Have you ever wondered how mental disorders are created, organized, and diagnosed? Who decides the specific criteria for each disorder? How does a clinician know how to diagnose someone a particular disorder? In the United States, many of the answers to these questions stem back to a big book called the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM is a guidebook that clinicians and researchers use in order to most accurately diagnose and classify mental disorders. Since its conception in 1952, the DSM has undergone several iterations as professionals in the field continue to improve our understanding of mental disorders and their classification. The year 2013 happens to be a particularly exciting time in the rich history of the DSM as it marks the publication of the fifth edition of this important manual. After years of research, meetings, discussions, and revisions, the American Psychological Association (APA) has approved the final diagnostic criteria for the new DSM-5.
The APA has revised the DSM with the sincere hope that this changes will lead to better detection, diagnosis, and treatment of mental disorders. The DSM-5 will have a new chapter structure in which disorders that appear similar to one another with regard to symptoms and underlying causes will be grouped together in chapters, of which there are 20 in total. As the OCD and Related Disorders program, we are particularly interested in the novel additions and intriguing changes to disorders classified under the Obsessive Compulsive and Related disorders chapter. We’ll review and discuss some of these revisions below!
Obsessive Compulsive Disorder
What’s different about Obsessive Compulsive Disorder (OCD) in DSM-5? Somewhat controversially, obsessive compulsive disorder has been removed from the anxiety disorders and given its own chapter referred to as Obsessive Compulsive and Related Disorders. This chapter, beginning with OCD, includes several disorders thought to be related to OCD, including Hoarding Disorder, Body Dysmorphic Disorder, Hair Pulling and Excoriation Disorder (previously, Skin Picking). Most other changes to OCD in the DSM-5 relate to the semantics of the diagnostic criteria. More specifically, the term impulse has been replaced with the word urge in order to more accurately capture the nature of obsessions. The APA opted to change the word “inappropriate” to the word “unwanted” to describe obsessions in OCD, given that the meaning of “inappropriate” can vary widely depending on one’s culture, gender, age etc. Finally, a few criteria have been removed from the DSM-IV definition of OCD including that individuals must recognize their obsessions and/or compulsions as unreasonable or excessive.
Historically, hoarding has been characterized as an obsessional characterological trait. Its origins as such can be linked to the psychoanalytical construct of the “anal character”, which has transformed into Obsessive Compulsive Personality Disorder in more recent diagnostic terms. In DSM_IV, hoarding was classified as a symptom of OCD and not considered its own diagnosis.
Due to more research and public discourse on hoarding in recent years, hoarding has been removed as a symptom of OCD and Hoarding Disorder (HD) has been added as an independent disorder. The first criteria for HD in DSM-5 state that the person must experience, “persistent difficulty parting with possessions regardless of their actual value.” Notably, in contrast to previous editions, these criteria avoid making explicit judgments about the value of the hoarded possessions. Rather, they focus on the perceived need to save the items and associated distress. According to the DSM-5, this difficulty parting with possessions must result in “the accumulation of possessions that congest and clutter active living areas and substantially compromise their intended use.” This criterion is designed to capture a hallmark of hoarding and one often highlighted in popular media: clutter. Although the clutter shown in TV shows is often quite extreme with piles of clothes and papers reaching the ceiling and covering every inch of the floor, the DSM-5 criteria emphasize the functionality of the living space rather than how much physical space is used up by the possessions. Finally, the DSM-5 includes a specifier as to whether symptoms of hoarding are accompanied by excessive collecting or stealing of items. This specifier represents a departure from previous conceptions of hoarding which conceded that all individuals with hoarding acquire excessively. With these new criteria, individuals who suffer from hoarding, but do not acquire excessively, will still be able to receive the diagnosis of HD.
Body Dysmorphic Disorder
Because of its focus on the body, Body Dysmorphic Disorder has historically been classified as a somatoform disorder. However, in DSM-5, BDD will be moved to the Obsessive Compulsive and Related Disorders chapter to reflect its similarities in presentation and treatment to OCD.
In addition to adjusting BDD’s structural placement within the manual, the DSM-5 includes a few changes with regard to the BDD diagnostic criterion. The criteria for BDD include, “preoccupation with one or more perceived defects or flaws in appearance that are not observable or appear slight to others.” This represents a change from the DSM-IV criteria which describe the individual’s “defects or flaws in appearance” as imagined, instead of perceived. Although these “flaws” may seem imagined to friends and family members of the person suffering from BDD, these imperfections may seem incredibly real to the individual. Thus, the wording has been changed to more accurately capture the experience of individuals with BDD. The DSM-5 diagnostic criteria additionally feature a newly added criteria that at some point during the disorder, the person has performed repetitive behaviors (mirror checking, grooming, etc.) or mental acts (comparing appearance to others) in response to their appearance concerns. This criterion is consistent with the symptomotology of BDD and reflects BDD’s position in the Obsessive Compulsive and Related Disorders chapter. Notably, the DSM-V criteria also include a specifier for muscle dysmorphia (the belief that one’s body is too small or insufficiently muscular), a subtype of BDD. See our muscle dysmorphia blog post for more information.
Other disorders in the Obsessive Compulsive and Related Disorders chapter include Excoriation Disorder (Previously, Skin Picking and a new addition to the DSM-5) and Hair Pulling Disorder (named changed from Trichotillomania). The DSM-5 is scheduled to be released in the spring of 2013. Stay tuned to our website and twitter for more information on its release!