Criteria
Diagnostic and statistical manual of mental disorders, fifth edition, text revision (DSM-5-TR) criteria[1]
The American Psychiatric Association's DSM-5-TR offers operationalised criteria to be used in establishing a diagnosis of OCD. OCD is classified within the general chapter on "Obsessive-compulsive and related disorders".
Must exhibit obsessions, compulsions, or both.
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.
The obsessions and/or compulsions are not attributable to the physiological effects of a substance or other medical condition.
The disorder is not better explained by the symptoms of another mental disorder, such as excessive worries in the context of generalised anxiety disorder, or ritualised eating behaviour in the context of an eating disorder.
Obsessions are:
Recurrent and persistent thoughts, urges, or images experienced, at some time during the disturbance, as intrusive and unwanted and in most individuals cause marked anxiety or distress.
There is some effort by the affected person to ignore or suppress such thoughts, impulses, or images, or to neutralise them with some other thought or action (i.e., by performing a compulsion).
Compulsions are:
Repetitive behaviours (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.
These behaviours or mental acts are performed in order to prevent or reduce anxiety or distress, or prevent some dreaded event or situation. However, they are either clearly excessive or not connected in a realistic way with what they are designed to neutralise or prevent.
In diagnosis, specify level of patient insight. Note that this may vary over the course of the condition.
With good or fair insight: individual recognises that OCD beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: individual thinks OCD beliefs are probably true.
With absent insight/delusional beliefs: individual is completely convinced that OCD beliefs are true.
Do not give these patients 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).
Also specify if the disorder is tic-related (i.e., does the patient have a current or past history of a tic disorder).
International classification of diseases 11th revision (ICD-11) definition[7]
Published by the World Health Organization, the ICD-11 offers an internationally recognised definition of OCD. It classifies OCD in the "Mental, behavioural or neurodevelopmental disorders" chapter within "Obsessive-compulsive or related disorders".
Essential diagnostic 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 neutralise 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 ischaemic 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
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.
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.
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)[37]
The Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) is the most widely used measure of OCD symptoms. It can be used as a self-report instrument or a semi-structured interview, and has been demonstrated to be valid in OCD. The Y-BOCS exists in both an adult and a child version.[37] This scale is not a diagnostic tool, but a reliable measure of symptom severity. The Y-BOCS has both a symptom checklist and a severity rating scale. The Y-BOCS symptom checklist also provides the therapist with information about the problem areas that need further focus in treatment. The Y-BOCS severity scale consists of 10 questions: 5 about obsessions and 5 about compulsions. This scale should be administered to patients who are beginning treatment for OCD and should be re-administered periodically, perhaps every 6 months, in order to track treatment progress. The definition of response and non-response to treatment is based on the Y-BOCS.
0 to 7: subclinical/asymptomatic
8 to 15: mild symptoms
16 to 23: moderate symptoms
24 to 31: severe symptoms
32 to 40: extremely severe
Clinical Global Impression (CGI)
The CGI is used to assess the general clinical severity of any mental disorder. It was developed for use in National Institute of Mental Health (NIMH)-sponsored clinical trials to provide a brief, single-item assessment of the clinician's view of the patient's global functioning prior to and after initiating a study medication. It is composed of two companion one-item measures evaluating the following: a) severity of psychopathology from 1 to 7, and b) change from the initiation of treatment on a similar 7-point scale. The response format for the CGI is:
0: not assessed
1: normal, not at all ill
2: borderline mentally ill
3: mildly ill
4: moderately ill
5: markedly ill
6: severely ill
7: among the most extremely ill patients.
Level of response[25]
Stage I: Recovery
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) <8
Stage II: Remission
Y-BOCS <16
Stage III: Full response
35% or greater reduction in Y-BOCS score
Clinical global impression (CGI) 1 or 2
Stage IV: Partial response
25% to 35% reduction in Y-BOCS score
Stage V: Non-response
<25% reduction in Y-BOCS score
CGI 4
Stage VI: Relapse
CGI 6 or 25% increase in Y-BOCS remission score after 3+ months of adequate treatment
Stage VII: Refractory
No change and no worsening with all available therapies
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