DSM: Anxiety and OCD

DSM-5 Purpose

to assist trained clinicians in the diagnosis of their patient’s mental disorders as part of a case formulation assessment that leads to a fully informed treatment plan for each individual

DSM overview 

• Intended for use in clinical practice.

• Relies on clinical judgment and experience to use. 

• Largely separates mental/physical disorders.

• Classifies illness, not people.

Clinical Definition: Mental Disorder

A syndrome characterized by clinically significant disturbance in an individuals cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying metal functioning

A mental disorder is NOT

Socially deviant behavior or an acceptable or culturally approved response

Differential Diagnosing

Best attempt to not over diagnose, process of determining the most accurate diagnosis, reviewing diagnostic criteria most relevant to the person and ruling out what can’t be confirmed and ruling in those than can be confirmed.

Other Specified Disorders

is coded when the clinician wants to indicate the reason why the client’s symptoms do not meet the criteria for a specific diagnosis (e.g., “other specified depressive disorder, recurrent brief depression”). 

Unspecified Disorders

is coded when the clinician does not want to indicate the reason why the client’s symptoms do not meet the criteria for a specific diagnosis. 

Separation Anxiety Disorder

Developmentally inappropriate and excessive fear or anxiety concerning separation from those to whom the individual is attached. At least three of the criteria must be present.

Separation Anxiety Disorder Duration

Lasts at least 4 weeks in children and 6+ months in adults.

Separation Anxiety Disorder can be diagnosed in which age group

Both in children and adults

To meet criteria for Selective Mutism, the individual must show a complete lack of speech in every social context for at least 3 consecutive months

False

Which of the following distinguishes Specific Phobia from Social Anxiety Disorder

The focus of fear is on performance or social scrutiny in SAD whereas Specific Phobia is tied to a specific object or situation

Selective Mutism

Consistent failure to speak in specific social situations where speaking is expected, despite speaking in other situations such as at home and among immediate family members

Selective Mutism Duration

At least one month (not limited to the first month of school). Not attributable to lack of knowledge of or comfort with the spoken language.

Selective Mutism Onset

Usually before age 5

Specific Phobia

Marked fear or anxiety about a specific object or situation (for example: flying, heights, animals, receiving an injection, seeing blood). The phobic object or situation almost always provokes immediate fear or anxiety, and is actively avoided or endured with intense fear.

Specific Phobia Duration

At least six months

Specific Phobia Onset

Typically childhood or adolescence. Median age at onset is between 7 and 11 years with the mean at about 10 years. This is one of the most commonly experienced disorders later in life. 

Social Anxiety Disorder (Social Phobia)

Marked fear or anxiety about social situations where the individual is exposed to possible scrutiny by others.

Social Anxiety Disorder Duration

At least six months

Social Phobia Onset

Median age is 13 years old and about 75% of individuals have an age onset between 8 and 15 years old

Panic Disorder

Abrupt surges of intense fear or intense discomfort that reaches a peak in minutes and during which 4 or more of the list of 13 physical and cognitive symptoms occur. 

Panic Disorder: Recurrent

more than one unexpected panic attack

Panic Disorder: Unexpected

refers to a panic attack for which there is no obvious cue or trigger at the time of occurrence and that the attack occurred out of the blue

Panic Disorder: Expected

refers to a panic attack that has an obvious cue or trigger, such as a situation in which a panic attack has already occurred

Panic Disorder: Essentially Features

Recurrent unexpected panic attacks. At least one attack followed by one month or more of persistent concern or worry about additional attacks or their consequences, or significant maladaptive behavior change related to the attacks

Panic Disorder: Onset

The median age of onset is 20-24 years old, and cross nationally is 32 years old. The mean age of onset is 34.7 years old and a small number of cases begin in childhood and onset after age 55 is unusual but can occur

Agoraphobia

Marked fear or anxiety about real or anticipated exposure to a wide range of situations

Agoraphobia

The diagnosis requires an individual to experience at least two of the following: 

• Using public transportation (e.g., automobiles, buses, trains, planes)

• Being in open spaces (e.g., parking lots, marketplaces, bridges)

• Being in enclosed places (e.g., shops, theaters, cinemas)

• Standing in line or being in a crowd.

• Being outside the home alone

Agoraphobia: Duration

At least six months

Generalized Anxiety Disorder

Excessive anxiety and worry occurring more days than not for at least six months, about a number of events or activities

Generalized Anxiety Disorder Criteria

difficulty controlling worry plus three (or more) of the following symptoms (one for children):

• Restlessness or feeling keyed up.

• Being easily fatigued.

• Difficulty concentrating or mind going blank.

• Irritability.

• Muscle tension.

• Sleep disturbance

Generalized Anxiety Disorder: Onset

Gradual, often in adolescence or early adulthood; median age of diagnosis in middle age

Obsessive-Compulsive Disorder: Obsessions

Recurrent and persistent thoughts, urges, or images that are intrusive and unwanted, causing marked anxiety or distress. The individual attempts to ignore, suppress, or neutralize them

Obsessive-Compulsive Disorder: Compulsions

Repetitive behaviors (such as handwashing, checking) or mental acts (such as counting, praying) that the person feels driven to perform in response to an obsession or according to rigid rules

OCD: Duration

Obsessions or compulsions are time-consuming (taking more than one hour per day) or cause clinically significant distress or impairment

OCD: Onset

Mean age of onset is 19.5 years old and 25% of cases start by age 14 years. Onset at 35 is unusual but does occur. Nearly 25% of men have an onset before the age of 10 years. The onset symptoms are typically gradual, however, acute onset can also occur

Body Dysmorphic Disorder

Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

Body Dysmorphic Disorder: Onset

The mean age of onset is 16-17 years, the median age is 15 years and then the most common age of onset is between 12-13 years old. 

Hoarding Disorder

Persistent difficulty discarding or parting with possessions, regardless of their actual value

Hoarding Disorder: Onset

Appears to begin early in life and spans well into the late stages of life. However, symptoms may first emerge around 15-19 years old, starting with everyday functioning by the mid 20s, and cause clinically significant impairment by the mid 30s

Trichotillomania (Hair-Pulling Disorder)

Essential Features: Recurrent pulling out of one’s hair, resulting in hair loss.

Location of hair pulling: can occur from any region of the body where hair grows; the most common sites are the scalp, eyebrows, and eyelids, while the less common sites are axillary, facial, and perirectal regions

Trichotillomania (Hair-Pulling Disorder): Onset

Typically coincides with or after puberty

Excoriation (Skin-Picking) Disorder

• Essential Features: Recurrent skin picking resulting in skin lesions.

• Common areas: Face, arms and hands, but many individuals pick from multiple body sites. 

Excoriation (Skin-Picking) Disorder

Onset: Commonly during adolescence and commonly coinciding with or following the onset of puberty. 

Excoriation (Skin-Picking) Disorder

The majority of individuals spend at least: 1 hour per day picking, thinking about picking, and resisting urges to pick. 

Emma, a 24-year-old graduate student, reports intense fear and anxiety during classroom presentations and group discussions. She avoids socializing with peers, fearing that they will judge her as incompetent. Emma often blushes, trembling during public speaking, which further reinforces her fear. Despite excelling academically, she feels her social anxiety is preventing her from networking and advancing in her career. She denies any traumatic social experiences in the past and is otherwise healthy.  What diagnostic criterion is most relevant in Emma's case?

Persistent fear of being negatively evaluated in social situations

Jenna, an 8-year-old female, displays excessive crying when she has to go to school, accompanied by abdominal pain and nausea. She fears that something might happen to her father while they are apart. She refuses to sleep away from home and avoids school trips. The family does not report specific traumas but mentions that her mother is often very anxious. Which of the following differential diagnoses should be ruled out

Agoraphobia

Which of the following distinguishes Specific Phobia from Social Anxiety Disorder

The focus of fear is on performance or social scrutiny in SAD whereas Specific Phobia is tied to a specific object or situation.

James, a 30 year old man, avoids flying due to an intense fear of being in enclosed spaces. Despite knowing air travel is statistically safe, he experiences rapid heartbeat, sweating, and dizziness at the thought of boarding a plane. He once booked a flight but canceled it at the last minute, opting to drive 12 hours to avoid flying. He has no history of traumatic events and his fear has not generalized to other forms of transportation. Based on the symptoms described above, what feature of his presentation is most relevant in this case

The fear is triggered by a specific situation rather than multiple settings - he may meet criteria for Specific Phobia

What is an important factor to rule out when diagnosing Specific Phobia

That the fear is not better explained by another mental disorder, such as Panic Disorder or PTSD

What is the most evidenced based intervention for OCD

CBT with Exposure and Response Prevention

which of the following would most likely be classified as an obsession in OCD

 A person is preoccupied with fears of contamination despite evidence to the contrary