Obsessive-compulsive disorder: a review of the diagnostic criteria and possible subtypes and dimensional specifiers for DSM-V

Abstract

Background Since the publication of the DSM-IV in 1994, research on obsessive–compulsive disorder (OCD) has continued to expand. It is timely to reconsider the nosology of this disorder, assessing whether changes to diagnostic criteria as well as subtypes and specifiers may improve diagnostic validity and clinical utility. Methods The existing criteria were evaluated. Key issues were identified. Electronic databases of PubMed, ScienceDirect, and PsycINFO were searched for relevant studies. Results This review presents a number of options and preliminary recommendations to be considered for DSM-V. These include: (1) clarifying and simplifying the definition of obsessions and compulsions(criterion A); (2) possibly deleting the requirement that people recognize that their obsessions or compulsions are excessive or unreasonable (criterion B); (3) rethinking the clinical significance criterion (criterion C) and, in the interim, possibly adjusting what is considered “time-consuming” for OCD; (4) listing additional disorders to help with the differential diagnosis (criterion D); (5) rethinking the medical exclusion criterion (criterion E) and clarifying what is meant by a “general medical condition”; (6) revising the specifiers (i.e., clarifying that OCD can involve a range of insight, in addition to “poor insight,” and adding “tic-related OCD”); and (7) highlighting in the DSM-V text important clinical features of OCD that are not currently mentioned in the criteria (e.g., the major symptom dimensions). Conclusions A number of changes to the existing diagnostic criteria for OCD are proposed. These proposed criteria may change as the DSM-V process progresses.

On the Nature of Obsessions and Compulsions

“…This is reasonable, given the driving force of tension and anxiety that most patients experience. However, not all patients report anxious feelings [7][8]. Some argue that OCD is more akin to disorders of impulse control such as addictions -which puts the volitional component at center stage [9].…”

“…In the case of absent insight, the question is whether such delusional beliefs should not be categorized as a psychotic disorder rather than OCD, as the current definition implies. In 2010, the DSM-V workgroup 'Anxiety, Obsessive-Compulsive Spectrum, Post-traumatic, and Dissociative Disorders' [8] recommended the elimination of 'OCD's delusional variant' (p.513) from the psychosis section, but this question is not yet resolved [11].…”

Values-Focused Exposure and Response Prevention in the Treatment of Comorbid Schizophrenia and Obsessive-Compulsive Disorder: The Case of "Mr. H"

“…Confusing the diagnostic question further is the DSM-IV specifier for OCD, "with poor insight," as it does not address whether a patient with OCD who lacks insight regarding the nature of his/her obsessive beliefs or fears should be diagnosed with a psychotic disorder rather than OCD (Leckman et al, 2010). The DSM-IV field trial of OCD (Foa et al, 1995) revealed that 4% of patients with OCD had no insight and 26% had little insight into the excessiveness or irrationality of their obsessions and/or compulsions.…”

Cognitive-Behavioral Therapy of Obsessive-Compulsive Disorder

“…Factor analytic studies have consistently identified five subgroups of symptoms: (a) contamination obsessions and washing/cleaning compulsions; (b) obsessions about responsibility for causing harm or making mistakes and checking compulsions; (c) obsessions about order and symmetry and ordering/arranging compulsions; (d) repugnant obsessional thoughts concerning sex, religion and violence along with mental compulsive rituals and other covert neutralizing strategies, and (e) hoarding (Abramowitz et al, 2010;Leckman et al,1997;Mataix-Cols et al, 2005). Some suggest that hoarding should be considered a distinct disorder from OCD, with its own diagnostic criteria in the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) (Pertusa et al, 2010;Leckman et al, 2010).…”