OBSESSIVE-COMPULSIVE AND RELATED

DISORDERS

According to the American Psychiatric Association (APA), the

publisher of the DSM-5, the major change for obsessive-

compulsive disorder is the fact that it and related disorders

now have their own chapter. They are no longer considered

“anxiety disorders.” This is due to increasing research evidence

demonstrating common threads running through a number of

OCD-related disorders — obsessive thoughts and/or repetitive

behaviors.

Disorders in this chapter include obsessive-compulsive

disorder, body dysmorphic disorder and trichotillomania (hair-

pulling disorder), as well as two new disorders: hoarding

disorder and excoriation (skin-picking) disorder.

OBSESSIVE-COMPULSIVE DISORDER

Obsessions:

OCD obsessions are repeated, persistent and unwanted urges or images that cause distress or anxiety. You might try to get rid of them by performing a compulsion or ritual. These obsessions typically intrude when you're trying to think of or do other things.

Obsessions often have themes to them, such as:

Fear of contamination or dirt

Having things orderly and symmetrical

Aggressive or horrific thoughts about harming yourself or others

Unwanted thoughts, including aggression, or sexual or religious subjects

OBSESSIVE-COMPULSIVE DISORDER

Examples of obsession signs and symptoms include:

Fear of being contaminated by shaking hands or by touching objects others have touched

Doubts that you've locked the door or turned off the stove

Intense stress when objects aren't orderly or facing a certain way

Images of hurting yourself or someone else

Thoughts about shouting obscenities or acting inappropriately

Avoidance of situations that can trigger obsessions, such as shaking hands

Distress about unpleasant sexual images repeating in your mind

OBSESSIVE-COMPULSIVE DISORDER

Compulsions:

OCD compulsions are repetitive behaviors that you feel driven to perform. These repetitive behaviors are meant to prevent or reduce anxiety related to your obsessions or prevent something bad from happening. However, engaging in the compulsions brings no pleasure and may offer only a temporary relief from anxiety.

You may also make up rules or rituals to follow that help control your anxiety when you're having obsessive thoughts. These compulsions are often not rationally connected to preventing the feared event.

As with obsessions, compulsions typically have themes, such as:

Washing and cleaning

Counting

Checking

Demanding reassurances

Following a strict routine

Orderliness

OBSESSIVE-COMPULSIVE AND RELATED

DISORDERS

Examples of compulsion signs and symptoms include:

Hand-washing until your skin becomes raw

Checking doors repeatedly to make sure they're locked

Checking the stove repeatedly to make sure it's off

Counting in certain patterns

Silently repeating a prayer, word or phrase

Arranging your canned goods to face the same way

INSIGHT & TIC SPECIFIERS FOR OBSESSIVE-

COMPULSIVE AND RELATED DISORDERS

The old DSM-IV specifier with poor insight has been modified from being a black-and-white specifier, to allowing for some degrees on a spectrum of insight:

Good or fair insight

Poor insight

Absent insight/delusional obsessive-compulsive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true)

These same insight specifiers have been included for body dysmorphic disorder and hoarding disorder as well. “These specifiers are intended to improve differential diagnosis by emphasizing that individuals with these two disorders may present with a range of insight into their disorder-related beliefs, including absent insight/delusional symptoms,” according to the APA.

This change also emphasizes that the presence of absent insight/delusional beliefs warrants a diagnosis of the relevant obsessive-compulsive or related disorder, rather than a schizophrenia spectrum and other psychotic disorder.

BODY DYSMORPHIC DISORDER

Body dysmorphic disorder in the DSM-5 remains largely unchanged from DSM-IV, but does include one additional criterion. This criterion describes repetitive behaviors or mental acts in response to preoccupations with perceived defects or flaws in physical appearance. It was added to the DSM-5, according to the APA, to be consistent with data indicating the prevalence and importance of this symptom.

A with muscle dysmorphia specifier has been added to reflect the research data, suggesting this is an important distinction to make for this disorder.

The delusional variant of body dysmorphic disorder (which identifies individuals who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delusional disorder, somatic type, and body dysmorphic disorder. Instead, it gets the new “absent/delusional beliefs” specifier.

BODY DYSMORPHIC DISORDER Signs and symptoms of body dysmorphic disorder include:

Preoccupation with your physical appearance with extreme self-consciousness

Frequent examination of yourself in the mirror, or the opposite, avoidance of mirrors altogether

Strong belief that you have an abnormality or defect in your appearance that makes you ugly

Belief that others take special notice of your appearance in a negative way

Avoidance of social situations

Feeling the need to stay housebound

The need to seek reassurance about your appearance from others

Frequent cosmetic procedures with little satisfaction

Excessive grooming, such as hair plucking or skin picking, or excessive exercise in an unsuccessful effort to improve the flaw

The need to grow a beard or wear excessive makeup or clothing to camouflage perceived flaws

Comparison of your appearance with that of others

Reluctance to appear in pictures

HOARDING DISORDER

Hoarding disorder graduates from being listed as just one symptom of obsessive-compulsive personality disorder in the DSM-IV, to a full-blown diagnostic category in the DSM-5. After the DSM-5 OCD working group examined the research literature on hoarding, they found little support to suggest this was simply a variant of a personality disorder, or a component of another mental disorder.

Hoarding disorder is characterized by the persistent difficulty discarding or parting with possessions, regardless of the value others may attribute to these possessions, according to the APA’s new criteria:

The behavior usually has harmful effects — emotional, physical, social, financial, and even legal — for the person suffering from the disorder and family members. For individuals who hoard, the quantity of their collected items sets them apart from people with normal collecting behaviors. They accumulate a large number of possessions that often fill up or clutter active living areas of the home or workplace to the extent that their intended use is no longer possible.

HOARDING DISORDER

Symptoms of the disorder cause clinically significant distress or

impairment in social, occupational or other important areas of

functioning including maintaining an environment for self and/or

others. While some people who hoard may not be particularly distressed

by their behavior, their behavior can be distressing to other people, such

as family members or landlords.

Hoarding disorder is included in DSM-5 because research shows that it

is a distinct disorder with distinct treatments. Using DSM-IV, individuals

with pathological hoarding behaviors could receive a diagnosis of

obsessive-compulsive disorder (OCD), obsessive-compulsive personality

disorder, anxiety disorder not otherwise specified or no diagnosis at all,

since many severe cases of hoarding are not accompanied by obsessive

or compulsive behavior. Creating a unique diagnosis in DSM-5 will

increase public awareness, improve identification of cases, and

stimulate both research and the development of specific

treatments for hoarding disorder.

HOARDING DISORDER

This is particularly important as studies show

that the prevalence of hoarding disorder is

estimated at approximately two to five percent

of the population. These behaviors can often

be quite severe and even threatening. Beyond

the mental impact of the disorder, the

accumulation of clutter can create a public

health issue by completely filling people’s

homes and creating fall and fire hazards

HOARDING DISORDER Hoarding affects emotions, thoughts and behavior. Signs and

symptoms of hoarding may include:

Cluttered living spaces

Inability to discard items

Keeping stacks of newspapers, magazines or junk mail

Moving items from one pile to another, without discarding anything

Acquiring unneeded or seemingly useless items, including trash or napkins from a restaurant

Difficulty managing daily activities, including procrastination and trouble making decisions

Difficulty organizing items

Shame or embarrassment

Excessive attachment to possessions, including discomfort letting others touch or borrow possessions

Limited or no social interactions

TRICHOTILLOMANIA (HAIR-PULLING DISORDER)

This disorder remains largely unchanged from the DSM-

IV, although the name has been updated to add “Hair-

pulling disorder” (we guess because people didn’t know

whattrichotillomania actually meant).

TRICHOTILLOMANIA (HAIR-PULLING DISORDER)

Signs and symptoms of trichotillomania often include:

Repeatedly pulling your hair out, typically from your scalp, eyebrows or eyelashes, but can be from other body areas, and sites may vary over time

An increasing sense of tension before pulling, or when you try to resist pulling

A sense of pleasure or relief after the hair is pulled

Shortened hair or thinned or bald areas on the scalp or other areas of your body, including sparse or missing eyelashes or eyebrows

Preference for specific types of hair, rituals that accompany hair pulling or patterns of hair pulling

Biting, chewing or eating pulled-out hair

Playing with pulled-out hair or rubbing it across your lips or face

EXCORIATION (SKIN-PICKING) DISORDER

Excoriation (skin-picking) disorder is a new disorder added to the DSM-5. It is estimated that between 2 and 4 percent of the population could be diagnosed with this disorder, and there exists a large research base that supports this new diagnostic category. Resulting problems may include medical issues such as infections, skin lesions, scarring and physical disfigurement.

According to the APA, this disorder is characterized by constant and recurrent picking at your skin, resulting in skin lesions. “Individuals with excoriation disorder must have made repeated attempts to decrease or stop the skin picking, which must cause clinically significant distress or impairment in social, occupational or other important areas of functioning. The symptoms must not be better explained by symptoms of another mental disorder.”

EXCORIATION (SKIN-PICKING) DISORDER

Specific DSM-5 criteria for excoriation disorder are as follows:

Recurrent skin-picking, resulting in lesions

Repeated attempts to decrease or stop skin picking

The skin picking causes clinically significant distress or impairment in important areas of functioning

The skin picking cannot be attributed to the physiologic effects of a substance or another medical condition

The skin picking cannot be better explained by the symptoms of another mental disorder

OTHER SPECIFIED AND UNSPECIFIED OBSESSIVE-

COMPULSIVE AND RELATED DISORDERS

DSM-5 includes the diagnoses other specified obsessive-compulsive and related disorders. These disorders can include conditions such as body-focused repetitive behavior disorder and obsessional jealousy, or unspecified obsessive-compulsive and related disorder.

Body-focused repetitive behavior disorder, for instance, is characterized by recurrent behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors.

Obsessional jealousy is characterized by nondelusional preoccupation with a partner’s perceived infidelity.