Diagnostic criteria

National Collaborating Centre for Mental Health (UK)

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National Collaborating Centre for Mental Health (UK). Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder. Leicester (UK): British Psychological Society (UK); 2006. (NICE Clinical Guidelines, No. 31.)

Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder.

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Appendix 15Diagnostic criteria

Table 10Diagnostic criteria for OCD in ICD-10 and DSM-IV

ICD-10 clinical descriptions and diagnostic guidelines	ICD-10 research diagnostic criteria	DSM-IV criteria
Definitions
Obsessional thoughts: distressing ideas, images, or impulses that enter a person's mind repeatedly. Often violent, obscene, or perceived to be senseless, the person finds these ideas difficult to resist.		Obsessions: persistent ideas, thoughts, impulses, or images that are experienced as inappropriate or intrusive and that cause anxiety and distress. The content of the obsession is often perceived as alien and not under the person's control.
Compulsive acts or rituals: stereotyped behaviours that are not enjoyable that are repeated over and over and are perceived to prevent an unlikely event that is in reality unlikely to occur. The person often recognises that the behaviour is ineffectual and makes attempts to resist it, but is unable to.		Compulsions: repetitive behaviours or mental acts that are carried out to reduce or prevent anxiety or distress and are perceived to prevent a dreaded event or situation.
Diagnostic criteria
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.	Either obsessions or compulsions (or both) are present on most days for a period of at least 2 weeks.	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.
2. Obsessional symptoms should have the following characteristics: they must be recognised as the individual's own thoughts or impulses. 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. 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). the thoughts, images, or impulses must be unpleasantly repetitive.	2. Obsessions (thoughts, ideas, or images) and compulsions (acts) share the following features, all of which must be present: they are acknowledged as originating in the mind of the patient, and are not imposed by outside persons or influences. they are repetitive and unpleasant, and at least one obsession or compulsion that is acknowledged as excessive or unreasonable must be present. the patient tries to resist them (but resistance to very long-standing obsessions or compulsions may be minimal). At least one obsession or compulsion that is unsuccessfully resisted must be present. experiencing the obsessive thought or carrying out the compulsive act is not in itself pleasurable. (This should be distinguished from the temporary relief of tensions or anxiety.)	2. 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 a Major Depressive Disorder.
	3. The obsessions or compulsions cause distress or interfere with the patient's social or individual functioning, usually by wasting time.	3. 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.
Differential diagnosis
Differentiating between obsessive-compulsive disorder and a depressive disorder may be difficult because the two types of symptoms frequently occur together. In an acute episode, presence 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.	n/a	Obsessive-compulsive disorder must be distinguished from: Anxiety disorder due to a general medical condition. Substance-induced anxiety disorder Recurrent or intrusive thoughts, impulses, images or behaviours may occur in the context of many other mental disorders. OCD is not diagnosed if the thoughts or activities is exclusively related to another disorder, such as Body dysmorphic disorder Specific or social phobia Hair pulling in trichotillomania Worries or ruminations are mood-congruent and aspects of the condition and are not ego-dystonic in Major depressive episode Worries are related to real-life circumstances in Generalised anxiety disorder Distressing thoughts are exclusively related to fears based on misinterpretation of bodily symptoms in: Hypochondriasis Ruminative delusional thoughts and stereotyped behaviours differ from obsessions and compulsions because they are not ego-dystonic and not subject to reality testing in: Schizophrenia Movements are typically less complex and are not aimed at neutralising an obsession in: Tic disorder Stereotypic movement disorder Activities are not considered to be compulsions because pleasure is usually derived in: Eating disorder Paraphilia Pathological gambling Alcohol dependence or abuse Condition is not characterised by the presence of obsessions and compulsions and instead involves a pervasive pattern of preoccupation with orderliness and cleanliness and must begin by early adulthood in: Obsessive compulsive personality disorder An additional diagnosis of OCD may be warranted if there are obsessions or compulsions not related to the other mental disorder.

: Adapted with permission from The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines (10th edn), Vol.1. Geneva: World Health Organization (1993) and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright 2000). American Psychiatric Association.

Table 11Diagnostic criteria for BDD in DSM-IV

DSM-IV Criteria
Diagnostic criteria
Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The preoccupation is not better accounted for by another mental disorder (e.g. dissatisfaction with body shape and size in anorexia nervosa).
Differential diagnosis
Unlike normal concerns about appearance, the preoccupation with appearance is excessively time consuming and associated with significant distress or impairment in social, occupational, or other areas of functioning. Condition is not characterised by an excessive preoccupation restricted to fatness as in: Eating disorders Condition is not characterised by a sense of inappropriateness about primary and secondary sex characteristics as in Gender identity disorder The preoccupation is not limited to mood-congruent ruminations involving appearance that occur exclusively during a: Major depressive episode Concerns with appearance are not prominent, persistent, distressing, time consuming and impairing in: Avoidant personality disorder Social phobia A separate diagnosis of BDD is only given when obsessions and compulsions are not restricted to concerns about appearance in Obsessive-compulsive disorder Removing body hair or picking skin does not occur in response to appearance concerns in Trichotillomania People with BDD may receive an additional diagnosis of delusional disorder, somatic type, if their preoccupation with an imagined defect in appearance is held with a delusional intensity.

: Adapted with permission from: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (Copyright 2000). American Psychiatric Association.

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National Collaborating Centre for Mental Health (UK). Obsessive-Compulsive Disorder: Core Interventions in the Treatment of Obsessive-Compulsive Disorder and Body Dysmorphic Disorder. Leicester (UK): British Psychological Society (UK); 2006. (NICE Clinical Guidelines, No. 31.) Appendix 15, Diagnostic criteria.
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