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Obsessive-Compulsive Disorder (OCD): Signs, Symptoms, and DSM-5 Criteria

Picture of Dr. Alexander Sidawi

Dr. Alexander Sidawi

Dr. Sidawi is an Orlando based, UF trained physician who is happy to be serving the community he grew up in by offering a combination of psychiatric medication management and psychodynamic psychotherapy.

What is Obsessive-Compulsive Disorder (OCD)?

Obsessive-Compulsive Disorder (OCD) is characterized by a challenging cycle of intrusive, distressing thoughts (obsessions) and/or repetitive behaviors and rituals (compulsions). OCD can significantly interfere with a person’s daily life, consuming a substantial amount of time and energy. Individuals may find it challenging to concentrate on other tasks or engage in meaningful activities due to the overwhelming presence of obsessions and compulsions.

It is an often misunderstood mental health condition, distinct from the similarly named but quite different Obsessive-Compulsive Personality Disorder (OCPD). OCD affects approximately 1% of the American population, disrupting daily life and mental well-being. In this blog post, we will explore the signs and symptoms of OCD, the diagnostic criteria outlined in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition), and treatment strategies for OCD.

Obsessions: The Unwanted Thoughts.

A key characteristic of OCD is the presence of intrusive and unwanted thoughts, images, or urges that cause significant distress. These obsessions can be distressing, disturbing, or fear-provoking and may include concerns about a number of different topics. There are a number of different obsessions that OCD can manifest as, including:

  1. Violent or Aggressive Thoughts: Thoughts of causing harm to oneself or others, such as physically hurting a loved one or a stranger.

  2. Contamination or Germ-Related Thoughts: Fear of being contaminated by germs or chemicals.

  3. Sexual Intrusive Thoughts: Inappropriate or taboo sexual thoughts that are unwanted and distressing, often causing shame and guilt.

  4. Religious or Moral Intrusive Thoughts: Obsessive doubts about one’s religious or moral beliefs, fear of committing blasphemy, or concerns about being a bad person.

  5. Symmetry and Order Intrusive Thoughts: An overwhelming need for everything to be perfectly symmetrical or arranged in a particular order.

  6. Health-Related Intrusive Thoughts: Fear of having a serious illness or becoming seriously ill, despite no evidence of illness.

  7. Fear of Accidents: Intrusive thoughts about accidentally harming oneself or others, such as causing a car accident or falling from a height.

  8. Fear of Losing Control: Worries about losing control and doing something harmful or embarrassing.

  9. Fear of Unintentionally Offending: Worrying about unintentionally saying or doing something offensive or inappropriate in social situations.

Compulsions: The Repetitive Rituals.

Individuals with OCD engage in repetitive behaviors or rituals (compulsions) to alleviate the distress caused by their obsessions temporarily. These compulsions often provide a false sense of control or relief. Common compulsions include:

  1. Washing and Cleaning: Excessive handwashing, showering, or cleaning of objects and surfaces due to fears of contamination or germs.

  2. Checking: Repeatedly checking locks, appliances, or other objects to ensure they are secure and no harm will come to oneself or others.

  3. Counting: Engaging in repetitive counting of objects, actions, or words to reduce anxiety or prevent a feared event.

  4. Repeating: Repeating specific phrases, prayers, or activities multiple times until it feels “just right.”

  5. Arranging and Ordering: Rearranging objects or items in a particular order to reduce feelings of discomfort or anxiety.

  6. Mental Rituals: Engaging in mental activities or prayers to neutralize or prevent intrusive thoughts.

  7. Seeking Reassurance: Constantly seeking reassurance from others to alleviate doubt or uncertainty.

  8. Avoidance: Avoiding specific situations, places, or people that trigger obsessive thoughts.

  9. Tapping or Touching: Tapping or touching objects or surfaces in a specific pattern or sequence.

  10. Hoarding: Collecting and holding onto items that others may view as useless or unnecessary, driven by anxiety about discarding them.

  11. Mental Reviewing: Going over past events or conversations repeatedly to ensure nothing was said or done to harm oneself or others.

  12. Ritualized Eating: Following strict or elaborate eating rituals to prevent potential harm or contamination.

DSM-5 Criteria for OCD:

The DSM-5 outlines specific criteria for diagnosing Obsessive-Compulsive Disorder including:

  1. Presence of Obsessions, Compulsions, or Both:

    1. Obsessions: Recurrent and persistent thoughts, urges, or images that cause anxiety or distress with attempts to ignore, suppress or neutralize them.

    2. Compulsions: Repetitive behaviors or mental acts performed in response to the obsessions to reduce distress or prevent a feared event.

  2. Time-Consuming or Interfering: The obsessions or compulsions take up a significant amount of time (more than one hour per day) or significantly interfere with daily functioning.

  3. Not Attributable to Other Conditions: The symptoms are not better explained by the effects of substances or another medical or psychological condition.

  4. Not better explained by another mental disorder: obsessive compulsive personality disorder, generalized anxiety disorder, body dysmorphic disorder, hoarding disorder, trichotillomania, excoriation disorder, eating disorders, etc.

Treatments for OCD:

Treatments for OCD generally include a combination of accurate diagnosis, medication and therapy. Treatment approaches are diverse and should be tailored to the individual’s unique symptoms and experiences. An important aspect of treatment is to determine an accurate diagnosis, especially since so many other psychiatric diagnoses have overlapping symptoms. 

Accurate diagnosis can be complex, as symptom overlap is particularly evident with Obsessive-Compulsive Personality Disorder (OCPD), Generalized Anxiety Disorder (GAD), Body Dysmorphic Disorder (BDD), tic disorders, skin and hair pulling disorders, and hoarding disorder. all share some overlapping symptoms with OCD. For example, OCD with a preoccupation on cleanliness or contamination can resemble the perfectionism and desire for control in OCPD. The pervasive worry characteristic of GAD can resemble the obsessive worries seen in OCD. Obsessions in OCD can resemble the intense preoccupation with physical appearance in BDD. Moreover, compulsive rituals of OCD shares similarities with the repetitive movements in tic disorders. OCD’s compulsions may also resemble the compulsive need to save items (regardless of their value) seen in hoarding disorder.

Evidence-based psychotherapies like Cognitive-Behavioral Therapy (CBT) and Exposure Response Prevention (ERP) are at the forefront of OCD treatment. CBT helps in identifying and altering negative thought patterns, while ERP involves gradual exposure to anxiety-provoking stimuli, teaching individuals to resist the urge to perform compulsions. Habit Reversal Therapy, another effective approach, is particularly beneficial in managing compulsive behaviors and tic symptoms often associated with OCD.

Medication management, particularly with antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRIs), plays a vital role in alleviating OCD symptoms. Medications like fluvoxamine (Luvox), escitalopram (Lexapro), fluoxetine (Prozac), sertraline (Zoloft), and duloxetine (Cymbalta) have been effective in reducing the intensity of OCD symptoms, helping to reduce how overwhelming the disorder can be and providing a more stable platform for individuals to engage in therapy.