Supplement

Obsessive-Compulsive Disorder and

-Compulsive Spectrum Disorders:
Diagnostic and Dimensional Issues
By Eric Hollander, MD, Suah Kim, BA, Sumant Khanna, MD, PhD,
and Stefano Pallanti, MD, PhD

ABSTRACT
Although obsessive-compulsive disorder (OCD)
is classified as an anxiety disorder in the DSM-IV,
recent considerations for a reclassification into an
obsessive-compulsive spectrum disorders (OCSDs)
cluster are gaining prominence. Similarities in
symptomatology, course of illness, patient popu-
lation, and neurocircuitry of OCD and OCSD are
supported by comorbidity, family, and neurological
studies, which also offer a critical re-evaluation of
the relationship between OCD and anxiety disor-
ders. This review examines potential classifications
of OCD among the wider spectrum of affective
disorders and at the interface between affective
disorders and addiction. In addition, it has been
suggested that the categorical diagnostic approach
would be enhanced by an additional dimensional
approach, including parameters such as stability
of mood and ability to sustain attention. With fur-
ther studies, it is ultimately the goal to define OCD
and related disorders based on endophenotypes.
FOCUS POINTS
Key findings support the validity of separating
obsessive-compulsive disorder (OCD) from the
anxiety disorders.
A new category of obsessive compulsive spectrum
disorders (OCSDs) is proposed.
Determining which disorders to include in this cat-
egory deserves further discussion.
Despite efforts in this field, there are several funda-
mental unresolved issues, including the question of
which disorders should be grouped together in this
category and which characteristics to include as
their shared common features. A reclassification of
OCD among the OCSDs would allow for better scru-
tiny of distinct obsessive-compulsive symptoms,
as currently this disorder often goes undetected
in patients who complain of a broad symptom of
anxiety. Advantages and disadvantages of estab-
lishing OCSDs and its implications for diagnosis,
treatment, and research are discussed.
CNSSpectr. 2007;12:2(Suppl 3):5-13

Dr. Hollander is Esther and Joseph Klingenstein professor and chair of psychiatry, and director of the Seaver and NY Autism Center
of Excellence at the Mount Sinai School of Medicine in New York City. Ms. Kim is research coordinator in the Compulsive, Impulsive,
and Anxiety Disorders Program at the Mount Sinai School of Medicine. Dr. Khanna is a psychiatrist at The Psychiatric Clinic, Vasant
Vihar, in New Delhi, India. Dr. Pallanti is associate professor of psychiatry at the Institute of Neuroscience at the University of Florence
in Italy, and adjunct associate professor at the Mount Sinai School of Medicine in New York City.
Disclosures: Dr. Hollander has been a speaker for Abbott, Lundbeck, Pfizer, and Wyeth; is on the advisory boards of Abbott, Neuropharm,
Somaxon, and Wyeth; has received grants/honoraria from Abbott, Eli Lilly, Forest, and Pfizer; and has a financial interest in Neuropharm.
Ms. Kim reports no financial, academic, or other interest in any organization that may pose a conflict of interest. Dr. Khanna has been
a speaker for and on the advisory board of Johnson & Johnson; and has received grants/honoraria from Pfizer. Dr. Pallanti has been a
speaker for and on the advisory boards of Eli Lilly, GlaxoSmithKline, and Pfizer; and has received grants/honoraria from Abbott, Eli Lilly,
GlaxoSmithKline, Innovapharma, Lundbeck, and Pfizer.
Submitted for publication: June 12, 2006; Accepted January 4, 2007.
Please direct all correspondence to: Eric Hollander, MD, Department of Psychiatry, One Gustave Levy Place, Box 1230, New York,
NY 10029; Tel: 212-659-8287; Fax: 212-987-4031; E-mail: eric.hollander@mssm.edu.
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 E. Hollander, S. Kim, S. Khanna, S. Pollanti
INTRODUCTION
Obsessive-compulsive disorder (OCD) is a
chronic and debilitating disorder marked by
recurrent obsessions and/or compulsive behav-
iors often performed to alleviate distress caused
by the pervasive thoughts. The most common
obsessions involve contamination, sexual imag-
ery, aggression, doubting, order, and symmetry.
Obsessions also have an egodystonic quality in
that many OCD sufferers describe their intrusive
thoughts as alien to themselves and not derived
from their mind but extrinsically imposed.
Compulsions are most often counting, washing,
checking, ordering, and hoarding. The obsessions
and compulsions associated with OCD are time
consuming and contribute to psychosocial impair-
ments and significant distress. There is also an
avoidance quality to OCD as many sufferers try
to evade situations and things that will trigger
OCD symptoms. Although OCD is currently clas-
sified as an anxiety disorder in the Diagnostic
and Statistical Manual of Mental Disorders,
Fourth Edition (DS/W-/1/),1 recent considerations
for a reclassification into an obsessive compul-
sive spectrum disorder (OCSD) cluster is gain-
ing prominence. Similarities in symptomatology,
course of illness, patient population and neurocir-
cuitry of OCD and OCSD are supported by comor-
bidity, family, and neurological studies, which
also offer a critical reevaluation into the relation-
ship between OCD and anxiety disorders.
NOSOLOGY OF OBSESSIVE-
COMPULSIVE DISORDfR
Under the current DSM-IV classification, OCD
is categorized as an anxiety disorder together with
agoraphobia, panic disorder, generalized anxiety
disorder (GAD) and posttraumatic stress disorder
(PTSD).The primary reason for this classification
is anxiety's principal role in OCD. The obsessions
associated with OCD contribute to escalating
anxiety, and the compulsive behaviors are often
performed to try to reduce this anxiety.2 Anxiety
disorder and OCD sufferers also exhibit an urge to
escape provoking stimuli with subsequent avoid-
ance behaviors.3The fault in this comparison is that
anxiety is a rather broad symptom that is apparent
in several other psychiatric disorders including
depression, schizophrenia, and bipolar disorder.
Classifying OCD as an anxiety disorder contrib-
utes little to understanding both the etiology of
this heterogeneous disorder and in development
of effective treatment. Because of shared obses-
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sive-compulsive features, comorbidities, lifetime
course, neurocircuitry, patient demographics, life-
time course, and treatment response, OCD may be
conceptualized as an OCSD alongside body dys-
morphic disorder (BDD), pathological gambling,
eating disorders, and autism.43
Leckman and colleagues 9 determined four
dimensions of OCD: (1) obsessions/checking; (2)
symmetry/ordering; (3) contamination/cleaning;
and (4) hoarding. The first dimension is character-
ized by obsessions of aggression, sex, religion,
or about the body, and checking behaviors; the
second dimension involves preoccupations with
order, symmetry, or exactness, and/or compul-
sions of counting, rearranging, or ritualistic rep-
etitions; the third dimension involves obsessions
about contamination and compulsive washing and
cleaning; and the fourth dimension includes hoard-
ing obsessions and compulsions. Correlates have
been found between symmetry/hoarding factors
and comorbid chronic tics and obsessive-compul-
sive personality disorder.10 Individuals diagnosed
withTourette's syndrome or chronic tic disorder
scored significantly higher on obsessions/check-
ing and symmetry/ordering factors.9 Furthermore,
hoarding was also associated with pathological
grooming behaviors seen in trichotillomania, skin-
picking, and nail-biting.11 This model reflects the
heterogeneous phenotype of OCD.12 Other inves-
tigators argue for subtyping of OCD,13 specifically
OCD with tics, as those patients who suffer from
comorbid tics show different symptomatology,
tend to be male, and are less responsive to sero-
tonin reuptake inhibitors (SRIs) compared to those
without comorbid tics.14
Alternatively, OCD may be conceptualized as
existing within a broad spectrum of affective dis-
orders (Figure 1) or one may consider it a group
of disorders lying midway between affective dis-
orders and addiction disorders (Figure 2). From
a dimensional viewpoint, these problems may
be visualized as lying along a phenomenological
dimension of compulsivity and impulsivity (Figure
3). Furthermore, by incorporating a more dimen-
sional approach with the categorical methodol-
ogy, patients must have sufficient severity of both
obsessions and compulsions to have a diagnosis
of OCD wherein this OCD may be classified with
associated symptom domains of varying sever-
ity (Figure 4). OCSDs can also be sub-divided
into three clusters: (A) body image and somatic
disorder; (B) impulse-control disorders; and (C)
neurological disorders With repetitive behaviors.5
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 Obsessive-Compulsive Disorder and Obsessive-Compulsive
Spectrum Disorders: Diagnostic and Dimensional Issues
The first cluster is characterized by obsessions
with the body, which includes hypochondriasis,
binge-eating disorder, anorexia nervosa, BDD,
and depersonalization disorder.These disorders
are similar to OCD in that they involve disrupting
preoccupations often coupled with ritualistic or
repetitive behavior such as repetitive visits to the
doctor, mirror checking, and multiple plastic sur-
geries intended to reduce the anxiety caused by
the intrusive obsessions. Moreover, the obses-
sions can be similar to those observed in OCD in
that they may involve symmetry, health issues,
or overblown ideas.The second cluster includes
impulse-control disorders such as sexual disorders
often involving obsessions, compulsions or para-
philias, pathological gambling, trichotillomania,
compulsive shopping disorder, Internet usage dis-
order, and pathological excoriation (skin-picking).
Although the impulsive behaviors characteristic
of these disorders offer short-term pleasure not
present in OCD, these impulse-control disorders
are similar to OCD in that sufferers experience ten-
sion and arousal associated with their behaviors.7
Even though these disorders are characterized by
impulsiveness, they share the compulsiveness
aspect of OCD as the behaviors displayed often
act to reduce distress from the obsessions that
are also prevalent in impulse-control disorders.15
FIGURE 1 .
Conceptualization of OCD Existence
Within a Spectrum of Affective Disorders
Affective spectrum disorders
depressive
disorders
Obsessive-compulsive
disorders
anxiety disorders
OCD=obsessive-compulsive disorder; ICDs=impulse control disorders;
BDD=body dysmorphic disorder; TS=Tourette's syndrome.
Hollander E, Kim S, Khanna S, Pallanti S. CNS Spectr. Vol 12, No 2 (Suppl
3). 2007.
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Pathological gamblers, for example, exhibit higher
levels of obsessionality than healthy controls.16
The third cluster of OCSD involves neurologically
based disorders such asTS, Sydenham's chorea,
and autism, which all display repetitive behav-
iors. In these disorders, compulsions are repetitive
motor behaviors and are usually without obses-
sions. It is thought that anomalies in the basal gan-
glia seen in these disorders are involved in the
displayed repetitive behaviors and stereotypies.1719
The content of the compulsions and obsessions
of these neurological disorders are also differ-
ent from those seen in OCD.TS typically displays
echophenomena, touching, mental play, and self-
injurious behaviors.20 Autistic characteristics usu-
ally involve hoarding, telling and asking, touching,
and repetitive ordering. Concerns about contami-
nation, symmetry, aggression, and somatic, reli-
gious, and sexual obsessions are less common in
this disorder. Cleaning, checking and counting are
also uncommon compulsions.21
EPIDEMIOLOGY OF OBSESSIVE-
COMPULSIVE DISORDER
While OCD is categorized as an anxiety disorder
under the DSM-IV, it is listed independently as a dis-
order but also within a grouping alongside neurotic,
stress-related, and somatoform disorders in the
FIGURE 2 .
Conceptualization of OCD as Existing
Between Affective and Addiction
Disorders
Obsessive-compulsive
disorders
OCD=obsessive-compulsive disorder; ICDs=impulse control disorders;
BDD=body dysmorphic disorder;TS=Tourette's syndrome; PG=pathological
gambling.
Hollander E, Kim S, Khanna S, Pallanti S. CNS Spectr. Vol 12, No 2 {Suppl
3). 2007.
February 2007
 E. Hollander, S. Kim, S. Khanna, S. Pallanti

International Classification of Diseases,Jenth Edition that very few OCD sufferers sought treatment at
{ICD-10).22 Research in the epidemiology of OCD has all3637 or were receiving inadequate, episodic treat-
gained interest in the past two decades amounting ment.38 Furthermore, the majority of OCD patients
to disparate findings that further exemplify both in worldwide phenomenological clinical studies
the fundamental differences in the patient popula- were thought to display both obsessions and com-
tion and in diagnostic assessment.The most com- pulsions simultaneously,39 but the obsessive type
monly used instruments to assess prevalence of appears in more epidemiological studies. Following
OCD are the Diagnostic Interview Schedule (DIS),2324 these mixed results, Fontenelle and colleagues32
the Composite International Diagnostic Instrument suggest determining a global assessment tool for
(CIDI)2626 the Schedule for Affective Disorders and OCD, producing more culturally applicable research
Schizophrenia (SADS)27 and the Clinical Interview instruments, and conducting multinational studies
Schedule-Revised (CIS-R).28The DIS was adapted
of the sociodemographic, clinical, and predictive
from the DSM-III and later, the DSM-III-R. Although
aspects of OCD to attain a better understanding of
its implementation yielded higher prevalence rates
the descriptive epidemiology of OCD.
across seven countries than previously reported
(from 1.9% to 2.5% for lifetime prevalence and
from 1.1% to 1.8% annual prevalence29), many have METHODS OF COMPARISONS
argued that the too-lenient severity criteria in this INTO OCD, ANXIETY DISORDERS,
assessment may falsely inflate figures for OCD.The AND OCSD
CIDI was adapted from both /CD and DSM criteria.
Prevalence rates based on this instrument varied Comorbidity Studies
from 0.3%30 to 3.1 %31 across studies. Some sug- A complication with relating two different dis-
gest that the CIDI also allows for overdiagnoses of orders via comorbidity studies is in determin-
OCD by lay interviewers as seen in the DIS. Also, ing if the comorbid disorder may actually be a
the variability in the results offered by the CIDI could long-term complication to the primary disorder.
be a reflection of DSM and ICD differences as prev- Comorbidities of mood and anxiety disorders in
alence rates using the ICD is typically lower than
OCD were investigated in several studies. The
when using DSM criteria across OCD studies.32 The
SADS adapted from the DSM-IVoffered a preva-
lence rate of 1.8% which was considered more real- FIGURE 4 .
istic.33There are also divergent findings in treatment Conceptualization that OCD Consists
seeking samples. While some studies showed OCD of Obsessions, Compulsions, and
patients were utilizing health services more fre- Symptom Domains of Varying Severity
quently than healthy individuals,3435 others showed

FIGURE 3 .
A Dimensional Approach to
Compulsivity and Impulsivity
Risk Aversive Impulsive

II
Illl
OCD BDO AN DEP
HYP TS

TRICH

1
1

Autisff
1
|•
Binge
KLEP
PG
SIB Sexua
Comp
BPD Anti-
socia
PD

Eating
Compulsi e Buying

OCD=obsessive-compulsive disorder; BDD=body dysmorphic disorder;

AN=anorexia nervosa; DEP=depression; HYP=hypochondriasis;TS=Tourette's
syndrome; TRICH=trichotillomania; KLEP=kleptomania; PG=pathological
gambling; BPD=borderline personality disorder; PD=personality disorder.

Hollander E, Kim S, Khanna S, Pallanti S. CNS Spectr. Vol 12, No 2 (Suppl Hollander E, Kim S, Khanna S, Pallanti S. CNS Spectr. Vol 12, No 2 (Suppl
3). 2007 3). 2007

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 Obsessive-Compulsive Disorder and Obsessive-Compulsive
Spectrum Disorders: Diagnostic and Dimensional Issues

most common comorbidity was major depressive in OCD.41 OCD sufferers only had a significantly
disorder (MDD) with prevalence rates of 20.7% increased risk for lifetime MDD but not for devel-
to 22% in current diagnoses and 54% to 66% in oping any other affective or anxiety disorders.42
lifetime diagnoses.40 Social phobia, with preva- Important to note is the finding that OCD typically
lence rates of 3.6% to 26% for current diagnosis precedes depression rather than following it, sug-
and 23% to 36% for lifetime diagnosis, was the gesting that depression may occur as a result of
most common anxiety disorder comorbidity. While the OCD without having an etiological relationship
some studies found anxiety disorders were more with OCD. Thus, results are mixed in the relation-
frequent in OCD probands than matched control ship between OCD and anxiety disorders.
probands, others have found that although MDD Across OCSDs, hypochondriasis, BDD, triehotil-
was ten times more prevalent in OCD populations lomania, and compulsive shopping had the high-
than in the general public, there was no evidence est lifetime prevalence rates in patients with a
of increased prevalence rates for anxiety disorders primary diagnosis of OCD. High prevalence rates

TABLE 1 .
Clinical and Endophenotypical Factors to Evaluate the Relationships Within the OCDs
Disorders
Sydenham's/PANDAS

Schizo-obsessive
Eating Disorders
Triehotillomania

Huntington's/
Parkinson's

Addiction
Hoarding

ICD-NOS
Autism
OCPD

ICDs
BDD
OCD

Phenomenology
Endophenotype
Demographics/
gender distribution
Phenomenology/
demographics
Natural history/course
Comorbidity
Course of illness
Family history
Genetic factors
Brain circuitry/
neurocognition
Cross species
Animal models
Immune function
Pharmacologic dissection
Interventional Treatment
CBT
Culture/ethnic

OCD=obsessive-compulsive disorder; OCPD=obsessive-compulsive personality disorder; TS=Tourette's syndrome; PANDAS=pediatric autoimmune neuropsy-
chiatric disorders associated with streptococcal infections; CBT=cognitive-behavioral therapy; BDD=body dysmorphic disorder; ICD=impulse control disorders;
N0S=not otherwise specified.
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 E. Hollander, S. Kim, S. Khanna, S. Pallonti
were also seen for anorexia, bulimia,Tourette's
syndrome, and trichotillomania in an OCD popu-
lation.43 Eating disorders were notably eight times
more common in OCD patients than in the general
populace.41 Reciprocally, higher OCD prevalence
rates were also found in patients with primary
diagnoses of OCSDs such as BDD (30%)44 and
anorexia (37%).45 Mixed results were also seen in
these studies as Jasisoorya and colleagues46 failed
to find evidence of greater prevalence rates for
impulse-control and eating disorders in patients
with primary diagnoses of OCD. Diverging results
in these studies may be due to methodology,
sampling, cross-cultural issues or, more broadly,
the heterogeneous quality of OCD. OCD subtypes
may have distinct comorbidity trends such as
in the case ofTS. In one study, 50% of 101 chil-
dren with Tourette's syndrome had an additional
diagnosis of OCD, and an another 8% developed
OCD during the observation period of the study.47
There may indeed be some similar genetic vul-
nerability in both childhood OCD (possibly a tic-
related subtype) andTS.48 Moreover, a distinct
OCD subtype with comorbid attention deficit dis-
order with hyperactivity may have greater risk of
pathological gambling or other impulse control
disorders compared to other OCD subtypes.5
Comorbidity studies are more telling when con-
ducted with matched healthy controls, and results
indicate that not only are OCD and OCSDs highly
correlated but that OCSDs should be more related
to OCD than any other anxiety disorder. In compar-
ing patients with lifetime diagnoses of OCD, panic
disorder, or social phobia, Richter and colleagues49
found that the OCD population had a greater prev-
alence (37%) of lifetime OCSD as compared with
the panic disorder and social phobia groups.Those
with OCD showed a greater number of spectrum
conditions, and more individuals in this group than
in the panic and social phobia groups had multiple
lifetime spectrum disorders.
Family Studies
In a family study of OCD, anxiety, and affective
disorders, Nestadt and colleagues50 found that in
families where a relative was diagnosed with OCD,
there was a greater prevalence of panic disorder,
recurrent MDD, and separation anxiety disorder.
On the other hand, GAD and agoraphobia occur-
rences were more frequent in case relatives irre-
spective of OCD diagnoses.The deduction arrived
from this study was a possible familial relationship
between OCD, GAD, and agoraphobia with other
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concurrent anxiety disorders being a consequence
of the OCD.These findings were also mixed as
Carter and colleagues51 reported that although
OCD occurred more frequently in case relatives
compared to control relatives, there were no differ-
ences between these two groups in terms of other
anxiety disorders and MDD frequencies. When
the case relative had clinical or subclinical OCD,
panic disorder, MDD, and GAD rates increased,
and this trend may suggest that the latter disor-
ders occurred as a consequence of the OCD.
Family studies suggest a relationship between
OCD and OCSDs as well. In one OCD family
study, case probands had greater occurrences
of hypochondriasis, BDD, anorexia, bulimia, and
excessive grooming disorders. However, the co-
occurrence of disorders may be due to a com-
mon latent vulnerability, that in and of itself may
be nonspecific to either condition. For example,
neuroticism may be a risk factor for OCD and
OCSDs, but neither is necessary nor sufficient for
either group of disorders. Such was the case in
first-degree relatives when compared with con-
trol proband relatives with the exception of eating
disorders. Additionally, these OCSDs occurred
even if the OCD proband did not have these disor-
ders.52 Although this study and a previous study53
did not find evidence of a higher prevalence of
eating disorders and impulse disorder, such as
pathological gambling in first-degree relatives
of OCD probands, some other studies suggest a
familial association between OCD or obsessive-
compulsive personality disorder and eating dis-
orders, but results are also mixed. First-degree
relatives of probands diagnosed with an eating
disorder had greater risk of an OCSD, and it was
independent of whether the probands were diag-
nosed with the OCSD, suggesting that these dis-
orders share similar etiology.54 In another study,
there was no apparent link between OCD diag-
nosis and eating disorders among relatives, but
there was a greater risk of obsessive-compulsive
personality disorder in relatives of anorexic pro-
bands, which may suggest a familial component
to the diffusion of these disorders.55
Some studies also show a familial link
between OCD and neurologically based OCSDs.
Relatives of OCD patients compared to relatives
of controls exhibited greater lifetime prevalence
of Tourette's syndrome and tic disorders, includ-
ing chronic motor and vocal tics.66 Moreover,
parents of autistic children who scored higher
on repetitive behavior domains were also more
10 February 2007
 Obsessive-Compulsive Disorder and Obsessive-Compulsive
Spectrum Disorders: Diagnostic and Dimensional Issues
likely to be diagnosed with OCD or OCSDs than
parents of those who scored lower.57 A possible
genetic association between OCD and OCSDs
was found in a study observing multiplex autism
families that showed a linked locus on chro-
mosome 1 in a subset of families who exhib-
ited severe obsessive compulsive behaviors.58
Furthermore, in an animal study conducted by
Greer and Capecchi,59 mutations found on the
hoxb8 gene in mice were linked with the com-
pulsive grooming and hair pulling characteristic
of trichotillomania. Because the hoxb8 gene can
be located in areas of the central nervous system
called the OCD circuit, trichotillomania and OCD
may share similar neurobiological bases.
NEUROLOGICAL STUDIES IN OCD,
ANXIETY DISORDERS, AND OCSDS
Saxena and Rauch60 proposed a pathophysiol-
ogy model of OCD that suggests dysfunction in
the orbitofrontal-subcortical circuitry composed
of direct and indirect pathways originating in the
frontal cortex and projecting into the striatum.
The direct pathway projects from the striatum to
the globus pallidus interna/substantia nigra, pars
reticulate (Gpi/SHr) complex (the primary output
location of the basal ganglia) and back to the cor-
tex, which activates the thalamic system that in
turn assists in complex motor activities.The indi-
rect pathway follows a route from the striatum
to the globus pallidus externa, the subthalamic
nucleus, globus pallidus-substantia nigra pars
reticula, thalamus, and then returns to the cortex.
By inhibiting the thalamus, this pathway stymies
complex motor activities. While there is a balance
between these two pathways in healthy individu-
als, OCD sufferers show preference for the direct
pathway, thereby increasing activity in the orbito-
frontal cortex, ventromedial caudate, and medial
dorsal thalamus, which results in obsessions and
compulsions. 60 Although previous research in
functional imaging supports this corticostriatal-
thalamocortical neurocircuity of OCD, a meta-
anaylysis of 13 functional neuroimaging studies in
OCD found no consistent differences in the orbi-
tofrontal cortex, caudate nucleus, or other previ-
ously mentioned regions between OCD patients
and healthy controls.61 Some research also sug-
gest limbic system activation in OCD in that after
symptom arousal, OCD patients displayed sig-
nificant activation in the amygdala, the medial
orbitofrontal, lateral, frontal, anterior temporal,
anterior cingulate insular cortex, and caudate.62
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The limbic activity found in this study was much
more prominent than in other studies.
The pathophysiology of anxiety disorders is
centered around a fear neurocircuitry involving
the amygdala.63-64 The amygdala's role in assess-
ing the fear stimuli for emotional significance
and forming memories of the emotion suggests
its function in provoking appropriate automatic
and behavioral responses to fear. Multiple pre-
frontal cortical structures may modulate anxiety
by sending feedback to the amygdala and alert-
ing it when the danger is no longer present or
relegating the importance of the fear stimulus.66
Because of its role in situational fear condition-
ing, the hippocampus may also be implicated in
anxiety disorders
The neurocircuitry of OCD and anxiety disor-
ders differs in that OCD demonstrates dysfunc-
tion in the frontal-striatal circuitry while anxi-
ety disorders involve the amygdala and a fear
response. While there are also possible anoma-
lies with the hippocampus and medial prefrontal
cortex, other abnormalities exhibited in OCD are
in the caudate nuclei, thalamus, and orbitofrontal
cortex. However, some research indicate possible
amydala involvement in OCD, orbitofrontal cortex
activation in simple phobia, and prefrontal and
thalamo-striatal regions in GAD.
NEUROCIRCUITRY OF OBSESSIVE
COMPULSIVE SPECTRUM DISORDERS
Research on the neurocircuitry of OCSDs is
more limited but suggests dysfunction in the
basal ganglia, specifically in autism, BDD, some
eating disorders, andTS. Enlarged caudate vol-
ume,19 increased right caudate and putamen vol-
umes65 were found in autism. Ritualistic behavior
but not communication or social behavior
were implicated with caudate volume. In BDD,
enlarged white matter volume and a leftward
shift in the caudate nucleus asymmetry were
observed when compared to healthy controls.66
Anorexia also displayed increased antiputamen
antibody levels.67 Finally, decreased volumes
in caudate, putamen, and globus pallidus were
found in aTS population.18
CONCLUSION
Although results are mixed in comorbity, fam-
ily, and neuroimaging studies in establishing the
relationships between OCD and anxiety disorders
and OCSDs, there is growing evidence that sup-
11 February 2007
 E. Hollander, S. Kim, S. Khanna, S. Pollanti
ports the latter; there appears to be more phe-
nomenological similarities between OCD and
OCSD than with anxiety disorders.The Obsessive
Compulsive Disorder Consensus Group was
assembled in 2005 to discuss a reorganization of
the DSM in its 5th edition and future international
classification systems to address these concerns.
The objectives of this collaborative effort is to
update the current data on OCD and OCSDs, dis-
cuss the controversies surrounding these issues,
engage experts from around the world, and dis-
seminate the conclusions via symposia consisting
of workgroup discussions and presentations.The
breadth of topics covered in areas of diagnosis,
specific topics and cross-cutting issues are dis-
played inTable 1 with the ultimate goal of defin-
ing OCSDs based on endophenotypical features.
The main unresolved issues and future direc-
tions of this topic are: (1) Should OCD be clas-
sified as an anxiety disorder; (2) If not, does it
TABLE 2 .
Reasons to Establish OCSDs
Advantages
I Classification is a better fit with the scientific data
Compatible with ICD-10
Help screening - clinic samples and epidemiological
surveys
Enhance treatment
Access to insurance - a serious and persistent disor-
der - increased resources for specialist services
Influence research funding agencies
• Enhance endophenotyping and neurological efforts
Facilitate drug development (larger market)
Decrease concerns regarding off-label prescribing
Disadvantages
Anxiety is a target for CBT. However, could lead to the
development of CBT strategies that are more specific
to OCDs
Against a long-standing tradition of classifying OCD as
part of anxiety disorders
Fragmentation of anxiety clinics
Decrease use of benzodiazepines and SGAs for OCD
(minor versus major tranquillizers)
OCSD=obsessive-compulsive spectrum disorders; ICD-Mklnternational
Classification of Diseases, Tenth Edition; CBT=cognitive-behavioral therapy;
OCD=obsessive-compulsive disorder; SGA=second-generation antipsychotics.
Hollander E, Kim S, Khanna S, Pallanti S. CNS Spectr. Vol 12, No 2 (Suppl
3). 2007.
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belong in this new category of OCSDs?; (3) Could
a common endophenotype (mediating factors
between genes and observable behaviors) across
the OCSDs be established?; (4) How would the
endophenotypes be defined?; and (5) what stud-
ies are needed?
In addressing these issues in future research,
we should: (1) examine evidence for the relation-
ship between OCD and OCSD in a comprehensive
manner and across various methods, which is cur-
rently underway as the research planning agenda
for DSM-V; (2) Reexamine the existing data-
bases to answer the aforementioned questions;
(3) Define a common endophenotype battery,
neurocognitive aspects, genotyping, functional
magnetic resonance imaging, symptom scales,
structured assessment for comorbidity, and treat-
ment response; and (4) Allow for multicenter tri-
als that include an endophenotyping project.
A reclassification of OCD as an OCSD would
allow for better scrutiny of distinct obsessive-
compulsive symptoms, as currently this disorder
often goes undetected in patients who complain
of a broad symptom of anxiety.Table 2 outlines
the advantages and disadvantages to establishing
OCSDs and its implications on diagnosis, treat-
ment, medication and research. Not only will this
reclassification bolster more accurate diagnoses
and appropriate treatment for OCD, it will also
give way to determining the biological underpin-
nings of the repetitive thoughts and compulsions
characteristic of OCSD. CNS
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