DEPRESSION AND ANXIETY 27:528–555 (2010)
SHOULD AN OBSESSIVE–COMPULSIVE SPECTRUM
GROUPING OF DISORDERS BE INCLUDED IN DSM-V?
Katharine A. Phillips, M.D.,1,2?Dan J. Stein, M.D., Ph.D,3Scott L Rauch, M.D.,4Eric Hollander, M.D.,5
Brian A. Fallon, M.D.,6Arthur Barsky, M.D.,7Naomi Fineberg, M.D.,8David Mataix-Cols, Ph.D.,9
Ygor Arzeno Ferra ˜o, M.D., Ph.D.,10Sanjaya Saxena, M.D.,11Sabine Wilhelm, Ph.D.,12Megan M. Kelly, Ph.D.,2,13
Lee Anna Clark, Ph.D.,14Anthony Pinto, Ph.D.,6O. Joseph Bienvenu, M.D., Ph.D.,15Joanne Farrow, M.D.,8and
James Leckman, M.D.16
The obsessive–compulsive (OC) spectrum has been discussed in the literature for
two decades. Proponents of this concept propose that certain disorders
characterized by repetitive thoughts and/or behaviors are related to obsessive–
compulsive disorder (OCD), and suggest that such disorders be grouped together
in the same category (i.e. grouping, or ‘‘chapter’’) in DSM. This article
addresses this topic and presents options and preliminary recommendations to be
considered for DSM-V. The article builds upon and extends prior reviews of this
topic that were prepared for and discussed at a DSM-V Research Planning
Conference on Obsessive–Compulsive Spectrum Disorders held in 2006. Our
preliminary recommendation is that an OC-spectrum grouping of disorders be
included in DSM-V. Furthermore, we preliminarily recommend that con-
sideration be given to including this group of disorders within a larger
supraordinate category of ‘‘Anxiety and Obsessive–Compulsive Spectrum
Disorders.’’ These preliminary recommendations must be evaluated in light of
recommendations for, and constraints upon, the overall structure of DSM-V.
Depression and Anxiety 27:528–555, 2010.
rrrr2010 Wiley-Liss, Inc.
Key words: obsessive–compulsive spectrum; obsessive–compulsive disorder;
11University of California, San Diego, California
12Massachusetts General Hospital and Harvard Medical
School, Boston, Massachusetts
13Edith Nourse Rogers Memorial Veterans Hospital, Bedford,
14University of Iowa, Iowa City, Iowa
15Johns Hopkins School of Medicine, Baltimore, Maryland
16Yale University School of Medicine, New Haven, Connecticut
?Correspondence to: Katharine A. Phillips, Rhode Island Hospital,
Coro Center West, 1 Hoppin Street, Providence, RI 02903.
Published online in Wiley InterScience (www.interscience.wiley.
Received for publication 23 December 2009; Revised 30 March
2010; Accepted 31 March 2010
This article is being co-published by Depression and Anxiety
and the American Psychiatric Association.
1Rhode Island Hospital, Butler Hospital, Providence, Rhode
2Alpert Medical School of Brown University, Providence,
3Department of Psychiatry, University of Cape Town, Cape
Town, South Africa
4McLean Hospital and Harvard Medical School, Boston,
5Montefiore Medical Center and Albert Einstein School of
Medicine, New York
6Columbia University and the New York State Psychiatric
Institute, New York
7Brigham and Women’s Hospital and Harvard Medical School,
8University of Hertfordshire, Hertfordshire, United Kingdom
9Kings College London, London, England
10Porto Alegre Health Sciences Federal University and
Psychiatric Service of the Presidente Vargas Hospital, Out-
patient Program of Anxiety Disorders, Porto Alegre, Brazil
rrrr 2010 Wiley-Liss, Inc.
For the past two decades, the concept of the
obsessive–compulsive (OC) spectrum has been dis-
cussed in the literature and increasingly studied.[1–10]
The term ‘‘spectrum’’ has been used to mean many
things; in the literature, and in this article, ‘‘OC
spectrum’’ refers to a group of disorders that are
presumed to be distinct from, but related to, obsessi-
ve–compulsive disorder (OCD), and which are char-
acterized by repetitive thoughts and/or behaviors. This
concept implies that such disorders might be grouped
together in the same supraordinate category (i.e.
grouping, or ‘‘chapter’’) in DSM. DSM-IV does not
include a category of OC spectrum disorders (OCSDs);
in DSM-IV, candidates for inclusion in this category
are classified under anxiety disorders, somatoform
disorders, impulse control disorders (ICDs) not else-
where classified, personality disorders (PDs), and
disorders usually first diagnosed in infancy, childhood,
or adolescence. Hoarding disorder, which is considered
in this review, is not in DSM-IV but is a candidate for
inclusion in DSM-V.
This review will examine the relatedness of putative
OCSDs to OCD and to selected other disorders. The
goal is to inform deliberations about DSM-V’s
organization/structure—namely, whether there is uti-
lity to including a category (i.e. grouping or chapter) of
OCSDs in DSM-V, and, if so, which disorders might
be included in this category. Any approach toward
formulating how disorders might be categorized in
DSM-V should be informed by several principles.
First, the approach should have clinical utility—i.e. be
helpful to clinicians in formulating diagnoses, assessing
patients, and selecting appropriate interventions, as this
is DSM’s primary purpose. It should also have face
validity and be evidence-based to the extent possible.
This article was commissioned by the DSM-V
Anxiety, Obsessive–Compulsive Spectrum, Posttrau-
matic, and Dissociative Disorders Work Group. It
represents the work of the authors for consideration by
the work group. Recommendations provided in this paper
should be considered preliminary at this time; they do not
necessarily reflect the final recommendations or decisions that
will be made for DSM-V, as the DSM-V development
process is still ongoing. It is possible that this article’s
recommendations will be revised as additional data and
input from experts in the field are obtained. In
addition, the categorization of disorders discussed in
this review needs to be harmonized with recommenda-
tions from other DSM-V workgroups and the DSM-V
Task Force for the overall structure of DSM-V.
This article builds upon and extends prior reviews of
this topic that were prepared for and discussed at a
DSM-V Research Planning Conference on Obsessive–
Compulsive Spectrum Disorders. This conference,
attended by 23 scientists from around the world in
2006, was one of 13 DSM-V Research Planning
Conferences that focused on the research evidence
for revisions of DSM-V and laid groundwork for the
formal development of DSM-V. The primary aim of
the conference was to review the evidence that certain
disorders may be related to OCD based on examination
of similarities and differences in terms of phenomen-
ology, comorbidity, course of illness, and additional
validating domains discussed below. Articles from this
conference have been published,[12,13]and summaries
are available at www.dsm5.org. Because the present
review covers many disorders and comparisons among
disorders, and because space is limited, all issues cannot
be reviewed in detail. Readers are encouraged to refer
to publications from this conference, other prior
publications on this topic, and articles in this issue on
individual disorders and on the relationship between
OCD and other anxiety disorders.[2,13,14]
STATEMENT OF THE ISSUES
(1) Does available research evidence, and considera-
tion of clinical utility and face validity, support
inclusion of a category (i.e. grouping, or chapter) of
OCSDs in DSM-V?
(2) If an OCSD chapter of disorders is included in
DSM-V, which disorders should it include? If this
category is not included, where might disorders
discussed in this review be classified?
(3) If DSM-V includes a group of OCSDs, should they
be in a separate chapter or classified in the same
chapter as another group of disorders?
SIGNIFICANCE OF THE ISSUES
(i.e. groupings, or chapters) of disorders—for example,
schizophrenia and other psychotic disorders, mood
disorders, and anxiety disorders. DSM-I had only 3
supraordinate categories,and DSM-II had 10.In
DSM-III, the number of categories was increased to
16, reflecting diagnostic classes proposed by Washing-
classes were subsequently handed down, with minor
modifications, to DSM-III-R and DSM-IV.[18,19]They
were based on clinical utility and enhancement of
How disorders are grouped together in DSM does
not influence caseness (i.e. who receives a particular
diagnosis), because groupings do not affect diagnostic
criteria. However, how disorders are grouped has
important implications. For example, disorders that
are classified together in the same section of DSM
are generally presumed to be related to one another
and thus to perhaps have shared pathophysiology and
etiology (although for most disorders, etiology and
pathophysiology remain to be determined). Related
disorders may be highly comorbid with one another,
have an increased prevalence in family members, or
529Review: OCS in DSM-V
Depression and Anxiety
have shared evaluation and treatment elements; in such
cases, optimally grouping disorders may usefully guide
clinical assessment and treatment approaches. Placing
disorders in the same category can also enhance
diagnosis and differential diagnosis, as clinicians may
pay particular attention to differentiating disorders in
the same grouping from one another. Not using such
groupings—for example, listing disorders randomly or
in alphabetical order—would be clinically unhelpful.
This review focuses on disorders commonly considered candidates
for inclusion in an OCSD grouping (also see Results section for a
discussion of the selection of disorders for this review). We use 11
validators, developed by the DSM-V Spectrum Study Group, to
examine similarities and differences between disorders and thus how
closely related they appear to be. These validators are: symptom
similarity, high comorbidity among disorders, course of illness,
familiality, genetic risk factors, environmental risk factors, neural
substrates, biomarkers, temperamental antecedents, cognitive and
emotional processing abnormalities, and treatment response. These
validators are based upon and extend those proposed by Robins and
Guze in 1970 and subsequently by others.[20,21]The field has used
them to examine the validity of individual syndromes as well as the
relatedness of disorders to other disorders. Most of these validators
were considered by the DSM-V Research Planning Conference on
the OCSDs. Because space is limited, it is not possible to present
comprehensive data on all 11 validators for all of the comparisons
considered in this review. Therefore, we focus on the most important
findings regarding similarities and differences with OCD and selected
We also consider clinical utility. Clinical utility can, to some
extent, be differentiated from issues of diagnostic reliability and
validity; in the context of diagnostic classification it refers to
considerations such as improving conceptualization of disorders,
enhancing communication, and helping to aid assessment and choose
treatment.There have also been efforts in the field, and as part of
the DSM-V process, to determine whether application of latent
structure statistical methods to nosological information (e.g. factor
analysis and latent class analysis) may be helpful in optimizing the
structure of the classification system.[23,24]However, these ap-
proaches have limitations;[24,25]in addition, data on OCD are only
occasionally available in these analyses, and data are lacking on most
A literature search used WebofScience, PubMed, PsychINFO, and
other relevant databases. An initial broad search was undertaken
for articles that directly address the relationship between putative
OCSDs, OCD, and other relevant disorders, and how these
disorders might be classified. Search terms included ‘‘obsessive–
compulsive spectrum,’’ ‘‘obsessive–compulsive spectrum disorders,’’
More directed searches used the above validators developed by the
DSM-V Spectrum Study Group. There was no time limit to the
search; only English language articles were sought. This review
additionally summarizes comorbidity and family study data from
recent secondary data analyses commissioned by the DSM-V Task
Force; this work was also supported by grants from the National
Institutes of Health. These data have been reviewed by the DSM-V
Obsessive–Compulsive Spectrum Sub-Workgroup (Bienvenu et al.,
of individual disorders.
THE OBSESSIVE–COMPULSIVE SPECTRUM
CONCEPT AND DSM-V RESEARCH
Earlier conceptualizations of the OC spectrum
included a broad range and large number of potential
members.Indeed, many candidate disorders were
reviewed and discussed at the DSM-V Research
Planning Conference in 2006.[12,13,26]On the basis of
literature reviews presented at the conference, which
examined a broad range of disorders and validators,
attendees concluded that the OC spectrum concept has
merit but recommended that relatively few disorders be
included in this category.[13,26]Attendees concluded
that research evidence most strongly supports inclusion
of body dysmorphic disorder (BDD), Tourette’s dis-
order, and hypochondriasis (HYP) (although HYP was
not reviewed in detail). They also concluded that
available evidence offers some support for inclusion of
hoarding (if hoarding is added as a separate disorder in
DSM-V), obsessive–compulsive personality disorder
(OCPD), and eating disorders (as well as Sydenham’s/
PANDAS, although PANDAS may be better concep-
tualized as a possible OCD subtype, rather than a
separate disorder.There was incomplete agreement
about including trichotillomania (TTM), and less
support for including other grooming/habit disorders
such as pathological skin picking. Based on presented
evidence, it was recommended that ICDs not be
We also mention here a recent survey of 187 OCD
experts from around the world, as it is unique and
highly relevant to this review.
concurred with attendees at the DSM-V Research
Planning Conference that if a new category of OCSDs
is included in DSM-V, it should be kept narrow.
Support was greatest for including BDD (72% agreed),
TTM (71% agreed), and tic disorders (61% agreed).
Support for including HYP (57% agreed) and OCPD
(45% agreed) was more mixed. Relatively few experts
agreed with including ICDs (33%) (excluding TTM)
or eating disorders (28%), and very few agreed with
including autism (9%) or addictions (5%). These
findings and those from the DSM-V Research Plan-
ning Conference influenced the disorders selected for
discussion in this review. (Classification of stereotypic
movement disorder (SMD) is discussed in a separate
Other recent reviews of this topic have been
published; some support the OC spectrum concept,
whereas others do not. Storch et al.discussed a very
broad OCSD construct, which included not only the
disorders focused on in the present review but also
disorders such as ICDs and eating disorders.They
concluded, based on examination of a number of
validators, that OCD has many similarities with other
anxiety disorders and that it is premature to remove
530Phillips et al.
Depression and Anxiety
OCD from the anxiety disorders and classify it in a
separate section of broadly defined OCSDs in DSM-V.
In contrast, Hollander et al.were more positive
about the value of including a new category of OCSDs
in DSM-V. Stein emphasized that there was unlikely to
be a single criterion that would allow a decision about
this complex matter; instead, good judgment would be
needed to weigh a range of considerations, including
those pertaining to diagnostic validity and clinical
Various theoretical approaches have been taken
toward the OC spectrum concept. Some approaches
have been substantially informed by experience in
clinical settings with different treatments. After ser-
otonin reuptake inhibitors (SRIs) were introduced and
demonstrated to be selectively efficacious for OCD,
research assessed their efficacy for various disorders
characterized by unwanted repetitive thoughts or
behaviors. Some putative OCSDs, such as BDD, may
also selectively respond to this medication class.[34–37]
In recent decades, a range of additional research has
informed the field’s views, including research on the
phenomenology of putative OCSDs as well as func-
tional brain imaging research, cross-cultural and
epidemiological research, and animal research on
habits.[38,39]Thus, we are closer to developing a view
that is more translational, developmental, and evolu-
tionary, rather than informed primarily by treatment
response (which is somewhat nonspecific). This kind
of evidence, too, was summarized in the DSM-V
Research Planning Conference on OCSDs.[12,13,26]
Animal motoric habits seem fairly analogous to
certain human stereotypies (including those in SMD,
intellectual disability, or pervasive developmental dis-
orders) and to tics in patients with tic disorder.We
might term these behaviors ‘‘motoric,’’ or ‘‘lower-order,
repetitive behaviors.’’ These behaviors may also have
some phenomenological and psychobiological overlap
with hair pulling in TTM and with certain other
body-focused repetitive symptoms (e.g. compulsive
skin picking).From a psychological perspective,
these behaviors may be undertaken to modulate self-
It is more difficult to develop animal models of the
more complex symptoms of OCD and cognitively
focused OCSDs;we might term these ‘‘cognitive,’’
or ‘‘higher-order,’’ OC symptoms. In humans, OCD is
characterized by concerns in several different dimen-
sions, including harm, cleanliness, order/symmetry,
and possibly hoarding.Candidate OCSDs with a
prominent cognitive component focus on concerns
about appearance (BDD) and health (HYP, or health
anxiety disorder), and fears of discarding or not having
available personally valuable possessions (hoarding
disorder). Compulsions may be seen as a means of
reducing anxiety induced by triggering obsessions or to
neutralize future threat.Indeed, there appears to be
some overlap between some of these disorders (see
below) in terms of symptoms and other validating
domains, such as possible involvement of orbitofronto-
A third group of repetitive behaviors are classified in
DSM-IV as ICDs not elsewhere classified, which have
also been termed ‘‘behavioral addictions.’’[13,26,42]Sub-
stance addiction seems to be driven initially by brain
reward systems and then becomes habitual in nature;
this may also apply to some of the behavioral
addictions.Whether these disorders should be
construed as ‘‘compulsive,’’ ‘impulsive,’’ or ‘‘impul-
sive-compulsive’’ is controversial. There may be some
overlap in the underlying psychobiology of OCD and
certain behavioral addictions,although, as noted
above, with the possible exception of TTM, a review of
relevant research suggests more differences than
similarities between these disorders and OCD.In
addition, clinical approaches to assessment and treat-
We now turn to a discussion of individual disorders.
BODY DYSMORPHIC DISORDER
DSM-IV classifies BDD, a distressing or impairing
preoccupation with an imagined or slight defect in
appearance, as a somatoform disorder. However,
BDD shares features with OCD, social phobia,
Three published studies directly
compared BDD to OCD across a broad range of
clinical features,[54–56]other studies compared them in
selected domains,[57–64]and two studies directly com-
pared BDD to eating disorders.[52,65]No published
studies to our knowledge have directly compared BDD
to other disorders, including somatoform disorders.
More comprehensive reviews of BDD’s relationship to
OCD,eating disorders,and other disorders
can be found elsewhere.
OCD and BDD are both
characterized by recurrent, time-consuming, intrusive,
persistent, and unwanted thoughts.These thoughts
cause anxiety or distress and are usually resisted to at
least some extent.Nearly all BDD patients perform
compulsive behaviors (e.g. mirror checking)[67,70,71]
that are similar to OCD compulsions. They are
repetitive, time-consuming, difficult to resist or con-
trol, and not pleasurable; are performed intentionally,
in response to an obsession; and aim to reduce anxiety
or distress.[54,66]Direct comparison studies with the
Yale-Brown Obsessive–Compulsive Scale
slightly modified version for BDDfound that scores
for preoccupations/obsessions and compulsive beha-
viors did not significantly differ for BDD versus OCD,
suggesting similarities in these symptoms.[54,55]
However, insight is poorer in BDD than in OCD, with
27–60% of BDD patients currently having delusional
beliefs versus only 2% of OCD patients.[55,74–76]
531 Review: OCS in DSM-V
Depression and Anxiety
Some BDD compulsions do not appear to follow a
simple model of anxiety reduction, which is common in
OCD.Core beliefs in BDD appear to focus more on
unacceptability of the self (e.g. being inadequate,
worthless, or unlovable);such negative self-focused
thoughts also occur in social phobiaand MDD.
And preliminary data suggest suicidality rates may be
higher in BDD than in OCD.[54,55]
Shared features with social phobia include high social
anxiety and social avoidance,[51,81,82]low extraver-
sion,embarrassment, and shame.However, one
study found that BDD was characterized by relatively
low levels of fear of being negatively evaluated by
others as a person (in a nonphysical sense), which may
differ from social phobia.And unlike social phobia,
BDD usually involves compulsions as a prominent
Eating disorders and BDD share body image
preoccupation, dissatisfaction, and distress, which
appear equally severe in both disorders.[52,65]Some
BDD patients diet and excessively exercise.[70,71]
However, dissatisfaction and preoccupation involve
more diverse body areas in BDD.[52,65,70]And com-
pared to patients with eating disorders, those with
BDD appear to have more negative self-evaluation and
self-worth due to appearance concerns, more avoidance
of activities due to self-consciousness about appear-
ance, and poorer functioning and quality of life due to
BDD and MDD share low self-esteem,[84,85]similar
core beliefs,[78,80]and rejection sensitivity,[86,87]but
compulsions do not occur in MDD. BDD appears to
have few similarities with somatoform disorders. For
example, in BDD, concern about bodily malfunction-
ing is uncommon,and somatic/somatization symp-
toms are elevated but do not appear higher than in
other psychiatric disorders.In addition, women with
BDD are less alert to being or becoming ill compared
to population norms.
In studies of BDD’s clinical features
(n5293 and n5200), a high proportion of BDD
subjects have comorbid lifetime OCD (32–33%).[71,90]
Comorbid lifetime MDD (75–76%) and social phobia
(37–39%) are even more common,[71,90]although these
disorders have higher base rates than OCD does.[91,92]
Lifetime anorexia nervosa or bulimia nervosa occur in
10–15% of BDD subjects; only 2–7% have a comorbid
somatoform disorder.[71,90]Conversely, BDD’s lifetime
prevalence ranges from 3 to 37% in patients with OCD
(average of 15–20% across studies), 8–42% in MDD,
11–13% in social phobia, and, in one study, 39% of
sa.[6,49,54,87,93–100]In a blinded and controlled study,
BDD was more common in OCD subjects than in
community controls (Bienvenu et al., unpublished
Three BDD-OCD comparison studies found no
significant differences in lifetime comorbidity for many
disorders, but two of the three studies found that
subjects with BDD were more likely than those with
OCD to have lifetime MDD and substance use
Course of illness.
BDD’s mean age at onset is
Two BDD-OCD comparison studies
found no significant difference in age at onset,[54,55]
but one study found earlier onset for BDD.
BDD’s mean age at onset is similar to that of anorexia
nervosa, somewhat later than that of social phobia, and
somewhat earlier than that of MDD and bulimia
BDD appears to usually be chronic.Studies using
methods nearly identical to those in a prospective BDD
course studyfound similarly low remission rates for
OCD, social phobia, and anorexia nervosa,[104–106]but
higher remission rates for MDD and bulimia nervo-
sa.[106,107]In the BDD study, which examined time-
varying associations between BDD and comorbid
disorders, change in the status of BDD and MDD
were closely linked in time, with MDD improvement
predicting BDD remission, and, conversely, BDD
improvement predicting MDD remission.OCD
improvement predicted BDD remission, but BDD
improvement did not predict OCD remission; no
significant longitudinal associations were found for
BDD and social phobia (social phobia and OCD results
were less numerically stable). These findings suggest
that BDD may be etiologically linked to MDD and
OCD. However, BDD does not appear to simply be a
symptom of these comorbid disorders, as BDD
persisted in a sizable proportion of subjects who
remitted from them.
In a blinded family history study, first-
degree relatives (n5325) of BDD and OCD probands
did not significantly differ in terms of lifetime OCD,
social phobia, MDD, or somatoform disorders.In a
blinded and controlled family study, BDD was more
common in first-degree relatives of OCD probands
than in relatives of control probands, whether or not
case probands also had BDD.Bienvenu et al.
(unpublished data) replicated this result with a larger
sample of case families. The latter studies suggest BDD
may be part of a familial OCD spectrum.
Genetic and environmental risk factors.
small candidate gene study of BDD subjects and
healthy controls, association was shown for GABAA-
g2 (5q31.1-q33.2)but not 5-HT1D-X (5HT1B),
which has been associated with OCD.
subjects appear to have a high prevalence of childhood
abuse and neglect;[110,111]such experiences are found in
many disorders, including OCD, MDD, social phobia,
and eating disorders[111–113]and thus may not sub-
stantially inform the question of BDD’s relatedness to
other disorders. However, in one study, childhood
emotional abuse and sexual abuse were more common
in BDD than in OCD (28% versus 2%, and 22%
versus 6%, respectively).
No neuroimaging studies have
directly compared BDD to other disorders. A small
532Phillips et al.
Depression and Anxiety
MRI study found a leftward shift in caudate volume
asymmetry and greater total white matter volume in
BDD than control subjects.A second small study
similarly found greater total white matter volume in
BDD relative to controls, as well as smaller orbito-
frontal cortex and anterior cingulate and larger
thalamic volumes.However, a third study found
no significant volumetric differences in BDD versus
healthy controls.These studies’ results differ from
OCD,although the first two studies’ findings can
be considered partially consistent with conceptualiza-
tion of BDD as an OCSD.A small BDD SPECT
study showed relative perfusion deficits in bilateral
anterior temporal and occipital regions and asymmetric
perfusion in the parietal lobes,unlike OCD.
In an fMRI study, while matching photographs of
faces, BDD subjects showed greater left hemisphere
activity than controls (particularly in lateral prefrontal
cortex and temporal lobe) and abnormal amygdala
activation.In another study, BDD subjects, com-
pared to controls, had relative hyperactivity in left
orbitofrontal cortex and bilateral head of the caudate
when viewing a photograph of their own face versus a
familiar face.This finding provides preliminary
evidence of a possible similarity between BDD and
OCD in functional neuroanatomy of orbitofrontal–
subcortical circuits, which may be associated with
obsessive thoughts and compulsive behaviors.[121,122]
However, the exaggerated left hemisphere and amyg-
dala activation in BDD differ from most OCD studies;
amygdala activation in response to face stimuli has
been found in anxiety disorders, including social
In a small study, platelet 5-HT
transporter binding density was significantly lower in
OCD, BDD, Tourette’s disorder, and ICDs than in
controls, suggesting a shared abnormality at the level of
the presynaptic 5-HT transporter.
studies have prospectively examined temperamental
antecedents of BDD. Cross-sectional studies, however,
indicate that patients with BDD, OCD, and eating
disorders are more perfectionistic than healthy con-
trols.[62,124]Low levels of extraversion and high levels
of neuroticism have been found in BDD,social
phobia,[79,125]and MDD.[126–129]Harm avoidance is
also higher in BDD, OCD, social phobia, eating
disorders, and MDD[130–135]than reported for healthy
controls, indicating that individuals with these dis-
orders share an increased tendency for intense adverse
responses to aversive stimuli and behavioral inhibition
in novel situations.[130–135]
Cognitive and emotional
OCD, and anorexia nervosa patients share poor
immediate and delayed visual recall on the Rey–
Osterrieth Complex Figure Test, which is mediated
by deficits in organizational strategy.[136–139]All three
groups tend to focus on details rather than the overall
organization of visual stimuli (although BDD was not
directly compared to OCD or anorexia). These
findings suggest dysfunction in frontal–striatal circuits
and prefrontal regions that mediate executive function-
ing.[136–139]However, BDD subjects rate attractive
faces as more attractive than do OCD subjects or
healthy controls.And BDD subjects have more
negative and threatening interpretations of ambiguous
social and appearance-related information than do
OCD subjects.Negative interpretation of ambig-
uous social information has also been found in social
phobia.In another study, relative to healthy control
and OCD subjects, BDD subjects more often mis-
identified emotional expressions as angry.
BDD and OCD share pre-
ferential response to SRIs as monotherapy[34–37]
(although very preliminary open-label studies raise
the possibility that BDD might also respond to
venlafaxine and the anti-epileptic medication levetir-
acetam as monotherapy).[142,143]Both BDD and OCD
require higher SRI doses than those typically needed
for MDD (although dose finding studies have not been
done in BDD).[33,35]However, unlike OCD, neurolep-
tic augmentation of SRIs does not appear efficacious
Although MDD, social phobia, and bulimia nervosa
respond well to SRIs, they also respond to other
BDD.[34,146–148]BDD appears to respond more fre-
quently and robustly to SRIs than does anorexia
CBT containing cognitive restructuring as well as
exposure and response prevention (ERP) appears
efficacious for BDD (although research is limited),
andit isefficacious for
ders.[36,37,147,150–155]ERP are key elements of CBT
for OCD, which also often involves cognitive restruc-
turing.[33,156]In social phobia, cognitive restructuring
and exposure to feared social situations are core
elements; prevention of safety behaviors is used as
needed.CBT for BDD shares treatment elements
with both OCD and social phobia, but clinical
experience indicates that because of their poor insight,
BDD patients are more difficult to engage in treatment
and typically require more intensive cognitive restruc-
turing than OCD patients. CBT for BDD involves
greater focus on response prevention than social phobia
does because compulsive behaviors are more character-
istic of BDD.And unlike social phobia and OCD,
habit reversal (for BDD-related skin picking and hair
plucking) and perceptual retraining are components of
some BDD treatments.CBT for BDD has some,
but fewer, shared features with CBT for MDD, eating
disorders, and somatoform disorders.
Conclusions, clinical utility, and preliminary
needed, BDD appears most similar to OCD and may
be part of a familial OC spectrum, consistent
with views over the past century that BDD appears
related to OCD.[159–162]BDD and OCD have some
notbethe case for
533Review: OCS in DSM-V
Depression and Anxiety
similarities in all of the above domains. Data on
symptom similarity, comorbidity, and familiality offer
the strongest support for BDD’s relatedness to OCD,
although other validators, such as treatment response,
also indicate some shared features. Emerging data from
some validators, such as neural substrates, suggest a
possible relationship between these disorders, although
data are still very limited, and more research is needed,
However, BDD also has similarities with social phobia
and some but fewer similarities with eating disorders
and MDD. BDD seems least similar to somatoform
disorders; thus, classifying BDD with them does not
Classifying BDD as an OCSD would have clinical
utility, as it might prompt clinicians to consider
comorbidity of BDD and OCD, a family history of
BDD in OCD patients, and use of somewhat similar
treatment approaches. However, BDD and OCD have
differences that need to be considered (for example,
poorer insight in BDD and the need for a somewhat
modified treatment approach), especially when treating
BDD patients. If OCSDs are classified with anxiety
disorders in DSM-V, placing BDD within this group-
ing would be reasonable, given BDD’s similarities to
social phobia and its association with social phobia in
TOURETTE’S DISORDER AND CHRONIC
DSM-IV classifies tic disorders as disorders usually
first diagnosed in infancy, childhood, or adoles-
cence.This review focuses on Tourette’s disorder
and chronic tic disorders.
Direct comparisons of the
symptoms of Tourette’s disorder and OCD indicate
that these disorders have some similarities.[165,166]Both
disorders involve a sequence of events in which a
stimulus precedes a largely habitual response. In
adolescents and adults with tic disorders, the stimulus
is typically a sensory urge followed by a sudden, rapid,
recurrent, nonrhythmic, stereotyped motor movement
or vocalization.[167–172]However, a difference between
these disorders is that compulsions are almost always
(but not necessarily) performed in response to mental
ideational content,whereas patients with Tourette’s
disorder report more sensory phenomena and many
fewer cognitive phenomena.Additional similarities
are that in both TS and OCD, many patients have the
need to perform the tic or the compulsion so they are
‘‘just right,’’[167,168]and a number of ‘‘sensory phenom-
ena’’ frequently accompany OCD.[164,166,174]At times,
it may be difficult to distinguish complex motor tics
that appear goal directed from compulsions (which are
not always preceded by obsessions). Both tics and
obsessions can be suppressed for brief periods of time,
but in both cases discomfort and anxiety may be
from 23% to 50% in patients with Tourette’s dis-
order.[49,174]Conversely, comorbid lifetime tic disor-
ders affect nearly 30% of OCD patients.(Bienvenu,
unpublished data). Given that tic disorders affect an
estimated 1 in 10,000 of the population, these markedly
elevated rates suggest that tic disorders and OCD may
be related. In one study, comorbid tic disorders were
significantly more prevalent in OCD patients than in
patients with either panic disorder or social phobia.
Course of illness.
Both Tourette’s disorder and
OCD may have early onset (childhood or adolescence)
and an extended course.The median age of
Tourette’s disorder onset is 5.5 years.In contrast,
although OCD may begin prepubertally, it often begins
later in life (e.g. during or after pregnancy),with a
median age of onset from 13 to 20 years of
age.[49,174,175]Chronic tics, Tourette’s disorder, and
OCD symptoms may both wax and wane in sever-
ity.[164–166,172,174]Tic disorders often peak in severity in
early adolescence and show a noticeable decline by
early adulthood;early onset OCD (o10 years)
frequently shows a similar course.[178–180]
Family-genetic studies reveal an in-
creased risk of tics, Tourette’s disorder, and OCD
among first-degree relatives of Tourette’s disorder
probands (compared to control probands), with a
higher prevalence of OCD among females relatives
(up to 15%) and a higher prevalence of tics (up to 20%)
and Tourette’s disorder (up to 17%) among male
relatives, independent of whether Tourette’s disorder
probands have co-morbid OCD.[176,177,181–186]Con-
versely, there is an increased prevalence of tics in
relatives of OCD probands (6.2%) compared to
relatives of controls (1.7%).These findings offer
fairly strong support for a familial relationship between
Tourette’s disorder, tics, and OCD.
Genetic and environmental risk factors.
is evidence that Tourette’s disorder has a genetic
basis[187–190]and that environmental factors, including
psychosocial stress,interact with genetic factors to
influence severity and course of the syndrome.
There is some evidence that some specific genes confer
vulnerability for Tourette’s syndrome (TS)[177,187–190]
and others for OCD,[182–185]with both OCD and tic
disorders rarely associated with the same single genetic
variants.[188,189]Gene pathways involving neurotrans-
mitter (serotonin, dopamine, glutamate) and neurode-
velopmental (synaptic, homeobox) domains have been
examined, but more complex genetic mechanisms of
TS and OCD remain largely unexplored.A major
gene for TS and/or OCD has not yet been identified,
probably owing to both genetic and phenotypic
heterogeneity of these disorders.
Extensive neuroimaging evi-
dence indicates the presence of abnormalities in
frontostriatal circuits in children and adults with
Tourette’s disorder and OCD.[191–197]These frontos-
triatal circuits are thought to subserve regulatory
Comorbid lifetime OCD ranges
534 Phillips et al.
Depression and Anxiety
control, for example, the ability to resist an underlying
urge to move or to perform a compulsive beha-
vior.[194,197]On average, caudate nucleus volume is
5% smaller in both children and adults with Tourette’s
disorder than in healthy controls, and caudate nucleus
volume in childhood is predictive of both future
Tourette’s disorder and OCD symptom severity in
Functional neuroimaging studies have found that
voluntary tic suppression involves deactivation of the
putamen and globus pallidus, coupled to partial
activation of prefrontal cortex and caudate nucleus.
Patients with Tourette’s disorder exhibit decreased
activity in the caudate and thalamus, together with
increased activity of the lateral and medial premotor
cortex, supplementary motor areas, anterior cingulate
gyrus, dorsolateral–rostral prefrontal cortex, inferior
parietal cortex, putamen, caudate, primary motor
cortex, Broca’s area, superior temporal gyrus, insula,
and claustrum.[193,194]Vocal tics appear to activate
prerolandic and postrolandic language regions, as well
as insula, caudate, thalamus, and cerebellum. Thus,
compared to OCD, Tourette’s disorder appears to
activate cortical areas other than the orbitofrontal
cortex,[195–198]especially sensorimotor brain areas.
Although OCD involves more ventral structures, with
cortical areas, circuits involved in Tourette’s disorder
encompass projections of primary, secondary, and
somatosensory cortex to the putamen and dorsolateral
caudate nucleus, putamen, and globus pallidus.
There is not yet strong evidence for
specific Tourette’s disorder biomarkers.
have investigated temperament and character in Tour-
ette’s disorder (neither had a prospective longitudinal
design), and no studies have directly compared Tour-
ette’s disorder and OCD. One study found that harm
avoidance tends to be higher in patients with Tourette’s
disorder and comorbid OCD than in patients with
Tourette’s disorder alone,which was associated
with reward deficiency in another study.
Cognitive and emotional processing.
chological studies of OCD and chronic tic disorders
have been characterized by inconsistent findings, which
may be due to small sample sizes, the range of
neuropsychological tasks performed, and disorder
heterogeneity.[201–206]Only a few studieshave
directly compared participants with Tourette’s disorder
and participants with OCD on neurocognitive mea-
sures sensitive to frontal–striatal system dysfunction
while controlling for each disorder’s comorbidity with
the other. In one study that compared children with
Tourette’s disorder alone or with OCD alone,
neither group demonstrated the pattern of memory
deficits expected of frontal–striatal dysfunction (encod-
ing deficits with intact recognition) and reported in the
adult OCD literature.In another study, direct
comparisons between Tourette’s disorder and OCD
Only two studies
subjects found significantly greater deficits for recogni-
tion memory latency and Go/No-go reversal for OCD
subjects, and quality of decision making for Tourette’s
patients, OCD patients performed significantly worse
than controls in the inhibition of cognitive interference
(Stroop test).Finally, there is evidence that both
TS and OCD are associated with procedural, as
opposed to declarative, memory deficits.[209,211,212]
neuroleptics (typicals or atypicals), whereas OCD
selectively responds to SRIs.[33,213]Nevertheless, ser-
otonergic pathways may play a role in the physiology of
Tourette’s disorder,[214,215]especially in patients with
tics,[217–220]indicating some overlap between Tourette’s
disorder and OCD treatments. Dopaminergic receptor
density (D2) may be decreasedand the dopami-
nergic transporter may be increased in the basal ganglia
of OCD patients.
Also, serotonergic neurons
produce inhibitory tonus on dopaminergic neurons in
the basal ganglia, suggesting that SRIs can also affect
ERP is the therapy of choice for OCD.[223,224]ERP is
also emerging as a promising treatment for Tourette’s
disorder.The most studied and best-established
behavioral technique for Tourette’s disorder and other
tic disorders is habit reversal training (HRT), which
consists of awareness training, self-monitoring, relaxation
training, competing response training, and contingency
However, there are similarities
between ERP and HRT, such as encouraging patients
to resist engaging in the compulsion or tic behavior.
Taken together, treatment findings suggest a large
number of differences in treatment approaches for
OCD and Tourette’s disorder, although some elements
Clinical utility, conclusions, and preliminary
The above data suggest both
similarities and differences between Tourette’s disorder
and OCD. Certain validators indicate that OCD and
Tourette’s disorder are closely related. Perhaps the most
compelling data comes from family-genetic studies.
Comorbidity studies also indicate that these disorders
may be related. However, they do have some clinically
important differences—e.g. treatment response.
From the perspective of clinical utility, including tic
disorders in an OCSD grouping may be useful in
encouraging clinicians to assess OCD in Tourette’s
disorder patients and to assess tics in those with OCD.
However, because there are some differences between
OCD and Tourette’s disorder, and given the early onset
of Tourette’s disorder and chronic tic disorder, it would
also be reasonable for these disorders to remain in a
section of disorders usually first diagnosed in infancy,
childhood, or adolescence. If the latter category is not
included in DSM-V, then a reasonable option would be
Tics respondwell to
535 Review: OCS in DSM-V
Depression and Anxiety
to include tic disorders in a neurodevelopmental
grouping (if included in DSM-V) or an OCSD
grouping, although alternative names for the latter
category would need to be considered, and the text
would need to clarify the important distinctions
between tic disorders and OCD.
TRICHOTILLOMANIA AND OTHER
DSM-IV classifies TTM as an ICD not otherwise
classified. Options for DSM-V include (1) continued
inclusion of TTM with ICDs and (2) inclusion of
TTM as an OCSD. (This issue is also addressed in a
separate review on TTM.) The relevant evidence
base addressing validators for comparisons of TTM
and ICDs, and of TTM with OCD and other anxiety
disorders, is, however, relatively sparse.
A number of studies have
undertaken detailed phenomenological comparisons of
patients with TTM and with OCD.[228,229]In general,
these studies indicate that there are some symptom
similarities. For example, TTM involves repetitive
behaviors and has important compulsive aspects,
including various rituals preceding and following hair
pulling (e.g. mouthing of the hair, biting of the root).
However, TTM and OCD have some differences; for
example, patients with TTM do not describe obses-
sions preceding hair pulling, and they often obtain a
sense of gratification from their behavior. Lochner
et al. reported that in contrast to OCD, all of their
TTM subjects had good insight.
Although TTM is currently classified as an ICD, as
discussed in more detail in a separate reviewnot all
patients with TTM describe impulsive hair pulling (i.e.
they do not meet TTM criteria B and C), and meeting
criteria B and C is not predictive of increased
psychological symptoms, pulling severity, or functional
Comparisons of subjects with TTM and other body-
focused repetitive behavioral symptoms, such as skin
picking, indicate similarity in symptom phenomenol-
Several studies indicate that OCD is
more prevalent in individuals with TTM than in
controls, and, conversely, that TTM is more prevalent
in individuals with OCD than in controls[5,49,232]
(Bienvenu et al., unpublished data), although one study
did not find this.Both TTM and OCD are often
comorbid with mood and anxiety disorders, as well as a
range of axis II disorders.Nevertheless, there are
distinctions in comorbidity patterns between the two
disorders. For example, Lochner et al. reported that in
130 patients with OCD and 49 patients with TTM,
lifetime prevalence of a range of anxiety and putative
OCSDs was similar, but depression was more prevalent
in OCD (66.9%) than TTM (49.0%), and OCD was
more likely to be associated with other psychiatric
disorders in general than was TTM.
Richter et al. compared lifetime rates of TTM in 98
OCD subjects, 86 panic disorder subjects, and 93 social
phobia subjects, finding that TTM was significantly
more common in OCD (9%) than in the other
disorders (1–2%), suggesting that they may be re-
lated.Skin picking and tic-related conditions were
also significantly more prevalent in OCD than in panic
Lifetime rates of TTM may be elevated in some
ICDs such as compulsive sexual behavior (6%)and
kleptomania (10%),although systematic compar-
isons with control groups are needed. However, TTM
has relatively low comorbidity with other ICDs,
particularly substance use disorders.[229,232]Further-
more, research on other ICDs (e.g. pathological
gambling, pyromania, intermittent explosive disorder)
has found little if any co-occurrence with TTM.[235,236]
TTM is often comorbid with stereotypic behaviors,
including skin picking.[232,237]
Course of illness.
Both TTM and OCD may have
early onset (e.g. childhood or adolescence) and
extended course.TTM’s mean age of onset is,
however, relatively narrow, with the large majority of
cases beginning around puberty.In contrast, age at
onset in OCD has a broader distribution; OCD may
begin prepubertally as well as at other times in the life
course (e.g. during or after pregnancy).
example, in a sample of similarly recruited subjects,
mean age of onset in OCD was 19.3 and for TTM was
11.8.Age of onset for most ICDs is generally later
than that for TTM (adolescence or early adult-
hood).There are few data on long-term outcomes
in TTM, but there is some evidence that, as in OCD,
these are also somewhat variable.
Family studies indicate a familial
relationship between OCD and TTM, although
neither condition appears very common in first-degree
relatives of probands with the other condition. For
example, a study of 16 TTM patients without OCD
found that 5% of 65 case relatives had OCD, compared
to 0% of 90 relatives of 18 normal controls.Similar
and statistically significant findings were reported in a
family history study of 22 TTM patients.
The few data that exist may also suggest a relation-
ship between TTM and other disorders. Schlosser et al.
reported that first-degree relatives of TTM probands
were significantly more likely to have substance use
disorders (21.6% alcohol use disorders and 14.7% drug
use disorders) than relatives of non-ill comparison
subjects (7.7% alcohol use disorders and 2.2% drug use
Bienvenu et al. found an increased rate of any
grooming disorder (TTM, skin picking, or nail biting)
in probands with OCD compared with controls, as well
as in first-degree relatives of OCD probands compared
with controls; TTM was uncommon in the sample.
Bienvenu et al. (unpublished data) recently replicated
these results using a much larger sample of families;
although TTM was not common, the prevalence of
536 Phillips et al.
Depression and Anxiety
TTM was higher in relatives of OCD-affected pro-
bands than control relatives, independent of TTM in
probands. Skin picking was a more common condition,
affecting substantially more OCD case probands than
control probands; skin picking was also more common
in case than control relatives, and this condition ‘‘ran in
the families’’ independently of skin picking in probands
and OCD in relatives.
Genetic and environmental risk factors.
and environmental risk factors for TTM are not well
elucidated. As in OCD, there may be greater vulner-
ability after early exposure to adversity or trauma,
but with little evidence that this association is specific.
Patients with the same rare gene variants may present
with TTM, OCD, or Tourette’s disorder.[244–246]Such
variants have not been well explored in ICDs or other
body-focused repetitive behaviors. It has been hy-
pothesized that common gene variants also share some
overlap in OCD and TTM,but the evidence base is
too thin to go beyond the speculative.
OCD has been associated with
altered findings in cortico-striatal-thalamic circuitry.
These circuits also play a role in TTM, but there are
fewer studies, and findings have been somewhat incon-
sistent. For example, left putamen volume was signifi-
cantly smaller in TTM subjects than in healthy controls
in a small study,but another study using a similar
design did not confirm this finding.Additionally,
there is limited evidence that TTM involves areas (e.g.
amygdalo-hippocampal formation, cerebellum) that have
not been strongly implicated in OCD.[251,252])
There have been few studies of
biomarkers in TTM and none that directly compare
TTM and OCD. Ninan et al. found no differences in
CSF metabolites in TTM and healthy controls,in
contrast to a number of OCD studies.
little work on temperament in TTM. A comparative
study of the Temperament and Character Inventory in
subjects with TTM and OCD showed higher harm
avoidance and lower novelty seeking in OCD, although
both groups had high harm avoidance compared to
Cognitive and emotional processing.
studies have compared neuropsychological findings in
OCD and TTM. Although not all data are consistent,
findings have often emphasized differences in the
pattern of deficits.For example, Chamberlain
et al. reported that impairment in inhibition of motor
responses was worse in TTM than in OCD, whereas
patients with OCD but not TTM had deficits in
cognitive flexibility.It is possible that impaired
inhibition of motor responses cuts across a number of
putative OCSDs including tic disorders, whereas other
neurocognitive deficits are more specific to each of
these conditions, but further work is needed to address
fully such a hypothesis.
clomipramine (CMI) was more effective than desipramine
There has been
An early trial found that
in TTM, mirroring findings in OCD.[195,256]There is also
a small literature suggesting that augmentation of SRIs
with dopamine blockers may be useful in TTM, as in
OCD.[257,258]Nevertheless, there appear also to be
important differences in pharmacotherapy response,
including inconsistent evidence in TTM for efficacy of
the SRIs, and less evidence of maintained response to
either CMI or SSRIs.It is possible that TTM, and
perhaps certain body-focused repetitive behaviors (such as
skin picking), respond to agents that are ineffective in
OCD—e.g. low-dose atypical neuroleptics as monother-
apy or n-acetylcysteine, although data are not defini-
tive.[260,261]TTM may also respond to some interventions
used for other ICDs (e.g. naltrexone),although
available data are too limited to draw definitive conclu-
sions. ERP is efficacious for OCD, whereas habit reversal
is efficacious for TTM, T ourette’s disorder, and body-
focused repetitive behavioral problems such as skin
picking[226,262](although, as noted earlier, habit reversal
and ERP have some overlapping features).
Conclusions, clinical utility, and preliminary
As discussed above, there is
some degree of overlap between OCD and TTM on
a number of validators, although this overlap is partial
at best. For example, there is evidence of partial overlap
(as well as some distinctions) in the neurocircuitry,
family history, and neurogenetics of OCD and TTM
(although data are still limited for TTM). In contrast,
TTM does not appear closely related to other ICDs or
behavioral addictions, such as pathological gambling.
For example, there is little evidence of comorbidity of
TTM with other ICDs or overlap in underlying
Although more research is needed, TTM may
overlap phenomenologically and psychobiologically
more with other body-focused repetitive behavioral
disorders, such as skin-picking disorder, than with
OCD. If body-focused repetitive behaviors are not
classified in a separate category in DSM-V, then there
is some evidence that they should be categorized as
From the viewpoint of clinical utility there are both
advantages and disadvantages of classifying TTM as an
OCSD. The DSM-V text should clarify that TTM is
not simply OCD, as there are some differences in these
disorders’ core features, assessment, and treatment.
This review examines HYP and its relationship to
OCD and, to a lesser extent, to somatization disorder
(SD) and panic disorder. We include SD because
DSM-IV classifies both SD and HYP as somatoform
disorders, and some studies suggest that they are
related. We also discuss panic disorder, as both HYP
and panic disorder involve health-related anxiety, and
some literature suggests that they have similarities.
Several studies have com-
pared HYP and OCD and/or panic disorder. Neziroglu
537 Review: OCS in DSM-V
Depression and Anxiety
et al. (n516 subjects with HYP versus 22 subjects with
OCD) found that although both groups had similar
levels of obsessionality, anxiety, and depression, HYP
subjects had less compulsivity, less insight, more
somatic fear, and greater avoidance.Abramowitz
et al. (n521 subjects with HYP versus 18 subjects with
OCD) found that although the two groups had similar
beliefs about the probability of becoming ill, HYP
patients had greater health anxiety and more cata-
strophic beliefs about disease.Deacon et al. com-
pared HYP (n523), OCD (n521), and panic disorder
(n550).Compared to OCD, HYP subjects had
comparable levels of bodily vigilance and intolerance of
uncertainty but greater health anxiety and fewer OC
symptoms. Compared to panic disorder, the HYP
patients had comparably low levels of OC symptoms
and high bodily vigilance but differed in having
elevated health anxiety and worse intolerance of
uncertainty. The symptom focus for panic disorder
was on arousal symptoms leading to feared immediate
consequences, whereas the focus for HYP encompassed
a broader symptom range related to longer-term
consequences. On balance, these studies indicate that
although there are areas of overlap between HYP and
OCD, particularly in intolerance of uncertainty, there
are also important differences. Few studies have
directly compared HYP and SD (or subthreshold
SD), but evidence indicates that HYP and SD patients
share multiple medically unexplained symptoms, but
they differ in that, compared to nonsomatoform
controls and to SD patients, HYP patients have
significantly higher levels of fear and conviction of
General population studies of cur-
rent DSM-IVHYP reveal
0.05–0.4%.[267–271]Lifetime rates of HYP among
patients with OCD vary from 8.2% (n585 OCD) to
15% (n580) of OCD patients.[6,272,273]Comorbid
HYP is even more common in other disorders,
however, with a prevalence of 20% in one primary-
care study of SDand 25–51%[275–277]in studies of
In primary-care samples, although the prevalence of
current OCD among patients with HYP was notably
low—less than 1%—in three studies,[278–280]lifetime
comorbidity of OCD in HYP appears higher—
9.5%.OCD is not the most common comorbid
disorder among HYP patients. Three primary-care
studies[274,278,280]in patients with HYP found increased
comorbidity among HYP patients compared to pri-
mary-care patients without HYP as follows: SD
(5.5–20?increased), panic disorder (6.4?), OCD
(3.7?), any depressive disorder (2.8?), generalized
anxiety disorder (GAD) (2.6?), pain disorder (2.5?),
and any anxiety disorder (2.0–2.8?). Of note, in three
primary-care studies (which would render a bias toward
somatic presentations),[274,278,280]comorbidity in com-
parison to the control sample was consistently far more
increased for SD than for any other disorder.
These studies therefore indicate that non-OCD
Axis 1 comorbidity is far more common than OCD
comorbidity in HYP patients and that among the
comorbid disorders the increase in SD is greatest
compared to primary-care base rates.
Course of illness.
Approximately one-third of
patients with HYP no longer meet diagnostic criteria
after 5 years.Although OCD has generally been
considered a more chronic disorder, with only a
minority of patients (o6%) attaining prolonged
remission,a more favorable long-term outcome
was suggested by a naturalistic follow-up of 144
patients with OCD, which found that 48% no longer
met diagnostic criteria after 40 years.Age of onset
is similar for HYP and OCD—a median age of 20 for
HYP from one primary-care study of DSM-IV
HYPand 19–23 for OCD from two community
studies in the United States.[92,285]Median age of onset
for panic disorder is slightly older (age 24 from one
community study),whereas that for SD is younger
(age 15 in the Epidemiologic Catchment Area study in
the US).However, studies from clinical OCD
samples reveal a bimodal distribution for age of onset
(ages 12–14 and ages 20–22).Childhood-onset
OCD has been reported
phenotypic differences from adult-onset OCD—for
example, more comorbidity with tics, somatoform, and
eating disorders.A bimodal pattern has not been
described for age of onset in HYP.
Noyes et al. interviewed 72 first-
degree relatives of 19 HYP probands and 97 first-
degree relatives of 24 non-HYP probands.The
prevalence of HYP, HYP symptoms, or OCD was not
increased in relatives of HYP probands, although SD
and GAD were increased. Bienvenu et al. evaluated 343
first-degree relatives of 80 OCD probands and 300
relatives of 73 nonpatient control probandsand
found no significant difference in the prevalence of
HYP in the first-degree relatives of the OCD probands
versus controls’ relative (3 versus 1%). However, in a
recent larger family study from the same research
group, HYP was significantly more common among
first-degree relatives of OCD versus control probands
(4% versus 1%) (Bienvenu, unpublished data). In the
only twin study of somatoform disorders, only one of
the co-twins of the six probands with HYP had a
psychiatric disorder (major depression), and none had
SD or an anxiety disorder, including OCD.
Genetic and environmental risk factors.
molecular genetic studies of HYP have been reported.
Although the prevalence of early childhood trauma
(particularly physical and sexual abuse) is high in the
somatoform disorders (HYP, SD),[290–292]it is also high
in PD and OCD,and no study has directly
compared these risk factors in somatoform disorders
and anxiety disorders.
Van den Heuvel et al. exam-
ined neurocognitive and neuroanatomical correlates of
attentional bias in 16 OCD patients, 13 HYP patients,
538Phillips et al.
Depression and Anxiety
15 panic disorder patients, and 19 controls using
fMRI.The HYP group differed from the OCD
group (but not the panic group) in cortical activation
patterns while completing a Stroop task. HYP and
panic patients’ cortical activation pattern was wide-
spread (frontal, striatal, temporal) in response to both
OCD- and panic-related words, which is consistent
with a more generalized attentional bias in response to
threat in HYP and in panic compared to OCD and
healthy controls. Only the OCD group activated
posterior and ventrolateral brain regions. Comparable
challenge or resting functional imaging studies with
SD have not been conducted.
No data are available in this domain.
dies have used comparable measures to enable compar-
isons on temperamental factors.
Cognitive and emotional processing.
have reported broad neurocognitive profiles of patients
with HYP. One study suggests attentional factors may
differentiate HYP from OCD.Compared to 19
healthy controls, Van der Heuvel found that perfor-
mance on the cognitive Stroop task was unimpaired for
HYP (n514) and panic disorder (n515) but impaired
for OCD (n518). On an emotional Stroop task, HYP
and panic disorder groups both showed greater
impairment of performance for panic-related words
versus neutral words compared to OCD and healthy
controls; no across-group difference was seen for OCD
words. On attentional tasks, therefore, HYP and panic
disorder patients appear to have more similarities than
do HYP and OCD patients. There are no cognitive
studies directly comparing HYP and SD to other
disorders. A small study of 10 SD patients versus 10
non-SD controls revealed that SD patients scored more
poorly on memory, visual-spatial, and attentional
CBT and SRIs are moder-
ately effective for both HYP and OCD.[33,283,296–305]
(Similarities in treatment response need not imply
similarity of underlying psychopathology or pathogen-
esis, however, as both CBTand SRIs are efficacious for
a wide variety of psychiatric disorders.) It is unclear
whether SRIs are preferentially efficacious for HYP (as
is the case for OCD), as some studies suggest that HYP
may respond to a broader range of antidepressant
medications, although data on this issue are quite
limited;in particular, no studies have directly
compared an SRI to a non-SRI medication in patients
with HYP. One long-term double-blind study of
fluoxetine for HYP suggested that patients may sustain
their response after fluoxetine is discontinued.If
replicated in larger samples, this would distinguish
OCD from HYP, as improvement among patients with
OCD has been shown to decline rapidly after medica-
tion is discontinued.The placebo response rate
may also distinguish HYP from OCD (although data
are limited for HYP). In the fluoxetine HYP study,
33% of patients given placebo were responders,
No published stu-
similar to the placebo responder rate in depressive
disorders.The response rate to placebo in OCD
using the same scale can be much lower, closer to
suggesting that the pathophysiologic
mechanisms that perpetuate each of these disorders
may differ. Similar to HYP and OCD, CBT has been
shown to be efficacious for syndromal and subsyndo-
mal SD, although specific strategies vary by disor-
der.[301,311]There are no controlled pharmacologic
studies of SD, but controlled studies of somatization
using a less restrictive set of criteria (multisomatoform
disorder) yielded favorable results for escitalopram,
opipramol,and St. John’s wort,whereas in a
controlled study venlafaxine was not efficacious in
reducing the total score for somatic symptoms.
Although no study has directly compared the relative
responsiveness to treatment of patients with HYP
versus SD, there are controlled studies using either
CBT or SSRI therapy among patients with HYP that
suggest that improvement is substantially greater on
measures of health anxiety than on measures of
Clinical utility, conclusions, and preliminary
HYP is a heterogeneous disor-
der characterized by varying amounts of fear, bodily
preoccupation, obsessive thoughts, and disease convic-
tion.[317,318]The relative weight of each of these
components guides treatment decisions and helps to
determine whether a patient appears to have a disorder
within a broader anxiety spectrum, a more specific OC
spectrum, a somatization spectrum, or a depressive
spectrum.One research limitation needs emphasis.
All studies that have directly compared HYP and OCD
have been done in general psychiatric or anxiety clinics.
These studies risk being biased toward an overempha-
sis on the anxious HYP patient who seeks treatment in
a psychiatric setting and may not reflect HYP patients
seen in primary-care settings, who may be more fixated
on the somatic symptoms of HYP. Large epidemiologic
community studies are needed to clarify the relative
contribution of somatic symptoms and illness anxiety
among patients with HYP.
In conclusion, this review suggests that although
HYP and OCD have some phenomenologic simila-
rities, the substantial differences between them on
almost all of the above validators lead to the conclusion
that there may be some overlap between HYP and
several anxiety disorders, but there does not appear to
be a preferential relationship between HYP and OCD.
Whether HYP bears a closer relationship to somatiza-
tion than to anxiety disorders can only be addressed by
studies that compare HYP, SD, and specific anxiety
disorders directly; these studies have not been done.
Another limitation is the paucity of studies comparing
HYP to SD directly, so whether there are more
similarities on these validators for HYP and SD than
for HYP and anxiety disorders remains an open
question. Given these deficits in the literature, the best
positioning of HYP in DSM remains uncertain.
539 Review: OCS in DSM-V
Depression and Anxiety
Finally, the diagnostic criteria for HYP have been
criticized as being overly restrictive and not represen-
tative of the larger number of patients with health
anxiety.If HYP is reconceptualized as not requiring
misinterpretation of bodily symptoms, and if greater
emphasis is placed on ruminative and fear dimensions,
as proposed by some and for which there are emerging
then placing a diagnosis of ‘‘Health
Anxiety Disorder’’ in the Anxiety Disorders section
would seem heuristically reasonable. At this time,
however, given the current DSM-IV criteria for HYP,
on balance there appears to be insufficient evidence to
justify moving this disorder out of the somatoform
section of DSM.
In DSM-IV-TR, hoarding is one of the eight
diagnostic criteria for OCPD, but it can sometimes
be considered a symptom of OCD ‘‘when hoarding is
As discussed elsewhere,
available data indicate that in a majority of cases
problematic hoarding cannot be better accounted for
by OCD or OCPD. This has led to the suggestion that
hoarding may be better conceptualized as a separate
disorder.At the time of this writing, it is unclear
whether hoarding will be added to DSM-V as a new
disorder (tentatively called hoarding disorder) and, if
so, whether it will be in the main part of DSM or an
Appendix of Criteria Sets Provided for Further Study.
Because these options are being considered, we include
hoarding in this review and ask where hoarding might
be classified. We review the relationship between
hoarding and other ‘near neighbor’ disorders, includ-
ing OCD, depression, anxiety, personality disorders
(PDs), and ICDs.
As reviewed elsewhere,
hoarding resembles OCD obsessions in that these
patients fear losing important items that they feel they
may need in the future or feel emotionally attached to,
and the excessive acquisition seen in many patients may
resemble OCD compulsions. The avoidance of dis-
carding items is similar to other avoidant behaviors
seen in many anxiety disorders. If other people touch
or move possessions without permission, this typically
provokes distress, which may be similar to and overlap
with some symmetry-related obsessions in OCD.
Measures of hoarding symptoms are moderately
correlated with measures of OCD symptoms in
nonclinical and clinical hoarding samples.How-
ever, hoarding symptoms are as strongly correlated
with non-OCD symptoms, like depression and anxi-
ety,[321,322]suggesting a nonspecific link with emotional
disorders in general.
There are also phenomenological links with ICDs—in
particular, compulsive buying, which is widely consid-
ered a type of ICD NOS. The ego-syntonic and
sometimes pleasurable nature of excessive acquisition in
hoarding resembles ICDs.
Many hoarders feel
compelled to collect or acquire free items, and to buy
excessively.Nearly 75% of hoarders excessively buy,
whereas just over half excessively acquire free things.
However, not everyone with hoarding problems reports
excessive acquisition. On balance, these data indicate that
hoarding shares some features with OCD but also with
other emotional disorders and ICDs.
Hoarding is relatively frequent in
patients with OCD; approximately 20–40% endorse
hoarding symptoms, but these symptoms are seldom
clinically significant.[173,324]In OCD clinics, severe
hoarding occurs in about 5% of cases,[173,324]although
it is unknown in how many of these cases hoarding is a
consequence of other OCD symptoms, such as con-
tamination or harm fears (i.e. an OCD compulsion)
versus a separate comorbid condition. Conversely, in
community-solicited samples of severe hoarders, OCD
is present in 17–25% of cases, suggesting a link between
hoarding and OCD.[325–327]However, other emotional
disorders such as depression and anxiety disorders may
be even more frequently comorbid with hoarding than
OCD is. For example, among 217 patients from the
community with a significant hoarding problem, 18%
had concurrent OCD (based on nonhoarding symp-
toms), whereas 36%, 20%, and 24% had concurrent
MDD, social phobia, and GAD, respectively,
although these latter disorders have higher base rates
than OCD, and thus higher rates are expected.
Regarding a possible link between hoarding and
ICDs, a high prevalence (about 25–40%) of hoarding
has been describedin
buyers.A recent epidemiological studyre-
ported significant correlations between measures of
hoarding and compulsive buying, and about two-thirds
of those with hoarding also had compulsive buying.
Preliminary data also suggest a link with other ICDs.
For example, one study found high levels of hoarding
symptoms among pathological gamblers.Another
studyfound a greater frequency of TTM and skin
picking among OCD patients with hoarding compared
to nonhoarding OCD patients (although TTM and
skin picking may be better conceptualized as OCSDs
than as ICDs).
Hoarding (regardless of whether it co-occurs with
OCD) is also frequently comorbid with several
PDs.[326,331–334]The association with OCPD could be
explained to some extent by the overlapping content
mixed.[11,335]Only about a third of hoarders meet
criteria for OCPD,and hoarders have been found
to have no more OCPD traits than controls once the
OCPD hoarding criterion is excluded.[326,333]Hoard-
ing severity does not correlate with OCPD severity.
On balance, there is comorbidity between hoarding,
OCD, and other putative OCSDs; other anxiety, mood,
personality, and certain other ICDs are at least as likely
to be comorbid with hoarding.
Course of illness.
Although no longitudinal co-
hort studies have been done, available data suggest that
samples of compulsive
540 Phillips et al.
Depression and Anxiety
hoarding typically has a chronic and progressive
course.[336–338]Several retrospective studies suggest
that, like OCD, other anxiety disorders, and ICDs,
hoarding symptoms usually first emerge in childhood
or early adolescence.[336–338]However, unlike these
other disorders, hoarding symptoms may only become
distressing and need treatment later in life, around the
mid-thirties.[326,337,338]The average age of consultation
for hoarding is 45–50.Also unlike OCD, where
symptom intensity can wax and wane, hoarding appears
to have a very stable course.
Hoarding appears to run in families,
with about 50% of severe hoarders reporting a relative
with hoarding problems.[336,339]In a family study,
hoarding and tics were more frequent in first-degree
relatives of hoarding than nonhoarding OCD pro-
bands.In a case–control study, 25.6% of severe
hoarders who did not meet diagnostic criteria for OCD
hada positive (self-reported)
OCD,suggesting a potential familial link between
examined, so it is unknown how specific the link with
Genetic and environmental risk factors.
degree of genetic similarity between hoarding and
other disorders is unclear. Genetic studies of hoarding
have so far been conducted in patients with other
disorders such as Tourette’s disorder or OCD.[340,341]
Results have been inconsistent but suggest that
hoarding may be etiologically distinct from these
disorders.The literature on environmental risk
factors is very limited. Three retrospective studies
reported an increased prevalence of traumatic life
events in patients with hoarding, compared with
nonhoarding OCD patients.[342–344]However, these
studies remain inconclusive until samples of severe
hoarders who do not meet criteria for OCD are
A handful of neuroimaging
studies of hoarding symptoms in patients with OCD or
ducted.[345–348]Hoarding (with or without OCD)
appears to be mediated by fronto-limbic circuits
involving the cingulate cortex, ventromedial prefrontal
cortex, and limbic structures,[345–347]whereas non-
hoarding OCD is characterized by involvement of
cuits.Based on this preliminary evidence, hoarding
appears to have a distinct neural substrate from OCD
and might share neural substrates with a wide
range of emotional disorders such as PTSD or
phobias.Comparisons with ICDs are not possible,
as very few studies have been done.
No data are available in this domain.
studies have investigated temperamental antecedents
of hoarding. Several studies examined the personality
profile of compulsive hoarders who met criteria for
OCD, finding that it seems broadly similar to that of
OCD havebeen con-
patients with a variety of emotional disorders, includ-
ing OCD, although there are no data directly compar-
ing hoarding as a disorder versus other disorders.
As reviewed elsewhere,hoarders share some char-
acteristics with OCD, such as increased sense of
responsibility (but limited to possessions, rather than
harm) and high levels of indecisiveness and perfection-
ism.[336,351]On the other hand, compulsive hoarding
and compulsive buying share certain features, including
decision-making difficulties, emotional attachment to
objects, and erroneous beliefs about possessions.
Cognitive and emotional processing.
neuropsychological studies have been conducted in
hoarding, suggesting deficits in executive functioning,
attention, memory, and categorization,[353–355]but it is
currently unclear to what extent these deficits are
specific to hoarding disorder or shared with other
studied alone in treatment trials.[349,356,357]In patients
with OCD, hoarding symptoms tend to be less
responsive than other OCD symptoms to evidence-
based treatments for OCD, that is, ERP[358,359]and
However, some preliminary evidence
from uncontrolled trials suggest that community-
solicited hoarders may respond to SRIsand to
adapted CBT protocols, which contain ERP elements
plus other CBT techniques not typically used in OCD,
such as motivational interviewing and skills training,
as well as hoarding-specific cognitive restructur-
Clinical utility, conclusions, and preliminary
If hoarding becomes a separate
disorder in DSM-V, it is unclear where it may be best
classified, because it shares features with OCD, other
anxiety disorders, and ICDs, particularly compulsive
buying. Given the phenomenological and historical
link between OCD and hoarding, it may make sense to
provisionally list it as an OCSD until more research is
Hoarding has rarely been
We focus primarily on OCPD’s relationship to OCD
and to other PDs.
DSM-IV OCPD is defined
as preoccupation with orderliness, perfectionism, and
mental and interpersonal control, at the expense of
flexibility, openness, and efficiency, as manifested by
eight specific criteria (of which four or more are needed
to make the diagnosis): preoccupation with details,
orderliness, and rules; rigidity; perfectionism; excessive
work devotion; reluctance to delegate; hypermorality;
miserliness; and hoarding. Some of the abnormal
cognitions considered to underpin OCD, which may
bethe focusof CBT,
with orderliness, perfectionism, scrupulosity, and be-
havioral (need for control) or cognitive (stubbornness)
541 Review: OCS in DSM-V
Depression and Anxiety
rigidity,[44,361,362]overlap with OCPD criteria. Thus,
DSM-IV warns that the two disorders may be
OCPD is differentiated from OCD by the absence of
strictly defined obsessions and compulsions.[164,363]
However, behavioral manifestations of OCPD traits
can have a compulsive quality (i.e. intentional, repeti-
tive, time-consuming, difficult to resist or control, not
pleasurable and associated with distress).[164,361]In
OCD, obsessions are intrusive, distressing and gen-
erally ego-dystonic. In contrast, OCPD traits and
symptomatic behaviors are considered ego-syntonic, as
they are viewed as correct.Arguably, OCPD may
be less impairing than OCD,although the full
impact of OCPD is not well understood, as the
disorder has not received much scientific atten-
Although not the DSM-IV definition, PD may be
conceptualized, broadly speaking, as the failure to
develop an adaptive self-concept and interpersonal
relations.Within this framework, OCPD could be
considered to represent such a rigid self-concept that
the ability to respond adaptively to environmental
contingencies, such as unexpected change in routines
or the need to prioritize timeliness over perfection, is
impaired. Like other PDs, OCPD features are traits
rather than ‘‘states,’’ but chronic symptoms, as often
seen in OCD, can have a trait-like quality. However,
OCPD differs in some respects from other PDs, and in
factor analyses forms its own factor.In some
studies, OCPD has been associated with less functional
impairment than other PDs,and adaptive aspects
have been recognized.Furthermore, among some
researchers, OCPD increasingly is conceptualized as
primarily a disorder of neurocognitive function (see
section on cognitive and emotional processing) rather
Compared to population norms,
OCPD rates are elevated in individuals with OCD
(25–32%)[369–371]and BDD (14–28%).[78,83]Although
OCPD is not uniquely or preferentially associated with
OCSDs (e.g. it is comorbid with MDD (31%),[372,373]
(20–61%)[375–378]), this comorbidity profile resembles
that of OCD and OCSDs. Moreover, compared to
other PDs, OCPD has been found to be the most
commonly comorbid PD with anorexia nervosa-re-
stricting type, binge eating disorder,and bipolar
disorder,[372,380]disorders that are highly comorbid
with OCD.[381,382]Conversely, the prevalence of OCD
(20%) is elevated in patients with OCPD, although the
majority of OCPD patients do not have comorbid
OCD.This extensive comorbidity does not favor
any one of the many theoretical models proposed to
explain the overlap between OCPD and Axis I
disorders (reviewed in Shea et al.).
OCPD also shares substantial comorbidity with
other PDs, at least in clinical samples. In one study,
a high proportion of OCPD patients (77%) had
concurrent PDs, but only comorbidity with paranoid
PD (23%) was significantly higher than expected.
Moreover, in a meta-analysis of 33 factor analyses of
PD comorbidity, OCPD formed its own factor.
Thus, comorbidity data are equivocal regarding the
placement of OCPD.
Course of illness.
Although OCPD personality
traits are typically stable over time, DSM-IV OCPD
per se may not be (e.g. only 42% of patients diagnosed
with OCPD at baseline in one study remained above
threshold for the diagnosis at 2-year follow-up).
There are some similarities between the course of
OCPD and OCD, which typically both emerge
relatively early in lifeand have a chronic course
that fluctuates in severity, although a subsample with
episodic OCD has also been described.A retro-
spective, long-term study comparing first psychiatric
admissions diagnosed with OCD or OCPD showed
similar levels of diagnostic stability over up to eight
years of followup.Another studyfailed to find a
clear longitudinal association between the course of
comorbid anxiety disorder (including OCD) and
OCPD, suggesting that the two disorders may share
only surface phenomenological similarity rather than
common underlying substrates, or that the expression
of such substrates is complex and varies over time.
Familiality/genetic and environmental risk fac-
Family and twin studies suggest high herit-
ability for OCPD.[200,390–392]In one study, OCPD was
the only PD to co-occur significantly more often in
relatives of OCD probands than in relatives of controls,
suggesting a specific shared heritability between
OCPD and OCD.Another studyreported a
higher incidence of DSM-IV OCPD in parents of
pediatric OCD probands compared to parents of
healthy children, even after parents with OCD were
excluded. Similarly, Bienvenu et al. (unpublished data)
found a raised prevalence of OCPD in first-degree
relatives of OCD-affected probands, independent of
OCPD in probands; notably, OCPD also appeared to
‘‘run in’’ these families independent of OCD itself.
However, OCPD traits also may constitute a specific
familial risk factor for anorexia nervosa.OCPD
runs together with tics and OCD in families with
PANDAS, hinting at a shared familial vulnerability to
poststreptococcal psychiatric sequelae.In contrast,
statistical modeling of genetic and familial factors
found limited shared genetic (11%) and environmental
(15%) variance between OCPD and the other cluster C
PDs.Thus, on balance, these data, although not
specific to OCD, offer fairly strong support for a
familial relationship between OCPD and OCD.
There are very limited data examining the contribu-
tion of environmental factors to the development of
OCPD. One studyfound that patients with OCPD
reported significantly lower levels of parental care and
significantly higher levels of overprotection compared
to healthy controls and to other psychiatric outpatients,
similar to OCD.[397,398]
542Phillips et al.
Depression and Anxiety
specifically investigated OCPD.
lactin responses have been reported for OCPD and also
for depression, anorexia nervosa, and binge-eating
disorder,[399–401]suggesting similarities in serotonergic
processing. Blunted fenfluramine responses have also
been reported for OCD, but increased responses have
also been reported (reviewed in Fineberg et al.).
Failure to screen for comorbid OCPD and depression
in some of these studies makes interpretation difficult.
In summary, there are only limited data on this topic
that do not allow clear conclusions about the related-
ness of OCPD to OCD or other disorders.
scores on the five-factor model of personality (e.g.
anxiety, self-consciousness, and vulnerability to stress)
characterize family members of individuals with OCD
and OCPD, even in the absence of symptoms of mental
disorder, suggesting shared temperamental factors for
OCD and OCPD.However, high neuroticism is a
nonspecific dimension that is associated with virtually
Cognitive and emotional processing.
OCPD is characterized by inability to respond flexibly
to environmental contingencies. A controlled study
(n520) suggests that patients with OCD and comor-
bid OCPD have greater cognitive inflexibility on a
set-shift paradigm (extra-dimensional set-shift; CAN-
TAB),thought to be mediated by prefrontal cortex
and associated subcortical brain-circuitry than patients
with OCD without comorbid OCPD.This ab-
normality is also present in OCD probands and their
unaffected first-degree relativesas well as patients
with schizo-OCDand may represent a neurocog-
nitive endophenotype for disorders sharing neurocir-
cuitry with OCD.
A small randomized place-
bo-controlled trial suggests OCPD may respond to
SRIs.In a study of patients with OCD, CMI was
more efficacious than imipramine in improving scores
on a self-rated OCPD inventory, suggesting that SRIs
traits;however, the results were not clinically
confirmed and were based on a completer-analysis
rather than the intention-to-treat sample. Borderline
PD has also been shown to respond to SRIs.
Conclusions, clinical utility, and preliminary
Integration of OCPD into a
broadly defined grouping of OCSDs is supported by
some evidence from the above validators, including its
comorbidity and relatively specific heritability within
families of OCD probands, its possible response to
SRIs (although treatment data are very limited, and
SRI response is not necessarily specific to OCPD
among PDs), and its neurocognitive profile implicating
frontostriatal neurocircuitry similar to that in OCD
(although data are preliminary). Evidence suggesting
notable differences between OCPD and other PDs
No brain-imaging studies have
Blunted fenfluramine-mediated pro-
include the separation of dimensional measures of
OCPD from other PDs on factor analysis, and
heritability patterns that differentiate OCPD from
other cluster C disorders. On the other hand, OCPD
differs in some ways from OCD. For example, whereas
OCPD is characterized by behaviors that have some
phenomenological similarities to OCD compulsions,
they lack the ‘ego-dystonic’ quality generally consid-
ered a key characteristic of OCD.
Although more systematic research would be desir-
able to fully justify moving OCPD from the PD to an
OCSD grouping, we consider that moving OCPD to a
grouping of OCSDs in DSM-V, while controversial,
would probably improve the clinical recognition and
endophenotypic evaluation of this neglected and
potentially treatable disorder, and may thereby enable
development of effective treatments. However, if PD is
conceptualized as a single disorder in DSM-V, as is
preliminarily recommended by the Personality and
Personality Disorders Work Group, it is not clear how
this would be effected. One possibility is that
personality traits commonly considered to comprise
OCPD (e.g. perfectionism, rigidity) may be risk factors
within the OC spectrum, although this possibility
needs to be studied.
DATIONS FOR DSM-V
From the perspectives of clinical utility, face validity,
and evidence from various validators, we conclude that,
on balance, a number of disorders discussed in this
review appear more closely related to OCD than to
other near-neighbor disorders, and that there is merit
to including an OC spectrum group of disorders in
DSM-V. Our preliminary recommendation is to
include within this category several cognitively focused
(‘‘higher-order’’) disorders—OCD and BDD—charac-
terized by both compulsive behaviors and obsessional
thoughts. If hoarding is added as a new disorder to the
main part of DSM-V (rather than an Appendix), this
review suggests that it would be reasonable to
categorize it with other OCSDs. We also recommend
including motorically focused (‘‘lower-order’’) disor-
ders characterized by stereotypic behaviors but not
obsessions, which would include TTM and possibly tic
disorders, particularly if disorders of childhood/ado-
lescent onset are not retained. HYP and OCPD could
potentially be included with OCSDs, as they have some
similarities to OCD, although evidence for their
relatedness to OCD is more mixed and less persuasive.
Placement of these two disorders requires further
consideration in collaboration with relevant DSM-V
Work Groups (Somatic Distress and Personality and
These preliminary recommendations are highly
congruent with recommendations from the previously
543 Review: OCS in DSM-V
Depression and Anxiety
noted worldwide survey of OCD expertsand fairly
congruent with those from the DSM-V Research
Planning Conference on OCSDs.[12,26]Other ICDs
and substance use disorders were not the focus of this
review, but we concur with prior recommendations
from these sources that these disorders should not be
included in an OCSD group of disorders.[13,26]
Several disorders that are not a focus of this review
merit comment. SMD, discussed in another review,
is classified in DSM-IV’s section of disorders usually
first diagnosed in infancy, childhood, or adolescence. If
DSM-V retains this section, there may be no compel-
ling reasons to move SMD elsewhere. If DSM-V does
not retain this section, there may be merit to
categorizing SMD as a motoric OCSD. This issue
requires further discussion with other relevant DSM-V
Work Groups. Skin-picking disorder and olfactory
reference syndrome are not included in DSM-IV but
are candidates for inclusion in DSM-V.[29,410]These
conditions have many similarities to cognitive OCSDs
(in the case of ORS) or motoric OCSDs (in the case of
It should be acknowledged that some disorders
preliminarily recommended for inclusion in an OCSD
category may not be closely related to one another,
although this is probably also the case for other current
and potential groupings of disorders in DSM. It should
also be acknowledged that although neuroimaging and
neurocognitive data support a heuristic focus on
frontostriatal circuitry with respect to the pathophy-
siology of candidate OCSDs, the case is empirically
well established only for OCD and Tourette’s disorder.
Moreover, there are some apparent differences in
neuroimaging findings across some OCSDs, although
these findings could be considered to have some
convergence in that they involve various striatal
subterritories (motoric versus cognitive versus affec-
tive) and their corresponding corticostriatal networks.
However, such neuroanatomical hypotheses pertaining
to OCSDs need further testing.
We believe that a category of OCSDs will increase the
diagnostic validity and clinical utility of the classification
system. From the perspective of clinical utility, there are
advantages to grouping these disorders together—e.g.
for purposes of diagnosis and differential diagnosis, given
similarities in their clinical features (obsessions/preoccu-
pations and/or driven repetitive behaviors). The repeti-
tive behaviors can involve complex compulsions or
simple motoric behaviors, which are often associated
with anxiety reduction and/or the regulation of arousal.
A category of OCSDs would potentially remind
clinicians to rigorously assess the range of repetitive
symptoms and obsessional thoughts that can occur in
these disorders (this is important, because of high
comorbidity among some of them), and to consider
similar assessment procedures (for example, standardized
symptom severity scales for a number of these disorders
have been modeled after the Yale-Brown Obsessive–
compulsive Scale for OCD[72,73,411–413]).
This approach to classification, however, should not
imply that OCSDs are simply subtypes or variants of
OCD. Indeed, as noted throughout this article,
candidate OCSDs have some clinically important
differences from OCD and from one another. Thus,
they need to be individually identified in clinical
settings and when selecting treatment and monitoring
treatment response. The potential for confusion about
this point is perhaps the most important possible
disadvantage of including OCSDs as a category. It
would be essential to clarify this issue in the DSM-V
text, to ensure appropriate diagnosis and treatment of
If OCSDs are grouped together in DSM-V, what
should this category be called? Many in the field have
adopted the term ‘‘obsessive–compulsive spectrum
disorders,’’ as it emphasizes the disorders’ core features
repetitive behaviors. However, some might consider
this name too ‘‘OCD-centric’’ (although, of note, this
name does not include the name of the disorder OCD).
Another potential problem is that some DSM users
might misinterpret this name to mean that all OCSDs
are simply types of OCD rather than being likely
related but distinct disorders. Alternative names could
be considered; we recommend that any alternative
names capture these disorders’ key features and be
Another important question is, if DSM-V includes a
group of OCSDs, should they be in their own separate
chapter, or should they be classified in the same chapter
as another group of disorders—for example, in a
chapter of ‘‘anxiety and obsessive–compulsive spectrum
disorders’’? Supporting the former view, motoric
OCSDs appear to have relatively little in common with
anxiety disorders. Supporting the latter view, OCD is
classified as an anxiety disorder in DSM-IV and has
much in common with other anxiety disorders.[30,41]
Although less researched, BDD, too, appears to have
much in common with anxiety disorders, especially
social phobia. A combined ‘‘anxiety and obsessive–com-
pulsive spectrum chapter’’ has the advantage of
emphasizing established links between anxiety disorders
and certain OCSDs while also emphasizing some
important distinctions between them. (The categoriza-
tion of PTSD is discussed in a separate review [Spiegel
et al., in preparation].) The majority of the authors of
this review consider the option of a combined,
supraordinate category of ‘‘anxiety and obsessive–com-
pulsive spectrum disorders’’ most satisfactory, especially
given that the overall number of categories in DSM-V
will likely be limited. We further recommend that this
supraordinate category contain two subcategories—one
for anxiety disorders and one for OCSDs. This
approach has some similarities to that in ICD-10,
where OCD and anxiety disorders are separate sub-
categories within the same larger, overarching, supraor-
dinate category (‘‘neurotic, stress-related, and somato-
544 Phillips et al.
Depression and Anxiety
This review, and the status of the field’s knowledge,
have some limitations. For some disorders, little or no
research evidence is available for certain validators,
and, for some validators, findings are inconsistent.
Direct comparison studies of putative OCSDs to one
another and to other disorders are still limited. Many
studies do not report effect sizes or another metric
reflecting degree of similarity between disorders,
and this review was qualitatively based (formal meta-
analyses were not done). Furthermore, the field does
not have clear indicators for how similar disorders must
be across validating domains to be considered closely
related, whether all validators should be weighted
equally, or whether similarities in particular validating
domains should be required for spectrum member-
ship.The selected validators may not be perfect,
and during the DSM-V process, thinking about which
validators to employ has evolved. These limitations are
relevant to decisions about groupings of disorders
across DSM (not just the OC spectrum); some may also
be relevant to certain nonpsychiatric medical disorders.
There is no perfect way to categorize disorders in
DSM-V; the field is not at the point where nature can
be carved perfectly at its joints. Ultimately, knowledge
of disorders’ etiology and pathophysiology may ad-
vance the field to the point where categories with
greater validity and utility are possible.[415,416]In the
meantime, many disorders across DSM share certain
features and also have meaningful differences. Argu-
ments could be made for alternative classification
schemes.Decisions about how to group disorders
in DSM-V must also consider constraints on the
overall number of categories that can be included in
Despite these limitations, research on this issue has
substantially advanced relevant knowledge since DSM-
IV was published 16 years ago. The challenge for
DSM-V is whether it can improve upon the disorder
groupings in DSM-IV, which were created before
much of the research discussed in this review had been
done. An important question is, how problematic is the
current placement of putative OCSDs? In other words,
how compelling is the need to move them to a different
category? BDD appears to have little in common with
the somatoform disorders, and thus it seems proble-
matic to leave it there. HYP as defined in DSM-IV
seems more closely related to other somatoform
disorders (or, at least, SD), and thus keeping it in that
group seems less problematic. Similarly, leaving OCPD
in the personality disorder section is a reasonable
alternative. Tourette’s disorder and tic disorders could
remain in a childhood chapter, but it is currently
unclear whether this chapter will remain in DSM-V;
good options (other than OCSDs or possibly a
neurodevelopmental disorder section, if added to
DSM-V) for classifying tic disorders are not apparent.
Leaving TTM with other ICDs is problematic insofar
as TTM differs from them in a number of ways and
requires a different assessment and treatment approach
(although its treatment also differs somewhat from
DSM-V’s final grouping scheme will have disadvan-
tages as well as advantages, and the text can be
helpful here. For example, if BDD is included in a
category of Anxiety and Obsessive–Compulsive Spec-
trum Disorders, the text could remind readers of
the overlap with mood disorders and, in some patients,
with eating disorders. Even more important, as in
DSM-IV,the text should
ences between disorders and their ‘‘nearest neighbors,’’
so disorders with some similar features are not
confused with one another and misdiagnosed. A good
description of differential diagnosis in the text will
enhance clinical care by facilitating accurate clinical
assessment and, in turn, selection of appropriate
M.D., for his comments on this article. We also thank
Dee Moniz for her assistance with manuscript pre-
We thankJamie Feusner,
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