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Should OCD be removed from Anxiety Disorders in DSM-5?

Diagnostic and Statistical Manual of Mental Disorders (DSM)

When working with patients, health professionals often refer to clinical diagnostic manuals to better understand the patient's illness and potential treatment. There are two main recognised diagnostic manuals commonly used around the world today. The International Classification of Diseases (ICD), is the international standard diagnostic classification for all recognised diseases and related health problems and is mainly used in the UK and much of Europe. These classifications are developed and monitored by the World Health Organization (WHO).

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is published by the American Psychiatric Association and provides clinicians with official definitions of, and criteria for, diagnosing mental disorders.

The current edition of the DSM (DSM-IV) categorises Obsessive-Compulsive-Disorder (OCD) under 'Anxiety Disorders'. However, some experts have controversially suggested that the upcoming revised edition of the DSM removes OCD from this category and grouping it with putatively related conditions under the heading of 'related OCD conditions'. The proposed OCD-related conditions would include Obsessive–Compulsive Personality Disorder (OCPD), Tic disorders, Hypochondriasis, Body Dysmorphic Disorder (BDD), Trichotillomania and other grooming disorders, Eating disorders, Pathological Gambling (PG) and other Impulse-control disorders, including alcohol and substance dependence and Kleptomania.

At present the European International Classification of Diseases (ICD) currently lists OCD in its own subcategory under the category of Neurotic, Stress-related and Somatoform Disorders, although within the same larger category as other anxiety disorders. The ICD is next planned for updating in 2015, and at this time there is no suggestion that it would follow suit with any changes made by the DSM.

The problem with the changed categorisation in the DSM is that it may well influence perceptions of OCD and ultimately potentially the way in which they are assessed and treated. For this reason, the question of where OCD should be located in the diagnostic system has been met with some controversy and received attention and generated debate.

An international survey of authors of OCD publications posed the question of whether OCD should be moved out of the anxiety disorders section of DSM and approximately 60% of the 187 respondents supported moving OCD out of the anxiety disorders section, but somewhat interestingly there was a significant difference in opinion between psychiatrists where 75% supported a move and other health professionals where only 40–45% supported a move. This difference of opinion between the various roles would make some sense because OCD-UK are often told by patients that their psychiatrist often does not seem to understand (unless an OCD specialist), and that they feel more comfortable talking to their CBT therapist (CPN or psychologist for example) who seem to understand their OCD better.

The most frequent reason for supporting a move out of the anxiety disorders section was that obsessions and compulsions, rather than anxiety, are the fundamental features of the disorder. The main reasons for disagreeing with such a move were that OCD and other anxiety disorders respond to similar treatments and tend to co-occur

To provide further evidence of this, O. J. Bienvenu of the Department of Psychiatry and Behavioral Sciences at John Hopkins University School of Medicine in Maryland conducted a study that examined the comorbidity and genetic relationship between many of these conditions, OCD, and anxiety.

For the study, Bienvenu gathered data from two existing OCD research projects, the John Hopkins OCD Family Study (JHOFS) and case family data from the OCD Collaborate Genetics Study (OCGS).

The two studies provided family history and comorbidity on more than 450 individuals over a period of 10 years, the JHOFS, directly interviewed 73 community control case studies and 233 of their first-degree relatives who were blind to the OCD and the OCGS study looked at 382 OCD sufferers and 974 of their first-degree relatives. After reviewing the data, to their knowledge the largest OCD family study to date, Bienvenu and colleagues discovered that anxiety disorders, related personality disorders, several putative OCD-related conditions (GAD, Agoraphobia, OCPD and BDD) and depressive disorders were more common in persons with OCD or had an immediate family member with OCD. However, eating disorders, impulse control issues, and alcohol or drug dependence were not common in this group of participants.

Bienvenu believes the evidence from this study underscores the concerns raised by mental health professionals with regard to the upcoming DSM-5. Bienvenu added, “Since anxiety disorders are highly comorbid with OCD, and they appear to share familial influences with OCD, we feel it would be erroneous to remove OCD from the anxiety disorders section in DSM-5.”

They went on to state that since several additional conditions are highly co-morbid with and appear to share familial influences with OCD, that it would be sensible to consider these as OCD-related conditions, specifically OCPD, tic disorders, BDD, trichotillomania and possibly skin picking.

Putting these findings together, they feel that their results lend credence to the recent proposal to include an ‘anxiety and Obsessive–Compulsive Spectrum Disorders’ chapter in DSM-5. Their research does not support the inclusion of some proposed OCD spectrum conditions in this chapter, specifically anorexia nervosa or bulimia nervosa, the impulse-control disorders such as gambling, pyromania or kleptomania, or alcohol and substance dependence which the research suggested does not appear particularly common in persons with OCD or their family members.

To further add weight to these findings, researchers of the paper 'Should OCD be Classified as an Anxiety Disorder in DSM-V?' reported that "Our preliminary recommendation is that OCD be retained in the category of anxiety disorders but that this category also includes OC-spectrum disorders along with OCD."

OCD-UK Chief Executive, Ashley Fulwood commented "I am surprised that any specialist in OCD would consider moving OCD from outside an anxiety category and within the same category as impulse-control disorders such as alcohol and substance dependence and Kleptomania. Surely anxiety is the key component that drives the OCD cycle of the obsessions and compulsions for people with OCD? The increased anxiety from the preceding Obsessional thought creates the main problem for a person, that leads to the compulsive behaviours, so categorising OCD within an anxiety category surely makes sense?"

Sources: Psychological Medicine. January 2012 - Volume 42, Issue 01. Is obsessive-compulsive disorder an anxiety disorder, and what, if any, are spectrum conditions? A family study perspective. and DSM-5 Development: Should OCD be Classified as an Anxiety Disorder in DSM-V?

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