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Obsessive-Compulsive Disorder for ICD-11: Proposed Changes to the Diagnostic Guidelines and Specifiers Helen Blair Simpson,1,2 Y

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Obsessive-Compulsive Disorder for ICD-11: Proposed Changes to the Diagnostic Guidelines and Specifiers Helen Blair Simpson,1,2 Y Revista Brasileira de Psiquiatria. 2014;36:S3––S13 ß 2014 Associac¸a˜ o Brasileira de Psiquiatria doi:10.1590/1516-4446-2013-1229 UPDATE ARTICLE Obsessive-compulsive disorder for ICD-11: proposed changes to the diagnostic guidelines and specifiers Helen Blair Simpson,1,2 Y. C. Janardhan Reddy3 1College of Physicians and Surgeons, Columbia University Medical College, New York, NY, USA. 2Anxiety Disorders Clinic and the Center for OCD and Related Disorders, New York State Psychiatric Institute, New York, NY, USA. 3Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India. Since the approval of the ICD-10 by the World Health Organization (WHO) in 1990, global research on obsessive-compulsive disorder (OCD) has expanded dramatically. This article evaluates what changes may be needed to enhance the scientific validity, clinical utility, and global applicability of OCD diagnostic guidelines in preparation for ICD-11. Existing diagnostic guidelines for OCD were compared. Key issues pertaining to clinical description, differential diagnosis, and specifiers were identified and critically reviewed on the basis of the current literature. Specific modifications to ICD guidelines are recommended, including: clarifying the definition of obsessions (i.e., that obsessions can be thoughts, images, or impulses/urges) and compulsions (i.e., clarifying that these can be behaviors or mental acts and not calling these ‘‘stereotyped’’); stating that compulsions are often associated with obsessions; and removing the ICD-10 duration requirement of at least 2 weeks. In addition, a diagnosis of OCD should no longer be excluded if comorbid with Tourette syndrome, schizophrenia, or depressive disorders. Moreover, the ICD-10 specifiers (i.e., predominantly obsessional thoughts, compulsive acts, or mixed) should be replaced with a specifier for insight. Based on new research, modifications to the ICD-10 diagnostic guidelines for OCD are recommended for ICD-11. Keywords: Obsessive-compulsive disorder; ICD-11; nosology; classification Introduction Historical background Global research on obsessive-compulsive disorder OCD was considered a rare disorder until epidemiological (OCD) has expanded dramatically since approval of the studies demonstrated that it was more common than ICD-10 in 1990 by the World Health Organization (WHO). schizophrenia.4,5 However, descriptions of the problem In preparation for ICD-11, this article evaluates what have existed for centuries. For example, in 1691, John changes may be needed to enhance the scientific validity, Moore, Bishop of Norwich, England, described individuals clinical utility, and global applicability of the diagnostic obsessed by ‘‘naughty, and sometimes blasphemous guidelines for OCD. The article briefly summarizes the thoughts that start in their minds, while they are exercised development of the concept of OCD and the approach in the worship of God, despite all their endeavors to stifle taken by ICD-10.1 Then, this approach is compared to and suppress them… the more they struggle with them, that taken by the DSM, focusing on DSM-5 criteria the more they increase…’’6 In The anatomy of melan- (approved in 20132). Key issues for ICD-11 are raised choly, by Robert Burton, published in 1883, an individual and specific revisions are recommended. These revisions is described ‘‘who dared not go over a bridge, come near reflect discussions of the WHO ICD-11 Working Group on a pool, rock, steep hill, lie in a chamber where cross the Classification of Obsessive-Compulsive and Related beams were, for fear he may be tempted to hang, drawn Disorders, appointed by the WHO Department of Mental or precipitate himself… he [was] afraid he shall speak Health and Substance Abuse and reporting to the aloud… something indecent, unfit to be said’’ (quoted in International Advisory Group for the Revision of ICD-10 Berrios7). Mental and Behavioural Disorders. The revisions also The conceptualization of OCD has evolved, and this, reflect the priorities of the WHO3: to develop a classifica- in turn, has led to evolution in its treatments. When OCD tion system that is scientifically valid, clinically useful, and was understood on religious terms, exorcism and torture globally applicable. were often employed as treatment options.8 Later, it was debated whether OCD was a disorder of will, intellect, or emotions.9 In 1838, Esquirol described OCD as a ‘‘monomania,’’ a disorder in which the sufferer is Correspondence: Helen Blair Simpson, 1051 Riverside Drive, Unit ‘‘chained to actions that neither reason nor emotion 69, New York, NY, USA, 10032. have originated, that conscience rejects, and will cannot E-mail: [email protected] suppress.’’10 In the later part of the 19th century, Morel S4 HB Simpson & YCJ Reddy (1860 & 1866) described OCD as a disease of the Summary of the ICD-10 approach to OCD autonomic nervous system and called it de´lire e´motif,a neurosis. In 1903, Pierre Janet described how obses- Approved in 1990, ICD-10 provides a brief description of sions and compulsions develop over three phases: OCD, specific diagnostic guidelines, rules for differential initially characterized by a ‘‘psychasthenic’’ state (inde- diagnosis, and specifiers for classifying those with the cisiveness, need for perfectionism and orderliness, and disorder. The diagnostic guidelines and specifiers are restricted emotional expression); followed by a stage of provided in Table 1. ‘‘forced agitations’’ (need for symmetry, repeating, and According to the diagnostic guidelines, a diagnosis of checking); and, finally, manifestations of frank obses- OCD requires obsessional symptoms or compulsive acts sions and compulsions (aggressive, religious, and (or both) that are a source of distress or interference with sexual themes) (quoted in Pitman11). Around this time, activities and are present for a minimal duration (i.e., Freud described the famous case of Rat Man and most days for at least 2 weeks). The obsessional popularized psychoanalytic explanations and therapy symptoms and compulsive acts must have the following for OCD.12 Inthemid-20thcentury, learning theories characteristics: 1) to be recognized by the individual as became popular and led to behavioral13,14 and cogni- their own thoughts or impulses; 2) to be resisted tive therapy for OCD.15 In parallel, neurobiological unsuccessfully (at least one thought or act); 3) to not be explanations of OCD were beginning to unfold. For pleasurable in themselves; and 4) to be ‘‘unpleasantly’’ example, clomipramine, a tricyclic antidepressant which repetitive. has serotonergic properties, was demonstrated to be The rules for differential diagnosis focus on differentiat- effective in treating OCD and led to the serotonin ing OCD from major depressive disorder ‘‘because these hypothesis of OCD.16 two types of symptoms so frequently occur together.’’ The OCD is recognized in the diagnostic systems of both following decision rule is provided: ‘‘in an acute episode of the WHO (i.e., ICD) and the American Psychiatric the disorder, precedence should be given to the symptoms Association (i.e., DSM). This recognition spurred sys- that developed first; when both types are present but tematic study of this disorder. As a result, it is now neither predominates, it is usually best to regard the established that OCD is a disabling disorder, with a depression as primary. In chronic disorders the symptoms lifetime prevalence of about 2%,17 moderate to severe that most frequently persist in the absence of the other symptom severity, onset usually in childhood or adoles- should be given priority.’’ Panic attacks or phobic cence,18 and a typical chronic waxing and waning symptoms ‘‘are no bar to the diagnosis.’’ However, if course.19-21 It is also established that people with OCD obsessive-compulsive symptoms occur in the presence of have reduced quality of life as well as high levels of social schizophrenia or Tourette syndrome, a separate diagnosis and occupational impairment.22,23 Thus, improving the of OCD should not be made. detection and treatment of OCD can help reduce the ICD-10 provides several specifiers: those with pre- global burden of disease. dominantly obsessional thoughts and rumination; those To improve the detection of OCD, scientifically valid, with predominantly compulsive acts; and those with clinically useful, and globally applicable diagnostic guide- mixed obsessional thoughts and compulsive acts. It is lines are needed. Below, the ICD approach to OCD is noted that the relationship between obsessional rumina- summarized. Then, ICD and DSM approaches are tions and depression is ‘‘particularly close’’ and that a compared. Several issues are raised, and specific diagnosis of OCD should only be made if ‘‘ruminations recommendations for revisions to ICD are made to arise or persist in the absence of a depressive disorder.’’ enhance the scientific validity, clinical utility, and global ICD-10 also allows people to be diagnosed with Other applicability of ICD diagnostic guidelines for OCD in obsessive-compulsive disorders and Obsessive-compul- advance of the new edition, ICD-11. sive disorder, unspecified. Table 1 Diagnostic guidelines and specifiers for OCD from ICD-10 Diagnostic guidelines For a definite diagnosis, obsessional symptoms or compulsive acts, or both, must be present on most days for at least 2 successive weeks and be a source of distress or interference with activities. The obsessional symptoms should have the following characteristics:
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