DSM-5 Diagnostic Criteria for OCD

a paranoid patient Credit: verywell mind Opens in new window

OCD Opens in new window needs to be distinguished from a different condition with a similar name: obsessive-compulsive personality disorder (OCPD) Opens in new window. Whereas OCD is an anxiety disorder, OCPD is a personality disorder, i.e., a disorder in those stable traits that make up one’s personality.

Because anxiety is aversive, people with OCD are generally opposed to their condition. People tend not to be similarly opposed to their own personalities, even when the personality causes distress, so those with OCPD are often not similarly opposed to their own condition.

In psychological terms, OCD tends to be “ego-dystonic” and OCPD tends to be “ego-syntonic,” although it is not clear whether these distinctions are categorical (e.g., Coles et al., 2008; Eisen et al., 2013).

In any case, the official distinction between OCD and OCPD lies in “the presence of true obsessions and compulsions in OCD” (DSM-5: 681; cf.242).

The official definition of OCD thus requires the “presence of obsessions, compulsions, or both” (DSM-5: 237), which are both related to the presence anxiety in the sufferer. DSM-5 (p. 237) diagnoses obsessions as the following:

  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).

The requirements, then, are that obsessions are:

  1. recurrent and persistent,
  2. unjustified
  3. thoughts, urges, or images that are
  4. intrusive and unwanted,
  5. anxiety or distress evoking, and that
  6. prompt compulsions.

Now, let’s look at these feature one at a time.

  1. Recurrent and Persistent

Some individuals might imagine their house being broken into. Maybe they’ve just been reading about another break-in, or maybe the thought springs to mind for no obvious reason. May be they imagine it vividly. Maybe they imagine something sentimental being stolen or a loved one being assaulted.

However they imagine it, they immediately feel great anxiety that pushes their other thoughts off to the side. It’s a fleeting thought, though: the thought and the anxiety soon go away without any effort on their part, and they go back to their ordinary life and thoughts.

If the incident is isolated and short-lived, as we’ve described it, then, however disturbing it might have been in the moment, it’s not an obsession Opens in new window. It’s just a disturbing thought. If the thought arises again, however, with the same accompanying anxiety, or if similar thoughts arise, or if the thoughts persist for longer, then the thoughts begin to look like obsessions.

The thoughts don’t need to be always about the same thing, but obsessions will often be on the same topics. For example, the thoughts may center on security and violation, or on death, on contamination of various sorts, on sex and purity, or, in the cases we’ll focus on here, on moral or religious violations or contaminations, on sin and spiritual or moral value.

What’s important to note here is that no one thought on its own is an obsession; obsessions are part of a pattern of thoughts. And, while any one obsession may be easy enough to dismiss or ignore, the pattern as a whole is not easily dismissed or ignored. It is repeated pattern that creates a problem for the person.

  1. Unjustified

The requirement that obsessions are unjustified is unstated in the diagnostic criteria, but it’s worth making this background assumption explicit for our purposes.

Fear, anxiety, and intrusive thoughts about danger and potential loss are sometimes very reasonable. Someone who lives in a community with lots of crime might very afraid of crime, or she might have particularly valuable and irreplaceable possessions, such as family heirlooms, that she isn’t able to secure or that no amount of insurance could replace.

An organ transplant patient with a compromised immune system should be very worried about avoiding germs. A solidier in an active war zone is reasonably unable to sleep out of worry about her safety. These higher-than-average levels of fear are entirely reasonable, understandable, and justifiable.

In order for anxiety-inducing thoughts to support a diagnosis of OCD, however, the anxiety must not be proportionate response to a reasonable and accurate assessment of a danger, threat, or genuine potential for losses.

One’s anxiety might be unjustified because it wasn’t justifiable to form the anxious thoughts or judgments in the first place. This is a common way in which OCD reasoning precedes:

There is some small possibility that something bad will happen, and the person fixates on that possibility and responds as if the possibility were serious and severe.

For example, I worry that I might have hit someone with my car while driving, despite there being absolutely no real evidence that I did so, or that anyone was hit where I was driving, and no evidence that anyone sober and attentive (as I am) has ever hit someone without realizing it.

It’s of course possible that I hit someone—possible, though so unlikely as not to be worth the thought.

The thought and related anxiety about having hit someone are reasonable if I have some justification that I might have hit someone, but, given that I have no such justification, the thought and related anxiety are also unjustifiable. What is unjustified is having the thought to begin with, so its subsequent anxiety is unjustified as well.

This raises the second way in which anxiety is unjustified in OCD cases. An anxious thought is not justified when there is only the merest possibility that a bad thing could happen.

Someone with OCD might put forward elaborate justification for why it’s possible that something worth worrying about has occurred or might occur. It is possible that one ran into a pedestrian when driving despite finding no evidence that anyone was hit.

Why stop with these possibilities?

It is possible a tornado will take out my house tomorrow—or even a few minutes from now!—despite the calm forecast. It is possible that a black hole could form on Long Island from the experiments being done there that would then destroy Earth. These are all possible!

The reason such anxieties aren’t justified is because there are infinitely many harmful possibilities that a person could worry about. If a worry were justifiable merely in virtue of its being a possibility, there would be literally no end to the amount of anxiety that could be justified.

But we don’t have an infinite capacity for anxiety. If we are extremely anxious about something with a minuscule probability of a moderate harm, it’s impossible for us to feel proportionately more anxiety for something that is equally harmful but somewhat likely, and we cannot then easily distinguish the serious cases from the frivolous ones. Ideally, one’s worries should be proportionate to the magnitude of the possible harms and their probability. At a minimum, one’s worries should be in proportion to each other.

  1. Thoughts, Urges, or Images (or Beliefs?)

The DSM characterizes obsessions as “thoughts, urges, or images.” A person with lock-checking OCD might, for example, constantly think that his door is not locked, feel an urge to lock it, or perhaps have an image of a burglar entering his house. A person with hand-washing OCD might constantly think of germs, feel an urge to wash, or imagine germs or tiny bugs crawling on her hands.

Analogously, someone with hand-washing OCD might have no evidence of actual dirt or germs on her hands, and she might recognize her lack of evidence for this.

Whether this person believes in the presence of dirt or germs then depends on the criteria we use for beliefs and also on what evidence is available to the person.

Even this notion of when evidence is available is complicated in cases of OCD: on some views, people with OCD have such difficulty breaking their focus away from their obsessional thoughts that they do not—perhaps cannot—notice counterevidence.

  1. Intrusive and Unwanted

Obsessive thoughts are also intrusive. Almost all of us have worried at some point about whether we locked a door, for example, or left on a stove or a light, and such thoughts can be hard to shake even when we have no evidence for the thing we’re worried about. Intrusive thoughts are likewise unbidden and unwelcome.

The intrusive thoughts of OCD vary by case, but one common type of thought—which is also common in cases of Scrupulosity Opens in new window— is the thought of contamination (Fergus, 2014).

Contamination can be by dirt or microbes or something else physical; but, more interestingly, the “contaminated” item might be physically completely clean. Its perceived contamination comes from something else, like its history, an association, or its symbolism: maybe it is a shirt once worn by a Nazi or a painting that hung in a convicted pedophile’s house.

The person with OCD might have no reason to believe that the shirt or painting was physically tainted in any such way, but she still cannot dismiss the thought that the item might somehow be unclean. The thought is unwelcome and incompatible with her other beliefs, yet she cannot shake it. If she does shake it for a while, it returns.

Concerns about non-physical contamination are present in non-pathological cases as well: many of us would be hesitant to wear a shirt worn by a Nazi or a pedophile, no matter how many times it was washed. Thus, aversion to non-physical contamination is not by itself pathological—or, at any rate, it is widespread. What makes a thought intrusive is that it’s both unwelcome and inconsistent with one’s other beliefs and desires, and it persists despite being both unwelcome and inconsistent.

What does it mean that intrusive thoughts are generally inconsistent with most of one’ other beliefs and desires?

If I have an unexpected thought that I’m probably going to flunk the test I’m about to take, but I also know I didn’t study enough, the painful thought that I’m about to fail isn’t intrusive, even if I would prefer not to have it and even if I would perform better on the test if I had higher confidence. What would be an intrusive thought is the thought that the exam was yesterday and I’ve missed it, despite my having confirmed that the exam is tomorrow and having no other evidence that I’ve missed it this time.

Intrusive thoughts are also unwelcome.

My sudden, unbidden thought as I talk to my boss that I should seduce him might be unprompted and inconsistent with my thoughts about what will make my life and career go best, but it might not be intrusive: I might find it funny that I have such inappropriately lewd thoughts, or I might wonder why my mind reacts to authority in this way, rather than finding the thought unwelcome.

In contrast, an intrusive thought is unwelcome or troubling and it doesn’t easily go away when I realize it’s intrusive. Consider this same unwelcome sexual thought when I’m talking to a parent or to a sibling.

It’s harder to shake that thought, which is equally unbidden in the way it arises, and even less consistent with my other desires and beliefs, especially my moral beliefs about incest. It’s also less unwelcome because it’s far more troubling.

The longer it sticks around, the more troubling it is. I would like to get rid of the thought; even once I get rid of it, I want never to have had the thought, and I might want to find some way to nullify it. This raises a further, crucial element of intrusive thoughts.

  1. Anxiety or Distress Evoking

Although most of us have intrusive thoughts at one time or another, we usually react to them in one of the following four ways (Wells & Davies, 1994).

  1. We check the evidence. We look at the knobs on the stove to be sure they’re switched to “off.”
  2. We shift our attention to something else. If we have a thought while at work that we left the door at home unlocked, we might decide just to think about something else instead.
  3. We try to analyze why the thought occurred. My unbidden thoughts about seducing my parent makes me think about the ways in which biological urges direct my thoughts and desires in ways that I don’t endorse.
  4. We discuss the thought with other people. Even if we’re unable to dismiss or make sense of thought, we can at least find others with similar thoughts who reassure us that we’re as normal as they are.

In contrast, those with OCD are more likely to react in two other ways (Moore & Abramowitz, 2007; Wells & Davies, 1994).

  1. They respond to the thought with anxiety. They worry about what it means that they even had the thought. They worry about whether it makes them a bad person. They worry about whether the thought will itself cause some bad effects in the world. They even worry that the thought itself has contaminated their mind in some way. These worries repeat and build up until they interfere with the person’s life. Or, they do more than merely worrying:
  2. They punish themselves in some way for having the thought. The punishment may be physical or mental. It might have the goal of preventing negative effects of the thought or it might serve as retribution for even having had the thought. One way or another, they gave themselves the punishment that they think they deserve.

Why do some react in these stronger, more punitive ways to an intrusive thought?

We’ll focus here on the anxiety that attends the thought. The thoughts feel serious, worrisome, and therefore harder to ignore or dismiss. If that’s true, then why would they seem so serious and worrisome?

To answer this question, we need to consider what anxiety is.

A range of emotions could count as anxiety. Given how common the word is, we suspect that clinicians—like the rest of us—use the term in various, related ways. Importantly for our purposes, one of the ways in which we use the word “anxiety” refers to a benign sense of excitement and anticipation that one feels when facing something unknown: anxiety about a blind date, performing onstage, or running the race that one trained for.

All of these events prompt anxiety, but not because one believes that they will go poorly. One might believe the event will go very well but won’t know until it’s over. It is this unknown element that prompts anxiety.

On the other hand, anxiety is sometimes prompted by something that could be terrible, like a long-delayed dental appointment, or something that at best will turn out to be only mildly bad.

Anxiety about a bad outcome is similar to fear about a bad outcome, but the difference is that anxiety is about nothing in particular, whereas fear is of some particular thing. I can be anxious about what is in the tall grass, but I fear the snake that I see. What distinguishes anxiety from fear is that anxiety typically involves uncertainty about a possible threat, and fear is of something determinate.

In anxiety disorders, the person takes the anxiety to be strongly aversive (Here, we’re using the term “anxiety disorders” broadly to include what the DSM-5 includes as OCD and anxiety disorders—all disorders that centrally involve anxiety.

We ignore here cases in which people seek out pain or other aversive states, either because they enjoy the pain itself or enjoy something about keeping oneself in the aversive state, e.g., the felling of mastery over the pain, or the way that the pain distracts from other aversive states.

Such exceptions to our general claims about aversive states will matter in discussions of other psychological disorders but are generally a concern neither with OCD nor with Scrupulosity Opens in new window, so we ignore them in our generalization here).

Its being aversive—like pain or disgust—means only that the person who feels it strongly wants not to feel it. What a person does as a result isn’t determined simply by its being aversive: pain is aversive, but one may react to a headache by taking an aspirin, taking a nap, trying to ignore it, complaining about it, or going to the doctor.

Similarly, most ways of reacting to anxiety are ordinary and unremarkable. If I’m anxious about whether I left the stove on, then I can go back to check, I can think about how likely it is I’ve actually left it on, I can wonder why I just had the thought, or I can tell my friend about it. But anxiety can also lead to spiraling compulsions and increasing harm. Anxiety about my stove can cripple my life by forcing me to check again and again.

Why do people with OCD respond to intrusive thoughts with such high anxiety?

There are, broadly, three reasons for these pathological reactions.

First, in some cases, the person’s beliefs may be exaggerated. A person might think her house is likely to be broken into, when it is merely possible that it will broken into. For probabilistic beliefs in particular, the person’s thought that it’s possible to transmit a disease with an unwashed hand, while true, might seem much more likely to the person with OCD than it actually is.

Or someone might believe that the risk of burglary is much higher than it really is or that the harms it would cause would be catastrophic, rather than merely inconvenient. In short, they might overestimate the probability or the degree of harm. If their thoughts were accurate, and the harm really were more likely, then they would be worrying the appropriate amount. But their thoughts are not accurate.

Second, instead of the thoughts themselves, the problem might lie in the accompanying emotions. The emotions of people with OCD might be stronger or more persistent than others’, even for the same thought. I know it’s possible that my house will be broken into when I’m gone, but, while the thought is uncomfortable for me just as it is for someone with OCD, it doesn’t prompt strong or persistent anxiety.

If I instead had strong or persistent anxiety about this possibility, it might be impossible for me to trust that the locks are in fact secure, perhaps unbearable even to leave the house. This doesn’t change the thoughts or beliefs, but only the accompanying emotion. So a second possibility is that those with OCD feel extreme anxiety in the face of normal risks and normal beliefs about risks.

Within this area, we should ask whether anxiety always arises from one’s thoughts or whether anxiety sometimes causes people to fixate on thoughts that justify why they feel so much anxiety.

We will return later to this question, but one common theory of OCD is a cognitive theory, according to which obsessive thoughts cause compulsions (O’Connor & Robillard, 1995; Salkovskis, 1999), and, while the person may be predisposed to feel anxiety, the obsessive thoughts prompt further anxiety. But the alternative causal story is also possible to tell. Anxiety could be a major cause of an obsession if anxiety causes someone to search for a way to rationalize that anxiety.

In actual cases, there is also feedback and mutual support between anxiety, obsessions, and compulsions, such that there is no simple causal story to tell about whether anxiety causes the anxious thoughts or anxious thoughts cause the anxiety is itself “the” cause of a person’s subsequent compulsions.

Finally, a third reason for a pathological reaction to intrusive thoughts is that people with OCD might have less ability to shift their attention consistently away from an obsession (Levy, 2018). In our example, they might have normal beliefs and normal initial anxiety reactions but lack a normal ability to ignore, influence, or behaviorally control those anxieties or their responses to the anxiety. They might not even try, either because they assume they would fail or because they don’t know any techniques to try. In that case, they might actually have the ability to shift their attention away from the intrusive thoughts, but they don’t know that they have this ability, or they don’t exercise it. Either way, they don’t succeed in shifting their attention or otherwise controlling their anxiety.

Of course, all three of these proposed explanations can interact. If one is unable to control or change one’s attention, this might lead one to attend only to certain pieces of evidence (e.g., the fact that there was a break-in down the street), which might lead to false beliefs (e.g., that a break-in here is likely).

Or, the difficulties of attention might keep one’s focus on one’s anxieties, which might reinforce and increase them.

Intense anxiety might keep one’s attention focused on the object of that anxiety, so feeling anxious about whether the door is locked might be a regular reminder to check it. Mistaken beliefs might both cause anxiety and be caused by anxiety and by attention focused on highly selective evidence. The explanations aren’t mutually exclusive and can reinforce each other, so there is often little point in trying to distinguish the best explanation in a particular case.

And of course the final requirement for OCD is that obsessions cause compulsions. See here for DSM-5 (p. 237) definition of compulsion Opens in new window.

    The research data for this work have been adapted from:
  1. Understanding Paranoia: A Guide for Professionals, Families, and Sufferers By Martin Kantor
  2. Personality Disorders: Toward the DSM-V By William O'Donohue, Katherine A. Fowler, Scott O. Lilienfeld.
  3. The Fundamentals of Psychological Medicine By R.R. Tilleard-Cole, J. Marks
  4. Personality Disorders in Modern Life By Theodore Millon, Carrie M. Millon, Sarah E. Meagher, Seth D. Grossman, Rowena Ramnath