File Name: obsessive compulsive and related disorders dsm 5 .zip
Obsessive—compulsive and related disorders OCRD result in potentially disabling conditions that trap individuals in endless cycles of repetitive thoughts and behaviors Katz, OCRD differ from developmentally normative preoccupations and rituals in that the obsessions or rituals are excessive and persist beyond developmentally appropriate stages American Psychiatric Association [APA], a. Common to these disorders is the presence of obsessions, compulsions, or both. Obsessions are defined as recurrent and distressing thoughts, fears, or images that the person cannot control.
Compulsions are repetitive, stereotyped thoughts and behaviors designed to reduce harm. Growing evidence suggests that the neurocognitive mechanisms mediating behavioral inhibition motor inhibition, cognitive inflexibility reversal learning and habit formation shift from goal-directed to habitual responding contribute toward compulsive activity in a broad range of disorders.
In obsessive compulsive disorder, distributed network perturbation appears focused around the prefrontal cortex, caudate, putamen, and associated neuro-circuitry. Obsessive compulsive disorder-related attentional set-shifting deficits correlated with reduced resting state functional connectivity between the dorsal caudate and the ventrolateral prefrontal cortex on neuroimaging. In contrast, experimental provocation of obsessive compulsive disorder symptoms reduced neural activation in brain regions implicated in goal-directed behavioral control ventromedial prefrontal cortex, caudate with concordant increased activation in regions implicated in habit learning presupplementary motor area, putamen.
The ventromedial prefrontal cortex plays a multifaceted role, integrating affective evaluative processes, flexible behavior, and fear learning. Findings from a neuroimaging study of Pavlovian fear reversal, in which obsessive compulsive disorder patients failed to flexibly update fear responses despite normal initial fear conditioning, suggest there is an absence of ventromedial prefrontal cortex safety signaling in obsessive compulsive disorder, which potentially undermines explicit contingency knowledge and may help to explain the link between cognitive inflexibility, fear, and anxiety processing in compulsive disorders such as obsessive compulsive disorder.
Compulsions are stereotyped behaviors, performed according to rigid rules and designed to reduce or avoid unpleasant consequences Chamberlain et al. However, compulsive behaviors are observed in many other psychiatric disorders, particularly those involving deficient impulse control.
As poorly understood lifespan disorders, they are difficult to treat and responsible for considerable psychiatric depression, suicide and somatic morbidity and cost to the individual and society as a whole Hollander et al. Regrettably, the development of new treatments in psychiatry is slowing, related, at least in part, to difficulties translating positive results from experiments using nonhuman illness models to the clinical setting.
These difficulties align with growing concern about the scientific utility of the existing diagnostic systems ICD, World Health Organisation , DSM-5, APA that tend to define psychiatric disorders according to symptoms and syndromes and give less prominence to neuropsychological substrates. It is thought likely that the considerable biological heterogeneity that exists within the current taxonomy is hampering identification of the underpinning mechanisms that may serve as new therapeutic targets.
Identifying the pathophysiological mechanisms underpinning compulsivity as a trans-diagnostic, neuropsychological domain would therefore be expected to advance the search for new treatment targets and support innovation in developing evidence-based treatments Fineberg et al a. Many different compulsive disorders are found clustered within the same individual comorbidity or within the families of affected individuals, implying that vulnerability to these disorders is mediated via shared pathophysiological mechanisms Fineberg et al.
The investigation of endophenotypes intermediate phenotypes that lie closer than do the expressed behaviors phenotypes to the genetic and environmental origins of compulsive disorders Gottesman and Gould, ; Chamberlain and Menzies, , such as changes in cognitive performance, or structural and functional brain imaging abnormalities, is expected to provide a clearer understanding of the biological processes underpinning these disorders.
Based on emerging data from the neurosciences, this narrative review, which was first delivered as a plenary lecture at the Annual Congress of the International College of Neuropsychopharmacology Fineberg et al. The research builds upon previous and ongoing research by other groups and, as it has progressed, has generated testable models of compulsivity as a biologically relevant trans-diagnostic domain that could be expected to advance diagnostic classification and identify new avenues for treatment, including novel psychological, pharmacological, and somatic treatment targets for these disabling and intransigent disorders.
The DSM-5 OCRD cluster, comprising obsessive—compulsive disorder OCD , body dysmorphic disorder BDD , hoarding disorder, hair-pulling disorder, and skin-picking disorder, represents some of the most costly, functionally disabling, and treatment-resistant brain disorders. By gathering together diagnoses previously listed in the DSM-IV under Anxiety Disorders, Somatoform Disorders, and Impulse-Control Disorders Not Elsewhere Classified, this new classification aims to advance the scientific study of the disorders as well as to improve their clinical recognition and management.
The disorders commonly occur together and yet are surprisingly poorly recognized, as individuals are often not forthcoming about their symptoms e. As a result, there is usually a considerable time-lag, in the case of OCD, amounting to approximately 15 years, before the correct diagnosis is made and the correct treatments initiated.
It is to be hoped that by introducing this new classification, clinicians would be more likely to enquire about and detect the other disorders. It is fully expected that the forthcoming ICD revision will adopt a similar approach and may even include additional new diagnoses among the OCRD grouping, such as olfactory reference syndrome Marras et al. OCRDs are generally thought to be highly heritable hoarding disorder, Iervolino et al.
They are characterized by the irresistible urge to perform distressing and time-consuming compulsive acts. Of these disorders, OCD has been subject to most study and is arguably the most well understood. Patients with OCD show difficulty in flexibly shifting attentional focus away from distressing intrusive, perseverative thoughts obsessions and behaviors compulsions Fineberg et al. Washing, checking, ordering, and arranging compulsions are extremely common.
Hoarding disorder is a separate, poorly understood, and highly treatment refractory OCRD that involves the compulsive acquisition of new items and difficulty discarding owned items. Hoarding compulsions are also commonly found in patients with OCD as well as those with neurodevelopmental disorders such as ASD. In young people with OCD, hoarding is associated with prominent executive function deficits Park et al. Hair-pulling disorder and skin-picking disorder, on the other hand, are defined by more obviously disinhibited behavior, in the form of repetitive, body-focused grooming habits that can be considered as either predominantly impulsive or compulsive, depending on the nature of the symptoms expressed Chamberlain et al.
Other phenotypic signs of an altered neurodevelopmental trajectory are also commonly observed in patients with OCRDs, such as traits or symptoms of tic disorder, ASD, and attention deficit hyperactivity disorder.
These comorbid traits and diagnoses appear to cluster in the same patient or within their family members, hinting that shared, heritable neuro-behavioral mechanisms contribute to the expression of many compulsive disorders de Vries et al. Additionally, tic-related OCD shows a more favorable response to adjunctive treatment with dopamine antagonist drugs Bloch et al.
In response to the emerging evidence, the DSM-5 has highlighted the presence of tic as the first neuro-behavioral specifier of a clinically relevant OCD subtype. One such recent study Darrow et al. Figure 1 summarizes the evidence-based treatment of the OCRDs based on a systematic review Grant et al. Apart from some studies of OCD and BDD, the pharmacotherapies were almost exclusively tested in small un-replicated trials, and the psychotherapies were not rigorously tested against a matched control of fair comparison.
Randomized controlled treatment trials of adequate size and power to enable the detection of predictive outcome markers are urgently needed to drive forward the clinical management of these disorders on an individualized basis Sachdev et al. The compulsions associated with ASD also respond to SSRI, though the increased risk of SSRI-induced adverse effects in the autistic population, such as behavioral activation and agitation, warrant care in dosage titration and subject selection Kolevzon et al.
Hoarding behavior has been mainly studied in the context of comorbid OCD and may respond to SSRI or venlafaxine Saxena and Sumner, , but as yet no effective pharmacological treatment has been established for primary hoarding disorder. CBT, even when delivered intensively over long periods, has so far been found to produce only limited improvement in hoarding behavior Uhm et al.
In hair-pulling disorder the data supporting the efficacy of SSRI and clomipramine are also not strong. Habit reversal therapy, rather than ERP, has emerged as the psychological therapy of choice McGuire et al. Other data from single randomized controlled trials in hair-pulling disorder suggest that olanzapine an antipsychotic agent Van Ameringen et al.
Naltrexone, an opiate antagonist, produced substantial benefits in a small open-label study of children with hair pulling disorder De Sousa, , but the drug was not effective in a double-blind placebo-controlled study. However, those in this study with a family history of addiction showed a greater but not statistically significant decrease in the urge to hair-pull Grant et al.
Skin picking disorder has been barely studied to date, but as with hair-pulling disorder, shows some response to SSRI and n-acetyl cysteine reviewed in Reghunandanan et al. Of great interest, a wide range of pharmacological compounds have been tested in treatment-resistant OCD and some have been found to be effective in small-sized trials, implicating a multiplicity of potential treatment targets and mechanisms see Figure 2.
Treatments with robust evidence of efficacy derived from randomized controlled trials of fair comparison are highlighted in bold black type. Thus, notwithstanding the limitations of the study data, some compulsive disorders e. In contrast, hair pulling and skin picking disorders, which are also characterized by prominent impulse control and addictive symptomatology, respond better to treatment with drugs acting on dopamine, glutamate, opioid, and noradrenergic systems, that is, potentially more like impulse-control disorders or even behavioral addictions e.
Grant et al. The pharmacological treatment response may be of particular value for parsing psychiatric disorders and defining the boundaries of diagnostic groups, as it depends on underpinning biological mechanisms. As the treatment trial data for the OCRDs accrues, it is possible that for some disorders more convincing similarities will be found with disorders classified elsewhere in the DSM, such as the behavioral addictions e. Alternatively, by taking a dimensional impulsive-compulsive-habit approach to the psychopharmacology of the OCRDs, the emerging evidence may instead be interpreted to support the inclusion of some of these other disorders into an expanded OCRDs grouping Sachdev et al.
Psychiatric symptoms and cognitive deficits can be conceptualized as disordered structure, connectivity, and function in large-scale neural networks. A series of evolutionarily well-conserved, parallel, cortico-striato-thalamo-cortical CSTC circuits are believed to underpin the expression of compulsive behaviors Alexander et al.
These circuits include direct positive feedback and indirect negative feedback pathways, projecting from specific cortical areas to the corresponding subregions of the striatum and thalamus with recurrent projections to the cortex.
They are involved in diverse computational activities, including reward processing, action selection, habit formation, and motor control Arnsten et al. They play an important role in recognizing behaviorally significant stimuli and in error detection and in regulating goal-directed responses Lovinger, and may therefore be particularly important for OCRDs. The anatomical overlap and functional interplay between these circuits may explain why compulsive behavior occurs in so many psychiatric syndromes.
Early indications that the compulsive behaviors seen in OCD and other compulsive disorders may be mediated by CSTC circuits reviewed in Reghunandanan et al. OCD patients have subsequently been found to demonstrate abnormalities in a broad series of measures used in neuropsychiatric e. These abnormalities have consistently implicated CSTC dysfunction and impaired control of the inhibition of thoughts and behaviors reviewed in Morein-Zamir et al.
Some evidence has suggested that they are relatively specific to disorders characterized by compulsive behaviors Purcell et al. Functional imaging in OCD has demonstrated increased activity in CSTC circuits connecting the orbitofrontal cortex, cingulate cortex, and striatum, both at rest and especially during exposure to feared stimuli reviewed in Reghunandanan et al. Somewhat different circuits may be involved in mediating different OCD symptom clusters such as hoarding Saxena et al.
The use of sophisticated cognitive and affective paradigms has generated new heuristics regarding the role of these circuits Fitzgerald et al. The observation that some behavioral challenges, such as exposure to OCD cues, induce over-activation of the orbitofrontal cortex on functional imaging and others induce underactivation e.
Chamberlain et al. Abnormal structure or function in other brain regions such as the temporal lobe structures involved in memory and fear processing Hugo et al. However, recent meta- and mega-analyses of structural imaging data collected from research sites worldwide found distinct patterns of subcortical abnormalities in pediatric and adult OCD patients. The hippocampus as well as the pallidum seemed to be of importance in adult OCD, whereas the thalamus was involved in pediatric OCD Boedhoe et al.
Baseline structure or activity may differentially predict response to pharmacotherapy and psychotherapy Brody et al. Magnetic resonance spectroscopy has demonstrated alterations in glutamate metabolites in CSTC circuits Rosenberg et al. Evidence from the relatively few positron emission tomography PET ligand studies so far performed in OCD have identified abnormal binding of the serotonin transporter in cortical and subcortical areas Reimold et al.
Techniques combining gene variants and brain imaging have been used to enhance the imaging findings. For example, in patients with OCD, genetic variation in the serotonin transporter was demonstrated to be associated with reduced orbitofrontal cortex volume as measured by magnetic resonance imaging MRI Atmaca et al.
Thus, in OCRDs, distributed network perturbation appears focused around the prefrontal cortex, caudate, putamen, and associated neurocircuitry. In OCD, convergent evidence points to deficient top-down inhibitory control in the prefrontal cortex nodes within this circuitry, coupled with the hijacking of flexible, contingency-dependent instrumental behavior in favor of excess habit generation mediated by dysfunction within the dorsal striatum reviewed in Fineberg et al.
Abnormal activation in the dorsal striatum, especially the head of the caudate nucleus and the putamen, is well replicated in the OCD literature reviewed in Reghunandanan et al. This neuroanatomical model goes some way to explain the link between compulsive acts and harm-related thoughts and activities. Involvement of the putamen may be particularly relevant for the development of sensorimotor symptom such as tics.
However, imaging research suggests that a wider range of CTSC circuits are involved in OCD, including systems responsible for reward processing more usually associated with addiction Klanker et al. Surgical disconnection of this circuitry via stereotactic capsulotomy, cingulotomy, or limbic leucotomy has been used to treat severe, intractable OCD for several decades, with some evidence of success.
A double-blind, sham-controlled trial has recently produced limited evidence of the efficacy and tolerability of ventral capsulotomy using gamma radio-surgery Lopes et al. There is experimental evidence that in patients with OCD, deep brain stimulation targeted to the nucleus accumbens reduced excessive fronto-striatal connectivity within that circuit Bourne et al.
The degree of such normalization correlated with reduced severity of symptoms Figee et al. Neurocognitive changes are likely to be of great value for studying the neurobiology of psychiatric disorders, as they are theoretically more directly linked to brain structure and function than are the more complex higher-level phenotypes such as compulsive symptoms Fineberg et al.
They are also more tractable to exploration across animal species Dalley et al. Of the available instruments, computerized cognitive tests have several advantages over pen and paper assessment.
To date, a number of tasks derived from the Cambridge Neuropsychological Test Automated Battery CANTAB , which includes tests that are adaptable for translational work in animals and for application during brain imaging, have shown considerable utility in fractionating cognitive processes in OCRDS and in localizing neural and neurochemical substrates.
Growing evidence from human and animal research using tests such as the CANTAB suggests that the neurocognitive mechanisms mediating behavioral inhibition motor inhibition, cognitive inflexibility and habit formation shift from goal-directed to habitual responding variably contribute toward vulnerability to compulsive activity in a broad range of compulsive disorders reviewed in Fineberg et al.
Moreover, some of these deficits can be found in unaffected healthy relatives of OCD probands, suggesting they represent vulnerability or trait markers of compulsivity that also exist in nonpatient groups. Multiple tiers of evidence, ranging from functional magnetic resonance imaging fMRI of individuals with focal frontal lobe lesions to animal research, have demonstrated that the inhibitory control of motor acts is sub-served by a neural network linking the right inferior frontal gyrus with its subcortical including subthalamic connections Rubia et al.
Pharmacological manipulation in rodents and humans suggests that motor response inhibition, as indexed by the SSRT, falls under the neuro-modulatory influence of the norepinephrine system Chamberlain et al.
Compulsions are repetitive, stereotyped thoughts and behaviors designed to reduce harm. Growing evidence suggests that the neurocognitive mechanisms mediating behavioral inhibition motor inhibition, cognitive inflexibility reversal learning and habit formation shift from goal-directed to habitual responding contribute toward compulsive activity in a broad range of disorders. In obsessive compulsive disorder, distributed network perturbation appears focused around the prefrontal cortex, caudate, putamen, and associated neuro-circuitry. Obsessive compulsive disorder-related attentional set-shifting deficits correlated with reduced resting state functional connectivity between the dorsal caudate and the ventrolateral prefrontal cortex on neuroimaging. In contrast, experimental provocation of obsessive compulsive disorder symptoms reduced neural activation in brain regions implicated in goal-directed behavioral control ventromedial prefrontal cortex, caudate with concordant increased activation in regions implicated in habit learning presupplementary motor area, putamen.
The DSM-5 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition provides clinicians with official definitions of and criteria for diagnosing mental disorders and dysfunctions. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action i. Repetitive behaviors e. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note : Young children may not be able to articulate the aims of these behaviors or mental acts. The obsessions or compulsions are time-consuming e.
Treatment recommendations, as well as payment by health care providers , are often determined by DSM classifications, so the appearance of a new version has practical importance. Changes in the DSM-5 include the reconceptualization of Asperger syndrome from a distinct disorder to an autism spectrum disorder ; the elimination of subtypes of schizophrenia ; the deletion of the "bereavement exclusion" for depressive disorders ; the renaming of gender identity disorder to gender dysphoria ; the inclusion of binge eating disorder as a discrete eating disorder; the renaming and reconceptualization of paraphilias , now called paraphilic disorders ; the removal of the five-axis system; and the splitting of disorders not otherwise specified into other specified disorders and unspecified disorders. Some authorities criticized the fifth edition both before and after it was published. Critics assert, for example, that many DSM-5 revisions or additions lack empirical support; inter-rater reliability is low for many disorders; several sections contain poorly written, confusing, or contradictory information; and the psychiatric drug industry may have unduly influenced the manual's content many DSM-5 workgroup participants had ties to pharmaceutical companies. The introductory section describes the process of DSM revision, including field trials, public and professional review, and expert review.
Obsessive-Compulsive and Related Disorder Due to Another Medical Condition The DSM-5 has classified body dysmorphic disorder as a subtype of OCRD. /AACAP/docs/facts_for_families/96_hair_pulling_nebraskansforjustice.org
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Obsessive-compulsive disorder OCD and related disorders have been the subject of significant revisions in the fifth edition of the Diagnostic and Statistical Manual DSM Previously considered a symptom of OCPD, and subsequently linked to OCD, it is now acknowledged that hoarding can emerge independently from any alternative condition. The present paper provides an updated review of recent investigations supporting the status of HD as an independent nosological entity.
Correspondence Address : Prof. The proposed OCRD section includes obsessive-compulsive disorder OCD , body dysmorphic disorder, olfactory reference disorder, hypochondriasis, hoarding disorder, trichotillomania, and skin-picking disorder. Tourette syndrome is also cross-referenced in OCRD.
Для него все шифры выглядят одинаково, независимо от алгоритма, на основе которого созданы. - Не понимаю, - сказала. - Мы же говорим не о реверсии какой-либо сложной функции, а о грубой силе. PGP, Lucifer, DSA - не важно. Алгоритм создает шифр, который кажется абсолютно стойким, а ТРАНСТЕКСТ перебирает все варианты, пока не находит ключ. Стратмор ответил ей тоном учителя, терпеливого и умеющего держать себя в руках: - Да, Сьюзан, ТРАНСТЕКСТ всегда найдет шифр, каким бы длинным он ни .
often referred to as obsessive-compulsive–related disorders (Table 3) OCD nebraskansforjustice.org nebraskansforjustice.org _files/nebraskansforjustice.org) and the DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder. A. Presence of.
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