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 Table of Contents  
DEBATE/PERSPECTIVE/VIEWPOINT
Year : 2018  |  Volume : 34  |  Issue : 5  |  Page : 34-43

Obsessive-compulsive and related disorders in international classification of Diseases-11 and its relation to international classification of Diseases-10 and diagnostic and statistical manual of mental Disorders-5


1 Department of Psychiatry OCD Clinic, OCD Clinic, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
2 Department of Psychiatry, Columbia University; Center for OCD and Related Disorders, New York State Psychiatric Institute, New York, USA
3 Department of Psychiatry and MRC Unit on Anxiety and Stress Disorders, Groote Schuur Hospital, Cape Town, South Africa

Date of Web Publication20-Nov-2018

Correspondence Address:
Prof. Y C Janardhan Reddy
OCD Clinic, National Institute of Mental Health and Neuro Sciences, Bengaluru - 560 029, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_38_18

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  Abstract 


The World Health Organization is in the process of publishing the 11th edition of international Classification of Diseases and Related Health Problems (ICD-11). This article discusses the rationale behind the creation of the new “Obsessive-Compulsive and Related Disorders (OCRD)” section in the ICD-11 chapter on Mental and Behavioral Disorders and compares it with the ICD-10 and the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The new section on OCRD was introduced in ICD-11 after a review of the relevant literature that has accumulated since the publication of ICD-10 in 1990. 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. These disorders are grouped together on the basis of considerations of diagnostic validity and clinical utility. The ICD-11 OCRD section is somewhat similar to the DSM-5 OCRD section, reflecting efforts to harmonize the two major classificatory systems. Clustering together disorders related to OCD may encourage clinicians in diverse settings worldwide to identify these disorders early and offer timely interventions.

Keywords: Classification, Diagnostic and Statistical Manual of Mental Disorders-5, International Classification of Diseases-10, International Classification of Diseases-11, obsessive-compulsive disorder, World Health Organization


How to cite this article:
Reddy Y C, Simpson H B, Stein DJ. Obsessive-compulsive and related disorders in international classification of Diseases-11 and its relation to international classification of Diseases-10 and diagnostic and statistical manual of mental Disorders-5. Indian J Soc Psychiatry 2018;34, Suppl S1:34-43

How to cite this URL:
Reddy Y C, Simpson H B, Stein DJ. Obsessive-compulsive and related disorders in international classification of Diseases-11 and its relation to international classification of Diseases-10 and diagnostic and statistical manual of mental Disorders-5. Indian J Soc Psychiatry [serial online] 2018 [cited 2018 Dec 11];34, Suppl S1:34-43. Available from: http://www.indjsp.org/text.asp?2018/34/5/34/245833




  Introduction Top


The World Health Organization (WHO) is revising the 10th edition of International Classification of Diseases (ICD-10), which was published in 1992.[1] The eleventh revision (ICD-11) is likely to be released soon. The ICD-11 guidelines reflect the priorities of the WHO, i.e., to develop a scientifically valid, clinically useful, and globally applicable classificatory system.[2] In this article, we discuss the changes made to obsessive-compulsive disorder (OCD) and disorders putatively related to OCD, the Obsessive-Compulsive and Related Disorders (OCRD) drawing extensively from the proposals made by the ICD-11 working group on the Classification of the OCRD.[3],[4],[5],[6],[7],[8],[9]

The ICD-11 workgroup on OCRD reviewed the extant scientific data[3],[4],[5],[6],[7],[8],[9] including reviews undertaken for the DSM-5,[10],[11],[12] focusing in particular on issues of clinical utility and global applicability. There are two key overarching changes to the ICD-10 clinical descriptions and diagnostic guidelines. First, OCD is moved from the section on “Neurotic, Stress-related, and Somatoform Disorders” to a new grouping now called OCRD, in line with a similar new chapter in DSM-5.[10] This section includes a number of diagnostic categories previously found elsewhere in ICD-10 as well as some new conditions. Body dysmorphic disorder (BDD) and hypochondriasis, which was previously classified as hypochondriacal disorder under “Somatoform Disorders,” and trichotillomania which was previously classified as one of the “Habit and Impulse Disorders” are now included in the OCRDs. Olfactory reference disorder (ORD), hoarding disorder, and excoriation (skin-picking) disorder are new diagnostic categories in ICD-11 OCRD. In ICD-10, Tourette syndrome (TS) is grouped under “Behavioural and Emotional Disorders with Onset Usually Occurring in Childhood and Adolescence,” but in the ICD-11, is classified under “Primary Tics and Tic Disorders” in the chapter on “Diseases of the Nervous System,” and is cross-referenced under OCRD because of its relationship to OCD. Second, diagnostic guidelines for OCD and other disorders in the OCRD section are extensively modified to reflect developments in the field. We discuss first the rationale for the creation of the new supraordinate category of OCRDs and then discuss key diagnostic guidelines for OCRD in ICD-11, comparing these with ICD-10 and DSM-5.[3],[4],[5],[6],[7],[8],[9],[13]


  Why does International Classification of Diseases-11 have an Obsessive-compulsive and Related Disorders Chapter? Top


OCD is traditionally described as an anxiety disorder, a concept reflected in the ICD-10 and DSM-IV classification. However, in the last two decades, there has been considerable progress in understanding the psychobiology of OCD and the putative spectrum disorders, and there has been renewed debate as to whether OCD is best understood as primarily an anxiety disorder or as a disorder of compulsivity. Extensive reviews on the topic suggest that several disorders appeared more closely related to OCD than to other neighboring disorders such as anxiety disorders.[3],[12],[14] While data on validators are not always consistent across these disorders,[15],[16] overlap in phenomenology and comorbidity may contribute to the clinical utility of clustering them together.[17]

One proposal has been that OCD be retained in the category of anxiety disorders, but that this category also includes OC spectrum disorders along with OCD to emphasize the link between certain OC spectrum disorders and anxiety disorders,[11] an approach similar to that taken in ICD-10 where OCD and anxiety disorders are subsumed under a larger, overarching category of “Neurotic, Stress-related, and Somatoform Disorders.” Data from OCD collaborative genetics study supported a familial relationship between OCD, some anxiety disorders (generalized anxiety disorder, agoraphobia), cluster C personality disorders (obsessive-compulsive and avoidant), certain OCRDs (BDD, hypochondriasis, grooming disorders), and tic disorders supporting a supraordinate category that would include anxiety and putative OC spectrum disorders.[18]

In both DSM-5 and ICD-11, the close relationship between anxiety disorders and OCRDs is acknowledged by having these sections follow one another. The OCRDs are, however, classified separately, on the basis of considerations of diagnostic validity and clinical utility (e.g., overlap in phenomenology and comorbidity,[12] as well as some evidence of shared involvement of frontostriatal and reward circuitry[19],[20] that is partly distinct from the circuits involved in other anxiety disorders,[21] some overlap in familial relationship, and partial overlap in treatment response).[12],[22] A diagnostic section that focuses on these underdiagnosed and undertreated conditions may have important positive public health implications[23] by increasing awareness of and clinical and research attention to a range of conditions that have been relatively overlooked in India and across the globe.


  Obsessive-compulsive and Related Disorders Section in Diagnostic and Statistical Manual of Mental Disorders-5 and International Classification of Diseases-11 Top


The OCRD sections in DSM-5 and ICD-11 are similar in many ways, for example, both now include BDD. At the same time, there are also some differences, with the OCRD section of ICD-11 including additional disorders such as ORD and hypochondriasis.

BDD is classified as part of hypochondriacal disorder in ICD-10, although individuals with more delusional symptoms might also have fallen under the rubric of a delusional disorder.[5] In DSM-IV, BDD was classified as somatoform disorder, but again those with poor/absent insight and delusions of self-reference could be diagnosed as suffering from delusional disorder. In ICD-11 and DSM-5, the point is explicitly made that BDD can be associated with poor or absent insight and delusions of reference and that such individuals should not be diagnosed with a delusional disorder. This change is based on data that delusional BDD responds to SSRIs and CBT in the same way that nondelusional BDD does, and so should not simply be managed as a psychotic condition.[5]

In ICD-10 and DSM-IV, ORD (preoccupation about emitting foul or offensive odor) without insight would most likely be classified as delusional disorder. In DSM-IV, ORD is also implicitly referred to in social phobia where the culture-bound syndrome “taijin kyofusho” is mentioned. The DSM-5 does not have a separate diagnosis of ORD, instead it is mentioned in the “not otherwise specified” section of the OCRD chapter. In contrast, the ICD-11 has a separate category of ORD under OCRD partly reflecting its greater recognition and prevalence in non-western societies and in line with a view that it has important overlaps with both BDD and OCD.[5]

The DSM-5 workgroup emphasized the heterogeneity of hypochondriasis regarding varying quantity of fear, somatic preoccupation, obsessive thoughts and disease conviction.[12] Given this heterogeneity, the condition may belong to various spectrums (e.g., a broader anxiety spectrum, an OCD spectrum, a somatization spectrum, or a depressive spectrum). In DSM-5 hypochondriasis is, however, termed “illness anxiety disorder” and remains in the “somatic symptom and related disorders” chapter. In contrast, the ICD-11 work-group recommended its inclusion under OCRD with cross reference to the anxiety disorders grouping, in view of its phenomenological similarity with both anxiety disorders (e.g., fear, hypervigilance to bodily symptoms, and avoidance) and OCRD (e.g., preoccupation and repetitive behaviors such as compulsive checking and reassurance seeking), the distinction from the somatoform disorders (presence of somatic symptom is not a critical characteristic), and similar treatment response of OCD/anxiety disorders and hypochondriasis to SSRIs and CBT.[6],[24] It is hoped that the classification of hypochondriasis in the OCRD section with cross-reference to anxiety disorders will improve its recognition and treatment across a range of healthcare settings globally.[6]

Hoarding has long been considered as a manifestation of OCD or obsessive-compulsive personality disorder (OCPD), a view implicitly taken by DSM-IV. Research on hoarding in the last two decades suggests that hoarding is distinct from OCD and OCPD in a number of aspects,[17] although it also has a number of overlaps with other OCRD, including in phenomenology. In view of these overlaps both the DSM-5 and ICD-11 include hoarding disorder under OCRD.

In ICD-10, trichotillomania is an impulse control disorder whereas skin-picking disorder is not a diagnostic entity. In DSM-5 and ICD-11, these conditions are listed in OCRD. In ICD-11, they are grouped under a subcategory of body-focused repetitive disorders (BFRD) because of shared phenomenology, bidirectional comorbidity, and similar treatment approaches.[8] This is in accordance with the view that BFRD is a “motoric” OCRD whereas other conditions are “cognitive” OCRDs.[11],[12] This subgrouping within OCRD is supported by the results of a large twin study that identified two latent vulnerability factors for OCRDs that are largely under genetic control, one common across all OCRDs and the other loading exclusively on trichotillomania and skin-picking disorder.[25] TS is cross-referenced in the ICD-11 section on OCRDs because OCD and TS have phenomenological overlap, are highly comorbid with each other, share familial history, and involve frontostriatal circuitry.[9]


  Diagnostic Guidelines for Obsessive-compulsive and Related Disorders in International Classification of Diseases-11 Top


Similarities and differences between ICD-10, ICD-11, and DSM-5 with respect to OCRDs are shown in [Table 1].
Table 1: Obsessive-compulsive and related disorders in International Classification of Diseases-11 and their comparison with International Classification of Diseases-10 and Diagnostic and Statistical Manual of Mental Disorders-5

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Obsessive-compulsive disorder

The diagnostic guidelines for OCD in ICD-11 retain the core features of OCD as in ICD-10 and DSM-5 (i.e., the presence of obsessions and/or compulsions). Departures from ICD-10 include refined definition of obsessions and compulsions, acknowledgment of the functional relation between obsessions and compulsions, removal of the duration criterion for diagnosis, allowing a diagnosis of OCD in the presence of other disorders such as depression, schizophrenia and Tourette's disorder, inclusion of insight and panic attack qualifiers, and removal of symptom subtype qualifiers.[3],[4]

Definition of obsessions and compulsions

The ICD-11 has changed “impulses” in ICD-10 to “impulses/urges” to maintain some consistency with DSM-5 and to give freedom to clinicians to use either “urges” or “impulses,” depending on the relevant context and language. In some languages, “urge” and “impulse” are used interchangeably because of similar if not identical meanings. In addition, “urge” may tap some sensory phenomena which are commonly reported in OCD.[26] Sensory phenomena are noncognitive or subjective experiences that precede compulsions.

The ICD-10 defines compulsions as “stereotyped behaviors” whereas compulsions are often “in relation to” obsessions.[4] The ICD-10 definition that compulsions are behavioral acts is also not consistent with the evidence that the majority of OCD patients have both behavioral as well as mental compulsions.[27],[28] Accordingly, the ICD-11 definition of compulsions does not include the word “stereotyped” and acknowledges that compulsions, as in DSM-5 are repetitive behaviors including repetitive mental acts.

The ICD-10 did not describe a functional relationship between obsessions and compulsions. The ICD-11 workgroup recognized that compulsions are performed “in relationship to” obsessions and not necessarily always “in response to” obsessions since some have hypothesized that compulsions can precede obsessions (for example in children).[4] However, since many patients report performing compulsions “in response to” obsessions and because this concept has clinical utility (e.g., this relationship is used in designing exposure and response prevention), the ICD-11, as in DSM-IV and DSM-5 acknowledges that compulsions can be performed “in response to” an obsession, according to rigid rules, or to achieve a sense of “completeness”. Identifying a relationship between obsessions and compulsions helps in differentiating OCD from other disorders with predominantly ruminations (anxious and depressive ruminations in anxiety and depression) and from disorders with repetitive behaviors without associated obsessions (trichotillomania and skin-picking disorder).[4] Recognizing compulsions as behaviors in response to obsessions may also help in implementation of CBT where exposure to obsessions is encouraged, but where the performance of compulsions is discouraged, to allow habituation and extinction of fear. Inclusion of “sense of completeness” is noteworthy since “sensory phenomena” or “not-just-right experiences” are common in OCD.[26]

Duration guideline

The ICD-10, unlike DSM-IV and DSM-5, requires that obsessive-compulsive symptoms be present on most days for at least 2 successive weeks. Arguably the duration criterion in ICD-10 may discourage clinicians from a making a diagnosis of OCD when in fact OC symptoms are part of other disorders such as depression or psychosis. However, there are no data to validate the 2-week duration criterion. Therefore, ICD-11 has removed the duration criterion. The ICD-11 workgroup recommended that the accompanying text mention that a diagnosis of OCD should be made cautiously in patients who present with a very short duration of illness.[4]

Diagnosis of obsessive-compulsive disorder when comorbid with other disorders

In ICD-10, a diagnosis of OCD cannot be made in the presence of coexisting depressive disorder, schizophrenia, or TS. OCD may be diagnosed in those with depression if OCD occurred first or if OCD persists in the absence of depression. While this may prevent misdiagnosis of depressive ruminations as OCD, it may also lead to underdiagnosis of depression in those with OCD since OCD in many sufferers precedes onset of depression and persists beyond a depressive episode. OCD is a common comorbid condition in schizophrenia[29] and TS[30] and may require treatment with SSRIs or CBT. It is in this context that ICD-11, as in DSM-5, employs a nonhierarchical approach and allows a diagnosis of OCD in the presence of co-existing depressive disorder, schizophrenia, or TS.

Qualifiers

Major changes to the ICD-10 guidelines for OCD are with respect to qualifiers. The ICD-10 symptom subtypes are eliminated in the ICD-11 since most OCD patients have both obsessions and compulsions[26] and outcome does not seem to differ based on symptom subtyping.[31]

Conventionally, OCD has been considered as a disorder with well-preserved insight, but more recent studies have shown that insight can be poor and even absent in OCD[27],[28],[32] contributing to poor treatment outcome.[33] Assessing insight has important clinical implications. Poor insight OCD often gets misdiagnosed as delusional disorder or psychosis and is treated with antipsychotics instead of SSRIs. However, poor insight OCD patients may respond to SSRIs just as well as those with good insight.[34] Assessing insight may also help in the choice of psychosocial treatment since those with very poor insight may benefit more by the inference-based approach than by the standard cognitive-behavior therapy.[35]

The ICD-11 and DSM-5 guidelines both reflect this new knowledge and depart in a significant way from DSM-IV and ICD-10. Specifically, the DSM-IV required that “at some point” the person has recognized that the obsessions or compulsions are excessive or unreasonable (except in children) and ICD-10 implied that insight is well preserved. ICD-11 and DSM-5 have removed this requirement. As a specifier, DSM-5 classifies insight into “good/fair,” “poor” and “absent/delusional,” so allowing a range of insight in OCD.[26] ICD-11 has a qualifier for insight, classifying it dichotomously into “fair to good” and “poor to absent.” The ICD-11 took the view that there was clinical utility in identifying poor insight, but that the clinical utility and global applicability of describing a broad spectrum of insight was unclear. Moreover, clinicians may be unable to reliably distinguish poor insight from “good/fair” and “delusional” insight.

The DSM-5 has a “tic-related” specifier. In ICD-11, it was thought that this specifier was not needed, given that tic disorders are cross-listed in the OCRD section.[36] As in DSM-5, the ICD-11 has a “panic attacks” qualifier, which can be given to a broad range of conditions, including the OCRDs. This has two purposes; first to avoid a diagnosis of panic disorder when panic attacks are in response to obsessions, and second as a measure of severity of OCRDs because recurrent panic attacks may be indicative of the greater severity of psychopathology, poorer response to treatment, and greater risk for suicide.

Other obsessive-compulsive and related disorders

Body dysmorphic disorder, olfactory reference disorder, hypochondriasis, and hoarding

In ICD-11, OCRDs other than BFRD and TS have an insight qualifier recognizing the existence of delusional forms of these disorders, to help ensure that these individuals receive appropriate treatment. The DSM-5 has a “muscle dysmorphia” specifier for BDD, which is absent in ICD-11 given the relative lack of evidence to show that this specifier entails a different treatment approach.

In ICD-10, delusional hypochondriasis may be diagnosed as delusional disorder whereas in DSM-5, there is no clarity on where to classify delusional patients. In contrast, ICD-11 is more nuanced in its description and has an insight qualifier identical to that of OCD and other OCRDs. The ICD-11 also differs from DSM-5 in that there is no “care-seeking” and “care-avoidant” qualifier.

Hoarding was not described in ICD-10 whereas the descriptions of hoarding in ICD-11 and DSM-5 are somewhat similar. The DSM-5 and the ICD-11 both have an insight qualifier for hoarding, but the DSM-5 also has a “with excessive acquisition” specifier. In DSM-5, “excessive acquisition” is not an essential criterion, while it is a key feature of the diagnostic guidelines for hoarding disorder in ICD-11. Indeed, there is some evidence that all patients with hoarding disorder have an acquisition tendency when exposed to relevant cues.[7]

Body-focused repetitive behavior disorders

The BFRD differ from OCD and other disorders in that the repetitive behaviors are not preceded by cognitive phenomena such as obsessions or preoccupations, but instead may be preceded by sensory phenomena. The clinical description of ICD-11 BFRD is similar to the descriptions of trichotillomania and skin-picking disorder in DSM-5.[8]

Tourette syndrome

Core clinical features are somewhat similar in ICD-10, DSM-IV, DSM-5, and ICD-11; however, the DSM-IV and DSM-5 require onset before 18 years for a diagnosis whereas in ICD-10 and ICD-11 this is not an essential requirement and adult-onset illness is recognized. The DSM-5 has a specifier for ‘lifetime’ tic-related OCD (any tic disorder) whereas ICD-11 cross-references TS in OCRD.


  Obsessive-compulsive and Related Disorders: Cultural Issues Top


OCD is now a globally familiar disorder recognized by clinicians and researchers worldwide. There have been attempts to understand the influence of culture, in particular, religion, on the clinical manifestation of OCD. It has been suggested that patients belonging to certain religions may have more religious/blasphemy obsessions than others.[37] Similarly, the washing/cleaning symptom dimension has been described as a “cultural neurosis” called “Suchi-Bai” syndrome among Bengali women in India.[38],[39] However, more systematic studies of symptoms in OCD from India[40] and Japan,[41] including data on insight from India,[32] demonstrate that OCD manifests similarly globally. While symptom content may reflect cultural differences, symptom form in OCD may reflect universal neurobiological mechanisms.

Although there is abundant literature on OCD from India,[42] the same cannot be said about other disorders in the OCRD section. For example, rates of BDD, trichotillomania, hypochondriasis, and tic disorders are relatively low even in specialized OCD clinic populations in India. Clinical descriptions resembling BDD and ORD are described in Asian cultures, particularly in Japan and China. Tajin kyofusho, a culture-bound syndrome, described in Japan and other Asian counties, is characterized by an intense fear of offending others through improper or awkward social behavior, movements, appearance, or body odor.[5],[24],[43] Variants of taijin kyofusho, shubo-kyofu (fear of having a deformed body), and jiko-shu-kyofu (offending others by emitting foul body odor) are similar to BDD and ORD, respectively. As in BDD, social anxiety and avoidance are common in ORD secondary to beliefs pertaining to fear of emitting foul odor but differs from social anxiety disorder in that in the latter, anxiety in social situations is because of fear of negative evaluation by others in social or performance situations (e.g., having a conversation, giving a speech e.g.)[5] An additional feature that may help differentiate ORD from social anxiety disorder is the poorer insight (as in jiko-shu-kyofu) in the former compared to well-preserved insight in the latter. Another culture-bound syndrome reported in Asia, koro or suo-yang (also called genital retraction syndrome) has been hypothesized to be a cultural variant of BDD,[44] but is more likely to reflect a state of intense transient anxiety often shared by the immediate family.

Hoarding disorder is not commonly diagnosed in India, and even in specialized OCD clinics patients who meet the clinical threshold for a diagnosis of this condition are rarely encountered. A study from India showed that clinically significant hoarding is not uncommon among patients with OCD, but none of the hoarders specifically sought treatment for hoarding.[45] The expression of hoarding may differ between individualistic and collectivist cultures; however, the role of culture in the expression of hoarding symptoms is not well studied and remains unclear.


  Conclusion Top


In accordance with WHO's priorities of developing a scientifically valid, clinically useful, and globally applicable classificatory system, the new section on OCRD was introduced in ICD-11 after a review of the relevant literature that had accumulated since the publication of ICD-10 in 1992. The disorders were grouped together because of accumulating evidence supporting a relationship among these conditions with respect to several validators as well as considerations of clinical utility. The ICD-11 OCRD section is similar to the OCRD chapter in DSM-5, although with some differences, reflecting efforts to harmonize the two major classificatory systems. Clustering together disorders that appear to be related to OCD may encourage clinicians in diverse settings worldwide to identify these disorders early and offer timely interventions. This may be true in Asian cultures and India in particular, where there is not much clinical attention to these disorders apart from OCD. Regarding research, prominence given to the disorders grouped with OCD may also encourage investigation of the shared and distinct neurobiological basis of these disorders, and this may, in turn, lead to the development of novel treatment strategies.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors of this manuscript were part of the ICD-11 workgroup on OCD and related disorders. Prof. Simpson and Dan Stein were also part of DSM-5 “Anxiety, OC spectrum, posttraumatic, and dissociative disorder” workgroup.



 
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