Anxiety and Obsessive-Compulsive Disorders in the DSM-5

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) changed the way anxiety and obsessive-compulsive disorders are categorized by introducing a new section: Obsessive-Compulsive and Related Disorders. This was a notable shift from the DSM-IV, in which obsessive-compulsive disorder was viewed as an anxiety disorder.

Other significant changes from the DSM-IV to the DSM-5 include the addition of separation anxiety disorder and selective mutism to the Anxiety Disorders section, various diagnostic criteria revisions, and the inclusion of several new disorders in the Obsessive-Compulsive and Related Disorders section.

Diagnostic Criteria of Anxiety Disorders in DSM-5

Anxiety disorders are characterized by excessive fear and anxiety, along with related behavioral disturbances. Anxiety disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) include the following:^[1]

• Separation anxiety disorder
• Selective mutism
• Specific phobia
• Social anxiety disorder (social phobia)
• Panic disorder
• Agoraphobia
• Generalized anxiety disorder
• Substance/medication-induced anxiety disorder
• Anxiety disorder due to another medical condition
• Other specified anxiety disorder
• Unspecified anxiety disorder

Separation Anxiety Disorder

This disorder is most commonly diagnosed in children and involves anxiety that occurs when an individual is separated from the people to whom they’re attached. Someone with separation anxiety disorder may constantly worry about being separated from their loved ones and may refuse to go to school or work due to their fear of separation.

They may struggle to sleep without a major attachment figure and have nightmares about being separated from them. These symptoms must last at least four weeks in children and adolescents and at least six months in adults to qualify for a diagnosis.^[1]

This disorder was previously in the section of the DSM called “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” It was moved to the Anxiety Disorders section to reflect the fact that adults can also experience this disorder.^[2]

Selective Mutism

People with selective mutism experience a recurrent failure to speak in certain social situations where there is an expectation to speak, although they can speak in other situations. For example, a child may fail to speak when called on to answer a question at school but talk to parents and siblings at home. This failure to speak must last at least one month and impact a person’s academic, social, or professional achievement.^[1]

Like separation anxiety disorder, selective mutism used to be in the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence section. However, it was moved to the Anxiety Disorders category because the underlying cause of selective mutism in children is anxiety and because adults can also experience this disorder, although it’s less common.^[2]

Specific Phobia

A specific phobia refers to significant anxiety and fear related to a particular object, entity, or situation. Common examples include arachnophobia (fear of spiders), claustrophobia (fear of confined spaces), and trypanophobia (fear of needles). This anxiety must last at least six months and be out of proportion with the actual danger posed by the feared situation or object.^[1]

Social Anxiety Disorder (Social Phobia)

Individuals with social anxiety disorder experience extreme anxiety related to social situations, often fearing they will embarrass themselves or be judged negatively by others. They may avoid social situations altogether due to their fears. These symptoms must last at least six months and impair an individual’s ability to function in different areas of life, such as their social life and professional life. In the DSM-5, a “performance only” specifier was added to describe individuals who only experience anxiety in performance-related social situations.^[1][2]

Panic Disorder

The primary characteristic of panic disorder is recurrent unexpected panic attacks. This usually leads to anxiety about the possibility of having additional panic attacks, as well as worries about the potential consequences of panic attacks. Panic disorder was linked to agoraphobia in the DSM-IV but is its own diagnosis in the DSM-5.^[1][2]

Agoraphobia

Agoraphobia is diagnosed when a person has anxiety about at least two of the following five situations: being outside of the home alone, standing in line or being in a crowd, using public transportation, being in open spaces, and being in enclosed spaces. Often, these fears lead people with agoraphobia to avoid leaving the house altogether.

Anxiety and avoidance symptoms must last for at least six months for a diagnosis of agoraphobia. As mentioned above, agoraphobia was previously linked to panic disorder but is a standalone diagnosis in the DSM-5.^[1][2]

Generalized Anxiety Disorder

Generalized anxiety disorder is characterized by persistent, difficult-to-control anxiety about a variety of situations. This anxiety must occur more days than not for at least six months and must contribute to functional impairment (for example, difficulties in a person’s social life and professional life).^[1]

OCD Diagnostic Criteria in the DSM-5

Obsessive-compulsive disorder was previously in the Anxiety Disorders section of the DSM, but in the DSM-5, it’s placed in the Obsessive-Compulsive and Related Disorders category. OCD DSM-5 criteria include the presence of obsessions (repetitive, intrusive, and unwanted thoughts or urges that lead to anxiety and distress), compulsions (repetitive behaviors or mental acts intended to relieve the anxiety associated with obsessions), or both. The obsessions and compulsions are often related to time-consuming or irrelevant tasks.^[1]

While much of the criteria for OCD remained the same from the DSM-IV to the DSM-5, there were a few notable changes. In the DSM-IV, diagnostic criteria specified that an individual’s intrusive thoughts couldn’t be excessive worries about real-life problems. This was dropped in the DSM-5. Similarly, the DSM-IV noted that the person must recognize that the obsessions were a product of their own mind, and this criterion was dropped in the DSM-5.^[3]

The DSM-IV also stated that the individual needed to recognize that their obsessions and compulsions were unreasonable or excessive. This criterion was eliminated in the DSM-5, and various specifiers were added to indicate a person’s level of insight into their disorder and symptoms. OCD specifiers in the DSM-5 include “with good or fair insight,” “with poor insight,” and “with absent insight/delusional beliefs,” as well as “tic related” for individuals who have a history of a tic disorder.^[3]

The Obsessive-Compulsive Spectrum

The DSM-5 introduced a new disorder category, Obsessive-Compulsive, and Related Disorders, as well as several new disorders. This section of the DSM includes the following:^[1]

• Obsessive-compulsive disorder (moved from the Anxiety Disorders section)^[3]
• Body dysmorphic disorder (moved from the Somatoform Disorders section)^[4]
• Hoarding disorder (a new diagnosis in the DSM-5)
• Trichotillomania (moved from the Impulse-Control Disorders Not Classified Elsewhere section)^[5]
• Excoriation disorder (a new diagnosis in the DSM-5)
• Substance/medication-induced obsessive-compulsive and related disorder (a new diagnosis in the DSM-5)
• Obsessive-compulsive and related disorder due to another medical condition (a new diagnosis in the DSM-5)
• Other specified obsessive-compulsive and related disorders (a new diagnosis in the DSM-5)
• Unspecified obsessive-compulsive and related disorder (a new diagnosis in the DSM-5)

Mental health disorders in this section of the DSM tend to have similar features but distinct presentations. Body dysmorphic disorder, for instance, involves a preoccupation with a perceived physical flaw and repetitive behaviors, like mirror-checking and excessive grooming, intended to fix the flaw.^[1]

Meanwhile, hoarding disorder involves a compulsive need to collect and keep possessions, as well as distress related to discarding them. Trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder involve compulsive urges to pull out one’s hair or pick at one’s skin, which often occurs during times of stress or boredom and are extremely difficult to resist.^[1]

Key Differences from the DSM-IV

The most significant change from the DSM-IV to the DSM-5 is the elimination of obsessive-compulsive disorder from the Anxiety Disorders section and the introduction of the Obsessive-Compulsive and Related Disorders section. Other notable changes in the DSM Anxiety Disorders and Obsessive-Compulsive and Related Disorders sections include the following:

Anxiety Disorders: Changes from the DSM-IV to the DSM-5

• Post-traumatic stress disorder and acute stress disorder were moved from the Anxiety Disorders section to the Trauma and Stressor-Related Disorders section.
• Individuals no longer need to recognize that their anxiety is unreasonable or excessive to receive a diagnosis of agoraphobia, social anxiety disorder, or specific phobia.
• Panic disorder and agoraphobia are now separate diagnoses instead of being linked.
• Social anxiety disorder now has a “performance only” specifier.
• Separation anxiety disorder and selective mutism were moved into the Anxiety Disorders section from the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence section.^[2]

Obsessive-Compulsive and Related Disorders: Changes from the DSM-IV to the DSM-5

• The Obsessive-Compulsive and Related Disorders section is new to the DSM-5.
• Excoriation (skin-picking) disorder, hoarding disorder, substance/medication-induced obsessive-compulsive and related disorder, obsessive-compulsive and related disorder due to another medical condition, and other specified and unspecified obsessive-compulsive and related disorders are new diagnoses in the DSM-5.
• Trichotillomania (hair-pulling disorder) was moved from the Impulse-Control Disorders Not Elsewhere Classified section to the Obsessive-Compulsive and Related Disorders section.
• Obsessive-compulsive disorder now has multiple specifiers indicating the individual’s level of insight and whether they have a history of a tic disorder.
• Body dysmorphic disorder was moved from the Somatoform Disorders section to the Obsessive-Compulsive and Related Disorders section. A diagnostic criterion involving repetitive behaviors or mental acts related to a preoccupation with a perceived flaw was added, as well as a “with muscle dysmorphia” specifier.^[2]

Challenges of Diagnosing Anxiety and Obsessive-Compulsive Disorders

It can be challenging for clinicians to accurately diagnose anxiety and obsessive-compulsive disorders due to multiple overlapping symptoms and the possibility of co-occurring disorders. For example, a person could have both obsessive-compulsive disorder and generalized anxiety disorder, but these disorders could also be mistaken for each other due to some symptom similarities. Conducting a differential diagnosis is crucial for accurate diagnoses.

Controversy Related to the Elimination of OCD from the Anxiety Disorders Section

The changes between the DSM-IV and DSM-5 have been the subject of controversy among some mental health professionals. A 2010 survey of authors of OCD publications revealed that around 60% of them supported the idea of moving obsessive-compulsive disorder out of the Anxiety Disorders section of the DSM. When psychiatrists were surveyed, approximately 75% supported the move, and around 45% of other mental health professionals also supported it.^[6]

Supporters of moving OCD out of the Anxiety Disorders section of the DSM generally held this viewpoint because the hallmarks of OCD are obsessions and compulsions rather than anxiety. Those who preferred to keep OCD in the Anxiety Disorders section stated that obsessive-compulsive disorder and anxiety frequently co-occur and usually respond to the same treatments.^[6]

Confusion About Obsessive-Compulsive and Related Disorders

The introduction of the Obsessive-Compulsive and Related Disorders section of the DSM has been met with some confusion. Some mistakenly believe that all disorders in this section, such as body dysmorphic disorder and excoriation disorder, are forms of OCD. This is not accurate. Although there are similarities between the disorders in this section, they have different symptoms and are distinct diagnoses.^[6]