15 - 10 Obsessive Compulsive and Related Disorders

01 - 10.1 Obsessive Compulsive Disorder
10.1 Obsessive-Compulsive Disorder
Obsessive-Compulsive and Related
Disorders
10.1 Obsessive-Compulsive Disorder
Obsessive-compulsive disorder (OCD) is represented by a diverse group of symptoms
that include intrusive thoughts, rituals, preoccupations, and compulsions. These
recurrent obsessions or compulsions cause severe distress to the person. The obsessions
or compulsions are time-consuming and interfere significantly with the person’s normal
routine, occupational functioning, usual social activities, or relationships. A patient with
OCD may have an obsession, a compulsion, or both.
An obsession is a recurrent and intrusive thought, feeling, idea, or sensation. In
contrast to an obsession, which is a mental event, a compulsion is a behavior.
Specifically, a compulsion is a conscious, standardized, recurrent behavior, such as
counting, checking, or avoiding. A patient with OCD realizes the irrationality of the
obsession and experiences both the obsession and the compulsion as ego-dystonic (i.e.,
unwanted behavior).
Although the compulsive act may be carried out in an attempt to reduce the anxiety
associated with the obsession, it does not always succeed in doing so. The completion of
the compulsive act may not affect the anxiety, and it may even increase the anxiety.
Anxiety is also increased when a person resists carrying out a compulsion. A variety of
OCD conditions are described in this section and those that follow (Sections 10.2–10.5).
EPIDEMIOLOGY
The rates of OCD are fairly consistent, with a lifetime prevalence in the general
population estimated at 2 to 3 percent. Some researchers have estimated that the
disorder is found in as many as 10 percent of outpatients in psychiatric clinics. These
figures make OCD the fourth most common psychiatric diagnosis after phobias,
substance-related disorders, and major depressive disorder. Epidemiological studies in
Europe, Asia, and Africa have confirmed these rates across cultural boundaries.
Among adults, men and women are equally likely to be affected, but among
adolescents, boys are more commonly affected than girls. The mean age of onset is
about 20 years, although men have a slightly earlier age of onset (mean about 19 years)
than women (mean about 22 years). Overall, the symptoms of about two thirds of
affected persons have an onset before age 25, and the symptoms of fewer than 15
percent have an onset after age 35. The onset of the disorder can occur in adolescence
or childhood, in some cases as early as 2 years of age. Single persons are more
frequently affected with OCD than are married persons, although this finding probably
reflects the difficulty that persons with the disorder have maintaining a relationship.
OCD occurs less often among blacks than among whites, although access to health care
rather than differences in prevalence may explain the variation.
COMORBIDITY
Persons with OCD are commonly affected by other mental disorders. The lifetime
prevalence for major depressive disorder in persons with OCD is about 67 percent and
for social phobia about 25 percent. Other common comorbid psychiatric diagnoses in
patients with OCD include alcohol use disorders, generalized anxiety disorder, specific
phobia, panic disorder, eating disorders, and personality disorders. OCD exhibits a
superficial resemblance to obsessive-compulsive personality disorder, which is associated
with an obsessive concern for details, perfectionism, and other similar personality traits.
The incidence of Tourette’s disorder in patients with OCD is 5 to 7 percent, and 20 to 30
percent of patients with OCD have a history of tics.
ETIOLOGY
Biological Factors
Neurotransmitters
SEROTONERGIC SYSTEM. The many clinical drug trials that have been conducted support
the hypothesis that dysregulation of serotonin is involved in the symptom formation of
obsessions and compulsions in the disorder. Data show that serotonergic drugs are more
effective in treating OCD than drugs that affect other neurotransmitter systems, but
whether serotonin is involved in the cause of OCD is not clear. Clinical studies have
assayed cerebrospinal fluid (CSF) concentrations of serotonin metabolites (e.g., 5hydroxyindoleacetic acid [5-HIAA]) and affinities and numbers of platelet-binding sites
of tritiated imipramine (Tofranil), which binds to serotonin reuptake sites, and have
reported variable findings of these measures in patients with OCD. In one study, the CSF
concentration of 5-HIAA decreased after treatment with clomipramine (Anafranil),
focusing attention on the serotonergic system.
NORADRENERGIC SYSTEM. Currently, less evidence exists for dysfunction in the
noradrenergic system in OCD. Anecdotal reports show some improvement in OCD
symptoms with use of oral clonidine (Catapres), a drug that lowers the amount of
norepinephrine released from the presynaptic nerve terminals.
NEUROIMMUNOLOGY. Some interest exists in a positive link between streptococcal
infection and OCD. Group Aβ-hemolytic streptococcal infection can cause rheumatic
fever, and approximately 10 to 30 percent of the patients develop Sydenham’s chorea
and show obsessive-compulsive symptoms.
Brain-Imaging Studies.
Neuroimaging in patients with OCD has produced
converging data implicating altered function in the neurocircuitry between orbitofrontal
cortex, caudate, and thalamus. Various functional brain-imaging studies—for example,
positron emission tomography (PET)—have shown increased activity (e.g., metabolism
and blood flow) in the frontal lobes, the basal ganglia (especially the caudate), and the
cingulum of patients with OCD. The involvement of these areas in the pathology of OCD
appears more associated with corticostriatal pathways than with the amygdala
pathways, which are the current focus of much anxiety disorder research.
Pharmacological and behavioral treatments reportedly reverse these abnormalities (Fig.
10.1-1). Data from functional brain-imaging studies are consistent with data from
structural brain-imaging studies. Both computed tomographic (CT) and magnetic
resonance imaging (MRI) studies have found bilaterally smaller caudates in patients
with OCD. Both functional and structural brain-imaging study results are also
compatible with the observation that neurological procedures involving the cingulum
are sometimes effective in the treatment of OCD. One recent MRI study reported
increased T1 relaxation times in the frontal cortex, a finding consistent with the location
of abnormalities discovered in PET studies.
FIGURE 10.1-1
Brain regions implicated in the pathophysiology of obsessive-compulsive disorder. (From
Rosenberg DR, MacMillan SN, Moore GJ. Brain anatomy and chemistry may predict
treatment
response
in
paediatric
obsessive-compulsive
disorder.
In
J
Neuropsychopharmacol. 2001; 4:179, with permission.)
Genetics.
Available genetic data on OCD support the hypothesis that the disorder
has a significant genetic component. Relatives of probands with OCD consistently have
a threefold to fivefold higher probability of having OCD or obsessive-compulsive
features than families of control probands The data, however, do not yet distinguish the
heritable factors from the influence of cultural and behavioral effects on the
transmission of the disorder. Studies of concordance for the disorder in twins have
consistently found a significantly higher concordance rate for monozygotic twins than
for dizygotic twins. Some studies also demonstrate increased rates of a variety of
conditions among relatives of OCD probands, including generalized anxiety disorder, tic
disorders, body dysmorphic disorder, hypochondriasis, eating disorders, and habits such
as nail-biting.
Other Biological Data.
Electrophysiological studies, sleep electroencephalogram
(EEG) studies, and neuroendocrine studies have contributed data that indicate some
commonalities between depressive disorders and OCD. A higher than usual incidence of
nonspecific EEG abnormalities occurs in patients with OCD. Sleep EEG studies have
found abnormalities similar to those in depressive disorders, such as decreased rapid eye
movement latency. Neuroendocrine studies have also produced some analogies to
depressive disorders, such as nonsuppression on the dexamethasone-suppression test in
about one-third of patients and decreased growth hormone secretion with clonidine
infusions.
As mentioned, studies have suggested a possible link between a subset of OCD cases
and certain types of motor tic syndromes (i.e., Tourette’s disorder and chronic motor
tics). A higher rate of OCD, Tourette’s disorder, and chronic motor tics are found in
relatives of patients with Tourette’s disorder than in relatives of controls, whether or not
they had OCD. Most family studies of probands with OCD have found increased rates of
Tourette’s disorder and chronic motor tics only among the relatives of probands with
OCD who also have some form of tic disorder. Evidence also suggests cotransmission of
Tourette’s disorder, OCD, and chronic motor tics within families.
Behavioral Factors
According to learning theorists, obsessions are conditioned stimuli. A relatively neutral
stimulus becomes associated with fear or anxiety through a process of respondent
conditioning by being paired with events that are noxious or anxiety producing. Thus,
previously neutral objects and thoughts become conditioned stimuli capable of
provoking anxiety or discomfort.
Compulsions are established in a different way. When a person discovers that a
certain action reduces anxiety attached to an obsessional thought, he or she develops
active avoidance strategies in the form of compulsions or ritualistic behaviors to control
the anxiety. Gradually, because of their efficacy in reducing a painful secondary drive
(anxiety), the avoidance strategies become fixed as learned patterns of compulsive
behaviors. Learning theory provides useful concepts for explaining certain aspects of
obsessive-compulsive phenomena—for example, the anxiety-provoking capacity of ideas
not necessarily frightening in themselves and the establishment of compulsive patterns
of behavior.
Psychosocial Factors
Personality Factors.
OCD differs from obsessive-compulsive personality disorder,
which is associated with an obsessive concern for details, perfectionism, and other
similar personality traits. Most persons with OCD do not have premorbid compulsive
symptoms, and such personality traits are neither necessary nor sufficient for the
development of OCD. Only about 15 to 35 percent of patients with OCD have had
premorbid obsessional traits.
Psychodynamic Factors.
Psychodynamic insight may be of great help in
understanding problems with treatment compliance, interpersonal difficulties, and
personality problems accompanying the Axis I disorder. Many patients with OCD may
refuse to cooperate with effective treatments such as selective serotonin reuptake
inhibitors (SSRIs) and behavior therapy. Even though the symptoms of OCD may be
biologically driven, psychodynamic meanings may be attached to them. Patients may
become invested in maintaining the symptomatology because of secondary gains. For
example, a male patient, whose mother stays home to take care of him, may
unconsciously wish to hang on to his OCD symptoms because they keep the attention of
his mother.
Another contribution of psychodynamic understanding involves the interpersonal
dimensions. Studies have shown that relatives will accommodate the patient through
active participation in rituals or significant modifications of their daily routines. This
form of family accommodation is correlated with stress in the family, rejecting attitudes
toward the patient, and poor family functioning. Often, the family members are
involved in an effort to reduce the patient’s anxiety or to control the patient’s
expressions of anger. This pattern of relatedness may become internalized and be recreated when the patient enters a treatment setting. By looking at recurring patterns of
interpersonal relationships from a psychodynamic perspective, patients may learn how
their illness affects others.
Finally, one other contribution of psychodynamic thinking is recognition of the
precipitants that initiate or exacerbate symptoms. Often, interpersonal difficulties
increase the patient’s anxiety and, thus, increase the patient’s symptomatology as well.
Research suggests that OCD may be precipitated by a number of environmental
stressors, especially those involving pregnancy, childbirth, or parental care of children.
An understanding of the stressors may assist the clinician in an overall treatment plan
that reduces the stressful events themselves or their meaning to the patient.
SIGMUND FREUD. In classic psychoanalytic theory, OCD was termed obsessive-compulsive
neurosis and was considered a regression from the oedipal phase to the anal
psychosexual phase of development. When patients with OCD feel threatened by anxiety
about retaliation for unconscious impulses or by the loss of a significant object’s love,
they retreat from the oedipal position and regress to an intensely ambivalent emotional
stage associated with the anal phase. The ambivalence is connected to the unraveling of
the smooth fusion between sexual and aggressive drives characteristic of the oedipal
phase. The coexistence of hatred and love toward the same person leaves patients
paralyzed with doubt and indecision.
An example of how Freud viewed OCD symptoms is described by Otto Fenichel in the
case study presented here.
A patient, who was not analyzed, complained in the first interview that he suffered
from the compulsion to look backward constantly, from fear that he might have
overlooked something important behind him. These ideas were predominant; he might
overlook a coin lying on the ground; he might have injured an insect by stepping on
it; or an insect might have fallen on its back and need his help. The patient was also
afraid of touching anything, and whenever he had touched an object he had to
convince himself that he had not destroyed it. He had no vocation because the severe
compulsions disturbed all his working activity; however, he had one passion:
housecleaning. He liked to visit his neighbors and clean their houses, just for fun.
Another symptom was described by the patient as his “clothes consciousness”; he was
constantly preoccupied with the question whether or not his suit fitted. He, too, stated
that sexuality did not play an important part in his life. He had sexual intercourse two
or three times a year only, and exclusively with girls in whom he had no personal
interest. Later on, he mentioned another symptom. As a child, he had felt his mother
to be disgusting and had been terribly afraid of touching her. There was no real
reason whatsoever for such a disgust, for the mother had been a nice person.
In the clinical picture for this case study, Freud believed the need to be clean and
not to touch is related to anal sexuality, and the disgust for the mother is a reaction
against incestuous fears.
One of the striking features of patients with OCD is the degree to which they are
preoccupied with aggression or cleanliness, either overtly in the content of their
symptoms or in the associations that lie behind them. The psychogenesis of OCD,
therefore, may lie in disturbances in normal growth and development related to the
anal-sadistic phase of development.
Ambivalence.
Ambivalence is an important feature of normal children during the analsadistic developmental phase; children feel both love and murderous hate toward the
same object, sometimes simultaneously. Patients with OCD often consciously experience
both love and hate toward an object. This conflict of opposing emotions is evident in a
patient’s doing and undoing patterns of behavior and in paralyzing doubt in the face of
choices.
Magical Thinking.
In magical thinking, regression uncovers early modes of thought
rather than impulses; that is, ego functions as well as id functions are affected by
regression. Inherent in magical thinking is omnipotence of thought. Persons believe that
merely by thinking about an event in the external world they can cause the event to
occur without intermediate physical actions. This feeling causes them to fear having an
aggressive thought (Fig. 10.1-2).
FIGURE 10.1-2
In magical thinking, one believes that the thought is equal to the deed, that wishing a
person dead will make it happen, as symbolized in this illustration. (Courtesy of Arthur
Tress.)
DIAGNOSIS AND CLINICAL FEATURES
As part of the diagnostic criteria for OCD, the fifth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5) allows clinicians to indicate whether the patient’s
OCD is characterized by good or fair insight, poor insight, or absent insight (Table 10.11). Patients with good or fair insight recognize that their OCD beliefs are definitely or
probably not true or may or may not be true. Patients with poor insight believe their
OCD beliefs are probably true, and patients with absent insight are convinced that their
beliefs are true.
Table 10.1-1
DSM-5 Diagnostic Criteria for Obsessive-Compulsive Disorder
Patients with OCD often take their complaints to physicians rather than psychiatrists
(Table 10.1-2). Most patients with OCD have both obsessions and compulsions—up to 75
percent in some surveys. Some researchers and clinicians believe that the number may
be much closer to 100 percent if patients are carefully assessed for the presence of
mental compulsions in addition to behavioral compulsions. For example, an obsession
about hurting a child may be followed by a mental compulsion to repeat a specific
prayer a specific number of times. Other researchers and clinicians, however, believe
that some patients do have only obsessive thoughts without compulsions. Such patients
are likely to have repetitious thoughts of a sexual or aggressive act that is reprehensible
to them. For clarity, it is best to conceptualize obsessions as thoughts and compulsions
as behavior.
Table 10.1-2
Nonpsychiatric Clinical Specialists Likely to See Obsessive-Compulsive
Disorder Patients
Obsessions and compulsions are the essential features of OCD. An idea or an impulse
intrudes itself insistently and persistently into a person’s conscious awareness. Typical
obsessions associated with OCD include thoughts about contamination (“My hands are
dirty”) or doubts (“I forgot to turn off the stove”).
A feeling of anxious dread accompanies the central manifestation, and the key
characteristic of a compulsion is that it reduces the anxiety associated with the
obsession. The obsession or the compulsion is ego-alien; that is, it is experienced as
foreign to the person’s experience of himself or herself as a psychological being. No
matter how vivid and compelling the obsession or compulsion, the person usually
recognizes it as absurd and irrational. The person suffering from obsessions and
compulsions usually feels a strong desire to resist them. Nevertheless, about half of all
patients offer little resistance to compulsions, although about 80 percent of all patients
believe that the compulsion is irrational. Sometimes, patients overvalue obsessions and
compulsions—for example, they may insist that compulsive cleanliness is morally
correct, even though they have lost their jobs because of time spent cleaning.
Symptom Patterns
The presentation of obsessions and compulsions is heterogeneous in adults (Table 10.13) and in children and adolescents (Table 10.1-4). The symptoms of an individual
patient can overlap and change with time, but OCD has four major symptom patterns.
Table 10.1-3
Obsessive-Compulsive Symptoms in Adults
Table 10.1-4
Reported Obsessions and Compulsions for 70 Consecutive Child and
Adolescent Patients
Contamination.
The most common pattern is an obsession of contamination,
followed by washing or accompanied by compulsive avoidance of the presumably
contaminated object. The feared object is often hard to avoid (e.g., feces, urine, dust, or
germs). Patients may literally rub the skin off their hands by excessive hand washing or
may be unable to leave their homes because of fear of germs. Although anxiety is the
most common emotional response to the feared object, obsessive shame and disgust are
also common. Patients with contamination obsessions usually believe that the
contamination is spread from object to object or person to person by the slightest
contact.
Pathological Doubt.
The second most common pattern is an obsession of doubt,
followed by a compulsion of checking. The obsession often implies some danger of
violence (e.g., forgetting to turn off the stove or not locking a door). The checking may
involve multiple trips back into the house to check the stove, for example. These
patients have an obsessional self-doubt and always feel guilty about having forgotten or
committed something.
Intrusive Thoughts.
In the third most common pattern, there are intrusive
obsessional thoughts without a compulsion. Such obsessions are usually repetitious
thoughts of a sexual or aggressive act that is reprehensible to the patient. Patients
obsessed with thoughts of aggressive or sexual acts may report themselves to police or
confess to a priest. Suicidal ideation may also be obsessive; but a careful suicidal
assessment of actual risk must always be done.
Symmetry.
The fourth most common pattern is the need for symmetry or precision,
which can lead to a compulsion of slowness. Patients can literally take hours to eat a
meal or shave their faces.
Other Symptom Patterns.
Religious obsessions and compulsive hoarding are
common in patients with OCD. Compulsive hair pulling and nail biting are behavioral
patterns related to OCD. Masturbation may also be compulsive.
Mental Status Examination
On mental status examinations, patients with OCD may show symptoms of depressive
disorders. Such symptoms are present in about 50 percent of all patients. Some patients
with OCD have character traits suggesting obsessive-compulsive personality disorder
(e.g., excessive need for preciseness and neatness), but most do not. Patients with OCD,
especially men, have a higher than average celibacy rate. Married patients have a
greater than usual amount of marital discord.
Ms. K was referred for psychiatric evaluation by her general practitioner. On
interview, Ms. K described a long history of checking rituals that had caused her to
lose several jobs and had damaged numerous relationships. She reported, for example,
that because she often had the thought that she had not locked the door to the car, it
was difficult for her to leave that car until she had checked repeatedly that it was
secure. She had broken several car door handles with the vigor of her checking and
had been up to an hour late to work because she spent so much time checking her car
door. Similarly, she had recurrent thoughts that she had left the door to her apartment
unlocked, and she returned several times daily to check her door before she left for
work. She reported that checking doors decreased her anxiety about security. Although
Ms. K reported that she had occasionally tried to leave her car or apartment without
checking the door (e.g., when she was already late for work), she found that she
became so worried about her car being stolen or her apartment being broken into that
she had difficulty going anywhere. Ms. K reported that her obsessions about security
had become so extreme over the past 3 months that she had lost her job due to
recurrent tardiness. She recognized the irrational nature of her obsessive concerns but
could not bring herself to ignore them. (Courtesy of Erin B. McClure-Tone, Ph.D., and
Daniel S. Pine, M.D.)
DIFFERENTIAL DIAGNOSIS
Medical Conditions
A number of primary medical disorders can produce syndromes bearing a striking
resemblance to OCD. The current conceptualization of OCD as a disorder of the basal
ganglia derives from the phenomenological similarity between idiopathic OCD and
OCD-like disorders that are associated with basal ganglia diseases, such as Sydenham’s
chorea and Huntington’s disease. Neurological signs of such basal ganglia pathology
must be assessed when considering the diagnosis of OCD in a patient presenting for
psychiatric treatment. It should also be noted that OCD frequently develops before age
30 years, and new-onset OCD in an older individual should raise questions about
potential neurological contributions to the disorder.
Tourette’s Disorder
OCD is closely related to Tourette’s disorder, as the two conditions frequently co-occur,
both in individuals over time and within families. About 90 percent of persons with
Tourette’s disorder have compulsive symptoms, and as many as two thirds meet the
diagnostic criteria for OCD.
In its classic form, Tourette’s disorder is associated with a pattern of recurrent vocal
and motor tics that bears only a slight resemblance to OCD. The premonitory urges that
precede tics often strikingly resemble obsessions, however, and many of the more
complicated motor tics are very similar to compulsions.
Other Psychiatric Conditions
Obsessive-compulsive behavior is found in a host of other psychiatric disorders, and the
clinician must also rule out these conditions when diagnosing OCD. OCD exhibits a
superficial resemblance to obsessive-compulsive personality disorder, which is associated
with an obsessive concern for details, perfectionism, and other similar personality traits.
The conditions are easily distinguished in that only OCD is associated with a true
syndrome of obsessions and compulsions.
Psychotic symptoms often lead to obsessive thoughts and compulsive behaviors that
can be difficult to distinguish from OCD with poor insight, in which obsessions border on
psychosis. The keys to distinguishing OCD from psychosis are (1) patients with OCD can
almost always acknowledge the unreasonable nature of their symptoms, and (2)
psychotic illnesses are typically associated with a host of other features that are not
characteristic of OCD. Similarly, OCD can be difficult to differentiate from depression
because the two disorders often occur comorbidly, and major depression is often
associated with obsessive thoughts that, at times, border on true obsessions such as those
that characterize OCD. The two conditions are best distinguished by their courses.
Obsessive symptoms associated with depression are only found in the presence of a
depressive episode, whereas true OCD persists despite remission of depression.
COURSE AND PROGNOSIS
More than half of patients with OCD have a sudden onset of symptoms. The onset of
symptoms for about 50 to 70 percent of patients occurs after a stressful event, such as a
pregnancy, a sexual problem, or the death of a relative. Because many persons manage
to keep their symptoms secret, they often delay 5 to 10 years before coming to
psychiatric attention, although the delay is probably shortening with increased
awareness of the disorder. The course is usually long but variable; some patients
experience a fluctuating course, and others experience a constant one.
About 20 to 30 percent of patients have significant improvement in their symptoms,
and 40 to 50 percent have moderate improvement. The remaining 20 to 40 percent of
patients either remain ill or their symptoms worsen.
About one-third of patients with OCD have major depressive disorder, and suicide is a
risk for all patients with OCD. A poor prognosis is indicated by yielding to (rather than
resisting)
compulsions,
childhood
onset,
bizarre
compulsions,
the
need
for
hospitalization, a coexisting major depressive disorder, delusional beliefs, the presence
of overvalued ideas (i.e., some acceptance of obsessions and compulsions), and the
presence of a personality disorder (especially schizotypal personality disorder). A good
prognosis is indicated by good social and occupational adjustment, the presence of a
precipitating event, and an episodic nature of the symptoms. The obsessional content
does not seem to be related to the prognosis.
TREATMENT
With mounting evidence that OCD is largely determined by biological factors, classic
psychoanalytic theory has fallen out of favor. Moreover, because OCD symptoms appear
to be largely refractory to psychodynamic psychotherapy and psychoanalysis,
pharmacological and behavioral treatments have become common. But psychodynamic
factors may be of considerable benefit in understanding what precipitates exacerbations
of the disorder and in treating various forms of resistance to treatment, such as
noncompliance with medication.
Many patients with OCD tenaciously resist treatment efforts. They may refuse to take
medication and may resist carrying out therapeutic homework assignments and other
activities prescribed by behavior therapists. The obsessive-compulsive symptoms
themselves, no matter how biologically based, may have important psychological
meanings that make patients reluctant to give them up. Psychodynamic exploration of a
patient’s resistance to treatment may improve compliance.
Well-controlled studies have found that pharmacotherapy, behavior therapy, or a
combination of both is effective in significantly reducing the symptoms of patients with
OCD. The decision about which therapy to use is based on the clinician’s judgment and
experience and the patient’s acceptance of the various modalities.
Pharmacotherapy
The efficacy of pharmacotherapy in OCD has been proved in many clinical trials and is
enhanced by the observation that the studies find a placebo response rate of only about
5 percent.
The drugs, some of which are used to treat depressive disorders or other mental
disorders, can be given in their usual dosage ranges. Initial effects are generally seen
after 4 to 6 weeks of treatment, although 8 to 16 weeks are usually needed to obtain
maximal therapeutic benefit. Treatment with antidepressant drugs is still controversial,
and a significant proportion of patients with OCD who respond to treatment with
antidepressant drugs seem to relapse if the drug therapy is discontinued.
The standard approach is to start treatment with an SSRI or clomipramine and then
move to other pharmacological strategies if the serotonin-specific drugs are not
effective. The serotonergic drugs have increased the percentage of patients with OCD
who are likely to respond to treatment to the range of 50 to 70 percent.
Selective Serotonin Reuptake Inhibitors.
Each of the SSRIs available in the
United States—fluoxetine (Prozac), fluvoxamine (Luvox), paroxetine (Paxil), sertraline
(Zoloft), citalopram (Celexa)—has been approved by the US Food and Drug
Administration (FDA) for the treatment of OCD. Higher dosages have often been
necessary for a beneficial effect, such as 80 mg a day of fluoxetine. Although the SSRIs
can cause sleep disturbance, nausea and diarrhea, headache, anxiety, and restlessness,
these adverse effects are often transient and are generally less troubling than the
adverse effects associated with tricyclic drugs, such as clomipramine. The best clinical
outcomes occur when SSRIs are used in combination with behavioral therapy.
Clomipramine.
Of all the tricyclic and tetracyclic drugs, clomipramine is the most
selective for serotonin reuptake versus norepinephrine reuptake and is exceeded in this
respect only by the SSRIs. The potency of serotonin reuptake of clomipramine is
exceeded only by sertraline and paroxetine. Clomipramine was the first drug to be FDA
approved for the treatment of OCD. Its dosing must be titrated upward over 2 to 3
weeks to avoid gastrointestinal adverse effects and orthostatic hypotension, and as with
other tricyclic drugs, it causes significant sedation and anticholinergic effects, including
dry mouth and constipation. As with SSRIs, the best outcomes result from a combination
of drug and behavioral therapy.
Other Drugs.
If treatment with clomipramine or an SSRI is unsuccessful, many
therapists augment the first drug by the addition of valproate (Depakene), lithium
(Eskalith), or carbamazepine (Tegretol). Other drugs that can be tried in the treatment
of OCD are venlafaxine (Effexor), pindolol (Visken), and the monoamine oxidase
inhibitors (MAOIs), especially phenelzine (Nardil). Other pharmacological agents for the
treatment of unresponsive patients include buspirone (BuSpar), 5-hydroxytryptamine (5HT), L-tryptophan, and clonazepam (Klonopin). Adding an atypical antipsychotic such
as risperidone (Risperdal) has helped in some cases.
Behavior Therapy
Although few head-to-head comparisons have been made, behavior therapy is as
effective as pharmacotherapies in OCD, and some data indicate that the beneficial
effects are longer lasting with behavior therapy. Many clinicians, therefore, consider
behavior therapy the treatment of choice for OCD. Behavior therapy can be conducted
in both outpatient and inpatient settings. The principal behavioral approaches in OCD
are exposure and response prevention. Desensitization, thought stopping, flooding,
implosion therapy, and aversive conditioning have also been used in patients with OCD.
In behavior therapy, patients must be truly committed to improvement.
Psychotherapy
In the absence of adequate studies of insight-oriented psychotherapy for OCD, any valid
generalizations about its effectiveness are hard to make, although there are anecdotal
reports of successes. Individual analysts have seen striking and lasting changes for the
better in patients with obsessive-compulsive personality disorder, especially when they
are able to come to terms with the aggressive impulses underlying their character traits.
Likewise, analysts and dynamically oriented psychiatrists have observed marked
symptomatic improvement in patients with OCD in the course of analysis or prolonged
insight psychotherapy.
Mr. P, a passive, emotionally vacant, exceedingly polite and quiet man in his 30s,
had obsessive-compulsive disorder and sought psychodynamic psychotherapy because
he was having difficulty functioning at work or in relationships. Mr. P had counting
rituals and a compulsion to keep checking that there were no sharp knives left with
their blades exposed and no shoes not properly hung on shoetrees or aligned in
closets. In sessions he often spoke endlessly about seemingly empty details of his work
life. The therapist became drowsy at one point as he listened to Mr. P, who noticed
this and, with uncharacteristic affect in his voice, asked, “Doctor, excuse me, but are
you listening?” To this the therapist replied, “No, I guess not. Are you?” Mr. P
apologized for having been boring.
This incident led to a direct discussion between them about the way Mr. P’s
obsessive, circumstantial, and emotionally empty recounting of details was a form of
resistance and one in which his therapist had joined him by becoming drowsy in the
session. Were they going to do the work of therapy together or not?
In subsequent sessions Mr. P made efforts to speak more about the origin of his
symptoms, which began with a ritual of kissing his parents each goodnight nine times
lest he be unable to sleep. On one occasion, while explaining this, Mr. P made a slip
of speech about having to kiss his father nine times, instead substituting the word
“kick” for “kiss.” When he heard this, the therapist asked Mr. P if he had noticed the
slip. Mr. P insisted he could not have made such a mistake, escalated his protests
about this for a minute or two as he became sadder, then burst into sobs. While
weeping Mr. P accused the therapist of pretending there had been a slip of speech to
make him look bad, and then, with an outburst of anger, recalled the hurt and injury
he had felt when the therapist had become drowsy in the session.
Surprised at the intensity of his feelings, Mr. P recalled when his need to kiss his
parents goodnight in a ritualized way had begun. It was after he had gotten a new
puppy. His controlling and intrusive father had kicked Mr. P’s beloved new puppy
after the latter had a series of toileting accidents in the house. Mr. P wept as he
recalled his revulsion and rage at his father and the way he had later comforted his
dog when alone. Mr. P recalled having repeatedly unfolded and refolded the blade of
his jackknife to show his dog his weapon and swore to his dog that he would use it on
his father if the latter ever tried to hurt him again. Soon after the kicking incident Mr.
P’s father decided he had had enough of this messy puppy and sent the dog away
while Mr. P was at school. Mr. P was bereft for a while, but soon settled into an
affectless, timid, and passive way of being.
Mr. P responded to what he had learned about his compulsions by actively trying to
suppress them and became more anxious. As his anxiety was explored, memories
emerged of Mr. P’s earlier struggle with his parents around toileting before the puppy
came into his life, when he had received regular enemas from his father to control the
frequency of bowel movements. Despite loving his father, Mr. P was also enraged at
him for taking his dog away without a chance to say goodbye and for the intrusive
and terrifying experience of the enemas, while he was also furious at his mother for
not stopping his father. Mr. P also felt humiliated that he had experienced this kind of
intrusion into his body and that he had let his dog be given away by his father after
swearing that he would protect the puppy from his father.
The meaning of Mr. P’s specific rituals about knives and shoes became apparent in
the course of his therapy as a result of his reaction to his therapist’s lapse in becoming
drowsy and a slip of speech that revealed aggression hidden beneath passivity and
compliance. Mr. P needed to be sure that no knife blades were exposed because such
blades represented the threat of a terrifying assault on his father or an equally
terrifying failure to protect the puppy that he loved but lost. Similarly, Mr. P’s
compulsive need to put shoes properly and safely on shoetrees was linked to an effort
to put away the memory of and prevent any recurrence of his beloved puppy being
kicked and injured by a shod foot. After these were clarified and Mr. P tried to control
his rituals, signal anxiety emerged, and with it the recovery of memories of an earlier
struggle with his parents about intrusive control of his toileting behavior. (Courtesy of
E. M. Plakun, M.D.)
Supportive psychotherapy undoubtedly has its place, especially for those patients with
OCD who, despite symptoms of varying degrees of severity, are able to work and make
social adjustments. With continuous and regular contact with an interested,
sympathetic, and encouraging professional person, patients may be able to function by
virtue of this help, without which their symptoms would incapacitate them.
Occasionally, when obsessional rituals and anxiety reach an intolerable intensity, it is
necessary to hospitalize patients until the shelter of an institution and the removal from
external environmental stresses diminish symptoms to a tolerable level.
A patient’s family members are often driven to the verge of despair by the patient’s
behavior. Any psychotherapeutic endeavors must include attention to the family
members through provision of emotional support, reassurance, explanation, and advice
on how to manage and respond to the patient.
Other Therapies
Family therapy is often useful in supporting the family, helping reduce marital discord
resulting from the disorder, and building a treatment alliance with the family members
for the good of the patient. Group therapy is useful as a support system for some
patients.
For extreme cases that are treatment resistant and chronically debilitating,
electroconvulsive therapy (ECT) and psychosurgery are considerations. ECT should be
tried before surgery. A psychosurgical procedure for OCD is cingulotomy, which may be
successful in treating otherwise severe and treatment-unresponsive patients. Other
surgical procedures (e.g., subcaudate tractotomy, also known as capsulotomy) have also
been used for this purpose.
Deep Brain Stimulation (DBS)
Nonablative surgical techniques involving indwelling electrodes in various basal ganglia
nuclei are under investigation to treat both OCD and Tourette’s disorder. DBS is
performed using MRI-guided stereotactic techniques in which electrodes are implanted
in the brain. Complications of DBS include infection, bleeding, or the development of
seizures, which are almost always controlled by treatment with phenytoin (Dilantin).
Some patients who do not respond to psychosurgery alone and who do not respond to
pharmacotherapy or behavior therapy before the operation do respond to
pharmacotherapy or behavior therapy after psychosurgery.
OBSESSIVE-COMPULSIVE OR RELATED DISORDER DUE TO ANOTHER
MEDICAL CONDITION
Many medical condition can result in obsessive-compulsive symptoms (i.e., hair pulling,
skin-picking). The diagnosis of obsessive-compulsive or related disorder attributable to
another medical condition is used when obsessive-compulsive symptoms develop in the
context of an identifiable medical condition.
OCD-like symptoms have been reported in children following group Aβ-hemolytic streptococcal infection and have been
called pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS). They are believed to result
from an autoimmune process that leads to inflammation of the basal ganglia that disrupts cortical-striatal-thalamic axis
functioning. For more information, see Section 31.14 OCD in childhood and adolescence.
SUBSTANCE-INDUCED OBSESSIVE-COMPULSIVE OR RELATED DISORDER
Substance-induced obsessive-compulsive or related disorder is characterized by the
emergence of obsessive-compulsive or related symptoms as a result of a substance,
including drugs, medications, and alcohol. Symptoms present either during use or within
a month after substance use, intoxication, or withdrawal. The symptoms cannot be
better accounted for by a specific obsessive-compulsive or related disorder or another
medical condition. The disturbance cannot occur exclusively during the course of
delirium.
OTHER SPECIFIED OBSESSIVE-COMPULSIVE OR RELATED DISORDER
This category is for patients who have symptoms characteristic of obsessive-compulsive
and related disorder but do not meet the full criteria for any specific obsessivecompulsive or related disorder. This diagnosis is appropriate under three situations:
(1) an atypical presentation, (2) another specific syndrome not listed in DSM-5, and (3)
the information presented is insufficient to make a full diagnosis of a obsessivecompulsive or related disorder.
Olfactory Reference Syndrome
Olfactory reference syndrome is characterized by a false belief by the patient that he or
she has a foul body odor that is not perceived by others. The preoccupation leads to
repetitive behaviors such as washing the body or changing clothes. The patient may
have good, fair, poor, or absent insight into the behavior. The syndrome is predominant
in males and single status. The mean age of onset is 25 years of age. The belief of a
subjective sense of smell that does not exist externally may rise to the level of a somatic
delusion, in which case a diagnosis of delusional disorder should be considered. The
syndrome has been well documented in the psychiatric literature, usually classified as a
delusion of perception. Whether or not it deserves a special diagnostic category is open
to question.
In assessing a patient with olfactory reference syndrome, it is important to exclude
somatic causes. Some patients with temporal lobe epilepsy may complain of smelling
foul odors. Local irritations of the hippocampus from pituitary tumors may also cause
olfactory sensations. Patients with inflammation of the frontal, ethmoidal, or sphenoidal
sinuses may also have a subjective sense of offensive odors. Olfactory reference
syndrome is included in the “other specified” designation for obsessive-compulsive and
related disorder of DSM-5.
REFERENCES
Cicek E, Cicek IE, Kayhan F, Uguz F, Kaya N. Quality of life, family burden and associated factors in relatives with
obsessive-compulsive disorder. Gen Hosp Psychiatry. 2013;35(3):253–258.
Endrass T, Schuermann B, Kaufmann C, Spielberg R, Kniesche R, Kathmann N. Performance monitoring and error
significance in patients with obsessive-compulsive disorder. Biol Psychol. 2010;84:257.
Gillan CM, Papmeyer M, Morein-Zamir S, Sahakian BJ, Fineberg NA, Robbins TW, de Wit S. Disruption in the balance
between goal-directed behavior and habit learning in obsessive-compulsive disorder. Am J Psychiatry. 2011;168:718.
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Genetics Initiative Bipolar Disorder Consortium, Depaulo JR, Potash JB. Co-morbid anxiety disorders in bipolar
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phobia, specific phobia and obsessive-compulsive disorder. Psychol Med. 2012;42(7):1449–1459.
Levy HC, McLean CP, Yadin E, Foa EB. Characteristics of individuals seeking treatment for obsessive-compulsive disorder.
Behav Ther. 2013;44(3):408–416.
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pathways to functional impairment in obsessive-compulsive disorder. Clin Psychol Rev. 2010;30:78.
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Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:1844.
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Cullen B, Pinto A, Knowles JA, Piacentini J, Pauls DL, Bienvenu OJ, Wang Y, Liang KY, Samuels JF, Roche KB.
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Peng ZW, Xu T, Miao GD, He QH, Zhao Q, Dazzan P, Chan RC. Neurological soft signs in obsessive-compulsive disorder:
The effect of co-morbid psychosis and evidence for familiality. Prog Neuropsychopharmacol Biol Psychiatry.
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Piallat B, Polosan M, Fraix V, Goetz L, David O, Fenoy A, Torres N, Quesada JL, Seigneuret E, Pollak P, Krack P, Bougerol
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Riesel A, Endrass T, Kaufmann C, Kathmann N. Overactive error-related brain activity as a candidate endophenotype for
obsessive-compulsive disorder: Evidence from unaffected first-degree relatives. Am J Psychiatry. 2011;168:317.
Smith AH, Wetterneck CT, Hart JM, Short MB, Björgvinsson T. Differences in obsessional beliefs and emotion appraisal in
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comparing mindfulness-based strategies and distraction in obsessive-compulsive disorder. Cogn Ther Res.
2013;37(4):752–761.

02 - 10.2 Body Dysmorphic Disorder
10.2 Body Dysmorphic Disorder
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Therapy with Adults: A Guide to Empirically-Informed Assessment and Intervention. New York: Cambridge University
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10.2 Body Dysmorphic Disorder
Body dysmorphic disorder is characterized by a preoccupation with an imagined defect
in appearance that causes clinically significant distress or impairment in important
areas of functioning. If a slight physical anomaly is actually present, the person’s
concern with the anomaly is excessive and bothersome.
The disorder was recognized and named dysmorphophobia more than 100 years ago by Emil Kraepelin, who considered it
a compulsive neurosis; Pierre Janet called it obsession de la honte du corps (obsession with shame of the body). Freud
wrote about the condition in his description of the Wolf-Man, who was excessively concerned about his nose. Although
dysmorphophobia was widely recognized and studied in Europe, it was not until the publication of the third edition of the
Diagnostic and Statistical Manual of Mental Disorders (DSM-III) in 1980 that dysmorphophobia, as an example of a typical
somatoform disorder, was specifically mentioned in the US diagnostic criteria. In the fourth text revision of DSM (DSMIV-TR), the condition was known as body dysmorphic disorder, because the DSM editors believed that the term
dysmorphophobia inaccurately implied the presence of a behavioral pattern of phobic avoidance. In the fifth edition of
DSM (DSM-5), body dysmorphic disorder is included in the obsessive-compulsive spectrum disorders due to its
similarities to obsessive-compulsive disorder (OCD).
EPIDEMIOLOGY
Body dysmorphic disorder is a poorly studied condition, partly because patients are
more likely to go to dermatologists, internists, or plastic surgeons than to psychiatrists
for this condition. One study of a group of college students found that more than 50
percent had at least some preoccupation with a particular aspect of their appearance,
and in about 25 percent of the students, the concern had at least some significant effect
on their feelings and functioning. DSM-5 reports a point prevalence in the United States
of 2.4 percent.
Available data indicate that the most common age of onset is between 15 and 30
years and that women are affected somewhat more often than men. Affected patients
are also likely to be unmarried. Body dysmorphic disorder commonly coexists with other
mental disorders. One study found that more than 90 percent of patients with body
dysmorphic disorder had experienced a major depressive episode in their lifetimes;
about 70 percent had experienced an anxiety disorder; and about 30 percent had
experienced a psychotic disorder.
ETIOLOGY
The cause of body dysmorphic disorder is unknown. The high comorbidity with
depressive disorders, a higher-than-expected family history of mood disorders and OCD,
and the reported responsiveness of the condition to serotonin-specific drugs indicate
that, in at least some patients, the pathophysiology of the disorder may involve
serotonin and may be related to other mental disorders. Stereotyped concepts of beauty
emphasized in certain families and within the culture at large may significantly affect
patients with body dysmorphic disorder. In psychodynamic models, body dysmorphic
disorder is seen as reflecting the displacement of a sexual or emotional conflict onto a
nonrelated body part. Such an association occurs through the defense mechanisms of
repression, dissociation, distortion, symbolization, and projection.
DIAGNOSIS
The DSM-5 diagnostic criteria for body dysmorphic disorder stipulate preoccupation with
a perceived defect in appearance or overemphasis of a slight defect. It also stipulates
that at some point during the course of the disorder, the patient performs compulsive
behaviors (i.e., mirror checking, excessive grooming) or mental acts (e.g., comparing
their appearance to that of others). The preoccupation causes patients significant
emotional distress or markedly impairs their ability to function in important areas.
CLINICAL FEATURES
The most common concerns (Table 10.2-1) involve facial flaws, particularly those
involving specific parts (e.g., the nose). Sometimes the concern is vague and difficult to
understand, such as extreme concern over a “scrunchy” chin. One study found that, on
average, patients had concerns about four body regions during the course of the
disorder. Other body parts of concern are hair, breasts, and genitalia. A proposed
variant of dysmorphic disorder among men is the desire to “bulk up” and develop large
muscle mass, which can interfere with ordinary living, holding a job, or staying healthy.
The specific body part may change during the time a patient is affected with the
disorder. Common associated symptoms include ideas or frank delusions of reference
(usually about persons’ noticing the alleged body flaw), either excessive mirror checking
or avoidance of reflective surfaces, and attempts to hide the presumed deformity (with
makeup or clothing). The effects on a person’s life can be significant; almost all affected
patients avoid social and occupational exposure. As many as one-third of patients may
be housebound because of worry about being ridiculed for the alleged deformities; and
approximately one-fifth of patients attempt suicide. As discussed, comorbid diagnoses of
depressive disorders and anxiety disorders are common, and patients may also have
traits of OCD, schizoid, and narcissistic personality disorders.
Table 10.2-1
Location of Imagined Defects in 30 Patients with Body Dysmorphic Disordera
Ms. R, a 28-year-old single woman, presented with the complaint that she is “ugly”
and that she feels others are laughing at her because of her ugliness. In reality, Ms. R
was an attractive woman. She first became preoccupied with her appearance when
she was 13, when she became obsessed with her “facial defects” (e.g., her nose was
too fat, her eyes were too far apart). Up until this point, Ms. R was confident, a good
student, and socially active. However, her fixation on her face caused her to socially
withdraw and have difficulty concentrating in school, which in turn had a negative
effect on her grades.
Ms. R dropped out of high school and went for her GED due to her preoccupation.
She began to frequently pick at “blemishes” and hairs on her face. She frequently
checked herself in mirrors and other reflectively surfaces (e.g., spoons, windows). She
found herself thinking about her defects almost all day every day. Despite reassuring
comments from family and others, Ms. R could not be convinced that there was
nothing wrong with her appearance.
DIFFERENTIAL DIAGNOSIS
The diagnosis of body dysmorphic disorder should not be made if the excessive bodily
preoccupation is better accounted for by another psychiatric disorder. Excessive bodily
preoccupation is generally restricted to concerns about being fat in anorexia nervosa; to
discomfort with, or a sense of wrongness about, his or her primary and secondary sex
characteristics occurring in gender identity disorder; and to mood-congruent cognitions
involving appearance that occur exclusively during a major depressive episode.
Individuals with avoidant personality disorder or social phobia may worry about being
embarrassed by imagined or real defects in appearance, but this concern is usually not
prominent, persistent, distressing, or impairing. Taijin kyofusho, a diagnosis in Japan,
is similar to social phobia but has some features that are more consistent with body
dysmorphic disorder, such as the belief that the person has an offensive odor or body
parts that are offensive to others. Although individuals with body dysmorphic disorder
have obsessional preoccupations about their appearance and may have associated
compulsive behaviors (e.g., mirror checking), a separate or additional diagnosis of OCD
is made only when the obsessions or compulsions are not restricted to concerns about
appearance and are ego-dystonic. An additional diagnosis of delusional disorder,
somatic type, can be made in people with body dysmorphic disorder only if their
preoccupation with the imagined defect in appearance is held with a delusional
intensity. Unlike normal concerns about appearance, the preoccupation with
appearance and specific imagined defects in body dysmorphic disorder and the changed
behavior because of the preoccupation are excessively time-consuming and are
associated with significant distress or impairment.
COURSE AND PROGNOSIS
Body dysmorphic disorder usually begins during adolescence, although it may begin
later after a protracted dissatisfaction with the body. Age of onset is not well understood
because variably a long delay occurs between symptom onset and treatment seeking.
The onset can be gradual or abrupt. The disorder usually has a long and undulating
course with few symptom-free intervals. The part of the body on which concern is
focused may remain the same or may change over time.
TREATMENT
Treatment of patients with body dysmorphic disorder with surgical, dermatological,
dental, and other medical procedures to address the alleged defects is almost invariably
unsuccessful. Although tricyclic drugs, monoamine oxidase inhibitors (MAOIs), and
pimozide (Orap) have reportedly been useful in individual cases, other data indicate
that serotonin-specific drugs—for example, clomipramine (Anafranil) and fluoxetine
(Prozac)—reduce symptoms in at least 50 percent of patients. In any patient with a
coexisting mental disorder, such as a depressive disorder or an anxiety disorder, the
coexisting disorder should be treated with the appropriate pharmacotherapy and
psychotherapy. How long treatment should be continued after the symptoms of body
dysmorphic disorder have remitted is unknown. Augmentation of the selective serotonin
reuptake inhibitor (SSRI) with clomipramine (Anafranil), buspirone (BuSpar), lithium
(Eskalith), methylphenidate (Ritalin), or antipsychotics may improve the response rate.
RELATION TO PLASTIC SURGERY
Few data exist about the number of patients seeking plastic surgery who have body
dysmorphic disorder. One study found that only 2 percent of the patients in a plastic
surgery clinic had the diagnosis, but DSM-5 reports the figure to be 7 to 8 percent. The
overall percentage may be much higher, however. Surgical requests are varied: removal
of facial sags, jowls, wrinkles, or puffiness; rhinoplasty; breast reduction or
enhancement; and penile enlargement. Men who request penile enlargements and
women who request cosmetic surgery of the labia of the vagina or the lips of the mouth
often are suffering from this disorder. Commonly associated with the belief about
appearance is an unrealistic expectation of how much surgery will correct the defect. As
reality sets in, the person realizes that life’s problems are not solved by altering the
perceived cosmetic defect. Ideally, such patients will seek out psychotherapy to
understand the true nature of their neurotic feelings of inadequacy. Absent that, patients
may take out their unfulfilled expectations and anger by suing their plastic surgeons—
who have one of highest malpractice-suit rates of any specialty—or by developing a
clinical depression.
REFERENCES
Body dysmorphic disorder. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American
Psychiatric Association; 2013:242.
Conrado LA, Hounie AG, Diniz JB, Fossaluza V, Torres AR, Miguel EC, Rivitti EA. Body dysmorphic disorder among
dermatologic patients: Prevalence and clinical features. J Am Acad Derm. 2010;63:235.
Escobar JI. Somatoform disorders. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of
Psychiatry. 9th ed. Baltimore: Lippincott Williams & Wilkins; 2009:1927.
Fang A, Hofmann SG. Relationship between social anxiety disorder and body dysmorphic disorder. Clin Psychol Rev.
2010;30:1040.
Feusner JD, Arienzo D, Li W, Zhan L, Gadelkarim J, Thompson PM, Leow AD. White matter microstructure in body
dysmorphic disorder and its clinical correlates. Psychiatry Res. 2013;211(2):132–140.
Greenberg JL, Falkenstein M, Reuman L, Fama J, Marques L, Wilhelm S. The phenomenology of self-reported body
dysmorphic disorder by proxy. Body Image. 2013;10(2):243–246.
Kelly MM, Didie ER, Phillips KA. Personal and appearance-based rejection sensitivity in body dysmorphic disorder. Body
Image. 2014;11(3), 260–265.

03 - 10.3 Hoarding Disorder
10.3 Hoarding Disorder
Mancuso SG, Knoesen NP, Castle DJ. Delusional versus nondelusional body dysmorphic disorder. Compr Psychiatry.
2010;51.177.
Park LE, Calogero RM, Young AF, Diraddo AM. Appearance-based rejection sensitivity predicts body dysmorphic disorder
symptoms and cosmetic surgery acceptance. J Soc Clin Psychol. 2010;29:489.
Philips KA, Pinto A, Hart AS, Coles ME, Eisen JL, Menard W, Rasmussen SA. A comparison of insight in body dysmorphic
disorder and obsessive-compulsive disorder. J Psych Res. 2012;46:1293.
Prazeres AM, Nascimento AL, Fontenelle LF. Cognitive-behavioral therapy for body dysmorphic disorder: A review of its
efficacy. Neuropsychiatr Dis Treat. 2013;9:307–316.
Smith AK, Mittal V. Delusions of body image in the prodrome. Schizophr Res. 2013;146(1–3):366–367.
Wilhelm S, Philips KA, Steketee G. Cognitive Behavioral Therapy for Body Dysmorphic Disorder: A Treatment Manual. New
York: Guilford; 2013.
10.3 Hoarding Disorder
Compulsive hoarding is a common and often disabling phenomenon associated with
impairment in such functions as eating, sleeping, and grooming. Hoarding may result in
health problems and poor sanitation, particularly when hoarding of animals is involved,
and may lead to death from fire or falling.
The disorder is characterized by acquiring and not discarding things that are deemed
to be of little or no value, resulting in excessive clutter of living spaces. Hoarding was
originally considered a subtype of obsessive-compulsive disorder (OCD), but is now
considered to be a separate diagnostic entity. It is commonly driven by an obsessive fear
of losing important items that the person believes may be of use at some point in the
future, by distorted beliefs about the importance of possessions, and by extreme
emotional attachment to possessions.
EPIDEMIOLOGY
Hoarding is believed to occur in approximately 2 to 5 percent of the population,
although some studies have found lifetime prevalence as high as 14 percent. It occurs
equally among men and women, is more common in single persons, and is associated
with social anxiety, withdrawal, and dependent personality traits. Hoarding usually
begins in early adolescence and persists throughout the lifespan.
COMORBIDITY
The most significant comorbidity is found between hoarding disorder and OCD, with as
many as 30 percent of OCD patients showing hoarding behavior.
Studies have found an association between hoarding and compulsive buying. Buying
or acquiring needless things (including receiving gifts) may be a source of comfort for
hoarders, many of whom find themselves with extra items for a perceived but irrational
future need. Approximately half of compulsive buyers display a high level of hoarding;
however, up to 20 percent of hoarders do not show signs of excessive buying.
Hoarding is associated with high rates of personality disorders in addition to OCD.
These include dependent, avoidant, schizotypal, and paranoid types.
Deficits in attention and executive function that occur in hoarding may resemble those
seen in attention-deficit/hyperactivity disorder (ADHD). In one study, 20 percent of
hoarding patients met the criteria for ADHD. This finding correlates with the fact that
OCD patients with hoarding symptoms had a ten times higher rate of developing ADHD
than those without.
Hoarding behaviors are relatively common among schizophrenic patients and have
been noted in dementia and other neurocognitive disorders. One study found hoarding
in 20 percent of dementia patients and 14 percent of brain injury patients. Onset of
hoarding has been reported in cases of frontotemporal dementia and may follow
surgery resulting in structural defects in prefrontal and orbitofrontal cortex. In a study
of patients with focal lesions of the telencephalon, 15 percent exhibited a sudden onset
of severe and persistent collecting and saving behavior.
Other disorders associated with hoarding include eating disorders, depression, anxiety
disorders, substance use disorders (particularly alcohol dependence), kleptomania, and
compulsive gambling. Among anxiety disorders, hoarding is most associated with
generalized anxiety disorder (27 percent) and social anxiety disorder (14 percent).
ETIOLOGY
Little is known about the etiology of hoarding disorder. Research has shown a familial
aspect to hoarding disorder, with about 80 percent of hoarders reporting at least one
first-degree relative with hoarding behavior. Biological research has shown a lower
metabolism in the posterior cingulate cortex and the occipital cortex of hoarders, which
may also account for various cognitive impairments within hoarders such as attention
and decision-making deficits. One study of the molecular genetics for hoarding found a
link between hoarding behavior and markers on chromosomes 4q, 5q, and17q. Another
study found that the catecholamine-O-methyltransferase (COMT) gene on chromosome
22q11.21 might contribute to the genetic susceptibility to hoarding.
DIAGNOSIS
Hoarding disorder is characterized by (1) the acquiring of and failure to discard a large
amount of possessions that are deemed useless or of little value; (2) greatly cluttered
living areas precluding normal activities; and (3) significant distress and impairment in
functioning due to hoarding. The fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) includes diagnostic specifiers that relate to insight, which may
be rated poor, fair, or good. Some patients are completely unaware of the full extent of
the problem and totally resistant to treatment. At times, delusional beliefs about
hoarded items are present.
CLINICAL FEATURES
Hoarding is driven by the fear of losing items that the patient believes will be needed
later and a distorted belief about or an emotional attachment to possessions. Most
hoarders do not perceive their behavior to be a problem. In fact, many perceive their
behavior to be reasonable and part of their identity. Most hoarding patients accumulate
possessions passively rather than intentionally, thus clutter accumulates gradually over
time. Common hoarded items include newspapers, mail, magazines, old clothes, bags,
books, lists, and notes. Hoarding poses risks to not only the patient, but also to those
around them. Clutter accumulated from hoarding has been attributed to deaths from fire
or patients being crushed by their possessions. It can also attract pest infestations that
can pose a health risk both to the patient and residents around them. Many sufferers
have been evicted from their home or threatened with eviction as a result of their
hoarding. In severe cases, hoarding can interfere with work, social interaction, and
basic activities such as eating or sleeping.
The pathological nature of hoarding comes from the inability to organize possessions
and keep them organized. Many hoard to avoid making decisions about discarding
items. Patients with hoarding disorder also overemphasize the importance of recalling
information and possessions. For example, a hoarder will keep old newspapers and
magazines because they believe that if discarded the information will be forgotten and
will never be retrieved again. In addition, patients believe that forgetting information
will lead to serious consequences and prefer to keep possessions in sight so as not to
forget them.
Ms. T, a 55-year-old single woman, presented to a therapist accompanied by her
adult son, who expressed concern about Ms. T’s inability to “throw things away.” He
reported that Ms. T’s home was extremely cluttered with “needless things.” Whenever
he attempted to help her “organize things,” however, Ms. T would become agitated
and argumentative. Ms. T confirmed her son’s complaint and reported having this
difficulty for as long as she could remember, but never really viewed it as a problem.
Over the past 5 years, Ms. T’s home had become increasingly cluttered to the point
that it became more and more difficult to move around within it. She was able to keep
the kitchen and bathroom relatively clutter free, but the rest of her home was filled
with boxes and bags filled with papers, magazines, clothes, and miscellaneous gifts
and trinkets. Her living room was the most affected. Her son reported no longer being
able to visit his mother because it was so difficult to move around and there were very
few places for them to sit comfortably. This, Ms. T admits, has been a major source of
depression for her. Ms. T used to enjoy entertaining family and friends, especially on
holidays, but has not had any guests over in years because she felt that her home was
no longer “suitable for company.” She had made a few attempts to clean out her
home, but was unable to discard most items. When asked why she was keeping them,
she replied “I may need them later.”
DIFFERENTIAL DIAGNOSIS
The diagnosis of hoarding disorder should not be made if the excessive acquisition and
inability to discard possessions is better accounted for by another medical or psychiatric
condition. Until recently, hoarding was considered to be a symptom of OCD and
obsessive-compulsive personality disorder. However, there are some major differences.
Hoarding disorder patients do not display some of the classic symptoms of OCD such as
recurring intrusive thoughts or compulsive rituals. Unlike symptoms of OCD, symptoms
of hoarding worsen with time, rituals are not fixed, and obsessions about dirt or
contamination are absent. OCD patients have better insight into their condition.
Symptoms are usually ego-dystonic, whereas in hoarding disorder they are ego-syntonic.
Hoarding behavior is seldom repetitive and is not viewed as intrusive or distressing to
the hoarder. Distress mainly comes at the prospect of discarding items, and it manifests
more as guilt and anger than anxiety. Hoarding disorder also tends to be less responsive
to classic treatments for OCD such as exposure therapy, cognitive-behavioral therapy
(CBT), and selective serotonin reuptake inhibitors (SSRIs).
Some case reports show the onset of this behavior in patients after suffering brain
lesions. Hoarding associated with brain lesions is more purposeless than hoarding that is
motivated by emotional attachment or high intrinsic value of possessions. It is a
common symptom in moderate to severe dementia. In cases of dementia, hoarding is
often associated with a higher prevalence of hiding, rummaging, repetitive behavior,
pilfering, and hyperphagia. Onset of the behavior usually coincides with onset of the
dementia, starting in an organized manner, and becomes more disorganized as the
disease progresses. The onset of dementia in a patient who has hoarded throughout his
or her lifetime can aggravate the hoarding behavior.
Hoarding behavior can be associated with schizophrenia. It is mostly associated with
severe cases and is seen as a repetitive behavior associated with delusions, self-neglect,
and squalor. Bipolar disorder is ruled out by the absence of severe mood swings.
COURSE AND PROGNOSIS
The disorder is a chronic condition with a treatment-resistant course. Treatment seeking
does not usually occur until patients are in their 40s or 50s, even if the hoarding began
during adolescence. Symptoms may fluctuate throughout the course of the disorder, but
full remission is rare. Patients have very little insight into their behavior and usually
seek treatment under pressure from others. Some patients begin hoarding in response to
a stressful event, while others report a slow and steady progression throughout life.
Those who report onset due to a stressful event have a later age of onset than those who
do not. Those with an earlier age of onset run a longer and more chronic course.
TREATMENT
Hoarding disorder is difficult to treat. Although it shows similarities to OCD, effective
treatments for OCD have shown little benefit for patients with hoarding disorder. In one

04 - 10.4 Hair Pulling Disorder (Trichotillomania)
10.4 Hair-Pulling Disorder (Trichotillomania)
study, only 18 percent of patients responded to medication and CBT. The challenges
posed by hoarding patients to typical CBT treatment include poor insight to the
behavior and low motivation and resistance to treatment.
The most effective treatment for the disorder is a cognitive behavioral model that
includes training in decision making and categorizing; exposure and habituation to
discarding; and cognitive restructuring. This includes both office and in-home sessions.
The role of the therapist in this model is to assist in the development of decision-making
skills, to provide feedback about normal saving behavior, and to identify and challenge
the patient’s erroneous beliefs about possessions. The goal in treatment is to get rid of a
significant amount of possessions, thereby making the living space livable, and to
provide the patient with the skills to maintain a positive balance between the amount of
possessions and livable space. Studies have shown a 25 to 34 percent reduction in
hoarding behaviors using this method. Restructuring of this method for group and webbased interventions are currently under study and show promise.
Pharmacological treatment studies using SSRIs have shown mixed results. Some
studies have shown a negative response to SSRI treatment in hoarding patients
compared with nonhoarders, while others have found no significant difference between
the two groups.
REFERENCES
DiMauro J, Genova M, Tolin DF, Kurtz MM. Cognitive remediation for neuropsychological impairment in hoarding
disorder: A pilot study. J Obsessive-Compulsive and Related Disorders. 2014;3(2), 132–138.
Frost RO, Steketee G, Tolin DF. Comorbidity in hoarding disorder. Depress Anxiety. 2011;28:876.
Frost RO, Tolin DF, Steketee G, Fitch KE, Selbo-Bruns A. Excessive acquisition in hoarding. J Anxiety Disord. 2009;23:632.
Grisham JR, Norberg MM, Williams AD, Certoma SP, Kadib R. Categorization and cognitive deficits in compulsive
hoarding. Behav Res Ther. 2010;48:886.
Hall BJ, Tolin DF, Frost RO, Steketee G. An exploration of comorbid symptoms and clinical correlates of clinically
significant hoarding symptoms. Depress Anxiety. 2013;30(1):67–76.
Hoarding disorder. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric
Association; 2013:247.
Iervolino AC, Perroud N, Fullana MA, Guipponi M, Cherkas L, Collier DA, Mataix-Cols D. Prevalence and heritability of
compulsive hoarding: A twin study. Am J Psychiatry. 2009;116:1156.
Mataix-Cols D, Billotti D, de la Cruz L, Nordsletten A. The London field trial for hoarding disorder. Psychol Med.
2013;43(4):837–847.
Timpano KR, Rasmussen J, Exner C, Rief W, Schmidt NB, Wilhelm S. Hoarding and the multi-faceted construct of
impulsivity: A cross-cultural investigation. J Psychiatr Res. 2013;47(3):363–370.
Tolin DF, Villavicencio A. Inattention, but not obsessive-compulsive disorder, predicts the core features of hoarding
disorder. Behav Res Ther. 2011;49:120.
10.4 Hair-Pulling Disorder (Trichotillomania)
Hair-pulling disorder is a chronic disorder characterized by repetitive hair pulling,
leading to variable hair loss that may be visible to others. It is also known as
trichotillomania, a term coined by a French dermatologist Francois Hallopeau in 1889.
The disorder was once deemed rare and little about it was described beyond
phenomenology. It is now regarded as more common. The disorder is similar to
obsessive-compulsive disorder and impulse control in that there is increased tension
prior to the hair pulling and a relief of tension or gratification after the hair pulling.
EPIDEMIOLOGY
The prevalence of hair-pulling disorder may be underestimated because of
accompanying shame and secretiveness. The diagnosis encompasses at least two
categories of hair pulling that differ in incidence, severity, age of presentation, and
gender ratio. Other subsets may exist.
The most serious, chronic form of the disorder usually begins in early to midadolescence, with a lifetime prevalence ranging from 0.6 percent to as high as 3.4
percent in general populations and with female to male ratio as high as 10 to 1. The
number of men may actually be higher, because men are even more likely than women
to conceal hair pulling. A patient with chronic hair-pulling disorder is likely to be the
only or oldest child in the family.
A childhood type of hair-pulling disorder occurs approximately equally in girls and
boys. It is said to be more common than the adolescent or young adult syndrome and is
generally far less serious dermatologically and psychologically.
An estimated 35 to 40 percent of patients with hair-pulling disorder chew or swallow
the hair that they pull out at one time or another. Of this group, approximately onethird develop potentially hazardous bezoars—hairballs accumulating in the alimentary
tract.
COMORBIDITY
Significant comorbidity is found between hair-pulling disorder and obsessive-compulsive
disorder (OCD); anxiety disorders; Tourette’s disorder; depressive disorders; eating
disorders;
and
various
personality
disorders—particularly
obsessive-compulsive,
borderline, and narcissistic personality disorders. Comorbid substance abuse disorder is
not encountered as frequently as it is in pathological gambling, kleptomania, and other
impulse disorders.
ETIOLOGY
Although hair-pulling disorder is regarded as multidetermined, its onset has been linked
to stressful situations in more than one-fourth of all cases. Disturbances in mother–child
relationships, fear of being left alone, and recent object loss are often cited as critical
factors contributing to the condition. Substance abuse may encourage development of
the disorder. Depressive dynamics are often cited as predisposing factors, but no
particular personality trait or disorder characterizes patients. Some see self-stimulation
as the primary goal of hair pulling.
Family members of hair-pulling disorder patients often have a history of tics, impulsecontrol disorders, and obsessive-compulsive symptoms, further supporting a possible
genetic predisposition.
One study looked at the neurobiology of hair-pulling disorder and found a smaller
volume of the left putamen and left lenticulate areas. More recently, a study of the
genetics of trichotillomania reported a relationship between a serotonin 2A (5-HT2A)
receptor gene polymorphism (T102C) and trichotillomania. However, because these
studies examined relatively few subjects, these findings need to be replicated in a larger
sample to be able to determine the role of basal ganglia abnormalities and serotonin in
the etiology of trichotillomania.
DIAGNOSIS AND CLINICAL FEATURES
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)
includes diagnostic criteria from hair-pulling disorder. Before engaging in the behavior,
patients with hair-pulling disorder may experience an increasing sense of tension and
achieve a sense of release or gratification from pulling out their hair. All areas of the
body may be affected, most commonly the scalp (Fig. 10.4-1). Other areas involved are
eyebrows, eyelashes, and beard; trunk, armpits, and pubic area are less commonly
involved (Fig. 10.4-2).
FIGURE 10.4-1
Hair-pulling disorder (trichotillomania). Note the typical findings of an area of
incomplete alopecia involving the frontal and vertex scalp. (From Sadock BJ, Sadock
VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed.
Philadelphia: Lippincott Williams & Wilkins; 2009, with permission.)
FIGURE 10.4-2
Example of plucking of the pubic hair because of hair-pulling disorder.
Two types of hair pulling have been described. Focused pulling is the use of an
intentional act to control unpleasant personal experiences, such as an urge, bodily
sensation (e.g., itching or burning), or thought. In contrast, automatic pulling occurs
outside the person’s awareness and most often during sedentary activities. Most patients
have a combination of these types of hair pulling.
Hair loss is characterized by short, broken strands appearing together with long,
normal hairs in the affected areas. No abnormalities of the skin or scalp are present.
Hair pulling is not reported as being painful, although pruritus and tingling may occur
in the involved area. Trichophagy, mouthing of the hair, may follow the hair plucking.
Complications of trichophagy include trichobezoars, malnutrition, and intestinal
obstruction. Patients usually deny the behavior and often try to hide the resultant
alopecia. Head banging, nail biting, scratching, gnawing, excoriation, and other acts of
self-mutilation may be present.
Ms. C, a 27-year-old single woman, came to a local clinic complaining of persistent
hair pulling. She first started at age 11, when she began to pick the hairs at the nape
of her neck. She would persistently pick at the hair until there was almost none left.
Fortunately, her hair was long, so no one noticed the lack of hair at the back of her
neck. Over the years, her hair picking progressed until she began picking hair from
her entire head, leaving noticeable small bald patches. She strategically hid the bald
patches by brushing over the remainder of her hair or with carefully placed scarves
and hats. Despite her habit, Ms. C was pretty normal. She got good grades in school
and was a year away from getting her master’s degree.
Ms. C’s habit was constant, occurring every day, often without her noticing it. She
could simply be reading an assignment for school and eventually her hand would find
its way into her hair to find a hair to pull. Soon she would notice a small pile of hairs
in her book or on her lap, indicating that she had been pulling her hair out for a
while. Whenever she tried to stop herself from pulling her hair, she would become
increasingly nervous and anxious until she resumed the hair pulling. Her hair pulling
sessions lasted anywhere from 10 minutes to an hour.
PATHOLOGY AND LABORATORY EXAMINATION
If necessary, the clinical diagnosis of hair-pulling disorder can be confirmed by punch
biopsy of the scalp. In patients with a trichobezoar, blood count may reveal a mild
leukocytosis and hypochromic anemia due to blood loss. Appropriate chemistries and
radiological studies should also be performed, depending on the bezoar’s suspected
location and impact on the gastrointestinal (GI) tract.
DIFFERENTIAL DIAGNOSIS
Hair pulling may be a wholly benign condition or it may occur in the context of several
mental disorders. The phenomenology of hair-pulling disorder and OCD overlap. As with
OCD, hair-pulling disorder is often chronic and recognized by patients as undesirable.
Unlike those with OCD, patients with hair-pulling disorder do not experience obsessive
thoughts, and the compulsive activity is limited to one act, hair pulling. Patients with
factitious disorder actively seek medical attention and the patient role and deliberately
simulate illness toward these ends. Patients who malinger or who have factitious
disorder may mutilate themselves to get medical attention, but they do not acknowledge
the self-inflicted nature of the lesions. Patients with stereotypic movement disorder have
stereotypical and rhythmic movements, and they usually do not seem distressed by their
behavior. A biopsy may be necessary to distinguish hair-pulling disorder from alopecia
areata and tine capitis.
COURSE AND PROGNOSIS
The mean age at onset of hair-pulling disorder is in the early teens, most frequently
before age 17, but onset has been reported much later in life. The course of the disorder
is not well known; both chronic and remitting forms occur. An early onset (before age
6) tends to remit more readily and responds to suggestions, support, and behavioral
strategies. Late onset (after age 13) is associated with an increased likelihood of
chronicity and poorer prognosis than the early-onset form. About a third of persons
presenting for treatment report a duration of 1 year or less, whereas in some cases, the
disorder has persisted for more than two decades.
TREATMENT
No consensus exists on the best treatment modality for hair-pulling disorder. Treatment
usually
involves
psychiatrists
and
dermatologists
in
a
joint
endeavor.
Psychopharmalogical methods that have been used to treat psychodermatological
disorders include topical steroids and hydroxyzine hydrochloride (Vistaril), an anxiolytic
with antihistamine properties; antidepressants; and antipsychotics. Initial case reports
showed efficacy of selective serotonin reuptake inhibitors (SSRIs) for hair-pulling
disorder. Patients who respond poorly to SSRIs may improve with augmentation with
pimozide (Orap), a dopamine receptor antagonist. Other medications that have been
reported to have some efficacy for hair-pulling disorder include fluvoxamine (Luvox),
citalopram (Celexa), venlafaxine (Effexor), naltrexone (ReVia), and lithium (Eskalith).
A report of successful lithium treatment cited the possible effect of the drug on
aggression, impulsivity, and mood instability as an explanation. In one study, patients
taking naltrexone had a reduction in symptom severity. Case reports also indicate
successful treatment with buspirone (BuSpar), clonazepam (Klonopin), and trazodone
(Desyrel).
Successful
behavioral
treatments,
such
as
biofeedback,
self-monitoring,
desensitization, and habit reversal, have been reported, but most studies have been
based on individual cases or a small series of cases with relatively short follow-up
periods. Chronic hair-pulling disorder has been treated successfully with insight-oriented
psychotherapy. Hypnotherapy has been mentioned as potentially effective in the
treatment of dermatological disorders in which psychological factors may be involved;
the skin has been shown to be susceptible to hypnotic suggestion.
REFERENCES
Bloch MH. Trichotillomania and other impulsive-control disorders. In: Hudak R, Dougherty DD, eds. Clinical ObsessiveCompulsive Disorders in Adults and Children. New York: Cambridge University Press; 2011:207.
Grant JE, Stein DJ, Woods DW, Keuthen NJ, eds. Trichotillomania, Skin Picking, and Other Body-Focused Repetitive
Behaviors. Arlington, VA: American Psychiatric Publishing; 2011.
Keuthen NJ, Rothbaum BO, Falkenstein MJ, Meunier S, Timpano KR, Jenike MA, Welch SS. DBT-enhanced habit reversal
treatment for trichotillomania: 3-and 6-month follow-up results. Depress Anxiety. 2011;28:310.
Klipstein KG, Berman L. Bupropion XL for the sustained treatment of trichotillomania. J Clin Psychopharm. 2012;32:298.
Kumar B. The mind-body connection: An integrated approach to the diagnosis of colonic trichobezoar. Int J Psychiatry
Med. 2011;41:263.
Lee HJ, Franklin SA, Turkel JE, Goetz AR, Woods DW. Facilitated attentional disengagement from hair-related cues among
individuals diagnosed with trichotillomania: An investigation based on the exogenous cueing paradigm. J Obsess Compul
Relat Disord. 2012;1:8.
Leombruni P, Gastaldi F. Oxcarbazepine for the treatment of trichotillomania. Clin Neuropharm. 2010:33:107.
Lochner C, Seedat S, Stein DJ. Chronic hair-pulling: Phenomenology-based subtypes. J Anxiety Disord. 2010;24:196.
McDonald KE. Trichotillomania: Identification and treatment. J Counsel Dev. 2012;90:421.
Moeller FG. Impulse-control disorders not elsewhere classified. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s
Comprehensive Textbook of Psychiatry. 9th ed. Baltimore: Lippincott Williams & Wilkins; 2009:2178.
Panza KE, Pittenger C, Bloch MH. Age and gender correlates of pulling in pediatric trichotillomania. J Am Acad Child
Adolesc Psychiatry. 2013;52(3):241–249.
Roos A, Fouche J-P, Stein DJ, Lochner C. White matter integrity in hair-pulling disorder (trichotillomania). Psychiatry Res.
2013;211(3):246–250.

05 - 10.5 Excoriation (Skin Picking) Disorder
10.5 Excoriation (Skin-Picking) Disorder
Walther MR, Ricketts EJ, Conelea CA, Woods DW. Recent advances in the understanding and treatment of trichotillomania.
J Cogn Psychother. 2010;24:46.
Walther MR, Snorrason I, Flessner CA, Franklin ME, Burkel R, Woods DW. The Trichotillomania Impact Project in Young
Children (TIP-YC): Clinical Characteristics, Comorbidity, Functional Impairment and Treatment Utilization. Child
Psychiatry & Hum Dev. 2014;45(1), 24–31.
White MP, Koran LM. Open-label trial of aripiprazole in the treatment of trichotillomania. Clin Psychopharm. 2011;31:503.
Woods DW. Treating trichotillomania across the lifespan. J Am Acad Child Adolesc Psychiatry. 2013;52(3):223–224.
10.5 Excoriation (Skin-Picking) Disorder
Excoriation or skin-picking disorder is characterized by the compulsive and repetitive
picking of the skin. It can lead to severe tissue damage and result in the need for various
dermatological treatments. Throughout history, skin-picking disorder has had many
names: skin-picking syndrome, emotional excoriation, nervous scratching artifact,
epidermotillomania, and para-artificial excoriation.
EPIDEMIOLOGY
Skin-picking disorder has lifetime prevalence between 1 to 5 percent in the general
population, about 12 percent in the adolescent psychiatric population, and occurs in 2
percent of patients with other dermatologic disorders. It is more prevalent in women
than in men.
COMORBIDITY
The repetitive nature of skin-picking behavior is similar to the repetitive compulsive
rituals found in obsessive-compulsive disorder (OCD), and skin-picking disorder is
associated with high rates of OCD. In addition, patients with OCD may have obsessions
about contamination and skin abnormalities or may be preoccupied with having smooth
skin, flawless complexion, and cleanliness. Other comorbid conditions include hairpulling disorder (trichotillomania, 38 percent), substance dependence (38 percent),
major depressive disorder (32 to 58 percent), anxiety disorders (23 to 56 percent), and
body dysmorphic disorder (27 to 45 percent). One study reported an association of both
borderline and obsessive-compulsive personality disorder (71 percent) in patients with
skin-picking disorder.
ETIOLOGY
The cause of skin-picking is unknown, however, several theories have been postulated.
Some theorists speculate that skin-picking behavior is a manifestation of repressed rage
at authoritarian parents. These patients pick at their skin and perform other selfdestructive acts to assert themselves. Patients may pick as a means to relieve stress. For
example, skin-picking has been associated with marital conflicts, passing of loved ones,
and unwanted pregnancies. According to psychoanalytic theory, the skin is an erotic
organ, and picking at the skin or scratching the skin leading to excoriations may be a
source of erotic pleasure. In that sense it has been considered a masturbatory
equivalent. Patients may be unaware of these affects presumed to be in the unconscious.
Many patients begin picking at the onset of dermatological conditions such as acne and
continue to pick after the condition has cleared.
Abnormalities in serotonin, dopamine, and glutamate metabolism have been theorized
to be an underlying neurochemical cause of the disorder, but further research is needed.
DIAGNOSIS
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) it was
called trichotillomania. It was also known as skin-picking syndrome. DSM-5 diagnostic
criteria for skin-picking disorder requires recurrent skin-picking resulting in skin lesions
and repeated attempts to decrease or stop picking. The skin-picking must cause
clinically relevant distress or impairment in functioning. The skin-picking behavior
cannot be attributed to another medical or mental condition and cannot be a result of a
substance use disorder (e.g., cocaine or methamphetamine use).
CLINICAL FEATURES
The face is the most common site of skin-picking (Fig. 10.5-1). Other common sites are
legs, arms, torso, hands, cuticles, fingers, and scalp. Although most patients report
having a primary picking area, many times they pick other areas of the body in order
for the primary area to heal. In severe cases, skin-picking can result in physical
disfigurement and medical consequences that require medical or surgical interventions
(e.g., skin grafts or radiosurgery).
FIGURE 10.5-1
Skin-picking disorder. Multiple erythematous and pigmented maculae and crusted
erosions on chin. (From Sadock BJ, Sadock VA, Ruiz P. Kaplan & Sadock’s Comprehensive
Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009, with
permission.)
Patients may experience tension prior to picking and a relief and gratification after
picking. Many report picking as a means to relieve stress, tension, and other negative
feelings. In spite of the relief felt from picking, patients often feel guilty or embarrassed
at their behavior. Up to 87 percent of patients report feeling embarrassed by the picking
and 58 percent report avoiding social situations. Many patients use bandages, makeup,
or clothing to hide their picking. Of skin-picking patients, 15 percent report suicidal
ideation due to their behavior and about 12 percent have attempted suicide.
Ms. J, a 22-year-old single woman, presented to a psychiatrist at the urging of her
dermatologist because of compulsive picking at the skin on her face. She picked at it
every day up to three times a day in sessions lasting from 20 minutes to over an hour.
She had massive scarring and lesions on her face. She went to a physician 6 months
prior when one of the lesions had become infected.
Ms. J began picking her face at age 11 at the onset of puberty. At first, she only
picked at acne that formed on her face, but as the urge to pick became greater, she
started picking at clear patches of skin as well. Due to the scaring and lesions, Ms. J
became increasingly withdrawn and avoided all social engagements. She reported
feeling great tension prior to picking and only after she began picking did she feel
relief.
DIFFERENTIAL DIAGNOSIS
The diagnosis of skin-picking disorder cannot be made if the behavior can be better
accounted for by another medical or psychological condition. Many medical and
dermatological conditions may result in urges to itch and pick at the skin. Conditions
include eczema, psoriasis, diabetes, liver or kidney disease, Hodgkin’s disease,
polycythemia vera, or systemic lupus. Skin-picking can also be seen in Prader-Willi
syndrome (97 percent). A thorough physical examination is crucial prior to psychiatric
diagnosis.
Skin-picking disorder is similar to OCD and it is associated with high rates of comorbid
OCD. The disorders differ in a few ways. Skin-picking disorder is prevalent in females
while OCD is equal between genders. The compulsions associated with OCD are usually
driven by intrusive thoughts, while the compulsion to pick the skin is usually not.
Although skin-picking generally decreases anxiety, it can also entice pleasure in the
patient, which is rarely the case in OCD. Skin-picking in OCD patients is usually the
result of obsessions about contamination or skin abnormalities.
Skin-picking is commonly seen in body dysmorphic disorder. In one study, 45 percent
of body dysmorphic patients report lifetime skin-picking disorder and 37 percent report
having skin-picking disorder secondary to body dysmorphic disorder. The skin-picking in
body dysmorphic disorder is primarily centered on removing or minimizing believed
imperfection in the patient’s appearance.
Substance use disorders often co-occur with skin-picking disorder. Methamphetamine
and cocaine use may result in the sensation that something is crawling on the body or
under the skin (formication), which can result in skin-picking. In order to make the
diagnosis of skin-picking disorder, however, skin-picking cannot be a physiological
effect of substance use.
Factitious Dermatitis
Factitious dermatitis or dermatitis artefacta is a disorder in which skin-picking is the
target of self-inflicted injury and the patient uses more elaborate methods than simple
excoriation to self-induce skin lesions. It is seen in 0.3 percent of dermatology patients
and has a female to male ratio of 8 to 1. It can present at any age, but occurs most
frequently in adolescents and young adults. It can present as an aggravation of
dermatosis, targeting a variety of skin lesions including blisters, ulcers, erythema,
edema, purpura, and sinuses. The morphology of factitious dermatitis lesions is often
bizarre and linear, with clear-cut, angulated, or geometric edges. Presence of completely
normal, unaffected skin adjacent to the horrific-looking lesions is a clue to the diagnosis
of factitious dermatitis (Fig. 10.5-2). In addition, the patient’s description of history of
the skin lesions is usually vague and lacks detail about the appearance and evolution of
the lesions.
FIGURE 10.5-2
Typical self-produced lesions with scabbing. (From Douthwaite AH, ed. French’s Index of
Differential Diagnosis. 7th ed. Baltimore: Williams & Wilkins; 1954, with permission.)
COURSE AND PROGNOSIS
The onset of skin-picking disorder is either in early adulthood or between 30 and 45
years of age. Onset in children before age 10 years has also been seen. The mean age of
onset is between 12 to 16 years of age. There may be a lag of time between onset and
actual diagnosis. Because little is known about the disorder, many are unaware that it
can be treated. Many times patients do not seek treatment until a severe dermatological
or medical condition has developed.
Typically, symptoms wax and wane over the course of the patient’s life.
Approximately 44 percent of women report that the amount of picking coincides with
their menstrual cycle.
TREATMENT
Skin-picking disorder is difficult to treat and there are few data on effective treatments.
Most patients do not actively seek treatment due to embarrassment or because they
believe their condition is untreatable. There is support for the use of selective serotonin
reuptake inhibitors (SSRIs). Studies comparing fluoxetine (Prozac) against placebo has
shown fluoxetine to be superior in reducing skin-picking. The opioid antagonist
naltrexone (Revia) has proven to reduce the urge to pick, particularly in patients who
experience pleasure from the behavior. Glutamatergic agents and lamotrigine (Lamictal)
have also shown efficacy. Nonpharmacological treatments include habit reversal and
brief cognitive-behavioral therapy (CBT).
Effective therapy requires both psychological and somatic treatment. In some cases
mechanical prevention of skin-picking by different protective measures may be of use in
an effort to break the cycle. Psychotherapy at the same time deals with the underlying
emotional factors.
REFERENCES
Grant JE, Odlaug BL, Chamberlain SR, Keuthen NJ, Lochner C, Stein DJ. Skin picking disorder. Am J Psychiatry.
2012;169(11):1143–1149.
Grant JE, Odlaug BL, Hampshire A, Schreiber LR, Chamberlain SR. White matter abnormalities in skin picking disorder: A
diffusion tensor imaging study. Neuropsychopharmacology. 2013;38(5):763–769.
Grant JE, Odlaug BL, Kim SW. A clinical comparison of pathologic skin picking and obsessive-compulsive disorder. Compr
Psychiatry. 2010;51:347.
Miller JL, Angulo M. An open-label pilot study of N-acetylcysteine for skin-picking in Prader–Willi syndrome. Am J Med
Gen. 2014;164(2):421–424.
Odlaug BL, Grant JE. Pathological skin-picking. Am J Drug Alcohol Abuse. 2010; 36:296.
Odlaug BL, Kim SW, Grant JE. Quality of life and clinical severity in pathological skin picking and trichotillomania. J
Anxiety Disord. 2010;24:823.
Schuck K, Keijsers GP, Rinck M. The effects of brief cognitive-behaviour therapy for pathological skin picking: A
randomized comparison to wait-list control. Behav Res Ther. 2011;49:11.
Snorrason I, Smari J, Ólafsson RP. Emotion regulation in pathological skin picking: Findings from a non-treatment seeking
sample. J Behav Ther Exp Psychiatry. 2010;41:238.
Snorrason I, Stein D, Woods D. Classification of excoriation (skin picking) disorder: Current status and future directions.
Acta Psychiatr Scand. 2013; 128(5):406–407.