears. For instance, they could believe that being unable to perform a task in a very specific manner could harm themselves or others around them.

The compulsions, which are repetitive behaviors or mental acts, are efforts to counteract or offset the anxiety provoked by these obsessions. For example, individuals might repeatedly wash their hands, check locks, or perform mental rituals like counting or praying in a specific pattern. While these actions might provide temporary relief, this is short-lived, which leads to a reinforcing cycle where the compulsive behaviors become more ingrained.

What is the difference between obsessions and compulsions?

When discussing obsessive-compulsive disorder (OCD), we often encounter two essential concepts: obsessions and compulsions.

Obsessions are essentially intrusive and unwanted thoughts, images, or urges that repeatedly appear in the mind. People with OCD usually find these obsessions disturbing, and they often manifest as fears of contamination, worries about safety, or disturbing religious or sexual thoughts. Unlike the everyday worries that we all experience, these intrusive thoughts are persistent and can cause significant anxiety and distress.

Imagine a patient who can't shake the idea that they've left the stove on despite having checked multiple times. This thought is more than a momentary concern. It is an obsession that can constantly be on their minds and cause distress.

Compulsions, on the other hand, are behaviors or mental acts that individuals feel compelled to perform in response to their obsessions or according to strict rules. These actions are done in an effort to reduce distress or prevent a feared event or situation from happening. Compulsions might provide brief relief from the anxiety but they are often not rationally connected to the problem they are meant to address.

Take the example of someone compelled to wash their hands exactly seven times to feel clean enough to be safe from contamination. This ritualistic behavior is a compulsion—a response to the obsession with contamination.

Symptoms of OCD

The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), is the authoritative manual of mental disorders by the American Psychiatric Association (2013), which is now widely used by healthcare professionals. The DSM-5 then provides us with a well-defined set of criteria characterizing the symptoms to diagnose OCD.

The DSM-5 highlights the presence of obsessions and compulsions along with significant distress and impairment. To begin with, obsessions should be characterized by the following:

• Persistent, intrusive thoughts, impulses, or images: This means these are unwanted ideas or visions that keep coming up in the mind of the person with OCD.
• Attempts to ignore or suppress: The person might try to suppress these unwelcome thoughts or counteract them with other thoughts or actions, leading to compulsive behavior.

On the other hand, compulsions are classified as:

• Repetitive behaviors or mental acts: These are repeated actions (like handwashing or checking locks) or mental rituals (like counting or repeating words) that someone needs to perform in response to the obsession.
• Aimed at preventing or reducing distress: More importantly, these actions are carried out to soothe the distress caused by obsessions or to prevent a feared event from happening.

Further diagnostic considerations specifically for OCD include the following:

• Time consumption: The obsessions or compulsions take up more than one hour per day or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Not attributable to other factors: The disturbance is not attributable to the physiological effects of a substance (e.g., drug abuse, medication) or another medical condition.
• Differentiation from other disorders: The symptoms cannot be better explained by the symptoms of another mental disorder (e.g., generalized anxiety disorder, body dysmorphic disorder).

What is the difference between OCD and obsessive-compulsive personality disorder?

It's crucial to differentiate between obsessive-compulsive disorder (OCD) and obsessive-compulsive personality disorder (OCPD). Despite their similar names, they are distinct disorders with unique diagnostic criteria as outlined in the DSM-5.

OCD is characterized by repetitive intrusive thoughts (obsessions) and/or behaviors that the person feels driven to perform (compulsions). The symptoms disrupt everyday life and cause significant levels of distress.

OCPD, on the other hand, is a type of personality disorder characterized by a generally lifelong pattern of continuous, habitual behaviors, rather than intrusive worries or distressing anxiety attacks. The defining features of OCPD are:

• Persistent and excessive concern with orderliness, perfectionism, and control. These concerns often come at the expense of flexibility, openness, and efficiency.
• The desire to keep things in control often leads to becoming overly occupied with details, rules, lists, order, organization, or schedules.
• The person may be excessively devoted to work and productivity, excluding leisure activities and friendships.
• Unlike OCD, those with OCPD often view their actions or habits as justified and are frequently unaware that the severity of their behaviors is problematic.

How does OCD emerge in a person?

The development of obsessive-compulsive disorder (OCD) involves a combination of genetic, neurological, behavioral, cognitive, and environmental factors. Understanding what causes OCD and why it persists can be beneficial in creating treatment plans for clients.

Genetic factors

There's a strong genetic component in OCD as evidenced by twin and family studies. If a person has a first-degree relative with OCD, such as a parent, sibling, or child, they are at a higher risk of developing the condition themselves.

Neurological factors

OCD has been linked to abnormalities in certain brain areas, including the orbitofrontal cortex, the anterior cingulate cortex, and the striatum. These areas are part of a circuit that regulates aspects of our behavior such as aggression and sexuality, which are elements often reflected in OCD obsessions. Brain imaging studies also suggest that OCD involves communication errors among different parts of the brain, including the deep structures of the basal ganglia and the frontal lobes.

Behavioral and cognitive factors

In the context of behavioral theories, it is suggested that compulsive behaviors are learned responses that help an individual reduce or prevent anxiety or discomfort associated with obsessions or urges.

From a cognitive viewpoint, it is believed that everyone experiences unwanted thoughts at times, but individuals with OCD may over-respond to these thoughts, leading to alarm and distress, which can mistakenly attribute meaning to them, which worsens the cycle of obsessions and compulsions.

Environmental factors

Life experiences such as childhood trauma or stressful events may trigger the onset of OCD in people who are predisposed to getting the condition. It's important to note that while these factors can increase the risk, they do not cause OCD.

How do healthcare professionals diagnose OCD?

The process of diagnosing Obsessive Compulsive Disorder (OCD) is thorough and involves multiple steps. It begins with a detailed interview about the person's symptoms, and the healthcare professional references the DSM-5 to ensure the symptoms align with the established criteria. Below is a more detailed step-by-step procedure:

Step 1: Comprehensive medical and psychiatric history

A healthcare professional will initially take a comprehensive medical and psychiatric history. This includes asking about the person's physical health, mental health, and any medications, drugs, or therapies currently in use. This information is crucial to eliminate any medical conditions or medications that could potentially mimic OCD symptoms.

Step 2: Symptom assessment

The healthcare professional will discuss symptoms in detail with the person, focusing on any recurrent thoughts, fears, or images (obsessions), and repetitive behaviors or mental rituals (compulsions). Peer, family, or caregiver feedback may also be valuable in case the person has difficulty recognizing their own behaviors or changes.

Step 3: Using the DSM-5 criteria

The healthcare professional will cross-reference the individual's symptoms with the specific criteria for OCD listed in the DSM-5. The criteria include:

• Presence of obsessions, compulsions, or both
• Obsessions and compulsions are time-consuming or cause clinically significant distress or impairment in functioning. Specifically, the patient's behaviors or thoughts must take over an hour per day.
• Symptoms are not attributable to the effects of a substance or another medical condition, ensuring the exclusion of confounding factors.
• The disturbance is not better explained by symptoms of another mental disorder such as autism spectrum disorder, anxiety disorders, or other psychotic disorders, which guarantees that a more fitting diagnosis isn't overlooked.

Step 4: Differential diagnosis

It's essential to distinguish OCD from other conditions that may have similar symptoms or those included the obsessive-compulsive and related disorders, such as obsessive-compulsive personality disorder (OCPD), body dysmorphic disorder, trichotillomania (hair-pulling disorder), hoarding disorder. This step requires a keen understanding of the differences in these mental health conditions.

Step 5: Determining functional impact

Lastly, the professional will assess the impact of symptoms on the person's daily functioning. This includes how behaviors or thoughts might limit or interfere with their ability to work, maintain relationships, or perform routine activities.

How do specialists treat and manage OCD?

Effective treatment and management of OCD often involve a combination of therapies, medications, self-care strategies, and lifestyle modifications. Here are five different approaches that specialists may use:

Cognitive-behavioral therapy (CBT)

CBT is considered the most effective form of therapy for OCD. It aims to change maladaptive patterns of thinking and behavior. The goal is not to eliminate the patient’s obsessive thoughts but to teach the individual to respond differently to these thoughts and fears.

Exposure and response prevention (ERP)

As a specific type of CBT, ERP assists individuals through gradual, repeated exposure to the thoughts, images, or situations that make them anxious. The response prevention element involves resisting the behaviors that usually follow anxiety-provoking situations. Over time, the person becomes less sensitive to these triggers.

Medication

Several types of medication are commonly used in the treatment of OCD, primarily selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants. These medications help regulate serotonin levels, a neurotransmitter that may be functionally imbalanced in individuals with OCD.

Deep brain stimulation (DBS)

Used in severe, treatment-resistant cases of OCD, DBS involves surgically implanting a device that sends electrical impulses to specific brain areas. This technique can help change the abnormal patterns of brain activity observed in OCD.

Self-care and lifestyle modifications

Lifestyle changes and self-care strategies can be beneficial alongside therapy and medication. Regular exercise, adequate sleep, a healthy diet, and mindfulness or relaxation exercises can help reduce the overall anxiety levels that fuel OCD symptoms.

Using worksheets in OCD treatment

Worksheets can also be extremely beneficial during OCD therapy. They serve as practical tools that help individuals recognize their fears and spot patterns in their thoughts and behaviors. These worksheets can assist in identifying symptoms among adults and children, tracking triggers and responses, recording patterns, and planning and practicing ERP tasks.

They also extend therapy beyond the confines of a practitioner's office, enabling therapeutic intervention in various real-life scenarios. This comprehensive approach to treatment provides continuity and reinforces the therapeutic process.

Reference

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC.