Obsessive-Compulsive and Related Disorders
Obsessive-Compulsive and Related Disorders
This chapter discusses disorders marked by repetitive thoughts and/or actions.
Includes: Obsessive-Compulsive Disorder (OCD), Body Dysmorphic Disorder (BDD), Hoarding Disorder (HD), Hair-Pulling Disorder (Trichotillomania), and Excoriation (Skin-Picking) Disorder.
Obsessive-Compulsive Disorder (OCD)
Characterized by intrusive thoughts (obsessions), rituals, preoccupations, and compulsions.
Obsessions: Repetitive, unwanted thoughts, urges, or impulses that increase anxiety or distress.
Compulsions: Repetitive behaviors or mental acts performed in response to obsessions or according to rigid rules.
These obsessions/compulsions cause distress and interfere with daily life (routine, work, social activities, relationships).
Patients can have only obsessions, only compulsions, or both.
The insistent intrusion of an idea or impulse is a core feature.
Typical obsessions: contamination fears ("My hands are dirty"), doubts ("I forgot to turn off the stove").
Symptom patterns cluster within dimensions like contamination/cleansing, forbidden thoughts/checking, symmetry/ordering, and hoarding.
Most OCD patients know their beliefs aren't real, but some have poor or no insight (delusional obsessions); these may be misdiagnosed with a psychotic disorder.
Presentation varies between adults (Table 9-1) and children/adolescents (Table 9-2).
Symptoms can overlap and change over time.
Four major symptom patterns:
Contamination/Cleansing:
Obsession with contamination and compulsive washing or avoidance.
Feared objects (feces, urine, dust, germs) are hard to avoid.
Can cause skin damage (excessive handwashing) or agoraphobia (fear of germs).
Emotional responses: anxiety, shame, disgust.
Belief that contamination spreads by slight contact.
Pathologic Doubt/Checking:
Obsession of doubt, followed by checking compulsions.
Obsession implies danger (e.g., forgetting to turn off the stove, not locking a door).
Checking involves repeated trips to check (e.g., the stove).
Obsessional self-doubt; feeling guilty about forgetting something.
Intrusive/Forbidden Thoughts:
Obsessional thoughts without compulsions.
Thoughts of sexual or aggressive acts that are reprehensible to the patient.
Patients may report themselves to the police or confess to a priest.
Suicidal ideation may occur (but is unlikely to be acted on); assess actual risk.
Symmetry/Ordering:
The need for symmetry/precision leads to slowness as a compulsion.
It can take hours to eat a meal or shave.
Other Symptom Patterns:
Religious obsessions and compulsive hoarding.
Compulsive hair-pulling and nail-biting are related behaviors.
Masturbation may be compulsive.
Case Example: Ms. K
Referred for psychiatric evaluation due to checking rituals.
Has a long history of checking rituals that caused job loss and damaged relationships.
Obsessive thought: door to the car is not locked.
Repeatedly checks the car door.
Broke car door handles due to vigorous checking.
Up to an hour late for work due to checking her car door.
Recurrent thoughts about the apartment door being unlocked.
Returns several times to check the door before leaving for work.
Checking doors decreases her anxiety about security.
Tried to leave without checking but became worried someone would steal her car or break into her apartment.
Obsessions about security became so extreme over past 3 months that she lost her job due to tardiness.
Recognizes the irrationality of her concerns but cannot ignore them.
Table 9-1: Obsessive-Compulsive Symptoms in Adults (N = 200)
Obsessions:
Contamination: 45%
Pathologic doubt: 42%
Somatic: 36%
Need for symmetry: 31%
Aggressive: 28%
Sexual: 26%
Other: 13%
Multiple obsessions: 60%
Compulsions:
Checking: 63%
Washing: 50%
Counting: 36%
Need to ask or confess: 31%
Symmetry and precision: 28%
Hoarding: 18%
Multiple comparisons: 48%
Course of illness (N = 100):
Continuous: 85%
Deteriorative: 10%
Episodic: 2%
Not present: 71%
Present: 29%
Age at onset:
Men: 17.5
pmsqrt 6.8 yearsWomen: 20.8
pmsqrt 8.5 years
Body Dysmorphic Disorder (BDD)
Persistent preoccupation with perceived defects or flaws in appearance.
Defects appear slight or unobservable to others.
Concerns lead to mental acts/behaviors like comparing oneself to others, mirror-checking, or camouflaging perceived flaws.
Common concerns involve the face and head (skin, nose shape/size, hair), but any body area can be the focus.
Concerns can be vague (e.g., extreme concern over a "scrunchy" chin).
Patients worry about around five to seven different body areas throughout their illness.
More than 25% are concerned with symmetry.
Associated symptoms: ideas/delusions of reference (others noticing the flaw), mirror checking/avoidance, attempts to hide the deformity.
Significant life impact; assess avoidance due to BDD symptoms (from minor social avoidance to being housebound).
Patients have less insight than OCD patients.
Only ~25% have reasonable insight, and ~33% have absent insight.
Table 9-2: Reported Obsessions and Compulsions for 70 Consecutive Child and Adolescent Patients
Obsession:
Concern or disgust with bodily wastes or secretions (urine, stool, saliva), dirt, germs, environmental toxins: 30 (43%)
Fear something terrible may happen (fire, death or illness of loved one, self, or others): 18 (24%)
Concern or need for symmetry, order, or exactness: 12 (17%)
Scrupulosity (excessive praying or religious concerns out of keeping with patient’s background): 9 (13%)
Lucky and unlucky numbers: 6 (8%)
Forbidden or perverse sexual thoughts, images, or impulses: 3 (4%)
Intrusive nonsense sounds, words, or music: 1 (1%)
Compulsion:
Excessive or ritualized handwashing, showering, bathing, toothbrushing, or grooming: 60 (85%)
Repeating rituals (e.g., going in and out of door, up and down from chair): 36 (51%)
Checking doors, locks, stove, appliances, car brakes: 32 (46%)
Cleaning and other rituals to remove contact with contaminants: 16 (23%)
Touching: 14 (20%)
Ordering and arranging: 12 (17%)
Measures to prevent harm to self or others (e.g., hanging clothes a certain way): 11 (16%)
Counting: 13 (18%)
Hoarding and collecting: 8 (11%)
Miscellaneous rituals (e.g., licking, spitting, special dress pattern): 18 (26%)
Case Example: 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, despite family telling her she was attractive.
First became preoccupied with her appearance at age 13; obsessed with "facial defects" (e.g., nose was fat, eyes were too far apart).
Prior to this, confident, a good student, and socially active.
Fixation on her face caused social withdrawal and difficulty concentrating, hurting grades.
Dropped out of high school and went for her GED due to preoccupation.
Frequently picked at “blemishes” and hairs on her face.
Frequently checked herself in mirrors/reflective surfaces and thought about her defects almost daily.
Family and others could not convince her that there was nothing wrong with her appearance.
Table 9-3: Location of Imagined Defects in 30 Patients with Body Dysmorphic Disorder
Hair: 19 (63%)
Involved head hair in 15 cases, beard growth in 2 cases, and other body hair in 3 cases.
Nose: 15 (50%)
Skin: 15 (50%)
Involved acne in 7 cases, facial lines in 3 cases, and other skin concerns in 7 cases.
Eyes: 8 (27%)
Head, face: 6 (20%)
Involved concerns with shape in 5 cases and size in 1 case.
Overall body build, bone structure: 6 (20%)
Lips: 5 (17%)
Chin: 5 (17%)
Stomach, waist: 5 (17%)
Teeth: 4 (13%)
Legs, knees: 4 (13%)
Breasts, pectoral muscles: 3 (10%)
Ugly face (general): 3 (10%)
Ears: 2 (7%)
Cheeks: 2 (7%)
Buttocks: 2 (7%)
Penis: 2 (7%)
Arms, wrists: 2 (7%)
Neck: 1 (3%)
Forehead: 1 (3%)
Facial muscles: 1 (3%)
Shoulders: 1 (3%)
Hips: 1 (3%)
Hoarding Disorder (HD)
Profound difficulty discarding or parting with possessions.
Leads to congestion/clutter and distress/impairment, differentiating it from regular collecting.
Impairs eating, sleeping, and grooming.
May result in health problems and poor sanitation (especially with animal hoarding).
Can lead to injuries from fire/falling.
People acquire things of little/no value and cannot throw them away.
Driven by fear of losing items needed later and distorted beliefs/emotional attachment to possessions.
Most hoarders don't perceive their behavior as a problem; many see it as reasonable and part of their identity.
Accumulate possessions passively (clutter accumulates gradually).
Commonly hoarded items: newspapers, mail, magazines, old clothes, bags, books, lists, notes.
Poses risks to the patient and those around them.
Clutter can cause deaths from fire/accidents.
Can attract pest infestations, posing health risks to residents.
Many sufferers are evicted/threatened with eviction.
Severe cases interfere with work, social interaction, and necessary activities.
Pathologic nature: inability to organize possessions.
Hoarders avoid decisions about discarding items.
Overemphasize the importance of recalling information/possessions.
Keep old newspapers/magazines, believing important information may be lost.
Believe forgetting information will lead to severe consequences; keep possessions within sight so as not to forget them.
Case Example: Ms. T
55-year-old single woman, presented with her adult son, who expressed concern about Ms. T’s inability to “throw things away.”
Son reported her home was extremely cluttered with “needless things.”
Whenever he attempted to help her “organize things,” Ms. T would become agitated and argumentative.
Ms. T confirmed son’s complaint. She reported having this difficulty for as long as she could remember but never viewed it as a problem.
Over the past 5 years, Ms. T’s home had become increasingly cluttered. It became more and more challenging to move around within it.
Keeps the kitchen and bathroom relatively clutter-free.
Boxes and bags filled with papers, magazines, clothes, miscellaneous gifts, and trinkets filled the rest of her home.
Her living room was the most affected.
Son could no longer visit his mother’s home because he was so uncomfortable.
Ms. T admits that his avoidance of her home has been a significant source of depression for her.
She had enjoyed entertaining family and friends, but had not done so in years as she felt her home was no longer suitable.
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.”
Hair-Pulling Disorder (Trichotillomania)
Chronic disorder characterized by repetitive hair-pulling, leading to hair loss that may be visible to others.
Also known as trichotillomania (from Greek trich (hair) and tillein (to pull or pluck)).
Although once considered rare, it appears to be relatively common.
Resembles both obsessive-compulsive and impulse control disorder: increased tension before the hair-pulling leads to the behavior and then subsequent relief or satisfaction.
The pulling is not for cosmetic reasons, but instead, individuals often describe an irresistible urge to pull out their hair.
Results in noticeable hair loss and is associated with repeated attempts to decrease/stop hair-pulling.
An increasing sense of tension before engaging in the behavior is relieved or gratified by pulling out their hair.
All body areas may be affected; most commonly the scalp.
Other areas involved: eyebrows, eyelashes, and beard; trunk, armpits, and pubic areas are less commonly involved.
Two types:
Intentional act to control unpleasant personal experiences (e.g., itching or burning).
Automatic pulling occurs outside the person’s awareness, often during sedentary activities.
Case Example: Ms. C
A 27-year-old single woman, came to a local clinic complaining of persistent hair-pulling.
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.
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.
Her habit was constant, occurring every day, often without her noticing it.
She would only be reading an assignment for school, and eventually, her hand would find its way into her hair to find 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 behavior.
Her hair-pulling sessions lasted anywhere from 10 minutes to an hour.
Excoriation (Skin-Picking) Disorder
People repeatedly pick their skin, causing lesions.
Attempt to decrease/stop skin-picking, but are unable to do so.
Causes clinically significant distress or impairment.
Skin-picking may be from any area of the body but is most commonly from the face, followed by the hands, fingers, arms, and legs
Patients may pick from multiple sites.
Result in physical disfigurement and medical consequences that require medical or surgical interventions (e.g., skin grafts or radiosurgery).
Experience tension before picking and relief/gratification after picking.
Patients may pick to relieve stress, tension, and other negative feelings.
Patients often feel guilty/embarrassed at their behavior.
Up to 87% report feeling embarrassed by the picking; 58% report avoiding social situations.
Many use bandages, makeup, or clothing to hide the picking.
Of skin-picking patients, 15% report suicidal ideation due to their behavior, and about 12% have attempted suicide.
Case Example: Ms. J
A 22-year-old single woman, presented to a psychiatrist at the urging of her dermatologist because of compulsively picking her facial skin.
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 scarring and lesions, Ms. J became increasingly withdrawn and avoided all social engagements.
She reported feeling great tension before picking, and only felt relief after she began picking.
Obsessive-Compulsive or Related Disorder Due to Another Medical Condition
When OCD (or another disorder in this category) is due to some other medical condition, we use a different diagnosis
Substance-Induced Obsessive-Compulsive or Related Disorder
Symptoms may be due to a substance, including drugs, medications, and alcohol (either during use or during withdrawal), and is not part of a delirium.
Other Specified Obsessive-Compulsive or Related Disorder
For patients who have symptoms characteristic of obsessive-compulsive and related disorder but do not meet the full criteria for any specific obsessive-compulsive or related disorder.
Appropriate under three situations:
An atypical presentation.
Another specific syndrome not listed in DSM-5 (such as Olfactory Reference Syndrome, described next).
The information presented is insufficient to make a full diagnosis of an obsessive-compulsive or related disorder.
Olfactory Reference Syndrome
People have a false belief that they have a foul body odor that is not perceived by others.
The preoccupation leads to repetitive behaviors such as washing the body or changing clothes.
Patients may have good, fair, poor, or absent insight into the behavior.
The syndrome is predominant in males and single persons.
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 a diagnosis of a delusional disorder may be more appropriate.
Whether or not it deserves a unique diagnosis remains controversial.
It is essential to exclude other medical 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.
DSM-5 includes olfactory reference syndrome in the “other specified” designation for the obsessive-compulsive and related disorder of DSM-5.
DIAGNOSIS
Obsessive-Compulsive Disorder
Table 9-4 lists the diagnostic approaches to OCD in DSM-5 and ICD-10.
We can usually diagnose OCD with a thorough psychiatric history and examination.
Patients often attempt to neutralize obsessions with compulsions.
When assessing the negative impact of OCD symptoms, it is important also to address avoidance of triggers of obsessions and compulsions.
Body Dysmorphic Disorder
Table 9-5 lists the diagnostic approaches to BDD in DSM-5 and ICD-10.
The DSM-5 diagnostic criteria for BDD stipulate preoccupation with a perceived defect in appearance or overemphasis of a slight defect.
It also requires that at some point during the disorder, the patient has compulsive behaviors or mental acts related to the preoccupation.
These compulsions may include mirror checking, excessive grooming, or comparing their appearance to that of others.
The preoccupation causes patients significant emotional distress or markedly impairs their ability to function in important areas.
Hoarding Disorder
Table 9-6 lists the diagnostic approaches to HD in DSM-5 and ICD-10.
We diagnose HD using the significant features of the disorder: patients acquire large amounts of useless or valueless possessions, they cannot throw them away, and this leads to significant clutter in living areas.
If their space is not cluttered, it is because others have stepped in to clean it.
Finally, it should cause significant distress or functional impairment.
The fifth edition of the 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 resistant to treatment.
Hair-Pulling Disorder (Trichotillomania)
Table 9-7 lists the diagnostic approaches to hair-pulling disorder in DSM-5 and ICD-10.
It emphasizes the repetitive and compulsive nature of the behavior as well as the fact that it is not motivated by cosmetic reasons.
Excoriation (Skin-Picking) Disorder
Table 9-8 lists the diagnostic approaches to excoriation (skin-picking) disorder in DSM-5 and ICD-10.
DSM-5 diagnostic criteria for skin-picking disorder require 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.
A thorough physical examination is crucial before a psychiatric diagnosis.
DIFFERENTIAL DIAGNOSIS
Medical Conditions
Several primary medical disorders can produce syndromes bearing a striking resemblance to OCD.
OCD-like symptoms have been reported in children following group A beta-hemolytic streptococcal infection and have been called pediatric autoimmune neuropsychiatric disorders associated with streptococcus (PANDAS).
They may result from an autoimmune process that leads to inflammation of the basal ganglia that disrupts cortical–striatal–thalamic axis functioning.
The current conceptualization of OCD as a disorder of the basal ganglia derives from the phenomenologic similarity between idiopathic OCD and OCD-like disorders that are associated with basal ganglia diseases, such as Sydenham chorea and Huntington disease.
It is essential to search for the neurologic signs of these disorders when assessing a patient with presumed OCD.
Also, OCD often develops before age 30 years, and new-onset OCD in an older individual should raise questions about potential neurologic contributions to the disorder.
Many medical disorders can cause alopecia.
A biopsy may be necessary to distinguish hair-pulling disorder from alopecia areata and tinea capitis.
Many dermatologic conditions can cause skin-picking.
Tourette Disorder
OCD is closely related to Tourette disorder, as the two conditions frequently co-occur, both in individuals over time and within families.
About 90 percent of persons with Tourette disorder have compulsive symptoms, and as many as two-thirds meet the diagnostic criteria for OCD.
Classically, patients with Tourette disorder have recurrent vocal and motor tics that bear 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
Many other psychiatric disorders include obsessive-compulsive symptoms, and we 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.
However, only OCD is associated with genuine obsessions and compulsions.
Worries in generalized anxiety disorder are about real-life concerns, and they tend to be less irrational and ego-dystonic than in OCD.
Similarly, the ruminations of depression and preoccupations of mania are typically mood-congruent and ego-syntonic; in neither case are symptoms neutralized by compulsions.
Psychotic symptoms often lead to obsessive thoughts and compulsive behaviors, bodily preoccupations, or hoarding behaviors that can be difficult to distinguish from the obsessive-compulsive and related disorder.
Patients with psychotic disorders, however, cannot acknowledge the unreasonableness of their behavior.
In some patients with BDD, their preoccupations have a delusional intensity.
In such cases, delusional disorder, somatic type can be made, generally in addition to BDD, to capture the true nature of the patient’s presentation.
Similarly, major depression is often associated with obsessive thoughts that, at times, border on actual obsessions.
However, in the case of major depression, the obsessive symptoms are only found during a depressive episode.
Individuals with an avoidant personality disorder or social phobia may worry about being embarrassed by imagined or real defects in appearance.
However, this concern is usually not prominent, persistent, distressing, or impairing.
Other psychiatric disorders may cause hoarding symptoms, including autism spectrum disorders (where collections may reflect a specific interest) and psychotic disorders.
We should only diagnose HD if the hoarding symptoms are independent of these other disorders.
Neurodevelopmental and neurodegenerative conditions may be associated with hoarding.
Damage to specific brain regions (anterior ventromedial prefrontal and cingulate cortices) may cause excessive and indiscriminate hoarding activity.
Patients with anorexia nervosa have a bodily preoccupation, but the focus is on weight.
Comorbidity
Obsessive-Compulsive Disorder
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.
Suicide is a risk for all patients with OCD.
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 disorder in patients with OCD is 5 to 7 percent, and 20 to 30 percent of patients with OCD have a history of tics.
Body Dysmorphic Disorder
Of the various obsessive-compulsive and related disorders, it appears that BDD is the one most associated with comorbid depression with a lifetime rate of 75 percent, as well as with suicidality, with 80 percent having experienced suicidal ideation.
About one-third of BDD patients have a lifetime history of OCD, and around 30 percent of BDD patients experience panic attacks triggered by appearance concerns.
BDD is also associated with high levels of rejection sensitivity and low self-esteem.
Many patients with BDD use substances to self-medicate symptoms of social anxiety or emotional pain.
Hoarding Disorder
Comorbid OCD is common in patients with HD.
Other prevalent comorbid disorders include generalized anxiety disorder and major depressive disorder.
Hair Pulling Disorder
Comorbid conditions include other body-focused repetitive behavior disorders, with excoriation disorder the most common.
OCD is also more prevalent in hair-pulling disorder than in the general population.
More than half of treatment-seeking individuals with hair-pulling disorder have a comorbid psychiatric disorder, with mood and anxiety disorders the most common.
Also, hair-pulling disorder can result in medical sequelae (e.g., trichobezoars) and decreased quality of life.
Excoriation Disorder
Comorbid conditions in excoriation disorder include other body-focused repetitive behavior disorders, with hair-pulling disorder the most common.
OCD and BDD are also more prevalent in excoriation disorder than in the general population.
Other common comorbid psychiatric disorders in excoriation disorder include mood and anxiety disorders.
COURSE AND PROGNOSIS
Obsessive-Compulsive Disorder
The course of OCD is generally chronic, and in the absence of intervention, symptoms may persist for decades.
Nevertheless, recent data emphasize that long-term outcomes can be positive.
Body Dysmorphic Disorder
The course of BDD is generally chronic, and in the absence of intervention, symptoms may persist for decades.
Earlier age of onset and more severe symptoms at intake may predict a worse course.
Hoarding Disorder
HD has a somewhat later course than most obsessive-compulsive and related disorders.
In the absence of intervention, its course appears to be often chronic and progressive.
Hoarding symptoms often begin in childhood and adolescence, with diagnostic criteria met only in the 30s, and worsening of symptoms in each subsequent decade.
Hair-Pulling Disorder
There are relatively little data on the long-term course of hair-pulling disorder.
In the absence of intervention, its course is likely often chronic.
However, some data indicate that in a proportion of cases, remission does occur.
Excoriation Disorder
Those data which exist on the long-term course of excoriation disorder suggest that, without intervention, this is often chronic, albeit with fluctuations in severity over time.
As is the case in other obsessive-compulsive and related disorders, individuals often report that they have not sought medical attention because they are embarrassed by their symptoms, feel that they should stop the symptoms by themselves, or because they are unaware that the symptoms may be part of a known condition or that there are efficacious treatments.
TREATMENT
Obsessive-Compulsive Disorder
Effective pharmacotherapy medications include clomipramine and selective serotonin reuptake inhibitors (SSRIs, sometimes called serotonin reuptake inhibitor [SRIs]).
Head-to-head comparisons of clomipramine and SSRIs show equal efficacy but better tolerability of the SSRIs.
In general, must use higher doses to achieve an optimal effect.
80 mg of fluoxetine or 200 mg of sertraline.
Some patients respond to even higher doses.
Exceeding the recommended doses is not advisable for clomipramine or citalopram, due to safety concerns.
Response to SRIs is slower in OCD than in depression; clinicians are therefore encouraged to prescribe an SRI for at least 12 weeks before deciding to switch agents or augment with another psychotropic.
Continue to use the dose that was required to obtain a response for at least 1 to 2 years.
When discontinuing medication, there is a real risk of relapse, so this should be done very gradually, with small adjustments made every few months.
Patients who fail to respond to one SRI may respond to another.
Among antipsychotics, risperidone and aripiprazole are best supported as adjuncts
When a response to these agents occurs, it typically happens relatively quickly (e.g., 4 weeks).
Clinical guidelines indicate that either pharmacotherapy or psychotherapy is a reasonable first-line intervention for the management of OCD.
Body Dysmorphic Disorder
SSRIs are efficacious in the treatment of BDD, including delusional BDD.
Clinicians have reported anecdotal evidence for using aripiprazole as an augmenting agent.
Surgical requests are varied: removal of facial sags, jowls, wrinkles, or puffiness; rhinoplasty; breast reduction or enhancement; and penile enlargement.
Commonly associated with the belief about appearance is an unrealistic expectation of how much surgery will correct the defect.
Hoarding Disorder
HD is challenging to treat.
Effective treatments for OCD have shown little benefit for patients with HD.
The challenges posed by hoarding patients to typical CBT treatment include poor insight into the behavior and low motivation and resistance to treatment.
Includes training in decision-making and categorizing.
Exposure and habituation to discarding.
Cognitive restructuring.
Both office and in-home sessions.
Therapist's role:
Assist in developing decision-making skills.
Provide feedback about normal saving behavior.
Identify and challenge erroneous beliefs about possessions.
Goal: Get rid of a significant amount of possessions and make the living space livable.
Skills to maintain a positive balance between the number of possessions and livable space.
Pharmacologic Treatment:
Limited and uncontrolled data.
Supports the use of SSRIs or venlafaxine.
Hair-Pulling Disorder (Trichotillomania) Treatment
Early data showed clomipramine was more effective than desipramine, similar to OCD and BDD.
Subsequent trials of SSRIs and venlafaxine have not consistently demonstrated efficacy.
NAC (N-Acetylcysteine):
Effective in adults at 1200 to 2400 mg/day.
Acts on the glutamatergic system.
A trial of NAC in pediatric hair-pulling disorder was negative.
Dopamine receptor blockers may be useful.
First-line treatment options:
NAC for adults due to its favorable side-effect profile.
SSRIs for patients with comorbid conditions.
Low-dose dopamine receptor blockers for treatment-refractory cases.
Habit Reversal Training (HRT):
Effective cognitive-behavioral techniques for childhood and adult hair-pulling disorder.
HRT components:
Awareness training.
Competing response training.
Social support.
Stimulus control (SC) to change the patient’s environment to make hair-pulling more effortful or less reinforcing.
Augmentation of HRT/SC with acceptance and commitment therapy, dialectical behavior therapy, or cognitive therapy has also shown efficacy.
Excoriation Disorder Treatment
Challenging to treat with limited data on effective treatments.
Most patients do not seek treatment due to embarrassment or belief that the condition is untreatable.
SSRIs:
Support for their use.
Fluoxetine has been shown to be superior to placebo in reducing skin-picking.
Limited data for other agents.
Lamotrigine has demonstrated inconsistent results.
Glutamatergic agents (e.g., NAC) and dopamine receptor blockers have anecdotal positive reports.
Nonpharmacologic treatments include HRT and brief CBT.
Epidemiology of OCD and Related Disorders
Obsessive-Compulsive Disorder (OCD):
Lifetime prevalence in the general population: 2 \text{ to } 3 \%. Relatively consistent rates.
Community studies: Higher prevalence in females.
Clinical contexts: Roughly equal numbers of male and female patients.
Mean age of onset: Approximately 19 years.
Early-onset more common in males.
Typically occurs in adolescence or childhood; onset after age 30 is rare.
Body Dysmorphic Disorder (BDD):
Point prevalence estimates range from 1.7 \text{ to } 2.4 \%. Common obsessive-compulsive and related disorder.
High rates of BDD in general adult psychiatric inpatients, cosmetic surgery clinics, and dermatology clinics.
Mean age of onset: Adolescence.
Community studies: Higher prevalence of females.
Clinical reports: Roughly even male:female ratio.
Hoarding Disorder (HD):
Most prevalence studies have not used DSM-5 diagnostic criteria.
Remarkably prevalent in Western countries.
One study using DSM-5 criteria: Point prevalence of 1.5 \%.
Male:female ratio is approximately 1.
In clinics, females are more common than males, possibly indicating greater insight.
Prevalence increases with age.
Average age of first treatment: Around 50.
Hair-Pulling Disorder (Trichotillomania):
Studies of select populations (e.g., college students): Point prevalence around 0.5 \text{ to } 2 \%.
Age of onset is typically at menarche.
Female:male ratio is about 4:1 in adults.
Pediatric samples include an equal distribution between males and females.
Excoriation Disorder:
Community-based prevalence studies: Point prevalence of 1.4 \text{ to } 5.4 \%.
Mean age of onset is 12 years, typically coinciding with the onset of puberty.
More females than males are affected but the ratio is more even than in hair-pulling disorder.
Etiology of OCD and Related Disorders
Obsessive-Compulsive Disorder (OCD):
Primarily viewed as a neuropsychiatric disorder mediated by specific neurocircuits.
Cognitive-affective neuroscience perspective: Specific neuropsychological impairments include cognitive inflexibility and alterations in the habit system.
Early clinical work: OCD could be precipitated by damage to striatal circuitry (e.g., global influenza epidemic in the early 20th century).
Neuroanatomy, neurocircuitry, neurotransmitters, and other molecules are involved in the pathogenesis of OCD.
Cognitive and neuropsychological studies: Alterations in executive function, cognitive inflexibility, motor impulsivity, and excessive habit formation.
Impaired control of automated, habitual behaviors.
Brain regions implicated: Anterior cingulate, orbitofrontal cortex, and striatum.
Cortico-striatal-thalamic-cortical (CSTC) circuitry plays a role, with activation or inhibition affecting compulsive and impulsive features.
Pharmacotherapy and CBT can normalize functional alterations in CSTC circuitry.
Neurotransmitter systems:
Serotonergic: Patients respond to treatment with SRIs, but there is little evidence serotonin plays a causal role.
Dopaminergic: Augmentation of serotonin reuptake blockers with dopamine receptor blockers is a first-line intervention for treatment-refractory OCD.
Glutamatergic: Some glutamatergic agents may be useful.
Genetic susceptibility plays a role, especially in childhood-onset OCD.
Body Dysmorphic Disorder (BDD):
Specific cognitive-affective impairments.
Neuropsychological studies: Deficits in executive functioning and visual processing.
Brain imaging and neurogenetic studies: CSTC circuits may be involved, as well as circuits involved in visual processing.
Family and twin data: Genetic susceptibility, as well as a relationship to OCD.
Etiology is still far from clear.
Hoarding Disorder (HD):
Impairment in neuropsychological domains, including spatial planning, working memory, response inhibition, and set-shifting.
Neurocircuitry overlaps only partially with that involved in OCD.
Ventromedial prefrontal/anterior cingulate cortices and medial temporal regions are involved.
Animal studies: Possible role for the dopaminergic system.
Twin studies indicate genetic susceptibility.
Hair-Pulling Disorder:
Deficits in working memory and visual-spatial learning.
Involvement of CSTC circuits relevant to habit learning, although data is sparse.
Brain regions associated with reward processing and affect regulation.
Family and twin studies: Genetic susceptibility, as well as a relationship to OCD and other body-focused repetitive behaviors.
Several candidate genes may be associated, but the evidence is preliminary.
Excoriation Disorder:
Overlap with OCD regarding motor impulsivity.
CSTC circuitry involvement, although the data is sparse, and other regions also appear to be implicated.
Dopaminergic system plays a role.
Family and twin studies: Genetic susceptibility, as well as a relationship to OCD and other body-focused repetitive behaviors.
Preliminary evidence has identified several candidate genes.