DSM diagnosis

The new fifth edition of the Diagnostic And Statistical Manual Of Mental Disorders, the “DSM-5,” has been just released. It replaces the old DSM-4 published in 1994. Thus, this documant represents the first official update in psychiatric diagnosis in almost 20 years. Since the DSM is the standard guide for diagnosing mental disorders in the United State, this release represents a major event for psychiatry, psychology and all mental-health related fields.

In the DSM-5, significant changes have been made in the manner by which a number of important disorders are diagnosed. The changes have sparked a great deal controversy. I personally disagree with some of the changes made regarding OCD, as do a number of other OCD specialists. But there are some good changes, too.

Here are the main changes with respect to how obsessive-compulsive disorder is diagnosed. First of all, the new DSM-5 differs from the old DSM-4 in placing OCD under a new heading entitled “Obsessive-Compulsive and Related Disorders.” Here, one finds in addition to obsessive-compulsive disorder the following diagnoses: body dysmorphic disorder, hoarding disorder, trichotillomania (hair pulling), excoriation disorder (skin picking), sybstance/medication induced obsessive-compulsive and related disorder, obsessive-compulsive and related disorder due to another medical disorder, and unspecified obsessive-compulsive disorder.

In the old DSM-4, OCD was included under the general heading “Anxiety Disorders.”Now, OCD is now longer an “anxiety disorder,” and rather has it’s own section. I believe this is a step backward. It seems almost self-evident: To virtually everyone who suffers from OCD, the disorder seems on a gut feeling-level to be characterized more than anything else by terrible anxiety.

In addition to that, however, research indicates strong ties between OCD and other common anxiety disorders such as panic disorder and agoraphobia. These ties include their response to similar treatments and shared occurence among family members.  

In the new “Obsessive-Compulsive and Related Disorders” category, we may also note that included are two impulse control disorders, hair pulling and skin picking.  I also have questions about this change. True, there are similarities between OCD and these disorders. The most prominent similarity is the prominence of troublesome repetitive acts. Yet, the motivation for the repetitive acts in OCD is completely different from that of hair pulling or skin picking. The latter are motivated by unquenchable desire. OCD, we know only too well, is motivated completely by fear. Fear and desire are completely different. It doesn’t seem to me to make sense to group OCD and impulse control disorders together.

There are also some changes in the way that OCD itself is diagnosed in the DSM-5. The new manual has removed two significan criteria that were present in the DSM-4. They are: “At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable,”  and “The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own  mind.” These “insight criteria,” while not present in 100% of cases of OCD, have been key to diagnosing OCD since the disorder was first recognized in the 19th century. I think this change tends to weaken the diagnosis and make it less specific.

On the positive side, research has demonstrated that the OCD-related problem “hoarding” has significant differences from other types of OCD, and it is now a separate diagnosis. This seems to be a good move.

Despite various objections, the the DSM-5 is still an excellent document. It is solidly research based, and attempts to be oriented only to provable fact. The DSM-5 diagnostic scheme is 100 times better than that used when I was in medical school, a crapshoot based on completely unproven Freudian assumptions. Psychiatry continues to move in the right direction.