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Obsessive-Compulsive Disorder

Suggested Diagnostic Criteria For Obsessive-Compulsive Disorder In Children

The two most common documents used for the diagnosis of Autistic Disorders are the DSM IV and ICD 10. The DSM IV is used mostly in the United States though it has been used elsewhere, including the U.K., whereas the ICD 10 is more commonly used in Europe. We have included the descriptions of both, as below.

DSM IV
ICD 10 (European Description)

Note: Consider a criterion met only if the behaviour is considerably more frequent than that of most people of the same mental age.



DSM IV (Diagnostic & Statistical Manual) Obsessive-Compulsive Disorder Diagnostic Criteria:

A. Either obsessions or compulsions:

Obsessions as defined by (1), (2), (3), and (4):

A. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress

B. the thoughts, impulses, or images are not simply excessive worries about real-life problems

C. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action

D. the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

Compulsions as defined by (1) and (2):

E. repetitive behaviors (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

F. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.

C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person's normal routine, occupational (or academic) functioning, or usual social activities or relationships.

D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).

E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Specify if:

With Poor Insight: if, for most of the time during the current episode the person does not recognize that the obsessions and compulsions are excessive or unreasonable

Differential Diagnosis

Anxiety Disorder Due to a General Medical Condition; Substance-Induced Anxiety Disorder; Body Dysmorphic Disorder; Specific Phobia; Social Phobia; Trichotillomania; Major Depressive Episode; Generalized Anxiety Disorder; Hypochondriasis; Specific Phobia; Delusional Disorder; Psychotic Disorder Not Otherwise Specified; Schizophrenia; Tic Disorder; Stereotypic Movement Disorder; Eating Disorders; Paraphilias; Pathological Gambling; Alcohol Dependence; Alcohol Abuse; Obsessive-Compulsive Personality Disorder; Superstitions; repetitive checking behaviors.

Obsessive-Compulsive Disorder - European Description:

The ICD-10 Classification of Mental and Behavioural Disorders World Health Organization, Geneva, 1992

F42 Obsessive-Compulsive Disorder

The essential feature of this disorder is recurrent obsessional thoughts or compulsive acts. (For brevity, "obsessional" will be used subsequently in place of "obsessive-compulsive" when referring to symptoms.) Obsessional thoughts are ideas, images or impulses that enter the individual's mind again and again in a stereotyped form. They are almost invariably distressing (because they are violent or obscene, or simply because they are perceived as senseless) and the sufferer often tries, unsuccessfully, to resist them. They are, however, recognized as the individual's own thoughts, even though they are involuntary and often repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. The individual often views them as preventing some objectively unlikely event, often involving harm to or caused by himself or herself. Usually, though not invariably, this behaviour is recognized by the individual as pointless or ineffectual and repeated attempts are made to resist it; in very long-standing cases, resistance may be minimal. Autonomic anxiety symptoms are often present, but distressing feelings of internal or psychic tension without obvious autonomic arousal are also common. There is a close relationship between obsessional symptoms, particularly obsessional thoughts, and depression. Individuals with obsessive-compulsive disorder often have depressive symptoms, and patients suffering from recurrent depressive disorder may develop obsessional thoughts during their episodes of depression. In either situation, increases or decreases in the severity of the depressive symptoms are generally accompanied by parallel changes in the severity of the obsessional symptoms. Obsessive-compulsive disorder is equally common in men and women, and there are often prominent anankastic features in the underlying personality. Onset is usually in childhood or early adult life. The course is variable and more likely to be chronic in the absence of significant depressive symptoms.

Diagnostic Guidelines

For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities. The obsessional symptoms should have the following characteristics:

(a) they must be recognized as the individual's own thoughts or impulses:
(b) there must be at least one thought or act that is still resisted unsuccessfully, even though others may be present which the sufferer no longer resists;
(c) the thought of carrying out the act must not in itself be pleasurable (simple relief of tension or anxiety is not regarded as pleasure in this sense);
(d) the thoughts, images, or impulses must be unpleasantly repetitive.

Includes:

* anankastic neurosis
* obsessional neurosis
* obsessive-compulsive neurosis

Differential Diagnosis

Differentiating between obsessive-compulsive disorder and a depressive disorder may be difficult because these two types of symptoms so frequently occur together. In an acute episode of disorder, precedence should be given to the symptoms that developed first; when both types are present but neither predominates, it is usually best to regard the depression as primary.

In chronic disorders the symptoms that most frequently persist in the absence of the other should be given priority. Occasional panic attacks or mild phobic symptoms are no bar to the diagnosis. However, obsessional symptoms developing in the presence of schizophrenia, Tourette's syndrome, or organic mental disorder should be regarded as part of these conditions.

Although obsessional thoughts and compulsive acts commonly coexist, it is useful to be able to specify one set of symptoms as predominant in some individuals, since they may respond to different treatments.

F42.0 Predominantly Obsessional Thoughts Or Ruminations

These may take the form of ideas, mental images, or impulses to act. They are very variable in content but nearly always distressing to the individual. A woman may be tormented, for example, by a fear that she might eventually be unable to resist an impulse to kill the child she loves, or by the obscene or blasphemous and ego-alien quality of a recurrent mental image. Sometimes the ideas are merely futile, involving an endless and quasi-philosophical consideration of imponderable alternatives. This indecisive consideration of alternatives is an important element in many other obsessional ruminations and is often associated with an inability to make trivial but necessary decisions in day-to-day living.

The relationship between obsessional ruminations and depression is particularly close: a diagnosis of obsessive-compulsive disorder should be preferred only if ruminations arise or persist in the absence of a depressive disorder.

F42.1 Predominantly Compulsive Acts (Obsessional Rituals)

The majority of compulsive acts are concerned with cleaning (particularly hand-washing), repeated checking to ensure that a potentially dangerous situation has not been allowed to develop, or orderliness and tidiness. Underlying the overt behaviour is a fear, usually of danger either to or caused by the patient, and the ritual act is an ineffectual or symbolic attempt to avert that danger. Compulsive ritual acts may occupy many hours every day and are sometimes associated with marked indecisiveness and slowness. Overall, they are equally common in the two sexes but hand-washing rituals are more common in women and slowness without repetition is more common in men.

Compulsive ritual acts are less closely associated with depression than obsessional thoughts and are more readily amenable to behavioural therapies.

ICD-10 copyright © 1992 by World Health Organization. Internet Mental Health (www.mentalhealth.com) copyright © 1995-1997 by Phillip W. Long, M.D.

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