The new DSM-5: Anxiety Disorders and Obsessive-Compulsive Disorders

Erin L. George, MFT
Erin L. George, MFT
Medical editor

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What are the DSM-5 Anxiety Disorders?

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) serves as a comprehensive classification system for mental health disorders, including anxiety disorders. It provides standardized criteria for diagnosing anxiety disorders, which can help guide treatment planning and research efforts. The DSM is regularly updated according to new research. 

One significant change from the DSM-4 to DSM-5 regarding anxiety disorders is the reclassification of obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD) under separate categories. This new classification emphasizes their distinct diagnostic criteria and treatment approaches. The DSM-5 has also introduced specific diagnostic criteria for separation anxiety disorder in adults, recognizing its prevalence and impact beyond childhood.[1,2]

In this article, we discuss how the former DSM-IV category of Anxiety Disorders became three separate categories in DSM-5. These three categories include:[1,2]

  1. Anxiety Disorders (separation anxiety disorder, selective mutism, specific phobia, social phobia, panic disorder, agoraphobia, and generalized anxiety disorder)
  2. Obsessive-Compulsive Disorders (obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotillomania, and excoriation disorder)
  3. Trauma and Stressor-Related Disorders (reactive attachment disorder, disinhibited social engagement disorder, PTSD, acute stress disorder, and adjustment disorder).

Understanding the DSM-5 and Its Role in Mental Health


The DSM-5 is a cornerstone in the field of mental health, providing a standardized framework for diagnosing and classifying psychiatric disorders. 

Professionals, including clinicians, researchers, and educators, rely on the DSM-5 to establish uniform diagnostic criteria, facilitate communication, and guide treatment planning. The book helps support research efforts in understanding mental health disorders, from major depression and anxiety disorders to personality disorders and trauma-related disorders.

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The DSM-5 has specifically influenced the diagnosis and treatment of anxiety disorders by refining diagnostic criteria, enhancing diagnostic accuracy, and promoting tailored treatment approaches. 

With clearer definitions and classifications, clinicians can now better differentiate between anxiety disorders, leading to more targeted interventions and better outcomes for individuals living with anxiety.  

Changes to Anxiety Disorders

Aside from separating obsessive-compulsive disorder and PTSD (see above), not much has changed. In keeping with the lifespan developmental approach, two disorders formerly classified as childhood disorders are now part of the anxiety disorders group. These are separation anxiety and selective mutism. Both children and adults may receive these diagnoses. Agoraphobia and Panic Disorder have been decoupled and now form two distinct disorders. Additionally, a panic attack specifier is now applicable to any diagnostic category, such as depressive disorder with panic attacks or PTSD with panic attacks.

Specific Anxiety Disorders in the DSM-5

The specific anxiety disorders listed in the DSM-5 are generalized anxiety disorder, panic disorder, social anxiety disorder, specific phobia, and separation anxiety disorder.[1,2]

Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder (GAD) is characterized by excessive worry and anxiety about various aspects of life, including work, health, and relationships, lasting for at least 6 months. The criteria in the DSM-5 include:[1],[2]

  • Excessive anxiety and worry that occur more days than not for at least 6 months about several events or activities
  • Issues controlling the worry
  • The anxiety and worry are associated with 3 (or more) of the following six symptoms, with at least some symptoms having been present for more days than not for the past 6 months:
  • Restlessness or edginess
  • Fatigue
  • Difficulty concentrating
  • Irritability
  • Muscle tension
  • Sleep disturbances

The anxiety, worry, or physical symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Erin L George, MA-MFT, says, "GAD can become severe enough to cause other health issues, like high blood pressure. Brain fog and exhaustion due to lack of sleep from worry are also big concerns. If you think you have GAD, it's important to tell your doctor because they can provide you with a variety of options to help relieve daily symptoms."

Panic Disorder

Panic Disorder involves recurrent unexpected panic attacks, which are sudden periods of intense fear or discomfort, peaking within minutes. Key diagnostic criteria from the DSM-5 include:[1,2}

  • Recurrent unexpected panic attacks, which are abrupt surges of intense fear or discomfort that peak within minutes
  • At least one of the attacks has been followed by 1 month (or more) of one or both of the following:
  • Persistent concern or worry about additional panic attacks or their consequences, such as losing control or having a heart attack
  • A significant maladaptive change in behavior related to the attacks, such as avoiding exercise or unfamiliar situations

Social Anxiety Disorder (Social Phobia)

Social Anxiety Disorder involves marked fear or anxiety about social situations. The criteria include:[1,2]

  • Persistent and intense fear or anxiety about social situations where an individual may be exposed to scrutiny by others
  • Fear of acting in a way that will be humiliating or embarrassing
  • Social situations almost always provoke fear or anxiety
  • Avoidance of feared social situations, or enduring intense fear or anxiety
  • Persistent fear or anxiety, typically lasting for 6 months or more

The fear or anxiety causes significant distress or impairment in social, occupational, or other important areas of functioning. Erin L George, MA-MFT, explains, "Social anxiety disorder is often confused with shyness or introversion. Social anxiety disorder is much more persistent and severe than a preference for small groups or being nervous around strangers—something many people experience that's entirely normal. People with social anxiety will allow their fears of judgment to stop them from certain careers, self-advocacy, and following their dreams. That is, their anxiety impedes their relationships and goals."

Specific Phobia

Specific Phobia is characterized by marked fear or anxiety about a specific object or situation, leading to avoidance behaviors. To be diagnosed with Specific Phobia, you must meet the following diagnostic criteria:[1,2]

  • Marked fear or anxiety about a specific object or situation, such as flying, heights, animals, or injections
  • Exposure to the feared object or situation almost invariably provokes an immediate anxiety response.
  • The fear or anxiety is out of proportion to the actual danger posed by the object or situation.
  • The fear, anxiety, or avoidance is persistent, typically lasting for 6 months or more.

The fear, anxiety, or avoidance causes significant distress or impairment in social, occupational, or other important areas of functioning.

Separation Anxiety Disorder

Separation Anxiety Disorder involves excessive fear or anxiety concerning separation from attachment figures, leading to significant distress or impairment. The diagnostic criteria for this condition include:[1,2]

  • Excessive fear or anxiety concerning separation from attachment figures or home
  • Persistent reluctance or refusal to go out or be away from home or attachment figures
  • Worry about losing attachment figures or harm befalling them
  • Fear of being alone without attachment figures at home or without significant adults in other settings
  • Reluctance or refusal to sleep away from home or to go to sleep without being near attachment figures
  • Repeated nightmares involving the theme of separation
  • Complaints of physical symptoms, such as headaches, stomachaches, nausea, or vomiting, when separation from attachment figures occurs or is anticipated

The fear, anxiety, or avoidance is persistent, typically lasting for 4 weeks or more in children and adolescents and 6 months or more in adults

DSM-5 added a new category of disorders called Obsessive-Compulsive and Related Disorders (OCRDs) (also called Obsessive-Compulsive Spectrum Disorders in the research literature). The OCRDs category includes the familiar obsessive-compulsive disorder. It also includes two newly defined disorders with obsessive-compulsive features.

These are hoarding disorder and excoriation (skin-picking) disorder. Also included in the new OCRD category are body dysmorphic disorder (previously classified as a Somatoform Disorder) and trichotillomania (hair-pulling, previously classified as an Impulse Control Disorder Not Elsewhere Classified).

Changes from DSM-4 to DSM-5

In the transition from DSM-4 to DSM-5, anxiety disorder classifications underwent significant revisions. 

DSM-IV grouped various anxiety disorders under a single category named Anxiety Disorders, which encompassed panic disorder, generalized anxiety disorder (GAD), social anxiety disorder, specific phobias, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD).

However, DSM-5 introduced separate categories for each anxiety disorder, distinguishing them based on unique diagnostic criteria and clinical features. For instance, OCD and PTSD were reclassified to their distinct categories, while separation anxiety disorder was added as a separate diagnosis in DSM-5.

These changes were implemented to refine diagnostic criteria, enhance diagnostic accuracy, and reduce diagnostic overlap among anxiety disorders. By separating OCD and PTSD from the broader category of anxiety disorders, DSM-5 aimed to provide clearer guidelines tailored to the unique symptomatology of each disorder.

The introduction of separation anxiety disorder as a distinct diagnosis acknowledged its prevalence and clinical significance beyond childhood, ensuring that clinicians have clearer guidance for assessment and treatment planning.

Rationale for a Separate Category of Disorders with Obsessive-Compulsive Features

Decisions about which disorders are grouped together in the DSM-5 are based on whether there is evidence of an underlying relationship between two or more disorders.

This relationship may be indicated by the following: 

  • Symptom similarity
  • Frequency of cooccurrence (comorbidity)
  • The onset, presentation, and progression of the disorders
  • Genetic risk factors
  • Environmental risk factors
  • Neural substrates
  • Biological markers
  • Treatment response

To date, the strongest evidence for an underlying relationship between the OCRDs comes from symptom similarity and a high degree of cooccurrence (comorbidity) among the disorders. While anxiety remains a key feature in OCRDs, there are enough unique differences between Anxiety Disorders and OCRDs to justify a separate category.

Similarities and Differences Between OCRDs

So, what are the symptoms that make these disorders similar? The OCRDs are characterized by repetitive thoughts, distressing emotions, and compulsive behaviors.

The specific types of thoughts, emotions, and behaviors vary according to each disorder within this group. Although there are symptom similarities and overlaps, each disorder has unique features. 

These differences affect treatment decisions in several important ways: 1) the type of treatment selected, 2) the order and pace of therapeutic interventions, and 3) the goals and expectations of clinicians, therapy participants, and family members.

The gold standard for obsessive-compulsive disorder remains cognitive-behavioral therapy. This generally includes exposure and response prevention. However, to participate in this therapy, sufficient motivation for treatment is necessary. This leads to an important difference between the OCRDs: insight. A person's insight into the magnitude and nature of their problems affects their motivation for treatment. In general, persons with body dysmorphic disorder and hoarding disorder tend to have poorer insight. This limited insight requires additional therapeutic strategies to increase motivation and strengthen the willingness to change.

In a related manner, different OCRDs have different types of dysfunctional beliefs. Obsessive-compulsive disorder is usually characterized by irrational beliefs. For instance, it is irrational to believe you will get sick every time you touch a doorknob unless you immediately wash your hands. In contrast, hoarding disorder and body dysmorphic disorders are characterized by distorted beliefs. Unlike irrational beliefs that cannot be factually supported, distorted beliefs often have a rational basis (albeit in grossly distorted form).

To illustrate, let's consider body dysmorphic disorder. It is perfectly sensible and rational to believe your appearance is important. However, it is a distortion of that belief if you believe your entire value and worth are determined by some small flaw or defect. Hoarding disorder provides another example of distorted beliefs. It is perfectly fine to value being thrifty and avoiding waste. However, it is a distortion of that value to believe that everything has equal value and nothing should ever be discarded.

This distinction has important treatment implications. Irrational beliefs are somewhat simpler to treat than distorted beliefs. This is because it is possible to refute irrational beliefs. It is more difficult to challenge distorted beliefs because they represent extreme interpretations of an otherwise normal, acceptable belief, value, or practice. 

For instance, imagine trying to convince someone that being thrifty is harmful or wrong. It only becomes problematic when taken to the extreme. When distorted beliefs are coupled with poor insight, it is quite difficult for a person to recognize their beliefs as extreme and their behavior as unhealthy. Without this recognition, motivation for treatment is poor because they see no compelling reason to change their beliefs and resulting behaviors. This is frequently a treatment obstacle that distinguishes both hoarding and body dysmorphic disorders.

Expansion of Insight Specifiers and Treatment Implications

Because of the important treatment implications of insight, the "with poor insight" specifier has been refined to include three degrees of insight. A person "with good or fair insight" recognizes that the house won't burn down even though they feel compelled to repeatedly check to see if the stove is turned off. 

A person "with poor insight" may believe the house will probably burn down without this degree of vigilance, while a person "with absent or delusional insight" remains convinced the house will certainly burn down despite all evidence to the contrary. 

When delusional beliefs accompanied OCD or body-focused behaviors, people were often misdiagnosed with a psychotic disorder. This led to ineffective pharmacotherapy using antipsychotic medications. 

SSRIs are the recommended treatment for a person with delusional beliefs associated with an OCRD rather than antipsychotic monotherapy. 

The DSM-5 authors hope that the expansion and clarification of the insight specifier will facilitate more accurate diagnosis and improve treatment outcomes.

As with all other categories of disorders, OCRDs include an "other specified-" and "unspecified-" diagnosis. Concerning the OCRDs, the other specified obsessive-compulsive and related disorders include presentations characterized by OCD features that cause significant distress or impairment but do not meet the full criteria. 

Some examples are body dysmorphic-like disorder with actual flaws, body-dysmorphic-like disorder without repetitive behaviors, body-focused repetitive behaviors such as nail biting, and obsessive jealousy. 

The unspecified obsessive-compulsive and related disorder is used when the clinician chooses not to specify the reason criteria are not met or in situations where there is insufficient information to make a more specific diagnosis. 

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Additional Resources

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  1. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
  2. National Institute of Mental Health. (2023). Anxiety Disorders.

Additional Resources

As advocates of mental health and wellness, we take great pride in educating our readers on the various online therapy providers available. MentalHelp has partnered with several thought leaders in the mental health and wellness space, so we can help you make informed decisions on your wellness journey. MentalHelp may receive marketing compensation from these companies should you choose to use their services.

MentalHelp may receive marketing compensation from the above-listed companies should you choose to use their services.