A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The person finds it difficult to control the worry.

C. The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: Only one item is required in children.

1. restlessness or feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or mind going blank
4. irritability
5. muscle tension
6. sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

D. The focus of the anxiety and worry is not confined to features of an Axis I disorder, e.g., the anxiety or worry is not about having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder.

E. The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

F. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hyperthyroidism) and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

Diagnostic Features

The essential feature of Generalized Anxiety Disorder is excessive anxiety and worry (apprehensive expectation), occurring more days than not for a period of at least 6 months, about a number of events or activities (Criterion A). The individual finds it difficult to control the worry (Criterion B). The anxiety and worry are accompanied by at least three additional symptoms from a list that includes restlessness, being easily fatigued, difficulty concentrating, irritability, muscle tension, and disturbed sleep (only one additional symptom is required in children) (Criterion C). The focus of the anxiety and worry is not confined to features of another Axis I disorder such as having a Panic Attack (as in Panic Disorder), being embarrassed in public (as in Social Phobia), being contaminated (as in Obsessive-Compulsive Disorder), being away from home or close relatives (as in Separation Anxiety Disorder), gaining weight (as in Anorexia Nervosa), having multiple physical complaints (as in Somatization Disorder), or having a serious illness (as in Hypochondriasis), and the anxiety and worry do not occur exclusively during Posttraumatic Stress Disorder (Criterion D). Although individuals with Generalized Anxiety Disorder may not always identify the worries as “excessive,” they report subjective distress due to constant worry, have difficulty controlling the worry, or experience related impairment in social, occupational, or other important areas of functioning (Criterion E). The disturbance is not due to the direct physiological effects of a substance (i.e., a drug of abuse, a medication, or toxin exposure) or a general medical condition and does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder (Criterion F).

The intensity, duration, or frequency of the anxiety and worry is far out of proportion to the actual likelihood or impact of the feared event. The person finds it difficult to keep worrisome thoughts from interfering with attention to tasks at hand and has difficulty stopping the worry. Adults with Generalized Anxiety Disorder often worry about everyday, routine life circumstances such as possible job responsibilities, finances, the health of family members, misfortune to their children, or minor matters (such as household chores, car repairs, or being late for appointments). Children with Generalized Anxiety Disorder tend to worry excessively about their competence or the quality of their performance. During the course of the disorder, the focus of worry may shift from one concern to another.

Associated Features and Disorders

Associated with muscle tension, there may be trembling, twitching, feeling shaky, and muscle aches or soreness. Many individuals with Generalized Anxiety Disorder also experience somatic symptoms (e.g., sweating, nausea, or diarrhea) and an exaggerated startle response. Symptoms of autonomic hyperarousal (e.g., accelerated heart rate, shortness of breath, dizziness) are less prominent in Generalized Anxiety Disorder than in other Anxiety Disorders, such as Panic Disorder and Posttraumatic Stress Disorder. Depressive symptoms are also common.

Generalized Anxiety Disorder very frequently co-occurs with Mood Disorders (e.g., Major Depressive Disorder or Dysthymic Disorder), with other Anxiety Disorders (e.g., Panic Disorder, Social Phobia, Specific Phobia), and with Substance-Related Disorders (e.g., Alcohol or Sedative, Hypnotic, or Anxiolytic Dependence or Abuse). Other conditions that may be associated with stress (e.g., irritable bowel syndrome, headaches) frequently accompany Generalized Anxiety Disorder.

Specific Culture, Age, and Gender Features

There is considerable cultural variation in the expression of anxiety (e.g., in some cultures, anxiety is expressed predominantly through somatic symptoms, in others through cognitive symptoms). It is important to consider the cultural context when evaluating whether worries about certain situations are excessive.

In children and adolescents with Generalized Anxiety Disorder, the anxieties and worries often concern the quality of their performance or competence at school or in sporting events, even when their performance is not being evaluated by others. There may be excessive concerns about punctuality. They may also worry about catastrophic events such as earthquakes or nuclear war. Children with the disorder may be overly conforming, perfectionist, and unsure of themselves and tend to redo tasks because of excessive dissatisfaction with less-than-perfect performance. They are typically overzealous in seeking approval and require excessive reassurance about their performance and their other worries.

Generalized Anxiety Disorder may be overdiagnosed in children. In considering this diagnosis in children, a thorough evaluation for the presence of other childhood Anxiety Disorders should be done to determine whether the worries may be better explained by one of these disorders. Separation Anxiety Disorder, Social Phobia, and Obsessive-Compulsive Disorder are often accompanied by worries that may mimic those described in Generalized Anxiety Disorder. For example, a child with Social Phobia may be concerned about school performance because of fear of humiliation. Worries about illness may also be better explained by Separation Anxiety Disorder or Obsessive-Compulsive Disorder.

In clinical settings, the disorder is diagnosed somewhat more frequently in women than in men (about 55%–60% of those presenting with the disorder are female). In epidemiological studies, the sex ratio is approximately two-thirds female.

Prevalence

In a community sample, the 1-year prevalence rate for Generalized Anxiety Disorder was approximately 3%, and the lifetime prevalence rate was 5%. In anxiety disorder clinics, up to a quarter of the individuals have Generalized Anxiety Disorder as a presenting or comorbid diagnosis.

Course

Many individuals with Generalized Anxiety Disorder report that they have felt anxious and nervous all their lives. Although over half of those presenting for treatment report onset in childhood or adolescence, onset occurring after age 20 years is not uncommon. The course is chronic but fluctuating and often worsens during times of stress.

Familial Pattern

Anxiety as a trait has a familial association. Although early studies produced inconsistent findings regarding familial patterns for Generalized Anxiety Disorder, more recent twin studies suggest a genetic contribution to the development of this disorder. Furthermore, genetic factors influencing risk of Generalized Anxiety Disorder may be closely related to those for Major Depressive Disorder.

A. Either obsessions or compulsions:
Obsessions as defined by (1), (2), (3), and (4):

1. recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress

2. the thoughts, impulses, or images are not simply excessive worries about real-life problems

3. the person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action

4. the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)

Compulsions as defined by (1) and (2):

5. repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly

6. the behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive

B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. Note: This does not apply to children.

C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.

D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorder; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).

E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

Specify if: With Poor Insight: if, for most of the time during the current episode, the person does not recognize that the obsessions and compulsions are excessive or unreasonable

Diagnostic Features

The essential features of Obsessive-Compulsive Disorder are recurrent obsessions or compulsions (Criterion A) that are severe enough to be time consuming (i.e., they take more than 1 hour a day) or cause marked distress or significant impairment (Criterion C). At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable (Criterion B). If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (Criterion D). The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (Criterion E).

Obsessions are persistent ideas, thoughts, impulses, or images that are experienced as intrusive and inappropriate and that cause marked anxiety or distress. The intrusive and inappropriate quality of the obsessions has been referred to as “ego-dystonic.” This refers to the individual’s sense that the content of the obsession is alien, not within his or her own control, and not the kind of thought that he or she would expect to have. However, the individual is able to recognize that the obsessions are the product of his or her own mind and are not imposed from without (as in thought insertion).

The most common obsessions are repeated thoughts about contamination (e.g., becoming contaminated by shaking hands), repeated doubts (e.g., wondering whether one has performed some act such as having hurt someone in a traffic accident or having left a door unlocked), a need to have things in a particular order (e.g., intense distress when objects are disordered or asymmetrical), aggressive or horrific impulses (e.g., to hurt one’s child or to shout an obscenity in church), and sexual imagery (e.g., a recurrent pornographic image). The thoughts, impulses, or images are not simply excessive worries about real-life problems (e.g., concerns about current ongoing difficulties in life, such as financial, work, or school problems) and are unlikely to be related to a real-life problem.

The individual with obsessions usually attempts to ignore or suppress such thoughts or impulses or to neutralize them with some other thought or action (i.e., a compulsion). For example, an individual plagued by doubts about having turned off the stove attempts to neutralize them by repeatedly checking to ensure that it is off.

Compulsions are repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) the goal of which is to prevent or reduce anxiety or distress, not to provide pleasure or gratification. In most cases, the person feels driven to perform the compulsion to reduce the distress that accompanies an obsession or to prevent some dreaded event or situation. For example, individuals with obsessions about being contaminated may reduce their mental distress by washing their hands until their skin is raw; individuals distressed by obsessions about having left a door unlocked may be driven to check the lock every few minutes; individuals distressed by unwanted blasphemous thoughts may find relief in counting to 10 backward and forward 100 times for each thought. In some cases, individuals perform rigid or stereotyped acts according to idiosyncratically elaborated rules without being able to indicate why they are doing them.

By definition, compulsions are either clearly excessive or are not connected in a realistic way with what they are designed to neutralize or prevent. The most common compulsions involve washing and cleaning, counting, checking, requesting or demanding assurances, repeating actions, and ordering. By definition, adults with Obsessive-Compulsive Disorder have at some point recognized that the obsessions or compulsions are excessive or unreasonable. This requirement does not apply to children because they may lack sufficient cognitive awareness to make this judgment. However, even in adults there is a broad range of insight into the reasonableness of the obsessions or compulsions. Some individuals are uncertain about the reasonableness of their obsessions or compulsions, and any given individual’s insight may vary across times and situations. For example, the person may recognize a contamination compulsion as unreasonable when discussing it in a “safe situation” (e.g., in the therapist’s office), but not when forced to handle money. At those times when the individual recognizes that the obsessions and compulsions are unreasonable, he or she may desire or attempt to resist them. When attempting to resist a compulsion, the individual may have a sense of mounting anxiety or tension that is often relieved by yielding to the compulsion. In the course of the disorder, after repeated failure to resist the obsessions or compulsions, the individual may give in to them, no longer experience a desire to resist them, and may incorporate the compulsions into his or her daily routines.

The obsessions or compulsions must cause marked distress, be time consuming (take more than 1 hour per day), or significantly interfere with the individual’s normal routine, occupational functioning, or usual social activities or relationships with others. Obsessions or compulsions can displace useful and satisfying behavior and can be highly disruptive to overall functioning. Because obsessive intrusions can be distracting, they frequently result in inefficient performance of cognitive tasks that require concentration, such as reading or computation. In addition, many individuals avoid objects or situations that provoke obsessions or compulsions. Such avoidance can become extensive and can severely restrict general functioning.

Specifier
With Poor Insight. This specifier can be applied when, for most of the time during the current episode, the individual does not recognize that the obsessions or compulsions are excessive or unreasonable.

Associated Features and Disorders

Associated descriptive features and mental disorders.

Frequently there is avoidance of situations that involve the content of the obsessions, such as dirt or contamination. For example, a person with obsessions about dirt may avoid public restrooms or shaking hands with strangers. Hypochondriacal concerns are common, with repeated visits to physicians to seek reassurance. Guilt, a pathological sense of responsibility, and sleep disturbances may be present. There may be excessive use of alcohol or of sedative, hypnotic, or anxiolytic medications. Performing compulsions may become a major life activity, leading to serious marital, occupational, or social disability. Pervasive avoidance may leave an individual housebound.

In adults, Obsessive-Compulsive Disorder may be associated with Major Depressive Disorder, some other Anxiety Disorders (i.e., Specific Phobia, Social Phobia, Panic Disorder, Generalized Anxiety Disorder), Eating Disorders, and some Personality Disorders (i.e., Obsessive-Compulsive Personality Disorder, Avoidant Personality Disorder, Dependent Personality Disorder). In children, it may also be associated with Learning Disorders and Disruptive Behavior Disorders. There is a high incidence of Obsessive-Compulsive Disorder in children and adults with Tourette’s Disorder, with estimates ranging from approximately 35% to 50%. The incidence of Tourette’s Disorder in Obsessive-Compulsive Disorder is lower, with estimates ranging between 5% and 7%. Between 20% and 30% of individuals with Obsessive-Compulsive Disorder have reported current or past tics.

Associated laboratory findings.

No laboratory findings have been identified that are diagnostic of Obsessive-Compulsive Disorder. However, a variety of laboratory findings have been noted to be abnormal in groups of individuals with Obsessive-Compulsive Disorder relative to control subjects. There is some evidence that some serotonin agonists given acutely cause increased symptoms in some individuals with the disorder. Individuals with the disorder may exhibit increased autonomic activity when confronted in the laboratory with circumstances that trigger an obsession. Physiological reactivity decreases after the performance of compulsions.

Associated physical examination findings and general medical conditions.

Dermatological problems caused by excessive washing with water or caustic cleaning agents may be observed.

Specific Culture, Age, and Gender Features

Culturally prescribed ritual behavior is not in itself indicative of Obsessive-Compulsive Disorder unless it exceeds cultural norms, occurs at times and places judged inappropriate by others of the same culture, and interferes with social role functioning. Although cultural factors may not lead to Obsessive-Compulsive Disorder per se, religious and cultural beliefs may influence the themes of obsessions and compulsions (e.g., Orthodox Jews with religious compulsions may have symptoms focusing on dietary practices). Important life transitions and mourning may lead to an intensification of ritual behavior that may appear to be an obsession to a clinician who is not familiar with the cultural context.

Presentations of Obsessive-Compulsive Disorder in children are generally similar to those in adulthood. Washing, checking, and ordering rituals are particularly common in children. Children generally do not request help, and the symptoms may not be ego-dystonic. More often the problem is identified by parents, who bring the child in for treatment. Gradual declines in schoolwork secondary to impaired ability to concentrate have been reported. Like adults, children are more prone to engage in rituals at home than in front of peers, teachers, or strangers. For a small subset of children, Obsessive-Compulsive Disorder may be associated with Group A beta-hemolytic streptococcal infection (e.g., scarlet fever and “strep throat”). This form of Obsessive-Compulsive Disorder is characterized by prepubertal onset, associated neurological abnormalities (e.g., choreiform movements and motoric hyperactivity) and an abrupt onset of symptoms or an episodic course in which exacerbations are temporally related to the streptococcal infections. Older adults tend to show more obsessions concerning morality and washing rituals compared with other types of symptoms.

In adults, this disorder is equally common in males and females. However, in childhood-onset Obsessive-Compulsive Disorder, the disorder is more common in boys than in girls.

Prevalence

Community studies have estimated a lifetime prevalence of 2.5% and a 1-year prevalence of 0.5%–2.1% in adults. However, methodological problems with the assessment tool used raise the possibility that the true prevalence rates are much lower. Community studies of children and adolescents have estimated a lifetime prevalence of 1%–2.3% and a 1-year prevalence of 0.7%. Research indicates that prevalence rates of Obsessive-Compulsive Disorder are similar in many different cultures around the world.

Course

Although Obsessive-Compulsive Disorder usually begins in adolescence or early adulthood, it may begin in childhood. Modal age at onset is earlier in males than in females: between ages 6 and 15 years for males and between ages 20 and 29 years for females. For the most part, onset is gradual, but acute onset has been noted in some cases. The majority of individuals have a chronic waxing and waning course, with exacerbation of symptoms that may be related to stress. About 15% show progressive deterioration in occupational and social functioning. About 5% have an episodic course with minimal or no symptoms between episodes.

Familial Pattern

The concordance rate for Obsessive-Compulsive Disorder is higher for monozygotic twins than it is for dizygotic twins. The rate of Obsessive-Compulsive Disorder in first-degree biological relatives of individuals with Obsessive-Compulsive Disorder and in first-degree biological relatives of individuals with Tourette’s Disorder is higher than that in the general population.

A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

B. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

C. The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

Diagnostic Features

The essential feature of Body Dysmorphic Disorder (historically known as dysmorphophobia) is a preoccupation with a defect in appearance (Criterion A). The defect is either imagined, or, if a slight physical anomaly is present, the individual’s concern is markedly excessive (Criterion A). The preoccupation must cause significant distress or impairment in social, occupational, or other important areas of functioning (Criterion B). The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa) (Criterion C).

Complaints commonly involve imagined or slight flaws of the face or head such as hair thinning, acne, wrinkles, scars, vascular markings, paleness or redness of the complexion, swelling, facial asymmetry or disproportion, or excessive facial hair. Other common preoccupations include the shape, size, or some other aspect of the nose, eyes, eyelids, eyebrows, ears, mouth, lips, teeth, jaw, chin, cheeks, or head. However, any other body part may be the focus of concern (e.g., the genitals, breasts, buttocks, abdomen, arms, hands, feet, legs, hips, shoulders, spine, larger body regions, overall body size, or body build and muscularity). The preoccupation may simultaneously focus on several body parts. Although the complaint is often specific (e.g., a “crooked” lip or a “bumpy” nose), it is sometimes vague (e.g., a “falling” face or “inadequately firm” eyes). Because of embarrassment over their concerns or for other reasons, some individuals with Body Dysmorphic Disorder avoid describing their “defects” in detail and may instead refer only to their general ugliness.

Most individuals with this disorder experience marked distress over their supposed deformity, often describing their preoccupations as “intensely painful,””tormenting,” or “devastating.” Most find their preoccupations difficult to control, and they may make little or no attempt to resist them. As a result, they often spend hours a day thinking about their “defect,” to the point where these thoughts may dominate their lives. Significant impairment in many areas of functioning generally occurs. Feelings of self-consciousness about their “defect” may lead to avoidance of work, school, or public situations.

Associated Features and Disorders

Frequent checking of the defect, either directly or in a reflecting surface (e.g., mirrors, store windows, car bumpers, watch faces) can consume many hours a day. Some individuals use special lighting or magnifying glasses to scrutinize their “defect.” There may be excessive grooming behavior (e.g., excessive hair combing, hair removal, ritualized makeup application, or skin picking). Although the usual intent of checking and grooming is to diminish anxiety, be reassured about one’s appearance, or temporarily improve one’s appearance, these behaviors often intensify the preoccupation and associated anxiety. Consequently, some individuals avoid mirrors, sometimes covering them or removing them from their environment. Others alternate between periods of excessive mirror checking and avoidance. Other behaviors aimed at improving the “defect” include excessive exercise (e.g., weight lifting), dieting, and frequent changing of clothes. There may be frequent requests for reassurance about the “defect,” but such reassurance leads to only temporary, if any, relief. Individuals with the disorder may also frequently compare their “ugly” body part with that of others. They may try to camouflage the “defect” (e.g., growing a beard to cover imagined facial scars, wearing a hat to hide imagined hair loss, stuffing their shorts to enhance a “small” penis). Some individuals may be excessively preoccupied with fears that the “ugly” body part will malfunction or is extremely fragile and in constant danger of being damaged. Insight about the perceived defect is often poor, and some individuals are delusional; that is, they are completely convinced that their view of the defect is accurate and undistorted, and they cannot be convinced otherwise. Ideas and delusions of reference related to the imagined defect are also common; that is, individuals with this disorder often think that others may be (or are) taking special notice of their supposed flaw, perhaps talking about it or mocking it.

Avoidance of usual activities may lead to extreme social isolation. In some cases, individuals may leave their homes only at night, when they cannot be seen, or become housebound, sometimes for years. Individuals with this disorder may drop out of school, avoid job interviews, work at jobs below their capacity, or not work at all. They may have few friends, avoid dating and other social interactions, have marital difficulties, or get divorced because of their symptoms. The distress and dysfunction associated with this disorder, although variable, can lead to repeated hospitalization and to suicidal ideation, suicide attempts, and completed suicide. Individuals with Body Dysmorphic Disorder often pursue and receive general medical (often dermatological), dental, or surgical treatments to rectify their imagined or slight defects. Occasionally, individuals may resort to extreme measures (e.g., self-surgery) to correct their perceived flaws.

Such treatment may cause the disorder to worsen, leading to intensified or new preoccupations, which may in turn lead to further unsuccessful procedures, so that individuals may eventually possess “synthetic” noses, ears, breasts, hips, or other body parts, which they are still dissatisfied with. Body Dysmorphic Disorder may be associated with Major Depressive Disorder, Delusional Disorder, Social Phobia, and Obsessive-Compulsive Disorder.

Specific Culture and Gender Features

Cultural concerns about physical appearance and the importance of proper physical self-presentation may influence or amplify preoccupations about an imagined physical deformity. Body Dysmorphic Disorder may be equally common in women and in men in outpatient mental health settings.

Prevalence

The prevalence of Body Dysmorphic Disorder in the community is unknown. In clinical mental health settings, reported rates of Body Dysmorphic Disorder in individuals with Anxiety or Depressive Disorders range from under 5% to approximately 40%. In cosmetic surgery and dermatology settings, reported rates of Body Dysmorphic Disorder range from 6% to 15%.

Course

Body Dysmorphic Disorder usually begins during adolescence but can begin during childhood. However, the disorder may not be diagnosed for many years, often because individuals with the disorder are reluctant to reveal their symptoms. The onset may be either gradual or abrupt. The disorder often has a fairly continuous course, with few symptom-free intervals, although the intensity of symptoms may wax and wane over time. The part of the body on which concern is focused may remain the same or may change.

A pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as indicated by four (or more) of the following:

1. is preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost

2. shows perfectionism that interferes with task completion (e.g., is unable to complete a project because his or her own overly strict standards are not met)

3. is excessively devoted to work and productivity to the exclusion of leisure activities and friendships (not accounted for by obvious economic necessity)

4. is overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values (not accounted for by cultural or religious identification)

5. is unable to discard worn-out or worthless objects even when they have no sentimental value

6. is reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things

7. adopts a miserly spending style toward both self and others; money is viewed as something to be hoarded for future catastrophes

8. shows rigidity and stubbornness

Diagnostic Features

The essential feature of Obsessive-Compulsive Personality Disorder is a preoccupation with orderliness, perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency. This pattern begins by early adulthood and is present in a variety of contexts.

Individuals with Obsessive-Compulsive Personality Disorder attempt to maintain a sense of control through painstaking attention to rules, trivial details, procedures, lists, schedules, or form to the extent that the major point of the activity is lost (Criterion 1). They are excessively careful and prone to repetition, paying extraordinary attention to detail and repeatedly checking for possible mistakes. They are oblivious to the fact that other people tend to become very annoyed at the delays and inconveniences that result from this behavior. For example, when such individuals misplace a list of things to be done, they will spend an inordinate amount of time looking for the list rather than spending a few moments re-creating it from memory and proceeding to accomplish the tasks. Time is poorly allocated, the most important tasks being left to the last moment. The perfectionism and self-imposed high standards of performance cause significant dysfunction and distress in these individuals. They may become so involved in making every detail of a project absolutely perfect that the project is never finished (Criterion 2). For example, the completion of a written report is delayed by numerous time-consuming rewrites that all come up short of “perfection.” Deadlines are missed, and aspects of the individual’s life that are not the current focus of activity may fall into disarray.

Individuals with Obsessive-Compulsive Personality Disorder display excessive devotion to work and productivity to the exclusion of leisure activities and friendships (Criterion 3). This behavior is not accounted for by economic necessity. They often feel that they do not have time to take an evening or a weekend day off to go on an outing or to just relax. They may keep postponing a pleasurable activity, such as a vacation, so that it may never occur. When they do take time for leisure activities or vacations, they are very uncomfortable unless they have taken along something to work on so they do not “waste time.” There may be a great concentration on household chores (e.g., repeated excessive cleaning so that “one could eat off the floor”). If they spend time with friends, it is likely to be in some kind of formally organized activity (e.g., sports). Hobbies or recreational activities are approached as serious tasks requiring careful organization and hard work to master. The emphasis is on perfect performance. These individuals turn play into a structured task (e.g., correcting an infant for not putting rings on the post in the right order; telling a toddler to ride his or her tricycle in a straight line; turning a baseball game into a harsh “lesson”).

Individuals with Obsessive-Compulsive Personality Disorder may be excessively conscientious, scrupulous, and inflexible about matters of morality, ethics, or values (Criterion 4). They may force themselves and others to follow rigid moral principles and very strict standards of performance. They may also be mercilessly self-critical about their own mistakes. Individuals with this disorder are rigidly deferential to authority and rules and insist on quite literal compliance, with no rule bending for extenuating circumstances. For example, the individual will not lend a quarter to a friend who needs one to make a telephone call, because “neither a borrower or lender be” or because it would be “bad” for the person’s character. These qualities should not be accounted for by the individual’s cultural or religious identification.

Individuals with this disorder may be unable to discard worn-out or worthless objects, even when they have no sentimental value (Criterion 5). Often these individuals will admit to being “pack rats.” They regard discarding objects as wasteful because “you never know when you might need something” and will become upset if someone tries to get rid of the things they have saved. Their spouses or roommates may complain about the amount of space taken up by old parts, magazines, broken appliances, and so on.

Individuals with Obsessive-Compulsive Personality Disorder are reluctant to delegate tasks or to work with others (Criterion 6). They stubbornly and unreasonably insist that everything be done their way and that people conform to their way of doing things. They often give very detailed instructions about how things should be done (e.g., there is one and only one way to mow the lawn, wash the dishes, build a doghouse) and are surprised and irritated if others suggest creative alternatives. At other times they may reject offers of help even when behind schedule because they believe no one else can do it right.

Individuals with this disorder may be miserly and stingy and maintain a standard of living far below what they can afford, believing that spending must be tightly controlled to provide for future catastrophes (Criterion 7). Individuals with Obsessive-Compulsive Personality Disorder are characterized by rigidity and stubbornness (Criterion 8). They are so concerned about having things done the one “correct” way that they have trouble going along with anyone else’s ideas. These individuals plan ahead in meticulous detail and are unwilling to consider changes. Totally wrapped up in their own perspective, they have difficulty acknowledging the viewpoints of others. Friends and colleagues may become frustrated by this constant rigidity. Even when individuals with Obsessive-Compulsive Personality Disorder recognize that it may be in their interest to compromise, they may stubbornly refuse to do so, arguing that it is “the principle of the thing.”

Associated Features and Disorders

When rules and established procedures do not dictate the correct answer, decision making may become a time-consuming, often painful process. Individuals with Obsessive-Compulsive Personality Disorder may have such difficulty deciding which tasks take priority or what is the best way of doing some particular task that they may never get started on anything. They are prone to become upset or angry in situations in which they are not able to maintain control of their physical or interpersonal environment, although the anger is typically not expressed directly. For example, a person may be angry when service in a restaurant is poor, but instead of complaining to the management, the individual ruminates about how much to leave as a tip. On other occasions, anger may be expressed with righteous indignation over a seemingly minor matter. People with this disorder may be especially attentive to their relative status in dominance-submission relationships and may display excessive deference to an authority they respect and excessive resistance to authority that they do not respect.

Individuals with this disorder usually express affection in a highly controlled or stilted fashion and may be very uncomfortable in the presence of others who are emotionally expressive. Their everyday relationships have a formal and serious quality, and they may be stiff in situations in which others would smile and be happy (e.g., greeting a lover at the airport). They carefully hold themselves back until they are sure that whatever they say will be perfect. They may be preoccupied with logic and intellect, and intolerant of affective behavior in others. They often have difficulty expressing tender feelings, rarely paying compliments. Individuals with this disorder may experience occupational difficulties and distress, particularly when confronted with new situations that demand flexibility and compromise.

Individuals with Anxiety Disorders, including Generalized Anxiety Disorder, Obsessive-Compulsive Disorder, Social Phobia, and Specific Phobias, have an increased likelihood of having a personality disturbance that meets criteria for Obsessive-Compulsive Personality Disorder. Even so, it appears that the majority of individuals with Obsessive-Compulsive Disorder do not have a pattern of behavior that meets criteria for this Personality Disorder. Many of the features of Obsessive-Compulsive Personality Disorder overlap with “type A” personality characteristics (e.g., preoccupation with work, competitiveness, and time urgency), and these features may be present in people at risk for myocardial infarction. There may be an association between Obsessive-Compulsive Personality Disorder and Mood and Eating Disorders.

Specific Culture and Gender Features

In assessing an individual for Obsessive-Compulsive Personality Disorder, the clinician should not include those behaviors that reflect habits, customs, or interpersonal styles that are culturally sanctioned by the individual’s reference group. Certain cultures place substantial emphasis on work and productivity; the resulting behaviors in members of those societies need not be considered indications of Obsessive-Compulsive Personality Disorder. In systematic studies, the disorder appears to be diagnosed about twice as often among males.

Prevalence

Studies that have used systematic assessment suggest prevalence estimates of Obsessive-Compulsive Personality Disorder of about 1% in community samples and about 3%–10% in individuals presenting to mental health clinics.

A. Both multiple motor and one or more vocal tics have been present at some time during the illness, although not necessarily concurrently. (A tic is a sudden, rapid, recurrent, nonrhythmic, stereotyped motor movement or vocalization.)

B. The tics occur many times a day (usually in bouts) nearly every day or intermittently throughout a period of more than 1 year, and during this period there was never a tic-free period of more than 3 consecutive months.

C. The onset is before age 18 years.

D. The disturbance is not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington’s disease or postviral encephalitis).

Diagnostic Features

The essential features of Tourette’s Disorder are multiple motor tics and one or more vocal tics (Criterion A). These may appear simultaneously or at different periods during the illness. The tics occur many times a day, recurrently throughout a period of more than 1 year. During this period, there is never a tic-free period of more than 3 consecutive months (Criterion B). The onset of the disorder is before age 18 years (Criterion C). The tics are not due to the direct physiological effects of a substance (e.g., stimulants) or a general medical condition (e.g., Huntington’s disease or postviral encephalitis) (Criterion D).

The anatomical location, number, frequency, complexity, and severity of the tics change over time. Simple and complex motor tics may affect any part of the body, including the face, head, torso, and upper and lower limbs. Simple motor tics are rapid, meaningless contractions of one or a few muscles, such as eye blinking. Complex motor tics involving touching, squatting, deep knee bends, retracing steps, and twirling when walking may be present. The vocal tics include various words or sounds such as clicks, grunts, yelps, barks, sniffs, snorts, and coughs. Coprolalia, a complex vocal tic involving the uttering of obscenities, is present in only a small minority of individuals (less than 10%) and is not required for a diagnosis of Tourette’s Disorder.

In approximately one-half of the individuals with this disorder, the first symptoms to appear are bouts of a single tic, most frequently eye blinking. Less frequently, initial tics involve another part of the face or the body, such as facial grimacing, head jerking, tongue protrusion, sniffing, hopping, skipping, throat clearing, stuttering-like block in speech fluency, or uttering sounds or words. Sometimes this disorder begins with multiple symptoms starting at the same time.

Associated Features and Disorders

The most common associated symptoms of Tourette’s Disorder are obsessions and compulsions. Hyperactivity, distractibility, and impulsivity are also relatively common. Social discomfort, shame, self-consciousness, and demoralization and sadness frequently occur. Persistent motor and vocal tics may cause a broad range of distress and impairment, ranging from none to severe. Younger children, in particular, may be unaware of their tics, suffer no distress, and show no impairment in any area of functioning. A high percentage of children, adolescents, and adults with Tourette’s Disorder do not seek medical attention for their tics. At the other end of the spectrum, there are individuals with Tourette’s Disorder who are burdened by intrusive, recurrent, forceful, and socially stigmatizing motor and vocal tics.

Social, academic, and occupational functioning may be impaired because of rejection by others or anxiety about having tics in social situations. Chronic tic symptoms can cause considerable distress and can lead to social isolation and personality changes. In severe cases of Tourette’s Disorder, the tics may directly interfere with daily activities (e.g., conversing, reading, or writing). Rare complications of Tourette’s Disorder include physical injury, such as blindness due to self-inflicted eye injury (from head banging or eye gouging), orthopedic problems (from knee bending, neck jerking, or head turning), skin problems (from picking or lip licking), and neurological sequelae (e.g., from disc disease related to many years of forceful neck movements). The severity of the tics may be exacerbated by administration of central nervous system stimulants, such as those used in the treatment of Attention-Deficit/Hyperactivity Disorder, although some individuals can tolerate these medications without an exacerbation of their tics or may even have a reduction in tics. Obsessive-Compulsive Disorder and Attention-Deficit/Hyperactivity Disorder often co-occur in individuals with Tourette’s Disorder. Attentional problems or obsessive symptomatology may precede or follow the onset of tics. Obsessive-compulsive symptoms found in individuals with Tourette’s Disorder may constitute a specific subtype of Obsessive-Compulsive Disorder. This subtype appears to be characterized by an earlier age at onset, male preponderance, higher frequency of certain obsessive-compulsive symptoms (more aggressive symptoms and less concern about contamination and hoarding), and poorer response to pharmacotherapy with selective serotonin reuptake inhibitors. Disruptive behavior, impulsiveness, and social immaturity are prominent features in those children and adolescents who also have Attention-Deficit/Hyperactivity Disorder. These clinical features may interfere with academic progress and interpersonal relationships and lead to greater impairment than that caused by the Tourette’s Disorder.

Specific Culture and Gender Features

Tourette’s Disorder has been widely reported in diverse racial and ethnic groups. Although in clinical settings the disorder is diagnosed approximately three to five times more often in males than in females, the gender ratio is perhaps as low as 2:1 in community samples.

Prevalence
The prevalence of Tourette’s Disorder is related to age. Many more children (5–30 per 10,000) are affected than adults (1–2 per 10,000).

Course

The age at onset of Tourette’s Disorder may be as early as age 2 years, is usually during childhood or early adolescence, and is by definition before age 18 years. The median age at onset for motor tics is about 6–7 years. The duration of the disorder may be lifelong, though periods of remission lasting from weeks to years may occur. In most cases, the severity, frequency, disruptiveness, and variability of the symptoms diminish during adolescence and adulthood. In other cases, the symptoms actually disappear entirely, usually by early adulthood. In a few cases, the symptoms may worsen in adulthood. The predictors of this course are not known.

Familial Pattern

The vulnerability to Tourette’s Disorder and related disorders is transmitted within families and appears to be genetic. The mode of genetic transmission, however, is not known. Pedigree studies suggest that there are genes of major effect. Although some early studies suggested a pattern of transmission that is consistent with an autosomal dominant pattern, other studies suggest a more complex mode of transmission. “Vulnerability” implies that the child receives the genetic or constitutional basis for developing a Tic Disorder; the precise type or severity of disorder may be different from one generation to another and is modified by nongenetic factors. Not everyone who inherits the genetic vulnerability will express symptoms of a Tic Disorder. The range of forms in which the vulnerability may be expressed includes Tourette’s Disorder, Chronic Motor or Vocal Tic Disorder, and some forms of Obsessive-Compulsive Disorder. It also appears that individuals with Tourette’s Disorder are at greater risk for Attention-Deficit/Hyperactivity Disorder. In some individuals with Tourette’s Disorder, there is no evidence of a familial pattern.

A. Recurrent failure to resist impulses to steal objects that are not needed for personal use or for their monetary value.

B. Increasing sense of tension immediately before committing the theft.

C. Pleasure, gratification, or relief at the time of committing the theft.

D. The stealing is not committed to express anger or vengeance and is not in response to a delusion or a hallucination.

E. The stealing is not better accounted for by Conduct Disorder, a Manic Episode, or Antisocial Personality Disorder.

Diagnostic Features

The essential feature of Kleptomania is the recurrent failure to resist impulses to steal items even though the items are not needed for personal use or for their monetary value (Criterion A). The individual experiences a rising subjective sense of tension before the theft (Criterion B) and feels pleasure, gratification, or relief when committing the theft (Criterion C). The stealing is not committed to express anger or vengeance, is not done in response to a delusion or hallucination (Criterion D), and is not better accounted for by Conduct Disorder, a Manic Episode, or Antisocial Personality Disorder (Criterion E). The objects are stolen despite the fact that they are typically of little value to the individual, who could have afforded to pay for them and often gives them away or discards them. Occasionally the individual may hoard the stolen objects or surreptitiously return them. Although individuals with this disorder will generally avoid stealing when immediate arrest is probable (e.g., in full view of a police officer), they usually do not preplan the thefts or fully take into account the chances of apprehension. The stealing is done without assistance from, or collaboration with, others.

Associated Features and Disorders

Individuals with Kleptomania experience the impulse to steal as ego-dystonic and are aware that the act is wrong and senseless. The person frequently fears being apprehended and often feels depressed or guilty about the thefts. Kleptomania may be associated with compulsive buying as well as with Mood Disorders (especially Major Depressive Disorder), Anxiety Disorders, Eating Disorders (particularly Bulimia Nervosa), Personality Disorders, and other Impulse-Control Disorders. The disorder may cause legal, family, career, and personal difficulties.

Specific Gender Features

Preliminary evidence suggests that, in clinical samples, approximately two-thirds of individuals with Kleptomania are female.

Prevalence

Kleptomania is a rare condition that appears to occur in fewer than 5% of identified shoplifters. Its prevalence in the general population is unknown.

Course

Age at onset of Kleptomania is variable. The disorder may begin in childhood, adolescence, or adulthood, and in rare cases in late adulthood. There is little systematic information on the course of Kleptomania, but three typical courses have been described: sporadic with brief episodes and long periods of remission; episodic with protracted periods of stealing and periods of remission; and chronic with some degree of fluctuation. The disorder may continue for years, despite multiple convictions for shoplifting.

Familial Pattern

There are no controlled family history studies of Kleptomania. However, preliminary data suggest that first-degree relatives of individuals with Kleptomania may have higher rates of Obsessive-Compulsive Disorder than the general population.

A. Recurrent pulling out of one’s hair resulting in noticeable hair loss.

B. An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior.

C. Pleasure, gratification, or relief when pulling out the hair.

D. The disturbance is not better accounted for by another mental disorder and is not due to a general medical condition (e.g., a dermatological condition).

E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Diagnostic Features

The essential feature of Trichotillomania is the recurrent pulling out of one’s own hair that results in noticeable hair loss (Criterion A). Sites of hair pulling may include any region of the body in which hair may grow (including axillary, pubic, and perirectal regions), with the most common sites being the scalp, eyebrows, and eyelashes. Hair pulling may occur in brief episodes scattered throughout the day or in less frequent but more sustained periods that can continue for hours. Hair pulling often occurs in states of relaxation and distraction (e.g., when reading a book or watching television) but may also occur during stressful circumstances. An increasing sense of tension is present immediately before pulling out the hair (Criterion B). For some, tension does not necessarily precede the act but is associated with attempts to resist the urge. There is gratification, pleasure, or a sense of relief when pulling out the hair (Criterion C). Some individuals experience an “itchlike” sensation in the scalp that is eased by the act of pulling hair. The diagnosis is not given if the hair pulling is better accounted for by another mental disorder (e.g., in response to a delusion or a hallucination) or is due to a general medical condition (e.g., inflammation of the skin or other dermatological conditions) (Criterion D). The disturbance must cause significant distress or impairment in social, occupational, or other important areas of functioning (Criterion E).

Associated Features and Disorders

Associated descriptive features and mental disorders.

Examining the hair root, twirling it off, pulling the strand between the teeth, or trichophagia (eating hairs) may occur with Trichotillomania. Hair pulling does not usually occur in the presence of other people (except immediate family members), and social situations may be avoided. Individuals commonly deny their hair-pulling behavior and conceal or camouflage the resulting alopecia. Some individuals have urges to pull hairs from other people and may sometimes try to find opportunities to do so surreptitiously. They may pull hairs from pets, dolls, and other fibrous materials (e.g., sweaters or carpets). Nail biting, scratching, gnawing, and excoriation is often associated with Trichotillomania. Individuals with Trichotillomania may also have Mood Disorders, Anxiety Disorders (especially Obsessive-Compulsive Disorder), Substance Use Disorders, Eating Disorders, Personality Disorders, or Mental Retardation.

Associated laboratory findings.

Certain histological findings are considered characteristic and may aid diagnosis when Trichotillomania is suspected and the affected individual denies symptoms. Biopsy samples from involved areas may reveal short and broken hairs. Histological examination will reveal normal and damaged follicles in the same area, as well as an increased number of catagen hairs. Some hair follicles may show signs of trauma (wrinkling of the outer root sheath). Involved follicles may be empty or may contain a deeply pigmented keratinous material. The absence of inflammation distinguishes Trichotillomania-induced alopecia from alopecia areata.

Associated physical examination findings and general medical conditions.

Pain is not routinely reported to accompany the hair pulling; pruritus and tingling in the involved areas may be present. The patterns of hair loss are highly variable. Areas of complete alopecia are common, as well as areas of noticeably thinned hair density. When the scalp is involved, there may be a predilection for the crown or parietal regions. The surface of the scalp usually shows no evidence of excoriation. There may be a pattern of nearly complete baldness except for a narrow perimeter around the outer margins of the scalp, particularly at the nape of the neck (”tonsure trichotillomania”). Eyebrows and eyelashes may be completely absent. Thinning of pubic hairs may be apparent on inspection. There may be areas of absent hair on the limbs or torso. Trichophagia may result in bezoars (hair balls) that may lead to anemia, abdominal pain, hematemesis, nausea and vomiting, and bowel obstruction and even perforation.

Specific Culture, Age, and Gender Features

Among children with Trichotillomania, males and females are equally represented. Among adults, Trichotillomania is much more common among females than among males. This may reflect the true gender ratio of the condition, or it may reflect differential treatment seeking based on cultural or gender-based attitudes regarding appearance (e.g., acceptance of normative hair loss among males).

Prevalence

No systematic data are available on the prevalence of Trichotillomania. Although Trichotillomania was previously thought to be an uncommon condition, it is now believed to occur more frequently. For example, a survey of college students found a lifetime rate of 0.6%.

Course

Transient periods of hair pulling in early childhood may be considered a benign “habit” with a self-limited course. Individuals who present with chronic Trichotillomania in adulthood often report onset in early adolescence. Some individuals have continuous symptoms for decades. For others, the disorder may come and go for weeks, months, or years at a time. Sites of hair pulling may vary over time.