Descriptive Psychopathology: The Signs and Symptoms of ...

294 Section 3: Examination domainsbetween the classic OCD syndrome and its variants, the DSM and ICD placeOCD in the anxiety disorders category and the recognized OCD variants in othercategories.The decision to place OCD in the anxiety disorders category was basedprimarily on the idea that obsessions lead to anxiety and associated avoidancebehaviors (phobic-like), while compulsions reduce anxiety. 3 Anxiety, however, isa non-specific phenomenon and most conditions listed in the DSM Axis I andthe ICD equivalent could be classified as an anxiety disorder by the criterion ofthe presence of substantial anxiety. The recognized OCD variants were placedinto different categories based on a narrow focus on one aspect of the condition(e.g. tics), or on the predominant content of the condition (e.g. hair pulling, noteating), and not on the form of symptoms: uncontrollable repetitive thoughtsand actions.The phenomenology, demographics, neurobiology, and treatment evidence thatdefine OCD, however, characterize it as a separate class from the other conditionsin the anxiety disorder category. The data show that the classic OCD syndrome hassubstantial similarity to tic disorder, body dysmorphic disorders, and most of thepresent impulse control disorders, such as trichotillomania. 4 Anorexia nervosa andsome of the paraphilias are also best classified in the OCD category. Pathologicalgambling, now in the impulse control class, appears to represent a heterogeneouscategory, but some of these persons also have OCD features warranting placementin the OCD class. 5 Kleptomania and pathological gambling appear to beco-occurring. Non-melancholic depression is also reported in patients with OCDand its spectrum, but is not part of the OCD pathophysiology. 6The OCD spectrum is seen as several descriptive clusters. 7 A somatic groupingincludes body image, body concerns and weight disorders, hypochondriasis, bodydysmorphic disorder, anorexia nervosa, and binge eating. 8 An impulse groupingincludes pathological gambling, some paraphilias, trichotillomania, kleptomania,and some forms of self-injury. 9 A repetitive movement grouping includes Gilles deLa Tourette’s syndrome and Syndenham’s chorea. 10 Table 12.1 displays the OCDspectrum conditions. Support for the spectrum is detailed in Chapter 16.Increasing numbers of conditions are proposed for the OCD spectrum. Someof these have substantial validation (see below), others assumed to be co-morbidwith OCD are unlikely to share the same pathophysiology. Mood disorder is anexample.Patients with depressive illness often ruminate and have repetitive, sometimesstereotypic behavior. These behaviors, however, are understood to result fromthe influence of the intense mood state on frontal circuitry regulation of motorand cognition function. The repetitive behaviors resolve with the successfultreatment of the depression. 11