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Report of the DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group 

April 2009
Katharine A. Phillips, M.D.


The Anxiety, Obsessive Compulsive (OC) Spectrum, Post-traumatic, and Dissociative Disorders Work Group, chaired by Katharine Phillips, M.D., has three sub-work groups: 1) Anxiety Disorders, chaired by Michelle Craske, Ph.D.; 2) Obsessive-Compulsive Spectrum Disorders, chaired by Dan Stein, M.D.; and 3) Post-trauma and Dissociative Disorders, chaired by Matthew Friedman, M.D.

Each of these sub-work groups regularly communicates with the other sub-work groups and has liaisons to other DSM-5 Work Groups and Study Groups for the purpose of working together on issues relevant to other groups, to get input from other groups, and to coordinate efforts across groups. Work group members participate in scientific and advocacy group meetings to discuss the DSM-5 development process and obtain input from the field. All sub-work groups have advisors; advisors are leaders in the field who have expertise in issues relevant to each sub-work group.

Anxiety Sub-Work Group

The Anxiety Sub-Work Group has been focusing on panic disorder, agoraphobia, social phobia (social anxiety disorder), specific phobia, and generalized anxiety disorder (and overanxious disorder), as well as separation anxiety disorder and selective mutism in collaboration with the Childhood and Adolescent Disorders Work group. Our overarching approach has been to (1) Review unresolved issues raised during the DSM-IV development process; (2) Conduct literature reviews on each topic, including literature reviews on lifespan issues, as requested by the Lifespan Study group, and on the topic of “What is an Anxiety Disorder?” (the literature reviews are completed or nearing completion); (3) Send surveys to experts around the world on various diagnostic issues requesting evidence-based input on key issues; (4) Involve advisors with expertise in the Anxiety Disorders; (5) Hold biweekly conference calls in which discussion is guided by recommendations from the literature reviews, survey results, and secondary data analyses. Secondary data analyses have included analyses relevant to the metastructure and structural issues within anxiety disorders. 

The following summarizes some of the issues being considered by this sub-work group. These issues will continue to be informed by literature reviews, secondary data analyses, and field trials. Field trials, which are currently being planned, will focus on changes in diagnostic criteria, examination of the most consistent and informative ways in which dimensions might be implemented, and some of the other issues discussed below.

1) Panic attacks and panic disorder: (a) Given that panic attacks are a significant marker of risk for developing a range of psychiatric disorders and for disorder severity and comorbidity, consideration is being given to the use of panic attacks as a dimension or specifier for any DSM-V disorder for which they are relevant. (b) Changes to the wording of panic attack criteria are being considered to enhance differentiation from pre-existing anxiety, improve cultural sensitivity, and clarify/simplify operationalization of unexpected versus expected panic attacks. (c) Although subtypes of panic attacks have been proposed in the literature (e.g., respiratory type), there appears to be insufficient evidence for subtyping panic attacks according to these symptom clusters. (d) Changes to the organization and wording of the diagnostic criteria for panic disorder are being considered for purposes of simplification and better separation from agoraphobia.

2) Agoraphobia: The criteria for agoraphobia and its relationship to panic disorder is under review.

3) Social phobia (social anxiety disorder): (a) This name of this disorder is under discussion, i.e., “social anxiety disorder” vs. “social phobia.” (b) Changes to the wording and organization of the diagnostic criteria to simplify and clarify them are being discussed.  The criterion requiring recognition of the excessiveness and unreasonableness of the fear and anxiety is being discussed, as not all patients have good insight. (c) The usefulness of the current “generalized” and “nongeneralized” distinction is being considered, as opposed to social interactional versus performance anxiety, with ongoing consideration of whether circumscribed performance anxiety is better placed under specific phobia. (d) The differential diagnosis between social anxiety disorder and avoidant personality disorder is being reviewed.

4) Generalized anxiety disorder: (a) The sub-work group is considering improvements to the wording and organization of the diagnostic criteria to simplify them and to enhance the precision regarding “excessive” nature of worry. (b) The nature of the link between generalized anxiety disorder and what used to be diagnosed as “overanxious disorder” in children is being reviewed.

5) Specific phobia: (a) The sub-work group is considering whether the DSM-IV subtypes of animal phobia, environmental, blood/injury/injection, situational, and other are supported by external validators. (b) The subworkgroup is also reviewing the differential diagnosis between agoraphobia and specific phobia.

6) Separation anxiety disorder: Consideration is being given to modifying the criteria for separation anxiety disorder to make them suitable for adults as well as youth; the empirical support for use of this diagnosis in adults is being reviewed.

7) Consistency across anxiety disorders: The sub-work group is considering the possibility of increasing consistency across the anxiety disorders—for example, in terms of duration (e.g., six months, except panic disorder); phobia criteria; how the terms ‘fear’ and ‘anxiety’ are used; and how impairment and distress are described.

8) Dimensions: A subset of the sub-work group, with the aid of advisors, has been examining the option of including dimensions in two different ways. The first option is as an adjunct to the diagnostic system, such that diagnostic criteria would be accompanied by ratings of levels of anxiety and avoidance behavior. Another option is to incorporate a dimensional approach directly into the diagnostic criteria to identify diagnostic thresholds. For both areas discussion includes the level of detail of these dimensions as well the construction of simple versus more multifaceted dimensions.

9) In collaboration with the Mood Disorders Work Group we are considering how the Appendix disorder mixed anxiety-depressive disorder could best be represented, in particular, how a dimensional perspective might be useful. 

Obsessive-Compulsive Spectrum Sub-Work Group

This sub-work group continues to work on literature reviews that address key issues for each of the diagnoses we are addressing. These include reviews of obsessive-compulsive disorder (OCD), hoarding, body dysmorphic disorder (BDD), Tourette’s disorder and tic disorders, trichotillomania and compulsive skin-picking, and stereotypic movement disorder. The subworkgroup is also reviewing larger issues about the optimal classification of these disorders; in particular, the relationship between OCD and anxiety disorders, and between the various conditions which have been conceptualized in the literature as obsessive-compulsive spectrum disorders. For example, if obsessive-compulsive spectrum disorders are ultimately classified together in DSM-5 (see below), they might be subclassified as A. Cognitive (e.g., BDD), and B. Motoric (e.g., trichotillomania). Our work is being done in consultation with advisors and has been informed by surveys sent to experts in the field in which input on key issues, based on the published literature, was invited. The sub-work group is collaborating with a number of other work groups and study groups (e.g., the Personality Disorders Work Group for issues pertaining to obsessive-compulsive personality disorder and the Somatic Distress Work Group for issues pertaining to hypochondriasis).

There is growing awareness of the heterogeneity of OCD, and various proposals have been put forward in the literature about how best to subtype it. We are considering whether it would be valuable to explicitly define specific symptom dimensions in OCD (in addition to diagnostic criteria) and, if so, what these dimensions should be. We are considering whether it would be useful to retain the insight subtype of OCD and add additional subtypes or specifiers such as early-onset OCD or tic-related OCD.

A number of researchers have suggested that while hoarding may be a symptom dimension of OCD, it may also merit classification as a separate disorder. The sub-work group is considering whether the empirical literature provides adequate support for adding hoarding to DSM, and hoarding is being considered for examination in a DSM-V field trial.

This sub-work group is considering whether particular diagnostic criteria for BDD should be altered. As with other disorders, we are considering how best to ensure that criteria and text are useful across different cultures and across developmental stages. We are also considering how best to classify BDD and its delusional variant. Our sub-work group is also reviewing the current diagnostic criteria for Tourette’s disorder and tic disorders. One question is whether Tourette’s disorder is substantially distinct from other chronic motor or vocal tic disorders and thus whether the tic disorder classification should be maintained to reflect known differences among them, or whether there is any utility in a chronic tic disorder category with subtypes reflecting these three chronic tic disorders. The clinical utility of the transient tic disorder diagnosis is being reviewed. Where tic disorders should be classified in DSM-5 is also being considered.

It has been suggested that the diagnostic criteria for trichotillomania require modification. We are therefore reviewing the relevant empirical literature and considering whether a more valid and useful criteria set is possible. For example, are criteria B and C valid or necessary? We are also reviewing questions about whether trichotillomania should have subtypes and, if so, what optimal subtyping might consist of. The question of whether trichotillomania deserves an alternate or additional name (e.g., hair-pulling disorder) is also being considered. Compulsive skin-picking (or skin-picking disorder) is another of the so-called body focused repetitive behavioral disorders, and we are considering whether the empirical literature on this condition is sufficient to support its inclusion as an independent entity in DSM.

Stereotypic movement disorder is currently diagnosed in patients with mental retardation if it is sufficiently severe to become a focus of medical attention. We are considering the possibility that a different diagnostic threshold may be useful, since the focus should arguably be on the behavior itself, not whether it requires medical attention. We are also addressing the question of whether stereotypic movement disorder should be altered to better capture the symptoms of patients who do not suffer from an intellectual disability.

Our sub-work group is also contributing to discussions about the optimal classification of disorders in DSM-5. One option is to retain the current classification of OCD within the anxiety disorders. A second option is to remove OCD from the anxiety section and classify it, along with OC spectrum disorders, in its own section of DSM. A third option is to broaden the current section on anxiety disorders so it is termed “anxiety and obsessive-compulsive spectrum disorders” and to include a number of OC spectrum conditions in this section.

In addition to completing literature reviews, the subworkgroup is reviewing data from secondary data analyses, including analyses on the relationship between OCD and other disorders, and planning field trials on key questions. Field trials will perhaps include (but not necessarily be limited to) hoarding, possible criteria changes for trichotillomania, and compulsive skin picking.

Posttraumatic and Dissociative Disorders Sub-Work Group

This sub-work group is reviewing current diagnostic criteria for PTSD, acute stress disorder (ASD), dissociative disorders, and adjustment disorder as well as other issues (see below). It has assembled a panel of advisors who have participated in biweekly conference calls, each devoted to a specific topic of interest. These have included: PTSD A1 and A2 criteria, other PTSD criteria, ASD, Adjustment Disorder, Conversion Disorder, Disorders of Extreme Stress Not Otherwise Specified (DESNOS; a proposed new disorder), Developmental Trauma Disorder (a proposed new disorder), and Dissociative Disorders.

In late 2008, the sub-work group created a survey that was sent out to approximately 50 recognized experts to obtain input based on the published literature on key issues being considered by the Work Group. Questions concerned the following: The PTSD A1 and A2 criteria, the best demarcation between acute and chronic PTSD (and whether this differentiation is needed), acute responses to stress, DESNOS, whether PTSD C criteria avoidant and numbing symptom clusters should be separated, possible reclassification of trauma-related and dissociative disorders to potentially group them together in a separate supraordinate category in DSM-5, the proper diagnostic placement for conversion disorder (with somatic distress disorders versus dissociative disorders), whether there should be a subsyndromal PTSD category, and cross-cultural issues. There was approximately a 50% response rate to the survey, and the answers to the questions have informed subsequent activities.

Currently, the sub-work group is involved in three major activities:

1) Completion of literature reviews on major topics;

2) Identification of extant data sets for secondary analyses that might address key questions (from a PTSD perspective the focus is on longitudinal data sets with good information about traumatic exposure, good follow-up evaluation through structured interviews, and a menu of posttraumatic symptoms that is more extensive than the current 17 symptoms listed in DSM-IV PTSD criteria); and

3) Planning field trials to address key questions, which will likely include (but not necessarily be limited to) a field trial on PTSD, ASD, DESNOS, and adjustment disorder. 

The following are some of the key questions that are being considered by the subworkgroup in light of evidence from literature reviews, secondary data analyses, and/or field trials:

1) Whether to revise the PTSD A1 criterion and, if so, how;

2) Whether to retain or revise the PTSD A2 criterion, possibly by including a broader range of acute posttraumatic reactions such as panic attacks, dissociation, shame, and guilt;

3) Whether the current PTSD B, C, and D cluster symptoms are adequate or whether they should be revised, reduced, or expanded;

4) Whether ASD diagnostic criteria need to be revised, especially with respect to dissociative symptoms;

5) Whether adjustment disorder should be reclassified and put in a larger grouping of disorders that includes PTSD and dissociative disorders;

6) How cross cultural factors influence the expression of acute and chronic posttraumatic and dissociative symptoms;

7) How best to classify dissociative disorders (where in DSM they should be classified);

8) Whether the diagnostic criteria for dissociative disorders would be improved by revisions, including better specification of clinical presentations currently diagnosed as dissociative disorder NOS;

9) Where conversion disorder should be classified (with dissociative disorders versus somatic disorders; this issue is being considered in collaboration with the Somatic Distress Work Group);

10) Whether to include several proposed new disorders (DESNOS and Developmental Trauma Disorder; the latter in collaboration with the Childhood and Adolescent Disorders Work Group) in DSM-5;

11) How to formulate developmentally sensitive criteria for PTSD (in collaboration with the Childhood and Adolescent Disorders Work Group).

Some of the cross-cutting issues on which the subworkgroup has collaborated with other DSM-5 groups include the following. First, there is ongoing collaboration with the Childhood and Adolescent Disorders Work Group on developmentally sensitive diagnostic criteria for PTSD and on reviewing a proposal to add Developmental Trauma Disorder to DSM-5. We are also collaborating on issues pertaining to Traumatic Brain Injury with the Neurocognitive Disorders Work Group, with that work group taking the lead on this issue. We are collaborating with other work groups and study groups on a variety of issues, including the Somatic Distress Work Group (regarding the placement of conversion disorder) and with the Gender/Cross-Cultural Study Group regarding the possible need to modify diagnostic criteria to reflect gender or cross-cultural issues.

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  American Psychiatric Association