overview

Obsessive-compulsive and related disorders encompass a group of conditions characterized by repetitive thoughts, urges, or behaviors that can cause significant distress or impairment. These disorders are unified by a common theme of preoccupations and repetitive behaviors or mental acts performed in response to these preoccupations. While each condition has unique features, they often involve a cycle of distressing thoughts and attempts to alleviate distress through specific behaviors.

Obsessive-Compulsive Disorder (OCD) serves as the prototypical disorder in this category, defined by the presence of obsessions and/or compulsions:

• Obsessions are recurrent, persistent thoughts, urges, or images that are intrusive and unwanted.
• Compulsions are repetitive behaviors or mental acts performed in response to obsessions or rigidly applied rules.

Other disorders within this category may focus more on body-related concerns or repetitive behaviors, such as skin picking, hair pulling, or hoarding. These behaviors are typically difficult to control despite efforts to reduce or stop them, and they often lead to significant distress or impairment in social, occupational, or other important areas of functioning.

DSM Chapter Sections:

1. Obsessive-Compulsive Disorder (OCD)
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 (e.g., nail biting, lip biting, cheek chewing, obsessional jealousy, olfactory reference disorder)
9. Unspecified Obsessive-Compulsive and Related Disorder

obsessive-compulsive disorder

A diagnosis of Obsessive-Compulsive Disorder (OCD) requires the presence of obsessions, compulsions, or both:

• Obsessions involve:
  1. Recurrent, intrusive, and unwanted thoughts, urges, or images causing significant distress.
  2. Efforts to ignore, suppress, or neutralize these thoughts through other actions or mental acts (e.g., compulsions).
• Compulsions involve:
  1. Repetitive behaviors (e.g., washing, checking) or mental acts (e.g., counting, praying) performed in response to obsessions or rigid rules.
  2. Actions aimed at reducing distress or preventing feared outcomes, though they are excessive or not realistically connected to the fear.

Additional criteria:

• Symptoms must be time-consuming (e.g., taking more than one hour per day) or cause significant distress or impairment in daily functioning.
• The symptoms are not attributable to substances, medical conditions, or another mental disorder.

Specifiers:

• Insight: Individuals may vary in their awareness of the irrationality of their beliefs:
  • Good or fair insight: Recognizing beliefs are probably untrue.
  • Poor insight: Believing obsessive fears are likely true.
  • Absent insight/delusional beliefs: Fully convinced the fears are true.
• Tic-related: Applies to individuals with a current or past history of tic disorders, which are more common in males with childhood-onset OCD.

Body Dysmoprhic disorder

Body dysmorphic disorder (BDD), formerly called dysmorphophobia, involves intrusive and unwanted preoccupations with physical appearance. Individuals perceive themselves as unattractive, abnormal, or deformed, though these flaws are imperceptible or minimal to others. Preoccupations can focus on one or more body areas, including skin (e.g., acne, scars), hair (e.g., thinning, excess), nose (e.g., size or shape), or other regions (e.g., eyes, teeth, stomach, legs).

Repetitive behaviors or mental acts performed in response to these concerns are a hallmark of BDD. Common examples include:

• Mirror checking or avoiding mirrors.
• Excessive grooming, hair styling, or applying makeup.
• Skin picking, often causing damage or infection.
• Comparing appearance to others.
• Reassurance seeking about perceived flaws.
• Camouflaging defects by altering clothing, hair, or makeup.
• Pursuing cosmetic procedures to “fix” perceived flaws.

These behaviors are time-consuming (e.g., averaging 3–8 hours per day) and do not provide lasting relief, often increasing anxiety and dysphoria.

Diagnostic Criteria:
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 disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing appearance with others) in response to 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 individuals meeting diagnostic criteria for an eating disorder.

Specify if:

• With muscle dysmorphia: Preoccupation with the idea that one’s body is too small or insufficiently muscular, even if other body areas are also a focus of concern.

Specify insight level:

• Good or fair insight: Recognition that body dysmorphic beliefs are definitely or probably not true, or that they may or may not be true.
• Poor insight: Belief that the body dysmorphic beliefs are probably true.
• Absent insight/delusional beliefs: Complete conviction that the beliefs are true.

hoarding disorder

Hoarding differs from normative collecting, which is selective, organized, and does not result in distress or impairment. In contrast, hoarding is disorganized, leads to excessive accumulation, and significantly impairs functioning.

Diagnostic Criteria:
A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
B. Difficulty is due to a perceived need to save items and distress associated with discarding them.
C. Accumulation of possessions results in clutter that congests and compromises the intended use of active living areas. If living areas are uncluttered, it is only due to third-party interventions (e.g., family members, cleaners, authorities).
D. The hoarding causes clinically significant distress or impairment in social, occupational, or other areas of functioning, including maintaining a safe environment.
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., obsessive-compulsive disorder, major depressive disorder, schizophrenia, autism spectrum disorder).

Specify if:

• With excessive acquisition: Difficulty discarding possessions is accompanied by excessive acquisition of items not needed or for which there is no available space.
• Insight level:
  • Good or fair insight: Recognition that hoarding-related behaviors are problematic.
  • Poor insight: Belief that hoarding behaviors are not problematic despite evidence to the contrary.
  • Absent insight/delusional beliefs: Complete conviction that hoarding behaviors are not problematic despite evidence to the contrary.

trichotillomania (Hair-Pulling)

Trichotillomania involves a persistent cycle of hair-pulling that results in hair loss, repeated attempts to stop, and significant distress or impairment. Individuals may struggle with feelings of shame and avoidance, and the behavior often occurs despite efforts to control it. This condition requires differentiation from medical and other psychiatric causes of hair-related behaviors.

Diagnostic Criteria:
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 resulting 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 address a perceived flaw in body dysmorphic disorder).

excoriation (Skin-Picking) Disorder

Excoriation disorder involves persistent, uncontrollable skin-picking that results in lesions and significant distress or functional impairment. The behavior often persists despite repeated attempts to stop and leads to emotional and social consequences, including avoidance and shame. This disorder is distinct from medical or other psychiatric causes of skin-picking behaviors.

Diagnostic Criteria:
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 the symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or nonsuicidal self-injury).

substance/medication-induced obsessive-compulsive and related disorder

Substance/medication-induced obsessive-compulsive and related disorder is marked by the development of obsessive-compulsive symptoms during or after substance intoxication, withdrawal, or medication use. The symptoms must be directly caused by the substance or medication and cannot be better explained by a pre-existing disorder. This diagnosis highlights the importance of evaluating timing, severity, and context in identifying the underlying cause of symptoms.

Diagnostic Criteria:
A. Prominent symptoms of obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of obsessive-compulsive and related disorders predominate in the clinical picture.

B. Evidence from history, physical examination, or laboratory findings confirms both:

1. Symptoms developed during or soon after substance intoxication, withdrawal, or exposure to a medication.
2. The substance/medication involved is capable of producing the symptoms in Criterion A.

C. The disturbance is not better explained by a non-substance/medication-induced obsessive-compulsive and related disorder. Indicators of an independent disorder may include:

• Symptoms preceded substance/medication use.
• Symptoms persist for a substantial time (e.g., 1 month) after cessation of intoxication or withdrawal.
• Other evidence of a pre-existing obsessive-compulsive and related disorder.

D. The disturbance does not occur exclusively during a delirium.

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Note: The diagnosis is made only when symptoms in Criterion A are the predominant clinical concern and severe enough to warrant attention beyond a diagnosis of substance intoxication or withdrawal.

Specifiers “With”:

• onset during intoxication: Symptoms develop during substance intoxication.
• onset during withdrawal: Symptoms develop during or shortly after substance withdrawal.
• onset after medication use: Symptoms develop at medication initiation, during dosage change, or withdrawal of the medication.

obsessive-compulsive and related disorder due to another medical condition

Obsessive-compulsive and related disorder due to another medical condition involves obsessive-compulsive symptoms directly attributable to an underlying medical condition. Accurate diagnosis requires evidence of a causal link, temporal association, and exclusion of other potential causes, including primary psychiatric disorders or substance-induced symptoms. This diagnosis emphasizes the importance of identifying and treating the underlying medical condition alongside the obsessive-compulsive symptoms. The symptoms must cause clinically significant distress or impairment in social, occupational, or other critical areas of functioning, further validating the need for diagnosis and treatment.

Diagnostic Criteria:
A. Obsessions, compulsions, preoccupations with appearance, hoarding, skin picking, hair pulling, or other symptoms characteristic of obsessive-compulsive and related disorders predominate in the clinical picture.
B. Evidence from history, physical examination, or laboratory findings confirms 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: Obsessions and compulsions predominate.
• appearance preoccupations: Concerns with perceived physical flaws predominate.
• hoarding symptoms: Hoarding behavior predominates.
• hair-pulling symptoms: Hair-pulling behaviors predominate.
• skin-picking symptoms: Skin-picking behaviors predominate.

other specified obsessive-compulsive and related disorder

This category is used for presentations where symptoms of an obsessive-compulsive and related disorder cause clinically significant distress or impairment but do not meet full criteria for any specific disorder within this diagnostic class. The clinician specifies the reason the criteria are unmet by recording “other specified obsessive-compulsive and related disorder” along with the specific subtype or reason (e.g., obsessional jealousy).

Examples of Specified Presentations:

1. Body Dysmorphic–Like Disorder with Actual Flaws:
   • Preoccupation with clearly observable physical flaws that are excessively distressing or impairing.
2. Body Dysmorphic–Like Disorder Without Repetitive Behaviors:
   • Preoccupation with perceived flaws without associated repetitive behaviors or mental acts.
3. Other Body-Focused Repetitive Behavior Disorder:
   • Recurrent body-focused behaviors (e.g., nail biting, lip biting, cheek chewing) with attempts to stop, causing distress or impairment.
4. Obsessional Jealousy:
   • Non-delusional preoccupation with a partner’s perceived infidelity, leading to distress and repetitive behaviors.
5. Olfactory Reference Disorder (Olfactory Reference Syndrome):
   • Persistent belief of emitting an offensive body odor, accompanied by excessive checking, grooming, or camouflaging behaviors.
6. Shubo-Kyofu:
   • Excessive fear of having a bodily deformity, a cultural variant of taijin kyofusho.
7. Koro:
   • Sudden, intense anxiety that genital organs will recede into the body and lead to death, a cultural variant associated with dhat syndrome.

Unspecified Obsessive-Compulsive and Related Disorder

This category applies to presentations where obsessive-compulsive symptoms cause clinically significant distress or impairment but do not meet full criteria for a specific disorder within the class.

Key Features:

• Used when the clinician opts not to specify the reason the criteria are unmet.
• Applies when insufficient information is available to make a more precise diagnosis (e.g., in emergency settings).

self-check

The following questions are in a set , and there are six questions. After you select an answer, it will identify whether the answer is correct or incorrect.  When the answer is incorrect, it will show the correct answer. To advance to the next question, click on the arrow at the bottom right side.