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Obsessive–compulsive spectrum

disorders: still in search of the

concept-affirming boundariesVladan Starcevica and Aleksandar Jancab

aUniversity of Sydney, Discipline of Psychiatry; SydneyMedical School – Nepean, Sydney, New South Wales,Australia and bUniversity of Western Australia; Schoolof Psychiatry and Clinical Neurosciences, Perth,Western Australia, Australia

Correspondence to Vladan Starcevic, Nepean Hospital,Department of Psychiatry, PO Box 63, Penrith, NSW2751, AustraliaTel: +61 2 4734 2585;e-mail: starcev@wahs.nsw.gov.au,vladan.starcevic@sydney.edu.au

Current Opinion in Psychiatry 2011, 24:55–60

Purpose of review

Controversy exists about the diagnostic grouping of obsessive–compulsive spectrum

disorders (OCSDs) – conditions that are to some extent related to obsessive–

compulsive disorder (OCD). This review will re-examine OCSDs in light of the currently

available evidence.

Recent findings

It appears that OCSDs will not constitute a separate nosological group and, if this term

is accepted, OCSDs may be grouped together with the anxiety disorders. Much needs

to be done to refine the criteria for membership in the OCSDs. In contrast to previous

proposals, only a few disorders may be included in the spectrum. The most likely

candidates for membership are body dysmorphic disorder and hoarding disorder, if the

latter becomes an independent condition. Mixed, but relatively strong, support for

inclusion also exists for Tourette’s disorder and trichotillomania.

Summary

The concept of OCSDs is largely a product of an unbridled nosographical activity,

resulting from a selective focus on the similar clinical features and an oversight of the

important differences. While the links between some of the putative OCSDs seem

important, the question remains as to whether the introduction of the spectrum to a

diagnostic and classification system would significantly improve our understanding of

these links.

Keywords

classification, obsessive–compulsive disorder, obsessive–compulsive spectrum

disorders

Curr Opin Psychiatry 24:55–60� 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins0951-7367

IntroductionThe concept of the obsessive–compulsive spectrum dis-

orders (OCSDs) has received much attention ever since

its introduction by Hollander [1] in the 1990s. The main

underlying idea of the OCSDs is that these psychiatric

conditions share similarities with obsessive–compulsive

disorder (OCD) to an extent that not only justifies their

name, but also has important implications for how these

conditions are understood and treated. The concept has

been challenged and revised over a period of almost 2

decades and OCSDs are now being considered for

inclusion in the upcoming revisions of the classifications

of mental disorders. The purpose of this article is to re-

examine the concept of OCSDs in light of the currently

available evidence.

Obsessive–compulsive disorder and relatedconditions: why a spectrum?Obsessive–compulsive disorder has been a puzzling ill-

ness for centuries. Its complex and heterogeneous nature

opyright © Lippincott Williams & Wilkins. Unauth

0951-7367 � 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins

presented a problem for psychiatrists, who tried to under-

stand its core features and to classify it accordingly. A

dilemma still exists as to whether OCD is primarily an

affective disorder, a disorder of thinking characterized by

obsessions, or a behavioural disorder, characterized by

compulsions. In DSM-IV, OCD has been classified as an

anxiety disorder. This nosological solution has not been

entirely satisfactory [2�], but it has been favoured by

some clinicians and researchers [3]. In some respects,

OCD is similar to other anxiety disorders, whereas in

others, it appears to differ from them (Table 1). Likewise,

some symptom subtypes of OCD (e.g. contamination

obsessions and cleaning/washing compulsions) seem to

be more related to anxiety disorders than others (e.g.

symmetry, ordering, and arranging obsessions and com-

pulsions).

The concept of OCSDs can be traced back to this

ambiguous and ‘uneasy’ position of OCD within the

group of anxiety disorders and to its heterogeneity. Links

were then made between OCD and other conditions

in which repetitive, compulsion-like behaviours are a

orized reproduction of this article is prohibited.

DOI:10.1097/YCO.0b013e32833f3b58

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56 Personality disorders and neurosis

Table 1 Some similarities and differences between obsessive–compulsive disorder (OCD) and other anxiety disorders

Similarities between OCD andother anxiety disorders

Differences between OCDand other anxiety disorders

OCD Other anxiety disorders

Underlying phenomenology Female-to-male ratioCatastrophic misinterpretation of

objectively nondangerous stimuliand counterproductive attemptsto deal with the resulting anxiety [4]

No convincing predominanceof women [5]

More common in women [5]

Maintenance of the disorders Response to biological challengesDisorders and the corresponding fears

are maintained by the underlyingthreat-related beliefs and safety-seeking behaviours [3]

No symptom worsening tochallenges with carbon dioxide,yohimbine, caffeine, orcholecystokinin [5,6]

Frequent symptom worsening tochallenges with carbon dioxide,yohimbine, caffeine, orcholecystokinin [5,6]

Morphometry MorphometryDecreased bilateral grey matter volume

in the dorsomedial frontal/anteriorcingulate gyri [7�]

Increased bilateral grey mattervolume in the basal ganglia(lenticular/caudate nuclei) [7�]

Decreased grey matter volume in thebasal ganglia (left lenticularnucleus) [7�]

Neurocircuitry NeurocircuitryExaggerated amygdala response to

disorder-specific stimuli, insularhyperactivation [2�]

Fronto-striatal hyperactivity andhyper-responsivity, attenuatedamygdala response to disorder-independent threat stimuli [2�]

Response to psychological treatments Response to pharmacologicaltreatments

Response to similar techniques ofcognitive-behavioural therapy,using very similar principles [3]

Selective response to serotonergicagents [5,6]

Response to a variety of pharmacologicalagents [5,6]

hallmark of their clinical presentation. When it became

apparent that some of these conditions shared a number

of other features with OCD, they were quickly con-

sidered to be related to OCD and to constitute a part

of the spectrum. It might have seemed more reasonable

to form the spectrum around OCD as a ‘parent disorder’

than around some other spectrum disorder (e.g. body

dysmorphic disorder or trichotillomania) because of the

long history of OCD, its indisputable face validity, and

clinicians’ familiarity with it.

Apart from providing OCD with the role of a ‘nosological

organizer’, the concept of OCSDs was proposed to alert

clinicians about similar approaches to the assessment and

treatment of conditions believed to constitute the spec-

trum. In the early days of the spectrum concept, the focus

was very much on the similarities between OCD and

other putative spectrum disorders. The differences

were neglected and it suddenly appeared that a very

large part of the psychopathology was related to OCD.

At that point, a more critical stance towards OCSDs was

adopted, allowing a number of issues to be identified and

examined.

Obsessive–compulsive spectrum disorders:core features and scopeThe OCSDs (or obsessive compulsive-related disorders

[1,8]) have been conceptualized as lying on a continuum

from compulsivity (and overestimation of harm and risk

avoidance) to impulsivity (and underestimation of harm

opyright © Lippincott Williams & Wilkins. Unautho

and risk-taking) [8]. The controversy regarding OCSDs is

first about the basis for grouping these disorders. Thus, a

lack of ability to delay or inhibit repetitive behaviours,

such as compulsions, impulsive acts, and tics, was pro-

posed as the key common feature of the conditions

postulated to constitute OCSDs [9]. This definition of

OCSDs via repetitive behaviours has been criticized as

reducing OCD to a condition characterized mainly by

repetitive behaviour [4]. The essence of compulsive

behaviour in OCD was suggested to specifically reside

not in its repetitiveness, but in its function to alleviate

obsession-induced anxiety and distress [10]; on the con-

trary, the function of compulsion-like behaviours in

most OCSDs is to provide pleasure or gratify an urge,

an impulse, or a need.

The other key reason for conflicting views about the

OCSDs is related to the first, in that any condition with

repetitive behaviour was considered eligible for member-

ship in the spectrum. As a result, many diverse psychiatric

and neurological disorders have been suggested to form

the spectrum. These have included body dysmorphic

disorder, hypochondriasis, eating disorders (e.g. anorexia

nervosa, bulimia nervosa), impulse control disorders (e.g.

trichotillomania), compulsive skin-picking, ‘behavioural

addictions’ (e.g. pathological gambling, ‘nonparaphilic

compulsive sexual behaviour’, ‘compulsive buying’, ‘Inter-

net addiction’), neurological disorders with repetitive

behaviours (e.g. Tourette’s disorder, Sydenham’s chorea),

pervasive developmental disorders (e.g. autistic and

Asperger’s disorders), stereotypic movement disorders,

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Obsessive–compulsive spectrum disorders Starcevic and Janca 57

repetitive self-injurious behaviours, depersonalization dis-

order, some personality disorders (e.g. obsessive–compul-

sive personality disorder), substance use disorders, and

others. It seemed untenable to keep the group of OCSDs

so broad, and the underlying assumption that all these

conditions are closely related to OCD and also closely

related to each other has been challenged.

The enthusiasm for a very broad category of the OCSDs

has thus decreased in recent years. However, the key

problem largely remains unresolved – that of the criteria

for membership in the spectrum. In other words, what is

the degree of closeness or relatedness to OCD that

qualifies a particular disorder for inclusion among the

OCSDs?

Criteria for membership and narrowing thespectrumSeveral strategies have been used to ascertain whether the

disorders believed to constitute the OCSDs really belong

there. Some candidate disorders were directly compared to

OCD to establish whether and to what extent they are

related [11–14]; similar comparisons were made between

candidate disorders, for example, between body dys-

morphic disorder and eating disorders [15] and between

trichotillomania and pathological skin picking [16].

Another approach was to compare co-occurrence rates of

putative spectrum disorders in OCD patients and other

groups [17,18]. One study has used the ‘models of comor-

bidity’ approach in an attempt to characterize the relation-

ship between OCD and eating disorders [19�]. A survey of

experts on OCD and related disorders from around the

world was conducted to seek professional opinion on the

issue [20]. Other articles were based on literature reviews

[8,21��,22,23��,24��,25,26,27��,28�].

One such review of the available evidence produced the

criteria for membership in the OCSDs [8]. According to

this proposal, a candidate disorder must be ‘characterized

by obsessions and/or compulsions that cause distress and/

or interference’. In addition, at least three of the follow-

ing five criteria must be present for a disorder to belong to

the OCSDs, and there has to be either a prominent family

history of OCD or OCD-related disorders, or involve-

ment of the fronto-striatal brain circuitry with caudate

hyperactivity:

(1) C

op

linical similarities with OCD (in terms of the pre-

sence of obsessions or obsession-like phenomena

and/or compulsions or compulsion-like behaviours

and course);

(2) P

attern of co-occurrence with other disorders similar

to that seen in OCD;

(3) P

rominent family history of OCD or OCD-related

disorders;

yright © Lippincott Williams & Wilkins. Unauth

(4) F

or

ronto-striatal brain circuitry dysfunction (i.e., cau-

date hyperactivity);

(5) T

reatment response similar to that seen in OCD.

In a recently published, comprehensive review [21��], the

following criteria were considered when discussing

potential inclusion of various conditions among the

OCSDs:

(1) S

iz

ymptom similarity

(2) C

o-occurrence

(3) C

ourse of illness

(4) F

amiliality

(5) G

enetic and environmental risk factors

(6) N

eural substrates

(7) B

iomarkers

(8) T

emperamental antecedents

(9) C

ognitive and emotional processing

(10) T

reatment response

Similar criteria were examined by other authors when

they considered candidates for the OCSDs, but the

comprehensiveness of these criteria varied from one

study to another [22,24��,25,26,27��,28�].

The results of all these endeavours are presented in

Table 2. They show that the greatest agreement and

support for inclusion in the spectrum exists for body

dysmorphic disorder. The evidence is also strong for

hoarding disorder as an OCSD if it becomes an indepen-

dent nosological entity, as suggested by recent expert

reviews [23��,29]. Support for including other disorders is

mixed, although it is stronger for some (Tourette’s dis-

order and trichotillomania) than for the others (hypochon-

driasis, obsessive–compulsive personality disorder, and

eating disorders). There is very little or no support for

inclusion of impulse control disorders and behavioural

addictions, and these conditions are not likely to become

a part of the OCSDs.

It is an irony that inclusion of some disorders in the

OCSDs may depend on ‘external’ factors that have

nothing to do with how close these disorders are to

OCD. For example, tic disorders are considered to more

appropriately belong to the group of disorders usually first

diagnosed in infancy, childhood, or adolescence or to

‘neurodevelopmental disorders’ [21��,25], whereas tri-

chotillomania might be better classified as one of the

‘body-focused repetitive behavioural disorders’ [21��,26]

or ‘habit or stereotypic disorders’ [24��]. Likewise, body

dysmorphic disorder might better fit a not-yet-created

group of body image disorders and hypochondriasis might

be more adequately conceptualized as an anxiety or

somatoform disorder. Classifying tic disorders and tricho-

tillomania among the OCSDs is suggested as a second-

line option [21��], that is, if the groups to which they

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58 Personality disorders and neurosis

Table 2 Levels of support for inclusion of candidate disorders into the obsessive–compulsive spectrum disorders (OCSDs)

Candidate disorders Support for inclusion into the OCSDs

Body dysmorphic disorder High [8,21��,22]; somewhat high [20]Hoarding disorder High [21��,23��]; somewhat high [29]Tourette’s disorder and chronic tic disorders High [8,24��] (for Tourette’s disorder); somewhat high [21��]; moderate [20];

lacking [25]Trichotillomania Somewhat high [20,21��,24��,26]; moderate [8]Hypochondriasis High [22]; moderate [20]; mixed, relatively low [21��]Obsessive–compulsive personality disorder Moderate [8]; mixed, relatively low [20,21��]Eating disorders Somewhat high [19�]; moderate [8]; low [20]Skin picking disorder (psychogenic excoriation) Moderate [26]; low [8,14]Stereotypic movement disorder Moderate [26]Nail biting Low [8]Impulse control disorders (as a group) Low [20]Pathological gambling Low [20]; lacking [27��,28�]Intermittent explosive disorder Lacking [27��]Compulsive buying Lacking [28�]

might belong ‘more naturally’ are not formed in the next

revisions of the diagnostic classifications due to a need to

keep the overall number of diagnostic groups relatively

small. This implies that some, if not many, of the putative

members of the OCSDs may become members by

default, not because of their significant relatedness

to OCD.

The question of membership in the OCSDs has been

approached from a statistical perspective in an important

article on methodological issues [30�]. This article argues

that a single statistical approach is not sufficient to

determine whether any particular condition belongs or

does not belong to the OCSDs and whether such a

condition may be better conceptualized as a subtype of

OCD. A good example of the potential confusion in

distinguishing between OCD subtypes and OCSDs is

a ‘tic-related OCD’. Whereas it has been conceptualized

as a subtype of OCD [31], it can also be regarded as OCD

co-occurring with one of the putative spectrum disorders

– chronic tic disorder. Moreover, it is unclear whether

spectrum conditions are independent disorders that may

co-occur with OCD or whether they are only different

manifestations of a single psychopathological entity [32].

In the latter case, OCSDs would share a common cause,

as has been suggested for the relationship between OCD

and eating disorders [19�].

Yet another issue deserves further consideration and

study. A suggestion to focus on behaviours and dimen-

sions when examining the links between OCD and

OCSDs [33] has been supported by the findings that

some putative spectrum conditions may be more related

to certain dimensions or subtypes of OCD than to OCD

as a unitary, heterogeneous entity. For example, eating

disorders were only associated with contamination obses-

sions and cleaning/washing compulsions, but not with

other dimensions or subtypes of OCD [34]; conversely,

tic disorders were found less likely to co-occur with

contamination obsessions and cleaning/washing compul-

opyright © Lippincott Williams & Wilkins. Unautho

sions, and they co-occurred more frequently with sym-

metry, ordering, counting, and arranging obsessions and

compulsions, hoarding, and sexual, aggressive, religious,

and somatic obsessions and related compulsions [35].

One of the key findings of the literature reviews and

closer scientific scrutiny is a suggestion that, except for

trichotillomania, impulse control disorders should be

kept separate from the putative OCSDs [21��,27��,

28�,36��]. This is important in view of the purported

compulsivity–impulsivity continuum as one of the hall-

marks of the OCSDs. Despite some similarities between

compulsive and impulsive behaviours, they have differ-

ent functions and different neurobiological and other

correlates, and every effort should be made to distinguish

them. Accordingly, the terms ‘compulsive’ and ‘impul-

sive’ should not be used interchangeably, whereas the

term ‘compulsive–impulsive’ appears confusing and may

be no more than a sign of conceptual sloppiness.

A growing evidence that OCD has much in common with

other anxiety disorders despite its specific features

[2�,3,7�] has led to a realization that it would be inap-

propriate to remove it from the group of anxiety disorders

in DSM-V. This has dampened down the enthusiasm for

OCSDs as a separate diagnostic group. Another contri-

buting factor has been a shrinkage in the scope of the

OCSDs. As a result, the current proposal is to classify

OCSDs along with the anxiety disorders to form a larger

group tentatively called ‘anxiety and OCSDs’ [21��]. Not

everyone agrees with this, and there are still views that

OCSDs should both be a separate nosological group and

encompass a large variety of conditions [37].

Is there a need for obsessive–compulsivespectrum disorders?It has been suggested that the concept of OCSDs will be

clinically useful in that it will encourage clinicians to look

more closely for the presence of other disorders that

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Obsessive–compulsive spectrum disorders Starcevic and Janca 59

otherwise might be overlooked [21��,38]. This does not

appear to be a very strong argument for introducing

OCSDs into a diagnostic and classification system. Just

because two disorders may be placed in two different

diagnostic groups does not mean that clinicians would be

less likely to know that these disorders may co-occur and

that clinicians would be less likely to pay attention to the

disorder that currently appears less prominent.

The other potential benefit of the concept of OCSDs was

suggested to relate to its implications for treatment [38].

Thus, in comparison to OCD patients who do not have a

co-occurring Tourette’s disorder, those with OCD and

Tourette’s disorder may be more likely to respond better

to an augmentation of the serotonergic antidepressant

with a dopamine blocker [39]. This, however, does not

imply that OCD and Tourette’s disorders should be

classified together. Furthermore, whereas some spectrum

disorders respond to the same pharmacological and

psychological treatments used to treat OCD [40], many

do not [21��].

The question remains as to what there is to gain from

introducing OCSDs to the diagnostic and classification

system. Likewise, what would there be to lose if the

spectrum were not introduced? Unfortunately, research

efforts have not provided a convincing body of evidence

that would make a strong case for the formal inclusion of

the spectrum. Stated perhaps less definitively, the con-

cept of the spectrum ‘seems fluid in 2010’ and needs to be

reappraised [32].

ConclusionThe controversy about the OCSDs has brought to

the surface the fundamental issue of the basis for

grouping psychiatric conditions together. The concept

of OCSDs was proposed as a result of the excessive

focus on repetitive behaviours, without taking into

account other, no less important and potentially dis-

tinguishing, characteristics of the relevant disorders.

This has led to numerous theoretical and practical

problems and unconvincing attempts to justify the

concept. As a result, it does not appear that with

OCSDs we would be closer to resolving the underlying

conundrums in the complex links that exist between

OCD and other disorders.

References and recommended readingPapers of particular interest, published within the annual period of review, havebeen highlighted as:� of special interest�� of outstanding interest

Additional references related to this topic can also be found in the CurrentWorld Literature section in this issue (p. 85).

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2

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21

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