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.     

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.     

Unexpected reduction in migraine and psychogenic headaches following rTMS treatment for major depression: a report of two cases

Our objective is to report a coincident reduction in headache pain in patients treated with repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder (MDD). Two patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of MDD, non-responsive to prior antidepressant treatment who were enrolled in a sham-controlled, double-blind study of rTMS for MDD. After the study, it was revealed that both were in the active-treatment arm. Both patients suffered from near daily headaches and kept logs of headache frequency and severity before, during, and after the study. Headache pain was significantly reduced under double-blind conditions with rTMS treatment, but returned to baseline following cessation of rTMS treatment. Ultimately, when receiving rTMS post-study as a maintenance intervention for MDD (approximately 2 rTMS sessions/week), the positive effects on headache amelioration were sustained. Headache pain is frequently comorbid with mood disorders and has been reported as the most common side effect with rTMS. In these subjects, rTMS was, in fact, associated with relief of depressive symptoms and preexisting headache pain. This indicates that rTMS may be beneficial for both disorders in some patients.     

Mind the gap: assessing impairment among children affected by proposed revisions to the diagnostic criteria for oppositional defiant disorder

The Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5) workgroup for disruptive behavior disorders is considering adopting a frequency threshold for symptoms of oppositional defiant disorder (ODD). In the present study, the impact of substituting the term "often" with a specific age-based frequency on impairment and prognosis among preschool children was tested in a longitudinal design. Mutually exclusive groups were created to identify children who met criteria for ODD based on a symptom threshold of "often," as in Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-4), and those that met criteria for ODD based on a threshold of "1-2 times per day," which approximated the proposal for DSM-5. Comparisons of these groups to each other and to nondiagnosed peers determined the impact of changing the symptom threshold on impairment and prognosis. Close to one-third of children who met DSM-4 criteria for ODD did not meet criteria under the alternative diagnosis; African American children were overrepresented in this group. Preschoolers who met DSM-4, but not the alternative criteria, had higher rates of ODD, conduct disorder (CD), and were more impaired than their nondiagnosed peers at baseline and follow-up. Preschoolers meeting DSM-4 criteria were less impaired than children meeting the alternative ODD criteria at baseline according to parent, but not according to teacher report. No differences could be detected between those meeting DSM-4 and those meeting the alternative criteria in rate of ODD, CD, or impairment at follow-up. Among clinically referred preschool children, changing the symptom threshold for ODD could result in a sizable group of children who would no longer meet diagnostic criteria, despite demonstrating significant morbidity concurrently and prospectively.     

The impact of comorbidity on the management of pathological gambling

A 30-year-old woman with severe pathological gambling and cyclothymia presented to our program with no previous history of pharmacologic or psychotherapeutic treatment. Pathological gambling is an impulse -control disorder not otherwise specified (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) in which comorbidity is common, particularly with substance abuse, obsessive-compulsive disorder and mood disorders. As described in this case, pathological gamblers with bipolar comorbidity may be effectively treated with mood stabilizers such as lithium. After receiving 10 weeks of lithium treatment, the patient showed improvement in both gambling behavior and affective instability. The identification of specific subtypes among patients with pathological gambling may be relevant to the choice of pharmacologic treatment.     

Marital dissatisfaction and psychiatric disorders: results from the National Comorbidity Survey

The association between marital dissatisfaction and 12-month prevalence rates of Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev., 1987) Axis I psychiatric disorders was examined in married respondents from the National Comorbidity Survey (N = 2,538). Results indicate that marital dissatisfaction was associated with the presence of any disorder, any mood disorder, any anxiety disorder, and any substance-use disorder; dissatisfaction was also associated with 7 of 12 specific disorders for women and 3 of 13 specific disorders for men. To evaluate the unique association between marital dissatisfaction and psychiatric disorders, analyses were conducted controlling for comorbid disorders. Covariance analyses generally attenuated the bivariate associations between marital dissatisfaction and specific disorders and groupings of disorders. Results indicate that marital dissatisfaction was uniquely related to major depression and posttraumatic stress disorder for women and dysthymia for men.     

Externalizing psychopathology in adulthood: a dimensional-spectrum conceptualization and its implications for DSM-V

Mental disorders involving antisocial behavior and substance use are genetically linked and vary continuously. The authors present a review and integrative conceptualization of these observations in terms of a dimensional and hierarchically organized externalizing spectrum. As a foundation for this conceptualization, the authors introduce a quantitative, model-based approach to comparing categorical and continuous conceptions of psychopathology and apply this approach in an empirical study of patterns of comorbidity among externalizing disorders as defined in the Diagnostic and Statistical Manual of Mental Disorders. The authors present evidence that comorbidity among externalizing disorders is best modeled by an underlying normally distributed continuum of risk for multiple disorders within the externalizing spectrum. The authors conclude by discussing implications of the externalizing spectrum conceptualization for classification of disorders in the upcoming 5th edition of the Diagnostic and Statistical Manual of Mental Disorders.     

Diagnostic issues in posttraumatic stress disorder: considerations for the DSM-IV

Four issues of key interest with regard to posttraumatic stress disorder in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) are discussed. These include: (a) how to define the stressor criterion, especially, whether or not the victim's response ought to be included and whether low-magnitude traumas qualify etiologically; (b) the cohesiveness of the syndrome and the validity of items across stressor groups; (c) the position of posttraumatic stress disorder within DSM-IV; and (d) comorbidity with other illnesses.     

Associations between lower order anxiety sensitivity dimensions and DSM-5 posttraumatic stress disorder symptoms

Anxiety sensitivity (AS), a well-established individual difference variable reflecting a tendency to fear bodily sensations associated with arousal, has been implicated in the development and maintenance of posttraumatic stress disorder (PTSD). Despite these associations, little research has examined the relations between AS subfactors (eg physical, cognitive, and social) and PTSD symptoms and none have examined these associations in the context of DSM-5 (Diagnostic Statistical Manual of Mental Disorders, Fifth Edition) PTSD clusters (ie intrusion, avoidance, negative alterations in cognitions/mood, and arousal). Participants included 50 veterans presenting to an outpatient Veteran Affairs Clinic for psychological services. Upon intake, veterans completed a brief battery of self-report questionnaires to assist with differential diagnosis and treatment planning. Results revealed unique associations between lower order AS dimensions, in particular the cognitive concerns dimension, and all four DSM-5 PTSD symptom clusters. Given the malleable nature of AS cognitive concerns, as well as the growing number of veterans in need of care, future research should determine the extent to which targeting this cognitive risk factor reduces PTSD symptom severity among veterans.     

Alcohol and drug abuse-dependence disorders in psychopathic and nonpsychopathic criminal offenders

Co-occurrence of psychopathy (assessed with the Psychopathy Checklist) and lifetime Diagnostic and Statistical Manual of Mental Disorders (3rd ed.) alcohol and drug disorders (assessed with the National Institute of Mental Health Diagnostic Interview Schedule) was examined in a sample of 360 male inmates. Consistent with previous research that used diagnoses of antisocial personality disorder, psychopaths were more likely than nonpsychopaths to have lifetime diagnoses of alcoholism, any drug disorder, and multiple drug disorders. We also examined the relation between substance abuse and the 2 factors of the Psychopathy Checklist. Substance abuse was significantly related to general social deviance (Factor 2) but was unrelated to core personality features of psychopathy (Factor 1). We present two possible models of psychopathy (unitary syndrome vs. dual-diathesis model) that may account for the association between psychopathy and substance abuse.     

Disruptive Behavior Disorders in Children and Adolescents: How Do Girls Differ From Boys?

Disruptive behavior disorders in children and adolescents can lead to a lifetime of problems. The 2 disruptive behavior disorders identified in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM‐IV; American Psychiatric Association, 1994) are oppositional defiant disorder and conduct disorder. Although much research has been conducted to learn more about these 2 disorders, little is known about gender differences in the disorders. There is a dearth of specific information regarding girls with disruptive behavior disorders. This article discusses the diagnosis, risk factors, and treatment of oppositional defiant disorder and conduct disorder while incorporating information specific to girls to investigate how disruptive behavior disorders differ for girls.     

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.     

Pharmacotherapeutic options in the treatment of comorbid depression and anxiety

Although anxiety and mood disorders are listed as separate disorders in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, they frequently coexist. They may be expressed phenotypically as comorbidities or as the provisional entity mixed anxiety-depressive disorder. Patients with both anxiety and depression are more symptomatic, use more health care resources, and have a worse prognosis than those with a single disorder. Recognizing and treating these patients are challenges for physicians because the symptoms of the two disorders often overlap. Administration of effective treatment, comprising both anxiolytic and antidepressant effects, can reduce patient distress and disability, as well as inappropriate utilization of medical services. Medications such as tricyclic antidepressants, selective serotonin reuptake inhibitors, nefazodone, venlafaxine XR (extended release) and mirtazapine, are highly effective in treating comorbid depression and anxiety. These newer agents now represent the pharmacotherapeutic treatments of choice for the comorbid conditions.     

Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) groups disorders into diagnostic classes on the basis of the subjective criterion of "shared phenomenological features." There are now sufficient data to eliminate this rational system and replace it with an empirically based structure that reflects the actual similarities among disorders. The existing structural evidence establishes that the mood and anxiety disorders should be collapsed together into an overarching class of emotional disorders, which can be decomposed into 3 subclasses: the bipolar disorders (bipolar I, bipolar II, cyclothymia), the distress disorders (major depression, dysthymic disorder, generalized anxiety disorder, posttraumatic stress disorder), and the fear disorders (panic disorder, agoraphobia, social phobia, specific phobia). The optimal placement of other syndromes (e.g., obsessive-compulsive disorder) needs to be clarified in future research.     

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.     

Prevalence and effects of life event exposure among undergraduate and community college students

The purposes of this study were to assess lifetime and recent exposure to various life events among undergraduate and community college students and to assess the relation between event exposure and a broad range of outcomes (i.e., mental and physical health, life satisfaction, grade point average). Undergraduate students from a midwestern university (N = 842) and a community college (N = 242) completed online measures of lifetime event exposure and outcomes at Time 1 and recent event exposure at Time 2 two months later. Life events assessed included events that did and did not meet the definition of a traumatic event (i.e., posttraumatic stress disorder Criterion A1) in the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric Association, 2000) as well as directly (e.g., own life-threatening illness) and indirectly (e.g., others' illness) experienced events. Students reported experiencing many lifetime and recent Criterion A1 and non-A1 events, and community college students reported more events than did university students. Generally, individuals who reported more lifetime events also reported poorer outcomes (e.g., poorer health). The number of non-Criterion A1 and directly experienced events tended to be more strongly correlated with negative outcomes than were the number of Criterion A1 and indirectly experienced events reported. These findings suggest that non-A1 events are important to assess and can be significantly related to outcomes for students.     

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.     

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.     

Disorder as harmful dysfunction: a conceptual critique of DSM-III-R's definition of mental disorder.

The Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-III-R) operationally defines disorder essentially as "statistically unexpectable distress or disability." This definition is an attempt to operationalize 2 basic principles: that a disorder is harmful and that a disorder is a dysfunction (i.e., an inability of some internal mechanism to perform its natural function). However, the definition fails to capture the idea of "dysfunction" and so fails to validly distinguish disorders from nondisorders, leading to invalidities in many of DSM-III-R's specific diagnostic criteria. These problems with validity are traced to DSM-III-R's strategies for increasing reliability.     

The diagnosis, symptomatology, and epidemiology of seasonal affective disorder

The operational criteria for seasonal affective disorder (SAD) have undergone several changes since first proposed in 1984. SAD is currently included as a specifier of either bipolar or recurrent major depressive disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. The International Classification of Diseases, Tenth Edition has provisional diagnostic criteria for SAD. The most characteristic quality of SAD is that the symptoms usually present during winter and remit in the spring. Furthermore, the symptoms tend to remit when the patients are exposed to daylight or bright light therapy. The cognitive and emotional symptoms are as in other types of depression but the vegetative symptoms are the reverse of classic depressive vegetative symptoms, namely increased sleep and increased appetite. SAD is a common condition, but the exact prevalence rates vary between different studies and countries and is consistently found to be more common in women and in youth. SAD probably possibly occurs in children although not as commonly as in young adults. Some studies have found that certain ethnic groups who live at high northern latitudes may have adapted to the long arctic winter.