Should OCD leave the anxiety disorders in DSM‐V? The case for obsessive compulsive‐related disorders

Recently in 2006, a group of experts in obsessive compulsive disorder (OCD) and obsessive compulsive-related disorders (OCRDs) convened in Washington, DC, to review existing data on the relationships between these various disorders, and to suggest approaches to address the gaps in our knowledge, in preparation for the upcoming Diagnostic and Statistical Manual (Fifth Edition) (DSM-V). As a result of this meeting, the Research Planning Agenda for DSM-V: OCRD Work Group suggested removing OCD from the anxiety disorders, where it is currently found. This proposal is in accordance with the current International Classification of Mental Disorders (ICD-10) classification of OCD as a separate category from the anxiety disorders. Although the ICD-10 places both OCD and the anxiety disorders under the umbrella category of "neurotic, stress-related, and somatoform disorders," they are two separate categories, distinct from one another. As OCD and other putative OCRDs share aspects of phenomenology, comorbidity, neurotransmitter/peptide systems, neurocircuitry, familial and genetic factors, and treatment response, it was proposed to create a new category in DSM-V entitled OCRDs. Alternatively, the OCRDs might be conceptualized as a new category within the broader category of anxiety disorders. Future studies are needed to better define the relationships among these disorders, and to study boundary issues for this proposed category. There are both advantages and disadvantages in creating a new diagnostic category in DSM-V, and these are discussed in this article.     

Should an obsessive–compulsive spectrum grouping of disorders be included in DSM‐V?

The obsessive–compulsive (OC) spectrum has been discussed in the literature for two decades. Proponents of this concept propose that certain disorders characterized by repetitive thoughts and/or behaviors are related to obsessive–compulsive disorder (OCD), and suggest that such disorders be grouped together in the same category (i.e. grouping, or “chapter”) in DSM. This article addresses this topic and presents options and preliminary recommendations to be considered for DSM‐V. The article builds upon and extends prior reviews of this topic that were prepared for and discussed at a DSM‐V Research Planning Conference on Obsessive–Compulsive Spectrum Disorders held in 2006. Our preliminary recommendation is that an OC‐spectrum grouping of disorders be included in DSM‐V. Furthermore, we preliminarily recommend that consideration be given to including this group of disorders within a larger supraordinate category of “Anxiety and Obsessive–Compulsive Spectrum Disorders.” These preliminary recommendations must be evaluated in light of recommendations for, and constraints upon, the overall structure of DSM‐V. Depression and Anxiety, 2010. © 2010 Wiley‐Liss, Inc.     

Where does obsessive–compulsive disorder belong in DSM‐V?

A reclassification of obsessive-compulsive disorder (OCD) into a new diagnostic category spectrum of "obsessive-compulsive spectrum disorders" (OCSDs) has recently been proposed, with considerable debate, for the forthcoming Diagnostic and Statistical Manual-Fifth Edition (DSM-V). This paper provides a critical analysis of the available empirical data regarding this conceptual and nosological shift. Specifically, we review research on shared commonalities and differences between OCD and the putative OCSDs in relation to their clinical presentation, phenotype, neurobiology, and treatment response. We conclude that a reclassification of OCD into a separate OCSD spectrum is premature and not supported by the currently available data.     

Hoarding disorder: a new diagnosis for DSM‐V?

This article provides a focused review of the literature on compulsive hoarding and presents a number of options and preliminary recommendations to be considered for DSM‐V. In DSM‐IV‐TR, hoarding is listed as one of the diagnostic criteria for obsessive–compulsive personality disorder (OCPD). According to DSM‐IV‐TR, when hoarding is extreme, clinicians should consider a diagnosis of obsessive–compulsive disorder (OCD) and may diagnose both OCPD and OCD if the criteria for both are met. However, compulsive hoarding seems to frequently be independent from other neurological and psychiatric disorders, including OCD and OCPD. In this review, we first address whether hoarding should be considered a symptom of OCD and/or a criterion of OCPD. Second, we address whether compulsive hoarding should be classified as a separate disorder in DSM‐V, weighing the advantages and disadvantages of doing so. Finally, we discuss where compulsive hoarding should be classified in DSM‐V if included as a separate disorder. We conclude that there is sufficient evidence to recommend the creation of a new disorder, provisionally called hoarding disorder. Given the historical link between hoarding and OCD/OCPD, and the conservative approach adopted by DSM‐V, it may make sense to provisionally list it as an obsessive–compulsive spectrum disorder. An alternative to our recommendation would be to include it in an Appendix of Criteria Sets Provided for Further Study. The creation of a new diagnosis in DSM‐V would likely increase public awareness, improve identification of cases, and stimulate both research and the development of specific treatments for hoarding disorder. Depression and Anxiety, 2010.© 2010 Wiley‐Liss, Inc.     

Is obsessive-compulsive disorder an anxiety disorder?

Obsessive-compulsive disorder (OCD) is classified as an anxiety disorder in the DSM-IV-TR [American Psychiatric Association, 2000. Diagnostic and statistical manual of mental disorders, Fourth ed., rev. Washington, DC: Author]; however, the notion of a spectrum of obsessive-compulsive (OC) related disorders that is comprised of such disparate disorders as OCD, body dysmorphic disorder, certain eating disorders, pathological gambling, and autism, is gaining acceptance. The fact that these disorders share obsessive-compulsive features and evidence similarities in patient characteristics, course, comorbidity, neurobiology, and treatment response raises the question of whether OCD is best conceptualized as an anxiety or an OC spectrum disorder. This article reviews evidence from comorbidity and family studies, as well as biological evidence related to neurocircuitry, neurotransmitter function, and pharmacologic treatment response that bear on this question. The implications of removing OCD from the anxiety disorders category and moving it to an OC spectrum disorders category, as is being proposed for the DSM-V, is discussed.     

Should schizophrenia be treated as a neurocognitive disorder?

The search is on for meaningful psychopharmacological and cognitive/behavioral interventions for neurocognitive deficits in schizophrenia. Findings in this area are emerging rapidly, and in the absence of integrating frameworks, they are destined to emerge chaotically. Clear guidelines for testing neurocognitive interventions and interpreting results are critical at this early stage. In this article, we present three models of increasing complexity that attempt to elucidate the role of neurocognitive deficits in schizophrenia in relation to treatment and outcome. Through discussion of the models, we will consider methodological issues and interpretive challenges facing this line of investigation, including direct versus indirect neurocognitive effects of antipsychotic medications, selection of particular neurocognitive constructs for intervention, the importance of construct validity in interpreting cognitive/behavioral studies, and the expected durability of treatment effects. With a growing confidence that some neurocognitive deficits in schizophrenia can be modified, questions that seemed irrelevant only a few years ago are now fundamental. The field will need to reconsider what constitutes a successful intervention, what the relevant outcomes are, and how to define treatment efficacy.     

What is an anxiety disorder?

Initiated as part of the ongoing deliberation about the nosological structure of DSM, this review aims to evaluate whether the anxiety disorders share features of responding that define them and make them distinct from depressive disorders, and/or that differentiate fear disorders from anxious‐misery disorders. The review covers symptom self‐report as well as on‐line indices of behavioral, physiological, cognitive, and neural responding in the presence of aversive stimuli. The data indicate that the anxiety disorders share self‐reported symptoms of anxiety and fear; heightened anxiety and fear responding to cues that signal threat, cues that signal no threat, cues that formerly signaled threat, and contexts associated with threat; elevated stress reactivity to aversive stimuli; attentional biases to threat‐relevant stimuli and threat‐based appraisals of ambiguous stimuli; and elevated amygdala responses to threat‐relevant stimuli. Some differences exist among anxiety disorders, and between anxiety disorders and depressive disorders. However, the differences are not fully consistent with proposed subdivisions of fear disorders vs. anxious misery disorders, and comparative data in large part are lacking. Given the high rates of co‐morbidity, advances in our understanding of the features of responding that are shared across vs. unique to anxiety and depressive disorders will require dimensional approaches. In summary, the extant data help to define the features of responding that are shared across anxiety disorders, but are insufficient to justify revisions to the DSM nosology at this time. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Should bipolar disorder be viewed as manic disorder? Implications for bipolar depression

This paper proposes that the syndrome of mania rather than mood swings is the central distinguishing feature of bipolar disorder, which may be more appropriately viewed as manic disorder. The theoretical consequence of this change in perspective is to regard the depressive mood states as being a co-morbid condition. This may lead to a more profound and broader understanding of the variety of states of depression that complicate manic disorder. The paper also reviews diagnostic issues relating to bipolar depression. A broader approach may extend therapeutic choices, and open innovative research avenues.     

Is generalized anxiety disorder an anxiety or mood disorder? Considering multiple factors as we ponder the fate of GAD

Generalized anxiety disorder (GAD) and major depressive disorder (MDD) demonstrate a strong relationship to each other at both genotypic and phenotypic levels, and both demonstrate substantial loadings on a higher-order negative affectivity factor [see Watson, 2005: J Abnorm Psychol 114:522-536]. On the basis of these findings, there have been a number of calls to reclassify GAD in the same category as MDD (the "distress disorders"). However, any consideration of the reclassification of GAD should also take into account a number of other factors not only related to GAD and MDD but also to the overlap of these disorders with other anxiety and mood disorders. First, GAD has established reliability and validity in its own right, and specific features (e.g., worry) may become obscured by attempts at reclassification. Second, examination of the nature of the overlap of GAD and MDD with each other and with other disorders suggests a more complex pattern of differences between these conditions than has been suggested (e.g., MDD has strong relationships with other anxiety disorders, and GAD may be more strongly related to fear than it may first appear). Third, although findings suggest that GAD and MDD may have overlapping heritable characteristics, other evidence suggests that the two disorders may be distinguished by both environmental factors and temporal presentations. Finally, although overlap between GAD and MDD is reflected in their relationships to negative affectivity, temporal relationships between these disorders may be demonstrated by functional changes in emotional responsivity.     

Should prolonged grief be reclassified as a mental disorder in DSM-5?: reconsidering the empirical and conceptual arguments for complicated grief disorder

The proposed changes to DSM-5 will create new categories of mental disorder (referred to here generically as Prolonged Grief Disorder' [PGD]) to diagnose individuals experiencing prolonged intense grief reactions to the loss of a loved one. Individuals could be diagnosed even if they have no depressive or anxiety symptoms but only symptoms typical of grief (e.g., yearning, avoidance of reminders, disbelief, feelings of emptiness). The main challenge for such proposals is to establish that the proposed diagnostic criteria validly discriminate a genuine psychiatric disorder of grief from intense normal grief. With this test in mind, I evaluate the soundness of four empirical arguments and one conceptual argument that have been put forward to support such proposals: (1) PGD has discriminant validity because distinctive, pathognomonic symptoms distinguish it from normal grief; (2) PGD has discriminant validity because it identifies grief symptoms that are of greater absolute severity than in normal grief; (3) PGD has predictive validity because it implies a chronic, interminable process of grieving, thus a derailment of the normal process of grief resolution; (4) PGD has predictive validity because it predicts negative mental and physical health outcomes unlikely in normal grief; and (5) PGD has conceptual validity because grief is analogous to a wound or, alternatively, lengthy grief is analogous to a wound that does not heal. Upon close examination, each of these arguments turns out to have serious empirical or conceptual deficiencies. I conclude that the proposed diagnostic criteria for PGD fail to discriminate disorder from intense normal grief and are likely to yield massive false-positive diagnoses. Consequently, the proposal to add pathological grief categories to DSM-5 should be withdrawn pending further research to identify more valid criteria for diagnosing PGD.     

Comorbid anxiety in bipolar disorder: does it have an independent effect on suicidality?

Objective:  Comorbid anxiety disorder is reported to increase suicidality in bipolar disorder. However, studies of the impact of anxiety disorders on suicidal behavior in mood disorders have shown mixed results. The presence of personality disorders, often comorbid with anxiety and bipolar disorders, may explain these inconsistencies. This study examined the impact of comorbid Cluster B personality disorder and anxiety disorder on suicidality in bipolar disorder.
Methods:  A total of 116 depressed bipolar patients with and without lifetime anxiety disorder were compared. Multiple regression analysis tested the association of comorbid anxiety disorder with past suicide attempts and severity of suicidal ideation, adjusting for the effect of Cluster B personality disorder. The specific effect of panic disorder was also explored.
Results:  Bipolar patients with and without anxiety disorders did not differ in the rate of past suicide attempt. Suicidal ideation was less severe in those with anxiety disorders. In multiple regression analysis, anxiety disorder was not associated with past suicide attempts or with the severity of suicidal ideation, whereas Cluster B personality disorder was associated with both. The results were comparable when comorbid panic disorder was examined.
Conclusions:  Comorbid Cluster B personality disorder appears to exert a stronger influence on suicidality than comorbid anxiety disorder in persons with bipolar disorder. Assessment of suicide risk in patients with bipolar disorder should include evaluation and treatment of Cluster B psychopathology.     

Is SCL‐90R helpful for the clinician in assessing DSM‐IV symptom disorders?

OBJECTIVE: To investigate associations between six of the Symptom Check-List 90R (SCL-90R) subscales and specific DSM-IV symptom disorders in a sample of patients with high comorbidity of axis I and axis II disorders. METHOD: SCL-90R questionnaires from 1202 patients admitted for treatment in the Norwegian Network of Psychotherapeutic Day Hospitals. Mean score differences on subscales among diagnostic categories were investigated. With diagnoses as external criteria, cut-off scores for different diagnostic groups were used to calculate diagnostic efficacy. Multiple regressions were conducted in order to disentangle variance of the subscales accounted for by symptom disorders. Frequency distributions of subscales for patients with and without symptom disorders were compared. RESULTS: Poor diagnostic efficacy was found for most of the subscales, except for the phobic anxiety subscale. The strongest association with each subscale was with its associated symptom disorder, except for dysthymia. CONCLUSION: Diagnostic inferences about DSM-IV symptom disorders based on SCL-90R should be conducted with care.     

Should art be integrated into cognitive behavioral therapy for anxiety disorders?

Although cognitive behavioral therapy (CBT) is the preferred treatment method for anxiety disorders, it is underutilized and has been critiqued for being too verbal or abstract. Due to the role of imagery in maintaining anxiety disorders, art may be a useful addition to CBT for anxiety disorders. Art was incorporated into a brief CBT model in two quantitative case studies: Case 1 for panic disorder with agoraphobia (PDA) and Case 2 for generalized anxiety disorder (GAD). The A-B, single-subject experimental design included a two-week baseline period and a seven-week intervention period in both cases. The participant with PDA recorded her symptoms of PDA and her level of general anxiety throughout the baseline and intervention periods using a panic diary, whereas the participant with GAD recorded her level of general anxiety. In Case 1 for PDA, the intervention resulted in statistically significant reductions in panic frequency and some features of panic anxiety and agoraphobia. In Case 2 for GAD, the decrease in general anxiety was marginally significant.     

Generalized anxiety disorder (ICD‐10) in primary care from a cross‐cultural perspective: a valid diagnostic entity?

OBJECTIVE: Generalized anxiety disorder (GAD) is a common psychiatric disorder. The nosological status of this diagnostic entity was critically discussed because of the very high rate of comorbidity with other psychiatric disorders, the assumed low degree of social disability associated with GAD in the absence of other disorders, and an ambigious definition. METHOD: We explored the frequency and associated social disability of GAD, and examined whether the ICD-10 definition of GAD is appropriate. The analysis was based on the WHO study on 'Psychological Problems in Primary Care' conducted in a standardized manner in 14 countries. RESULTS: We found GAD (total and without another psychiatric disorder) to be common in primary care in nearly all countries (mean 1-month prevalence rate, 7.9%), with about 25% of these cases presenting with GAD in the absence of any comorbid psychiatric disorder. GAD in general, as well as non-comorbid GAD, are associated with social disability which is as severe as that in chronic somatic diseases. CONCLUSION: It remains questionable whether the current ICD-10 diagnosis of GAD defining 6 months as a minimum duration and requiring at least four associated symptoms for diagnosis is the most appropriate option. Using this definition, a substantial proportion of psychosocially disabled subjects characterized by anxiety, tension and worrying remain undetected, and are possibly therefore not adequately treated.     

Does anxiety increase impulsivity in patients with bipolar disorder or major depressive disorder?

The objective of this study was to examine whether anxiety increases impulsivity among patients with bipolar disorder (BPD) and major depressive disorder (MDD). Subjects comprised 205 BPD (mean age ± SD 36.6 ± 11.5 y; 29.3% males) and 105 with MDD (mean age ± SD 38 ± 13.1 y; 29.5% males) diagnosed using the DSM-IV-SCID. Impulsivity was assessed with the Barratt Impulsivity Scale and anxiety with the Hamilton Anxiety Rating Scale. Comorbid anxiety disorders were present in 58.9% of the BPD and 29.1% of MDD. BPD were significantly more impulsive than MDD (p < 0.001), and both BPD and MDD subjects showed significantly higher impulsivity when anxiety was present either as a comorbidity (p = 0.010) or as a symptom (p = 0.011). Impulsivity rose more rapidly with increasing anxiety symptoms in MDD than in BPD. The presence of anxiety, either as a comorbid disorder or as current anxiety symptoms, is associated with higher impulsivity in subjects with either BPD or MDD.