Impact of DSM-5 Revisions to Obsessive-Compulsive Disorder on Prevalence Rates in Youth

The Diagnostic and Statistical Manual of Mental Disorders (DSM), used to diagnose psychiatric disorders, was revised to DSM-5 in 2013 (1). Changes were made to the criteria for Obsessive-Compulsive Disorder (OCD) in DSM-5 and prior revisions to OCD criteria (from DSM-III to DSM-IV) resulted in lower reported prevalence rates (2) but this is not yet clear with DSM-5 OCD criteria. OCD has a lifetime prevalence of 1–3% in children (3). DSM-5 revisions broadened the definition of obsessions (Table 1) and removed the requirement that obsessions cause marked anxiety or distress (1). Thus we report changes in prevalence of OCD within the Adolescent Brain Cognitive Development (ABCD) study (4) using both DSM-IV and DSM-5 criteria.

Table 1:

Revisions to the diagnostic criteria for Obsessive-Compulsive Disorder (OCD) from DSM-IV to DSM-5. Changes are indicated in red text.

DSM-IV OCD criteria	DSM-5 OCD criteria - revisions
A. The presence of either obsessions or compulsions	A. The presence of either obsessions or compulsions
Obsessions as defined by (1), (2), (3), and (4):	Obsessions as defined by (1 and 2):
1. Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.	1. Recurrent and persistent thoughts, urges, or impulses that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The thoughts, impulses, or images are not simply excessive worries about real-life problems	2. REMOVED
3. The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action	3. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
4. the person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion)	3. REMOVED
Compulsions as defined by (1) and (2) (Unchanged between DSM-IV and DSM-5)
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly
2. The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive
B. At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable. NOTE: this does not apply to children	B. REMOVED
C. The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships.	C. UNCHANGED
D. If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g., preoccupation with food in the presence of an Eating Disorders; hair pulling in the presence of Trichotillomania; concern with appearance in the presence of Body Dysmorphic Disorder; preoccupation with drugs in the presence of a Substance Use Disorder; preoccupation with having a serious illness in the presence of Hypochondriasis; preoccupation with sexual urges or fantasies in the presence of a Paraphilia; or guilty ruminations in the presence of Major Depressive Disorder).	D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possession, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder); stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder)
E. The disturbance is not due to the direct physiological effects of a substance(e.g., a drug of abuse, a medication) or a general medical condition.	E. UNCHANGED

Methods:

The ABCD study is a large, longitudinal study of adolescent brain development and health (4). Child psychiatric diagnoses are identified using the parent computerized version of the Kiddie Schedule of Affective Disorders (K-SADS-COMP; 5). Other reported measures include the Child Behavior Checklist (CBCL) (6) and parent-reported child psychiatric diagnosis at screening.

Data was accessed from the NIMH Data Archive and included 11,694 youth age 9/10 with complete data. OCD, using DSM-5 criteria, was assessed with the K-SADS-COMP. To evaluate OCD prevalence using DSM-IV criteria, responses were re-scored such that obsessions included significant distress (Table 1). The definition of compulsions and the significance criteria (obsessions and/or compulsions that either cause significant distress, take excessive time, or interfere with functioning) were unchanged. CBCL scales were analyzed using linear mixed-models including site (and family nested within site) as random effects, and age, sex and race as additional fixed effects.

Results:

Demographic data and OCD prevalence by DSM-IV and DSM-5 criteria are presented in Table 2. There was a 10% increase in identified OCD associated with DSM-5 criteria, with 7% of the sample meeting DSM-IV OCD criteria and 7.7% meeting DSM-5 criteria. This additional 0.7% reflected an increase based on obsessional symptomatology (from 1.5% to 2.3% of the total sample; a 65% increase)

Table 2.

Sample Demographics and Rates of Obsessive-Compulsive Disorder

	Both DSM-IV and DSM-5 OCD	DSM-5 OCD Only	CTRL - no OCD
n	816 (7.0%)	83 (0.7%)	10,795 (92.3%)
Age	118.5 ±7.3	118.5 ±6.9	119.0 ±7.5
Sex (female)	40.6%	32.5%	48.4% &
Race: White	44.7%	61.5%#	52.7%
Race: Black	20.8%	8.4%#	14.6%
Race: Hispanic	21.5%	18.1%	20.1%
Race: Asian	1.1%	1.2%	2.2%
Race: Other	11.9%	10.8%	10.4%
Parent reported mental health diagnosis at screen	33.6%	30.1%	14.9%*
CBCL - Total Problems (t-score)	54.3 [53.6–55.1]	52.6 [50.4–54.9]	45.2 [44.8–45.5]*
CBCl - Anxious Depressed (t-score)	58.2 [57.7–58.6]	57.9 [56.7–59.1]	53.1 [52.9–53.3]*

^{& =}p<.001 CTRL different from DSM-5 group by χ²

^{* =}p<.001 CTRL different from all diagnostic groups by χ², or mixed model ANOVA

^{# =}p<.05 DSM5 group different from DSM-IV group by χ²

Children who met only DSM-5 criteria did not differ in age or sex from those identified using DSM-IV criteria (all of whom also met DSM-5 criteria; Table 2). The rates of other psychiatric diagnoses were similar in both OCD groups (DSM-5 only 28.8%; BOTH DSMs 29.4%). Finally, the OCD groups did not differ in Total Problems or Anxious-Depressed scale-scores on the CBCL, although both OCD groups had significantly higher scores than participants without OCD (Total Problems [F(2,1824)=305.8, p<.001]); [Anxious-Depressed [F(2,1824) = 335.2, p<.001] (Table 2).

Discussion:

DSM-5 revisions to the definition of obsessions resulted in an overall 10% increase in identified OCD. As DSM-5 also removed two criteria for obsessions (that they are not excess worry about real-life problems, and that they are recognized as a product of ones’ own mind), this increase in prevalence is likely a conservative estimate. The overall rate of OCD in the ABCD study (7.7%) is higher than the 1–3% reported in previous literature (2). Validation research on the KSADS-COMP found parents’ diagnoses of OCD to be 2.8 times higher than clinicians (5), suggesting that rates of OCD in the current sample would likely be around 2.7% using DSM-5 if assessed by a clinician.

OCD criteria were met for compulsions more often than obsessions. Ritualized behavior (i.e. a rigid bedtime routine) is common in children and may be difficult for parents to distinguish from compulsions. However, given that comorbidity and parent-rated total problems were higher for both OCD groups than for those without OCD, there is little reason to believe that the KSADS-COMP identifies a less severe form of OCD.