10/30/25 OCD related disorders

Obsessive Compulsive Related Disorders (OCRDs)

• Body dysmorphic disorder (shares cognitive patterns and behavioral responses with OCD)

• Hoarding disorder (shares cognitive patterns with OCD)

• Trichotillomania and Excoriation disorder (share repetitive behaviors with OCD)

core features of OCD

presence of obsessions or compulsions or both

• obsessions = intrusive thought that cannot be easily dismissed

• compulsion = behavior that helps dismiss obsessions

Body Dysmorphic Disorder

• preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others

• at some point during the course of the disorder, the individual has performed repetitive behaviors (ex. mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (ex. comparing appearance to others) in response to the appearance concerns

• the preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

• the appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder

What body areas and characteristics are commonly involved in body preoccupations?

• usually more than one region of the body is seen as flawed

• common areas are nose, face, skin, hair stomach

• concerns may involve size, texture, symmetry, color, shape

How are body preoccupations experienced psychologically?

• concerns are often very specific and, consistent with diagnostic criteria, not perceived by others or not viewed as significant as they are to the person

• like obsessions, they are unwanted, distressing, and difficult to dismiss

How much time do people spend on body preoccupations, and how intense are the beliefs?

• time consuming (most ppl spend 3+ hrs/day thinking about their body, ¼ spend over 8 hrs/day)

• people believe these preoccupations, they are intense

delusion definition

strong persistent conviction that does not change, even if there is significant evidence that it is not true

How are body preoccupations in Body Dysmorphic Disorder (BDD) often characterized?

They are often considered delusional, as individuals firmly believe their perceived flaws are real and significant despite evidence to the contrary

What behaviors do people with body preoccupations commonly engage in?

ppl respond in a variety of ways, most often by checking their perceived flaws in the mirror, asking others for reassurance, or engaging in elaborate social comparisons

How do response behaviors in BDD differ from those in OCD?

unlike in OCD, where response behaviors alleviate distress, in BDD they often worsen the distress associated with perceived flaws

What are the key features of the onset and course of Body Dysmorphic Disorder (BDD)?

• Can begin at any age, even as early as 4–5 years old, but most commonly emerges during adolescence.

• Often develops gradually — starts as mild dissatisfaction with a body part and progresses into full BDD over 4–5 years.

• Affects about 2–3% of the population.

• Recurrent disorder: periods of remission may occur, but symptoms often return (usually about the same body part, though sometimes a different one).

BDD is an OCRD, not an eating disorder

BDD is considered different from an ED, bc perceived flaws do not center on weight and fatness

What is muscle dysmorphia, and what behaviors are associated with it?

• A subset of people with BDD who believe their body is too lean and their muscles are not sufficiently developed.

• This belief persists even when muscles are clearly well-developed (e.g., bodybuilders).

• Common behaviors: extreme exercise, protein-heavy diets, and steroid use.

treatment for BDD (3 types)

very difficult to treat, only ~25-50% reach remission though more show improvement

1. SSRIs

2. EX/RP- exposure to situations that usually bring on thoughts of bodily flaws (ex. looking at a picture or changing clothes)

3. Mirror retraining

mirrors and BDD

mirrors are very tough for ppl with BDD, they either avoid them or spend hours looking at them

• the gaze tends to be over-selective (focusing on flawed area) and standing very close

mirror retraining procedure

mirror retraining involves looking in the mirror, from a distance, taking in the entirety of the body, and tracking the thoughts that occur and work

Trichotillomania

• recurrent pulling out one’s hair, resulting in hair loss

• repeated attempts to decrease or stop hair pulling

• hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (ppl are upset that they are hair pulling)

• hair pulling/loss is not attributable to another medical condition (ex. a dermatological condition)

• hair pulling is not better explained by the symptoms of another mental disorder (ex. attempts to improve a perceived defect or flaw in appearance in BDD)

where do people pull hair?

most ppl have 1-2 preferred places (can be eyebrows, head, arms, etc.)

• loss of hair is generally visible to others and may be embarrassing

2 types of hair pulling

1. automatic pulling: tendency to pull hair unintentionally, almost without any awareness of the action

2. focused pulling: intentional hair pulling, occurs either in reaction to stress or distress OR people search for a hair that feels “different/wrong” in some way and remove it (similar to OCD’s NJRE)

most ppl do both- thought one type may be more prominent at some points in time and the other more prominent at other points

What are the key features of Trichotillomania’s prevalence, onset, and course?

• Affects about 2–3% of the population.

• Typically begins in adolescence.

• No major gender difference in prevalence, though women often develop it earlier and report more distress related to hair pulling.

• Around 25% of people experience spontaneous recovery, stopping hair pulling without treatment.

age is a strong predictor of natural recovery for Trichotillomania

the older ppl are, the more likely it is they stop pulling on their own and without trying to do so

Trichotillomania shares a lot of similarities with what disorder?

Excoriation disorder

Excoriation Disorder

• repetitive skin picking resulting in skin lesions

• repeated attempts to decrease or stop skin picking

• skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning

• skin picking is not attributable to the physiological effects of a substance (ex. cocaine) or another medical condition (ex. scabies)

• skin picking is not better explained by symptoms of another mental disorder (ex. delusion or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in BDD, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury)

What are the main characteristics and behaviors in Excoriation (Skin-Picking) Disorder?

• Picking typically occurs on the face, arms, and hands (especially cuticles).

• Focus is often on scars, pimples, or perceived skin irregularities.

• About 25% of people pick even while asleep.

• May involve tweezers, tools, rubbing, or squeezing the skin.

excoriation in Excoriation Disorder is extreme

• can result in needing antibiotics, hospitalization or surgery for infections

• repetitive strain injuries in the hand are common

• many find picking pleasurable but later experience intense shame about their picking

2 types of picking in Excoriation Disorder

1. automatic: people describe almost a trance-like state, they report a strange physical sensation prior to picking, picking “must be done” to stop this sensation

2. functional (aka intentional)

habit reversal training

a form of CBT that is effective for both trichotillomania and excoriation disorder, with 3 parts:

1. awareness training to help ppl figure out when they are most likely to pick/pull and what sensations/urges precede picking/pulling

2. identify a competing response that can be done instead

3. identify social supports to help transition to using competing response

when do competing responses work best?

when they offer the benefits of picking or pulling

• can mimic picking or pulling (ex. pulling threads out a tassel)

• can be a pleasurable substitute (ex. fidget toy or a treat)

What are key features of Habit Reversal Training (HRT) for hair pulling and skin picking?

• Works best for intentional/functional hair pulling or skin picking.

• Can be adapted across ages, even for young children.

• Less successful with automatic pulling/picking

• Can be combined with other therapies for better outcomes.

How does Acceptance and Commitment Therapy (ACT) help with hair pulling and skin picking behaviors?

• A third-wave cognitive behavioral therapy (CBT) approach.

• Especially beneficial for focused pulling or picking.

• Helps people observe and accept urges without acting on them.

• Emphasizes that urges may always be present, but individuals can develop comfort with them rather than engage in the behavior.

pharmacological treatments for Excoriation and Trichotillomania

currently no recommended pharmacotherapy for Excoriation Disorder and Trichotillomania, although SSRIs are sometimes used “off label”

Hoarding Disorder

• persistent difficulty discarding or parting with possessions, regardless of their actual value

• this difficulty is due to a perceived need to save the items and to distress associated with discarding them

• the difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living spaces and substantially compromises their intended use. If living areas are uncluttered, it is only bc of the interventions of third parties (ex. family, cleaners, authorities)

• hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining safe enviro for self or others)

• hoarding is not attributable to another medical condition (ex. brain injury, cerebrovascular disease, Prader-Willi syndrome)

• hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in OCD, decreased energy in MDD, delusions in schizophrenia/psychotic disorders, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder)

why do people hoard?

• they think the objects could be useful or might be needed someday (fear of being unprepared for something)

• feel emotionally connected to items (or the memories associated with them)

• they think the objects reflect who they are as people

• wish to avoid being wasteful

• hoarding often involves a god feeling (pleasure/satisfaction/security from holding on to objects)

prevalence of Hoarding Disorder

about 2-6% of population

• no significant gender differences in prevalence

comorbidity and Hoarding Disorder

highly comorbid with MDD (about 50% of ppl with hoarding also have MDD)

What are the main similarities between OCD and OCRDs?

• Both involve repetitive, distress-driven thoughts and behaviors.

• Compulsions or rituals aim to reduce anxiety or distress.

• Intrusive, unwanted urges are common.

• Often time-consuming and cause functional impairment.

• Varying levels of insight (from good to poor/delusional).

How do OCD and OCRDs differ in the focus of obsessions?

• OCD: Fears about contamination, harm, symmetry, or control.

• OCRDs: Preoccupation with appearance, skin, hair, or body parts.

How do behaviors differ between OCD and OCRDs?

• OCD: Rituals like checking, cleaning, or counting.

• OCRDs: Body-focused behaviors such as picking, pulling, or mirror checking.

How do the emotional motivations behind behaviors differ between OCD and OCRDs?

• OCD: Behaviors aim to prevent feared outcomes or dangers.

• OCRDs: Behaviors aim to fix or reduce perceived physical flaws.

How do treatments for OCD and OCRDs differ?

• Both respond to CBT and SSRIs.

• OCRDs may require habit reversal training (HRT) or acceptance-based therapies (ACT) in addition to standard CBT.