OCD through the Lens of HiTOP — Not a Disorder in Isolation, but Part of a Spectrum
Obsessive–Compulsive Disorder (OCD) has long been placed under anxiety disorders (DSM-IV), and later reclassified into its own category (DSM-5: Obsessive–Compulsive and Related Disorders).
But even this separation doesn’t fully explain:
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Why OCD often exists with anxiety and depression
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Why some OCD patients are perfectionistic, guilt-driven — while others are impulsive or tic-related
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Why intrusive thoughts resemble ruminations in depression, or obsessions in personality disorders
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Why brain imaging shows overlaps between OCD, anxiety, and trauma
This is where HiTOP offers a clearer, dimensional perspective.
📍 Where Does OCD Fit in HiTOP?
HiTOP does not see OCD as a standalone disorder. It is part of the Internalizing Spectrum, particularly under the “Fear & Distress (Anxious-Misery)” subfactor.
Hierarchy View (HiTOP structure):
| Level | Where OCD Fits |
|---|---|
| Symptom Level | Obsessions (intrusive thoughts), compulsions (rituals), checking, contamination fears |
| Syndrome Level | OCD (as a clinical diagnosis) |
| Subfactor Level | Fear & Distress Disorders (along with panic disorder, generalized anxiety disorder, illness anxiety) |
| Spectrum Level (Broad) | Internalizing Spectrum — includes Depression, Anxiety, OCD, PTSD, Eating Disorders |
| p-Factor (General) | Shared vulnerability to all mental disorders |
So OCD isn’t separate — it’s part of a wider internal distress system in the brain.
🧠 Why This Matters: Understanding the “Type” of OCD
HiTOP helps explain why OCD is not one disorder, but has different profiles:
| OCD Variant | HiTOP-Relevant Traits | Typical Brain/Cognitive Patterns |
|---|---|---|
| Classic Fear-Based OCD (contamination, checking) | High internalizing, high fear, harm avoidance | Hyperactivity in cortico-striatal-thalamic loops |
| Scrupulosity/Guilt OCD | Distress + perfectionism + moral sensitivity | Overactive error-detection (ACC) |
| Pure-O / Rumination type | Internalizing + depression + worry loops | Similar to GAD + depressive rumination |
| OCD + Tics / Impulsive Subtype | Mix of internalizing + externalizing + motor disinhibition | Linked to Tourette’s / ADHD overlaps |
| OCD + Personality Traits (perfectionistic, rigid, anxious attachment) | OCD + Obsessive–Compulsive Personality + Harm avoidance | Higher anxiety + rigidity; low flexibility |
💥 Why OCD Often Comes with Anxiety, Depression, Eating Disorders
Under HiTOP, this is not comorbidity but shared spectrum vulnerability.
Internalizing Spectrum =
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Fear-based conditions → Phobias, Panic Disorder, OCD
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Distress-based conditions → Depression, GAD, PTSD
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Body-related → Somatic anxiety, eating disorders
This explains why:
✔ 70% of OCD patients also have anxiety
✔ 50–60% have depression at some point
✔ Perfectionistic teen with OCD may later develop anorexia or social anxiety
✔ Stress worsens all internalizing conditions, not just OCD
🩺 Clinical Implications: How HiTOP Helps Us Treat OCD Better
| Traditional View | HiTOP-Informed View |
|---|---|
| “This is OCD. Let’s treat obsessions & compulsions.” | “This person lies high on the internalizing spectrum with fear-driven compulsions, trauma sensitivity, and depressive rumination.” |
| Focus only on ERP (Exposure & Response Prevention) | Combine ERP + emotional regulation + treat depressive/intrusive rumination components |
| Separate OCD from personality traits | See perfectionism, moral rigidity, guilt as dimensional modifiers |
| Anxiety + OCD = two diagnoses | Actually part of the same spectrum — one treatment plan, not fragmented |
🎯 Treatment Approach (HiTOP-Aligned OCD Management)
✅ First — Identify the dominant spectrum features:
– Fear-dominant? Depressive-dominant? Trauma-linked? Tic-related?
✅ Then personalise therapy:
| Spectrum Influence | Add-On Treatment |
|---|---|
| High Fear/Compulsions | ERP (Exposure & Response Prevention) |
| High Distress/Depression | CBT + SSRI + Rumination-focused therapy |
| Perfectionism/Morality OCD | Schema Therapy / Compassion-Focused Therapy |
| Tic-related / Externalizing OCD | Combine ERP + habit reversal + possibly dopamine blockers |
⚖️ Final Thought
HiTOP helps us see OCD not as a box but as a spectrum experience within a larger emotional system. It removes artificial boundaries and helps us treat people, not labels.
👨⚕️ Dr. Srinivas Rajkumar T
MD (AIIMS), DNB, MBA
Consultant Psychiatrist — Mind & Memory Clinic
Apollo Clinic, Velachery (Opp. Phoenix MarketCity), Chennai
📞 +91-8595155808 | 🌐 www.srinivasaiims.com