The new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has a number of changes to obsessive-compulsive and related disorders, such as hoarding and body dysmorphic disorder. This article outlines some of the major changes to these conditions.
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.
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.
Also, the APA notes that the new tic-related specifier for obsessive-compulsive disorder reflects the research validity (and clinical validity) of “identifying individuals with a current or past comorbid tic disorder, because this comorbidity may have important clinical implications.”
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.
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.
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.
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.
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 what trichotillomania actually meant).
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.”
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.