Obsessive Compulsive and Related Disorders in the DSM 5 TR | Symptoms and Diagnosis

Summary

The presentation reviews obsessive-compulsive and related disorders in the DSM-5-TR, focusing especially on obsessive-compulsive disorder (OCD) and hoarding disorder. It also discusses hair-pulling and skin-picking disorders, common diagnostic overlaps, suicide risk, and treatment approaches.

Disorders in This Category and Prevalence Cited

The category includes OCD, body dysmorphic disorder (BDD), hoarding disorder, trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, substance/medication-induced OCD and related disorders, and other specified or unspecified disorders. The presenter also mentions nail-biting, lip-biting, cheek-chewing, obsessional jealousy, and olfactory reference disorder—the belief that one emits an odor others can detect despite there being no such odor.

The presenter cites approximate prevalence estimates of 1.2% for OCD, 2.5% for trichotillomania or excoriation disorder, and 2.6% for hoarding disorder. She also describes studies reporting a marked rise in contamination- and illness-related OCD symptoms during and after the pandemic. She emphasizes that reported symptoms do not necessarily mean that everyone met diagnostic criteria for OCD.

OCD: Diagnostic Features and Common Themes

OCD requires obsessions, compulsions, or both:

• Obsessions are recurrent, persistent thoughts, urges, or images that are intrusive and cause significant anxiety or distress. People may try to suppress or ignore them, or neutralize them with actions or other thoughts.
• Compulsions are repetitive behaviors or mental acts performed in response to an obsession or according to rigid rules. They are intended to reduce distress or prevent a feared event, but may be unrealistic in relation to what they are meant to prevent—or clearly excessive.

Symptoms must take more than an hour a day or cause clinically significant distress or impairment. They must not be better explained by a substance, medical condition, or another mental disorder. The presenter notes that children may be unable to explain why they perform compulsive behaviors, making assessment more difficult.

Common obsession and compulsion themes include:

• Contamination: Fears of germs, bodily fluids, or environmental toxins; washing, cleaning, changing clothes, or seeking reassurance.
• Symmetry, ordering, and counting: Distress about things being uneven, misaligned, or incomplete.
• Taboo thoughts: Religious, aggressive, or sexual thoughts that the person experiences as unacceptable, sometimes followed by attempts to atone for or suppress them.
• Harm and safety: Fears of fire, accidents, break-ins, or harming someone; checking appliances, locks, or other safety-related details.
• Losing control or forgetting something important: Fears about acting on impulses or losing important objects or information.

A preference for neatness or occasional checking is not, by itself, OCD. Assessment should consider the time involved, distress or impairment, the meaning of the behavior, and what the person fears would happen if they did not perform it.

Hoarding Disorder

Hoarding disorder involves persistent difficulty discarding possessions, regardless of their actual value. The difficulty is linked to a perceived need to save the items and distress associated with discarding them. The resulting clutter must compromise living areas—for example, making furniture unusable or preventing the person from using a table normally. Clutter limited to an attic, basement, garage, or closet does not by itself establish the feature described here.

If living areas are uncluttered only because other people intervene—such as family members or cleaning crews—the person may begin accumulating possessions again afterward. The presenter notes that excessive acquisition is reported in many cases, and that both discarding items and being prevented from acquiring more may cause distress.

Animal hoarding is described as accumulating many animals while failing to provide adequate nutrition, sanitation, or veterinary care. The presenter encourages clinicians to explore what the animals or possessions mean to the person, including possible connections to safety, control, or past experiences.

Hair-Pulling and Skin-Picking Disorders

Trichotillomania involves recurrent hair-pulling that results in hair loss; excoriation disorder involves recurrent skin-picking that results in lesions or sores. In both cases, the person has made unsuccessful attempts to stop, and the behavior causes significant distress or impairment. The behavior must not be better explained by a medical condition, substance, or another mental disorder.

The presenter distinguishes these disorders from BDD, where grooming or picking may be focused on a perceived appearance flaw that is not observable or is only minimally noticeable to others. Stressful situations may also be associated with hair-pulling or skin-picking, sometimes with limited awareness of the behavior.

Development, Triggers, and Possible Causes

The presenter cites an average onset around age 19.5 for OCD and ages 15–19 for hoarding disorder. She suggests considering developmental changes, stress, identity formation, trauma, and triggering events when exploring symptom onset.

She also describes superstitious reinforcement: a person may link a ritual or ordinary action to a later event and believe the action caused or prevented that event. If a ritual fails to prevent a feared outcome, the person may intensify it or develop new rituals. Symptoms may emerge gradually or, as the presenter says occurred for some people during the pandemic, more abruptly.

The presentation repeatedly encourages clinicians to ask how symptoms function for the individual. In particular, it suggests exploring whether compulsions, collecting, hair-pulling, or skin-picking provide a sense of safety, control, or empowerment, including in the context of trauma.

Differential Diagnosis and Medication Effects

The presenter emphasizes assessing the person’s actual symptoms rather than relying too heavily on a diagnostic label. Conditions that may overlap with or resemble OCD include:

• BDD: The focus is a perceived appearance flaw.
• Eating disorders: Concerns and behaviors center on food, weight, body shape, or caloric intake.
• Illness anxiety disorder: Preoccupation with having or developing an illness, often involving repeated medical visits or reassurance from others.
• Generalized anxiety disorder: Worries cover multiple areas and typically are not accompanied by compulsions, though overlap can complicate assessment.
• Depression: Guilt and rumination tend to occur with the depressive mood state and may lessen when the depression improves.
• Postpartum depression or psychosis: Intrusive, frightening thoughts can occur postpartum. The presenter says ego-dystonic thoughts—thoughts the person does not want and recognizes as inconsistent with their wishes—should still be addressed. Beliefs that the thoughts are true or real may indicate postpartum psychosis and require immediate medical intervention.
• Substance-use, gambling, and gaming disorders: Urges and repetitive behavior may be driven by craving or reward processes rather than attempts to avert a feared catastrophe.
• Schizophrenia-spectrum disorders: Other symptoms, beyond obsessions or compulsions, are relevant to diagnosis.
• Autism spectrum disorder: Repetitive behaviors and difficulty with changes in routine may occur, but are not necessarily performed to neutralize obsessions.
• PTSD: Intrusive thoughts and avoidance can overlap with OCD symptoms.

The presenter also notes that some medications or substances may cause or worsen symptoms. She cites atypical antipsychotics and dopamine-related medications as possible contributors to OCD symptoms, and mentions cocaine, opioids, and amphetamines as possible contributors to itching or skin-picking. She recommends considering whether symptoms began after a medication or substance change and discussing concerns with the person’s physician.

Suicide Risk and Co-Occurring Conditions

The presentation highlights significant suicide risk, citing the following figures:

• OCD: 25.9% current suicidal ideation, 44% lifetime suicidal ideation, and 14.2% lifetime suicide attempts.
• Trichotillomania or excoriation disorder: Approximately 40% lifetime suicidal ideation and about 14% lifetime attempts.
• BDD: 74.5% lifetime suicidal ideation and a 35% attempt rate, described as higher when substance misuse is also present.
• Hoarding disorder: A 24.1% lifetime suicide-attempt rate.

These figures are presented as reasons to screen for suicide risk, offer support, and address hopelessness—not as a substitute for individual assessment.

The presenter also cites co-occurring anxiety disorders (76%), depressive or bipolar disorders (63%), impulse-control disorders (56%), substance-use disorders (39%), and tic disorders (30%) among people with obsessive-compulsive and related disorders. She recommends assessing for tic disorders and related symptoms in both directions.

Treatment Approaches Discussed

The presenter describes treatment as individualized, with medication and psychological approaches potentially used together:

• Medication: SSRIs and SNRIs are described as common first-line pharmacological treatments, with OCD often requiring higher doses than other disorders. Medication decisions and possible side effects should be discussed with a qualified prescriber.
• Cognitive behavioral therapy: Use CBT to address the thoughts, interpretations, and behaviors associated with symptoms.
• Exposure and response prevention (ERP) or systematic desensitization: Gradually expose the person to triggering thoughts or situations while helping them refrain from the usual compulsion, using appropriate support and coping tools.
• Identify vulnerabilities: Explore what happened before a particular episode, such as stressors or other factors that made the person more susceptible to obsessions.
• Build distress-tolerance skills: Practice coping with distress that arises when a ritual is delayed or prevented. The presenter suggests deep breathing, guided imagery, distraction, and sensory strategies such as splashing cold water on the face.
• “Unhook” from thoughts and urges: Help the person recognize that having a thought or urge does not make it part of their identity and does not require them to act on it.
• Examine beliefs and evidence: Use methods such as the ABC model (activating event, beliefs, consequences) or review facts for and against a belief. Consider what the person can control and how likely the feared outcome is.
• Cognitive restructuring: Help the person develop more balanced interpretations rather than treating feared outcomes as certain.
• Journal after response prevention: Record the thought or urge, what it was like not to perform the ritual, and how the person felt afterward.
• Address common thinking patterns: Work on overestimating threats, inflated responsibility, perfectionism, intolerance of uncertainty, difficulty planning and organizing, and taking personal responsibility for events outside one’s control.
• Consider trauma treatment: If trauma is relevant, the presenter says EMDR may help process traumatic memories and reactions, potentially improving the person’s sense of safety.

The overall clinical message is to intervene early when symptoms begin affecting daily life, relationships, sleep, work, or health. Treatment should be tailored to the person’s symptoms and circumstances rather than assuming that one approach works for everyone with a particular diagnosis.

Speakers and Sources Featured

• Presenter: A woman clinician and educator introduced in the subtitles as “Dr. Donnelly Snipes”; this appears likely to be an auto-caption error for Dr. Dawn-Elise Snipes.
• Sources discussed: The DSM-5-TR and research cited by the presenter on pandemic-related OCD symptoms, symptom overlap in veterans, medication and dopamine effects, prevalence, suicide risk, comorbidities, and sensory experiences in OCD. The subtitles do not identify the specific studies or authors.