Diagnostic subtyping of obsessive-compulsive disorder : have we got it all wrong?

The presenting complaint of patients with obsessive-compulsive disorder (OCD) is often their predominant OCD symptom (e.g. excessive checking, hand-washing, or distressing intrusive thoughts). Yet OCD symptoms do not feature as OCD specifiers in any of the major diagnostic classificatory systems such as the ICD-10 (World Health Organization, 1992), DSM-IV-TR (American Psychiatric Association, 1994), or even in the proposed changes for DSM-5 (American Psychiatric Association, 2012). Instead, the degree of insight and the presence of comorbid tics are preferred as specifiers, and hoarding is proposed to constitute a separate disorder in DSM-5 (American Psychiatric Association, 2012). The mounting evidence supporting the role of predominant OCD symptoms in explaining the heterogeneity of OCD (Bloch et al., 2008; Mataix-Cols et al., 2005) may lead one to wonder why they are not featured in major diagnostic classificatory systems and whether we have got it all wrong.