# Obsessive-compulsive & related disorders

DSM-5 moved OCD out of the anxiety chapter into its own family: disorders driven by repetitive behaviour that relieves distress. (In Nepali PSC training OCD is still taught within the anxiety block; answer exams accordingly.)

## Obsessive-Compulsive Disorder (OCD)

Unwanted intrusive thoughts (obsessions) and the rituals performed to neutralise them (compulsions).

**In plain words:** Unwanted thoughts that keep coming back (germs, harm, doubt), and rituals (washing, checking, counting) done to quiet them.

DSM-5 Criteria

  - Presence of obsessions, compulsions, or both. **Obsessions:** recurrent, persistent, intrusive, unwanted thoughts, urges, or images causing anxiety; the person tries to ignore, suppress, or neutralise them with another thought or action.
  - **Compulsions:** repetitive behaviours (washing, checking, ordering) or mental acts (counting, praying, repeating words) performed in response to an obsession or rigid rules, aimed at reducing distress or preventing a dreaded event, but not realistically connected to it, or clearly excessive.
1. Time-consuming (more than **1 hour/day**) or causing clinically significant distress or impairment.
2. Not attributable to a substance or medical condition.
3. Not better explained by another disorder (GAD worry, BDD appearance-preoccupation, hoarding, eating-disorder food rituals…).
Specifiers:

- Insight: good/fair
- Insight: poor
- Insight: absent-delusional
- Tic-related
Common themes:

- Contamination
- Doubt/harm
- Symmetry
- Forbidden (religious/sexual) thoughts
International

Lifetime prevalence ~1–2% worldwide with a remarkably similar picture across countries; content follows culture: religious scrupulosity dominates in devout communities (fear of blasphemy in one faith, ritual-purity doubts in another), contamination in germ-aware urban settings.

Nepal

Culture supplies ready-made ritual channels: *chokho/jutho* (pure/polluted) rules, bathing after contact, puja repetition. The diagnostic line is function, not content: ritual purity observed like one's community is culture; washing until the skin breaks, or repeating puja for hours out of dread, is disorder. The National Mental Health Survey found a current rate of 0.2% (95% CI 0.1 to 0.4), so the condition is uncommon here and most people with it are never counted. Families often reach a dhami-jhankri first; engage respectfully rather than dismissing. See [Nepal in numbers](https://manoatlas.com/data.md) for the full survey figures.

## Body Dysmorphic Disorder (BDD)

Preoccupation with perceived appearance defects that others cannot see or find slight: formerly "dysmorphophobia".

**In plain words:** Being consumed by a flaw in one's appearance that others barely see, with hours spent checking, hiding or fixing it.

DSM-5 Criteria

1. Preoccupation with one or more perceived defects or flaws in physical appearance not observable, or appearing slight, to others.
2. At some point, repetitive behaviours (mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (comparing one's appearance with others') in response to the concerns.
3. Clinically significant distress or impairment.
4. Not better explained by an eating disorder (weight/fat concern in a person meeting eating-disorder criteria is not BDD).
Specifiers: muscle dysmorphia (mostly men); insight; one-third or more hold delusional conviction. High suicide risk. Cosmetic treatment almost never helps and often worsens it.

International

~2.4% of US adults; 9–15% of dermatology patients. *Shubo-kyofu* in Japan (fear of a deformed body) is the recognised cultural variant. Onset is adolescent: two-thirds before 18.

Nepal

Expect it in beauty parlours, dermatology OPDs and among urban youth on Instagram/TikTok, not in counselling rooms. Fairness-cream culture and marriage-market appearance pressure give the preoccupation local content (skin tone, nose shape). Screen when a young client repeatedly seeks skin or cosmetic fixes for a defect you cannot see.

## The rest of the OCD family; at a glance

| Disorder | Code | Core feature |
| --- | --- | --- |
| Hoarding disorder | 300.3 · F42 | Persistent difficulty discarding possessions regardless of value; accumulation clutters living areas |
| Trichotillomania | 312.39 · F63.3 | Recurrent hair pulling with hair loss; repeated attempts to stop |
| Excoriation disorder | 698.4 · L98.1 | Recurrent skin picking causing lesions; repeated attempts to stop |

The OCD loop. The ritual is the trap: it works for a minute and teaches the brain to demand it again. Treatment (ERP) breaks the loop at the compulsion, which is why reassurance and helping with rituals, however kind, keep it turning.

A skill to try · two minutes

**Urge surfing.** When the urge to check or wash rises, name it ("the alarm again"), set a five-minute delay, and watch the urge like a wave. Often it crests and passes; sometimes it lingers, and the practice is the same: not obeying it.

Every ridden wave weakens the loop from the diagram on [Fear: the foundation](https://manoatlas.com/foundation.md). Full treatment belongs with a professional; this is practice for small waves.

A coping skill, not a treatment: it supports care, it does not replace it.

**A worked example:** A 24-year-old named Raj has intrusive thoughts that his hands are contaminated. He washes them for 40 minutes each time, missing work. His therapist names the obsession and compulsion, explains that the ritual feeds the loop shown in the figure above, and starts exposure with response prevention: he touches a doorknob and delays washing by five minutes.

Key points

1. OCD is obsessions (unwanted thoughts) plus compulsions (rituals that relieve them), taking more than an hour a day.
2. The ritual works for a minute and feeds the loop for years; that is why reassurance does not help.
3. Exposure with response prevention (ERP) is the treatment; body dysmorphic disorder, hoarding and hair-pulling are the same family.
Learn more

Pick one, not all: these are chosen to be light, not exhaustive.

Video · 4 min[Debunking the myths of OCD (TED-Ed)](https://www.youtube.com/watch?v=DhlRgwdDc-E): Four minutes that fix the "I'm so OCD" misunderstanding.

Book**Brain Lock (Jeffrey Schwartz)**: The four-step self-treatment method: read chapters 1–2.

Video · 10 min[Eating & Body Dysmorphic Disorders (Crash Course #33)](https://www.youtube.com/watch?v=eMVyZ6Ax-74): Covers BDD alongside eating disorders: pairs with the Eating disorders page.


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*Source: https://manoatlas.com/ocd · Licence: CC BY-NC-SA 4.0. Mano Atlas is an educational resource, not a diagnostic tool.*