Module 6: New Age Psychological Disorders

Section 1: DSM-5 Information

1. Structural Overview & Reclassification Trends

DSM-5 introduced major nosological revisions that elevated several previously under-recognized or subsumed clinical presentations into primary diagnostic entities:

• Creation of Obsessive-Compulsive and Related Disorders (OCRD): Separated from Anxiety Disorders to house conditions characterized by preoccupations and repetitive behaviors, introducing Hoarding Disorder and Excoriation (Skin-Picking) Disorder.

• Recognition of Non-Substance Behavioral Addictions: Expanded Substance-Related and Addictive Disorders to include Gambling Disorder as the sole non-substance behavioral addiction, while placing Internet Gaming Disorder in Section III (Conditions for Further Study).

• Developmental Emotion Dysregulation: Added Disruptive Mood Dysregulation Disorder (DMDD) to Depressive Disorders to address severe, non-episodic pediatric irritability and prevent the overdiagnosis of pediatric bipolar disorder.

2. Excoriation (Skin-Picking) Disorder (698.4 / L98.1)

• Chapter Placement: Obsessive-Compulsive and Related Disorders.

• Diagnostic Criteria:

  • Criterion A: Recurrent skin picking resulting in skin lesions.

  • Criterion B: Repeated attempts to decrease or stop skin picking.

  • Criterion C: The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • Criterion D: Not attributable to the physiological effects of a substance (e.g., cocaine, amphetamines) or another medical condition (e.g., scabies).

  • Criterion E: Not better explained by symptoms of another mental disorder (e.g., delusions/tactile hallucinations in psychosis, attempts to correct perceived appearance flaws in Body Dysmorphic Disorder, stereotypies in Stereotypic Movement Disorder, or nonsuicidal self-injury).

• Epidemiology & Demographics: Adult lifetime prevalence in the general population is ~1.4%. Females represent 75% or more of cases. Onset most commonly occurs during adolescence, frequently coinciding with or following the onset of puberty or a dermatological condition (e.g., acne).

• Clinical Features: Picking sites vary over time (face, arms, and hands are most common). Individuals spend significant time (often $\ge 1$ hour/day) picking, thinking about picking, or resisting urges. Associated with both focused picking (preceded by tension and followed by relief) and automatic picking (occurring without full awareness).

3. Disruptive Mood Dysregulation Disorder (DMDD) (296.99 / F34.8)

• Chapter Placement: Depressive Disorders.

• Diagnostic Criteria:

  • Criterion A: Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) grossly out of proportion in intensity or duration to the situation.

  • Criterion B: Outbursts are inconsistent with developmental level.

  • Criterion C: Outbursts occur, on average, three or more times per week.

  • Criterion D: Mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and observable by others.

  • Criterion E: Criteria A–D present for 12 or more months (without a period lasting $\ge 3$ consecutive months free of all symptoms).

  • Criterion F: Present in at least two of three settings (home, school, with peers) and severe in at least one.

  • Criterion G–I (Age Thresholds): Diagnosis should not be assigned for the first time before age 6 or after age 18. Age at onset of Criteria A–E must be before age 10.

  • Criterion J (Exclusionary Hierarchy): There has never been a distinct period lasting more than 1 day meeting full criteria for a manic or hypomanic episode. Cannot coexist with Oppositional Defiant Disorder (ODD), Intermittent Explosive Disorder (IED), or Bipolar Disorder (if criteria for both DMDD and ODD are met, assign only DMDD).

• Epidemiology & Rationale: 6-month to 1-year prevalence is 2%–5% in children and adolescents. Male predominant in clinical and community samples. Added to DSM-5 to curb the dramatic rise in pediatric bipolar disorder diagnoses; follow-up studies show children with DMDD predominantly develop unipolar depressive or anxiety disorders in adulthood, not bipolar disorder.

4. Hoarding Disorder (300.3 / F42.3)

• Chapter Placement: Obsessive-Compulsive and Related Disorders.

• Diagnostic Criteria:

  • Criterion A: Persistent difficulty discarding or parting with possessions, regardless of their actual value.

  • Criterion B: Difficulty is due to a perceived need to save items and distress associated with discarding them.

  • Criterion C: Results in accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use (if uncluttered, only due to third-party intervention).

  • Criterion D: Causes clinically significant distress or impairment (including maintaining a safe environment).

  • Criterion E & F: Not attributable to another medical condition (e.g., brain injury) or mental disorder (e.g., OCD obsessions, MDE fatigue, schizophrenia delusions, neurocognitive deficits).

• Specifiers:

  • With excessive acquisition: Present in 80%–90% of cases (excessive buying or collecting free items).

  • Insight Specifiers: With good or fair insight, With poor insight, With absent insight/delusional beliefs.

• Epidemiology & Development: Point prevalence is 2%–6% in US/European community samples. Affects males and females, though clinical samples are female-predominant. Prevalence is nearly 3-fold higher in older adults (ages 55–94) compared to younger adults. Symptoms emerge early (ages 11–15), start interfering by the mid-20s, and produce severe impairment by the mid-30s with a chronic, progressive course.

5. Gambling Disorder (312.31 / F63.0)

• Chapter Placement: Substance-Related and Addictive Disorders (Non-Substance-Related Disorders). Reclassified from DSM-IV Impulse-Control Disorders based on shared neurobiological reward circuitry, behavioral features, and genetic links with substance use disorders.

• Diagnostic Criteria:

  • Criterion A: Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, endorsing 4 (or more) of the following in a 12-month period:

    1. Tolerance: Needs to gamble with increasing amounts of money to achieve desired excitement.

    2. Withdrawal: Restless or irritable when attempting to cut down or stop.

    3. Loss of Control: Repeated unsuccessful efforts to control, cut back, or stop.

    4. Preoccupation: Persistent thoughts of gambling experiences, planning next venture, or getting money.

    5. Mood Escape: Gambles when feeling distressed (helpless, guilty, anxious, depressed).

    6. Chasing Losses: After losing money, often returns another day to get even.

    7. Deceit: Lies to conceal extent of involvement with gambling.

    8. Jeopardized Opportunities: Has jeopardized or lost a significant relationship, job, or career opportunity.

    9. Bailout: Relies on others to provide money to relieve desperate financial situations caused by gambling.

  • Criterion B: Gambling behavior is not better explained by a manic episode.

• Specifiers & Severity:

  • Course: Episodic vs. Persistent; In early remission (3–12 months) vs. In sustained remission ($\ge 12$ months).

  • Severity: Mild (4–5 criteria), Moderate (6–7 criteria), Severe (8–9 criteria).

• Epidemiology & Suicide Risk: Past-year prevalence is 0.2%–0.3%. Male-to-female ratio is higher in young adults, though progression is faster in females ("telescoping"). High suicide risk: up to 50% report suicidal ideation and ~17% report suicide attempts.

6. Internet Gaming Disorder (Section III / Conditions for Further Study)

• Status: Proposed diagnostic category in DSM-5 Section III requiring further empirical research before formal integration into Section II.

• Proposed Criteria: Persistent and recurrent use of the Internet to engage in games (typically group games, non-gambling), leading to clinically significant impairment or distress, endorsing 5 (or more) of the following in a 12-month period:

  1. Preoccupation with Internet games.

  2. Withdrawal symptoms when gaming is taken away (irritability, anxiety, sadness; no physical signs).

  3. Tolerance (need to spend increasing amounts of time).

  4. Unsuccessful attempts to control participation.

  5. Loss of interests in previous hobbies/entertainment.

  6. Continued excessive use despite knowledge of psychosocial problems.

  7. Deception of family members, therapists, or others regarding amount of gaming.

  8. Use to escape or relieve a negative mood.

  9. Jeopardized or lost a significant relationship, job, or educational/career opportunity.

• Exclusions: Excludes non-gaming Internet use (social media, business/work use, online pornography) and online gambling (coded under Gambling Disorder).

• Epidemiology: Highest point prevalence reported in Asian countries (particularly China and South Korea) among male adolescents aged 12–20 (up to 8.4% in male adolescents).

Section 2: ICD-10 Information

1. Structural Overview & Classification Limitations

• Absence of Dedicated OCRD Chapter: ICD-10 lacks a consolidated Obsessive-Compulsive and Related Disorders block. Conditions are scattered across Habit and impulse disorders (F63), Obsessive-compulsive disorder (F42), and Diseases of the skin (L-codes).

• Absence of Behavioral Addiction Category: ICD-10 does not recognize a unified behavioral addiction framework in Chapter V. Non-substance repetitive behaviors are categorized under F63 Habit and impulse disorders.

• Lack of Standalone Emerging Entities: ICD-10 contains no primary operational equivalents for DMDD, Hoarding Disorder, Excoriation Disorder, or Internet Gaming Disorder as distinct psychiatric diagnoses.

2. Specific ICD-10 Operational Categories & Equivalents

Excoriation Pathology in ICD-10

• Primary Coding Options:

  • L98.1 Factitial dermatitis [Neurotic excoriation]: Classified under Chapter XII (Diseases of the skin and subcutaneous tissue).

  • F63.8 Other habit and impulse disorders: Assigned if classified as a psychiatric impulse control issue.

  • F42.8 Other obsessive-compulsive disorders: Used if conceptualized as an OC-spectrum manifestation.

• Limitations: Lacks explicit psychiatric diagnostic criteria, severity specifiers, or standardized duration thresholds.

Severe Temper Outbursts & Irritability in ICD-10

• Primary Coding Options:

  • F91.3 Oppositional Defiant Disorder: Includes "unusually frequent and severe temper tantrums" as a descriptive symptom criterion.

  • F91.8 / F91.9 Conduct Disorders: Broad behavioral disruption codes.

  • F92.8 Other mixed disorders of conduct and emotions: Used when severe behavioral outbursts co-occur with marked anxiety or depression.

• Limitations: ICD-10 provides no standalone code for chronic, non-episodic severe irritability (DMDD was introduced later in ICD-11).

Hoarding Pathology in ICD-10

• Primary Coding Options:

  • F60.5 Anankastic Personality Disorder: Criterion 5 includes "inability to discard worn-out or worthless objects."

  • F42.8 Other obsessive-compulsive disorders: Used when hoarding is secondary to severe obsessions/compulsions.

• Limitations: No independent code or criteria set for primary Hoarding Disorder.

F63.0 Pathological Gambling

• Classification: Block F60–F69 (Disorders of adult personality and behaviour), sub-block F63 (Habit and impulse disorders).

• Clinical Description: Consists of frequent, repeated episodes of gambling that dominate the patient's life to the detriment of social, occupational, material, and family values and commitments ("compulsive gambling").

• Exclusions: Excludes excessive gambling by manic patients (F30.-), gambling in dissocial personality disorder (F60.2), and social gambling/betting NOS (Z72.6).

Internet Gaming & Electronic Media in ICD-10

• Primary Coding Options:

  • Z72.8 Other problems related to lifestyle: Non-psychiatric administrative coding.

  • F63.8 Other habit and impulse disorders: Unspecified behavioral excess.

• Limitations: Completely unrecognized as a specific clinical entity in ICD-10 (Gaming Disorder was formally added in ICD-11 under 6C51).

Section 3: Side-by-Side Comparison Table

Section 4: Narrative Comparison & High-Yield Summary

Narrative Analysis

1. Evolution of Obsessive-Compulsive Spectrum Entities: DSM-5 achieved a major structural advancement by establishing a dedicated Obsessive-Compulsive and Related Disorders chapter, formally validating Hoarding Disorder and Excoriation Disorder as distinct primary conditions. This reclassification reflects neuroimaging, genetic, and clinical data showing that hoarding and skin-picking possess unique clinical courses and treatment responses distinct from classic OCD. ICD-10 lacks an OCRD chapter, relegating excoriation to dermatological listings (L98.1) or generic habit codes (F63.8), and subsuming hoarding under F60.5 Anankastic Personality Disorder.

2. Pediatric Mood Dysregulation vs. Conduct Pathology: The addition of DMDD in DSM-5 created an explicit, age-delimited category for severe, non-episodic irritability and frequent temper outbursts ($\ge 3$/week for $\ge 12$ months), placing it within Depressive Disorders because affected youths predominantly transition into unipolar depression in adulthood. ICD-10 lacks a DMDD equivalent, forcing clinicians to classify severe temper outbursts under F91.3 Oppositional Defiant Disorder or F92 Mixed Disorders of Conduct and Emotions, which frames the disturbance primarily as a disruptive conduct problem rather than a primary mood dysregulation disorder.

3. Conceptualization of Behavioral Addictions: DSM-5 made a major paradigm shift by reclassifying Gambling Disorder out of impulse-control disorders and into Substance-Related and Addictive Disorders, recognizing that pathological gambling activates brain reward systems similarly to drugs of abuse. Furthermore, DSM-5 created an empirical blueprint for Internet Gaming Disorder in Section III. ICD-10 maintains the traditional impulse-control framework, coding F63.0 Pathological Gambling alongside kleptomania and pyromania under Habit and impulse disorders, while omitting gaming disorder entirely.

High-Yield Discrepancy Summary for Exam Retention

• Excoriation (Skin-Picking) Status:

  • DSM-5: Standalone diagnosis in OCRD (698.4 / L98.1); requires skin lesions and failed attempts to stop.

  • ICD-10: Dermatological code L98.1 (Neurotic excoriation) or psychiatric code F63.8.

• DMDD Placement & Age Rules:

  • DSM-5: Primary code in Depressive Disorders (296.99 / F34.8); onset before age 10, diagnosis between ages 6–18; $\ge 3$ outbursts/week for $\ge 12$ months.

  • ICD-10: No DMDD code; temper tantrums coded under F91.3 (ODD) or F92.

• Hoarding Disorder Standalone Diagnosis:

  • DSM-5: Primary code in OCRD (300.3 / F42.3); includes With excessive acquisition specifier.

  • ICD-10: No standalone code; criterion under F60.5 Anankastic PD or F42.8.

• Gambling Reclassification:

  • DSM-5: Classified under Substance-Related and Addictive Disorders; 4/9 threshold; 3 severity tiers.

  • ICD-10: Classified under F63.0 Pathological Gambling in Habit and impulse disorders.

• Internet Gaming Disorder:

  • DSM-5: Listed in Section III (Conditions for Further Study) with 9 proposed criteria (cutoff $\ge 5$).

  • ICD-10: Unrecognized in Chapter V (requires ICD-11 for formal Gaming Disorder code 6C51).