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Whereas the specific diagnostic criteria for obsessive- pharmacological treatments exist. The recent transition
compulsive disorder (OCD) have changed in only minor from DSM-IV to DSM-5 has a number of clinical and
ways in the transition from DSM-IV to DSM-5, a more research implications, as several key changes have been
substantial change is that OCD is no longer classified as made concerning OCD. The present article begins
an anxiety disorder. Rather, it is now the flagship
with a description of the nature of obsessional prob-
lemsnot simply the DSM definition of OCD, but
diagnosis of a new diagnostic category: the obsessive-
rather an evidence-based picture of the fundamental
compulsive and related disorders (OCRDs). In this arti-
features of this problem and the mechanisms that serve
cle, we describe the nature of obsessional problems as
to maintain them. We then transition to a discussion of
determined through empirical research before turning
OCD as it is defined in previous editions of the DSM
to a consideration of how OCD is defined in previous and now in DSM-5, before turning a critical eye
editions of the DSM and in DSM-5. We then critically toward changes that were made as well as noteworthy
consider the DSM criteria, as well as the basis for diagnostic issues that were not changed in the transi-
removing OCD from the anxiety disorders and creating tion. The article closes with a consideration of the
the new OCRD category. Finally, we consider the impli- implications of DSM-5 for clinical practice and research
cations of these changes for clinical practice and where OCD is concerned.
research on OCD.
Key words: behavioral therapy, cognitive therapy, THE NATURE OF OBSESSIONAL PROBLEMS
pulsive, obsessive-compulsive disorder. [Clin Psychol Sci Unwanted and distressing intrusive thoughtsoften
Prac 21:221235, 2014] called obsessionsare senseless ideas, images, urges,
doubts, and ideas that the person experiences as repug-
Obsessional problems, and indeed obsessive-compulsive nant, invasive, uncontrollable, guilt-provoking, and
disorder (OCD) as defined in the Diagnostic and Statisti- decidedly persistent (Rachman & Hodgson, 1980).
cal Manual of Mental Disorders (DSM), involve a com- Although highly individualized, the general themes of
plex and heterogeneous collection of thoughts, obsessions usually pertain to contamination, responsibil-
behaviors, and their interplay. While the precise ity for causing (or failing to prevent) harm (to oneself or
etiology remains uncertain, the nature and phenome- others), uncertainty, taboo topics such as sex, violence,
nology of obsessional problems are well researched and and blasphemy, and the need for order and symmetry.
well understood, and effective psychological and The content of obsessions is typically incongruent with
the persons belief system and is not the type of thought
one would expect of him- or herself. In fact, it is typical
Address correspondence to Jonathan S. Abramowitz, PhD, for obsessions to cast a menacing shadow on matters the
Department of Psychology, UNC-Chapel Hill, Campus Box person happens to hold most dear (e.g., a devoutly reli-
3270 (Davie Hall), Chapel Hill, NC 27599. E-mail: jabramo
gious person with recurrent blasphemous images, or a
witz@unc.edu.
2014 American Psychological Association. Published by Wiley Periodicals, Inc., on behalf of the American Psychological Association.
All rights reserved. For permissions, please email: permissionsuk@wiley.com. 221
highly conscientious person with persistent doubts that Clinical observations of individuals with obsessional
he is responsible for injuring an innocent person). Obses- problems reveal an internal consistency in the themes
sions might be triggered by stimuli in the environment of obsessions and the strategies used to resist such
(e.g., a religious icon or driving a car) or occur without mental intrusions. Research findings support these
an apparent trigger (e.g., the impulse to yell a curse word observations, consistently showing that obsessions and
in a place of worship). Finally, obsessions are subjectively resistance strategies are thematically related (e.g., Abra-
resisted, meaning that they are accompanied by the sense mowitz et al., 2010; McKay et al., 2004): contamina-
that they need to be dealt with, neutralized, or alto- tion obsessions often co-occur with washing/cleaning
gether avoided. The motivation to resist is activated by rituals; responsibility obsessions with checking and reas-
the fear that if action is not taken, disastrous conse- surance-seeking rituals; obsessions about order or exact-
quences will likely occur. ness with arranging rituals; and unacceptable taboo
violent, sexual, or blasphemous thoughts with mental
Subjective Resistance to Obsessions rituals and more covert forms of resistance. Avoidance
The most conspicuous type of resistance to obsessional behavior can also generally be predicted by the types of
thoughts is compulsive ritualizing. Compulsive rituals are obsessional fears the individual has. For example,
performed deliberately in response to an obsession, someone with obsessional thoughts of harming her
usually with the aim of preventing the feared disaster children is likely to avoid knives and other potential
and/or reducing the associated anxiety or distress (e.g., weapons. These observations underscore the relation-
hand washing for 30 min after touching a possibly con- ship between obsessions and the various forms of sub-
taminated doorknob; Rachman & Hodgson, 1980). jective resistance.
Common compulsive rituals include washing or clean-
ing, checking, or seeking reassurance from others, Maintenance of Obsessional Problems
repeating a routine activity until it feels right, order- Although intrusive thoughts are a universal experience,
ing and arranging items, and performing mental rituals people with clinically severe obsessional problems (i.e.,
(e.g., saying a phrase or prayer to oneself). Such rituals OCD) encounter more persistent intrusions that pro-
are usually senseless and excessive in relation to the voke more intense anxiety and distress relative to non-
obsessional fear, and often need to be performed sufferers. They also experience more persistent urges to
repeatedly and according to rules that the person resist their intrusions and expend greater time and
derives on his or her own. energy engaged in such activities. One explanation for
Noncompulsive (i.e., neither rule-bound nor this is that people with clinically significant obsessions
repeated) forms of resistance to obsessions are also catastrophically appraise the meaning and significance
common (e.g., Freeston & Ladouceur, 1997; Ladouc- of the otherwise harmless intrusions (e.g., thinking an
eur et al., 2000). Examples of this sort of resistance immoral thought is the same as performing an immoral
include purposely distracting oneself from obsessional deed), leading to distress, greater preoccupation with
thoughts and triggers, trying to suppress (i.e., not think the intrusion, and more intense urges to resist (e.g.,
about) the unwanted thoughts, and brief (covert) neu- Salkovskis, 1999). Moreover, the very resistance strate-
tralization strategies such as gripping the steering gies that are deployed in response to intrusions may
wheel more tightly in response to an obsessional paradoxically intensify the intrusion: for example,
thought of driving into opposing traffic. The passive attempted thought suppression, which leads to an
avoidance of obsessional stimuli (e.g., toilets) is also a increase in the thought to be suppressed (e.g., Abramo-
form of resistance to obsessions. Avoidance, however, witz, Tolin, & Street, 2001).
is intended to prevent obsessional thoughts and feared Other resistance strategies, such as avoidance and rit-
consequences from occurring in the first place, whereas uals, maintain obsessional distress by preventing the
neutralizing and other forms of resistance represent reac- correction of the unrealistic catastrophic appraisals
tions to obsessions that have already occurred (Rach- when feared outcomes do not occur. That is, poten-
man & Hodgson, 1980). tially corrective experiences are understood as near
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V21 N3, SEPTEMBER 2014 222
misses in which the resistance strategy is perceived as criteria also specify that compulsive rituals are per-
removing a threat (even if there was little danger to formed deliberately and in response to a sense of pres-
begin with). For example, a person who always avoids sure to act, yet usually are perceived as senseless or
knives due to harm-related intrusions fails to learn that excessive. Beginning with DSM-IV (APA, 1994), the
these unwanted thoughts will in all likelihood not lead diagnostic criteria for OCD included the specifier
to committing acts of harm. Similarly, one who com- with poor insight to denote when a person did not
pulsively washes his hands following contact with (for most of the time while having the problem) recog-
feared contaminants (e.g., money) will never learn that nize the senselessness of the obsessions or compulsions.
he is unlikely to become ill. Moreover, because resis-
tance strategies often result in immediate short-term Changes in DSM-5
distress reduction (or the temporary removal of the The OCD diagnostic criteria per se have undergone
unwanted thought), they are negatively reinforced and only minor changes from DSM-IV-TR to DSM-5. In
become habitual. This completes a self-sustaining general, the definitions of obsessions and compulsions
vicious cycle that leads to the escalation of intrusions, remain the same, save a few updates. The word
subjective distress, and maladaptive resistance strategies. impulse, which was used in the description of obses-
sions in DSM-IV, has been replaced with the word
Insight urge. The word inappropriate, which was used to
Research and clinical observations also indicate that describe the content of obsessional thoughts, has been
whereas most people at some point recognize that their replaced with the word unwanted. Indeed, what is
obsessions are senseless and unrealistic, and that their inappropriate varies with factors such as culture, age,
subjective resistance is excessive and unnecessary, this and gender, whereas unwanted is a more subjective
type of insight wavers across time (Abramowitz, 2006). and culturally neutral term. As in DSM-IV-TR, the
Moreover, people vary in how convinced they are that presence of either obsessions or compulsions (or both)
their obsessions are senseless, with about 4% of people is required for a diagnosis of OCD, yet the require-
with an OCD diagnosis being extremely strongly con- ment in DSM-IV that individuals recognize that their
vinced that their obsessional fears are realistic (Foa & obsessions and compulsions are senseless and excessive
Kozak, 1995). has been removed in DSM-5.
Another change related to recognition of the sense-
OCD ACCORDING TO THE DSM lessness of OCD symptoms is that the insight specifier
DSM-III Through DSM-IV-TR has been further distilled in DSM-5 to allow for a dis-
The main diagnostic criteria for OCDthe presence tinction between people with (a) good or fair insight
of obsessions or compulsionshave been relatively (who recognize that their OCD-related fears are proba-
unchanged since DSM-III (American Psychiatric Asso- bly or definitely not true, or may or may not be true),
ciation [APA], 1980). Through DSM-IV-TR (APA, (b) poor insight (who think their fears are probably
2000), OCD was grouped among the anxiety disorders true), and (c) absent insight/delusional beliefs (who
and defined by the presence of either obsessions or appear completely convinced that their fears are true).
compulsions (or both) that produce significant distress This change was made with the hope of improving dif-
and cause noticeable interference with various aspects ferential diagnosis by highlighting that people with
of functioning, such as academic, occupational, social, OCD have a range of insight into the senselessness of
leisure, or family settings. Obsessions are defined in their symptoms. It also emphasizes that the absence of
the DSM as intrusive thoughts, ideas, images, impulses, insight (or the presence of delusion-like beliefs) can
or doubts that the person experiences in some way as warrant a diagnosis of OCD, and not necessarily
senseless and that evoke affective distress (i.e., anxiety, schizophrenia or a psychotic disorder.
doubt). Compulsions are defined as urges to perform Additionally, a tic-related specifier has been included
behavioral (e.g., checking, washing) or mental rituals to distinguish individuals presenting with a blend of
(e.g., praying) in response to obsessions. The diagnostic OCD and tic-like symptoms (or a history of a tic
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V21 N3, SEPTEMBER 2014 224
medication for all OCRDs even without proper will be more readily recognized by clinicians in the
empirical support. mental health field and elsewhere, and that more peo-
ple will seek treatment for these problems.
New Markets for SRI Medications. Other than
OCD, the disorders that comprise the OCRD chapter Better Identification of Potential Treatment Nonre-
in DSM-5 do not have any medications that are specif- sponders. Another potentially positive implication of
ically indicated for them. This is primarily because changes to OCD in the DSM-5 is that the new specifi-
there is not sufficient evidence from well-conducted ers could assist with identifying individuals at greater
randomized controlled trials that such medications are risk of nonresponse to both ERP and pharmacological
efficacious for these disorders. Yet as a result of the treatments. Research suggests that poor insight is pre-
OCRD chapter, which now links BDD, hoarding dis- dictive of attenuated response to empirically supported
orders, skin-picking disorder, and hair-pulling disorder treatment for OCD (e.g., Foa, Abramowitz, Franklin,
with OCD, we would anticipate an increase in the & Kozak, 1999). Thus, identification of individuals
prescription rates for medications used in the treatment with very poor insight might lead to the use of more
of OCDnamely, SRIsfor these other problems as intensive treatment regimens, which might be of
well (which is problematic given a lack of evidence of greater benefit. Similarly, individuals with tic-related
their efficacy). OCD are often found to be treatment refractory
(Ferr~ao, Miguel, & Stein, 2009; Franklin, Harrison, &
Improved Psychological Treatment for BDD. If our Benavides, 2012; Mansueto & Keuler, 2005; see Verd-
prediction is correct that treatments used for OCD will ellen et al., 2004, for an exception), and with the addi-
become more widely used for other OCRDs, then the tion of the tic-related specifier in DSM-5, future
use of appropriate psychological treatment of BDD directions can explore potential treatment modifications
stands to increase. That is because similar ERP tech- for improving outcomes with this population.
niques that are effective for OCD are also effective in
the treatment of BDD (e.g., Greenberg & Wilhelm, Implications for Research on OCD
2011). Previously categorized as a somatoform disorder, The new specifiersthree levels of insight and tic-
however, many clinicians overlooked the overlaps related OCDwill have potential implications for
between OCD and BDD in terms of their nature and research. It will be interesting to determine the extent
treatment. BDD, however, is characterized by body- to which these specifications are predictive of phenom-
focused thoughts and preoccupations that are phenom- enology and treatment response. OCD is well known
enologically similar to obsessions in OCD. Moreover, as a heterogeneous condition, yet the heterogeneity is
individuals with BDD deploy subjective resistance commonly considered to occur in the form of obses-
strategies similar to those used in OCD, such as avoid- sional or compulsive themes. It remains to be deter-
ance, checking mirrors and other shiny surfaces, and mined whether results of studies on individuals with
asking for reassurance. As with the analogous strategies nontic-related OCD symptoms extend to those with
in OCD, while these behaviors might reduce physical tic-related OCD. This will help address whether future
defect-related preoccupation in the short term, they OCD studies should include individuals with tic-
maintain the problem in the long run. Thus, ERP is related OCD, or whether it is best to study tic- and
an appropriate intervention (Abramowitz, 2013). nontic-related OCD presentations separately.
To a similar end, it is unfortunate that the DSM-5
Increased Recognition and Attention to Hoarding and does not speak to the heterogeneity of OCD and the
Skin Picking. Hoarding and, to a lesser extent, severe fact that various symptom dimensions have been repli-
skin picking have long been recognized as chronic, cated across the empirical literature (e.g., McKay et al.,
harmful, distressing, and often functionally interfering 2004). These dimensions are characterized by some-
problems. With the inclusion of these problems as new what different psychopathology and treatment response
diagnostic entities in DSM-5, we anticipate that they (McKay et al., 2004). While some researchers continue
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V21 N3, SEPTEMBER 2014 226
cognitive-behavior therapy for obsessive-compulsive Clark, D. M. (1999). Anxiety disorders: Why they persist and
disorder. Journal of Consulting and Clinical Psychology, 71, how to treat them. Behaviour Research & Therapy, 37, S5
10491057. doi:10.1037/0022-006X.71.6.1049 S27. doi:10.1016/S0005-7967(99)00048-0
Abramowitz, J. S., & Houts, A. C. (2002). What is OCD and Clark, D. A. (2004). Cognitive behavioral therapy for OCD.
what is not: Problems with the OCD spectrum concept. New York, NY: Guilford Press.
Scientific Review of Mental Health Practice, 1, 139156. Cororve, M. B., & Gleaves, D. H. (2001). Body dysmorphic
Abramowitz, J. S., Taylor, S., & McKay, D. (2009). disorder: A review of conceptualizations, assessment, and
Obsessive-compulsive disorder. The Lancet, 374, 491499. treatment strategies. Clinical Psychology Review, 21, 949
doi:10.1016/S0140-6736(09)60240-3 970. doi:10.1016/S0272-7358(00)00075-1
Abramowitz, J. S., Tolin, D. F., & Street, G. P. (2001). Deacon, B. J. (2013). The biomedical model of mental
Paradoxical effects of thought suppression: A meta-analysis disorder: A critical analysis of its validity, utility, and
of controlled studies. Clinical Psychology Review, 21, 683 effects on psychotherapy research. Clinical Psychology
703. doi:10.1016/S0272-7358(00)00057-X Review, 33, 846861. doi:10.1016/j.cpr.2012.09.007
Abramowitz, J. S., Wheaton, M. G., & Storch, E. A. (2008). DeVeaugh-Geiss, J., Moroz, G., Biederman, J. B., Cantwell,
The status of hoarding as a symptom of obsessive- D., Fontaine, R., Greist, J. H., . . . Landau, P. (1992).
compulsive disorder. Behaviour Research and Therapy, 46, Clomipramine hydrochloride in childhood and adolescent
10261033. doi:10.1016/j.brat.2008.05.006 obsessive-compulsive disorder: A multicenter trial. Journal of
American Psychiatric Association. (1980). Diagnostic and the American Academy of Child and Adolescent Psychiatry, 31,
statistical manual of mental disorders (3rd ed.). Washington, 4549. doi:10.1097/00004583-199201000-00008
DC: Author. Dougherty, D. D., Loh, R., Jenike, M. A., & Keuthen, N. J.
American Psychiatric Association. (1994). Diagnostic and (2006). Single modality versus dual modality treatment for
statistical manual of mental disorders (4th ed.). Washington, trichotillomania: Sertraline, behavioral therapy, or both?
DC: Author. Journal of Clinical Psychiatry, 67, 10861092. doi:10.4088/
American Psychiatric Association. (2000). Diagnostic and JCP.v67n0711
statistical manual of mental disorders (4th ed., text revision). Ferr~ao, Y., Miguel, E., & Stein, D. (2009). Tourettes
Washington, DC: Author. syndrome, trichotillomania, and obsessivecompulsive
American Psychiatric Association. (2013). Diagnostic and disorder: How closely are they related? Psychiatry Research,
statistical manual of mental disorders (5th ed.). Arlington, VA: 170(1), 3242. doi:10.1016/j.psychres.2008.06.008
American Psychiatric Publishing. Fineberg, N., Saxena, S., Zohar, J., & Craig, K. (2011).
Barlow, D. H. (2002). Anxiety and its disorders. (2nd ed.). Obsessive-compulsive disorder: Boundary issues. In E.
New York, NY: Guilford. Hollander, J. Zohar, P. J. Sirovatka, & D. A. Regier
Bienvenu, O. J., Samuels, J. F., Riddle, M. A., Hoehn-Saric, (Eds.), Obsessive-compulsive spectrum disorders: Refining the
R., Liang, K. Y., Cullen, B. A., . . . Nestadt, G. (2000). research agenda for DSM-V (pp. 132). Washington, DC:
The relationship of obsessive-compulsive disorder to American Psychiatric Association.
possible spectrum disorders: Results from a family study. Foa, E. B., Abramowitz, J. S., Franklin, M. E., & Kozak, M.
Biological Psychiatry, 48, 287293. doi:10.1016/S0006-3223 J. (1999). Feared consequences, fixity of belief, and
(00)00831-3 treatment outcome in patients with obsessive-compulsive
Boyer, W. (1995). Serotonin uptake inhibitors are superior to disorder. Behavior Therapy, 30, 717724. doi:10.1016/
imipramine and alprazolam in alleviating panic attacks: A S0005-7894(99)80035-5
meta-analysis. International Clinical Psychopharmacology, 10, Foa, E. B., & Kozak, M. J. (1995). DSM-IV field trial:
4549. doi:10.1097/00004850-199503000-00006 Obsessive-compulsive disorder. American Journal of
Campsi, T. A. (1995). Exposure and response prevention in Psychiatry, 152, 9096.
the treatment of body dysmorphic disorder. Dissertation Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S.,
Abstracts International: Section B: The Sciences and Engineering, Campeas, R., Franklin, M. E., . . . Tu, X. (2005).
56, 7036. Randomized, placebo-controlled trial of exposure and
Christenson, G. A., Mackenzie, T. B., Mitchell, J. E., & ritual prevention, clomipramine, and their combination in
Callies, A. L. (1991). A placebo controlled, double-blind the treatment of obsessive compulsive disorder. American
crossover study of fluoxetine in trichotillomania. American Journal of Psychiatry, 162, 151161. doi:10.1176/appi.ajp
Journal of Psychiatry, 148, 15661571. .162.1.151
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V21 N3, SEPTEMBER 2014 230
medication for all OCRDs even without proper will be more readily recognized by clinicians in the
empirical support. mental health field and elsewhere, and that more peo-
ple will seek treatment for these problems.
New Markets for SRI Medications. Other than
OCD, the disorders that comprise the OCRD chapter Better Identification of Potential Treatment Nonre-
in DSM-5 do not have any medications that are specif- sponders. Another potentially positive implication of
ically indicated for them. This is primarily because changes to OCD in the DSM-5 is that the new specifi-
there is not sufficient evidence from well-conducted ers could assist with identifying individuals at greater
randomized controlled trials that such medications are risk of nonresponse to both ERP and pharmacological
efficacious for these disorders. Yet as a result of the treatments. Research suggests that poor insight is pre-
OCRD chapter, which now links BDD, hoarding dis- dictive of attenuated response to empirically supported
orders, skin-picking disorder, and hair-pulling disorder treatment for OCD (e.g., Foa, Abramowitz, Franklin,
with OCD, we would anticipate an increase in the & Kozak, 1999). Thus, identification of individuals
prescription rates for medications used in the treatment with very poor insight might lead to the use of more
of OCDnamely, SRIsfor these other problems as intensive treatment regimens, which might be of
well (which is problematic given a lack of evidence of greater benefit. Similarly, individuals with tic-related
their efficacy). OCD are often found to be treatment refractory
(Ferr~ao, Miguel, & Stein, 2009; Franklin, Harrison, &
Improved Psychological Treatment for BDD. If our Benavides, 2012; Mansueto & Keuler, 2005; see Verd-
prediction is correct that treatments used for OCD will ellen et al., 2004, for an exception), and with the addi-
become more widely used for other OCRDs, then the tion of the tic-related specifier in DSM-5, future
use of appropriate psychological treatment of BDD directions can explore potential treatment modifications
stands to increase. That is because similar ERP tech- for improving outcomes with this population.
niques that are effective for OCD are also effective in
the treatment of BDD (e.g., Greenberg & Wilhelm, Implications for Research on OCD
2011). Previously categorized as a somatoform disorder, The new specifiersthree levels of insight and tic-
however, many clinicians overlooked the overlaps related OCDwill have potential implications for
between OCD and BDD in terms of their nature and research. It will be interesting to determine the extent
treatment. BDD, however, is characterized by body- to which these specifications are predictive of phenom-
focused thoughts and preoccupations that are phenom- enology and treatment response. OCD is well known
enologically similar to obsessions in OCD. Moreover, as a heterogeneous condition, yet the heterogeneity is
individuals with BDD deploy subjective resistance commonly considered to occur in the form of obses-
strategies similar to those used in OCD, such as avoid- sional or compulsive themes. It remains to be deter-
ance, checking mirrors and other shiny surfaces, and mined whether results of studies on individuals with
asking for reassurance. As with the analogous strategies nontic-related OCD symptoms extend to those with
in OCD, while these behaviors might reduce physical tic-related OCD. This will help address whether future
defect-related preoccupation in the short term, they OCD studies should include individuals with tic-
maintain the problem in the long run. Thus, ERP is related OCD, or whether it is best to study tic- and
an appropriate intervention (Abramowitz, 2013). nontic-related OCD presentations separately.
To a similar end, it is unfortunate that the DSM-5
Increased Recognition and Attention to Hoarding and does not speak to the heterogeneity of OCD and the
Skin Picking. Hoarding and, to a lesser extent, severe fact that various symptom dimensions have been repli-
skin picking have long been recognized as chronic, cated across the empirical literature (e.g., McKay et al.,
harmful, distressing, and often functionally interfering 2004). These dimensions are characterized by some-
problems. With the inclusion of these problems as new what different psychopathology and treatment response
diagnostic entities in DSM-5, we anticipate that they (McKay et al., 2004). While some researchers continue
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V21 N3, SEPTEMBER 2014 232
cognitive-behavior therapy for obsessive-compulsive Clark, D. M. (1999). Anxiety disorders: Why they persist and
disorder. Journal of Consulting and Clinical Psychology, 71, how to treat them. Behaviour Research & Therapy, 37, S5
10491057. doi:10.1037/0022-006X.71.6.1049 S27. doi:10.1016/S0005-7967(99)00048-0
Abramowitz, J. S., & Houts, A. C. (2002). What is OCD and Clark, D. A. (2004). Cognitive behavioral therapy for OCD.
what is not: Problems with the OCD spectrum concept. New York, NY: Guilford Press.
Scientific Review of Mental Health Practice, 1, 139156. Cororve, M. B., & Gleaves, D. H. (2001). Body dysmorphic
Abramowitz, J. S., Taylor, S., & McKay, D. (2009). disorder: A review of conceptualizations, assessment, and
Obsessive-compulsive disorder. The Lancet, 374, 491499. treatment strategies. Clinical Psychology Review, 21, 949
doi:10.1016/S0140-6736(09)60240-3 970. doi:10.1016/S0272-7358(00)00075-1
Abramowitz, J. S., Tolin, D. F., & Street, G. P. (2001). Deacon, B. J. (2013). The biomedical model of mental
Paradoxical effects of thought suppression: A meta-analysis disorder: A critical analysis of its validity, utility, and
of controlled studies. Clinical Psychology Review, 21, 683 effects on psychotherapy research. Clinical Psychology
703. doi:10.1016/S0272-7358(00)00057-X Review, 33, 846861. doi:10.1016/j.cpr.2012.09.007
Abramowitz, J. S., Wheaton, M. G., & Storch, E. A. (2008). DeVeaugh-Geiss, J., Moroz, G., Biederman, J. B., Cantwell,
The status of hoarding as a symptom of obsessive- D., Fontaine, R., Greist, J. H., . . . Landau, P. (1992).
compulsive disorder. Behaviour Research and Therapy, 46, Clomipramine hydrochloride in childhood and adolescent
10261033. doi:10.1016/j.brat.2008.05.006 obsessive-compulsive disorder: A multicenter trial. Journal of
American Psychiatric Association. (1980). Diagnostic and the American Academy of Child and Adolescent Psychiatry, 31,
statistical manual of mental disorders (3rd ed.). Washington, 4549. doi:10.1097/00004583-199201000-00008
DC: Author. Dougherty, D. D., Loh, R., Jenike, M. A., & Keuthen, N. J.
American Psychiatric Association. (1994). Diagnostic and (2006). Single modality versus dual modality treatment for
statistical manual of mental disorders (4th ed.). Washington, trichotillomania: Sertraline, behavioral therapy, or both?
DC: Author. Journal of Clinical Psychiatry, 67, 10861092. doi:10.4088/
American Psychiatric Association. (2000). Diagnostic and JCP.v67n0711
statistical manual of mental disorders (4th ed., text revision). Ferr~ao, Y., Miguel, E., & Stein, D. (2009). Tourettes
Washington, DC: Author. syndrome, trichotillomania, and obsessivecompulsive
American Psychiatric Association. (2013). Diagnostic and disorder: How closely are they related? Psychiatry Research,
statistical manual of mental disorders (5th ed.). Arlington, VA: 170(1), 3242. doi:10.1016/j.psychres.2008.06.008
American Psychiatric Publishing. Fineberg, N., Saxena, S., Zohar, J., & Craig, K. (2011).
Barlow, D. H. (2002). Anxiety and its disorders. (2nd ed.). Obsessive-compulsive disorder: Boundary issues. In E.
New York, NY: Guilford. Hollander, J. Zohar, P. J. Sirovatka, & D. A. Regier
Bienvenu, O. J., Samuels, J. F., Riddle, M. A., Hoehn-Saric, (Eds.), Obsessive-compulsive spectrum disorders: Refining the
R., Liang, K. Y., Cullen, B. A., . . . Nestadt, G. (2000). research agenda for DSM-V (pp. 132). Washington, DC:
The relationship of obsessive-compulsive disorder to American Psychiatric Association.
possible spectrum disorders: Results from a family study. Foa, E. B., Abramowitz, J. S., Franklin, M. E., & Kozak, M.
Biological Psychiatry, 48, 287293. doi:10.1016/S0006-3223 J. (1999). Feared consequences, fixity of belief, and
(00)00831-3 treatment outcome in patients with obsessive-compulsive
Boyer, W. (1995). Serotonin uptake inhibitors are superior to disorder. Behavior Therapy, 30, 717724. doi:10.1016/
imipramine and alprazolam in alleviating panic attacks: A S0005-7894(99)80035-5
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