Obsessive Compulsive and Other Related Disorders in DSM 5-TR

OCD DISORDERS in DSM 5-TR

• Obsessive-Compulsive Disorder

• Body Dysmorphic Disorder

• Hoarding Disorder

• Trichotillomania (Hair-Pulling Disorder)

• Excoriation (Skin-Picking) Disorder

• Substance/Medication-Induced Obsessive-Compulsive and Related Disorder

• Obsessive-Compulsive and Related Disorder Due to Another Medical Condition

• Other Specified Obsessive-Compulsive and Related Disorder

• Unspecified Obsessive-Compulsive and Related Disorder

Obsessive Compulsive Disorders

• Characterized by the presence of obsessions and/or compulsions.These disorders differ from developmentally normative preoccupations and rituals by being excessive or persisting past developmentally appropriate periods.

Obsessions

recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted

Compulsions

repetitive behaviors or mental acts an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly

Obsessive Compulsive Disorder (F 42)

• A. Presence of obsession, compulsions, or both:

  • Obsessions are defined by (1) & (2)

    • Recurrent persistent thoughts, urges, or images that are experienced as intrusive and unwanted & cause marked anxiety & distress

    • Individual attempts to ignore or suppress the thoughts, urges, or images or to neutralize them with other thought or action

  • Compulsions are defined by (1) & (2)

    • Repetitive behaviors or mental acts that the individual feels driven to perform in response to an obsession or according to the rules that must be applied rigidly

      • Repetitive Behaviors

        • Hand washing

        • Ordering

        • Checking

  • These behaviors or mental acts are not realistically connected to what they were designed to prevent, clearly excessive. Behaviors or mental acts aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation.

    • Mental Acts

    • Counting

    • Checking

    • Repeating word

    • Mantras

• B. Time consuming obsessions & compulsions (e.g., more than hour day) or cause significant distress or impairment in social, occupational or other functioning

• C. Symptoms are not attributable to physiological effects of substance, medication or medical condition

• D. Not better explained by another mental disorder.

Specifiers for OCD

• With good or fair insight

  • recognizes that beliefs are definitely or probably not true or may not be true e

• With poor insight

  • thinks their beliefs are probably true

• With absent insight/delusional beliefs

  • Completely convinced the obsessive-compulsive beliefs are true

• If Tic related

  • Tic-related : DSM 5-TR indicates that up to 30% of individuals with OCD have a tic disorder.

  • More common in men with OCD onset in childhood

Rituals not in DSM 5-TR

Behaviors repeatedly performed in specified manner to relieve the anxiety of the obsessions, a rite or ceremony that becomes compulsive for the individual.

Categories in OCD

• Washers are afraid of contamination. They usually have cleaning or hand-washing compulsions.

• Checkers repeatedly check things (oven turned off, door locked, etc.) that they associate with harm or danger.

• Doubters and sinners are afraid that if everything isn’t perfect or done just right something terrible will happen, or they will be punished.

• Counters and arrangers are obsessed with order and symmetry. They may have superstitions about certain numbers, colors, or arrangements.

• Hoarders fear that something bad will happen if they throw anything away. They compulsively hoard things that they don’t need or use

Some obsessive thoughts

• Fear of being contaminated by germs or dirt or contaminating others

• Fear of losing control and harming yourself or others

• Intrusive sexually explicit or violent thoughts and images

• Excessive focus on religious or moral ideas

• Fear of losing or not having things you might need

• Order and symmetry: the idea that everything must line up “just right”

• Superstitions; excessive attention to something considered lucky or unlucky

Some Compulsive Behaviors

• Excessive double-checking of things, such as locks, appliances, and switches

• Repeatedly checking in on loved ones to make sure they’re safe

• Counting, tapping, repeating certain words, or doing other senseless things to reduce anxiety

• Spending a lot of time washing or cleaning

• Ordering or arranging things “just so”

• Praying excessively or engaging in rituals triggered by religious fear

• Accumulating “junk” such as old newspapers or empty food containers

Prevalence and Course of OCD

• Prevalence in U.S. is 1.2% with similar prevalence internationally.

• Slightly higher rate in women than men with men more commonly affected in
  childhood.

• Onset is 19.5 year with 25% of cases beginning by 14 years.

• Onset after 35 is unusual.

• Men have earlier age of onset with 25% onset at age 10.

• Untreated can lead to disorder being comorbid with anxiety disorder, depressive disorder, and bipolar disorder

OCD Associated Features

• Preceding compulsions are reported by 60% of individuals

• They report sensory phenomena, such as physical sensations, just-right sensations, or feelings of incompleteness.

• Individuals report being triggered by anxiety, feelings of disgust, sense of incompleteness, or uneasiness until things “feel right.”

• Avoidance behaviors are common to reduce exposure to triggering situations.

• Dysfunctional beliefs are common in individuals

Body Dysmorphic Disorder (F45.22)

(formerly dysmorphophobia) become preoccupied with a perceived defect or flaw in their appearance that they believe renders them ugly, unattractive, abnormal, or deformed

• A. Preoccupation with one or more perceived defects or flaws in physical appearance
  that are not observed or appear slight to others

• B. Individual has in disorder performed repetitive behaviors or mental acts like comparing to others

  • Mirror checking

  • Excessive grooming

  • Skin picking

  • Reassurance seeking

  • Compensatory behaviors

• C. The preoccupation causes clinically significant distress or impairment in social, occupational or other functioning.

• D. Not explained by concerns about body fat or weight in someone whose symptoms meet criteria for an eating disorder

Specifiers for Body Dysmorphic Disorder

• Muscle dysmorphia

  • Individual is preoccupied with the idea that he or she has a body build that is too small or insufficiently muscular.

  • May also be concerned with skin or hair.

  • Most often men.

  • On average insight is poor for this condition.

• Good or fair insight

  • Recognizes body dysmorphic beliefs are definitely or probably not true

    • (e.g., I look ugly or I look deformed)

• Poor insight

  • Thinks body dysmorphic beliefs are probably true

• Absent insight/ delusional beliefs

  • Completely convinced the body dysmorphic beliefs are true

Body Dysmorphic Disorder Prevelance

• Prevalence in United States was 2.4% (2.5% women & 2.2% in men). Lower in Germany and outside U.S.

• Globally prevalence is 11% to 13% in dermatology patients, 13% to 15% in cosmetic
  surgery patients, 20% in rhinoplasty surgery patients, 11% in adult jaw cosmetic surgery patients, & 5% to 10% in adult orthodontia or cosmetic dentistry patients.

• In adolescents & young adults higher in young women/girls than young men/boys.

• Mean age of onset 16 to 17 years but most common age of onset 12 to 13 years.

Hoarding Disorder (F42)

Essential feature is persistent difficulties in discarding or parting with possessions regardless of actual value.

Term persistent is a pattern of long-standing difficulty rather than transient life circumstances, such as inheriting property.

• A. Persistent difficulty discarding or parting with possessions regardless of their value

• B. Due to perceived need to save items and distress with discarding them

• C. The difficulty discarding possessions results in an accumulation of possessions that congest and clutter living areas and compromise their integrity. If areas are uncluttered it is only because of intervention by relatives, cleaners, or authorities

• D. Hoarding causes significant distress or impairment in life areas or maintaining safe environment for self or others

• E. Not attributable to medical condition or mental disorder

  • Prader Willi, neurovascular disease, brain injury

• F. Hoarding is not better explained
  by another mental disorder

  • Decreased energy in MDD

  • Delusions in Schizophrenia

  • Obsessions in OCD

Specifiers for Hoarding Disorder

• Specify if

  • Excessive acquisition of items

• Specify if

  • Good to fair insight

    • Realizes beliefs & behaviors are problematic

  • Poor insight

    • Convinced beliefs & behaviors are not problematic, evidence to contrary

  • Absent insight or delusional beliefs

    • Totally convinced that hoarding related beliefs and behaviors are not problematic due to evidence to contrary

Hoarding Features and Prevalence

• Features: indecisiveness, perfectionism, avoidance, procrastination, difficulty planning & organizing tasks, distractibility

• May include unsanitary & unsafe housing

• Animal hoarding is large accumulation of animals with poor nutrition, sanitation, vet care & deterioration of animal health leading to disease, starvation, and/or death

• Prevalence in United States & Europe is 1.5% to 6%

• Gender difference is either minimal or in direction of women

• May begin early in life, 15-19 years, & interfere with functioning in mid 20s, causing severe impairment in mid 30s.

• Severity increases across life span

Trichotillomania (F63.2)

Essential feature is recurrent pulling out of one’s hair causing hair loss

Hair pulling may come from common sites: scalp, eyebrows, or eyelids, less common sites are axillary, facial, pubic, perirectal region

• A. Recurrent pulling out of one’s hair, resulting in hair loss

• B. Repeated attempts to stop or decrease hair pulling behaviors.

• C. Hair pulling causes significant distress or impairment in social, occupational or other functioning.

• D. Not attributed to a medical condition or mental disorder

Trichotillomania Prevalence and Features

• Prevalence in range of 1% to 2% and more frequent in women than men at 10:1 ratio

• In children, boys & girls are represented

• Hair pulling behaviors may be ritualized (e.g., hair with specific texture or color, extraction with hair root, biting hair into pieces, rolling hair in fingers, swallowing hair)

• Hair pulling may be triggered by anxiety or boredom, need for gratification, lack of awareness, or tingling of scalp relieved by hair pulling

Excoriation Disorder (F42.4)

The essential feature is recurrent picking at one’s own skin that leads to skin lesions.

Most common sites are face, arms, and hands.

May pick healthy skin, minor skin irregularities, lesions, such as pimples or calluses, or at scabs.

May pick skin, rub skin, squeeze, lance or bite. Instruments include, fingernails , tweezers, scissors, razor blades , or other sharp instruments

• A. Recurrent skin picking resulting in skin lesions

• B. Repeated attempts to decrease or stop skin picking

• C. Causes clinically significant distress or impairment

• D. Not attributable to physiological effects of substance use

  • Formication from amphetamine or cocaine

• E. Not explained by another mental disorder

  • Hallucinations from psychosis

  • Attempt to improve perceived defect in BDD

• Occurs over several hours a day and may continue for months or years.

Excoriation Disorder Prevalence

• Prevalence in United States at 2.1% with three quarters of individuals with the disorder women

• Individuals may search for scabs to pull & may examine or even swallow this skin

• May be triggered by anxiety or boredom

• May be preceded by tension that is relieved when picking behaviors are engaged in by individual

• Some may pick the skin of others

Substance/Medication-Induced Obsessive Compulsive and Related Disorder

• A. Obsessions, compulsions, skin picking, hair pulling or other body- focused repetitive behaviors or other symptoms predominate the clinical picture

• B. There is evidence from history, physical exam, or lab findings that both

  • The symptoms of Criteria A developed during or soon after substance intoxication or withdrawal or exposure to a medication

  • Involved substance/medication is capable of producing the symptoms in Criteria A

• C. Disturbance not better explained by obsessive compulsive disorder that is not substance induced

  • The symptoms precede the onset of substance/medication us; symptoms persist for a month after the cessation of intoxication or withdrawal or other evidence

• D. Disturbance does not occur during course of delusion

• E. Disturbance causes clinically significant distress or impairment

Substance/Medication Induced OCD and Related Disorder Codes

• If the substance/medication induced obsessive compulsive disorder is comorbid with a substance use disorder present for the same class of substance, code the 4th position with

  • “1” for mild substance use disorder,

  • “2” for moderate/severe substance use disorder.

  • If no comorbid substance use disorder code with “9.”

• Amphetamine

  • With use mild---F15.188

  • With use moderate/severe---F15.288

  • Without use disorder----- F15.988

• Cocaine

  • With use mild---F14.188

  • With use moderate/severe---F14.288

  • Without use disorder----- F14.988

• Other (unknown)

  • With use mild---F19.188

  • With use moderate/severe---F19.288

  • Without use disorder----- F19.988

Substance/Medication Induced OCD and Related Disorder Specifiers

• With onset during intoxication

  • Criteria met for intoxication with substance and symptoms develop during intoxication

• With onset during withdrawal

  • Criteria met for withdrawal for substance and symptoms met during or shortly after withdrawal

• With onset after medication use

  • Symptoms appear either at initiation of medication or after a modification or change
    in use

Obsessive Compulsive and Related Disorder due to Medical Condition (F06.8)

• A. Obsessions, compulsions, and preoccupations with appearance, hoarding, skin picking, hair pulling, other body-focused repetitive behaviors

• B. Evidence from physical exam, lab findings direct pathophysiological consequence of medical condition

• C. Not better explained by another mental disorder

• D. Not exclusively during course of delirium
  • E. Causes distress or impairment

Obsessive Compulsive and Related Disorder due to Medical Condition Specifiers

• With obsessive compulsive disorder symptoms

• With appearance preoccupation

  • Flaws or defects predominate

• With hoarding symptoms

• With hair-pulling symptoms

• With skin-picking symptoms

• Indicate name of the other medical condition in the name of the medical disorder (e.g., 294.8 (F06.8) obsessive compulsive and related disorder due to cerebral infarction)

Other Specified Obsessive Compulsive and Related Disorder (F42.8)

• Presentations causes distress or impairment, but do not meet full criteria for any of the
  disorders in the category

• When clinician communicates why presentation does not meet criteria for any specific disorder in OCD disorders

Body Dysmorphic-Like Disorder with Actual Flaws

Defects are clearly observed by others (more than slight)

Preoccupation is clearly excessive with impairment

Body Dsymorphic-Like Disorder Without Repetitive Behaviors

Presentation clearly body dysmorphic disorder without repetitive behaviors

Other Body-Focused Repetitive Behavior Disorder

Repetitive behaviors other than hair pulling & skin picking (e.g., nail biting, cheek chewing) with attempts to decrease or stop and with distress and impairment

Obsessive Jealousy

Non-delusional preoccupation with partner’s perceived infidelity.

May lead to repetitive behaviors or mental acts in response to concerns

Olfactory Reference Disorder (Olfactory Reference Syndrome)

• This is characterized by the individual’s persistent preoccupation with the belief that he or she emits a foul or offensive body odor that is unnoticeable or only slightly noticeable to others; in response to this preoccupation, these individuals often engage in repetitive and excessive behaviors such as repeatedly checking for body odor, excessive showering, or seeking reassurance, as well as excessive attempts to camouflage the perceived odor. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • In traditional Japanese this disorder is know as jikoshu-kyofu, a variant of taijin kyofusho (see “Culture and Psychiatric Diagnosis” in Section III)

Shubo-kyofy

Variant of taijin kyofusho

Excessive fear of body deformity

Koro

Related to dhat syndrome
Sudden intense anxiety about the penis (nipples or vulva in women) receding into the body, resulting in death

Unspecified Obsessive Compulsive and Related Disorder (F42)

Presentation is which symptoms of obsessive –compulsive and related disorder causes distress or impairment , but do not meet full criteria for any of the disorders in this category.

Used in situations in which clinician does not choose to specify reason criteria are not met, (e.g., emergency room settings)

Dhat Syndrome

• It is a culture-bound psychiatric syndrome most commonly found in the Indian subcontinent.

• It has been characterized as the experiential fear of losing semen through ejaculation, nocturnal emission, or other means

Jikoshu-Kyofu

• The phobia of having foul body odor

• Japan specific

Taijin Kyofush

• An intense fear that one's body parts or functions displease, embarrass or are offensive to others.

• Japan specific