OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

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1 OBSESSIVE-COMPULSIVE AND RELATED DISORDERS According to the American Psychiatric Association (APA), the publisher of the DSM-5, the major change for obsessivecompulsive 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 (hairpulling disorder), as well as two new disorders: hoarding disorder and excoriation (skin-picking) disorder.

2 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

3 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

4 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

5 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

6 INSIGHT & TIC SPECIFIERS FOR OBSESSIVE- COMPULSIVE AND RELATED DISORDERS The old DSM-IV specifier with poor insight has been modified from being a blackand-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.

7 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.

8 BODY DYSMORPHIC DISORDER Signs and symptoms of body dysmorphic disorder include: Preoccupation with your physical appearance with extreme selfconsciousness 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

9 HOARDING DISORDER Hoarding disorder graduates from being listed as just one symptom of obsessive-compulsive personality disorder in the DSM-IV, to a fullblown 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.

10 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.

11 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

12 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

13 TRICHOTILLOMANIA (HAIR-PULLING DISORDER) This disorder remains largely unchanged from the DSM- IV, although the name has been updated to add Hairpulling disorder (we guess because people didn t know whattrichotillomania actually meant).

14 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

15 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.

16 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

17 OTHER SPECIFIED AND UNSPECIFIED OBSESSIVE- COMPULSIVE AND RELATED DISORDERS DSM-5 includes the diagnoses other specified obsessivecompulsive 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.