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DSM-5 Changes: Obsessive-Compulsive and Related Disorders

chapter 5 case study for obsessive compulsive and related disorders katherine

As research grows regarding obsessive-compulsive disorder (OCD) and conditions like it, clinical guides like the Diagnostic and Statistical Manual of Mental Disorders (DSM) are revised and updated.

In 2013, the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) was released by the American Psychiatric Association (APA).

In addition to including a lifespan perspective for conditions, the new edition made sweeping changes in how disorders were categorized and defined.

In 2022, a moderate revision came out — the DSM-5-TR — which included cultural, racial, and ethnic inclusivity adjustments and the recognition of a new disorder: Prolonged grief disorder.

Obsessive-compulsive disorder (OCD) and related conditions saw some big changes from the DSM-IV-TR to the DSM-5-TR, namely the creation of their own diagnostic class.

Disorders in this class include:

  • obsessive-compulsive disorder (OCD)
  • body dysmorphic disorder
  • trichotillomania (hair-pulling disorder)
  • hoarding disorder
  • excoriation (skin-picking) disorder

What are the changes in the DSM-5-TR?

According to the APA, the publisher of the DSM-5-TR , the major change for obsessive-compulsive disorder is the fact that it and related disorders now have their own chapter.

These conditions were previously labeled “anxiety disorders” in the DSM-IV-TR.

But increasing evidence since the DSM-IV-TR has demonstrated a common thread running through a number of OCD-related disorders is that obsessive thoughts or repetitive behaviors are not just anxiety.

Direct OCD DSM-IV-TR to DSM-5-TR changes

Under a chapter of their own, OCD and related disorders received some diagnostic criteria updates:

  • The inclusion of “unwanted” as a defining factor for intrusive thoughts, urges, and images.
  • The elimination of criteria stating obsessions aren’t simply excessive worries about real-life problems.
  • The elimination of criteria stating the person recognizes obsessions are the product of their own mind.

Compulsions

  • The elimination of criteria stating the person, at some time, has recognized obsessions and compulsions are unreasonable or excessive.
  • Rewording of criteria that reflects DSM-IV-TR to DSM-5-TR changes for other differential and comorbid diagnoses, such as generalized anxiety disorder , substance use disorders , and schizophrenia spectrum disorders .
  • Inclusion of new “insight” specifiers related to the level of obsessive-compulsive belief awareness.
  • Inclusion of a new specifier indicating if there is a current or past history of a tic disorder.

Insight and tic specifiers for OCD and related disorders

The old DSM-IV-TR specifier “with poor insight”— the only specifier in that edition for OCD disorders — has been modified to allow for diagnosis on a spectrum of awareness.

The new specifiers in the DSM-5-TR for these conditions are:

  • good or fair insight
  • poor insight
  • absent insight/delusional obsessive-compulsive disorder beliefs (complete conviction that obsessive-compulsive disorder beliefs are true)

The decision to add these specifiers was made in an effort to emphasize that some OCD and related disorders can present with a wide range of patient insight.

These same insight specifiers have been included for body dysmorphic disorder and hoarding disorder.

This change was also made to emphasize that absent insight or delusional beliefs may warrant a diagnosis of the relevant obsessive-compulsive or related disorder, rather than schizophrenia spectrum and other psychotic disorders.

In the DSM-5-TR, the APA included the new tic-related specifier for obsessive-compulsive disorder to acknowledge a growing body of clinical and research evidence showing a link between these types of conditions.

Body dysmorphic disorder

Body dysmorphic disorder in the DSM-5-TR was moderately changed from DSM-IV-TR. Along with the four specifiers mentioned above, three regarding insight, an additional criterion was also added.

This criterion notes repetitive behaviors or mental acts are in response to preoccupation with perceived defects or flaws in physical appearance.

It’s this fixation on flawed appearance that sets body dysmorphic disorder apart from other conditions that may share similar features.

A “with muscle dysmorphia” specifier has been added to reflect research data suggesting this is an important distinction to make for this condition.

The delusional variant of body dysmorphic disorder (which identifies people who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delusional disorder, somatic type, and body dysmorphic disorder.

Instead, it gets the new “absent/delusional beliefs” specifier.

Hoarding disorder

Hoarding disorder graduates from being listed as just one symptom of obsessive-compulsive personality disorder in the DSM-IV-TR to an individually recognized condition in the DSM-5-TR.

After the DSM-5 OCD working group examined the research literature on hoarding, they found little support to suggest this was simply a variant of a personality disorder or a component of another mental health condition.

Hoarding disorder is characterized by the persistent difficulty of discarding or parting with possessions, regardless of the value others may attribute to these possessions.

Symptoms can be impairing and distressing, often compromising physical safety due to excessive clutter, fall risk, and fire hazards.

Hoarding behaviors were characterized in the DSM-IV-TR as obsessive-compulsive disorder (OCD), obsessive-compulsive personality disorder (OCPD) , or anxiety disorder not otherwise specified.

By recognizing hoarding disorder as a distinct condition with its own criteria and treatments, the APA hopes to improve identification, research, and awareness of the condition.

The four specifiers mentioned earlier were also added to hoarding disorder.

Trichotillomania (hairpulling disorder)

This condition remains largely unchanged from the DSM-IV-TR, although the name has been updated to add the explanatory phrase “ hairpulling disorder .”

Excoriation (skin-picking) disorder

Excoriation (skin-picking) disorder is a new condition added to the DSM-5-TR.

At the time of publication, the DSM-5-TR estimated that between 2% to 4% of the population could be diagnosed with this condition, though more recent statistics suggest the numbers may be closer to 2% to 3%.

The resulting problems may include medical issues such as infections, skin lesions, scarring, and physical disfigurement.

The DSM-5-TR states excoriation (skin-picking) disorder is characterized by constant and recurrent picking at your skin, resulting in skin lesions.

The face, arms, and hands tend to be the most common areas affected, though any part of the body can receive focus.

If you live with excoriation (skin-picking) disorder, it’s likely you’ve tried many times to stop. You may also use makeup, clothing, or other means in an attempt to conceal the marks from picking behaviors.

Like other mental health conditions, excoriation results in distress and functional impairment. You might experience a sense of embarrassment, shame, or loss of control of this condition.

Other specified and unspecified obsessive-compulsive and related disorders

The DSM-5-TR includes the diagnoses of “other” specified obsessive-compulsive and related disorders.

These conditions are notably present but don’t meet all the necessary diagnostic criteria in the clearly defined DSM-5-TR OCD and related disorders group.

This type of diagnosis could include conditions such as body-focused repetitive behaviors and obsessional jealousy .

Body-focused repetitive behaviors, for instance, are characterized by recurrent behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors.

Obsessional jealousy is characterized by nondelusional preoccupation with a partner’s perceived infidelity.

Let’s recap

OCD in the DSM-5-TR exists in its own chapter along with related disorders with features of uncontrollable obsessive thoughts and compulsive behaviors.

This separation from anxiety disorders in the DSM-IV-TR was a huge step toward improved diagnostic procedures and awareness of these conditions.

As research grows and the understanding of mental health conditions expands, future editions of the DSM will likely see more changes and improved clarity on OCD and related disorders.

Last medically reviewed on June 20, 2022

8 sources collapsed

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.) text revision. Arlington, VA: American Psychiatric Association.
  • Browne HA, et al. (2015). Familial clustering of tic disorders and obsessive-compulsive disorder. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2119328
  • Substance Abuse and Mental Health Services Administration. Chapter 2. DSM-IV to DSM-5 changes: Overview. DSM-5 changes: Implications for child serious emotional disturbance. (2016). https://www.ncbi.nlm.nih.gov/books/NBK519711/
  • Grant JE, et al. (2020). Prevalence of skin picking (excoriation) disorder. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7115927/
  • Highlights of changes from DSM-IV-TR to DSM-5. (2013). https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf
  • Substance Abuse and Mental Health Services Administration. Table 3.13 DSM-IV to DSM-5 obsessive-compulsive disorder comparison. Impact of the DSM-IV to DSM-5 changes on the National Survey on drug use and health. (2016). https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t13/
  • Mataix-Cols D. (2010). Diagnosis of hoarding disorder proposed for DSM-5. https://psychnews.psychiatryonline.org/doi/full/10.1176/pn.45.14.psychnews_45_14_004
  • Updated DSM-5 text revisions to be released in March. (2021). https://psychnews.psychiatryonline.org/doi/10.1176/appi.pn.2022.1.20

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Handbook on Obsessive-Compulsive and Related Disorders

  • Jennifer Lissemore , B.Sc. ,
  • Thomas E. Nordahl , M.D., Ph.D. ,
  • Chawki Benkelfat , M.D.

Search for more papers by this author

The recent switch from DSM-IV to DSM-5 led to considerable changes in the classification and characterization of obsessive-compulsive disorder (OCD) and various phenotypes that fall within the obsessive-compulsive spectrum, now collectively termed obsessive-compulsive and related disorders (OCRDs). The Handbook on Obsessive-Compulsive and Related Disorders concisely and systematically covers the assessment, phenomenology, etiology, and treatment of each OCRD, including OCD, body dysmorphic disorder, and trichotillomania (hair-pulling disorder), as well as hoarding disorder and excoriation (skin-picking) disorder, which are new to DSM-5. Surprisingly, “related disorders” encompassed longer and more detailed portions of the text than OCD per se. Still, this book complements the new DSM design in illustrating the relationship between OCRDs that were previously dispersed throughout, or excluded from, the DSM. Chapter order in DSM-5 now also reflects disorder relatedness; thus, although OCD was removed from Anxiety Disorders, the chapter on OCRDs lies immediately adjacent to Anxiety Disorders, reflecting the similarities between these two classes of disorders.

This handbook provides an intriguing glimpse into the research, literature reviews, and careful deliberations that brought about the DSM-5 OCRD chapter. Many of the authors played integral roles in the DSM-5 development process and were well suited to contribute insight into its evolution. Each chapter examines the clinical importance of large and subtle changes made to the DSM for this category of disorders. For example, the addition of an insight specifier for OCD, body dysmorphic disorder, and hoarding disorder has notable clinical implications—patients with “absent insight/delusional beliefs” should follow treatment for the appropriate OCRD, rather than for psychotic disorders. Whereas both strengths and weaknesses of the new chapter are mentioned, suggestions for improvement of the DSM development process (beyond additional research) are sparse. For instance, given that the contributors to the OCRD chapter are primarily American, there is a lack of diversity in perspectives fueling the development of OCRD concepts. The authors do not address how novel, unorthodox ideas can be incorporated into the discussion to prevent the DSM process from becoming self-perpetuating.

Additional book chapters are included on disorders that were considered for inclusion in the DSM-5 OCRD chapter but were ultimately classified elsewhere: tic disorder, illness anxiety disorder, and obsessive-compulsive personality disorder. Although these phenotypes were not classified under the OCRD heading, their significant overlap with OCRDs continues to merit consideration. Inclusion of these disorders in the handbook perhaps emphasizes the transient and inconclusive nature of DSM-5.

This guide to OCRDs is primarily aimed toward clinicians. In particular, treatment sections are heavily emphasized and geared toward those with an understanding of available psychotropic medications. The consistent structure followed by each chapter allows the information to be easily navigated and absorbed. Each chapter also includes summary tables and key points for quick reference, making this manual a valuable clinical tool.

Unfortunately, the etiological descriptions of these phenotypes are brief and limited in scope. Sections on etiology consist of basic introductions to the relevant pathophysiology for those unfamiliar with the disorder. Those hoping to garner an understanding of the neurobiological and genetic underpinnings that are shared among OCRDs will be disappointed. As a result, experts may find the contents to be overly familiar. By failing to discuss common etiologies that link OCRDs, one might be left questioning the true relatedness of these disorders.

Nevertheless, both researchers and clinicians must develop a comprehensive and uniform understanding of OCRDs, if research is intended to guide clinical practice. The differential diagnoses provided in each chapter carefully tease apart disorders with overlapping symptoms, thus supporting accurate research and correct diagnoses. For instance, the authors disentangle compulsions in OCD from stereotypic behaviors in stereotypic movement disorder, and hair pulling in trichotillomania from hair pulling in body dysmorphic disorder. A better handle on the OCRD phenotypes is critical to an understanding of their distinct pathophysiologies.

The disorders discussed in this book are commonly overlooked or poorly understood in practice in part because obsessive-compulsive symptoms can evoke excessive feelings of shame and are often concealed during assessment. Accordingly, each chapter includes screening tools and summaries of DSM-5 diagnostic criteria to facilitate the identification of these disorders. The authors offer a thorough discussion of comorbidities associated with each disorder, thus prompting clinicians to screen for OCRDs when patients present with common comorbid disorders, such as mood and anxiety disorders. Further encouraging the recognition of OCRDs in the clinic and in society, the authors convey a strong sense for the significant impairment associated with each disorder, as well as the need for treatment to be implemented effectively. The authors create a sense of compassion for OCRD patients by incorporating the patient’s perspective into the discussion and including illustrative case examples.

This book does not critically assess the new OCRD classification but instead disseminates and expands upon the contents of the DSM-5 OCRD chapter. It is only by increasing awareness and understanding of OCRDs that we can begin to enhance the quality of life of patients with these conditions. By offering a clear summary of what is known, this book takes the first step in that direction.

The authors report no financial relationships with commercial interests.

  • Consolation Gestures as Non-Verbal Markers of Stress when Discussing an Acute Social Issue 30 May 2023 | NSU Vestnik. Series: Linguistics and Intercultural Communication, Vol. 21, No. 1

chapter 5 case study for obsessive compulsive and related disorders katherine

15.5 Obsessive-Compulsive and Related Disorders

Learning objectives.

  • Describe the main features and prevalence of obsessive-compulsive disorder, body dysmorphic disorder, and hoarding disorder
  • Understand some of the factors in the development of obsessive-compulsive disorder

Obsessive-compulsive and related disorders are a group of overlapping disorders that generally involve intrusive, unpleasant thoughts and repetitive behaviors. Many of us experience unwanted thoughts from time to time (e.g., craving double cheeseburgers when dieting), and many of us engage in repetitive behaviors on occasion (e.g., pacing when nervous). However, obsessive-compulsive and related disorders elevate the unwanted thoughts and repetitive behaviors to a status so intense that these cognitions and activities disrupt daily life. Included in this category are obsessive-compulsive disorder (OCD), body dysmorphic disorder, and hoarding disorder.

Obsessive-Compulsive Disorder

People with obsessive-compulsive disorder (OCD) experience thoughts and urges that are intrusive and unwanted (obsessions) and/or the need to engage in repetitive behaviors or mental acts (compulsions). A person with this disorder might, for example, spend hours each day washing his hands or constantly checking and rechecking to make sure that a stove, faucet, or light has been turned off.

Obsessions are more than just unwanted thoughts that seem to randomly jump into our head from time to time, such as recalling an insensitive remark a coworker made recently, and they are more significant than day-to-day worries we might have, such as justifiable concerns about being laid off from a job. Rather, obsessions are characterized as persistent, unintentional, and unwanted thoughts and urges that are highly intrusive, unpleasant, and distressing (APA, 2013). Common obsessions include concerns about germs and contamination, doubts (“Did I turn the water off?”), order and symmetry (“I need all the spoons in the tray to be arranged a certain way”), and urges that are aggressive or lustful. Usually, the person knows that such thoughts and urges are irrational and thus tries to suppress or ignore them, but has an extremely difficult time doing so. These obsessive symptoms sometimes overlap, such that someone might have both contamination and aggressive obsessions (Abramowitz & Siqueland, 2013).

Compulsions are repetitive and ritualistic acts that are typically carried out primarily as a means to minimize the distress that obsessions trigger or to reduce the likelihood of a feared event (APA, 2013). Compulsions often include such behaviors as repeated and extensive hand washing, cleaning, checking (e.g., that a door is locked), and ordering (e.g., lining up all the pencils in a particular way), and they also include such mental acts as counting, praying, or reciting something to oneself ( Figure 15.11 ). Compulsions characteristic of OCD are not performed out of pleasure, nor are they connected in a realistic way to the source of the distress or feared event. Approximately 2.3% of the U.S. population will experience OCD in their lifetime (Ruscio, Stein, Chiu, & Kessler, 2010) and, if left untreated, OCD tends to be a chronic condition creating lifelong interpersonal and psychological problems (Norberg, Calamari, Cohen, & Riemann, 2008).

Body Dysmorphic Disorder

An individual with body dysmorphic disorder is preoccupied with a perceived flaw in her physical appearance that is either nonexistent or barely noticeable to other people (APA, 2013). These perceived physical defects cause the person to think she is unattractive, ugly, hideous, or deformed. These preoccupations can focus on any bodily area, but they typically involve the skin, face, or hair. The preoccupation with imagined physical flaws drives the person to engage in repetitive and ritualistic behavioral and mental acts, such as constantly looking in the mirror, trying to hide the offending body part, comparisons with others, and, in some extreme cases, cosmetic surgery (Phillips, 2005). An estimated 2.4% of the adults in the United States meet the criteria for body dysmorphic disorder, with slightly higher rates in women than in men (APA, 2013).

Hoarding Disorder

Although hoarding was traditionally considered to be a symptom of OCD, considerable evidence suggests that hoarding represents an entirely different disorder (Mataix-Cols et al., 2010). People with hoarding disorder cannot bear to part with personal possessions, regardless of how valueless or useless these possessions are. As a result, these individuals accumulate excessive amounts of usually worthless items that clutter their living areas ( Figure 15.12 ). Often, the quantity of cluttered items is so excessive that the person is unable use his kitchen, or sleep in his bed. People who suffer from this disorder have great difficulty parting with items because they believe the items might be of some later use, or because they form a sentimental attachment to the items (APA, 2013). Importantly, a diagnosis of hoarding disorder is made only if the hoarding is not caused by another medical condition and if the hoarding is not a symptom of another disorder (e.g., schizophrenia) (APA, 2013).

Causes of OCD

The results of family and twin studies suggest that OCD has a moderate genetic component. The disorder is five times more frequent in the first-degree relatives of people with OCD than in people without the disorder (Nestadt et al., 2000). Additionally, the concordance rate of OCD among identical twins is around 57%; however, the concordance rate for fraternal twins is 22% (Bolton, Rijsdijk, O’Connor, Perrin, & Eley, 2007). Studies have implicated about two dozen potential genes that may be involved in OCD; these genes regulate the function of three neurotransmitters: serotonin, dopamine, and glutamate (Pauls, 2010). Many of these studies included small sample sizes and have yet to be replicated. Thus, additional research needs to be done in this area.

A brain region that is believed to play a critical role in OCD is the orbitofrontal cortex (Kopell & Greenberg, 2008), an area of the frontal lobe involved in learning and decision-making (Rushworth, Noonan, Boorman, Walton, & Behrens, 2011) ( Figure 15.13 ). In people with OCD, the orbitofrontal cortex becomes especially hyperactive when they are provoked with tasks in which, for example, they are asked to look at a photo of a toilet or of pictures hanging crookedly on a wall (Simon, Kaufmann, Müsch, Kischkel, & Kathmann, 2010). The orbitofrontal cortex is part of a series of brain regions that, collectively, is called the OCD circuit; this circuit consists of several interconnected regions that influence the perceived emotional value of stimuli and the selection of both behavioral and cognitive responses (Graybiel & Rauch, 2000). As with the orbitofrontal cortex, other regions of the OCD circuit show heightened activity during symptom provocation (Rotge et al., 2008), which suggests that abnormalities in these regions may produce the symptoms of OCD (Saxena, Bota, & Brody, 2001). Consistent with this explanation, people with OCD show a substantially higher degree of connectivity of the orbitofrontal cortex and other regions of the OCD circuit than do those without OCD (Beucke et al., 2013).

The findings discussed above were based on imaging studies, and they highlight the potential importance of brain dysfunction in OCD. However, one important limitation of these findings is the inability to explain differences in obsessions and compulsions. Another limitation is that the correlational relationship between neurological abnormalities and OCD symptoms cannot imply causation (Abramowitz & Siqueland, 2013).

Connect the Concepts

Conditioning and ocd.

The symptoms of OCD have been theorized to be learned responses, acquired and sustained as the result of a combination of two forms of learning: classical conditioning and operant conditioning (Mowrer, 1960; Steinmetz, Tracy, & Green, 2001). Specifically, the acquisition of OCD may occur first as the result of classical conditioning, whereby a neutral stimulus becomes associated with an unconditioned stimulus that provokes anxiety or distress. When an individual has acquired this association, subsequent encounters with the neutral stimulus trigger anxiety, including obsessive thoughts; the anxiety and obsessive thoughts (which are now a conditioned response) may persist until she identifies some strategy to relieve it. Relief may take the form of a ritualistic behavior or mental activity that, when enacted repeatedly, reduces the anxiety. Such efforts to relieve anxiety constitute an example of negative reinforcement (a form of operant conditioning). Recall from the chapter on learning that negative reinforcement involves the strengthening of behavior through its ability to remove something unpleasant or aversive. Hence, compulsive acts observed in OCD may be sustained because they are negatively reinforcing, in the sense that they reduce anxiety triggered by a conditioned stimulus.

Suppose an individual with OCD experiences obsessive thoughts about germs, contamination, and disease whenever she encounters a doorknob. What might have constituted a viable unconditioned stimulus? Also, what would constitute the conditioned stimulus, unconditioned response, and conditioned response? What kinds of compulsive behaviors might we expect, and how do they reinforce themselves? What is decreased? Additionally, and from the standpoint of learning theory, how might the symptoms of OCD be treated successfully?

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Textbook of Psychiatry for Intellectual Disability and Autism Spectrum Disorder pp 625–654 Cite as

Obsessive-Compulsive and Related Disorders

  • Jarrett Barnhill 6  
  • First Online: 12 May 2022

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1 Citations

The DSM-5 revamped the diagnosis of obsessive-compulsive disorder (OCD) by removing it from the anxiety disorders and creating a separate diagnostic category, obsessive-compulsive and related disorders (OCRD). OCRD includes a broader spectrum of repetitive behaviors that differ from classic obsessions and compulsions (intrusiveness, aversion, distress, and a limited repertoire of anxiety-reducing avoidance behaviors). The related disorders appear less anxiety motivated and habitual (less goal-directed). On the other hand, there is considerable overlap and co-occurrence between these subgroups.

This expansion creates new challenges for clinicians and researchers struggling to understand the boundaries between tic disorders, movement disorders, and comorbid psychiatric disorders. In addition, the overlapping boundaries between OCD and co-occurring neurodevelopmental disorders influence not only their clinical presentation but also the efficacy of current treatment modalities. This heterogeneity contributes to the clinical reality that treatment outcomes favor clinical improvement in a majority of patients, failure rate approaching 15% and remission rates below 30%. As a result, incomplete responders require psychopharmacological augmentation, combined treatment with cognitive-behavioral psychotherapies, and more invasive biological or neurosurgical procures for persistent nonresponders.

  • Obsessive-compulsive disorder
  • Endophenotype
  • Transdiagnostic
  • Intellectual disability
  • Tic disorders
  • Stereotypies
  • Neuropharmacology
  • Behavioral therapies
  • Neurosurgery
  • Brain stimulation

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Del Casale A, Sorice S, Padovano A, Simmaco M, Farracuti S, Lamis DA, Rapinesi C, Sani G, Giraldi P, Kotzalidis GO, Pampili M. Psychopharmacological treatment of obsessive-compulsive disorder. Curr Neuropharmacol. 2019;17:710–36.

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Barnhill, J. (2022). Obsessive-Compulsive and Related Disorders. In: Bertelli, M.O., Deb, S.(., Munir, K., Hassiotis, A., Salvador-Carulla, L. (eds) Textbook of Psychiatry for Intellectual Disability and Autism Spectrum Disorder. Springer, Cham. https://doi.org/10.1007/978-3-319-95720-3_24

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