Does obsessive-compulsive personality disorder belong within the obsessive-compulsive spectrum?

It has been proposed that certain Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Axis I disorders share overlapping clinical features, genetic contributions, and treatment response and fall within an "obsessive-compulsive" spectrum. Obsessive-compulsive personality disorder (OCPD) resembles obsessive-compulsive disorder (OCD) and other spectrum disorders in terms of phenomenology, comorbidity, neurocognition, and treatment response. This article critically examines the nosological profile of OCPD with special reference to OCD and related disorders. By viewing OCPD as a candidate member of the obsessive-compulsive spectrum, we gain a fresh approach to understanding its neurobiology, etiology, and potential treatments.     

Evidence for a Multi-Dimensional Latent Structural Model of Externalizing Disorders

Strong associations between conduct disorder (CD), antisocial personality disorder (ASPD) and substance use disorders (SUD) seem to reflect a general vulnerability to externalizing behaviors. Recent studies have characterized this vulnerability on a continuous scale, rather than as distinct categories, suggesting that the revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) take into account the underlying continuum of externalizing behaviors. However, most of this research has not included measures of disorders that appear in childhood [e.g., attention-deficit/hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD)], nor has it considered the full range of possibilities for the latent structure of externalizing behaviors, particularly factor mixture models, which allow for a latent factor to have both continuous and categorical dimensions. Finally, the majority of prior studies have not tested multidimensional models. Using lifetime diagnoses of externalizing disorders from participants in the Fast Track Project (n?=?715), we analyzed a series of latent variable models ranging from fully continuous factor models to fully categorical mixture models. Continuous models provided the best fit to the observed data and also suggested that a two-factor model of externalizing behavior, defined as (1) ODD+ADHD+CD and (2) SUD with adult antisocial behavior sharing common variance with both factors, was necessary to explain the covariation in externalizing disorders. The two-factor model of externalizing behavior was then replicated using a nationally representative sample drawn from the National Comorbidity Survey-Replication data (n?=?5,692). These results have important implications for the conceptualization of externalizing disorders in DSM-5.     

Group comparisons of DSM-IV subtypes of chronic depression: validity of the distinctions, part 2

The nosology of chronic depression in Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV, American Psychiatric Association, 1994) is highly complex and requires clinicians to differentiate among several chronic course subtypes. This study replicates an earlier investigation (J. McCullough et al., 2000; see record 2000-05424-007) that found few differences among Diagnostic and Statistical Manual of Mental Disorders (3rd ed. rev.; DSM-III-R; American Psychiatric Association, 1987) categories of chronic depression. In the present study, 681 outpatients with chronic major depression, double depression, recurrent major depression without full interepisode recovery, and chronic major depression superimposed on antecedent dysthymia were compared. Few differences were observed on a broad range of demographic, clinical, psychosocial, family history, and treatment response variables. The authors suggest that chronic depression should be viewed as a single, broad condition that can assume a variety of clinical course configurations.     

Diagnosis of Mood Disorders

This article provides an overview of mood disorders according to Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria and other relevant information. Differential diagnosis is facilitated through discussion of differences and similarities among mental disorders, age and gender-related patterns of mood disorders, and useful diagnostic tools.     

Screening for principal versus comorbid conditions in psychiatric outpatients with the Psychiatric Diagnostic Screening Questionnaire

In examining the performance of screening scales, a distinction should be made between principal and additional diagnoses. The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a brief, psychometrically strong self-report scale designed to screen for the most common Diagnostic and Statistical Manual of Mental Disorders (4th ed; DSM-IV) Axis I disorders encountered in outpatient mental health settings. In the present report, the authors compared the performance of the PDSQ in identifying principal and comorbid disorders. Seven hundred ninety-nine psychiatric outpatients completed the PDSQ and were interviewed with the Structured Clinical Interview for DSM-IV. The sensitivity and negative predictive values of the PDSQ subscales were similar for principal and additional diagnoses.     

The clenching-grinding spectrum and fear circuitry disorders: clinical insights from the neuroscience/paleoanthropology interface

This review discusses the clenching-grinding spectrum from the neuropsychiatric/neuroevolutionary perspective. In neuropsychiatry, signs of jaw clenching may be a useful objective marker for detecting or substantiating a self-report of current subjective emotional distress. Similarly, accelerated tooth wear may be an objective clinical sign for detecting, or substantiating, long-lasting anxiety. Clenching-grinding behaviors affect at least 8 percent of the population. We argue that during the early paleolithic environment of evolutionary adaptedness, jaw clenching was an adaptive trait because it rapidly strengthened the masseter and temporalis muscles, enabling a stronger, deeper and therefore more lethal bite in expectation of conflict (warfare) with conspecifics. Similarly, sharper incisors produced by teeth grinding may have served as weaponry during early human combat. We posit that alleles predisposing to fear-induced clenching-grinding were evolutionarily conserved in the human clade (lineage) since they remained adaptive for anatomically and mitochondrially modern humans (Homo sapiens) well into the mid-paleolithic. Clenching-grinding, sleep bruxism, myofacial pain, craniomaxillofacial musculoskeletal pain, temporomandibular disorders, oro-facial pain, and the fibromyalgia/chronic fatigue spectrum disorders are linked. A 2003 Cochrane meta-analysis concluded that dental procedures for the above spectrum disorders are not evidence based. There is a need for early detection of clenching-grinding in anxiety disorder clinics and for research into science-based interventions. Finally, research needs to examine the possible utility of incorporating physical signs into Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition posttraumatic stress disorder diagnostic criteria. One of the diagnostic criterion that may need to undergo a revision in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition is Criterion D (persistent fear-circuitry activation not present before the trauma). Grinding-induced incisor wear, and clenching-induced palpable masseter tenderness may be examples of such objective physical signs of persistent fear-circuitry activation (posttraumatic stress disorder Criterion D).     

Important questions remain to be addressed before adopting a dimensional classification of mental disorders

Comments on the original article "Plate tectonics in the classification of personality disorder: Shifting to a dimensional model," by T. A. Widiger and T. J. Trull. Widiger and Trull raised important nosological issues that warrant serious consideration not only for the personality disorders but for all mental disorders as the Diagnostic and Statistical Manual of Mental Disorders (DSM) is revised during the next few years. As argued compellingly by these authors, dimensional classification may indeed offer substantial improvement over the present categorical system. Several questions remain to be addressed in evaluating whether this is the case and, if so, how dimensional classification can be implemented to best serve the disparate users of the DSM.     

Dimensional versus categorical classification of mental disorders in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and beyond: comment on the special section

The value of including dimensional elements in the Diagnostic and Statistical Manual of Mental Disorders (DSM) has been recognized for decades. Nevertheless, no proposals have been made for introducing dimensional classification in the diagnostic system in a valid and feasible manner. As an initial step in this endeavor, the authors suggest introducing dimensional severity ratings to the extant diagnostic categories and criteria sets. Although not without difficulties, this would begin to determine the feasibility of dimensional classification and would address some limitations of the purely categorical approach (e.g., failure to capture individual differences in disorder severity, and clinically significant features subsumed by other disorders or falling below conventional DSM thresholds). The utility of incorporating broader dimensions of temperament and personality in diagnostic systems beyond the fifth edition of the DSM is also discussed.     

Social anxiety and premorbid personality disorders in paranoid schizophrenic patients treated with clozapine

The concept of anxiety as a distinct comorbid disorder in schizophrenia has recently been rediscovered after having been neglected for a long period of time due to both theoretical and clinical approaches adopted from the appearance of the first edition of the Diagnostic and Statistical Manual of Mental Disorders in 1950. This rediscovery was accentuated by the fact that the concept of comorbidity in various psychiatric disorders has recently won widespread favor within the scientific community, and that the use of atypical neuroleptic medication to treat patients with schizophrenia has been reported to lead to the emergence of anxiety symptoms. Of the atypical neuroleptic medications used to treat schizophrenia, clozapine has most frequently been reported to induce anxiety symptoms. In this paper, 12 cases of patients with paranoid schizophrenia who developed social phobia during clozapine treatment are reported, and their response to fluoxetine augmentation is assessed. Premorbid personality disorders were also investigated; patients were assessed using the Structured Clinical Interview for DSM-III-R-Patient Version and the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (DSM-III-R=Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised; DSM-IV=Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition). In addition, the Scale for the Assessment of Negative Symptoms, the Scale for the Assessment of Positive Symptoms, the Liebowitz Social Anxiety Scale (LSAS), the Frankfurt Beschwerde Fragebogen (Frankfurt Questionnaire of Complaints), and the Brief Psychiatric Rating Scale were used to rate clinical symptomatology. All patients were reevaluated after 12 weeks of cotreatment with clozapine and fluoxetine. In 8 (66.6%) of the 12 cases, symptoms responded (>/=35% LSAS score reduction) to an adjunctive regimen of fluoxetine. Furthermore, in 7 (58.3%) of the 12 cases, an anxious personality disorder (avoidant=33.3%; dependent=25%) was identified, but no significant differences in the prevalence of comorbid personality disorders emerged in comparison with a group of 16 patients with paranoid schizophrenia treated with clozapine who did not show symptoms of social phobia. The clinical relevance of the assessment and treatment of anxiety disorders is discussed in light of a clinical therapeutic approach that overcomes the implicit hierarchy of classification. Considering that the onset of anxiety-spectrum disorders (such as social phobia) can occur during the remission of psychotic symptoms in clozapine-treated patients with schizophrenia, a comprehensive approach to pharmacological therapy for patients with schizophrenia (or, at least for those treated with clozapine) should be adopted.     

DSM-IV: WhatY's New

The significant differences between the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R; American Psychiatric Association, 1987) and the DSM-IV (American Psychiatric Association, 1994) are described, focusing on the types of mental disorders counselors frequently diagnose and treat. These include several disorders included in the children's section as well as Adjustment Disorders, Substance-Related Disorders, Mood Disorders, Anxiety Disorders, and Personality Disorders.     

Impulsive-compulsive sexual behavior

Impulsive-compulsive sexual behavior is a little studied clinical phenomenon which affects approximately 5% to 6% of the population. In the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision, it is classified as an impulse control disorder not otherwise specified or a sexual disorder not otherwise specified. It may be placed in a possible new category in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition called substance and behavioral addictions. This clinical entity is reviewed and the merit of classifying it as an addiction is assessed. Information is presented regarding its diagnostic criteria, epidemiology, types of behavior it can involve, relationship to hypersexuality, comorbidities, treatment, and etiology. The data regarding this disorder and its overlap with chemical addiction is limited. If the two disorders are to be grouped together, further data are needed.     

Diagnostic categories or dimensions? A question for the Diagnostic And Statistical Manual Of Mental Disorders--fifth edition

The question of whether mental disorders are discrete clinical conditions or arbitrary distinctions along dimensions of functioning is a long-standing issue, but its importance is escalating with the growing recognition of the frustrations and limitations engendered by the categorical model. The authors provide an overview of some of the dilemmas of the categorical model, followed by a discussion of research that addresses whether mental disorders are accurately or optimally classified categorically or dimensionally. The authors' intention is to document the importance of this issue and to suggest that future editions of the Diagnostic and Statistical Manual of Mental Disorders give more recognition to dimensional models of classification. They conclude with a dimensional mental disorder classification that they suggest provides a useful model.     

Assessment and Diagnosis of DSM-IV Anxiety Disorders

Anxiety disorders, the 2nd most common type of mental disorders, are among the most frequently missed or misdiagnosed disorders (Frances & Ross, 1996). Once they are diagnosed, effective treatments exist for them. This article provides a review of current knowledge on the assessment and diagnosis of anxiety disorders classified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (American Psychiatric Association, 1994). Emphasis is on the recognition of anxiety as a dominant symptom, frameworks for determining specific anxiety disorders, and patterns of comorbidity.     

Neurocognitive endophenotypes of impulsivity and compulsivity: towards dimensional psychiatry

A key criticism of the main diagnostic tool in psychiatry, the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV), is that it lacks a biological footing. In this article, we argue for a biological approach to psychiatry based on 'neurocognitive endophenotypes', whereby changes in behavioural or cognitive processes are associated with discrete deficits in defined neural systems. We focus on the constructs of impulsivity and compulsivity as key examples of the approach and discuss their possible cross-diagnostic significance, applying them to co-morbidities and commonalities across a range of disorders (attention-deficit/hyperactivity disorder, substance dependence, obsessive-compulsive disorder and eating disorders). We argue that this approach has important implications for the future classification of psychiatric disorders, genetics and therapeutics.     

Toward a Developmental Diagnostic and Statistical Manual: The Vitality of a Contextual Framework

Counselors of all types need an understanding of and an ability to work with issues described by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association, 1994). The traditional approach to the DSM-IV tends to locate the problem in the client, whereas a developmental approach focuses on the client in social and historical context. Specific recommendations for organizing a comprehensive treatment plan are presented. The authors endorse an educational and developmental role for counselors.     

Pattern of comorbidity among anxious and odd personality disorders: the case of obsessive-compulsive personality disorder

The aim of this study was to examine the pattern of comorbidity among obsessive-compulsive personality disorder (OCPD) and other personality disorders (PDs) in a sample of 400 psychiatric inpatients. PDs were assessed using the Semistructured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Odds ratios (ORs) were calculated to determine significant comorbidity among OCPD and other axis II disorders. The most elevated odds ratios were found for the cooccurrence of OCPD with cluster A PDs (the "odd" PDs, or paranoid and schizoid PDs). These results are consistent with those of previous studies showing a higher cooccurrence of OCPD with cluster A than with cluster C ("anxious") PDs. In light of these observations, issues associated with the nosologic status of OCPD within the Diagnostic and Statistical Manual of Mental Disorders clustering system remain unsettled.     

Integrating normal and abnormal personality structure: a proposal for DSM-V

The personality disorders section of the American Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is currently being developed. The purpose of the current paper is to encourage the authors of DSM-V to integrate normal and abnormal personality structure within a common, integrative model, and to suggest that the optimal choice for such an integration would be the five-factor model (FFM) of general personality structure. A proposal for the classification of personality disorder from the perspective of the FFM is provided. Discussed as well are implications and issues associated with an FFM of personality disorder, including validity, coverage, feasibility, clinical utility, and treatment implications.     

Psychopathology in anxiety disorders

Complaints of anxiety, often meetingDiagnostic and Statistical Manual of Mental Disorders, 3rd ed. (DSM-III), criteria for anxiety disorder, are among the most common problems presenting to health practitioners. In spite of the frequency of anxiety and anxiety disorders, little is known about the basic psychopathology of these conditions that would lead to the development of more efficient and effective treatments and possible preventive efforts. Recently, there has been an increase in research on the psychopathology of anxiety disorders from biological, psychological, and social perspectives. The National Institute of Mental Health's Clinical Research Branch sponsored a 2-day workshop of investigators representing diverse research approaches to discuss emerging issues and research practices within the anxiety disorders. Discussions centered on a review of the general areas of classification, phenomenology, and etiology. A selective summary of this workshop is presented along with recommendations for specific research directions.