The Diagnostic and Statistical Manual of Mental Disorders - Research Paper Example

? Obsessive-compulsive disorder (OCD) Obsessive-compulsive disorder (OCD) The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV, TR) provides the diagnostic criteria for this anxiety disorder (American Psychiatric Association 456-463). In order to be diagnosed with OCD, an individual must present with recurrent obsessions and/or compulsions that are severe enough to cause marked impairment in everyday functioning. Obsessions are defined as persistent ideas, thoughts, impulses, or images that are perceived as intrusive or unwarranted, and lead to marked anxiety or distress. Compulsions are defined as repetitive behaviors, or mental acts, that serve to prevent or alleviate anxiety or distress. Compulsions may take the form of behavioral acts such as hand washing, checking, and ordering. They may also constitute mental acts such as praying, counting, and repeating words silently. Although most individuals diagnosed with OCD present with both obsessions and compulsions, only one of these symptomatic types is necessary for diagnosis. To be classified as obsessions, such thoughts must be considered intrusive and repugnant by the person experiencing them, and, when present, these symptoms must lead to marked distress and anxiety. As alluded to, compulsions are performed with the intent of ameliorating the discomfort associated with obsessions (APA 456-463). Most individuals with OCD recognize that their obsessions and/or compulsions are excessive or unreasonable. There is a smaller subset of individuals, however, who have difficulty recognizing the irrationality of their concerns, but such people continue to meet the diagnostic criteria for OCD, not another mental disorder. The specifier, With Poor Insight, is provided when the person does not recognize that the obsessions or compulsions are excessive or unreasonable during the majority of the OCD episode (APA 463). Clinically, such cases are likely to present significant challenges to mental health professionals. Differential Diagnosis of OCD It is critical to distinguish OCD for what it is and what it is not. In order to differentiate OCD from other conditions or disorders with similar symptoms, one has to do a thorough review of the differential diagnosis of OCD. OCD-like symptoms can also be seen in dementia, especially as a compensatory mechanism in early stages. For example, excessive list making, hoarding, repeating rituals, and counting resemble compulsive behaviors, although their purpose is organizational. These behaviors serve to establish structure in individuals with dementia rather than to reduce anxiety (Pigott et a1., 15). Sustained cognitive and intellectual impairment can also be associated with obsessive or compulsive features. Individuals with mental retardation, autism, or pervasive developmental disorders can display repetitive touching. While these actions are often stereotyped or ritualistic, they do not appear to be coupled with the intrusive thoughts or anxiety seen in OCD patients (McDougle, Price, & Goodman 537). OCD symptoms may occur as secondary phenomena in other psychiatric disorders as well. Depression, especially in the elderly, can involve ruminations (APA 456-463). While these ruminations are irrational and often intrusive, they are not considered primary OCD symptoms unless they predated the onset of affective disorder and were associated with substantial functional impairment prior to the depressive episode. Individuals with primary psychotic disturbances can also exhibit symptoms suggestive of OCD. Persons with schizophrenia can display bizarre contamination concerns and eccentric hoarding behaviors that resemble OCD symptoms. However, the primary symptoms of schizophrenia are psychotic in nature (APA 456-463). Delusional disorders can be characterized by obsessive thinking, such as obsessive delusional jealousy, but symptoms are limited to a single emotional dimension. On the other hand, people with OCD usually have multifaceted symptoms and acknowledge that these symptoms are irrational and excessive. Persons with anorexia or bulimia nervosa have a severely distorted body image and regularly engage in practices designed to ensure low body weight and/or the "right" appearance. Both anorexic and bulimic patients show an intense fear of obesity. They also exhibit an apparent inability to deemphasize their preoccupation with their physical appearance (APA 456-463). Interestingly, anorexia nervosa is often associated with excessive cleaning behaviors, contamination concerns, and an irresistible urge to complete tasks in a "perfect" manner, whereas individuals with bulimia engage in excessive physical exercise that is frequently performed in a ritualistic manner (Pigott et al. 25). Irrational fear of obesity, contamination concerns, perfectionistic styles, and obsessive pursuit of thinness resemble OCD symptoms. However, with anorexics and bulimics, the main focus of symptoms are centered around and restricted to their own physical state and body image. On the other hand, people with OCD have symptoms that are much broader in content and they have excessive fears about potential harm or misfortune to others, rather than themselves. Generalized anxiety disorder, posttraumatic stress disorder, panic disorder, and social phobia share some clinical features with OCD that make them hard to distinguish from OCD. For example, patients with OCD often complain of panic attacks. If these episodes of discrete anxiety are temporally preceded or elicited by obsessive thoughts or occur only during the interruption of compulsive behaviors, panic disorder should not be diagnosed. Individuals with panic disorder, in contrast to OCD, often have spontaneous anxiety attacks (Pigott et al., 15-27). In addition, patients with panic disorder often describe chronic anxiety or phobic avoidance even between panic attacks. Situations or sites are avoided due to their association with the occurrence of panic attacks, whereas individuals with OCD have obsessive thoughts such as contamination fears that result in avoidance behaviors (APA 456-463). Persons with social phobia describe excessive concerns about public humiliation. These concerns maybe limited to certain situations such as public speaking, performing in public or may involve any social situation. An excessive fear of criticism or review by others seems to be the primary feared consequence in individuals with social phobia. This extreme fear of public scrutiny resembles the altered risk assessment that is often present in persons with OCD. However, individuals with OCD have symptoms that generally occur both in social and private places, unlike with social phobia where the impaired risk assessment and phobic avoidance are limited to the public sphere. General anxiety patients complain of chronic worry and anxiety. They exhibit evidence of physiological arousal but do not usually have ritualistic behaviors designed to reduce their anxiety. In addition, they do not acknowledge specific concerns about aggressive or sexual impulses or other intrusive thoughts On the other hand, individuals with Post Traumatic Stress Disorder (PTSD) will frequently experience intrusive thoughts or recurrent images. However, PTSD symptoms are preceded by a traumatic event that has actually occurred, whereas in OCD there is no occurrence of a real traumatic event (APA 456-463).. Individuals with persistent somatic complaints in the absence of demonstrable pathology, such as hypochondriasis, appear to have distorted concerns about their health. However, patients with hypochondriasis consider their health concerns to be realistic and do not try to resist or diminish their health-seeking behaviors. In contrast, most patients with OCD try to resist or oppose their fears or perseverative behaviors (APA 456-463). Body dysmorphic disorder (BDD) is characterized by imagined concerns about ugliness or illusory body or body part defect(s) or malformation. Individuals with BDD have obsessional preoccupations about their appearance and may have compulsive behaviors such as mirror checking. But all preoccupations and compulsive behaviors are limited to concerns about appearance (APA 456-463). Compulsions are repetitive behaviors that serve to reduce or neutralize anxiety, not to provide pleasure or gratification. Therefore, they should be distinguished from Impulse-Control disorders such as compulsive gambling, shopping and kleptomania. Impulse control disorders such as compulsive gambling or kleptomania are characterized by complaints of irresistible urges that are reduced only by the performance of these behaviors. Most people with impulse control disorders give into or perform these behaviors for pleasure or relief, whereas OCD patients do it in search of relief from anxiety (APA 456-463). Obsessive compulsive personality disorder (OCPD), can be confused with the far more disabling OCD. Certain criteria set them apart. First, OCPD is characterized by rigidity, constricted affect, prominent desire for order and control, decreased capacity for beneficence, and parsimony. Second, OCD causes significant functional impairment, whereas in OCPD obsessions and compulsions are more like personality quirks or idiosyncrasies, however unpleasant. Third, people with OCPD have no real desire to change and in many ways enjoy performing their compulsions. On the other hand, although people with OCD dread their compulsions, they simply cannot stop performing them. Fourth, individuals with OCPD, in contrast to OCD, seldom experience their symptoms as excessive and do not report associated anxiety or discomfort (Schwartz 105). As demonstrated by the extensive phenomenological overlap, the differential diagnosis of OCD can be quite complex. Diagnostic boundaries become less distinct as shared clinical features and potential response patterns suggest that patients with OCD, by the current diagnostic scheme, may represent a fairly heterogeneous disorder. This heterogeneity points to the necessity that an OCD subtype typology might be useful for better classification and understanding of the disorder. Sub-typing may be done via the use of primary symptom contents (i.e., washing, checking, etc) or by the use of sophisticated statistical analysis techniques such as factor and cluster analysis. Axis I Comorbid Conditions of OCD Comorbid conditions are very common in OCD. Individuals with OCD rarely have complaints of OCD symptoms alone. Instead, they often also have additional complaints such as depressed mood, feelings of prominent anxiety or tension, or somatic complaints. Most OCD studies report at least a 50% rate of comorbid Axis I disorders and at least 40% of patients with OCD also meet criteria for a personality disorder (Rasmussen & Eisen 4-10). Major depressive disorder is the most common comorbid disorder in patients with OCD. In fact, at least 30 to 40 % of adult OCD patients will also meet criteria for a concurrent major depressive episode (Weissman, Bland, & Canino 5-10). Previous studies have suggested that the lifetime prevalence rate for major depressive disorder in patients with OCD approaches 70% (Rasmussen, Eisen & Pato, 4-9). In another study, major depressive disorder was found to be present in 61%, and the lifetime prevalence rate for major depressive disorder was 85% and criteria for bipolar affective disorder were met by 13% of the OCD patients (Karno, Golding, & Sorenson 1099). The extensive overlap between OCD and depressive disorder has contributed to speculation that depression may represent a secondary phenomenon. That is, individuals with OCD may reactively develop depressive symptoms as a response to their primary affliction, OCD. Most patients with OCD report that affective symptoms occurred chronologically after the onset of substantial OCD symptoms. However, other findings do not support such conclusions. For example, many patients describe a distinctly different course for their affective disorder symptoms versus OCD symptoms suggesting autonomous or at least separate disorders (Rasmussen & Eisen 4-10). In addition there may be a differential treatment response between OCD and depressive symptoms. In other words, psychotropic drugs that are effective in treating depressive symptoms in an OCD patient may be associated with negligible anti-obsessive effects. Several controlled studies have demonstrated that anti-obsessive treatment response is independent of antidepressant response in individuals with OCD (Leonard, Swedo, & Rapoport 922). Nondepressed OCD patients respond to this treatment similarly to OCD patients with concurrent depressive disorder. Fortunately effective antiobsessive therapy is generally associated with significant reductions in depressive symptoms (Schwartz 99). After major depressive disorder, the most common comorbid disorder reported in patients with OCD appears to be other anxiety disorders, eating disorders, trichotillomania, alcohol abuse, and Tourette's syndrome. For example, Rasmussen and Eisen (466-470), administered structured or semi structured interviews to 100 patients with primary OCD. Social phobia (11 %), eating disorder (8%), alcohol dependence (8%), simple phobia (7%), panic disorder (6%), and Tourette's syndrome (5%) were the most prevalent coexisting diagnoses in the OCD patients. The most prevalent lifetime comorbid di­agnoses had similar frequencies: simple phobia (22%), social phobia (18%), eating disorder (17%), alcohol dependence (14%), panic disorder (12%), and Tourette's syndrome (7%). Because comorbid disorders appear to represent the rule rather than the exception in individuals with primary OCD, closer scrutiny may provide useful information concerning the underlying cause of OCD. Moreover, the presence of comorbid conditions in patients with primary OCD may represent useful prognostic and/or treatment response indicators. With these issues in mind, three major categories of comorbid Axis I disorders that commonly occur in individuals with OCD will be presented and discussed. According to Pigott et al. (15­-27), there are three major categories of OCD comorbid conditions. Three categories are: (a) Disorders of altered risk assessment (Anxiety, Eating, and Somatoform Disorders) (b) Incompleteness/habit spectrum disorders, and (c) Psychotic spectrum disorders. Axis II Comorbid Conditions of OCD In addition to the Axis I comorbid conditions discussed, most individuals with OCD have at least one Axis II personality disorder. Baer and Jenike (803-812) suggest that over 50% of OCD patients meet criteria for at least one personality disorder. Avoidant, dependent, or histrionic disorders appear to be the most frequent type of personality disorders in individuals with OCD. Personality disorders classified in Cluster C (avoidant, dependent, and obsessive compulsive) are more common than Cluster A (paranoid, schizoid, schizotypal) or Cluster B (histrionic, borderline, narcissistic, antisocial) personality disorders in OCD patients (Baer & Jenike, 803-812). OCD and OCPD Although the definitions and criteria for diagnosis of obsessive compulsive disorder and obsessive compulsive personality disorder are now better established by the DSM-IV - TR, the relationship between OCD and Obsessive Compulsive Personality Disorder (OCPD) remains controversial. Historically, OCD patients were theorized to have premorbid obsessional personality traits that intensified under stress. Continued environmental stress interacting with primitive defense mechanisms was hypothesized to result in severe regression, disabling anxiety, and eventually OCD symptom formation. However, most research studies have suggested that OCPD is uncommon in patients with OCD and therefore unlikely to be critical for the development of OCD (Joffe, Swinson & Regan, 1127-1129). Despite the findings that OCPD and OCD are distinct rather than on a continuum, opposite literatures continue to exist. Treatment First-line treatments for OCD include cognitive­behavioral therapy, such as exposure and response prevention techniques, and pharmacological intervention, which often includes the prescription of serotonin reuptake inhibitors (SRls). Although studies have supported the efficacy of these various interventions in the treatment of OCD (e.g., Rasmussen & Eisen 9-13), there is a subset of individuals with this disorder who will gain only limited benefits from these, and other, therapeutic interventions. Researchers continue to investigate the shortcomings of such treatments, considering modified treatment options that may serve to reduce symptom severity more effectively and, ultimately, sustain such treatment gains. Conclusion OCD was once believed to be a rare disorder, affecting only a very small group of individuals as compared to the general population. However, it is now well-recognized that OCD is a more common disorder, with a prevalence rate per lifetime of approximately 2 to 3 percent of the population within the United States. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV, TR) provides the diagnostic criteria for this anxiety disorder. In order to be diagnosed with OCD, an individual must present with recurrent obsessions and/or compulsions that are severe enough to cause marked impairment in everyday functioning. Although most individuals diagnosed with OCD present with both obsessions and compulsions, only one of these symptomatic types is necessary for diagnosis. Work Cited American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000. Baer, L., & Jenike, M. A., “Personality disorders in obsessive compulsive disorder.” Psychiatric Clinics of North America, 15(4), (1992); 803-812. Joffe, R. T., Swinson, R. P. & Regan, J. J. “Personality features of obsessive ­compulsive disorder”. American Journal of Psychiatry. 145, (1988):1127-1129. Karno, M., Golding, J. M., & Sorenson, S. B. “The epidemiology of obsessive compulsive disorder in five US communities.” Archives of General Psychiatry 45, (1988):1094-1099. Leonard, H.L., Swedo, S.E., & Rapoport, J. L. “A double-blind desipramine Obsessive Compulsive substitution during long-term clomipramine treatment in children and adolescents with obsessive­compulsive disorder.” Archives of General Psychiatry 48, (1991): 922-927. McDougle, c., Price, L. & Goodman, W. “Fluvoxamine treatment of coincident autistic disorder and OCD.” Journal of Autism Developmental Disorders, 20, (1990): 537-543. Pigott, T. A, L'Heureux, F., Dubbert, B., Bernstein, S. & Murphy, D. L. “Obsessive compulsive disorder: comorbid conditions.” Journal of Clinical Psychiatry, 55(10), (1994): 15­-27. Rasmussen, S. A, & Eisen, J. L. “The epidemiology and differential diagnosis of obsessive compulsive disorder.” Journal of Clinical Psychiatry, 53(4), (1992):4-10. Rasmussen, S. A, Eisen, J. 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