2.9% among adults in the general communit y of the United Stat es. The 12-month preva-
lence for the disorder in other countries ranges from 0.4% to 3.6%. The lifetime morbid risk
is 9.0%. Females are twice as likely as males to  experience generalized  anxiety disorder. The
prevalence of the diagnosis peak s in middle age and declines across the later years of life.
Individuals of European descent tend to ex perience generalized anxiety disorder more
frequently than do individuals of non-Euro pean descent (i.e., Asian, African, Native
American and Pacific Islander ). Furthermore, individuals from developed countries are
more likely than individuals from nondeveloped  countries to report that they have expe-
rienced symptoms that meet criteria for ge neralized anxiety disorder in their lifetime.
Development and Course
Many individuals with generalized anxiety disord er report that they have felt anxious and
nervous all of their lives. The median age at  onset for generalized anxiety disorder is 30
years; however, age at onset is spread over a very broad range. The median age at onset is
later than that for the other anxiety disorder s. The symptoms of excessive worry and anx-
iety may occur early in life but are then ma nifested as an anxious temperament. Onset of
the disorder rarely occurs prior to adolesce nce. The symptoms of generalized anxiety dis-
order tend to be chronic and wax and wane across the lifespan, fluctuating between syn-
dromal and subsyndromal forms of the diso rder. Rates of full re mission are very low.
The clinical expression of generalized anxiet y disorder is relatively consistent across
the lifespan. The primary difference across age groups is in the content of the individual’s


the lifespan. The primary difference across age groups is in the content of the individual’s
worry. Children and adolescents tend to worr y more about school and sporting perfor-
mance, whereas older adults report greater co ncern about the well-bein g of family or their
own physical heath. Thus, the content of an in dividual’s worry tends to be age appropri-
ate. Younger adults experience greater severity of symptoms than do older adults.
The earlier in life individuals have symptoms that meet criteria for generalized anxiety


ate. Younger adults experience greater severity of symptoms than do older adults.
The earlier in life individuals have symptoms that meet criteria for generalized anxiety
disorder, the more comorbidity they tend to have and the more impaired they are likely to


224 Anxiety Disorders
be. The advent of chronic physical disease can be a potent issue for excessive worry in the
elderly. In the frail elderly, worries abou t safety—and especially about falling—may limit
activities. In those with early cognitive impairment, what appears to be excessive worry
about, for example, the whereabouts of things  is probably better regarded as realistic
given the cognitive impairment.
In children and adolescents with generalized  anxiety disorder, the anxieties and wor-
ries often concern the quality of  their performance or competen ce at school or in sporting
events, even when their performance is not being evaluated by others. There may be ex-
cessive concerns about punctuality. They ma y also worry about ca tastrophic events, such
as earthquakes or nuclear war. Children with  the disorder may be overly conforming, per-
fectionist, and unsure of themselves and tend to redo tasks because of excessive dissatis-
faction with less-than-perfect  performance. They are typi cally overzealous in seeking
reassurance and approval and require exces sive reassurance about their performance and
other things they are worried about.
Generalized anxiety disorder may be overdiagnosed in children. When this diagnosis
is being considered in children, a thorough ev aluation for the presence of other childhood
anxiety disorders and other mental disorders should be done to determine whether the
worries may be better explained by one of thes e disorders. Separation anxiety disorder, so-
cial anxiety disorder (social phobia), and obsessive-compulsive disorder are often accom-
panied by worries that may mimic those described in generalized anxiety disorder. For
example, a child with social anxiety disorder  may be concerned abou t school performance
because of fear of humiliation. Worries about illness may also be better explained by sep-
aration anxiety disorder or obsessive-compulsive disorder.


aration anxiety disorder or obsessive-compulsive disorder.
Risk and Prognostic Factors
Temperamental. Behavioral inhibition, negative affectivity (neuroticism), and harm
avoidance have been associated wi th generalized anxiety disorder.
Environmental. Although childhood adversities and parental overprotection have been
associated with generalized anxiety disorder, no environmental factors have been identi-
fied as specific to generalized anxiety disorder or necessary or sufficient for making the di-
agnosis.
Genetic and physiological. One-third of the risk of expe riencing generalized anxiety
disorder is genetic, and these genetic factors overlap with the risk of neuroticism and are
shared with other anxiety and mood disorder s, particularly major depressive disorder.
Culture-Related Diagnostic Issues
There is considerable cultural variation in th e expression of generalized anxiety disorder.
For example, in some cultures, somatic symptoms predominat e in the expression of the
disorder, whereas in other cult ures cognitive symptoms tend to predominate. This differ-
ence may be more evident on initial presentation than su bsequently, as more symptoms
are reported over time. There is no information as to whether the propensity for excessive
worrying is related to culture, although the topic being worried about can be culture spe-
cific. It is important to consider the social and cultural context when evaluating whether
worries about certain situations are excessive.
Gender-Related Diagnostic Issues
In clinical settings, generalized anxiety diso rder is diagnosed somewhat more frequently
in females than in males (about 55%–60% of  those presenting wi th the disorder are
female). In epidemiological studies, approx imately two-thirds are female. Females and
males who experience generalized anxiety diso rder appear to have similar symptoms but


Generalized Anxiety Disorder 225
demonstrate different patterns of comorbidity consistent with gender differences in the
prevalence of disorders. In females, comorbidity is largely confined to the anxiety disor-
ders and unipolar depression, whereas in male s, comorbidity is more likely to extend to
the substance use disorders as well.
Functional Consequences of
Generalized Anxiety Disorder
Excessive worrying impairs the individual’s capa city to do things quickly and efficiently,
whether at home or at work. The worrying takes time and energy; the associated symp-
toms of muscle tension and feeling keyed up or on edge, tiredness,  difficulty concentrat-
ing, and disturbed sleep contri bute to the impairment. Importantly the excessive worrying
may impair the ability of individuals with ge neralized anxiety disorder to encourage con-
fidence in their children.
Generalized anxiety disorder is associated with  significant disability and distress that is
independent of comorbid disorders, and most non-institutionalized adults with the disorder
are moderately to seriously di sabled. Generalized anxiety di sorder accounts for 110 mil-
lion disability days per annum in the U.S. population.
Differential Diagnosis
Anxiety disorder due to another medical condition. The diagnosis of anxiety disorder
associated with another medical condition should be assigned if the individual’s anxiety
and worry are judged, based on history, labora tory findings, or physical examination, to
be a physiological effect of another specific medical condition (e.g., pheochromocytoma,
hyperthyroidism).
Substance/medication-induced anxiety disorder. A substance/medication-induced
anxiety disorder is distinguished from generaliz ed anxiety disorder by the fact that a sub-


anxiety disorder is distinguished from generaliz ed anxiety disorder by the fact that a sub-
stance or medication (e.g., a drug of abuse, ex posure to a toxin) is judged to be etiologically
related to the anxiety. For example, severe anxi ety that occurs only in the context of heavy
coffee consumption would be diagnosed as caffeine-induced anxiety disorder.
Social anxiety disorder. Individuals with social anxiety disorder often have anticipa-
tory anxiety that is focused on upcoming social situations in which they must perform or
be evaluated by others, whereas individuals with generalized anxiety disorder worry,
whether or not they are being evaluated.
Obsessive-compulsive disorder. Several features distinguish the excessive worry of
generalized anxiety disorder fr om the obsessional thoughts of obsessive-compulsive dis-
order. In generalized anxiety disorder the focus of the worry is about forthcoming prob-
lems, and it is the excessivene ss of the worry about future events that is abnormal. In
obsessive-compulsive disorder, the obsessions are inappropriate ideas that take the form of
intrusive and unwanted thou ghts, urges, or images.
Posttraumatic stress disorder  and adjustment disorders. Anxiety is invariably pres-
ent in posttraumatic stress disorder. Generali zed anxiety disorder is not diagnosed if the
anxiety and worry are better explained by sy mptoms of posttraumatic stress disorder.
Anxiety may also be present in adjustment di sorder, but this residual category should be
used only when the criteria are not met for any other disorder (including generalized anx-
iety disorder). Moreover, in adjustment disorders, the anxi ety occurs in response to an
identifiable stressor within 3 months of the onset of the stressor and does not persist for
more than 6 months after the terminatio n of the stressor or  its consequences.


Depressive, bipolar, and psychotic disorders. Generalized anxiety/worry is a common
associated feature of depressive, bipolar, an d psychotic disorders and should not be di-


226 Anxiety Disorders
agnosed separately if the excessive worry h as occurred only during the course of these
conditions.
Comorbidity
Individuals whose presen tation meets criteria for genera lized anxiety disorder are likely
to have met, or currently meet, criteria for other anxiety and unip olar depressive disor-
ders. The neuroticism or emotional liability th at underpins this pattern of comorbidity is
associated with temperamental antecedents and genetic and environmental risk factors
shared between these disorders, although in dependent pathways are also possible. Co-
morbidity with substance use, conduct, psychotic, neurodevelopmental, and neurocogni-
tive disorders is less common.
Substance/Medication-Induced
 Anxiety Disorder
Diagnostic Criteria
A. Panic attacks or anxiety is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings of both
(1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication
or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms in Crite-
rion A.
C. The disturbance is not better explained by an anxiety disorder that is not substance/
medication-induced. Such evidence of an independent anxiety disorder could include
the following:
The symptoms precede the onset of the substance/medication use; the symptoms
persist for a substantial period of time (e.g., about 1 month) after the cessation of
acute withdrawal or severe intoxication; or there is other evidence suggesting the
existence of an independent non-substance/medication-induced anxiety disorder
(e.g., a history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.


D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
Note:  This diagnosis should be made instead of a diagnosis of substance intoxication or
substance withdrawal only when the symptoms in Criterion A predominate in the clinical
picture and they are sufficiently severe to warrant clinical attention.
Coding note:  The ICD-9-CM and ICD-10-CM codes for the [specific substance/medica-
tion]-induced anxiety disorders are indicated in the table below. Note that the ICD-10-CM
code depends on whether or not there is a comorbid substance use disorder present for
the same class of substance. If a mild substance use disorder is comorbid with the sub-
stance-induced anxiety disorder, the 4th positio n character is “1,” and the clinician should
record “mild [substance] use disorder” bef ore the substance-induced anxiety disorder
(e.g., “mild cocaine use disorder with cocai ne-induced anxiety disorder”). If a moderate or
severe substance use disorder is comorbid with the substance-induced anxiety disorder,
the 4th position character is “2,” and the clinician should record “moderate [substance] use
disorder” or “severe [substance] use disorder,” depending on the severity of the comorbid
substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-


Substance/Medication-Induced Anxiety Disorder 227
time heavy use of the substance), then the 4th position character is “9,” and the clinician
should record only the substance-induced anxiety disorder.
Specify if (see Table 1 in the chapter “Substance-Related and Addictive Disorders” for di-
agnoses associated with substance class):
With onset during intoxication: This specifier applies if criteria are met for intoxica-
tion with the substance and the symptoms develop during intoxication.
With onset during withdrawal:  This specifier applies if criteria are met for withdrawal
from the substance and the symptoms develop during, or shortly after, withdrawal.
With onset after medication use:  Symptoms may appear either at initiation of medi-
cation or after a modification or change in use.
Recording Procedures
ICD-9-CM. The name of the substance/medicati on-induced anxiety disorder begins
with the specific substance (e.g ., cocaine, salbutamol) that is  presumed to be causing the
anxiety symptoms. The diagnostic code is sele cted from the table included in the criteria
set, which is based on the drug class. For substa nces that do not fit into any of the classes
(e.g., salbutamol), the code for “other substance” should be used; and in cases in which
a substance is judged to be an etiological fact or but the specific class of substance is un-
known, the category “unknown substance” should be used.
The name of the disorder is followed by the specification of onset (i.e., onset during in-
toxication, onset during withdr awal, with onset duri ng medication use). Unlike the record-
ing procedures for ICD-10-CM, which comb ine the substance-induced disorder and


ing procedures for ICD-10-CM, which comb ine the substance-induced disorder and
substance use disorder in to a single code, for ICD-9-CM a se parate diagnostic code is given
for the substance use disorder. For example, in the case of anxiety symptoms occurring dur-
ing withdrawal in a man with a severe lorazepam use disorder, the diagnosis is 292.89 loraz-
epam-induced anxiety disorder, with onset du ring withdrawal. An additional diagnosis of
304.10 severe lorazepam use disorder is also given. When more than one substance is judged
to play a significant role in the development of  anxiety symptoms, each should be listed sep-ICD-10-CM
ICD-9-CMWith use
disorder,
mildWith use
disorder,
moderate
or severeWithout
use
disorder
Alcohol 291.89 F10.180 F10.280 F10.980
Caffeine 292.89 F15.180 F15.280 F15.980
Cannabis 292.89 F12.180 F12.280 F12.980
Phencyclidine 292.89 F16.180 F16.280 F16.980
Other hallucinogen 292.89 F16.180 F16.280 F16.980
Inhalant 292.89 F18.180 F18.280 F18.980
Opioid 292.89 F11.188 F11.288 F11.988
Sedative, hypnotic, or anxiolytic 292.89 F13.180 F13.280 F13.980
Amphetamine (or other
stimulant)292.89 F15.180 F15.280 F15.980


228 Anxiety Disorders
arately (e.g., 292.89 methylphenidate-induced an xiety disorder, with on set during intoxica-
tion; 292.89 salbutamol-induced anxiety di sorder, with onset after medication use).
ICD-10-CM. The name of the substance/medication-induced anxiety disorder begins
with the specific substance (e.g ., cocaine, salbutamol) that is  presumed to be causing the
anxiety symptoms. The di agnostic code is selected from the table included in the criteria
set, which is based on the drug class and presence or absence of a comorbid substance use
disorder. For substances that do not fit into any of the classes (e.g., salbutamol), the code
for “other substance” should be used; and in cases in which a substance is judged to be an
etiological factor but the specific class of substance is unknown, the category “unknown
substance” should be used.
When recording the name of the disorder, th e comorbid substance use disorder (if any)
is listed first, followed by the word “with,” followed by the name of the substance-induced
anxiety disorder, followed by the specification of onset (i.e., onset during intoxication,
onset during withdrawal, with onset during medication use). For example, in the case of
anxiety symptoms occurring during withdrawal  in a man with a severe lorazepam use dis-
order, the diagnosis is F13.280 severe lor azepam use disorder with lorazepam-induced
anxiety disorder, with onset du ring withdrawal. A separate diagnosis of the comorbid se-
vere lorazepam use disorder is not given. If the substance-induced anxiety disorder occurs
without a comorbid substance use disorder (e.g., after a one-time heavy use of the substance),


no accompanying substance use disorder is no ted (e.g., F16.980 psilocybin-induced anxi-
ety disorder, with onset during intoxication).  When more than one substance is judged to
play a significant role in the development of  anxiety symptoms, each should be listed sep-
arately (e.g., F15.280 severe methylphenidate use disorder with methylphenidate-induced
anxiety disorder, with onset during intoxica tion; F19.980 salbutamol-induced anxiety dis-
order, with onset after medication use).
Diagnostic Features
The essential features of substance/medicati on-induced anxiety di sorder are prominent
symptoms of panic or anxiety (Criterion A) that  are judged to be due to the effects of a sub-
stance (e.g., a drug of abuse, a medication, or  a toxin exposure). The panic or anxiety symp-
toms must have developed duri ng or soon after substance in toxication or withdrawal or
after exposure to a medication, and the substa nces or medications must be capable of pro-
ducing the symptoms (Criteri on B2). Substance/medication-induced anxiety disorder
due to a prescribed treatment for a mental disorder or another medical condition must
have its onset while the individual is receivin g the medication (or during withdrawal, if a
withdrawal is associated with the medication ). Once the treatment is discontinued, the
panic or anxiety symptoms will usually improv e or remit within days to several weeks to
a month (depending on the half-life of the su bstance/medication and the presence of with-
drawal). The diagnosis of substance/medicati on-induced anxiety disorder should not be
given if the onset of the panic or anxiety symptoms precedes the substance/medication in-


given if the onset of the panic or anxiety symptoms precedes the substance/medication in-
toxication or withdrawal, or if the symptoms persist for a subs tantial period of time (i.e.,
usually longer than 1 month) from the time of severe intoxication or withdrawal. If the
panic or anxiety symptoms persist for substantial periods of time, other causes for the
symptoms should be considered.
The substance/medication-ind uced anxiety disorder diagnosis should be made in-
stead of a diagnosis of substance intoxication or substance withdrawal only when the
symptoms in Criterion A are predominant in th e clinical picture and are sufficiently severe
to warrant independent clinical attention.
Associated Features Supporting Diagnosis


symptoms in Criterion A are predominant in th e clinical picture and are sufficiently severe
to warrant independent clinical attention.
Associated Features Supporting Diagnosis
Panic or anxiety can occur in association with intoxication with the following classes of sub-
stances: alcohol, caffeine, cannabis, phencyc lidine, other hallucinogens, inhalants, stimu-


Substance/Medication-Induced Anxiety Disorder 229
lants (including cocaine), and other (or unknown) substances. Panic or anxiety can occur in
association with withdrawal from the following classes of substances: alcohol; opioids; sed-
atives, hypnotics, and anxiolytics; stimulants  (including cocaine); and other (or unknown)
substances. Some medications that evoke anxi ety symptoms include anesthetics and anal-
gesics, sympathomimetics or other bronchodilato rs, anticholiner gics, insulin, thyroid prep-
arations, oral contraceptives, antihistamines, antiparkinsonian medica tions, corticosteroids,
antihypertensive and ca rdiovascular medications, anticon vulsants, lithium carbonate, an-
tipsychotic medications, and antidepressant medications. Heavy metals and toxins (e.g.,
organophosphate insecticide, nerve gases, ca rbon monoxide, carbon dioxide, volatile sub-
stances such as gasoline and paint) may also cause panic or anxiety symptoms.
Prevalence
The prevalence of substance/me dication-induced anxiety disorder is not clear. General
population data suggest that it may be rare, with a 12-month prevalence of approximately
0.002%. However, in clinical populations,  the prevalence is likely to be higher.
Diagnostic Markers
Laboratory assessments (e.g., urine toxicology) may be useful  to measure substance intox-
ication as part of an assessment for subs tance/medication-induced anxiety disorder.
Differential Diagnosis
Substance intoxication and substance withdrawal. Anxiety symptoms commonly oc-
cur in substance intoxi cation and substance withdrawal. The diagnosis of the substance-
specific intoxication or substance-specific wi thdrawal will usually suffice to categorize the


specific intoxication or substance-specific wi thdrawal will usually suffice to categorize the
symptom presentation. A diag nosis of substance/medication-induced anxiety disorder
should be made in addition to  substance intoxication or su bstance withdrawal when the
panic or anxiety symptoms are predominant in the clinical picture and are sufficiently se-
vere to warrant independent c linical attention. For example, panic or anxiety symptoms
are characteristic of alcohol withdrawal.
Anxiety disorder (i.e., not indu ced by a substance/medication). Substance/medication-
induced anxiety disorder is judged to be etio logically related to the substance/medication.
Substance/medication-induced anxiety disord er is distinguished from a primary anxiety
disorder based on the onset, course, and othe r factors with respect to substances/medica-
tions. For drugs of abuse, there must be eviden ce from the history, physical examination, or
laboratory findings for use,  intoxication, or withdrawal . Substance/medication-induced
anxiety disorders arise only in association with  intoxication or with drawal states, whereas
primary anxiety disorders may precede the onse t of substance/medication use. The pres-
ence of features that are atypical of a primary anxiety disorder, such as atypical age at onset
(e.g., onset of panic disorder after age 45 year s) or symptoms (e.g., atypical panic attack
symptoms such as true vertigo, loss of balanc e, loss of consciousness , loss of bladder con-
trol, headaches, slurred speech) may suggest a substance/medication -induced etiology. A
primary anxiety disorder diagnosis is warranted if the panic or anxiety symptoms persist
for a substantial period of time (about 1 mont h or longer) after the end of the substance in-


toxication or acute withdr awal or there is a histor y of an anxiety disorder.
Delirium. If panic or anxiety symptoms occur exclusively during the course of delirium,
they are considered to be an  associated feature of the de lirium and are not diagnosed sep-
arately.
Anxiety disorder due to another medical condition. If the panic or anxiety symptoms
are attributed to the physiological consequenc es of another medical condition (i.e., rather
than to the medication taken for the medical condition), anxi ety disorder due to another


230 Anxiety Disorders
medical condition should be diagnosed. The history often provides the basis for such a
judgment. At times, a change in the treatment  for the other medical condition (e.g., med-
ication substitution or discontinuation) may be needed to determine whether the medica-
tion is the causative agent (in which case  the symptoms may be better explained by
substance/medication-induced anxiety disorder).  If the disturbance is  attributable to both
another medical condition and substance use, bo th diagnoses (i.e., anxiety disorder due to
another medical condition and substance/me dication-induced anxi ety disorder) may be
given. When there is insufficie nt evidence to determine whether the panic or anxiety symp-
toms are attributable to a subs tance/medication or to anothe r medical condition or are pri-
mary (i.e., not attributable to either a subs tance or another medical condition), a diagnosis
of other specified or unspecified an xiety disorder wo uld be indicated.
Anxiety Disorder Due to
Another Medical Condition
Diagnostic Criteria 293.84 (F06.4)
A. Panic attacks or anxiety is predominant in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the dis-
turbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning.
Coding note: Include the name of the other medical condition within the name of the men-


Coding note: Include the name of the other medical condition within the name of the men-
tal disorder (e.g., 293.84 [F06.4] anxiety disorder due to pheochromocytoma). The other
medical condition should be coded and listed separately immediately before the anxiety
disorder due to the medical condition (e.g., 227.0 [D35.00] pheochromocytoma; 293.84
[F06.4] anxiety disorder due to pheochromocytoma.
Diagnostic Features
The essential feature of anxiety disorder due to  another medical condition is clinically signifi-
cant anxiety that is judged to be best explaine d as a physiological effect of another medical con-
dition. Symptoms can include pr ominent anxiety symptoms or panic attacks (Criterion A).
The judgment that the symptoms are best explai ned by the associated physical condition must
be based on evidence from the history, physical  examination, or laboratory findings (Criterion
B). Additionally, it must be judged that the sy mptoms are not better accounted for by another
mental disorder, in particular, adjustment disorder, with anxiety,  in which the stressor is the
medical condition (Criterion C). In  this case, an individual with  adjustment disorder is espe-
cially distressed about the mean ing or the consequences of th e associated medical condition.
By contrast, there is often a prominent physical component to  the anxiety (e.g., shortness of
breath) when the anxiety is due to another medica l condition. The diagnosis is not made if the
anxiety symptoms occur only during the course of a delirium (Criterion D). The anxiety symp-
toms must cause clinically significant distress or impairment in  social, occupational, or other
important areas of functioning (Criterion E).


important areas of functioning (Criterion E).
In determining whether the anxiety symptoms  are attributable to  another medical con-
dition, the clinician must first establish the presence of the medica l condition.  Further-
more, it must be established that anxiety symptoms can be etiologically related to the
medical condition through a physiological mech anism before making a judgment that this
is the best explanation for the symptoms in a specific individual. A careful and compre-


Anxiety Disorder Due to Another Medical Condition 231
hensive assessment of multiple factors is ne cessary to make this judgment. Several aspects
of the clinical presentation should be consider ed: 1) the presence of a clear temporal asso-
ciation between the onset, exacerbation, or re mission of the medical condition and the anx-
iety symptoms; 2) the presence of features th at are atypical of a primary anxiety disorder
(e.g., atypical age at onset or course); and 3) evidence in the literature that a known phys-
iological mechanism (e.g., hyperthyroidism) ca uses anxiety. In addi tion, the disturbance
must not be better explained by a primar y anxiety disorder, a substance/medication-
induced anxiety disorder, or an other primary mental disorder (e.g., adjustment disorder).
Associated Features Supporting Diagnosis
A number of medical conditions are known to  include anxiety as a symptomatic manifes-
tation. Examples include endocrine disease (e.g., hyperthyroidis m, pheochromocytoma,
hypoglycemia, hyperadrenocortisolism), cardiovascular disorders (e.g., congestive heart
failure, pulmonary embolism, arrhythmia such as atrial fibrillation), respiratory illness
(e.g., chronic obstructive pulmonary diseas e, asthma, pneumonia), metabolic distur-
bances (e.g., vitamin B12 deficiency, porphyria), and neurological illness (e.g., neoplasms,
vestibular dysfunction, encephalitis, seizure disorders). Anxiety due to another medical
condition is diagnosed when the medical cond ition is known to induce anxiety and when
the medical condition preceded the onset of the anxiety.
Prevalence
The prevalence of anxiety disorder due to an other medical condition is unclear. There ap-


The prevalence of anxiety disorder due to an other medical condition is unclear. There ap-
pears to be an elevated prevalence of anxi ety disorders among individuals with a variety
of medical conditions, including asthma, hypert ension, ulcers, and arthritis. However, this
increased prevalence may be due to reasons ot her than the anxiety disorder directly caus-
ing the medical condition.
Development and Course
The development and course of anxiety diso rder due to another medical condition gen-
erally follows the course of the underlying illness. This diagnosis is not meant to include
primary anxiety disorders that arise in the co ntext of chronic medical illness. This is im-
portant to consider with older adults, who may experience chronic medical illness and
then develop independent anxiety disorder s secondary to the chronic medical illness.
Diagnostic Markers
Laboratory assessments and/or medical examin ations are necessary to confirm the diag-
nosis of the associated medical condition.
Differential Diagnosis
Delirium. A separate diagnosis of anxiety disord er due to another medical condition is
not given if the anxiety disturbance occurs exclusively during the course of a delirium.
However, a diagnosis of anxiety disorder du e to another medical condition may be given
in addition to a diagnosis of major neurocognitive disorder (dementia) if the etiology of
anxiety is judged to be a physiological consequence of the pathological process causing the
neurocognitive disorder and if anxiety is a prominent part of the clinical presentation.
Mixed presentation of symptoms (e.g., mood and anxiety). If the presentation includes
a mix of different types of symptoms, the spec ific mental disorder due to another medical
condition depends on which symptoms predominate in the clinical picture.
Substance/medication-induced anxiety disorder. If there is evidence of recent or pro-


Substance/medication-induced anxiety disorder. If there is evidence of recent or pro-
longed substance use (including medications with psychoactive effects), withdrawal from


232 Anxiety Disorders
a substance, or exposure to a toxin, a su bstance/medication-induced anxiety disorder
should be considered. Certain medications are known to increase anxiety (e.g., corticoste-
roids, estrogens, metoclopramide), and when this is the case, the medication may be the
most likely etiology, although it may be difficult to distinguish whether the anxiety is at-
tributable to the medications or to the medica l illness itself. When a diagnosis of substance-
induced anxiety is being made in relation to recreational or nonprescribed drugs, it may be
useful to obtain a urine or blood drug screen  or other appropriate laboratory evaluation.
Symptoms that occur during or shortly after (i.e., within 4 weeks of) substance intoxication
or withdrawal or after medication use may be  especially indicative of a substance/medi-
cation-induced anxiety disorder, depending on  the type, duration, or amount of the sub-
stance used. If the disturbance is associate d with both another medical condition and
substance use, both diagnoses (i.e., anxiety disorder due to anothe r medical condition and
substance/medication-induced an xiety disorder) can be given. Features such as onset af-
ter age 45 years or the presence of atypical symptoms during a panic attack (e.g., vertigo,
loss of consciousness, loss of bladder or bowe l control, slurred speech, amnesia) suggest
the possibility that another medical condition or  a substance may be causing the panic at-
tack symptoms.
Anxiety disorder (not due to a known medical condition). Anxiety disorder due to an-
other medical condition should be distinguis hed from other anxiety disorders (especially
panic disorder and generalized anxiety disorder). In other anxiety disorders, no specific
and direct causative physiological mechanisms  associated with anot her medical condition


and direct causative physiological mechanisms  associated with anot her medical condition
can be demonstrated. Late age at onset, atyp ical symptoms, and the absence of a personal
or family history of anxiety disorders suggest the need for a thorough assessment to rule
out the diagnosis of anxiety diso rder due to another medical condition. Anxiety disorders
can exacerbate or pose increased risk for me dical conditions such as cardiovascular events
and myocardial infarction and should not be diagnosed as anxiety disorder due to another
medical condition in these cases.
Illness anxiety disorder. Anxiety disorder due to anothe r medical condition should be
distinguished from illness anxiety disorder. Illness anxiety disorder is characterized by
worry about illness, concern about pain, and bod ily preoccupations. In the case of illness
anxiety disorder, individuals may or may not have diagnosed medical conditions. Al-
though an individual with illness anxiety di sorder and a diagnose d medical condition is
likely to experience anxiety about the medical condition, the medical condition is not
physiologically related to the anxiety symptoms.
Adjustment disorders. Anxiety disorder due to another medical condition should be
distinguished from adjustment disorders, with anxiety, or with anxiety and depressed
mood. Adjustment diso rder is warranted when individual s experience a maladaptive re-
sponse to the stress of having another medical condition. The reaction to stress usually
concerns the meaning or consequences of the stress, as compared with the experience of
anxiety or mood symptoms that occur as a phy siological consequence of the other medical
condition. In adjustment disorder, the anxi ety symptoms are typically related to coping
with the stress of having a general medical condition, whereas in anxiety disorder due to
another medical condition, individuals are more likely to have prominent physical symp-
toms and to be focused on issues other than the stress of the illness itself.


toms and to be focused on issues other than the stress of the illness itself.
Associated feature of another mental disorder. Anxiety symptoms may be an associ-
ated feature of another ment al disorder (e.g., schizo phrenia, anorexia nervosa).


Associated feature of another mental disorder. Anxiety symptoms may be an associ-
ated feature of another ment al disorder (e.g., schizo phrenia, anorexia nervosa).
Other specified or unspeci fied anxiety disorder. This diagnosis is given if it cannot be
determined whether the anxiety symptoms are primary, substance-induced, or associated
with another medical condition.


Other Specified Anxiety Disorder 233
Other Specified Anxiety Disorder
300.09 (F41.8)
This category applies to presentations in which symptoms characteristic of an anxiety dis-
order that cause clinically significant distre ss or impairment in social, occupational, or oth-
er important areas of functioning predominate but do not meet the full criteria for any of the
disorders in the anxiety disorders diagnostic class. The other specified anxiety disorder
category is used in situations in which the clinician chooses to communicate the specific
reason that the presentation does not meet the criteria for any specific anxiety disorder.
This is done by recording “other specified anxiety disorder” followed by the specific reason
(e.g., “generalized anxiety not occurring more days than not”).
Examples of presentations that can be specified using the “other specified” designation
include the following:
1.Limited-symptom attacks.
2.Generalized anxiety not occurring more days than not.
3.Khyâl cap  (wind attacks):  See “Glossary of Cultural Concepts of Distress” in the Ap-
pendix.
4.Ataque de nervios  (attack of nerves): See “Glossary of Cultural Concepts of Distress”
in the Appendix.
Unspecified Anxiety Disorder
300.00 (F41.9)
This category applies to presentations in which symptoms characteristic of an anxiety dis-
order that cause clinically significant distre ss or impairment in social, occupational, or oth-
er important areas of functioning predominate but do not meet the full criteria for any of the
disorders in the anxiety disorders diagnostic cl ass. The unspecified anxiety disorder cate-
gory is used in situations in which the clinician chooses not to specify the reason that the
criteria are not met for a specific anxiety disorder, and includes presentations in which


criteria are not met for a specific anxiety disorder, and includes presentations in which
there is insufficient information to make a more specific diagnosis (e.g., in emergency room
settings).


235 Obsessive-Compulsive and
Related Disorders
Obsessive-compulsive  and related disorders in clude obsessive-compulsive
disorder (OCD), body dysmor phic disorder, hoarding diso rder, trichotillomania (hair-
pulling disorder), excoriation (skin-picking) disorder, substance/medication-induced ob-
sessive-compulsive and related disorder, obsessive-compulsive and related disorder due
to another medical condition, and other spec ified obsessive-compulsive and related dis-
order and unspecified obsessive-compulsive and related disorder (e.g ., body-focused re-
petitive behavior disorder, obsessional jealousy).
OCD is characterized by the presence of obsessions and/or compulsions. Obsessions
are recurrent and persistent th oughts, urges, or images that are experienced as intrusive
and unwanted, whereas compulsions  are repetitive behaviors or mental acts that an indi-
vidual feels driven to perform in response to  an obsession or according to rules that must
be applied rigidly. Some other obsessive-comp ulsive and related disorders are also char-
acterized by preoccupations and by repetitive behaviors or mental acts in response to the
preoccupations. Other obsessive-compulsive and related disorders are characterized pri-
marily by recurrent body -focused repetitive behaviors (e.g.,  hair pulling, sk in picking) and
repeated attempts to decrease or stop the behaviors.
The inclusion of a chapter on  obsessive-compulsive and rela ted disorders in DSM-5 re-
flects the increasing evidence of these disorders’ relatedness to one an other in terms of a
range of diagnostic validators as well as the c linical utility of grouping these disorders in
the same chapter. Clinicians are encouraged to  screen for these cond itions in individuals


the same chapter. Clinicians are encouraged to  screen for these cond itions in individuals
who present with one of them and be aware of overlaps between these conditions. At the
same time, there are important differences in  diagnostic validators and treatment ap-
proaches across these disorders. Moreover, there are close relationships between the anx-
iety disorders and some of the obsessive-compulsive and related disorders (e.g., OCD),
which is reflected in the sequence of DSM-5 chapters, with obsessive-compulsive and re-
lated disorders following anxiety disorders.
The obsessive-compulsive and related diso rders differ from developmentally norma-
tive preoccupations and rituals by being exce ssive or persisting beyond developmentally
appropriate periods. The distinction between the presence of subclinical symptoms and a
clinical disorder requires assessment of a nu mber of factors, including the individual’s
level of distress and impa irment in functioning.
The chapter begins with OCD. It then co vers body dysmorphic disorder and hoarding
disorder, which are characterized by cognit ive symptoms such as perceived defects or
flaws in physical appearance or the perceived need to save possessions, respectively. The
chapter then covers trichotillomania (hair-pulling disorder) and excoriation (skin-picking)
disorder, which are characterized by recurrent body-focused repetitive behaviors. Finally,
it covers substance/medication-induced obsessive-compulsive an d related disorder,
obsessive-compulsive and relate d disorder due to another me dical condition, and other
specified obsessive-compulsive and related disorder and unspecified obsessive-compul-
sive and related disorder.
While the specific content of obsessions and compulsions varies among individuals,
certain symptom dimensions are common in OCD, including th ose of cleaning (contami-


certain symptom dimensions are common in OCD, including th ose of cleaning (contami-
nation obsessions and cleaning compulsions); symmetry (symmetry obsessions and repeat-


236 Obsessive-Compulsive and Related Disorders
ing, ordering, and counting compulsions); fo rbidden or taboo thoug hts (e.g., aggressive,
sexual, and religious obsessions and related co mpulsions); and harm (e .g., fears of harm to
oneself or others and related checking comp ulsions). The tic-related specifier of OCD is
used when an individual has a curren t or past history of a tic disorder.
Body dysmorphic disorder is characterize d by preoccupation with one or more per-
ceived defects or flaws in physical appearance that are not observable or appear only slight
to others, and by repetitive  behaviors (e.g., mirror checking, excessive grooming, skin
picking, or reassurance seeking) or mental acts (e.g., comparing one’s appearance with that
of other people) in response to the appear ance concerns. The appearance preoccupations
are not better explained by concerns with body fat or weight in an individual with an eat-
ing disorder. Muscle dysmorphia is a form of body dysmorphic disord er that is character-
ized by the belief that one’s body build is too small or is insu fficiently muscular.
Hoarding disorder is characterized by persis tent difficulty discarding or parting with
possessions, regardless of their actual value, as a result of a strong perceived need to save
the items and to distress associated with disc arding them. Hoarding disorder differs from
normal collecting. For example, symptoms of hoarding disorder result in the accumula-
tion of a large number of possessions that co ngest and clutter active living areas to the ex-
tent that their intended use is substantially  compromised. The excessive acquisition form
of hoarding disorder, which characterizes most  but not all individuals with hoarding dis-


of hoarding disorder, which characterizes most  but not all individuals with hoarding dis-
order, consists of excessive collecting, buying , or stealing of items that are not needed or
for which there is no available space.
Trichotillomania (hair-pulling disorder) is characterized by recurrent pulling out of
one's hair resulting in hair loss, and repeated  attempts to decrease or stop hair pulling.
Excoriation (skin-picking) disord er is characterized by recurrent picking of one’s skin re-
sulting in skin lesions and repeated attempts to decrease or stop skin picking. The body-
focused repetitive behaviors that characterize  these two disorders are not triggered by ob-
sessions or preoccupations; however, they ma y be preceded or accompanied by various
emotional states, such as feelin gs of anxiety or boredom. They may also be preceded by an
increasing sense of tension or may lead to gr atification, pleasure, or  a sense of relief when
the hair is pulled out or the skin is picked. In dividuals with these disorders may have vary-
ing degrees of conscious awareness of the beha vior while engaging in it, with some indi-
viduals displaying more focused attention on  the behavior (with preceding tension and
subsequent relief) and other individuals displaying more automatic behavior (with the be-
haviors seeming to occur without full awareness).
Substance/medication-i nduced obsessive-compulsive an d related disorder consists of
symptoms that are due to substance intoxicati on or withdrawal or to a medication. Obses-
sive-compulsive and related disorder due to another medica l condition involves symptoms
characteristic of obsessive-comp ulsive and related disorders th at are the direct pathophysio-
logical consequence of a medical disorder. Othe r specified obsessive-compulsive and related


logical consequence of a medical disorder. Othe r specified obsessive-compulsive and related
disorder and unspecified obsessive-compulsive and related disorder consist of symptoms
that do not meet criteria for a specific obse ssive-compulsive and related disorder because of
atypical presentation or uncertain etiology; th ese categories are also used for other specific
syndromes that are not listed in Section II and when insufficient information is available to di-
agnose the presentation as another obsessive -compulsive and related disorder. Examples of


syndromes that are not listed in Section II and when insufficient information is available to di-
agnose the presentation as another obsessive -compulsive and related disorder. Examples of
specific syndromes not listed in Section II, an d therefore diagnosed as other specified obses-
sive-compulsive and related disorder or as unspecified obsessive-co mpulsive and related
disorder include body-focused  repetitiv e behavior disord er and obsessional jealousy.
Obsessive-compulsive and relate d disorders that have a cognitive component have in-
sight as the basis for specifiers; in each of th ese disorders, insight ranges from “good or fair
insight” to “poor insight” to “absent insight/ delusional beliefs” with respect to disorder-
related beliefs. For individuals whose obsess ive-compulsive and related disorder symp-
toms warrant the “with absent insight/delu sional beliefs” specifier, these symptoms
should not be diagnosed as a psychotic disorder.


Obsessive-Compulsive Disorder 237
Obsessive-Compulsive Disorder
Diagnostic Criteria 300.3 (F42)
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some
time during the disturbance, as intrusive and unwanted, and that in most individuals
cause marked anxiety or distress.
2. The individual attempts to ignore or suppres s such thoughts, urges, or images, or to
neutralize them with some other thought or  action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g.,
praying, counting, repeating words silently ) that the individual feels driven to per-
form in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or dis-
tress, or preventing some dreaded event or situation; however, these behaviors or
mental acts are not connected in a realistic way with what they are designed to neu-
tralize or prevent, or are clearly excessive.
Note:  Young children may not be able to articulate the aims of these behaviors or
mental acts.
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per
day) or cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects
of a substance (e.g., a drug of abuse, a medication) or another medical condition.


D. The disturbance is not better explained by the symptoms of another mental disorder
(e.g., excessive worries, as in generalized anxiety disorder; preoccupation with ap-
pearance, as in body dysmorphic disorder; difficulty discarding or parting with posses-
sions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder];
skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic
movement disorder; ritualized eating behavior, as in eating disorders; preoccupation
with substances or gambling, as in substance-related and addictive disorders; preoc-
cupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies,
as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct dis-
orders; guilty ruminations, as in major depressive disorder; thought insertion or delu-
sional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or
repetitive patterns of behavior, as in autism spectrum disorder).
Specify if:
With good or fair insight:  The individual recognizes that obsessive-compulsive dis-
order beliefs are definitely or probably not true or that they may or may not be true.
With poor insight:  The individual thinks obsessive-compulsive disorder beliefs are
probably true.
With absent insight/delusional beliefs:  The individual is completely convinced that
obsessive-compulsive disorder beliefs are true.
Specify if:
Tic-related:  The individual has a current or past history of a tic disorder.


238 Obsessive-Compulsive and Related Disorders
Specifiers
Many individuals with obsessive-compulsive disorder (OCD) have dysfunctional beliefs.
These beliefs can include an inflated sense of responsibility and the tendency to overesti-
mate threat; perfectionism and intolerance of uncertainty; an d over-importance of thoughts
(e.g., believing that having a fo rbidden thought is as bad as acting on it) and the need to
control thoughts.
Individuals with OCD vary in the degree of insight they have about the accuracy of the
beliefs that underlie their obsessive-compulsive symptoms. Many individuals have good or
fair insight  (e.g., the individual believes that the house definitely will not, probably will not,
or may or may not burn down if the stove is not checked 30 times). Some have poor insight
(e.g., the individual believes that the house w ill probably burn down if the stove is not
checked 30 times), and a few (4% or less) have absent insight/delu sional beliefs  (e.g., the in-
dividual is convinced that the house will burn down if the stove is not checked 30 times).
Insight can vary within an individual over the course of the illness. Poorer insight has been
linked to worse long-term outcome.
Up to 30% of individuals with OCD have a lifetime tic disorder. This is most common
in males with onset of OCD in childhood. Thes e individuals tend to differ from those with-
out a history of tic disorders in the themes of their OCD sy mptoms, comorbidity, course,
and pattern of fam ilial transmission.
Diagnostic Features
The characteristic symptoms of OCD are the pr esence of obsessions and compulsions (Cri-
terion A). Obsessions  are repetitive and persistent thoughts (e.g., of contamination), images


(e.g., of violent or horrific scenes), or urges (e.g., to stab someone) . Importantly, obsessions
are not pleasurable or experi enced as voluntary: they ar e intrusive and unwanted and
cause marked distress or anxiety in most indi viduals. The individual attempts to ignore or
suppress these obsessions (e.g., avoiding tri ggers or using thought suppression) or to neu-
tralize them with another thought or ac tion (e.g., performing a compulsion). Compulsions
(or rituals) are repetitive behaviors (e.g., washing, checking) or mental acts (e.g., counting,
repeating words silently) that the individual feels driven to perform in response to an
obsession or according to rules that must be  applied rigidly. Most individuals with OCD
have both obsessions and compulsions. Comp ulsions are typically performed in response
to an obsession (e.g., thoughts of contaminatio n leading to washing rituals or that some-
thing is incorrect leading to repeating rituals unt il it feels “just right”). The aim is to reduce
the distress triggered by obsessions or to pr event a feared event (e.g., becoming ill). How-
ever, these compulsions either are not connected in a realistic way to the feared event (e.g.,
arranging items symmetrically to prevent harm  to a loved one) or are clearly excessive
(e.g., showering for hours each day). Compulsions are not done for pleasure, although some
individuals experience relief from anxiety or distress.
Criterion B emphasizes that obsessions and compulsions must be time-consuming (e.g.,
more than 1 hour per day) or cause clinically significant distress or impairment to warrant
a diagnosis of OCD. This criterion helps to distinguish the disorder from the occasional in-
trusive thoughts or repetitive behaviors that  are common in the general population (e.g.,


trusive thoughts or repetitive behaviors that  are common in the general population (e.g.,
double-checking that a door is locked). The frequency and severity of obsessions and com-
pulsions vary across individuals with OCD (e.g., some have mild to moderate symptoms,
spending 1–3 hours per day obsessing or doin g compulsions, where as others have nearly
constant intrusive thoughts or comp ulsions that can be  incapacitating).
Associated Features Supporting Diagnosis
The specific content of obsessions and comp ulsions varies between individuals. However,


Associated Features Supporting Diagnosis
The specific content of obsessions and comp ulsions varies between individuals. However,
certain themes, or dimensions, are common, including those of cleaning (contamination
obsessions and cleaning compulsions); sy mmetry (symmetry obsess ions and repeating,


Obsessive-Compulsive Disorder 239
ordering, and counting compulsions); forbidden or taboo th oughts (e.g., aggressive, sexual,
or religious obsessions and related compulsions) ; and harm (e.g., fears of harm to oneself
or others and checking compulsions). Some individuals also  have difficulties discarding
and accumulate (hoard) object s as a consequence of typical obsessions and compulsions,
such as fears of harming othe rs. These themes occur across different cultures, are rela-
tively consistent over time in adults with th e disorder, and may be as sociated with differ-
ent neural substrates. Importantly, individu als often have symptoms  in more than one
dimension.
Individuals with OCD experience a range of  affective responses when confronted with
situations that trigger obsessions and compul sions. For example, many individuals expe-
rience marked anxiety that can include recurren t panic attacks. Others report strong feel-
ings of disgust. While perfor ming compulsions, some individuals report a distressing
sense of “incompleteness” or uneasiness unt il things look, feel, or sound “just right.”
It is common for individuals with the disorder to avoid people, places, and things that
trigger obsessions and compulsions. For example, individuals with contamination con-
cerns might avoid public situat ions (e.g., restaurants, public  restrooms) to reduce ex-
posure to feared contaminants; individuals with intrusive thoughts about causing harm
might avoid social interactions.
Prevalence
The 12-month prevalence of OCD in the United St ates is 1.2%, with a similar prevalence in-
ternationally (1.1%–1.8%). Females are affected  at a slightly higher rate than males in


adulthood, although males are more commonly affected in childhood.
Development and Course
In the United States, the mean age at onset of OCD is 19.5 years, and 25% of cases start by
age 14 years. Onset after age 35 years is unusual but does occur. Males have an earlier age
at onset than females: nearly 25% of males have onset before age 10 years. The onset of
symptoms is typically gradual; however,  acute onset has also been reported.
If OCD is untreated, the cour se is usually chronic, often with waxing and waning symp-
toms. Some individuals have an episodic course, and a minority have a deteriorating
course. Without treatment, remission rates in  adults are low (e.g., 20% for those reevalu-
ated 40 years later). Onset in childhood or adolescence can le ad to a lifetim e of OCD. How-
ever, 40% of individuals with onset of OCD in childhood or adolescence may experience
remission by early adulthood. The course of OCD is often complicated by the co-occurrence
of other disorders (see section “C omorbidity” for this disorder).
Compulsions are more easily diagnosed in  children than obsessions are because com-
pulsions are observable. However, most childr en have both obsessions and compulsions
(as do most adults). The pattern  of symptoms in adults can be stable over time, but it is
more variable in children. Some differences in the content of obsessions and compulsions
have been reported when children and adol escent samples have been compared with
adult samples. These differences likely refl ect content appropriate to different develop-
mental stages (e.g., higher rates of sexual an d religious obsessions in adolescents than in


mental stages (e.g., higher rates of sexual an d religious obsessions in adolescents than in
children; higher rates of harm obsessions [e.g ., fears of catastrophic events, such as death
or illness to self or loved ones] in ch ildren and adolescents than in adults).
Risk and Prognostic Factors
Temperamental. Greater internalizing symptoms, hi gher negative emotionality, and
behavioral inhibition in childhood are possible temperamental risk factors.
Environmental. Physical and sexual abuse in childho od and other stressful or traumatic
events have been associated with an increased risk for de veloping OCD. Some children


240 Obsessive-Compulsive and Related Disorders
may develop the sudden onset of obsessive- compulsive symptoms, which has been asso-
ciated with different environmental factors,  including various infectious agents and a
post-infectious auto immune syndrome.
Genetic and physiological. The rate of OCD among first-degree relatives of adults with
OCD is approximately two times that among fi rst-degree relatives of those without the
disorder; however, among first-degree relatives of individuals with onset of OCD in child-
hood or adolescence, the rate is increased 10-fold. Familial transmission is due in part to
genetic factors (e.g., a concordance rate of 0.57  for monozygotic vs. 0.22  for dizygotic twins).
Dysfunction in the orbitofrontal cortex, anteri or cingulate cortex, and striatum have been
most strongly implicated.
Culture-Related Diagnostic Issues
OCD occurs across the world. There is substant ial similarity across cultures in the gender
distribution, age at onset, and comorbidity of OCD. Moreover, around the globe, there is a
similar symptom structure in volving cleaning, symmetry, hoarding, taboo thoughts, or
fear of harm. However, regional variation in symptom expression exists, and cultural
factors may shape the content of obsessions and compulsions.
Gender-Related Diagnostic Issues
Males have an earlier age at onset of OCD than females and are more likely to have co-
morbid tic disorders. Gender differences in the pattern of symptom dimensions have been
reported, with, for example, females more likel y to have symptoms in the cleaning dimen-
sion and males more likely to have symptoms in the forbidden thoughts and symmetry di-
mensions. Onset or exacerbation of OCD, as well as symptoms that can interfere with the


mother-infant relationship (e.g., aggressive ob sessions leading to avoidance of the infant),
have been reported in the peripartum period.
Suicide Risk
Suicidal thoughts occur at some point in as many as about half of individuals with OCD.
Suicide attempts are also report ed in up to one-quarter of individuals with OCD; the pres-
ence of comorbid major depressiv e disorder increases the risk.
Functional Consequences of
Obsessive-Compu lsive Disorder
OCD is associated with reduced quality of life as  well as high levels of social and occupa-
tional impairment. Impairment occurs across many different domains of life and is asso-
ciated with symptom severity. Impairment can be caused by the time spent obsessing and
doing compulsions. Avoi dance of situations that can tr igger obsessions or compulsions
can also severely restrict functioning. In addition, specific sympto ms can create specific
obstacles. For example, obsessions about harm can make relationships with family and
friends feel hazardous; the result can be av oidance of these rela tionships. Obsessions
about symmetry can derail the timely completion of school or work projects because the
project never feels “just right,” potentially resulting in school failure or job loss. Health
consequences can also occur. For example, individuals with contamination concerns may
avoid doctors’ offices and hospit als (e.g., because of fears of exposure to germs) or develop
dermatological problems (e.g., skin lesion s due to excessive washing). Sometimes the
symptoms of the disorder inte rfere with its own treatment (e .g., when medications are con-
sidered contaminated). When th e disorder starts in childhood  or adolescence, individuals
may experience developmental difficulties. Fo r example, adolescents may avoid socializ-


may experience developmental difficulties. Fo r example, adolescents may avoid socializ-
ing with peers; young adults may struggle when they leave home to live independently.


Obsessive-Compulsive Disorder 241
The result can be few significant relationship s outside the family and a lack of autonomy
and financial independence from their family of origin. In addition, some individuals with
OCD try to impose rules and prohibitions on  family members beca use of their disorder
(e.g., no one in the family can have visitors to the house for fear of contamination), and this
can lead to family dysfunction.
Differential Diagnosis
Anxiety disorders. Recurrent thoughts, avoidant behavi ors, and repetitive requests for
reassurance can also occur in anxiety disorders. Ho wever, the recurrent thoughts that are
present in generalized anxiety disorder (i.e., worries) are usually ab out real-life concerns,
whereas the obsessions of OCD usually do no t involve real-life concerns and can include
content that is odd, irrational, or of a se emingly magical nature; moreover, compulsions
are often present and usually linked to the obsessions. Like individuals with OCD, indi-
viduals with specific phobia can have a fear re action to specific objects or situations; how-
ever, in specific phobia the feared object is usually much more circ umscribed, and rituals
are not present. In social anxiety disorder (social phobia), the feared objects or situations
are limited to social interactions, and avoida nce or reassurance seeking is focused on re-
ducing this social fear.
Major depressive disorder. OCD can be distinguished from the rumination of major
depressive disorder, in whic h thoughts are usually mood-c ongruent and not necessarily
experienced as intrusive or distressing; mo reover, ruminations are not linked to compul-
sions, as is typical in OCD.
Other obsessive-compulsive and related disorders. In body dysmorphic disorder, the


Other obsessive-compulsive and related disorders. In body dysmorphic disorder, the
obsessions and compulsions are limited to concerns about physical appearance; and in
trichotillomania (hair-pulling diso rder), the compulsive behavior is limited to hair pulling
in the absence of obsessions. Hoarding diso rder symptoms focus exclusively on the per-
sistent difficulty discarding or parting with  possessions, marked distress associated with
discarding items, and excessive accumulation of  objects. However, if an individual has ob-
sessions that are typical of OCD (e.g., concer ns about incompleteness or harm), and these
obsessions lead to compulsive hoarding behaviors (e.g., acquirin g all objects in a set to at-
tain a sense of completeness or not discarding old newspape rs because they may contain
information that could prevent harm), a di agnosis of OCD should be given instead.
Eating disorders. OCD can be distinguished from anorexia nervosa in that in OCD the
obsessions and compulsions are not limite d to concerns about weight and food.
Tics (in tic disorder) and stereotyped movements. A tic is a sudden, rapid, recurrent,
nonrhythmic motor movement or vocalization (e.g., eye blinking, th roat clearing). A ste-
reotyped movement  is a repetitive, seemingly driven, nonfunctional motor behavior (e.g.,
head banging, body rocking,  self-biting). Tics and ster eotyped movements are typically
less complex than compulsions and are not aimed at neutralizing obsessions. However,
distinguishing between complex tics and comp ulsions can be difficult. Whereas compul-
sions are usually preceded by obsessions, tics  are often preceded by premonitory sensory


urges. Some individuals have symptoms of both OCD and a tic disorder, in which case
both diagnoses may be warranted.
Psychotic disorders. Some individuals with OCD have poor insight or even delusional
OCD beliefs. However, they have obsessions and compulsions (disting uishing their
condition from delusional diso rder) and do not have other features of schizophrenia or
schizoaffective disorder (e.g., hallucinations or formal thought disorder).
Other compulsive-like behaviors. Certain behaviors are sometimes described as “com-
pulsive,” including sexual behavior (in the ca se of paraphilias), ga mbling (i.e., gambling


242 Obsessive-Compulsive and Related Disorders
disorder), and substance use (e.g., alcohol us e disorder). However, these behaviors differ
from the compulsions of OCD in that the pers on usually derives pleasure from the activity
and may wish to resist it only beca use of its deleterious consequences.
Obsessive-compulsive personality disorder. Although obsessive-compulsive person-
ality disorder and OCD have similar names, the clinical manifestations of these disorders
are quite different. Obsessive- compulsive personality disorder is not characterized by in-
trusive thoughts, images, or ur ges or by repetitive behavior s that are performed in re-
sponse to these intrusions; instead, it in volves an enduring and pervasive maladaptive
pattern of excessive perfectionism and rigid co ntrol. If an individual manifests symptoms
of both OCD and obsessive-compulsive persona lity disorder, both diagnoses can be given.
Comorbidity
Individuals with OCD often have other psycho pathology. Many adults with the disorder
have a lifetime diagnosis of an anxiety disord er (76%; e.g., panic disorder, social anxiety
disorder, generalized anxiety disorder, specific  phobia) or a depressive or bipolar disorder
(63% for any depressive or bipolar disorder, with the most common being major depres-
sive disorder [41%]). Onset of OCD is usually later than for most co morbid anxiety disor-
ders (with the exception of separation anxiet y disorder) and PTSD bu t often precedes that
of depressive disorders. Comorbid obsessi ve-compulsive personality disorder is also
common in individuals with OCD (e.g., ranging from 23% to 32%).
Up to 30% of individuals with OCD also have a lifetime tic disorder. A comorbid tic
disorder is most common in males with onset of OCD in childhood. These individuals


disorder is most common in males with onset of OCD in childhood. These individuals
tend to differ from those without a history of tic disorders in the themes of their OCD
symptoms, comorbidity, course, and pattern of familial transmission. A triad of OCD, tic
disorder, and attention-deficit/hyperactivit y disorder can also be seen in children.
Disorders that occur more frequently in individuals with OCD than in those without
the disorder include several obsessive-compulsive and related disorders such as body
dysmorphic disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-pick-
ing) disorder. Finally, an association betw een OCD and some disorders characterized by
impulsivity, such as oppositional de fiant disorder, has been reported.
OCD is also much more common in individuals with certain other disorders than
would be expected based on its prevalence in  the general population ; when one of those
other disorders is diagnosed, the individual should be assessed for OCD as well. For ex-
ample, in individuals with schizophrenia or  schizoaffective disorder, the prevalence of
OCD is approximately 12%. Rates of OCD are also  elevated in bipolar disorder; eating dis-
orders, such as anorexia nervosa and bu limia nervosa; and Tourette’s disorder.
Body Dysmorphic Disorder
Diagnostic Criteria 300.7 (F45.22)
A. Preoccupation with one or more perceived defects or flaws in physical appearance that
are not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed repetitive
behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seek-
ing) or mental acts (e.g., comparing his or her appearance with that of others) in re-


sponse to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social, occu-
pational, or other important areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or
weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.


Body Dysmorphic Disorder 243
Specify if:
With muscle dysmorphia:  The individual is preoccupied with the idea that his or her
body build is too small or insufficiently muscular. This specifier is used even if the indi-
vidual is preoccupied with other body areas, which is often the case.
Specify if:
Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., “I look ugly” or
“I look deformed”).
With good or fair insight:  The individual recognizes that the body dysmorphic disor-
der beliefs are definitely or probably not true or that they may or may not be true.
With poor insight:  The individual thinks that the body dysmorphic disorder beliefs are
probably true.
With absent insight/delusional beliefs:  The individual is completely convinced that
the body dysmorphic disorder beliefs are true.
Diagnostic Features
Individuals with body dysmorphic disorder (formerly known as dysmorphophobia ) are pre-
occupied with one or more perceived defects or flaws in their physical appearance, which
they believe look ugly, unattractive, abnormal , or deformed (Criterion A). The perceived
flaws are not observable or appear only slig ht to other individuals. Concerns range from
looking “unattractive” or “not  right” to looking “hideous” or “like a monster.” Preoccu-
pations can focus on one or many body are as, most commonly the skin (e.g., perceived
acne, scars, lines, wrinkles, paleness), hair (e.g., “thinning” hair or “e xcessive” body or fa-
cial hair), or nose (e.g., size or shape). Howe ver, any body area can be the focus of concern


(e.g., eyes, teeth, weight, stomach, breasts, le gs, face size or shape, lips, chin, eyebrows,
genitals). Some individuals are concerned abou t perceived asymmetry of body areas. The
preoccupations are intrusive,  unwanted, time-consuming (occurring, on average, 3–8
hours per day), and usually diff icult to resist or control.
Excessive repetitive behaviors or mental ac ts (e.g., comparing) are performed in re-
sponse to the preoccupation (Criterion B). The individual feels driven to perform these be-
haviors, which are not pleasurable and may increase anxiety and dysphoria. They are
typically time-consuming and difficult to re sist or control. Common behaviors are com-
paring one’s appearance with that of other individuals; repeatedly checking perceived
defects in mirrors or other reflecting surf aces or examining them directly; excessively
grooming (e.g., combing, stylin g, shaving, plucking, or pull ing hair); camouflaging (e.g.,
repeatedly applying makeup or covering dislik ed areas with such things as a hat, clothing,
makeup, or hair); seeking reassurance about how the perceived flaws look; touching dis-
liked areas to check them; excessively exerci sing or weight lifting; and seeking cosmetic
procedures. Some individuals exce ssively tan (e.g., to darken “pale” skin or diminish per-
ceived acne), repeatedly change their clothe s (e.g., to camouflage perceived defects), or
compulsively shop (e.g., for beauty produc ts). Compulsive skin picking intended to
improve perceived skin defects is common and can cause skin damage, infections, or
ruptured blood vessels. The preoccupation must cause clinically significant distress or im-


ruptured blood vessels. The preoccupation must cause clinically significant distress or im-
pairment in social, occupational, or other important areas of functioning (Criterion C);
usually both are present. Body dysmorphic diso rder must be differentiated from an eating
disorder.
Muscle dysmorphia, a form of body dysmorphic disorder occurring almost exclusively
in males, consists of preoccup ation with the idea that one’s body is too small or insuffi-
ciently lean or muscular. Individuals with this  form of the disorder actually have a nor-
mal-looking body or are even very muscular . They may also be preoccupied with other
body areas, such as skin or hair. A majority (b ut not all) diet, exerc ise, and/or lift weights
excessively, sometimes causing bodily damage . Some use potentially dangerous anabolic-


244 Obsessive-Compulsive and Related Disorders
androgenic steroids and other substances to try to make their body bigger and more mus-
cular. Body dysmorphic disorder by proxy is a form of body dy smorphic disorder in
which individuals are preoccupied with defects they perceive in another person’s appear-
ance.
Insight regarding body dysmorphic disorder  beliefs can range from good to absent/
delusional (i.e., delusional beliefs consisting of complete conviction that the individual’s
view of their appearance is accurate and un distorted). On average, insight is poor; one-
third or more of individuals currently have delusional body dysmorphic disorder beliefs.
Individuals with delusional body dysmorphic di sorder tend to have greater morbidity in
some areas (e.g., suicidality), but this appears accounted fo r by their tendency to have
more severe body dysmorphic disorder symptoms.
Associated Features Supporting Diagnosis
Many individuals with body dysmorphic disord er have ideas or delusions of reference,
believing that other people take special notice  of them or mock them because of how they
look. Body dysmorphic disorder is associated with high levels of anxiety, social anxiety,
social avoidance, depressed mood, neuroticism, and perfectionism as well as low extro-
version and low self-esteem. Many individuals are ashamed of their appearance and their
excessive focus on how they look, and are relu ctant to reveal their concerns to others. A
majority of individuals receiv e cosmetic treatment to try to  improve their perceived de-
fects. Dermatological treatment and surgery ar e most common, but any type (e.g., dental,
electrolysis) may be received . Occasionally, individuals may perform surgery on them-
selves. Body dysmorphic disorder appears to respond poorly to  such treatments and


selves. Body dysmorphic disorder appears to respond poorly to  such treatments and
sometimes becomes worse. Some individuals ta ke legal action or are violent toward the
clinician because they are dissat isfied with the cosmetic outcome.
Body dysmorphic disorder has been associat ed with executive dysfunction and visual
processing abnormalities, with a bias for an alyzing and encoding details rather than ho-
listic or configural aspects of vi sual stimuli. Individuals with this disorder tend to have a
bias for negative and threatening interpretati ons of facial expressions and ambiguous sce-
narios.
Prevalence
The point prevalence among U.S.  adults is 2.4% (2.5% in females and 2.2% in males). Out-
side the United States (i.e., Germany), cu rrent prevalence is approximately 1.7%–1.8%,
with a gender distribution similar to that in  the United States. The current prevalence is
9%–15% among dermatology patients, 7%–8% am ong U.S. cosmetic surgery patients, 3%–
16% among international cosmetic surgery patients (most studies), 8% among adult orth-
odontia patients, and 10% among patients presenting for oral or maxillofacial surgery.
Development and Course
The mean age at disorder onset is 16–17 years, the median age at onset is 15 years, and the
most common age at onset is 12–13 years. Two-thirds of individuals have disorder onset
before age 18. Subclinical body dysmorphic diso rder symptoms begin, on average, at age
12 or 13 years. Subclinical concerns usually ev olve gradually to the full disorder, although
some individuals experience abrupt onset of body dysmorphic disorder. The disorder


some individuals experience abrupt onset of body dysmorphic disorder. The disorder
appears to usually be chronic, although improvement is likely when evidence-based
treatment is received. The disorder’s clinical features appear largely similar in children/
adolescents and adults. Body dysm orphic disorder occurs in th e elderly, but little is known
about the disorder in this age group. Individu als with disorder onset before age 18 years
are more likely to attempt suicide, have more comorbidity, and have  gradual (rather than
acute) disorder onset than those with adult-onset body dysmorphic disorder.


Body Dysmorphic Disorder 245
Risk and Prognostic Factors
Environmental. Body dysmorphic disorder has been as sociated with high rates of child-
hood neglect and abuse.
Genetic and physiological. The prevalence of body dysmor phic disorder is elevated in
first-degree relatives of individuals with  obsessive-compulsi ve disorder (OCD).
Culture-Related Diagnostic Issues
Body dysmorphic disorder has be en reported internationally. It appears that the disorder
may have more similarities th an differences across races and cultures but that cultural
values and preferences may influence symptom content to some degree. Taijin kyofusho,
included in the traditional Japanese diagnost ic system, has a subtype similar to body dys-
morphic disorder: shubo-kyofu  (“the phobia of a deformed body”).
Gender-Related Diagnostic Issues
Females and males appear to have more similariti es than differences in terms of most clin-
ical features— for example, di sliked body areas, types of repetitive behaviors, symptom
severity, suicidality, comorbidity, illness course, and receipt of cosmetic procedures for
body dysmorphic disorder. However, males ar e more likely to have genital preoccupa-
tions, and females are more likely to have a comorbid eating disord er. Muscle dysmorphia
occurs almost exclusively in males.
Suicide Risk
Rates of suicidal ideation and suicide attemp ts are high in both adults and children/ado-
lescents with body dysmorphic disorder. Furthe rmore, risk for suicide appears high in ad-
olescents. A substantial proportion of individuals attribute suicidal ideation or suicide
attempts primarily to their appearance concerns. Individuals with body dysmorphic dis-
order have many risk factors for completed suic ide, such as high rates of suicidal ideation


order have many risk factors for completed suic ide, such as high rates of suicidal ideation
and suicide attempts, demographic characterist ics associated with suicide, and high rates
of comorbid major depressive disorder.
Functional Consequences of
Body Dysmorphic Disorder
Nearly all individuals with body dysmorphic disorder experience impaired psychosocial
functioning because of their appearance concerns. Impairment can range from moderate
(e.g., avoidance of some social situations) to  extreme and incapacitating (e.g., being com-
pletely housebound). On average, psychosocial functioning and quality of life are mark-
edly poor. More severe body dysmorphic diso rder symptoms are associated with poorer
functioning and quality of life. Most individu als experience impairment in their job, aca-
demic, or role function ing (e.g., as a parent or caregive r), which is often severe (e.g., per-
forming poorly, missing school  or work, not working). About 20% of youths with body
dysmorphic disorder report dropping out of school primarily because of their body dys-
morphic disorder symptoms. Impair ment in social functioning (e.g., social activities, rela-
tionships, intimacy), includ ing avoidance, is common. In dividuals may be housebound
because of their body dysmor phic disorder symptoms, some times for years. A high pro-
portion of adults and adolescents have been psychiatrically hospitalized.
Differential Diagnosis
Normal appearance concerns and cl early noticeable physical defects. Body dysmor-
phic disorder differs from normal appearance  concerns in being characterized by exces-


246 Obsessive-Compulsive and Related Disorders
sive appearance-related preoccupations and re petitive behaviors that are time-consuming,
are usually difficult to resist or control, and ca use clinically significant distress or impair-
ment in functioning. Physical defects that ar e clearly noticeable (i.e., not slight) are not
diagnosed as body dysmorphic disorder. Ho wever, skin picking as a symptom of body
dysmorphic disorder can cause noticeable skin lesions and scarring; in such cases, body dys-
morphic disorder should be diagnosed.
Eating disorders. In an individual with an eating di sorder, concerns ab out being fat are
considered a symptom of the eating disorder  rather than body dysmorphic disorder.
However, weight concerns may occur in body  dysmorphic disorder. Eating disorders and
body dysmorphic disorder can be comorbid, in which case both should be diagnosed.
Other obsessive-compulsive and related disorders. The preoccupations and repetitive
behaviors of body dysmorphic  disorder differ from obsessions and compulsions in OCD
in that the former focus only on appearance. These disorders have other differences, such
as poorer insight in body dysmorphic disorder. When sk in picking is intended to improve
the appearance of perceived skin defects, bo dy dysmorphic disorder, rather than excoria-
tion (skin-picking) disorder, is diagnosed. Wh en hair removal (plucking, pulling, or other
types of removal) is intended to improve pe rceived defects in the appearance of facial
or body hair, body dysmorphic disorder is diagnosed rather than trichotillomania (hair-
pulling disorder).
Illness anxiety disorder. Individuals with body dysmor phic disorder are not preoccu-
pied with having or acquiring a serious illness and do not have particularly elevated levels


pied with having or acquiring a serious illness and do not have particularly elevated levels
of somatization.
Major depressive disorder. The prominent preoccupation with appearance and exces-
sive repetitive behaviors in body dysmorphi c disorder differentiate it from major de-
pressive disorder. However, major depressi ve disorder and depressive symptoms are
common in individuals with body dysmorphic disorder, often appearing to be secondary
to the distress and impairment that body dysmorphic disorder causes. Body dysmorphic
disorder should be diagnosed in  depressed individuals if diag nostic criteria for body dys-
morphic disorder are met.
Anxiety disorders. Social anxiety and avoidance are common in body dysmorphic dis-
order. However, unlike social anxiety disorder (social phobia), agoraphobia, and avoidant
personality disorder, body dy smorphic disorder includes prominent appearance-related
preoccupation, which may be delusional, and repetitive behaviors, and the social anxiety
and avoidance are due to concerns about perceived appearance defects and the belief or
fear that other people will consider these indivi duals ugly, ridicule them, or reject them be-
cause of their physical features. Unlike gene ralized anxiety disorder, anxiety and worry in
body dysmorphic disorder focus on  perceived appearance flaws.
Psychotic disorders. Many individuals with body dy smorphic disorder have delu-
sional appearance beliefs (i.e., complete convic tion that their view of their perceived de-
fects is accurate), which is diagnosed as body dysmorphic disorder, with absent insight/
delusional beliefs, not as delusional disorder. Appearance-related ideas or delusions of
reference are common in body dysmorphic di sorder; however, unlike schizophrenia or
schizoaffective disorder, body dysmorphic disorder involves  prominent appearance pre-


schizoaffective disorder, body dysmorphic disorder involves  prominent appearance pre-
occupations and related repetitive behaviors,  and disorganized behavior and other psy-
chotic symptoms are absent (except for appearance beliefs , which may be delusional).
Other disorders and symptoms. Body dysmorphic disorder should not be diagnosed if
the preoccupation is limited to discomfort with  or a desire to be rid of one’s primary and/


Other disorders and symptoms. Body dysmorphic disorder should not be diagnosed if
the preoccupation is limited to discomfort with  or a desire to be rid of one’s primary and/
or secondary sex characteristics in an individu al with g ender dysphoria or if the preoccu-
pation focuses on the belief th at one emits a foul or offens ive body odor as in olfactory
reference syndrome (which is not a DSM-5 di sorder). Body identity integrity disorder


Hoarding Disorder 247
(apotemnophilia) (which is not a DSM-5 disord er) involves a desire to have a limb ampu-
tated to correct an experience of mismatch be tween a person’s sense of body identity and
his or her actual anatomy. However, the conc ern does not focus on the limb’s appearance,
as it would in body dysmorphic disorder. Koro,  a culturally related disorder that usually
occurs in epidemics in Southeastern Asia, consists  of a fear that the penis (labia, nipples, or
breasts in females) is shrink ing or retracting and will disa ppear into the abdomen, often
accompanied by a belief that death will result . Koro differs from body dysmorphic disor-
der in several ways, including a focus on death rather than preoccupation with perceived
ugliness. Dysmorphic concern  (which is not a DSM-5 disorder) is a much broader construct
than, and is not equivalent to, body dysmorphi c disorder. It involves symptoms reflecting
an overconcern with slight or imagined flaws in appearance.
Comorbidity
Major depressive disorder is the most commo n comorbid disorder, with onset usually af-
ter that of body dysmorphic disorder. Comorb id social anxiety disorder (social phobia),
OCD, and substance-related disorders are also common.
Hoarding Disorder
Diagnostic Criteria 300.3 (F42)
A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
B. This difficulty is due to a perceived need to save the items and to distress associated
with discarding them.
C. The difficulty discarding possessions results in the accumulation of possessions that
congest and clutter active living areas and substantially compromises their intended


congest and clutter active living areas and substantially compromises their intended
use. If living areas are uncluttered, it is only because of the interventions of third parties
(e.g., family members, cleaners, authorities).
D. The hoarding causes clinically significant distress or impairment in social, occupa-
tional, or other important areas of functioning (including maintaining a safe environ-
ment for self and others).
E. The hoarding is not attributable to another medical condition (e.g., brain injury, cere-
brovascular disease, Prader-Willi syndrome).
F. The hoarding is not better explained by the symptoms of another mental disorder (e.g.,
obsessions in obsessive-compulsive disorder, decreased energy in major depressive
disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in
major neurocognitive disorder, restricted interests in autism spectrum disorder).
Specify if:
With excessive acquisition:  If difficulty discarding possessions is accompanied by ex-
cessive acquisition of items that are not needed or for which there is no available space.
Specify if:
With good or fair insight: The individual recognizes that hoarding-related beliefs and
behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are
problematic.
With poor insight : The individual is mostly convinced that hoarding-related beliefs
and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisi-
tion) are not problematic despite evidence to the contrary.
With absent insight/delusional beliefs:  The individual is completely convinced that
hoarding-related beliefs and behaviors (pertaini ng to difficulty discarding items, clutter,
or excessive acquisition) are not problematic despite evidence to the contrary.


248 Obsessive-Compulsive and Related Disorders
Specifiers
With excessive acquisition. Approximately 80%–90% of individuals with hoarding
disorder display excessive acquisition. The most frequent form of acqu isition is excessive
buying, followed by acquisition of free item s (e.g., leaflets, items discarded by others).
Stealing is less common. Some individuals may deny excessive acquisition when first as-
sessed, yet it may appear later during the co urse of treatment. Individuals with hoarding
disorder typically experience distress if they are unable to or are prevented from acquiring
items.
Diagnostic Features
The essential feature of hoarding  disorder is persistent difficulties discarding or parting
with possessions, regardless of their actual value (Criterion A). The term persistent  indi-
cates a long-standing difficulty rather than more transient life circumstances that may lead
to excessive clutter, such as inheriting prop erty. The difficulty in discarding possessions
noted in Criterion A refers to  any form of discarding, including throwing away, selling,
giving away, or recycling. The main reasons given for these difficult ies are the perceived
utility or aesthetic value of the items or stro ng sentimental attachment to the possessions.
Some individuals feel responsi ble for the fate of their possessions and often go to great
lengths to avoid being wasteful. Fears of lo sing important information are also common.
The most commonly saved item s are newspapers, magazines, old clothing, bags, books,
mail, and paperwork, but virtually any item can be saved. The nature of items is not lim-
ited to possessions that most other people would define as useles s or of limited value.
Many individuals collect and save large numbers of valuable things as well, which are of-
ten found in piles mixed with other less valuable items.


ten found in piles mixed with other less valuable items.
Individuals with hoarding disorder purpos efully save possessions and experience dis-
tress when facing the prospect of discarding them (Criterion B). This criterion emphasizes
that the saving of possessions is intentional,  which discriminates hoarding disorder from
other forms of psychopathology that are ch aracterized by the pa ssive accumulation of
items or the absence of distress  when possessions are removed.
Individuals accumulate large numbers of items that fill up and clutter active living ar-
eas to the extent that their intended use is no longer possible (Criterion C). For example,
the individual may not be able to cook in the kitchen, sleep in his or her bed, or sit in a
chair. If the space can be used, it  is only with great difficulty. Clutter  is defined as a large
group of usually unrelated or marginally rela ted objects piled together in a disorganized
fashion in spaces designed for ot her purposes (e.g., tabletops,  floor, hallway). Criterion C
emphasizes the “active” living areas of the ho me, rather than more peripheral areas, such
as garages, attics, or basements, that are so metimes cluttered in homes of individuals with-
out hoarding disorder. However, individuals with hoarding disorder often have posses-
sions that spill beyond the active living areas and can occupy and impair the use of other
spaces, such as vehicles, yards, the workplace,  and friends’ and relatives’ houses. In some
cases, living areas may be uncluttered because of the intervention of third parties (e.g.,
family members, cleaners, loca l authorities). Individuals who have been forced to clear
their homes still have a symptom picture that meets criteria fo r hoarding disorder because


their homes still have a symptom picture that meets criteria fo r hoarding disorder because
the lack of clutter is due to a third-party intervention. Hoarding disorder contrasts with
normative collecting beha vior, which is organized and systematic, even if in some cases
the actual amount of possessions may be similar to the amount accumulated by an indi-
vidual with hoarding disord er. Normative collecting does not produce the clutter, dis-
tress, or impairment typi cal of hoarding disorder.


vidual with hoarding disord er. Normative collecting does not produce the clutter, dis-
tress, or impairment typi cal of hoarding disorder.
Symptoms (i.e., difficulties discarding and/or  clutter) must cause clinically significant
distress or impairment in social, occupational , or other important area s of functioning, in-
cluding maintaining a safe environment for self  and others (Criterion D). In some cases,


Hoarding Disorder 249
particularly when there is poor insight, the individual may not report distress, and the im-
pairment may be apparent only to those arou nd the individual. However, any attempts to
discard or clear the possessions by third pa rties result in high levels of distress.
Associated Features Supporting Diagnosis
Other common features of hoarding disorder include indecisiveness, perfectionism,
avoidance, procrastination, di fficulty planning and organizing tasks, and distractibility.
Some individuals with hoarding disorder live in unsanitary conditions that may be a log-
ical consequence of severely cluttered spaces and/or that are related to planning and or-
ganizing difficulties. Animal hoarding  can be defined as the accumulation of a large number
of animals and a failure to provide minimal st andards of nutrition, sanitation, and veter-
inary care and to act on the de teriorating condition of the an imals (including disease, star-
vation, or death) and the en vironment (e.g., severe overcrowding, extremely unsanitary
conditions). Animal hoarding may be a spec ial manifestation of ho arding disorder. Most
individuals who hoard animals also hoard inan imate objects. The mo st prominent differ-
ences between animal and object hoarding are the extent of unsanitary conditions and the
poorer insight in animal hoarding.
Prevalence
Nationally representative prevalence studies of hoarding disorder are not available. Com-
munity surveys estimate the point prevalence of clinically significant hoarding in the
United States and Europe to be approximately 2%–6%. Hoarding disorder affects both
males and females, but some epidemiological studies have reported a significantly greater
prevalence among males. This contrasts with clinical samples, which are predominantly
female. Hoarding symptoms appear to be almost three times more prevalent in older


female. Hoarding symptoms appear to be almost three times more prevalent in older
adults (ages 55–94 years) compared with younger adults (ages 34–44 years).
Development and Course
Hoarding appears to begin early in life and spans well into the late stages. Hoarding symp-
toms may first emerge around ages 11–15 years, start interfering with the individual’s ev-
eryday functioning by the mid-20s, and cause clinically significant impairment by the
mid-30s. Participants in clinical research stud ies are usually in their 50s. Thus, the severity
of hoarding increases with each decade of lif e. Once symptoms begin, the course of hoard-
ing is often chronic, with few individuals reporting a waxing and waning course.
Pathological hoarding in children appears to be easily distin guished from develop-
mentally adaptive saving and collecting behaviors. Because children and adolescents
typically do not control their living environm ent and discarding behaviors, the possible
intervention of third parties (e.g., parents ke eping the spaces usable and thus reducing in-
terference) should be considered when making the diagnosis.
Risk and Prognostic Factors
Temperamental. Indecisiveness is a prominent featur e of individuals wi th hoarding dis-
order and their first-degree relatives.
Environmental. Individuals with hoarding disorder often retrospectively report stressful
and traumatic life events preceding the onset of the disorder or causing an exacerbation.
Genetic and physiological. Hoarding behavior is familial,  with about 50% of individu-
als who hoard reporting having a relative who also hoards. Twin studies indicate that ap-
proximately 50% of the variability in hoarding behavior is attr ibutable to additive genetic
factors.