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Anxiety Disorders, Obsessive-Compulsive and

Related Disorders, Trauma- and Stressor-
Related Disorders, and...

Article in American Journal of Psychiatry · June 2014

DOI: 10.1176/appi.ajp.2014.14010003 · Source: PubMed

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 Commentary

Anxiety Disorders, Obsessive-Compulsive and

Related Disorders, Trauma- and Stressor-Related
Disorders, and Dissociative Disorders in DSM-5

D SM-5 introduced a number of substantial and clinically relevant changes in

the classification of anxiety and related disorders. One of the most striking was the
decision to have separate chapters for anxiety disorders, obsessive-compulsive and
related disorders, and trauma- and stressor-related disorders. This decision reflects
the growing evidence base on the diagnostic validity and clinical utility of these
different groupings. Furthermore, adoption of these new groupings helps to explain
a number of other changes in DSM-5, including some of the new diagnostic criteria.
In this commentary, we also discuss the chapter on dissociative disorders, whose
placement next door to the chapter on trauma- and stressor-related disorders is
consistent with guiding principles for the overall organization of DSM-5 chapters.
The DSM-5 chapter on anxiety disorders comprises separation anxiety disorder,
selective mutism, specific phobia, social anxiety disorder (social phobia), panic dis-
order, agoraphobia, generalized anxi-
ety disorder, substance/medication-
induced anxiety disorder, anxiety disorder The DSM-5 chapter on trauma- and
due to another medical condition, other stressor-related disorders is [a] new
specified anxiety disorder, and unspec- chapter that includes disorders that
ified anxiety disorder. Each disorder in
this chapter is characterized by exces-
were dispersed throughout DSM-IV.
sive fear and anxiety as well as related
behavioral disturbances, including avoidance symptoms. However, the anxiety dis-
orders differ from one another insofar as each has a different mean age of onset (the
chapter is arranged from earlier onset to later onset, as is generally the case across
DSM-5), symptoms are precipitated by different situations or objects, and most are
characterized by cognitive ideation that differs across disorders.
Despite these differences, DSM-5 diagnostic criteria for anxiety disorders typi-
cally have close parallels, with greater consistency than in DSM-IV. The criteria
highlight marked fear or anxiety symptoms, the specific thoughts associated with
these symptoms, their disproportionate and persistent nature, consequent distress
and impairment, and that symptoms are not attributable to physiological effects of
a substance or another medical condition, and are not better explained by the symp-
toms of another mental disorder. These similarities reflect important parallels in the
assessment and management of these prevalent and often disabling disorders.
The new DSM-5 chapter on obsessive-compulsive and related disorders contains
some of the most substantial changes in the manual, including two new disorders:
hoarding disorder and excoriation (skin-picking) disorder. The other disorders in this
chapter are obsessive-compulsive disorder (OCD), body dysmorphic disorder, tricho-
tillomania (hair-pulling disorder), substance/medication-induced obsessive-compulsive

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COMMENTARY

and related disorder, obsessive-compulsive and related disorder due to another

medical condition, other specified obsessive-compulsive and related disorder, and
unspecified obsessive-compulsive and related disorder. Some of these disorders are
characterized by obsessions or preoccupations as well as by consequent repetitive
behaviors or mental acts, whereas others are characterized primarily by recurrent
body-focused repetitive behaviors (i.e., hair pulling and skin picking) and repeated
attempts to decrease or stop these behaviors.
As in the anxiety disorders chapter, there are some parallels in the diagnostic
criteria and specifiers across these disorders; for example, OCD, body dysmorphic
disorder, and hoarding disorder may be specified as having good or fair insight,
poor insight, or absent insight/delusional disorder-related beliefs. These parallels
are intended to encourage particular approaches to assessment and treatment. Of
note, the new insight specifier highlights the fact that individuals with obsessive-
compulsive and related disorders and poor or absent disorder-related insight
should not be diagnosed with a psychotic disorder and should be managed using
evidence-based treatments for the obsessive-compulsive and related disorders
rather than for psychotic disorders.
The DSM-5 chapter on trauma- and stressor-related disorders is another new
chapter that includes disorders that were dispersed throughout DSM-IV. This
chapter includes reactive attachment disorder, disinhibited social engagement
disorder, posttraumatic stress disorder (PTSD), acute stress disorder, adjustment
disorders, other specified trauma- and stressor-related disorders, and unspecified
trauma- and related-disorders. These disorders are characterized by a precipitating
exposure to a traumatic or stressful event. Although other disorders in DSM may be
precipitated by a traumatic or stressful event, the disorders in this chapter differ in
that a trauma or stressor is required for the disorder’s onset (although genetic and
neurobiological factors also play a role). However, these disorders differ in a num-
ber of ways, including the type of precipitating event and the duration and pattern
of symptoms. For example, social neglect or deprivation are present in both reac-
tive attachment disorder and in disinhibited social engagement disorder, but the
former is characterized by internalizing symptoms and the latter by externalizing
symptoms.
Establishing this as a new, separate chapter—and moving PTSD and acute stress
disorder from the anxiety disorders—reflects a great deal of evidence that anxiety is
only one of several emotional responses to trauma and other adverse events. For
example, whereas some individuals with a trauma- and stressor-related disorder
may exhibit anxiety- or fear-based symptoms, other individuals may instead, or in
addition, display anhedonic and dysphoric symptoms, externalizing anxiety and
aggressive symptoms, or dissociative symptoms. Classifying these disorders in a
way that emphasizes that a traumatic or stressful event is a required diagnostic
criterion encourages clinicians to assess these events and use appropriate trauma-
and stressor-based treatments.
Dissociative disorders include depersonalization/derealization disorder, disso-
ciative amnesia, and dissociative identity disorder. Dissociative symptoms are
characterized in DSM-5 by “a disruption of and/or discontinuity in the normal
integration of consciousness, memory, identity, emotion, perception, body rep-
resentation, motor control, and behavior.” Placement of the dissociative disorders
chapter next to the trauma- and stressor-related disorders chapter is based on con-
siderable evidence that traumatic experiences, especially in childhood, predispose
individuals to dissociative symptoms. Indeed, dissociative symptoms are included

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 COMMENTARY

in the diagnostic criteria for posttraumatic and acute stress disorders. On the other
hand, the association between trauma exposure and dissociative disorders is var-
iable, and these disorders may occur without prior trauma exposure (1). Thus, the
dissociative disorders are classified in a separate chapter but one that immediately
follows trauma- and stressor-related disorders. This juxtaposition is intended to
underscore similarities among some disorders in these two chapters and to stim-
ulate further research on the relationship between traumatic exposure and the
development of dissociative disorders.
The order of diagnostic categories has more meaning in DSM-5 than in DSM-IV.
The fact that anxiety disorders follow depressive disorders, that obsessive-compulsive
and related disorders follow anxiety disorders, and that dissociative disorders follow
trauma- and stressor-related disorders is intended to emphasize the close relation-
ships among some of the conditions in these contiguous chapters (2). However, it is
important to emphasize that even within each of these DSM-5 chapters, disorders
have substantive differences across many validators, such as their neurobiology and
treatment. Thus, for example, not all medications useful for panic disorder are
efficacious in social anxiety disorder. While any particular classification approach
to these disorders has pros and cons (2), the DSM-5 approach is based on multiple
studies of diagnostic validity (3–6) and should optimize clinical utility and lead to
better patient care. We also believe that these revisions in DSM-5 meta-structure
will stimulate important research which, in turn, will inform future iterations of the
diagnostic classification.
References
1. Friedman MJ, Resick PA, Bryant RA, Strain J, Horowitz M, Spiegel D: Classification of trauma and stressor-
related disorders in DSM-5. Depress Anxiety 2011; 28:737–749
2. Stein DJ, Craske MG, Friedman MJ, Phillips KA: Meta-structure issues for the DSM-5: how do anxiety disorders,
obsessive-compulsive and related disorders, posttraumatic disorders, and dissociative disorders fit together?
Curr Psychiatry Rep 2011; 13:248–250
3. Phillips KA, Friedman MJ, Stein DJ, Craske M: Special DSM-V issues on anxiety, obsessive-compulsive spectrum,
posttraumatic, and dissociative disorders. Depress Anxiety 2010; 27:91–92
4. Craske MG, Rauch SL, Ursano R, Prenoveau J, Pine DS, Zinbarg RE: What is an anxiety disorder? Depress Anxiety
2009; 26:1066–1085
5. Friedman MJ, Resick PA, Bryant RA, Brewin CR: Considering PTSD for DSM-5. Depress Anxiety 2011; 28:750–
769
6. Phillips KA, Stein DJ, Rauch SL, Hollander E, Fallon BA, Barsky A, Fineberg N, Mataix-Cols D, Ferrão YA, Saxena
S, Wilhelm S, Kelly MM, Clark LA, Pinto A, Bienvenu OJ, Farrow J, Leckman J: Should an obsessive-compulsive
spectrum grouping of disorders be included in DSM-V? Depress Anxiety 2010; 27:528–555
DAN J. STEIN, M.D., PH.D.
MICHELLE A. CRASKE, PH.D.
MATTHEW J. FRIEDMAN, M.D., PH.D.
KATHARINE A. PHILLIPS, M.D.

From the Department of Psychiatry, University of Cape Town, South Africa; the Department of Clinical
Psychiatry, University of California, Los Angeles; the Department of Psychiatry, Dartmouth University, Hanover,
N.H.; and the Department of Psychiatry and Human Behavior, Brown University, Providence, R.I. Address
correspondence to Dr. Stein (dan.stein@uct.ac.za). Commentary accepted for publication January 2014 (doi: 10.
1176/appi.ajp.2014.14010003).

Dr. Stein is supported by the Medical Research Council of South Africa and has received research grants or
consultancy honoraria from Biocodex, Lundbeck, Novartis, Servier, and Sun. Dr. Craske is an NIH grant
recipient and has received royalties from books published at APA and Oxford Press. Dr. Phillips has received
research or salary support from NIMH, Norman Prince Neurosciences Institute/Brown Institute for Brain
Science, Transcept Pharmaceuticals, Forest Laboratories, and the Food and Drug Administration; consulting
fees from Janssen Research and Development; and honoraria, royalties, or travel reimbursement from Oxford
University Press, Guilford Press, Elsevier, American Psychiatric Publishing, and Global Medical Education.
Dr. Friedman reports no financial relationships with commercial interests.

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