Fractionation of impulsive and compulsive trans-diagnostic phenotypes and their longitudinal associations.

OBJECTIVE: Young adulthood is a crucial neurodevelopmental period during which impulsive and compulsive problem behaviours commonly emerge. While traditionally considered diametrically opposed, impulsive and compulsive symptoms tend to co-occur. The objectives of this study were as follows: (a) to identify the optimal trans-diagnostic structural framework for measuring impulsive and compulsive problem behaviours, and (b) to use this optimal framework to identify common/distinct antecedents of these latent phenotypes. METHOD: In total, 654 young adults were recruited as part of the Neuroscience in Psychiatry Network, a population-based cohort in the United Kingdom. The optimal trans-diagnostic structural model capturing 33 types of impulsive and compulsive problem behaviours was identified. Baseline predictors of subsequent impulsive and compulsive trans-diagnostic phenotypes were characterised, along with cross-sectional associations, using partial least squares. RESULTS: Current problem behaviours were optimally explained by a bi-factor model, which yielded dissociable measures of impulsivity and compulsivity, as well as a general disinhibition factor. Impulsive problem behaviours were significantly explained by prior antisocial and impulsive personality traits, male gender, general distress, perceived dysfunctional parenting and teasing/arguments within friendships. Compulsive problem behaviours were significantly explained by prior compulsive traits and female gender. CONCLUSION: This study demonstrates that trans-diagnostic phenotypes of 33 impulsive and compulsive problem behaviours are identifiable in young adults, utilising a bi-factor model based on responses to a single questionnaire. Furthermore, these phenotypes have different antecedents. The findings yield a new framework for fractionating impulsivity and compulsivity, and suggest different early intervention targets to avert emergence of problem behaviours. This framework may be useful for future biological and clinical dissection of impulsivity and compulsivity.

Latent traits of impulsivity and compulsivity: toward dimensional psychiatry.

BACKGROUND: The concepts of impulsivity and compulsivity are commonly used in psychiatry. Little is known about whether different manifest measures of impulsivity and compulsivity (behavior, personality, and cognition) map onto underlying latent traits; and if so, their inter-relationship. METHODS: A total of 576 adults were recruited using media advertisements. Psychopathological, personality, and cognitive measures of impulsivity and compulsivity were completed. Confirmatory factor analysis was used to identify the optimal model. RESULTS: The data were best explained by a two-factor model, corresponding to latent traits of impulsivity and compulsivity, respectively, which were positively correlated with each other. This model was statistically superior to the alternative models of their being one underlying factor ('disinhibition') or two anticorrelated factors. Higher scores on the impulsive and compulsive latent factors were each significantly associated with worse quality of life (both p < 0.0001). CONCLUSIONS: This study supports the existence of latent functionally impairing dimensional forms of impulsivity and compulsivity, which are positively correlated. Future work should examine the neurobiological and neurochemical underpinnings of these latent traits; and explore whether they can be used as candidate treatment targets. The findings have implications for diagnostic classification systems, suggesting that combining categorical and dimensional approaches may be valuable and clinically relevant.

Understanding eating disorders within internalizing psychopathology: A novel transdiagnostic, hierarchical-dimensional model.

BACKGROUND: Several problems with the classification and diagnosis of eating disorders (EDs) have been identified, including proliferation of 'other specified' diagnoses, within-disorder heterogeneity, and frequent diagnostic migration over time. Beyond problems within EDs, past research suggested that EDs fit better in a spectrum of internalizing psychopathology (characterized by mood and anxiety disorders) than in a separate diagnostic class. PURPOSE: To develop a transdiagnostic, hierarchical-dimensional model relevant to ED psychopathology that: 1) reduces diagnostic heterogeneity, 2) includes important dimensions of internalizing psychopathology that are often excluded from ED diagnostic models, and 3) predicts clinical impairment. PROCEDURES: Goldberg's (2006) method and exploratory structural equation modeling were used to identify a hierarchical model of internalizing in community-recruited adults with EDs (N=207). FINDINGS: The lowest level of the hierarchy was characterized by 15 factors that defined specific aspects of eating, mood, and anxiety disorders. At the two-factor level, Internalizing bifurcated into Distress (low well-being, body dissatisfaction, suicidality, dysphoria, ill temper, traumatic intrusions) and Fear-Avoidance (claustrophobia, social avoidance, panic symptoms, dietary restricting, excessive exercise, and compulsions). Results showed that the lowest level of the hierarchy predicted 67.7% of the variance in clinical impairment. In contrast, DSM eating, mood, and anxiety disorders combined predicted 10.6% of the variance in impairment secondary to an ED. CONCLUSIONS: The current classification model represents an improvement over traditional nosologies for predicting clinically relevant outcomes for EDs.

Conceptualization and Assessment of Hypersexual Disorder: A Systematic Review of the Literature.

INTRODUCTION: Despite the rejection of hypersexual disorder (HD) as a new diagnosis in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), clinical and research interest in HD continues. AIM: To systematically review the existing scientific literature on the conceptualization and assessment of HD and out-of-control sexual behavior. METHODS: Studies were identified from PsychInfo, PubMed, JSTOR, Google Scholar, and Scholar's Portal using an exhaustive list of key terms. Of 299 total articles identified and screened, 252 were excluded, and 47 are included in this review. MAIN OUTCOME MEASURES: To review two categories of articles: HD conceptualization and HD psychometric assessment. RESULTS: First, results of the review of theoretical conceptualizations of HD reflected a large proportion of the peer-reviewed literature devoted to discussing conceptualizations of HD without reaching consensus. Second, results of the review of HD psychometric assessments were analyzed using Hunsley and Mash's (2008) criteria to evaluate psychometric adequacy of evidence-based assessment measurements. The six most researched measurements of HD were evaluated, including the Hypersexual Disorder Screening Inventory, the Hypersexual Behavior Inventory, the Sexual Compulsivity Scale, the Sexual Addiction Screening Test, the Sexual Addiction Screening Test-Revised, and the Compulsive Sexual Behavior Inventory. Psychometric properties of the scales are reviewed, evaluated, and discussed. CONCLUSION: The Hypersexual Disorder Screening Inventory, the measurement proposed for the clinical screening of HD by the DSM-5 workgroup, currently has the strongest psychometric support. Future research and clinical directions are discussed in light of findings after the literature review and synthesis. Montgomery-Graham S. Conceptualization and Assessment of Hypersexual Disorder: A Systematic Review of the Literature. Sex Med Rev 2017;5:146-162.

Obsessive compulsive and related disorders: comparing DSM-5 and ICD-11.

Obsessive-compulsive disorder (OCD) has been recognized as mainly characterized by compulsivity rather than anxiety and, therefore, was removed from the anxiety disorders chapter and given its own in both the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the Beta Draft Version of the 11th revision of the World Health Organization (WHO) International Classification of Diseases (ICD-11). This revised clustering is based on increasing evidence of common affected neurocircuits between disorders, differently from previous classification systems based on interrater agreement. In this article, we focus on the classification of obsessive-compulsive and related disorders (OCRDs), examining the differences in approach adopted by these 2 nosological systems, with particular attention to the proposed changes in the forthcoming ICD-11. At this stage, notable differences in the ICD classification are emerging from the previous revision, apparently converging toward a reformulation of OCRDs that is closer to the DSM-5.

Expanding the definition of addiction: DSM-5 vs. ICD-11.

While considerable efforts have been made to understand the neurobiological basis of substance addiction, the potentially "addictive" qualities of repetitive behaviors, and whether such behaviors constitute "behavioral addictions," is relatively neglected. It has been suggested that some conditions, such as gambling disorder, compulsive stealing, compulsive buying, compulsive sexual behavior, and problem Internet use, have phenomenological and neurobiological parallels with substance use disorders. This review considers how the issue of "behavioral addictions" has been handled by latest revisions of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD), leading to somewhat divergent approaches. We also consider key areas for future research in order to address optimal diagnostic classification and treatments for such repetitive, debilitating behaviors.

Compulsivity and Impulsivity in Pathological Gambling: Does a Dimensional-Transdiagnostic Approach Add Clinical Utility to DSM-5 Classification?

Although the phenomenology of Pathological Gambling (PG) is clearly characterized by impulsive features, some of the Diagnostic and Statistical Manual of Mental Disorder (DSM-5) criteria for PG are similar to those of Obsessive Compulsive Disorder (OCD). Therefore, the compulsive-impulsive spectrum model may be a better (or complementary) fit with PG phenomenology. The present exploratory research was designed to further investigate the compulsive and impulsive features characterizing PG, by comparing PG individuals, alcohol dependents (ADs), OCD patients, and healthy controls (HCs) on both self-report and cognitive measures of compulsivity and impulsivity. A better understanding of the shared psychological and cognitive mechanisms underlying differently categorized compulsive and impulsive disorders may significantly impact on both clinical assessment and treatment strategies for PG patients. With respect to self-report measures, PG individuals reported more compulsive and impulsive features than did HCs. As regards motor inhibition ability indices, PG individuals and HCs performed similarly on the Go/No-go task and better than AD individuals and OCD patients. Results from the Iowa Gambling Task highlighted that PG, AD, and OCD participants performed worse than did HCs. An in-depth analysis of each group's learning profile revealed similar patterns of impairment between PG and AD individuals in decision-making processes. Current findings support the utility of adopting a dimensional-transdiagnostic approach to complement the DSM-5 classification when working with PG individuals in clinical practice. Indeed, clinicians are encouraged to assess both compulsivity and impulsivity to provide individualized case conceptualizations and treatment plans focusing on the specific phenomenological features characterizing each PG patient.

Hoarding disorder: a new diagnostic category in ICD-11?

Despite the long-held view that hoarding is a symptom of both obsessive-compulsive disorder and obsessive-compulsive personality disorder, increased evidence has emerged during the last 20 years suggesting that hoarding represents a distinct form of psychopathology. This study reflects the discussions on the nosological status of hoarding carried out by the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders. The distinctiveness of hoarding is based on its having core symptoms that differ from those of other disorders, as well as distinctive neurobiological correlates and treatment responses. Furthermore, data showing the clinical utility, global applicability, and appropriateness of the concept of hoarding disorder outside specialty mental health settings suggest that this condition should be included in ICD-11. Finally, given the focus of ICD-11 on primary care and public health, the Working Group suggests that poor insight and severe domestic squalor may be considered as specifiers for hoarding disorder in ICD-11.

Compulsivity, impulsivity, and the DSM-5 process.

Compulsivity and impulsivity are cross-cutting, dimensional symptom domains that span traditional diagnostic boundaries. We examine compulsivity and impulsivity from several perspectives and present implications for these symptom domains as they relate to classification. We describe compulsivity and impulsivity as general concepts, from the perspectives of the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) Research Planning Agenda, and from the DSM-5 workgroups, literature reviews, and field trials. Finally, we detail alternative modes of classification for compulsivity and impulsivity in line with the Research Domain Criteria (RDoC) and International Classification of Diseases (ICD-11).

The relationships between obsessive-compulsive symptom dimensions and cognitions in obsessive-compulsive disorder.

Several studies have linked obsessive-compulsive symptoms to specific obsessive-compulsive cognitions, however methodologies have varied, and no study has determined obsessive-compulsive symptoms using the most widely used clinician rating scale, the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS). Considering that almost all studies that used factor analysis to ascertain OCD symptom dimensions were based on the Y-BOCS and that self-report instruments assessing obsessive-compulsive symptoms correlate poorly with the Y-BOCS, there is a need to use the Y-BOCS to examine the relationship between obsessive-compulsive cognitions and obsessive-compulsive symptom dimensions. This study examined the relationship between five Y-BOCS-derived obsessive-compulsive symptom dimensions and the three obsessive-compulsive cognitive domains identified by the obsessive-beliefs questionnaire (OBQ). The symmetry/ordering symptom dimension was associated with increased perfectionism/intolerance of uncertainty, the unacceptable/taboo thoughts symptom dimension was associated with increased importance/control of thoughts and the doubt/checking symptom dimension was associated with increased responsibility/threat estimation. There was no statistical evidence of an association between any OBQ belief sub-scale and the hoarding symptom dimension nor the contamination/cleaning symptom dimension. The findings encourage symptom-based approaches to cognitive-behavioural therapy for some OCD symptoms and call for further research on cognitions associated with contamination/cleaning symptoms and hoarding.

Hoarding disorder: a new diagnostic category in ICD-11?

Despite the long-held view that hoarding is a symptom of both obsessive-compulsive disorder and obsessive-compulsive personality disorder, increased evidence has emerged during the last 20 years suggesting that hoarding represents a distinct form of psychopathology. This study reflects the discussions on the nosological status of hoarding carried out by the WHO ICD-11 Working Group on the Classification of Obsessive-Compulsive and Related Disorders. The distinctiveness of hoarding is based on its having core symptoms that differ from those of other disorders, as well as distinctive neurobiological correlates and treatment responses. Furthermore, data showing the clinical utility, global applicability, and appropriateness of the concept of hoarding disorder outside specialty mental health settings suggest that this condition should be included in ICD-11. Finally, given the focus of ICD-11 on primary care and public health, the Working Group suggests that poor insight and severe domestic squalor may be considered as specifiers for hoarding disorder in ICD-11.

Where on the obsessive impulsive-compulsive spectrum does hair-pulling disorder belong?

OBJECTIVE: Hair-pulling disorder (HPD) is a putative obsessive-compulsive spectrum disorder, but proper categorization is challenging. Distinct subgroups of HPD may exist, depending on the primary motivation in the act of pulling. Two notable proposed subgroups are "relief pullers" (pulling primarily to reduce anxiety- a "compulsive" subgroup) and "pleasure/gratification pullers" (pulling primarily for reward- an "impulsive" subgroup) which we sought to examine in order to contribute to conversations on the categorization of HPD. METHODS: A total of 111 HPD subjects (mean age 33.7 ± 10.7 [range 18-61] years; 87.4% female) were included. Demographic and clinical characteristics were compared between subgroups (pleasure: n = 51; relief: n = 60); and cognitive performance where data were available (n = 29 per group) and 32 matched healthy controls. RESULTS: No significant demographic differences were noted between groups. Pleasure pullers were significantly more conscious of their pulling. Response inhibition and set shifting deficits were noted in HPD versus controls; however, pleasure and relief pullers did not differ significantly from each other on neurocognitive measures. CONCLUSIONS: The results suggest common clinical features and associated neural dysfunction between relief and pleasure/gratification pullers, rather than supporting their existence as discrete clinical entities. Selection of appropriate treatment may focus on other aspects of hair pulling, including family history and comorbidity.

Behavioral addictions: where to draw the lines?

Behavioral addictions can present in a variety of subtle and deceptive patterns. Because of the intense shame, guilt, and embarrassment felt by patients, it may fall to providers to utilize screening tools and deeper interviewing techniques to uncover the extent of these behaviors. Identifying when the line is crossed from recreation/habit to psychopathology relies on understanding current diagnostic criteria and consideration of cultural, ethnic, and local community standards. Individuals are also likely to cross back and forth between this line of pathology and habit, further clouding provider's opinions of diagnosis; therefore, tracking and monitoring these symptoms over time is critical to establishing patterns of use and documenting ongoing consequences. Treatment for these conditions is emerging slowly, and treatment outcomes for these conditions appear to be similar to those with other addictive disorders.

Towards a post-traumatic subtype of obsessive-compulsive disorder.

We evaluated whether traumatic events are associated with a distinctive pattern of socio-demographic and clinical features of obsessive-compulsive disorder (OCD). We compared socio-demographic and clinical features of 106 patients developing OCD after post-traumatic stress disorder (PTSD; termed post-traumatic OCD), 41 patients developing OCD before PTSD (pre-traumatic OCD), and 810 OCD patients without any history of PTSD (non-traumatic OCD) using multinomial logistic regression analysis. A later age at onset of OCD, self-mutilation disorder, history of suicide plans, panic disorder with agoraphobia, and compulsive buying disorder were independently related to post-traumatic OCD. In contrast, earlier age at OCD onset, alcohol-related disorders, contamination-washing symptoms, and self-mutilation disorder were all independently associated with pre-traumatic OCD. In addition, patients with post-traumatic OCD without a previous history of obsessive-compulsive symptoms (OCS) showed lower educational levels, greater rates of contamination-washing symptoms, and more severe miscellaneous symptoms as compared to post-traumatic OCD patients with a history of OCS.

Clarifying exercise addiction: differential diagnosis, co-occurring disorders, and phases of addiction.

This paper sets out to clarify the unique features of exercise addiction. It begins by examining how this addiction can be distinguished from compulsions and impulse control disorders both of which, like an addiction, involve excessive behavior that creates adverse effects. Assessment of exercise addiction also requires that clinicians be attuned to other forms of excessive behavior, especially eating disorders that can co-occur with exercise. Finally in an effort to clarify exercise addiction, this paper uses the four phases of addiction to examine the attributes of exercise that define it as a healthy habit distinct from an addiction. The paper ends with a discussion of the implications of these topics for effective assessment and treatment.

The epidemiology of the proposed DSM-5 hoarding disorder: exploration of the acquisition specifier, associated features, and distress.

OBJECTIVE: Compulsive hoarding, characterized by the acquisition of and failure to discard a large number of possessions, is increasingly recognized as a significant public health burden. Many facets of the phenomenology, including an understanding of the population prevalence and associated features, are not yet fully understood. There is growing evidence that hoarding may warrant its own diagnosis in DSM-5, and it is therefore imperative to investigate the proposed cardinal symptoms along with correlated features that may be diagnostically relevant. METHOD: The present investigation examined the point prevalence of hoarding disorder in a nationally representative sample from the German population (N = 2,512). The hoarding definition considered in this study was derived from the Hoarding Rating Scale (HRS) and informed by 3 of the proposed DSM-5 criteria. Several hypothesized core components of hoarding disorder were also assessed using questions from the HRS and the UCLA Hoarding Severity Scale, including types of acquisition, perfectionism, indecision, procrastination, distress, and impairment. Data were collected from May 16, 2009, to June 19, 2009. RESULTS: Analyses revealed a current population estimate of 5.8%. Hoarding prevalence did not differ between men and women. Hoarders were significantly more likely to buy items, acquire free things, and steal items they did not need, compared to nonhoarders (P < .001). Perfectionism, indecision, and procrastination were all uniquely and significantly associated with hoarding status (P < .001). Relationships between the proposed core features and distress/impairment are also detailed. CONCLUSIONS: The current investigation identified the proposed hoarding disorder as a highly prevalent syndrome; however, it should be noted that we were not able to fully ascertain the DSM-5 criteria and that the current estimate may be higher than the actual population rate. Future research on the diagnostic criteria and associated features will be necessary to help clarify etiologic underpinnings, treatment efforts, and diagnostic nosology.

Personality prototypes in individuals with compulsive buying based on the Big Five Model.

Personality prototypes based on the Big Five factor model were investigated in a treatment-seeking sample of 68 individuals with compulsive buying (CB). Cluster analysis of the NEO Five-Factor Inventory (NEO-FFI) scales yielded two distinct personality clusters. Participants in cluster II scored significantly higher than those in cluster I on neuroticism and lower on the other four personality traits. Subjects in cluster II showed higher severity of CB, lower degree of control over CB symptoms, and were more anxious, interpersonally sensitive and impulsive. Furthermore, cluster II was characterized by higher rates of comorbid anxiety disorders, and cluster B personality disorders. The two personality prototypes did not differ with respect to obsessive-compulsive features. Finally and of considerable clinical significance, participants in cluster II reported lower remission rates after undergoing cognitive-behavioral therapy. Implications of the results for treatment are discussed.

Scrupulosity: a unique subtype of obsessive-compulsive disorder.

The earliest descriptions of obsessive-compulsive disorder (OCD) were religious, as was the understanding of their origins. With the emancipation, religion in OCD was relegated to its status today: a less common symptom of OCD in most Western societies known as scrupulosity. The frequency of scrupulosity in OCD varies in the literature from 0% to 93% of cases, and this variability seems predicated on the importance of religious belief and observance in the community examined. Despite the similarities between religious ritual and compulsions, the evidence to date that religion increases the risk of the development of OCD is scarce. Scrupulosity is presented as a classic version of OCD, with obsessions and compulsions, distress, and diminished functioning similar to those of other forms of OCD. The differentiation between normal religiosity and scrupulosity is presented, and the unique aspects of cognitive-behavioral therapy in treating scrupulosity, especially in religious populations, are reviewed.