Week 3 Discussion

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Fears and Phobias

A significant change to the DSM-5 is the separation of diagnoses formerly grouped together in the DSM-IV. Anxiety disorders no longer include obsessive-compulsive disorders, which are now their own classification (obsessive-compulsive and related disorders). Also separated from anxiety disorders are posttraumatic stress disorder and acute stress disorder, which are now included in the classification of trauma- and stressor-related disorders.

Anxiety Disorders

There are few changes to the diagnoses in this classification that directly impact individuals under the age of 18. In fact, the primary change has been the re-grouping of disorders to more accurately reflect associations in diagnostic criteria. This revised classification includes separation anxiety disorder, selective mutism (formerly included in disorders usually first diagnosed in infancy, childhood, or adolescence in the DSM-IV), specific phobia, social anxiety disorder (formerly social phobia), panic disorder, agoraphobia, generalized anxiety disorder, anxiety due to another medical condition, other specified anxiety disorder, and unspecified anxiety disorder. The diagnosis anxiety disorder not otherwise specified has been removed, and two new diagnoses added: other specified anxiety disorder and unspecified anxiety disorder. Both of these diagnoses represent significant clinical distress or impairment based on anxiety disorder diagnostic criteria, but do not meet full criteria for a specific diagnosis. Clinicians should use other specified anxiety disorder and add the specific reason for the more general diagnosis (e.g., short duration of symptoms or cultural association). The latter diagnosis—unspecified anxiety disorder—is used when clinicians cannot (or choose not to) identify reasons for an inability to make a more specific diagnosis, yet clearly observe multiple criteria from the anxiety disorders classification. Below is a summary of additional changes to the diagnoses in this classification that may impact individuals under the age of 18. Social Anxiety Disorder (Social Phobia) The preferred diagnostic descriptor is now social anxiety disorder, reflecting a more specific association with symptomology. Wording of criteria has been altered to be more clear and applicable across social situations and age ranges. For children, anxiety must occur in peer settings (i.e., not exclusively with adults); the requirement that the child must exhibit a capacity for age-appropriate social interaction with familiar people has been removed. Also, consistency across ages has been supported by the requirement of duration to be at least six months (for all ages) and by the deletion of the need for individuals over 18 to recognize the fear is unreasonable. Separation Anxiety Disorder This disorder—formerly included in disorders usually first diagnosed in infancy, childhood, or adolescence—has been moved to the anxiety disorders classification and criteria descriptions changed somewhat to reflect the core anxiety associated with the disorder. The requirement for

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onset has been removed (formerly under 18 years), being replaced by terminology reflecting “developmentally inappropriate” language. This change supports the recognition of the disorder’s existence in both children and adults, although duration prior to diagnosis does vary— at least 4 weeks in children and at least 6 months in adults. Selective Mutism This disorder—formerly included in disorders usually first diagnosed in infancy, childhood, or adolescence—has been moved to the anxiety disorders to highlight the anxiety often associated with the disorder. The core criteria remain unchanged.

Obsessive-Compulsive and Related Disorders This classification—new to the DSM-5—recognizes the similarities in presentation and diagnostic criteria of disorders characterized by obsessions and/or compulsions. The former refers to thoughts that are persistent and intrusive, while the latter denotes behaviors an individual feels compelled to perform. This classification includes obsessive-compulsive disorder, body dysmorphic disorder (formerly included in somatoform disorders in the DSM-IV), hoarding disorder, trichotillomania (hair-pulling disorder; formerly included in impulse control disorders not elsewhere classified), excoriation (skin-picking) disorder, substance/medication- induced obsessive-compulsive and related disorder, obsessive-compulsive and related disorder due to another medical condition, other specified obsessive-compulsive and related disorder, and unspecified obsessive-compulsive and related disorder. Several new specifiers have been added to diagnoses in this group, including those pertaining to degree of insight regarding diagnosis-related behaviors. This change underscores the potential for beliefs and perceptions related to the disorder to be void of insight and/or delusional, while differentiating between these characteristics and a potential diagnosis in the schizophrenia spectrum and other psychotic disorders. As noted with the anxiety disorders, two new diagnoses have been added that reflect non- specific, yet classification-bound characteristics: other specified obsessive-compulsive and related disorder and unspecified obsessive-compulsive and related disorder. Both of these diagnoses represent significant clinical distress or impairment based on obsessive-compulsive and related disorder criteria, but do not meet full criteria for a specific diagnosis within this classification. Clinicians should use other specified obsessive-compulsive and related disorder with the specific reason for the more general diagnosis (e.g., body-dysmorphic-like disorder with actual flaws or culturally associated behaviors). The latter diagnosis—unspecified obsessive- compulsive and related disorder—is used when clinicians cannot (or choose not to) identify reasons for inability to make a more specific diagnosis, yet clearly observe multiple criteria from the obsessive-compulsive and related disorder criteria classification. Below is a summary of significant changes to existing diagnoses and brief descriptions of new diagnoses. Body Dysmorphic Disorder

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This diagnosis has been moved to this new classification and several criteria altered, including specifications for repetitive behavior and preoccupied thoughts. In addition, a specifier of “with muscle dysmorphia” has been added, which denotes a persistent belief that the individual’s body is insufficiently developed in size and/or musculature. The inclusion of the “absent insight/delusional beliefs” specifier when applicable eliminates the potential for a second diagnosis of delusional disorder, somatic type that was possible under DSM-IV diagnostic criteria. Hoarding Disorder New to the DSM-5, this diagnosis is marked by significant difficulty discarding or otherwise parting with possessions. The stress associated with discarding items causes an accrual of items that eventually impedes normal functioning in a living area. Hoarding characteristics may first appear in early to mid adolescence, and have neurobiological correlates. Individuals with this diagnosis often have a comorbid mood or anxiety disorder as well. It is of note that hoarding can be a symptom of obsessive-compulsive disorder; however, research shows that hoarding can also exist in the absence of obsessive-compulsive disorder and has, therefore, been identified as a separate diagnosis. Trichotillomania (Hair-Pulling Disorder) The diagnostic criteria for this disorder have changed slightly in the DSM-5, reflecting specific language more closely associated with obsessive-compulsive disorders (moving away from its previous association with impulse control). Also, hair-pulling disorder has been added parenthetically for clarity. Excoriation (Skin-Picking) Disorder This disorder is new to the DSM-5 and is characterized primarily by recurring skin picking resulting in lesions and/or scarring. Attempts to decrease or stop picking and significant distress attributable to the skin picking are also diagnostic criteria. The most common onset for the disorder is during adolescence, and often begins with a dermatological condition. It is also commonly comorbid with obsessive-compulsive disorder, trichotillomania, and depressive disorder. Substance/Medication-Induced Obsessive-Compulsive and Related Disorder This new diagnosis is defined by a combination of repetitive behaviors characteristic of obsessive-compulsive disorders—including obsessions, compulsions, skin picking, or hair pulling—that began during or immediately following substance intoxication or exposure to medication. Obsessive-Compulsive and Related Disorder Due to Another Medical Condition This new diagnosis is defined by a combination of repetitive behaviors characteristic of obsessive-compulsive disorders—including obsessions, compulsions, skin picking, or hair pulling—that are a direct result of another medical condition. Other specified obsessive-compulsive and related disorder, and unspecified obsessive- compulsive and related disorder.

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Reference: • American Psychiatric Association. (2013). Highlights of changes from DSM-IV-TR to

DSM-5. Retrieved from: http://www.dsm5.org/Documents/changes%20from%20dsm-iv- tr%20to%20dsm-5.pdf

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