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Exploring anxiety
Exploring anxiety

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PTSD and OCD in DSM-5

Post-traumatic stress disorder (PTSD) and acute stress disorder have been moved from ‘Anxiety Disorders’ to an independent category of ‘Trauma and Stressor-Related Disorders’ or TSRD. PTSD has been traditionally conceptualised as a ‘fear disorder’ defined by three clusters of symptoms: (i) re-experiencing of fear (intrusive memories), (ii) avoidance of the reminders of trauma (amnesia, withdrawal, avoidance of situational reminders), and (iii) hyperarousal (disturbances in sleep, heightened startle response) (Nemeroff et al., 2013). DSM-5 has moved beyond the fear-based anxiety construct, and PTSD criteria have been revised to include negative emotional states and symptoms of distress – dysphoria, aggression, guilt and shame − on account that those with PTSD (e.g. war veterans and victims of crime or of abuse) often present for clinical assistance with such negative emotional states. A new PTSD subtype introduced for children aged 6 and under is considered to take into account the variation of symptom presentation in young children.

DSM-5 also lists obsessive-compulsive disorder and related disorders (OCRDs) as a separate category (along with new conditions such as hoarding disorder and excoriation or ‘skin-picking’ disorder). The decision was based on a review of evidence suggesting that OCD differs from anxiety disorders on a number of diagnostic validators and psychobiological and phenomenological overlap between OCD and some related conditions. The ‘close relationship’ with anxiety disorders is still reflected by the sequential order of corresponding chapters in DSM-5 (Nemeroff et al., 2013).

An emphasis − the potential advantage for clinical practice − of segregating PTSD and OCRDs from anxiety-related disorders, was to raise awareness amongst clinicians and the public, of these 'underdiagnosed and undertreated conditions', encouraging 'researchers to use structured diagnostic interviews and standardised symptom measures to investigate and evaluate the full range of these conditions in a systematic way' (Nemeroff et al., 2013).

Critics of the DSM continue to debate the definition and classification of ‘psychiatric disorders’ stressing that is important to avoid medicalising problems of daily living (Stein et al., 2010; Aftab, 2014). While acknowledging this view, proponents of the DSM stress that 'those who meet diagnostic criteria for these conditions experience distress or impairment and deserve appropriate intervention' (Nemeroff et al., 2013).