The Obsessive–Compulsive Spectrum: A Systematic Review

The Obsessive–Compulsive Spectrum: A Systematic Review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review The Obsessive–Compulsive Spectrum: A Systematic Review Fernando Filipe Paulos Vieira This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8299723/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The concept of the obsessive–compulsive spectrum (OCS) has expanded over the last three decades, encompassing disorders characterized by intrusive thoughts, repetitive behaviors, and difficulties in impulse control. Objective To systematically review the literature describing the phenomenology, neurobiology, comorbidity patterns, and treatment implications of OCS conditions. Methods A systematic search of PubMed, Scopus, and Web of Science (1990–2024) identified studies on obsessive–compulsive disorder (OCD), related disorders (trichotillomania, excoriation disorder, body dysmorphic disorder, hoarding disorder), and compulsive behavioral addictions (e.g., gambling, internet gaming). Results Findings indicate partially shared neurobiological circuits—particularly cortico-striatal-thalamo-cortical (CSTC) loops—alongside genetic overlap and frequent clinical comorbidity. Treatment response across the spectrum varies, with SSRIs and CBT effective for OCD and BDD, while behavioral addictions respond better to CBT and opioid antagonists. Conclusion The obsessive–compulsive spectrum framework provides a dimensional approach to mental disorders, though boundaries between impulsive and compulsive behaviors remain debated. Psychology Psychiatry Obsessive–Compulsive Spectrum OCD-Related Disorders Compulsivity and Impulsivity Cortico-Striatal-Thalamo-Cortical Circuits Cognitive-Behavioral Therapy Introduction Obsessive–compulsive disorder (OCD) has long been regarded as a prototypical anxiety disorder, characterized by intrusive thoughts, images, or urges (obsessions) and repetitive behaviors or mental acts (compulsions) performed to neutralize distress ( 1 ). However, beginning in the 1980s and 1990s, researchers increasingly recognized that OCD shares clinical, genetic, and neurobiological features with a group of conditions marked by similar patterns of intrusive phenomena and repetitive behaviors. This led to the emergence of the concept of the obsessive–compulsive spectrum (OCS), a dimensional framework that aims to describe a cluster of disorders that lie at the interface between anxiety, impulse control, and habit-driven behaviors ( 2 , 3 ). The OCS model was initially proposed to explain the overlap between OCD and disorders such as body dysmorphic disorder (BDD), trichotillomania, tic disorders, hypochondriasis, and certain impulse-control disorders ( 4 ). These conditions appear to share phenomenological characteristics—such as intrusive, distressing thoughts or urges and repetitive, ritualized behaviors—and often respond to similar treatments, including selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapies (CBT) ( 5 , 6 ). Over time, the concept expanded to include disorders involving compulsive reward-seeking or impaired inhibition, including pathological gambling and internet gaming disorder—conditions that contain both impulsive and compulsive elements ( 7 , 8 ). The publication of the DSM-5 in 2013 formalized part of this spectrum by creating a dedicated chapter for Obsessive–Compulsive and Related Disorders (OCRDs), separating OCD from the anxiety disorders ( 9 ). This new category includes BDD, hoarding disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-picking) disorder—conditions now recognized as sharing core features with OCD, despite notable differences in motivation, insight, and symptom expression ( 9 , 10 ). Nevertheless, the DSM-5 OCS grouping remains narrower than the original conceptual spectrum, which included impulsive and addictive disorders. This discrepancy continues to fuel debate about where the boundaries of the OCS should be drawn ( 11 ). Neurobiological evidence provides substantial support for spectrum models. Functional neuroimaging studies show abnormalities across the cortico-striatal-thalamo-cortical (CSTC) circuits in OCD, BDD, and grooming disorders, suggesting shared mechanisms of impaired cognitive control, habit formation, and motor inhibition ( 12 , 13 ). Genetic studies also demonstrate moderate heritability for OCD and related disorders, with overlapping susceptibility loci that involve serotoninergic and glutamatergic pathways ( 14 ). From a cognitive perspective, disorders within the spectrum often exhibit patterns of perfectionism, intolerance of uncertainty, and maladaptive beliefs related to threat, responsibility, or body image ( 15 ). Clinically, individuals with OCD frequently present with comorbidities that reflect this shared vulnerability. For example, BDD is present in up to 15% of OCD patients, while grooming disorders, impulse-control problems, and certain addictive behaviors occur at higher-than-expected rates across populations with OCD or related traits ( 16 , 17 ). These overlapping clinical presentations have practical implications for diagnosis and treatment, as recognizing shared mechanisms may guide clinicians toward more integrated treatment strategies. Despite the appeal of a unifying dimensional framework, significant controversies remain. Critics argue that grouping disorders based on superficial similarities may obscure important differences in pathophysiology and treatment response ( 18 ). Others contend that the spectrum model better reflects current evidence than traditional categorical systems and may ultimately improve the precision of psychiatric diagnosis ( 19 ). As neuroscience increasingly highlights the dimensional nature of psychopathology, the obsessive–compulsive spectrum remains a valuable—though evolving—framework for conceptualizing these complex disorders. Methods This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. The methodology was prospectively defined to ensure transparency, reproducibility, and methodological rigor. Study Design This review aimed to synthesize evidence on the clinical features, neurobiology, comorbidity patterns, and treatment responses of disorders within the obsessive–compulsive spectrum (OCS). The review followed a narrative-systematic hybrid approach, integrating quantitative findings from randomized and observational studies with qualitative and theoretical literature fundamental to the conceptual evolution of the OCS. Data Sources and Search Strategy A comprehensive literature search was conducted in the following electronic databases: PubMed/MEDLINE Scopus Web of Science Core Collection PsycINFO The search covered the period from January 1, 1990, to December 31, 2024, capturing the emergence and maturation of OCS conceptual models. Core Search Terms The search strategy combined controlled vocabulary (e.g., MeSH terms) and free-text keywords. Boolean operators (AND/OR/NOT) were used to optimize sensitivity and specificity. The core search string used in PubMed was: (“obsessive-compulsive disorder” OR OCD OR “obsessive-compulsive spectrum” OR “OCD-related disorders” OR “body dysmorphic disorder” OR “trichotillomania” OR “excoriation disorder” OR “hoarding disorder” OR “compulsivity” OR “impulsive-compulsive spectrum”) AND (“neurobiology” OR “phenomenology” OR “treatment” OR “cognitive-behavioral therapy” OR SSRIs OR “cortico-striatal-thalamo-cortical”). Parallel adaptations were applied to the other databases. Additional Search Procedures To ensure completeness: The reference lists of included studies and key reviews were hand-searched. Grey literature (conference abstracts, dissertations) was screened in OpenGrey and ProQuest. The World Health Organization ICTRP and ClinicalTrials.gov were searched for unpublished or ongoing clinical trials. Eligibility Criteria Inclusion Criteria Studies were eligible if they met the following criteria: 1. Population: Adults or adolescents diagnosed with OCD or related disorders as defined by DSM-IV, DSM-5, or ICD-10/11, including: Body dysmorphic disorder Hoarding disorder Trichotillomania (hair-pulling disorder) Excoriation (skin-picking) disorder Tic-related OCD Behavioral addictions (considered in OCS theories) 2. Study Types: Randomized controlled trials (RCTs) Non-randomized clinical trials Cohort, case-control, or cross-sectional studies Systematic reviews or meta-analyses Neuroimaging, genetic, or neurocognitive studies Major theoretical papers proposing OCS classification 3. Outcomes: Phenomenological characteristics Neurobiological findings Comorbidity patterns Therapeutic outcomes (psychotherapy, pharmacotherapy, neuromodulation) Exclusion Criteria Studies were excluded if they: Presented single case reports or case series with n < 5 Focused on non-clinical populations (e.g., “subclinical OCD traits”) Examined unrelated conditions without compulsive/impulsive features Were purely descriptive without methodological detail Were non–peer reviewed (except registered clinical trials) Study Selection Process All retrieved records were imported into Rayyan QCRI, and duplicates were removed. Study selection occurred in three stages: Title screening by two independent reviewers Abstract screening by the same reviewers Full-text screening based on eligibility criteria Discrepancies were resolved through consensus or consultation with a third reviewer. A total of 142 studies were included after full-text evaluation. Data Extraction A standardized data extraction form was used. The following variables were collected: Author(s), year, country Diagnostic criteria used Sample size, demographics Study design and methodology Neurobiological or clinical outcomes Comorbidities Type and effectiveness of treatments Measurement instruments (e.g., Y-BOCS, BDD-YBOCS, MGH-HPS) Data extraction was performed by two independent reviewers. Quality Assessment Relevant quality assessment tools were applied according to study design: Cochrane Risk of Bias 2 (RoB2) for randomized controlled trials Newcastle–Ottawa Scale (NOS) for observational studies AMSTAR-2 for systematic reviews QUADAS-2 for diagnostic accuracy studies NIH Quality Assessment Tool for cross-sectional studies Studies were classified as low, moderate, or high risk of bias. Quality ratings were used descriptively and informed the narrative synthesis. Data Synthesis Given the conceptual and methodological heterogeneity across studies—ranging from neuroimaging investigations to treatment trials—a meta-analysis was not feasible. Instead, a narrative synthesis was performed: Phenomenological features Neurobiological domains (neuroimaging, neurochemistry, genetics) Comorbidity patterns Treatment modalities (psychotherapy, pharmacotherapy, neuromodulation) Spectrum conceptual models Patterns of convergence and divergence across disorders were identified, allowing for an integrative interpretation of the obsessive–compulsive spectrum. Results A total of 4,382 records were identified through database searches. After removing duplicates, 2,916 citations underwent title and abstract screening. Of these, 274 full-text articles were reviewed in detail, and 142 studies met the inclusion criteria. The included studies comprised randomized controlled trials, cohort and case-control studies, neuroimaging investigations, genetic analyses, and major theoretical contributions to the obsessive–compulsive spectrum (OCS) concept. The heterogeneity of study designs and populations precluded meta-analysis, but patterns of convergence and divergence across phenotypic, neurobiological, and therapeutic domains enabled a structured narrative synthesis. Phenomenological Patterns Across the Spectrum The most consistent finding across included studies was the presence of intrusive experiences—thoughts, images, impulses, or sensory urges—paired with repetitive behaviors aimed at reducing distress or tension. OCD studies (n = 41) consistently identified four core symptom dimensions—contamination/cleaning, symmetry/ordering, forbidden thoughts, and checking/harm obsessions. Body dysmorphic disorder (BDD) studies (n = 18) described appearance-related preoccupations accompanied by ritualistic checking, grooming, or camouflaging behaviors. Grooming disorders (trichotillomania and excoriation disorder; n = 22) were characterized by repetitive behaviors driven primarily by mounting internal tension rather than fear-based preoccupations. Hoarding disorder studies (n = 15) demonstrated a distinct pattern, with behavioral rigidity, emotional attachment to possessions, and difficulty discarding items more salient than intrusive thoughts. Gambling disorder and internet gaming disorder studies (n = 12) illustrated a shift from impulsive reward-seeking toward compulsive habitual engagement as illness severity progressed. Insight levels varied widely across disorders, with BDD and hoarding disorder demonstrating the highest frequency of poor insight—often associated with delayed treatment-seeking and poorer prognosis. Table 1 Core Phenomenological Features of OCS Disorders. Disorder Intrusive Thoughts/Urges Repetitive Behaviors Primary Motivational Drive Insight Level OCD Prominent Compulsions/rituals Anxiety reduction Good → poor BDD Appearance-related obsessions Checking/grooming Body-image distress Moderate → poor Trichotillomania Sensory/urge-driven Hair-pulling Tension reduction Moderate Excoriation Disorder Sensory/urge-driven Skin-picking Tension reduction Moderate Hoarding Disorder Minimal intrusions Saving/acquiring Emotional attachment/avoidance Often poor Gambling Disorder Reward cravings Gambling behaviors Reward-seeking → habit Often poor Neurobiological Findings Neuroimaging studies (n = 38) collectively demonstrated substantial involvement of cortico-striatal-thalamo-cortical (CSTC) circuits, though disorder-specific patterns added nuance to the spectrum framework. OCD consistently showed hyperactivation of the orbitofrontal cortex, anterior cingulate cortex, and caudate nucleus. BDD exhibited abnormalities in visual processing networks and heightened ventral striatal reactivity to self-referential stimuli. Grooming disorders demonstrated dysregulation in habit circuitry, including the supplementary motor area and ventral striatum. In contrast, hoarding disorder studies revealed reduced anterior cingulate activation during decision-making tasks, suggesting neurocognitive mechanisms distinct from classic OCD. Behavioral addictions showed hyperactivation of dopaminergic reward circuits, particularly the nucleus accumbens, consistent with theories of compulsive reinforcement. Genetic studies (n = 17) reported moderate heritability across OCS conditions, with overlapping genetic contributions involving serotonin transporter genes (SLC6A4), glutamate transporter genes (SLC1A1), and SAPAP3, a gene implicated in animal models of compulsive grooming. Neurochemical investigations (n = 12) supported serotonergic dysfunction in OCD and BDD, glutamatergic abnormalities in OCD and grooming disorders, and dopaminergic abnormalities in behavioral addictions. Table 2 Neurobiological Overlap Across OCS Conditions. Disorder CSTC Dysfunction Serotonergic Role Glutamate Role Reward-Pathway Involvement OCD Strong Strong Moderate → strong Low BDD Moderate Strong Possible Low Trichotillomania Moderate Weak Strong Moderate Excoriation Disorder Moderate Weak Moderate Moderate Hoarding Disorder Distinct ACC deficits Weak ? Low Gambling/Gaming Disorder Minimal CSTC Weak Weak Strong The convergence of findings suggests a shared architecture of impaired inhibitory control, habit circuitry hyperactivation, and altered salience processing, though the balance of these mechanisms varies across disorders. Comorbidity and Functional Impairment Comorbidity was highly prevalent across all spectrum disorders. Anxiety disorders co-occurred in 40–60% of individuals with OCD, while major depressive disorder was common across OCD, BDD, hoarding, and grooming disorders. BDD occurred in approximately 10–15% of OCD patients, and grooming disorders frequently coexisted with ADHD and tic disorders. Behavioral addictions exhibited high rates of substance-use disorders (20–30%) and mood dysregulation. Functional impairment was substantial. OCD and BDD were associated with social avoidance and occupational impairment, with up to 25% of BDD patients becoming housebound. Hoarding disorder was frequently associated with unsafe living environments and increased medical complications. Grooming disorders, though sometimes underestimated clinically, led to social embarrassment, avoidance, and reduced quality of life. Gambling disorder caused severe financial, relational, and legal consequences. Table 3 Comorbidity Patterns Across the OCS. Disorder Common Psychiatric Comorbidities Functional Impact OCD Anxiety, depression, BDD High occupational/social impairment BDD OCD, depression, social anxiety Severe social avoidance Hoarding Depression, social anxiety Environmental hazards Trichotillomania Tic disorders, ADHD Social shame, avoidance Excoriation Disorder Anxiety, depression Dermatological harm Gambling Disorder Substance-use disorders, depression Financial/legal consequences These patterns reinforce the conceptual framing of OCS disorders as sharing underlying vulnerabilities while exhibiting heterogeneity in expression and impairment. Treatment Outcomes Psychotherapy Psychotherapy studies (n = 32) highlighted modality-specific effectiveness. Exposure and Response Prevention (ERP) demonstrated strong efficacy for OCD, with consistent improvements across all symptom dimensions. Cognitive-behavioral therapy with perceptual restructuring was effective for BDD, particularly when combined with exposure to avoided situations. Habit Reversal Training (HRT) emerged as the most effective intervention for trichotillomania and excoriation disorder. CBT models targeting cognitive distortions and reward expectation were effective for gambling and gaming disorders, with moderate-to-large effect sizes. Pharmacotherapy Pharmacological studies (n = 26) found SSRIs effective for OCD and BDD, with clomipramine particularly beneficial in treatment-resistant OCD. Glutamate-modulating agents such as N-acetylcysteine (NAC) showed promise for grooming disorders. Naltrexone was effective in reducing gambling urges and behaviors. Evidence for pharmacotherapy in hoarding disorder was limited and inconsistent. Table 4 Summary of Treatment Effectiveness Across OCS Disorders. Disorder Most Effective Psychotherapy Most Effective Pharmacotherapy Other Interventions OCD ERP SSRIs, clomipramine DBS, rTMS BDD CBT with perceptual restructuring SSRIs – Hoarding CBT (decision-making focus) Mixed SSRI results – Trichotillomania HRT NAC – Excoriation Disorder HRT/CBT NAC – Gambling Disorder CBT (reward-focused) Naltrexone – Neuromodulation Eight studies evaluated neuromodulation. Deep Brain Stimulation (DBS) demonstrated substantial improvement in severe, treatment-refractory OCD when targeting the anterior limb of the internal capsule or nucleus accumbens. Repetitive Transcranial Magnetic Stimulation (rTMS) offered modest but clinically meaningful benefits, particularly when focused on the dorsolateral prefrontal cortex or the supplementary motor area. Evidence for tDCS remained mixed and insufficient to support consistent clinical application. Overall Summary of Findings In summary, the 142 included studies illustrate: Strong phenomenological and neurobiological overlap across OCS disorders. CSTC circuit dysfunction as a unifying mechanism, with disorder-specific patterns. High rates of psychiatric comorbidity and substantial functional impairment across the spectrum. Disorder-specific treatment responses, underscoring the importance of mechanism-driven therapeutic approaches. Discussion This systematic review synthesized findings across 142 studies on disorders traditionally conceptualized within the obsessive–compulsive spectrum (OCS). Overall, the evidence supports the notion that these conditions share transdiagnostic mechanisms involving compulsivity, intrusive mental events, and impaired inhibitory control, consistent with dimensional models of psychopathology ( 20 , 21 ). Intrusive experiences—whether harm obsessions in OCD, defect-focused preoccupations in body dysmorphic disorder (BDD), sensory urges in grooming disorders, or reward-driven impulses in behavioral addictions—were consistently paired with repetitive behaviors aimed at reducing distress or tension ( 22 ). Yet the motivational architecture underlying these phenomena diverged: OCD patients typically acted to prevent perceived harm ( 23 ), while individuals with trichotillomania or excoriation disorder acted to relieve mounting sensory tension ( 24 ), and those with gambling or gaming disorder were driven by dysregulated reward processing ( 25 ). Neurobiological findings also demonstrated both overlap and dissociation. Across multiple disorders, dysfunction in cortico-striatal-thalamo-cortical (CSTC) pathways emerged as a key shared mechanism linked to impaired inhibitory control and persistent habits ( 26 ). Still, disorder-specific patterns were evident. BDD consistently showed abnormalities in visual information processing and fronto-limbic integration ( 27 ). Hoarding disorder exhibited reduced anterior cingulate activation during conflict-heavy decision-making tasks ( 28 ). Grooming disorders were associated with structural and functional alterations in premotor and striatal circuits implicated in urge-driven behaviors ( 29 ). Meanwhile, behavioral addictions showed enhanced activation in reward circuitry, particularly the ventral striatum, supporting models of compulsivity emerging from dysregulated reinforcement learning ( 30 ). Genetic research similarly pointed to partial overlap, with shared contributions from glutamatergic and serotonergic pathways across multiple OCS disorders ( 31 ), yet also highlighted distinct genetic architectures, especially in hoarding and grooming conditions ( 32 ). Comorbidity patterns further reinforced the interconnected nature of these disorders. High rates of major depressive disorder and generalized anxiety disorder were observed among patients with OCD, BDD, and hoarding disorder ( 33 ), while grooming disorders were frequently associated with tic disorders and ADHD ( 34 ). Gambling disorder and other behavioral addictions demonstrated elevated rates of substance-use disorders and mood dysregulation ( 35 ). These findings align with dimensional models positing that compulsivity, impulsivity, and affective dysregulation share overlapping neurocognitive substrates ( 36 ). Treatment studies revealed both transdiagnostic efficacy and important disorder-specific distinctions. Exposure and Response Prevention (ERP) remained the most effective intervention for OCD, with consistent medium to large effect sizes ( 37 ). CBT models incorporating perceptual retraining showed benefit for BDD ( 38 ), while habit reversal training (HRT) produced robust improvements in trichotillomania and excoriation disorder ( 39 ). In behavioral addictions, cognitive-behavioral and motivational approaches were associated with significant symptom reduction and improved functional outcomes ( 40 ). Pharmacotherapy demonstrated a more restricted transdiagnostic utility: SSRIs were effective for OCD and BDD but produced limited improvements in grooming or hoarding disorders ( 41 ). Glutamate-modulating agents such as N-acetylcysteine showed promising results in trichotillomania and skin-picking ( 42 ). In gambling disorder, opioid antagonists—particularly naltrexone—significantly reduced urges and behavior frequency ( 43 ). Neuromodulation approaches, including deep brain stimulation (DBS), offered substantial benefits for treatment-resistant OCD, achieving clinically meaningful response rates through modulation of ventral capsule/ventral striatum pathways ( 44 ). Altogether, the evidence supports conceptualizing the obsessive–compulsive spectrum as a cluster of related but distinct disorders that share core dimensions of compulsivity and repetitive behavior but diverge across phenomenological drivers, neurobiological mechanisms, and treatment responses. This aligns with modern frameworks advocating for multidimensional and network-based models of psychopathology ( 45 ), which may ultimately enhance diagnostic precision and treatment personalization. Nevertheless, heterogeneity in methodologies and uneven representation of non-OCD disorders remain important limitations of the current literature. Future research should focus on identifying transdiagnostic biomarkers, delineating developmental trajectories between impulsive and compulsive behaviors, and evaluating mechanism-based interventions across the spectrum. Importantly, patients within the obsessive–compulsive spectrum may report uncomfortable bodily sensations and heightened interoceptive awareness, which in some cases might include chest discomfort or tightness, suggesting a somatic manifestation of anxiety intertwined with compulsive urges. Sensory phenomena — uncomfortable internal sensations (e.g. visceral or somatic discomfort, “just‑right” inner tension, urge‑only sensations) often precede, trigger, or accompany repetitive compulsive behaviours in individuals across the OCS ( 46 , 47 ). The experience of chest tightness or pain could potentially serve as both a trigger and a consequence of obsessive–compulsive behaviors, reflecting the embodied dimension of intrusive thoughts, heightened autonomic arousal, and altered interoception ( 48 , 49 ). Repetitive compulsive acts, aimed at reducing psychological tension, might be accompanied by somatic symptoms such as thoracic discomfort, highlighting the intersection between emotional distress and bodily sensations in OCS disorders. Moreover, obsessive thinkings about harm, health, or contamination may precipitate acute anxiety responses — possibly experienced as chest pain — demonstrating a bidirectional relationship between cognitive intrusions and somatic expression. Neurobiological models propose that dysregulation of cortico‑striatal circuits and altered interoceptive processing in OCS may not only drive compulsivity but also exacerbate autonomic sensitivity, potentially manifesting as chest tightness or discomfort during episodes of heightened obsessive anxiety ( 50 ). However, it is important to note that although the prevalence of sensory phenomena and interoceptive alterations in OCS has been consistently documented, there is currently little empirical evidence specifically addressing chest pain or chest tightness as a recurring or characteristic symptom — especially in representative, large-scale samples. Thus, the proposed link should be framed as a hypothesis rather than an established conclusion, and interpreted with caution; future empirical studies are required to directly assess the occurrence, phenomenology, and clinical significance of thoracic somatic symptoms in OCS populations. References American Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th edn. APA, Washington, DC Hollander E, Kwon JH, Stein DJ, Broatch J, Rowland CT, Himelein CA (1996) Obsessive–compulsive spectrum disorders. CNS Spectr 1(5):16–27 Bernstein GA, Victor AM, Pipal AJ, Nelson PM (2013) Pediatric OCD and related disorders: a review of the literature. Child Psychiatry Hum Dev 44(1):137–150 Phillips KA, Stein DJ (1997) Obsessive–compulsive spectrum disorders. J Clin Psychiatry 58(Suppl 12):3–6 Fineberg NA, Reghunandanan S, Simpson HB et al (2015) Obsessive–compulsive disorder (OCD): practical strategies for pharmacological and somatic treatment in adults. Psychiatry Res 227(1):114–125 Foa EB, McLean CP (2016) The efficacy of exposure therapy for anxiety-related disorders and OCD. Dialogues Clin Neurosci 18(3):293–304 Grant JE, Potenza MN (2004) Compulsive aspects of impulse-control disorders. Psychiatr Clin North Am 27:757–779 Stein DJ, Fineberg NA, Chamberlain SR (2014) Emerging concepts of compulsivity across clinical disorders. J Clin Psychiatry 75(11):e1258–e1260 Vieira FFP (2024) Transtornos de na ansiedade e transtorno obsessivo-compulsivo. In: F. Lotufo Neto & T. Pântano (coords.). Saúde Mental e Psicopatologias (pp. 99–104). Manole. ISBN: 978-65-6109-024-7 Mataix-Cols D, de la Fernández L et al (2013) Hoarding disorder: a new diagnosis for DSM-5. Depress Anxiety 30(6):556–566 Abramowitz JS, Jacoby RJ (2015) Obsessive–compulsive and related disorders: a critical review of the new diagnostic group in DSM-5. Clin Psychol Sci Pract 22:258–279 Menzies L, Chamberlain SR et al (2008) Integrating neuroimaging and neuropsychological findings in OCD: the orbitofronto-striatal model revisited. Neurosci Biobehav Rev 32:525–549 Feusner JD, Hembacher E, Phillips KA (2010) The neuroanatomy of BDD. CNS Spectr 15(4):1–11 van Grootheest DS, Cath DC et al (2005) Twin studies on OCD. Psychol Med 35:1–12 Salkovskis PM (1985) Cognitive theory of OCD. Behav Res Ther 23(5):571–583 Phillips KA, Menard W et al (2005) Clinical features of BDD in OCD. Am J Psychiatry 162:1422–1423 Grant JE, Odlaug BL, Chamberlain SR (2010) Trichotillomania, skin picking, and other compulsive behaviors. Psychiatr Clin North Am 33:565–583 Kendler KS (2016) The nature of psychiatric disorders: toward a new nosology. World Psychiatry 15(1):5–12 Insel T, Cuthbert B, Garvey M et al (2010) Research Domain Criteria (RDoC): toward a new classification framework for mental disorders. Am J Psychiatry 167:748–751 Dalley JW, Robbins TW (2017) Fractionating impulsivity: neuropsychiatric implications. Nat Rev Neurosci 18(3):158–171 Kotov R, Krueger RF, Watson D, Achenbach TM, Althoff RR, Bagby RM et al (2017) The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Psychol Med 47(8):1423–1437 Vieira FFP, Lotufo Neto F (2019) Understanding the Obsessive- Compulsive Disorder: A Book Review. Revista Multidisciplinar Núcleo do Conhecimento, 10 (10), 146–154. https://doi. org/10.32749/nucleodoconhecimento.com.br/psychology/obsessive-compulsivedisorder Salkovskis PM, Millar JF, Gregory JD (2016) Cognitive-behavioural theory and treatment of obsessive–compulsive disorder. Behav Res Ther 90:31–46 Odlaug BL, Lust K, Schreiber LRN, Christenson GA, Derbyshire K, Grant JE (2010) Pathophysiology and clinical features of excoriation (skin-picking) disorder. J Psychiatr Res 45(11):1580–1588 Limbrick-Oldfield EH, van Holst RJ, Clark L (2017) Fronto-striatal dysregulation and compulsivity in gambling disorder. Nat Rev Neurol 13(7):439–452 Pauls DL, Abramovitch A, Rauch SL, Geller DA (2014) Obsessive–compulsive disorder: an integrative genetic and neurobiological perspective. Nat Rev Neurosci 15(6):410–424 Feusner JD, Hembacher E, Phillips KA (2017) The neurobiology of body dysmorphic disorder: a systematic review and new neurobiological model. CNS Spectr 22(4):311–320 Tolin DF, Stevens MC, Villavicencio AL, Norberg MM, Calhoun VD, Karlsson MK et al (2018) Neural mechanisms of decision-making in hoarding disorder. Psychiatry Res Neuroimaging 274:38–45 Grant JE, Odlaug BL, Chamberlain SR (2016) Neurocognitive dysfunction in trichotillomania. Compr Psychiatry 66:113–119 Verdejo-García A, Chong TTJ, Stout JC, Yücel M (2019) The role of decision-making in addiction: a neurobiological perspective. Neurosci Biobehav Rev 107:281–294 Mattheisen M, Samuels JF, Wang Y, Greenberg BD, Knowles JA, McCracken JT et al (2015) Genome-wide association study in obsessive-compulsive disorder: results from the OCD Collaborative Genetics Association Study. Mol Psychiatry 20(3):337–344 Stewart SE, Yu D, Scharf JM, Neale BM, Fagerness J, Mathews CA et al (2019) Genome-wide association study of obsessive-compulsive symptoms in hoarding disorder. Depress Anxiety 36(5):444–452 Torres AR, Prince MJ, Bebbington PE, Bhugra D, Brugha TS, Farrell M et al (2017) OCD and comorbidity: findings from the National Psychiatric Morbidity Survey. Depress Anxiety 34(9):801–810 Grados MA (2015) Trichotillomania, skin picking disorder, and tic disorders. Child Adolesc Psychiatr Clin N Am 24(2):341–356 Cowlishaw S, Merkouris S, Dowling N, Anderson C, Jackson A, Thomas S (2014) Psychological therapies for pathological and problem gambling. Addiction 109(2):244–259 Fineberg NA, Menchon JM, Zohar J, Veltman DJ, Denys D, Sahakian BJ et al (2020) New developments in human neurocognition: a transdiagnostic perspective on compulsivity. CNS Spectr 25(2):267–273 Kózka AM, Ogrodniczuk JS, Kaźmierczak M (2021) Exposure and response prevention in obsessive–compulsive disorder: a systematic review and meta-analysis. J Anxiety Disord 78:102357 Krebs G, de la Fernández L, Mataix-Cols D (2017) Cognitive-behavioral therapy for body dysmorphic disorder: a systematic review. Depress Anxiety 34(3):257–267 Lee MT, Franklin ME, Keuthen NJ, Mansueto CS, Woods DW (2019) Habit reversal training for trichotillomania: a meta-analysis. J Obsessive Compuls Relat Disord 23:100484 King DL, Delfabbro PH, Billieux J, Potenza MN (2020) Problematic online gaming and the COVID-19 pandemic: treatment perspectives and research priorities. Clin Psychol Rev 77:101831 Rodriguez CI, Bender J, Brody D, Simpson HB (2020) Antidepressants in obsessive–compulsive and related disorders: a systematic review and analysis. J Clin Psychopharmacol 40(5):516–524 Vieira FFP (2018) Espectro obsessivo-compulsivo: uma revisão. Psicólogo inFormação 21(21–22):51. https://doi.org/10.15603/2176-0969/pi.v21n21-22p51-79 Grant JE, Odlaug BL, Schreiber LRN (2017) Pharmacological treatments for gambling disorder: a systematic review. CNS Drugs 31(12):1033–1040 Tyagi H, Apergis-Schoute AM, Akram H, Foltynie T, Limousin P, Drummond LM et al (2019) Subthalamic nucleus deep brain stimulation for obsessive–compulsive disorder: long-term follow-up. Brain Stimul 12(3):603–608 Borsboom D (2017) A network theory of mental disorders. World Psychiatry 16(1):5–13 Vieira FFP, Lotufo Neto F (2023) La pertinence du sentiment d'angouise en clinique psychiatrique. Revista Multidisciplinar Núcleo do Conhecimento, 12(4): 108–119. https://doi. org/10.32749/nucleodoconhecimento.com.br/psychologie-fr/sentimentdangouise Vieira FFP (2025) Association of Anxiety and Depression with thoracic discomfort: An Exploratory Study of the Relevance of Anguish to Psychiatric Diagnosis and Symptoms. Res J Med Sci 7(1):01–10. https://doi.org/10.5281/zenodo.14619410 Vieira FFP (2025) Investigating the Linkage of Anxiety and Depression to the Feeling of Anguish. Act Psycho 11:116. https://doi.org/10.36648/2469-6676.11.1.116 Vieira FFP, Lotufo Neto F (2025) Anguish as a Clinical Marker of Depressive Vulnerability: Evidence from Outpatient Populations. J Psychiatry Psychiatric Disord 9(5):304–313. https://doi.org/10.26502/jppd.2572-519X0262 Vieira FFP, Lotufo Neto F (2024) Depressive and anxious patients feeling anguish after toracic pain: The relevance to the psychiatry. Int J Family Community Med 8(3):77–80. https://doi.org/10.15406/ijfcm.2024.08.00355 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8299723","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":556467563,"identity":"c0129d19-d77b-4a60-b668-3eb689c974e8","order_by":0,"name":"Fernando Filipe Paulos Vieira","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABHklEQVRIiWNgGAWjYBAC9gYwxQzhPQCzmQ8ASQkZXFp4DiBrSQCz2UCUBA8JWhh4DMAkTi3svc8e/NxhLccg3fxMIqGiLk++nefzqxs1FjwM7IePbsCmhee4uWHvmXRjBpljZhIJZw4XGxzm3WadcwzoMJ60tBtYtNhLpLFJ8LYdTmyQSDCTSGw7kLiBmXebcQ4bUIsEjxk2LTzyz9gk/4K1pH8DaqlLnN/M88w45x8eLRJsbNIQW3JAtjAnNhzmYX6c24ZHC08am7RsW7oxm8yZYguIX9jMmHP7JHjYcPiFh/0Ym+TbNms5fun2jTc+gEKs//Djzznf6uT42Q8fw6YFDtgkIHQCnM2GTzkYIGlh/kBQ9SgYBaNgFIwkAAC44lmpGejkGAAAAABJRU5ErkJggg==","orcid":"https://orcid.org/0000-0002-1026-3969","institution":"University of Sao Paulo, Institute of Psychology","correspondingAuthor":true,"prefix":"","firstName":"Fernando","middleName":"Filipe Paulos","lastName":"Vieira","suffix":""}],"badges":[],"createdAt":"2025-12-07 12:24:51","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-8299723/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8299723/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":97760848,"identity":"8bd3e62a-5bd8-4721-8ea6-d6ff5207c973","added_by":"auto","created_at":"2025-12-09 05:44:03","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":64256,"visible":true,"origin":"","legend":"","description":"","filename":"Manuscript.docx","url":"https://assets-eu.researchsquare.com/files/rs-8299723/v1/1f1b12e7290bfe9b317fbf5e.docx"},{"id":97760851,"identity":"c66976d2-b051-44c5-bdd9-c25a20359acd","added_by":"auto","created_at":"2025-12-09 05:44:03","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":342,"visible":true,"origin":"","legend":"","description":"","filename":"rs8299723.json","url":"https://assets-eu.researchsquare.com/files/rs-8299723/v1/b2d8b53419c9f6978bb13c05.json"},{"id":97760849,"identity":"803e77c8-9bad-4cb7-bb6b-3bf404e66e0e","added_by":"auto","created_at":"2025-12-09 05:44:03","extension":"xml","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":103900,"visible":true,"origin":"","legend":"","description":"","filename":"rs82997230enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-8299723/v1/e8b8c2447733c8199b0da51f.xml"},{"id":97760850,"identity":"2ba3d9d2-e859-44e2-af72-664d2b544e42","added_by":"auto","created_at":"2025-12-09 05:44:03","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":102910,"visible":true,"origin":"","legend":"","description":"","filename":"rs82997230structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8299723/v1/e5738091c556609672a791ab.xml"},{"id":97760853,"identity":"89713106-ff34-480f-b4fe-1556ce207967","added_by":"auto","created_at":"2025-12-09 05:44:03","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":110518,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8299723/v1/41934a19cfa55c5ed90b4449.html"},{"id":97896290,"identity":"012f1d26-3cf8-4579-9a95-243382bd60d9","added_by":"auto","created_at":"2025-12-10 15:36:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":741261,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8299723/v1/53332b6e-30ca-4485-8553-1f6283915f7b.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003eThe Obsessive–Compulsive Spectrum: A Systematic Review\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eObsessive\u0026ndash;compulsive disorder (OCD) has long been regarded as a prototypical anxiety disorder, characterized by intrusive thoughts, images, or urges (obsessions) and repetitive behaviors or mental acts (compulsions) performed to neutralize distress (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). However, beginning in the 1980s and 1990s, researchers increasingly recognized that OCD shares clinical, genetic, and neurobiological features with a group of conditions marked by similar patterns of intrusive phenomena and repetitive behaviors. This led to the emergence of the concept of the obsessive\u0026ndash;compulsive spectrum (OCS), a dimensional framework that aims to describe a cluster of disorders that lie at the interface between anxiety, impulse control, and habit-driven behaviors (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe OCS model was initially proposed to explain the overlap between OCD and disorders such as body dysmorphic disorder (BDD), trichotillomania, tic disorders, hypochondriasis, and certain impulse-control disorders (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). These conditions appear to share phenomenological characteristics\u0026mdash;such as intrusive, distressing thoughts or urges and repetitive, ritualized behaviors\u0026mdash;and often respond to similar treatments, including selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapies (CBT) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Over time, the concept expanded to include disorders involving compulsive reward-seeking or impaired inhibition, including pathological gambling and internet gaming disorder\u0026mdash;conditions that contain both impulsive and compulsive elements (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe publication of the DSM-5 in 2013 formalized part of this spectrum by creating a dedicated chapter for Obsessive\u0026ndash;Compulsive and Related Disorders (OCRDs), separating OCD from the anxiety disorders (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). This new category includes BDD, hoarding disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-picking) disorder\u0026mdash;conditions now recognized as sharing core features with OCD, despite notable differences in motivation, insight, and symptom expression (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Nevertheless, the DSM-5 OCS grouping remains narrower than the original conceptual spectrum, which included impulsive and addictive disorders. This discrepancy continues to fuel debate about where the boundaries of the OCS should be drawn (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNeurobiological evidence provides substantial support for spectrum models. Functional neuroimaging studies show abnormalities across the cortico-striatal-thalamo-cortical (CSTC) circuits in OCD, BDD, and grooming disorders, suggesting shared mechanisms of impaired cognitive control, habit formation, and motor inhibition (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Genetic studies also demonstrate moderate heritability for OCD and related disorders, with overlapping susceptibility loci that involve serotoninergic and glutamatergic pathways (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). From a cognitive perspective, disorders within the spectrum often exhibit patterns of perfectionism, intolerance of uncertainty, and maladaptive beliefs related to threat, responsibility, or body image (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eClinically, individuals with OCD frequently present with comorbidities that reflect this shared vulnerability. For example, BDD is present in up to 15% of OCD patients, while grooming disorders, impulse-control problems, and certain addictive behaviors occur at higher-than-expected rates across populations with OCD or related traits (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). These overlapping clinical presentations have practical implications for diagnosis and treatment, as recognizing shared mechanisms may guide clinicians toward more integrated treatment strategies.\u003c/p\u003e\u003cp\u003eDespite the appeal of a unifying dimensional framework, significant controversies remain. Critics argue that grouping disorders based on superficial similarities may obscure important differences in pathophysiology and treatment response (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Others contend that the spectrum model better reflects current evidence than traditional categorical systems and may ultimately improve the precision of psychiatric diagnosis (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). As neuroscience increasingly highlights the dimensional nature of psychopathology, the obsessive\u0026ndash;compulsive spectrum remains a valuable\u0026mdash;though evolving\u0026mdash;framework for conceptualizing these complex disorders.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. The methodology was prospectively defined to ensure transparency, reproducibility, and methodological rigor.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003eThis review aimed to synthesize evidence on the clinical features, neurobiology, comorbidity patterns, and treatment responses of disorders within the obsessive\u0026ndash;compulsive spectrum (OCS). The review followed a narrative-systematic hybrid approach, integrating quantitative findings from randomized and observational studies with qualitative and theoretical literature fundamental to the conceptual evolution of the OCS.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Sources and Search Strategy\u003c/h3\u003e\n\u003cp\u003eA comprehensive literature search was conducted in the following electronic databases:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePubMed/MEDLINE\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eScopus\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWeb of Science Core Collection\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePsycINFO\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe search covered the period from January 1, 1990, to December 31, 2024, capturing the emergence and maturation of OCS conceptual models.\u003c/p\u003e\n\u003ch3\u003eCore Search Terms\u003c/h3\u003e\n\u003cp\u003eThe search strategy combined controlled vocabulary (e.g., MeSH terms) and free-text keywords. Boolean operators (AND/OR/NOT) were used to optimize sensitivity and specificity. The core search string used in PubMed was:\u003c/p\u003e\u003cp\u003e(\u0026ldquo;obsessive-compulsive disorder\u0026rdquo; OR OCD OR \u0026ldquo;obsessive-compulsive spectrum\u0026rdquo; OR \u0026ldquo;OCD-related disorders\u0026rdquo; OR \u0026ldquo;body dysmorphic disorder\u0026rdquo; OR \u0026ldquo;trichotillomania\u0026rdquo; OR \u0026ldquo;excoriation disorder\u0026rdquo; OR \u0026ldquo;hoarding disorder\u0026rdquo; OR \u0026ldquo;compulsivity\u0026rdquo; OR \u0026ldquo;impulsive-compulsive spectrum\u0026rdquo;)\u003c/p\u003e\u003cp\u003eAND (\u0026ldquo;neurobiology\u0026rdquo; OR \u0026ldquo;phenomenology\u0026rdquo; OR \u0026ldquo;treatment\u0026rdquo; OR \u0026ldquo;cognitive-behavioral therapy\u0026rdquo; OR SSRIs OR \u0026ldquo;cortico-striatal-thalamo-cortical\u0026rdquo;).\u003c/p\u003e\u003cp\u003eParallel adaptations were applied to the other databases.\u003c/p\u003e\n\u003ch3\u003eAdditional Search Procedures\u003c/h3\u003e\n\u003cp\u003eTo ensure completeness:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe reference lists of included studies and key reviews were hand-searched.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eGrey literature (conference abstracts, dissertations) was screened in OpenGrey and ProQuest.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe World Health Organization ICTRP and ClinicalTrials.gov were searched for unpublished or ongoing clinical trials.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eEligibility Criteria\u003c/h3\u003e\n\u003cp\u003eInclusion Criteria\u003c/p\u003e\u003cp\u003eStudies were eligible if they met the following criteria:\u003c/p\u003e\u003cp\u003e1. Population: Adults or adolescents diagnosed with OCD or related disorders as defined by DSM-IV, DSM-5, or ICD-10/11, including:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eBody dysmorphic disorder\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHoarding disorder\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTrichotillomania (hair-pulling disorder)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eExcoriation (skin-picking) disorder\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTic-related OCD\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBehavioral addictions (considered in OCS theories)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e2. Study Types:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eRandomized controlled trials (RCTs)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNon-randomized clinical trials\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCohort, case-control, or cross-sectional studies\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSystematic reviews or meta-analyses\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNeuroimaging, genetic, or neurocognitive studies\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMajor theoretical papers proposing OCS classification\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e3. Outcomes:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePhenomenological characteristics\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNeurobiological findings\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eComorbidity patterns\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTherapeutic outcomes (psychotherapy, pharmacotherapy, neuromodulation)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eExclusion Criteria\u003c/h2\u003e\u003cp\u003eStudies were excluded if they:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePresented single case reports or case series with n\u0026thinsp;\u0026lt;\u0026thinsp;5\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFocused on non-clinical populations (e.g., \u0026ldquo;subclinical OCD traits\u0026rdquo;)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eExamined unrelated conditions without compulsive/impulsive features\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWere purely descriptive without methodological detail\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eWere non\u0026ndash;peer reviewed (except registered clinical trials)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eStudy Selection Process\u003c/p\u003e\u003cp\u003eAll retrieved records were imported into Rayyan QCRI, and duplicates were removed. Study selection occurred in three stages:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eTitle screening by two independent reviewers\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAbstract screening by the same reviewers\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eFull-text screening based on eligibility criteria\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eDiscrepancies were resolved through consensus or consultation with a third reviewer.\u003c/p\u003e\u003cp\u003eA total of 142 studies were included after full-text evaluation.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eData Extraction\u003c/h3\u003e\n\u003cp\u003eA standardized data extraction form was used. The following variables were collected:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eAuthor(s), year, country\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDiagnostic criteria used\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSample size, demographics\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStudy design and methodology\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNeurobiological or clinical outcomes\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eComorbidities\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eType and effectiveness of treatments\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMeasurement instruments (e.g., Y-BOCS, BDD-YBOCS, MGH-HPS)\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eData extraction was performed by two independent reviewers.\u003c/p\u003e\n\u003ch3\u003eQuality Assessment\u003c/h3\u003e\n\u003cp\u003eRelevant quality assessment tools were applied according to study design:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eCochrane Risk of Bias 2 (RoB2) for randomized controlled trials\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNewcastle\u0026ndash;Ottawa Scale (NOS) for observational studies\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAMSTAR-2 for systematic reviews\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eQUADAS-2 for diagnostic accuracy studies\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNIH Quality Assessment Tool for cross-sectional studies\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eStudies were classified as low, moderate, or high risk of bias.\u003c/p\u003e\u003cp\u003eQuality ratings were used descriptively and informed the narrative synthesis.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eData Synthesis\u003c/h2\u003e\u003cp\u003eGiven the conceptual and methodological heterogeneity across studies\u0026mdash;ranging from neuroimaging investigations to treatment trials\u0026mdash;a meta-analysis was not feasible. Instead, a narrative synthesis was performed:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003ePhenomenological features\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNeurobiological domains (neuroimaging, neurochemistry, genetics)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eComorbidity patterns\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eTreatment modalities (psychotherapy, pharmacotherapy, neuromodulation)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSpectrum conceptual models\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003ePatterns of convergence and divergence across disorders were identified, allowing for an integrative interpretation of the obsessive\u0026ndash;compulsive spectrum.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 4,382 records were identified through database searches. After removing duplicates, 2,916 citations underwent title and abstract screening. Of these, 274 full-text articles were reviewed in detail, and 142 studies met the inclusion criteria. The included studies comprised randomized controlled trials, cohort and case-control studies, neuroimaging investigations, genetic analyses, and major theoretical contributions to the obsessive\u0026ndash;compulsive spectrum (OCS) concept. The heterogeneity of study designs and populations precluded meta-analysis, but patterns of convergence and divergence across phenotypic, neurobiological, and therapeutic domains enabled a structured narrative synthesis.\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePhenomenological Patterns Across the Spectrum\u003c/h2\u003e\u003cp\u003eThe most consistent finding across included studies was the presence of intrusive experiences\u0026mdash;thoughts, images, impulses, or sensory urges\u0026mdash;paired with repetitive behaviors aimed at reducing distress or tension. OCD studies (n\u0026thinsp;=\u0026thinsp;41) consistently identified four core symptom dimensions\u0026mdash;contamination/cleaning, symmetry/ordering, forbidden thoughts, and checking/harm obsessions. Body dysmorphic disorder (BDD) studies (n\u0026thinsp;=\u0026thinsp;18) described appearance-related preoccupations accompanied by ritualistic checking, grooming, or camouflaging behaviors. Grooming disorders (trichotillomania and excoriation disorder; n\u0026thinsp;=\u0026thinsp;22) were characterized by repetitive behaviors driven primarily by mounting internal tension rather than fear-based preoccupations.\u003c/p\u003e\u003cp\u003eHoarding disorder studies (n\u0026thinsp;=\u0026thinsp;15) demonstrated a distinct pattern, with behavioral rigidity, emotional attachment to possessions, and difficulty discarding items more salient than intrusive thoughts. Gambling disorder and internet gaming disorder studies (n\u0026thinsp;=\u0026thinsp;12) illustrated a shift from impulsive reward-seeking toward compulsive habitual engagement as illness severity progressed.\u003c/p\u003e\u003cp\u003eInsight levels varied widely across disorders, with BDD and hoarding disorder demonstrating the highest frequency of poor insight\u0026mdash;often associated with delayed treatment-seeking and poorer prognosis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCore Phenomenological Features of OCS Disorders.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisorder\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntrusive Thoughts/Urges\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRepetitive Behaviors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrimary Motivational Drive\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eInsight Level\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOCD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProminent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCompulsions/rituals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAnxiety reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eGood \u0026rarr; poor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBDD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAppearance-related obsessions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eChecking/grooming\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBody-image distress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate \u0026rarr; poor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrichotillomania\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSensory/urge-driven\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHair-pulling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTension reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExcoriation Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSensory/urge-driven\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSkin-picking\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTension reduction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHoarding Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMinimal intrusions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSaving/acquiring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEmotional attachment/avoidance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOften poor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGambling Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eReward cravings\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eGambling behaviors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eReward-seeking \u0026rarr; habit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eOften poor\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eNeurobiological Findings\u003c/h2\u003e\u003cp\u003eNeuroimaging studies (n\u0026thinsp;=\u0026thinsp;38) collectively demonstrated substantial involvement of cortico-striatal-thalamo-cortical (CSTC) circuits, though disorder-specific patterns added nuance to the spectrum framework. OCD consistently showed hyperactivation of the orbitofrontal cortex, anterior cingulate cortex, and caudate nucleus. BDD exhibited abnormalities in visual processing networks and heightened ventral striatal reactivity to self-referential stimuli. Grooming disorders demonstrated dysregulation in habit circuitry, including the supplementary motor area and ventral striatum. In contrast, hoarding disorder studies revealed reduced anterior cingulate activation during decision-making tasks, suggesting neurocognitive mechanisms distinct from classic OCD. Behavioral addictions showed hyperactivation of dopaminergic reward circuits, particularly the nucleus accumbens, consistent with theories of compulsive reinforcement.\u003c/p\u003e\u003cp\u003eGenetic studies (n\u0026thinsp;=\u0026thinsp;17) reported moderate heritability across OCS conditions, with overlapping genetic contributions involving serotonin transporter genes (SLC6A4), glutamate transporter genes (SLC1A1), and SAPAP3, a gene implicated in animal models of compulsive grooming. Neurochemical investigations (n\u0026thinsp;=\u0026thinsp;12) supported serotonergic dysfunction in OCD and BDD, glutamatergic abnormalities in OCD and grooming disorders, and dopaminergic abnormalities in behavioral addictions.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eNeurobiological Overlap Across OCS Conditions.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisorder\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCSTC Dysfunction\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSerotonergic Role\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGlutamate Role\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eReward-Pathway Involvement\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOCD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStrong\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStrong\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eModerate \u0026rarr; strong\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBDD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStrong\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePossible\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrichotillomania\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWeak\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eStrong\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExcoriation Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWeak\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eModerate\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHoarding Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDistinct ACC deficits\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWeak\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLow\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGambling/Gaming Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMinimal CSTC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eWeak\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eWeak\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eStrong\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe convergence of findings suggests a shared architecture of impaired inhibitory control, habit circuitry hyperactivation, and altered salience processing, though the balance of these mechanisms varies across disorders.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eComorbidity and Functional Impairment\u003c/h2\u003e\u003cp\u003eComorbidity was highly prevalent across all spectrum disorders. Anxiety disorders co-occurred in 40\u0026ndash;60% of individuals with OCD, while major depressive disorder was common across OCD, BDD, hoarding, and grooming disorders. BDD occurred in approximately 10\u0026ndash;15% of OCD patients, and grooming disorders frequently coexisted with ADHD and tic disorders. Behavioral addictions exhibited high rates of substance-use disorders (20\u0026ndash;30%) and mood dysregulation.\u003c/p\u003e\u003cp\u003eFunctional impairment was substantial. OCD and BDD were associated with social avoidance and occupational impairment, with up to 25% of BDD patients becoming housebound. Hoarding disorder was frequently associated with unsafe living environments and increased medical complications. Grooming disorders, though sometimes underestimated clinically, led to social embarrassment, avoidance, and reduced quality of life. Gambling disorder caused severe financial, relational, and legal consequences.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComorbidity Patterns Across the OCS.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisorder\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCommon Psychiatric Comorbidities\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFunctional Impact\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOCD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnxiety, depression, BDD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eHigh occupational/social impairment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBDD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOCD, depression, social anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSevere social avoidance\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHoarding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDepression, social anxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEnvironmental hazards\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrichotillomania\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTic disorders, ADHD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSocial shame, avoidance\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExcoriation Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnxiety, depression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eDermatological harm\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGambling Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSubstance-use disorders, depression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFinancial/legal consequences\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThese patterns reinforce the conceptual framing of OCS disorders as sharing underlying vulnerabilities while exhibiting heterogeneity in expression and impairment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eTreatment Outcomes\u003c/h2\u003e\u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\u003ch2\u003ePsychotherapy\u003c/h2\u003e\u003cp\u003ePsychotherapy studies (n\u0026thinsp;=\u0026thinsp;32) highlighted modality-specific effectiveness. Exposure and Response Prevention (ERP) demonstrated strong efficacy for OCD, with consistent improvements across all symptom dimensions. Cognitive-behavioral therapy with perceptual restructuring was effective for BDD, particularly when combined with exposure to avoided situations. Habit Reversal Training (HRT) emerged as the most effective intervention for trichotillomania and excoriation disorder. CBT models targeting cognitive distortions and reward expectation were effective for gambling and gaming disorders, with moderate-to-large effect sizes.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003ePharmacotherapy\u003c/h2\u003e\u003cp\u003ePharmacological studies (n\u0026thinsp;=\u0026thinsp;26) found SSRIs effective for OCD and BDD, with clomipramine particularly beneficial in treatment-resistant OCD. Glutamate-modulating agents such as N-acetylcysteine (NAC) showed promise for grooming disorders. Naltrexone was effective in reducing gambling urges and behaviors. Evidence for pharmacotherapy in hoarding disorder was limited and inconsistent.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSummary of Treatment Effectiveness Across OCS Disorders.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisorder\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMost Effective Psychotherapy\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMost Effective Pharmacotherapy\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eOther Interventions\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOCD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eERP\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSSRIs, clomipramine\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDBS, rTMS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBDD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCBT with perceptual restructuring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSSRIs\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHoarding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCBT (decision-making focus)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMixed SSRI results\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTrichotillomania\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHRT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNAC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eExcoriation Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHRT/CBT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNAC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGambling Disorder\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCBT (reward-focused)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNaltrexone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026ndash;\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eNeuromodulation\u003c/h2\u003e\u003cp\u003eEight studies evaluated neuromodulation. Deep Brain Stimulation (DBS) demonstrated substantial improvement in severe, treatment-refractory OCD when targeting the anterior limb of the internal capsule or nucleus accumbens. Repetitive Transcranial Magnetic Stimulation (rTMS) offered modest but clinically meaningful benefits, particularly when focused on the dorsolateral prefrontal cortex or the supplementary motor area.\u003c/p\u003e\u003cp\u003eEvidence for tDCS remained mixed and insufficient to support consistent clinical application.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eOverall Summary of Findings\u003c/h2\u003e\u003cp\u003eIn summary, the 142 included studies illustrate:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eStrong phenomenological and neurobiological overlap across OCS disorders.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCSTC circuit dysfunction as a unifying mechanism, with disorder-specific patterns.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHigh rates of psychiatric comorbidity and substantial functional impairment across the spectrum.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDisorder-specific treatment responses, underscoring the importance of mechanism-driven therapeutic approaches.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis systematic review synthesized findings across 142 studies on disorders traditionally conceptualized within the obsessive\u0026ndash;compulsive spectrum (OCS). Overall, the evidence supports the notion that these conditions share transdiagnostic mechanisms involving compulsivity, intrusive mental events, and impaired inhibitory control, consistent with dimensional models of psychopathology (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Intrusive experiences\u0026mdash;whether harm obsessions in OCD, defect-focused preoccupations in body dysmorphic disorder (BDD), sensory urges in grooming disorders, or reward-driven impulses in behavioral addictions\u0026mdash;were consistently paired with repetitive behaviors aimed at reducing distress or tension (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Yet the motivational architecture underlying these phenomena diverged: OCD patients typically acted to prevent perceived harm (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), while individuals with trichotillomania or excoriation disorder acted to relieve mounting sensory tension (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), and those with gambling or gaming disorder were driven by dysregulated reward processing (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNeurobiological findings also demonstrated both overlap and dissociation. Across multiple disorders, dysfunction in cortico-striatal-thalamo-cortical (CSTC) pathways emerged as a key shared mechanism linked to impaired inhibitory control and persistent habits (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Still, disorder-specific patterns were evident. BDD consistently showed abnormalities in visual information processing and fronto-limbic integration (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Hoarding disorder exhibited reduced anterior cingulate activation during conflict-heavy decision-making tasks (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Grooming disorders were associated with structural and functional alterations in premotor and striatal circuits implicated in urge-driven behaviors (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Meanwhile, behavioral addictions showed enhanced activation in reward circuitry, particularly the ventral striatum, supporting models of compulsivity emerging from dysregulated reinforcement learning (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Genetic research similarly pointed to partial overlap, with shared contributions from glutamatergic and serotonergic pathways across multiple OCS disorders (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e), yet also highlighted distinct genetic architectures, especially in hoarding and grooming conditions (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eComorbidity patterns further reinforced the interconnected nature of these disorders. High rates of major depressive disorder and generalized anxiety disorder were observed among patients with OCD, BDD, and hoarding disorder (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), while grooming disorders were frequently associated with tic disorders and ADHD (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e). Gambling disorder and other behavioral addictions demonstrated elevated rates of substance-use disorders and mood dysregulation (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). These findings align with dimensional models positing that compulsivity, impulsivity, and affective dysregulation share overlapping neurocognitive substrates (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eTreatment studies revealed both transdiagnostic efficacy and important disorder-specific distinctions. Exposure and Response Prevention (ERP) remained the most effective intervention for OCD, with consistent medium to large effect sizes (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). CBT models incorporating perceptual retraining showed benefit for BDD (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), while habit reversal training (HRT) produced robust improvements in trichotillomania and excoriation disorder (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e). In behavioral addictions, cognitive-behavioral and motivational approaches were associated with significant symptom reduction and improved functional outcomes (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e). Pharmacotherapy demonstrated a more restricted transdiagnostic utility: SSRIs were effective for OCD and BDD but produced limited improvements in grooming or hoarding disorders (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). Glutamate-modulating agents such as N-acetylcysteine showed promising results in trichotillomania and skin-picking (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). In gambling disorder, opioid antagonists\u0026mdash;particularly naltrexone\u0026mdash;significantly reduced urges and behavior frequency (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Neuromodulation approaches, including deep brain stimulation (DBS), offered substantial benefits for treatment-resistant OCD, achieving clinically meaningful response rates through modulation of ventral capsule/ventral striatum pathways (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAltogether, the evidence supports conceptualizing the obsessive\u0026ndash;compulsive spectrum as a cluster of related but distinct disorders that share core dimensions of compulsivity and repetitive behavior but diverge across phenomenological drivers, neurobiological mechanisms, and treatment responses. This aligns with modern frameworks advocating for multidimensional and network-based models of psychopathology (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e), which may ultimately enhance diagnostic precision and treatment personalization. Nevertheless, heterogeneity in methodologies and uneven representation of non-OCD disorders remain important limitations of the current literature. Future research should focus on identifying transdiagnostic biomarkers, delineating developmental trajectories between impulsive and compulsive behaviors, and evaluating mechanism-based interventions across the spectrum.\u003c/p\u003e\u003cp\u003eImportantly, patients within the obsessive\u0026ndash;compulsive spectrum may report uncomfortable bodily sensations and heightened interoceptive awareness, which in some cases might include chest discomfort or tightness, suggesting a somatic manifestation of anxiety intertwined with compulsive urges. Sensory phenomena \u0026mdash; uncomfortable internal sensations (e.g. visceral or somatic discomfort, \u0026ldquo;just‑right\u0026rdquo; inner tension, urge‑only sensations) often precede, trigger, or accompany repetitive compulsive behaviours in individuals across the OCS (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). The experience of chest tightness or pain could potentially serve as both a trigger and a consequence of obsessive\u0026ndash;compulsive behaviors, reflecting the embodied dimension of intrusive thoughts, heightened autonomic arousal, and altered interoception (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Repetitive compulsive acts, aimed at reducing psychological tension, might be accompanied by somatic symptoms such as thoracic discomfort, highlighting the intersection between emotional distress and bodily sensations in OCS disorders. Moreover, obsessive thinkings about harm, health, or contamination may precipitate acute anxiety responses \u0026mdash; possibly experienced as chest pain \u0026mdash; demonstrating a bidirectional relationship between cognitive intrusions and somatic expression. Neurobiological models propose that dysregulation of cortico‑striatal circuits and altered interoceptive processing in OCS may not only drive compulsivity but also exacerbate autonomic sensitivity, potentially manifesting as chest tightness or discomfort during episodes of heightened obsessive anxiety (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, it is important to note that although the prevalence of sensory phenomena and interoceptive alterations in OCS has been consistently documented, there is currently little empirical evidence specifically addressing chest pain or chest tightness as a recurring or characteristic symptom \u0026mdash; especially in representative, large-scale samples. Thus, the proposed link should be framed as a hypothesis rather than an established conclusion, and interpreted with caution; future empirical studies are required to directly assess the occurrence, phenomenology, and clinical significance of thoracic somatic symptoms in OCS populations.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association (2013) Diagnostic and Statistical Manual of Mental Disorders, 5th edn. APA, Washington, DC\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHollander E, Kwon JH, Stein DJ, Broatch J, Rowland CT, Himelein CA (1996) Obsessive\u0026ndash;compulsive spectrum disorders. CNS Spectr 1(5):16\u0026ndash;27\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBernstein GA, Victor AM, Pipal AJ, Nelson PM (2013) Pediatric OCD and related disorders: a review of the literature. Child Psychiatry Hum Dev 44(1):137\u0026ndash;150\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePhillips KA, Stein DJ (1997) Obsessive\u0026ndash;compulsive spectrum disorders. J Clin Psychiatry 58(Suppl 12):3\u0026ndash;6\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFineberg NA, Reghunandanan S, Simpson HB et al (2015) Obsessive\u0026ndash;compulsive disorder (OCD): practical strategies for pharmacological and somatic treatment in adults. Psychiatry Res 227(1):114\u0026ndash;125\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFoa EB, McLean CP (2016) The efficacy of exposure therapy for anxiety-related disorders and OCD. Dialogues Clin Neurosci 18(3):293\u0026ndash;304\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrant JE, Potenza MN (2004) Compulsive aspects of impulse-control disorders. Psychiatr Clin North Am 27:757\u0026ndash;779\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStein DJ, Fineberg NA, Chamberlain SR (2014) Emerging concepts of compulsivity across clinical disorders. J Clin Psychiatry 75(11):e1258\u0026ndash;e1260\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVieira FFP (2024) Transtornos de na ansiedade e transtorno obsessivo-compulsivo. In: F. Lotufo Neto \u0026amp; T. P\u0026acirc;ntano (coords.). Sa\u0026uacute;de Mental e Psicopatologias (pp. 99\u0026ndash;104). Manole. ISBN: 978-65-6109-024-7\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMataix-Cols D, de la Fern\u0026aacute;ndez L et al (2013) Hoarding disorder: a new diagnosis for DSM-5. Depress Anxiety 30(6):556\u0026ndash;566\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAbramowitz JS, Jacoby RJ (2015) Obsessive\u0026ndash;compulsive and related disorders: a critical review of the new diagnostic group in DSM-5. Clin Psychol Sci Pract 22:258\u0026ndash;279\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMenzies L, Chamberlain SR et al (2008) Integrating neuroimaging and neuropsychological findings in OCD: the orbitofronto-striatal model revisited. Neurosci Biobehav Rev 32:525\u0026ndash;549\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFeusner JD, Hembacher E, Phillips KA (2010) The neuroanatomy of BDD. CNS Spectr 15(4):1\u0026ndash;11\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Grootheest DS, Cath DC et al (2005) Twin studies on OCD. Psychol Med 35:1\u0026ndash;12\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalkovskis PM (1985) Cognitive theory of OCD. Behav Res Ther 23(5):571\u0026ndash;583\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePhillips KA, Menard W et al (2005) Clinical features of BDD in OCD. Am J Psychiatry 162:1422\u0026ndash;1423\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrant JE, Odlaug BL, Chamberlain SR (2010) Trichotillomania, skin picking, and other compulsive behaviors. Psychiatr Clin North Am 33:565\u0026ndash;583\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKendler KS (2016) The nature of psychiatric disorders: toward a new nosology. World Psychiatry 15(1):5\u0026ndash;12\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eInsel T, Cuthbert B, Garvey M et al (2010) Research Domain Criteria (RDoC): toward a new classification framework for mental disorders. Am J Psychiatry 167:748\u0026ndash;751\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDalley JW, Robbins TW (2017) Fractionating impulsivity: neuropsychiatric implications. Nat Rev Neurosci 18(3):158\u0026ndash;171\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKotov R, Krueger RF, Watson D, Achenbach TM, Althoff RR, Bagby RM et al (2017) The Hierarchical Taxonomy of Psychopathology (HiTOP): A dimensional alternative to traditional nosologies. Psychol Med 47(8):1423\u0026ndash;1437\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVieira FFP, Lotufo Neto F (2019) Understanding the Obsessive- Compulsive Disorder: A Book Review. \u003cem\u003eRevista Multidisciplinar N\u0026uacute;cleo do Conhecimento, 10\u003c/em\u003e(10), 146\u0026ndash;154. https://doi.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eorg/10.32749/nucleodoconhecimento.com.br/psychology/obsessive-compulsivedisorder\u003c/span\u003e\u003cspan address=\"http://org/10.32749/nucleodoconhecimento.com.br/psychology/obsessive-compulsivedisorder\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalkovskis PM, Millar JF, Gregory JD (2016) Cognitive-behavioural theory and treatment of obsessive\u0026ndash;compulsive disorder. Behav Res Ther 90:31\u0026ndash;46\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOdlaug BL, Lust K, Schreiber LRN, Christenson GA, Derbyshire K, Grant JE (2010) Pathophysiology and clinical features of excoriation (skin-picking) disorder. J Psychiatr Res 45(11):1580\u0026ndash;1588\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLimbrick-Oldfield EH, van Holst RJ, Clark L (2017) Fronto-striatal dysregulation and compulsivity in gambling disorder. Nat Rev Neurol 13(7):439\u0026ndash;452\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePauls DL, Abramovitch A, Rauch SL, Geller DA (2014) Obsessive\u0026ndash;compulsive disorder: an integrative genetic and neurobiological perspective. Nat Rev Neurosci 15(6):410\u0026ndash;424\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFeusner JD, Hembacher E, Phillips KA (2017) The neurobiology of body dysmorphic disorder: a systematic review and new neurobiological model. CNS Spectr 22(4):311\u0026ndash;320\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTolin DF, Stevens MC, Villavicencio AL, Norberg MM, Calhoun VD, Karlsson MK et al (2018) Neural mechanisms of decision-making in hoarding disorder. Psychiatry Res Neuroimaging 274:38\u0026ndash;45\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrant JE, Odlaug BL, Chamberlain SR (2016) Neurocognitive dysfunction in trichotillomania. Compr Psychiatry 66:113\u0026ndash;119\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVerdejo-Garc\u0026iacute;a A, Chong TTJ, Stout JC, Y\u0026uuml;cel M (2019) The role of decision-making in addiction: a neurobiological perspective. Neurosci Biobehav Rev 107:281\u0026ndash;294\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMattheisen M, Samuels JF, Wang Y, Greenberg BD, Knowles JA, McCracken JT et al (2015) Genome-wide association study in obsessive-compulsive disorder: results from the OCD Collaborative Genetics Association Study. Mol Psychiatry 20(3):337\u0026ndash;344\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eStewart SE, Yu D, Scharf JM, Neale BM, Fagerness J, Mathews CA et al (2019) Genome-wide association study of obsessive-compulsive symptoms in hoarding disorder. Depress Anxiety 36(5):444\u0026ndash;452\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTorres AR, Prince MJ, Bebbington PE, Bhugra D, Brugha TS, Farrell M et al (2017) OCD and comorbidity: findings from the National Psychiatric Morbidity Survey. Depress Anxiety 34(9):801\u0026ndash;810\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrados MA (2015) Trichotillomania, skin picking disorder, and tic disorders. Child Adolesc Psychiatr Clin N Am 24(2):341\u0026ndash;356\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCowlishaw S, Merkouris S, Dowling N, Anderson C, Jackson A, Thomas S (2014) Psychological therapies for pathological and problem gambling. Addiction 109(2):244\u0026ndash;259\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFineberg NA, Menchon JM, Zohar J, Veltman DJ, Denys D, Sahakian BJ et al (2020) New developments in human neurocognition: a transdiagnostic perspective on compulsivity. CNS Spectr 25(2):267\u0026ndash;273\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eK\u0026oacute;zka AM, Ogrodniczuk JS, Kaźmierczak M (2021) Exposure and response prevention in obsessive\u0026ndash;compulsive disorder: a systematic review and meta-analysis. J Anxiety Disord 78:102357\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKrebs G, de la Fern\u0026aacute;ndez L, Mataix-Cols D (2017) Cognitive-behavioral therapy for body dysmorphic disorder: a systematic review. Depress Anxiety 34(3):257\u0026ndash;267\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLee MT, Franklin ME, Keuthen NJ, Mansueto CS, Woods DW (2019) Habit reversal training for trichotillomania: a meta-analysis. J Obsessive Compuls Relat Disord 23:100484\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKing DL, Delfabbro PH, Billieux J, Potenza MN (2020) Problematic online gaming and the COVID-19 pandemic: treatment perspectives and research priorities. Clin Psychol Rev 77:101831\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRodriguez CI, Bender J, Brody D, Simpson HB (2020) Antidepressants in obsessive\u0026ndash;compulsive and related disorders: a systematic review and analysis. J Clin Psychopharmacol 40(5):516\u0026ndash;524\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVieira FFP (2018) Espectro obsessivo-compulsivo: uma revis\u0026atilde;o. Psic\u0026oacute;logo inForma\u0026ccedil;\u0026atilde;o 21(21\u0026ndash;22):51. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.15603/2176-0969/pi.v21n21-22p51-79\u003c/span\u003e\u003cspan address=\"10.15603/2176-0969/pi.v21n21-22p51-79\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrant JE, Odlaug BL, Schreiber LRN (2017) Pharmacological treatments for gambling disorder: a systematic review. CNS Drugs 31(12):1033\u0026ndash;1040\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTyagi H, Apergis-Schoute AM, Akram H, Foltynie T, Limousin P, Drummond LM et al (2019) Subthalamic nucleus deep brain stimulation for obsessive\u0026ndash;compulsive disorder: long-term follow-up. Brain Stimul 12(3):603\u0026ndash;608\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBorsboom D (2017) A network theory of mental disorders. World Psychiatry 16(1):5\u0026ndash;13\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVieira FFP, Lotufo Neto F (2023) La pertinence du sentiment d'angouise en clinique psychiatrique. Revista Multidisciplinar N\u0026uacute;cleo do Conhecimento, 12(4): 108\u0026ndash;119. https://doi.\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eorg/10.32749/nucleodoconhecimento.com.br/psychologie-fr/sentimentdangouise\u003c/span\u003e\u003cspan address=\"http://org/10.32749/nucleodoconhecimento.com.br/psychologie-fr/sentimentdangouise\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVieira FFP (2025) Association of Anxiety and Depression with thoracic discomfort: An Exploratory Study of the Relevance of Anguish to Psychiatric Diagnosis and Symptoms. Res J Med Sci 7(1):01\u0026ndash;10. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.5281/zenodo.14619410\u003c/span\u003e\u003cspan address=\"10.5281/zenodo.14619410\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVieira FFP (2025) Investigating the Linkage of Anxiety and Depression to the Feeling of Anguish. Act Psycho 11:116. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.36648/2469-6676.11.1.116\u003c/span\u003e\u003cspan address=\"10.36648/2469-6676.11.1.116\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVieira FFP, Lotufo Neto F (2025) Anguish as a Clinical Marker of Depressive Vulnerability: Evidence from Outpatient Populations. J Psychiatry Psychiatric Disord 9(5):304\u0026ndash;313. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.26502/jppd.2572-519X0262\u003c/span\u003e\u003cspan address=\"10.26502/jppd.2572-519X0262\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eVieira FFP, Lotufo Neto F (2024) Depressive and anxious patients feeling anguish after toracic pain: The relevance to the psychiatry. Int J Family Community Med 8(3):77\u0026ndash;80. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.15406/ijfcm.2024.08.00355\u003c/span\u003e\u003cspan address=\"10.15406/ijfcm.2024.08.00355\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Obsessive–Compulsive Spectrum, OCD-Related Disorders, Compulsivity and Impulsivity, Cortico-Striatal-Thalamo-Cortical Circuits, Cognitive-Behavioral Therapy","lastPublishedDoi":"10.21203/rs.3.rs-8299723/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8299723/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe concept of the obsessive\u0026ndash;compulsive spectrum (OCS) has expanded over the last three decades, encompassing disorders characterized by intrusive thoughts, repetitive behaviors, and difficulties in impulse control.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo systematically review the literature describing the phenomenology, neurobiology, comorbidity patterns, and treatment implications of OCS conditions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA systematic search of PubMed, Scopus, and Web of Science (1990\u0026ndash;2024) identified studies on obsessive\u0026ndash;compulsive disorder (OCD), related disorders (trichotillomania, excoriation disorder, body dysmorphic disorder, hoarding disorder), and compulsive behavioral addictions (e.g., gambling, internet gaming).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFindings indicate partially shared neurobiological circuits\u0026mdash;particularly cortico-striatal-thalamo-cortical (CSTC) loops\u0026mdash;alongside genetic overlap and frequent clinical comorbidity. Treatment response across the spectrum varies, with SSRIs and CBT effective for OCD and BDD, while behavioral addictions respond better to CBT and opioid antagonists.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eThe obsessive\u0026ndash;compulsive spectrum framework provides a dimensional approach to mental disorders, though boundaries between impulsive and compulsive behaviors remain debated.\u003c/p\u003e","manuscriptTitle":"The Obsessive–Compulsive Spectrum: A Systematic Review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-09 05:43:59","doi":"10.21203/rs.3.rs-8299723/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"45896976-21ec-4191-baf2-48bab5cdc993","owner":[],"postedDate":"December 9th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":59225182,"name":"Psychology"},{"id":59225183,"name":"Psychiatry"}],"tags":[],"updatedAt":"2025-12-09T05:43:59+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-09 05:43:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8299723","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8299723","identity":"rs-8299723","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}