As research grows regarding obsessive-compulsive disorder (OCD) and conditions like it, clinical guides like the Diagnostic and Statistical Manual of Mental Disorders (DSM) are revised and updated.
In 2013, the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) was released by the American Psychiatric Association (APA).
In addition to including a lifespan perspective for conditions, the new edition made sweeping changes in how disorders were categorized and defined.
In 2022, a moderate revision came out — the DSM-5-TR — which included cultural, racial, and ethnic inclusivity adjustments and the recognition of a new disorder: Prolonged grief disorder.
Obsessive-compulsive disorder (OCD) and related conditions saw some big changes from the DSM-IV-TR to the DSM-5-TR, namely the creation of their own diagnostic class.
Disorders in this class include:
- obsessive-compulsive disorder (OCD)
- body dysmorphic disorder
- trichotillomania (hair-pulling disorder)
- hoarding disorder
- excoriation (skin-picking) disorder
These conditions were previously labeled “anxiety disorders” in the DSM-IV-TR.
But increasing evidence since the DSM-IV-TR has demonstrated a common thread running through a number of OCD-related disorders is that obsessive thoughts or repetitive behaviors are not just anxiety.
Direct OCD DSM-IV-TR to DSM-5-TR changes
Under a chapter of their own, OCD and related disorders received some diagnostic criteria updates:
- The inclusion of “unwanted” as a defining factor for intrusive thoughts, urges, and images.
- The elimination of criteria stating obsessions aren’t simply excessive worries about real-life problems.
- The elimination of criteria stating the person recognizes obsessions are the product of their own mind.
- The elimination of criteria stating the person, at some time, has recognized obsessions and compulsions are unreasonable or excessive.
- Rewording of criteria that reflects DSM-IV-TR to DSM-5-TR changes for other differential and comorbid diagnoses, such as generalized anxiety disorder, substance use disorders, and schizophrenia spectrum disorders.
- Inclusion of new “insight” specifiers related to the level of obsessive-compulsive belief awareness.
- Inclusion of a new specifier indicating if there is a current or past history of a tic disorder.
The old DSM-IV-TR specifier “with poor insight”— the only specifier in that edition for OCD disorders — has been modified to allow for diagnosis on a spectrum of awareness.
The new specifiers in the DSM-5-TR for these conditions are:
- good or fair insight
- poor insight
- absent insight/delusional obsessive-compulsive disorder beliefs (complete conviction that obsessive-compulsive disorder beliefs are true)
The decision to add these specifiers was made in an effort to emphasize that some OCD and related disorders can present with a wide range of patient insight.
These same insight specifiers have been included for body dysmorphic disorder and hoarding disorder.
This change was also made to emphasize that absent insight or delusional beliefs may warrant a diagnosis of the relevant obsessive-compulsive or related disorder, rather than schizophrenia spectrum and other psychotic disorders.
In the DSM-5-TR, the APA included the new tic-related specifier for obsessive-compulsive disorder to acknowledge a growing body of clinical and
Body dysmorphic disorder in the DSM-5-TR was moderately changed from DSM-IV-TR. Along with the four specifiers mentioned above, three regarding insight, an additional criterion was also added.
This criterion notes repetitive behaviors or mental acts are in response to preoccupation with perceived defects or flaws in physical appearance.
It’s this fixation on flawed appearance that sets body dysmorphic disorder apart from other conditions that may share similar features.
A “with muscle dysmorphia” specifier has been added to reflect research data suggesting this is an important distinction to make for this condition.
The delusional variant of body dysmorphic disorder (which identifies people who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delusional disorder, somatic type, and body dysmorphic disorder.
Instead, it gets the new “absent/delusional beliefs” specifier.
Hoarding disorder graduates from being listed as just one symptom of obsessive-compulsive personality disorder in the DSM-IV-TR to an individually recognized condition in the DSM-5-TR.
After the DSM-5 OCD working group examined the research literature on hoarding, they found little support to suggest this was simply a variant of a personality disorder or a component of another mental health condition.
Hoarding disorder is characterized by the persistent difficulty of discarding or parting with possessions, regardless of the value others may attribute to these possessions.
Symptoms can be impairing and distressing, often compromising physical safety due to excessive clutter, fall risk, and fire hazards.
Hoarding behaviors were characterized in the DSM-IV-TR as obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder (OCPD), or anxiety disorder not otherwise specified.
By recognizing hoarding disorder as a distinct condition with its own criteria and treatments, the APA hopes to improve identification, research, and awareness of the condition.
The four specifiers mentioned earlier were also added to hoarding disorder.
This condition remains largely unchanged from the DSM-IV-TR, although the name has been updated to add the explanatory phrase “hairpulling disorder.”
Excoriation (skin-picking) disorder is a new condition added to the DSM-5-TR.
At the time of publication, the DSM-5-TR estimated that between 2% to 4% of the population could be diagnosed with this condition, though more
The resulting problems may include medical issues such as infections, skin lesions, scarring, and physical disfigurement.
The DSM-5-TR states excoriation (skin-picking) disorder is characterized by constant and recurrent picking at your skin, resulting in skin lesions.
The face, arms, and hands tend to be the most common areas affected, though any part of the body can receive focus.
If you live with excoriation (skin-picking) disorder, it’s likely you’ve tried many times to stop. You may also use makeup, clothing, or other means in an attempt to conceal the marks from picking behaviors.
Like other mental health conditions, excoriation results in distress and functional impairment. You might experience a sense of embarrassment, shame, or loss of control of this condition.
The DSM-5-TR includes the diagnoses of “other” specified obsessive-compulsive and related disorders.
These conditions are notably present but don’t meet all the necessary diagnostic criteria in the clearly defined DSM-5-TR OCD and related disorders group.
Body-focused repetitive behaviors, for instance, are characterized by recurrent behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors.
Obsessional jealousy is characterized by nondelusional preoccupation with a partner’s perceived infidelity.
OCD in the DSM-5-TR exists in its own chapter along with related disorders with features of uncontrollable obsessive thoughts and compulsive behaviors.
This separation from anxiety disorders in the DSM-IV-TR was a huge step toward improved diagnostic procedures and awareness of these conditions.
As research grows and the understanding of mental health conditions expands, future editions of the DSM will likely see more changes and improved clarity on OCD and related disorders.