Dan J. Stein

Hoarding disorder: a new diagnosis for DSM-V?

This article provides a focused review of the literature on compulsive hoarding and presents a number of options and preliminary recommendations to be considered for DSM‐V. In DSM‐IV‐TR, hoarding is listed as one of the diagnostic criteria for obsessive–compulsive personality disorder (OCPD). According to DSM‐IV‐TR, when hoarding is extreme, clinicians should consider a diagnosis of obsessive–compulsive disorder (OCD) and may diagnose both OCPD and OCD if the criteria for both are met. However, compulsive hoarding seems to frequently be independent from other neurological and psychiatric disorders, including OCD and OCPD. In this review, we first address whether hoarding should be considered a symptom of OCD and/or a criterion of OCPD. Second, we address whether compulsive hoarding should be classified as a separate disorder in DSM‐V, weighing the advantages and disadvantages of doing so. Finally, we discuss where compulsive hoarding should be classified in DSM‐V if included as a separate disorder. We conclude that there is sufficient evidence to recommend the creation of a new disorder, provisionally called hoarding disorder. Given the historical link between hoarding and OCD/OCPD, and the conservative approach adopted by DSM‐V, it may make sense to provisionally list it as an obsessive–compulsive spectrum disorder. An alternative to our recommendation would be to include it in an Appendix of Criteria Sets Provided for Further Study. The creation of a new diagnosis in DSM‐V would likely increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatments for hoarding disorder. Depression and Anxiety, 2010.© 2010 Wiley‐Liss, Inc.

OBSESSIVE-COMPULSIVE DISORDER: A REVIEW OF THE DIAGNOSTIC CRITERIA AND POSSIBLE SUBTYPES AND DIMENSIONAL SPECIFIERS FOR DSM-V

Background: Since the publication of the DSM‐IV in 1994, research on obsessive–compulsive disorder (OCD) has continued to expand. It is timely to reconsider the nosology of this disorder, assessing whether changes to diagnostic criteria as well as subtypes and specifiers may improve diagnostic validity and clinical utility. Methods: The existing criteria were evaluated. Key issues were identified. Electronic databases of PubMed, ScienceDirect, and PsycINFO were searched for relevant studies. Results: This review presents a number of options and preliminary recommendations to be considered for DSM‐V. These include: (1) clarifying and simplifying the definition of obsessions and compulsions (criterion A); (2) possibly deleting the requirement that people recognize that their obsessions or compulsions are excessive or unreasonable (criterion B); (3) rethinking the clinical significance criterion (criterion C) and, in the interim, possibly adjusting what is considered “time‐consuming” for OCD; (4) listing additional disorders to help with the differential diagnosis (criterion D); (5) rethinking the medical exclusion criterion (criterion E) and clarifying what is meant by a “general medical condition”; (6) revising the specifiers (i.e., clarifying that OCD can involve a range of insight, in addition to “poor insight,” and adding “tic‐related OCD”); and (7) highlighting in the DSM‐V text important clinical features of OCD that are not currently mentioned in the criteria (e.g., the major symptom dimensions). Conclusions: A number of changes to the existing diagnostic criteria for OCD are proposed. These proposed criteria may change as the DSM‐V process progresses. Depression and Anxiety, 2010.

Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: Toward DSM-V

In DSM‐IV‐TR, trichotillomania (TTM) is classified as an impulse control disorder (not classified elsewhere), skin picking lacks its own diagnostic category (but might be diagnosed as an impulse control disorder not otherwise specified), and stereotypic movement disorder is classified as a disorder usually first diagnosed in infancy, childhood, or adolescence. ICD‐10 classifies TTM as a habit and impulse disorder, and includes stereotyped movement disorders in a section on other behavioral and emotional disorders with onset usually occurring in childhood and adolescence. This article provides a focused review of nosological issues relevant to DSM‐V, given recent empirical findings. This review presents a number of options and preliminary recommendations to be considered for DSM‐V: (1) Although TTM fits optimally into a category of body‐focused repetitive behavioral disorders, in a nosology comprised of relatively few major categories it fits best within a category of motoric obsessive–compulsive spectrum disorders, (2) available evidence does not support continuing to include (current) diagnostic criteria B and C for TTM in DSM‐V, (3) the text for TTM should be updated to describe subtypes and forms of hair pulling, (4) there are persuasive reasons for referring to TTM as “hair pulling disorder (trichotillomania),” (5) diagnostic criteria for skin picking disorder should be included in DSM‐V or in DSM‐Vs Appendix of Criteria Sets Provided for Further Study, and (6) the diagnostic criteria for stereotypic movement disorder should be clarified and simplified, bringing them in line with those for hair pulling and skin picking disorder. Depression and Anxiety, 2010.

Body dysmorphic disorder: some key issues for DSM-V†

Body dysmorphic disorder (BDD), a distressing or impairing preoccupation with an imagined or slight defect in appearance, has been described for more than a century and increasingly studied over the past several decades. This article provides a focused review of issues pertaining to BDD that are relevant to DSM‐V. The review presents a number of options and preliminary recommendations to be considered for DSM‐V: (1) Criterion A may benefit from some rewording, without changing its focus or meaning; (2) There are both advantages and disadvantages to adding a new criterion to reflect compulsive BDD behaviors; this possible addition requires further consideration; (3) A clinical significance criterion seems necessary for BDD to differentiate it from normal appearance concerns; (4) BDD and eating disorders have some overlapping features and need to be differentiated; some minor changes to DSM‐IVs criterion C are suggested; (5) BDD should not be broadened to include body integrity identity disorder (apotemnophilia) or olfactory reference syndrome; (6) There is no compelling evidence for including diagnostic features or subtypes that are specific to gender‐related, age‐related, or cultural manifestations of BDD; (7) Adding muscle dysmorphia as a specifier may have clinical utility; and (8) The ICD‐10 criteria for hypochondriacal disorder are not suitable for BDD, and there is no empirical evidence that BDD and hypochondriasis are the same disorder. The issue of how BDDs delusional variant should be classified in DSM‐V is briefly discussed and will be addressed more extensively in a separate article. Depression and Anxiety, 2010.

Culture and the anxiety disorders: recommendations for DSM-V.

Background: The anxiety disorders specified in the fourth edition, text revision, of The Diagnostic and Statistical Manual (DSM‐IV‐TR) are identified universally in human societies, and also show substantial cultural particularities in prevalence and symptomatology. Possible explanations for the observed epidemiological variability include lack of measurement equivalence, true differences in prevalence, and limited validity or precision of diagnostic criteria. One central question is whether, through inadvertent “over‐specification” of disorders, the post‐DSM‐III nosology has missed related but somewhat different presentations of the same disorder because they do not exactly fit specified criteria sets. This review canvases the mental health literature for evidence of cross‐cultural limitations in DSM‐IV‐TR anxiety disorder criteria. Methods: Searches were conducted of the mental health literature, particularly since 1994, regarding cultural or race/ethnicity‐related factors that might limit the universal applicability of the diagnostic criteria for six anxiety disorders. Results: Possible mismatches between the DSM criteria and the local phenomenology of the disorder in specific cultural contexts were found for three anxiety disorders in particular. These involve the unexpectedness and 10‐minute crescendo criteria in Panic Disorder; the definition of social anxiety and social reference group in Social Anxiety Disorder; and the priority given to psychological symptoms of worry in Generalized Anxiety Disorder. Limited evidence was found throughout, particularly in terms of neurobiological markers, genetic risk factors, treatment response, and other DSM‐V validators that could help clarify the cross‐cultural applicability of criteria. Conclusions: On the basis of the available data, options and preliminary recommendations for DSM‐V are put forth that should be further evaluated and tested. Depression and Anxiety, 2010© 2009 Wiley‐Liss, Inc.

Should OCD be classified as an anxiety disorder in DSM‐V?

In DSM‐III, DSM‐III‐R, and DSM‐IV, obsessive–compulsive disorder (OCD) was classified as an anxiety disorder. In ICD‐10, OCD is classified separately from the anxiety disorders, although within the same larger category as anxiety disorders (as one of the “neurotic, stress‐related, and somatoform disorders”). Ongoing advances in our understanding of OCD and other anxiety disorders have raised the question of whether OCD should continue to be classified with the anxiety disorders in DSM‐V. This review presents a number of options and preliminary recommendations to be considered for DSM‐V. Evidence is reviewed for retaining OCD in the category of anxiety disorders, and for moving OCD to a separate category of obsessive–compulsive (OC)‐spectrum disorders, if such a category is included in DSM‐V. Our preliminary recommendation is that OCD be retained in the category of anxiety disorders but that this category also includes OC‐spectrum disorders along with OCD. If this change is made, the name of this category should be changed to reflect this proposed change. Depression and Anxiety, 2010.

OLFACTORY REFERENCE SYNDROME: ISSUES FOR DSM-V

The published literature on olfactory reference syndrome (ORS) spans more than a century and provides consistent descriptions of its clinical features. The core symptom is preoccupation with the belief that one emits a foul or offensive body odor, which is not perceived by others. This syndrome is associated with substantial distress and disability. DSM‐IV and ICD‐10 do not explicitly mention ORS, but note convictions about emitting a foul body odor in their description of delusional disorder, somatic type. However, the fact that such symptoms can be nondelusional poses a diagnostic conundrum. Indeed, DSM‐IV also mentions fears about the offensiveness of ones body odor in the social phobia text (as a symptom of taijin kyofusho). There also seems to be phenomenological overlap with body dysmorphic disorder, obsessive–compulsive disorder, and hypochondriasis. This article provides a focused review of the literature to address issues for DSM‐V, including whether ORS should continue to be mentioned as an example of another disorder or should be included as a separate diagnosis. We present a number of options and preliminary recommendations for consideration for DSM‐V. Because research is still very limited, it is unclear how ORS should best be classified. Nonetheless, classifying ORS as a type of delusional disorder seems problematic. Given this syndromes consistent clinical description across cultures for more than a century, substantial morbidity and a small but growing research literature, we make the preliminary recommendation that ORS be included in DSM‐Vs Appendix of Criteria Sets Provided for Further Study, and we suggest diagnostic criteria. Depression and Anxiety, 2010.

Is disorder x in category or spectrum y? General considerations and application to the relationship between obsessive–compulsive disorder and anxiety disorders

Is obsessive–compulsive disorder (OCD) best categorized as an anxiety disorder? This question has been raised previously, but advances in the psychobiology of OCD and the anxiety disorders, and preparations for Diagnostic and Statistical Manual of Mental Disorders—V and International Classification of Diseases—11, make reconsideration timely. The debate in turn raises the more general issue of how best to address any question of the form “is disorder x in category or spectrum y?” Such questions are related to a number of key debates in philosophy of science and language and have also increasingly been addressed by the cognitive–affective neuroscience of categorization. Here, we review this background debate and use OCD as a relevant exemplar. Depression and Anxiety 25:330–335, 2008.

Special DSM-V issues on anxiety, obsessive-compulsive spectrum, posttraumatic, and dissociative disorders†‡

We are very pleased to introduce a special series of review articles in Depression and Anxiety which focus on key issues for DSM-V. These literature reviews were commissioned by the DSM-V Work Group on Anxiety, Obsessive–Compulsive Spectrum, Posttraumatic, and Dissociative Disorders. These articles present some options and preliminary recommendations to be considered for DSM-V. The DSM-V development process has been under way for many years. For the past several years, our Work Group has been considering possible changes to DSM-IV, the goal of which is to enhance the reliability, validity, and clinical utility of DSM. By introducing reliable and atheoretical diagnostic criteria, DSM-III was a groundbreaking document; changes made in DSM-III-R and DSM-IV further advanced the diagnostic system. Nevertheless, nearly two decades have passed since DSM-IV was developed, and the field has advanced substantially since then. The literature reviews in the Depression and Anxiety special series are an important part of the evidence-based process our Work Group is using. These reviews focus on selected topics that are especially relevant to the Work Group’s deliberations; they are not intended to be general reviews of disorders, and they needed to adhere to space constraints. The first issue of the special series—the current issue—focuses on most of the anxiety disorders. The second issue will focus on obsessive–compulsive disorder (OCD) and other disorders assigned to our Work Group which many in the field consider to be related to OCD. The third issue in this special series will focus on trauma and stress-related disorders as well as dissociative disorders. We anticipate that additional reviews on selected topics will be published elsewhere. By summarizing and synthesizing what is in many cases a large published literature, these reviews have been invaluable to the Work Group, and they have informed the Work Group’s deliberations. One caveat, however, is that the reviews represent work by their authors for consideration by the Work Group. Thus, the reviews may not completely reflect the collective view of the Work Group or perfectly match the Work Group’s preliminary proposed criteria (which are posted on DSM5.org). The Work Group’s preliminary recommendations have also been informed by additional secondary data analyses of existing data sets, collection of new data for DSM-V, surveys of experts, and invaluable input and data provided by the Work Group’s many advisors and liaisons, DSM-V Task Force members, other members of the scientific community, and other stakeholders. Another caveat: final recommendations and decisions for DSM-V have not been made yet! Thus, recommendations in these review articles, and those posted on DSM5.org, should be considered preliminary at this time. Recommendations may evolve further over time, as the DSM-V development process has many remaining steps. For example, field trials will test some of the proposed changes, more new data will be obtained, additional secondary data analyses will be conducted, and input will be obtained from experts and the broader mental health community. The Work Group commissioned these literature reviews because recommended changes to DSM-IV should be as evidence based as possible. Evidence regarding the reliability and validity of proposed changes needs to be weighed, as does clinical utility— i.e., changes should be helpful to clinicians in formulating diagnoses, assessing patients, and selecting

The Classification of Anxiety and Fear-Related Disorders in the ICD-11

Anxiety disorders are highly prevalent worldwide and engender substantial economic costs and disability. The World Health Organization is currently developing the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD‐11), which represents the first opportunity to improve the validity, clinical utility, and global applicability of the classification in more than 25 years. This article describes changes in the organization and diagnostic guidelines for anxiety and fear‐related disorders proposed by the ICD‐11 Working Group on the Classification of Mood and Anxiety Disorders and the rationale and evidence base for the proposals. In ICD‐11, anxiety and fear‐related disorders that manifest across the lifespan are brought together under a new grouping, and are partly distinguished by their focus of apprehension. The focus of apprehension is the stimulus or situation that triggers the fear or anxiety and may be highly specific as in specific phobia or relate to a broader class of situations as in social anxiety disorder. The guidelines also clarify the relationship between panic disorder and agoraphobia and a qualifier is provided for panic attacks in the context of other disorders. A standardized format emphasizing essential features of anxiety disorders is intended to improve clinical utility. Guidelines will be further refined based on findings from two types of field studies: those using a case‐controlled vignette methodology disseminated via the Internet to practitioners worldwide (http://gcp.network) and clinic‐based field trials implemented globally at participating field study centers.