Obsessions as defined by exhibiting both (1) and (2):
- 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 causes marked anxiety or distress (they are not simply excessive worries about real-life problems)
- 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).
Compulsions as defined by exhibiting both (1) and (2):
- Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
- The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
Note: Young children may not be able to articulate what their aims are in performing these behaviors or mental acts.
— AND —
- The obsessions or compulsions cause significant distress or interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.
- Importantly, obsessive-compulsive actions are time-consuming (take more than 1 hour a day). This criterion helps to distinguish the disorder from the occasional intrusive thoughts or repetitive behaviors that are common in the general population (e.g., double-checking that a door is locked). The frequency and severity of obsessions and compulsions vary across individuals with OCD (e.g., some have mild to moderate symptoms, spending 1–3 hours per day obsessing or doing compulsions, whereas others have nearly constant intrusive thoughts or compulsions that can be incapacitating).
- If another disorder is present, the content of the obsessions or compulsions is not attributable to it (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder). 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.
In summary, obsessions are repetitive and persistent thoughts (e.g., of contamination with germs), images (e.g., of violent or horrific scenes), or urges (e.g., to stab someone). The specific content of obsessions and compulsions varies between individuals. However, certain themes, or dimensions, are common, including those of cleaning & contamination; symmetry (symmetry obsessions and repeating, ordering, and counting compulsions); forbidden or taboo thoughts (e.g., aggressive, sexual, or religious obsessions and related compulsions); and harm (e.g., fears of harm to oneself or others and checking compulsions).
Individuals with obsessions typically attempt to behave in a way to compensate for these thoughts by performing mental acts (e.g., counting, repeating words silently) or ritual behaviors called compulsions (e.g., washing, checking). However, performing compulsive acts are often not effective and fail to neutralize the obsessions; instead, this leads to the exacerbation of such thoughts and to ultimately, greater distress. One example of a compulsion performed in response to an obsession is where an individual who has extreme thoughts of contamination attempts to repetitively/ritually wash their hands in a fashion that feels “just right” (e.g., 10 times). Though their aim is to reduce the distress triggered by obsessions or to prevent a feared event (e.g., becoming ill), the original obsession and compulsion are not connected in a realistic way to the feared event and are clearly excessive (e.g., showering for hours each day). Compulsions are not done for pleasure, although some individuals experience temporary relief from their anxiety.
Moreover, many individuals with obsessive-compulsive disorder (OCD) have dysfunctional beliefs. These beliefs can include an inflated sense of responsibility and the tendency to overestimate threat; perfectionism; and over-importance of thoughts (e.g., believing that having a forbidden thought is as bad as acting on it); and the need to control thoughts. Despite the fact that these beliefs may appear consistent with the person’s general personality, the key requirement for meeting for OCD is that the obsessions in OCD are not perceived as pleasurable or experienced as voluntary. In fact a hallmark symptom of obsessions is that they are intrusive and unwanted.
Individuals with OCD vary in the degree of insight they have about the accuracy of the beliefs that underlie their obsessive-compulsive symptoms. Many individuals have good or fair insight (e.g., the individual believes that the house definitely will not, probably will not, or may or may not burn down if the stove is not checked 30 times). Some have poor insight (e.g., the individual believes that the house will probably burn down if the stove is not checked 30 times), and a few (4% or less) have absent insight/delusional beliefs (e.g., the individual is convinced that the house will burn down if the stove is not checked 30 times). Insight can vary within an individual over the course of the illness. Poorer insight has been linked to worse long-term outcome.
This criteria has been updated for DSM-5; diagnostic code: 300.3.