Obsessive Compulsive and Related Disorders in the DSM 5 TR | Symptoms and Diagnosis

Dr. Donnelly Snipes introduces a presentation on obsessive-compulsive and related disorders as outlined in the DSM-5 TR. The session aims to review the disorders in this category, focusing on the diagnostic criteria for OCD and hoarding disorders. It will also cover associated features and differential diagnoses. The disorders discussed include OCD, body dysmorphic disorder, hoarding disorder, trichotillomania, excoriation disorder, and substance-induced obsessive-compulsive disorder. The presentation notes the addition of specific disorders like nail-biting, lip biting, cheek chewing, obsessional jealousy, and olfactory reference disorder. The prevalence of OCD is highlighted, showing an increase in symptoms post-pandemic across the general population, not limited to healthcare workers or those with comorbid mental health issues.

This paragraph delves into the diagnostic criteria for obsessive-compulsive disorder. It clarifies that a person must exhibit obsessions, compulsions, or both for a diagnosis. Obsessions are defined as recurrent, persistent thoughts or images causing anxiety or distress, while compulsions are repetitive behaviors or mental acts in response to obsessions or to adhere to rigid rules. The paragraph explains that compulsions aim to reduce distress or prevent a dreaded event but are not realistically connected to what they intend to prevent. It also addresses the complexity of diagnosing OCD in young children and the importance of differentiating it from autism spectrum disorders. The criteria specify that obsessions or compulsions must cause significant distress or impairment, and should not be attributed to substances, medical conditions, or other mental disorders.

The discussion shifts to hoarding disorder, emphasizing its impact on approximately 2.6% of the general population. Hoarding disorder is characterized by persistent difficulty parting with possessions, regardless of their value, due to a perceived need to save them or fear of distress upon discarding. This often results in cluttered and compromised living areas. The disorder is distinguished by the degree of clutter that spills over into living spaces, and it is noted that uncluttered living areas may be due to third-party interventions. The paragraph also touches on the concept of excessive acquisition, which is prevalent in 80 to 90% of hoarding cases. It is important to understand the meaning and function of hoarding behaviors, as they may be linked to a person's sense of control and safety, particularly in the context of trauma.

This section focuses on a specific type of hoarding—animal hoarding—which involves the accumulation of a large number of animals without providing adequate nutrition, sanitation, or veterinary care. It highlights the tendency of animal hoarders to collect 'rejects,' such as homeless, injured, or abandoned animals. The behavior is examined for its parallels with the hoarder's own life experiences, suggesting that animal hoarding may serve as a form of self-expression or coping mechanism related to the individual's childhood or personal history. The paragraph underscores the importance of understanding the meaning behind such behaviors and their significance to the individual.

The paragraph explores the development and course of obsessive-compulsive and related disorders, noting the mean age of onset for OCD as 19.5 years and for hoarding as 15 to 19. It discusses the potential contributing factors during early to mid-adolescence, such as individuation, stress, identity development, hormonal changes, and socio-emotional changes. The gradual onset of OCD symptoms is described, along with the possibility of acute onset during stressful events like the pandemic. The discussion also includes the role of superstitious reinforcement in the development of OCD symptoms and the importance of addressing these connections in treatment.

This section discusses trichotillomania and excoriation, which involve recurrent hair pulling resulting in hair loss and skin picking resulting in lesions or sores. The importance of differentiating these behaviors from other conditions like body dysmorphic disorder is emphasized. The paragraph also highlights the need to recognize the distress and impairment caused by these behaviors and to rule out other medical or mental health conditions as the cause. It mentions the prevalence of these disorders and the challenges they pose in differentiating them from similar conditions.

The paragraph delves into the complexities of differential diagnosis for obsessive-compulsive and related disorders. It contrasts hoarding disorder with OCD, emphasizing the significance of clutter and distress associated with the inability to collect or discard items. Trichotillomania and excoriation are differentiated based on the intentionality and unconsciousness of the behaviors. Body dysmorphic disorder is distinguished by its focus on a perceived flaw. Eating disorders, illness anxiety disorder, and other conditions like generalized anxiety, major depressive disorder, postpartum depression, substance use disorders, gambling, gaming disorder, schizophrenia spectrum disorders, autism spectrum disorder, PTSD, and the impact of certain medications are also considered in the differential diagnosis process.

This section addresses the critical issue of suicidality in individuals with obsessive-compulsive and related disorders. It presents statistics on suicidal ideation and attempts for OCD, trichotillomania, excoriation, body dysmorphic disorder, and hoarding disorder, highlighting the elevated risks associated with these conditions. The paragraph also discusses comorbidities, noting that a significant percentage of individuals with these disorders also have anxiety, depressive or bipolar disorders, impulse-control disorders, substance use, and tic disorders. The importance of early intervention and assessment for comorbid conditions is emphasized.

The final paragraph outlines the treatment approaches for obsessive-compulsive and related disorders. It mentions the use of SSRIs and SNRIs as first-line pharmacological interventions and cognitive-behavioral therapy for addressing non-neurochemical symptoms. Techniques such as backward chaining, exposure and response prevention, distress tolerance skills, unhooking, cognitive processing, cognitive restructuring, and journaling are discussed as part of the therapeutic process. The paragraph also highlights the importance of addressing common cognitive distortions, negative emotionality, intolerance of uncertainty, and sensory phenomena associated with these disorders. It concludes by emphasizing the need for early intervention and the potential role of EMDR in treating individuals with a history of trauma.