Obsessive-Compulsive & Related Disorders – Comprehensive Study Notes

Page 1

• Chapter scope: disorders with repetitive, intrusive thoughts and/or behaviors.

  • Included: obsessive-compulsive disorder (OCD), body-dysmorphic disorder (BDD), hoarding disorder (HD), hair-pulling disorder (trichotillomania), excoriation (skin-picking) disorder, plus related/secondary conditions.

• OCD – core definitions

  • Obsessions: intrusive, unwanted, repetitive thoughts/urges/impulses → marked anxiety/distress.

  • Compulsions: repetitive behaviors/mental acts performed in response to obsessions or according to rigid rules.

  • Either/both must be present, cause severe distress, be time-consuming, and interfere with routine, work, social life, or relationships.

  • Typical obsessions: contamination (“My hands are dirty”), pathologic doubt (“I forgot to turn off the stove”).

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• Four major OCD symptom clusters (dimensions may overlap/change):

  1. Contamination / Cleansing.

  2. Pathologic Doubt / Checking.

  3. Intrusive Forbidden Thoughts.

  4. Symmetry / Ordering (discussed on next page).

• Insight spectrum

  • Most adults have good insight; some have poor; a minority are delusional → risk of misdiagnosis as psychosis.

• Contamination/Cleansing pattern

  • Fear object hard to avoid (feces, urine, dust, germs).

  • Excessive washing → skin damage; avoidance → housebound.

  • Emotional responses: anxiety, shame, disgust.

  • Belief that contamination spreads by slightest contact.

• Pathologic Doubt/Checking pattern

  • Obsession implies danger (fire, burglary).

  • Multiple returns to house/car, self-doubt, guilt.

• Intrusive/Forbidden Thoughts pattern

  • Pure obsessions (no compulsion) of sexual/aggressive content; patients may confess/report; suicidal ideation may be obsessive but evaluate real risk.

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• Symmetry/Ordering pattern

  • Need for symmetry/precision → compulsion of slowness (hours to eat, shave).

• Other OCD patterns

  • Religious obsessions, compulsive hoarding, hair-pulling, nail-biting, compulsive masturbation.

• Case vignette Ms. K (checking rituals)

  • Intrusive doubts about locking car/apartment → repeated checking, property damage, tardiness → job loss; recognizes irrationality but cannot stop.

Page 4

• Table 9-1 Adult OCD symptom frequencies (N = 200 unless noted)

  • Obsessions: Contamination $45\%$, Pathologic doubt $42\%$, Somatic $36\%$, Symmetry $31\%$, Aggressive $28\%$, Sexual $26\%$, Other $13\%$, Multiple $60\%$.

  • Compulsions: Checking $63\%$, Washing $50\%$, Counting $36\%$, Ask/Confess $31\%$, Symmetry/Precision $28\%$, Hoarding $18\%$, Multiple $48\%$.

  • Course (N = 100): Continuous $85\%$, Deteriorative $10\%$, Episodic $2\%$. Onset: men $17.5\pm6.8$ yrs, women $20.8\pm8.5$ yrs.

Page 5

• Body Dysmorphic Disorder (BDD) core features

  • Persistent preoccupation with perceived (slight/unobservable) defect in appearance → compulsive behaviors (mirror checking, comparing, camouflaging).

  • Common foci: face/head (skin, nose, hair). Avg patient worries about $5\text{–}7$ body areas; >25\% fret over symmetry.

  • Associated: ideas/delusions of reference, avoidance (minor → housebound), mirror checking or mirror avoidance, low insight (only $\approx25\%$ reasonable insight, $\approx33\%$ absent insight).

• Table 9-2 Child & Adolescent OCD (70 pts) – see next page for detailed numbers.

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• Pediatric obsessions (initial interview; multiple per pt)

  • Bodily waste/germ concern $30\,(43\%)$.

  • Catastrophic fear $18\,(24\%)$.

  • Symmetry/order $12\,(17\%)$.

  • Scrupulosity $9\,(13\%)$.

  • Lucky/unlucky numbers $6\,(8\%)$.

  • Forbidden sexual thoughts $3\,(4\%)$.

  • Intrusive sounds/words $1\,(1\%)$.

• Pediatric compulsions

  • Excessive washing/grooming $60\,(85\%)$.

  • Repeating rituals $36\,(51\%)$.

  • Checking $32\,(46\%)$.

  • Cleaning rituals $16\,(23\%)$.

  • Touching $14\,(20\%)$, Ordering $12\,(17\%)$, Harm-prevention $11\,(16\%)$, Counting $13\,(18\%)$, Hoarding $8\,(11\%)$, Misc $18\,(26\%)$.

Page 7

• Ms. R vignette (BDD)

  • Preoccupation with being “ugly” since 13 yrs; believes nose fat/eyes apart → social withdrawal, academic decline, mirror checking, skin picking, unpersuaded by others.

• Table 9-3 BDD imagined defect locations (30 pts; multiple per pt)

  • Hair $63\%$, Nose $50\%$, Skin $50\%$, Eyes $27\%$, Head/face shape $20\%$, Overall build $20\%$, Lips $17\%$, Chin $17\%$, Stomach $17\%$, etc.

Page 8

• Continuation of Table 9-3 listing additional body areas (breasts $10\%$, ears $7\%$, etc.).

Page 9

• Hoarding Disorder (HD)

  • Persistent difficulty discarding possessions → clutter, distress, functional impairment. Differentiated from normal collecting by quantity, useless value, and impairment.

  • Dangers: sanitation, fire, falls, pest infestation, eviction, social isolation, interference with ADLs.

  • Cognitions: fear of needing items, distorted importance of possessions/memory.

  • Most lack insight; clutter accumulates passively.

  • Common items: newspapers, mail, magazines, clothes, bags, books, notes.

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• Ms. T vignette (HD)

  • Lifelong saving, worsened over 5 yrs; living room filled with papers/clothes; son avoids visiting; attempts to discard provoke agitation; rationale “I may need them later.”

• Hair-Pulling Disorder (Trichotillomania)

  • Chronic repetitive hair pulling → visible hair loss; tension before act, relief after.

  • Term coined 1889 by Hallopeau.

  • Overlaps OCD & impulse-control.

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• Hair-pulling features

  • Common sites: scalp (see Fig 9-1), eyebrows, eyelashes, beard; less often trunk/axilla/pubic.

  • Two types:

  1. Focused pulling – intentional to reduce urge/sensation/thought.

  2. Automatic pulling – outside awareness during sedentary tasks.

  • Result: short broken hairs among normal hairs; skin/scalp normal.

  • Sensations: pain, pruritus, tingling.

  • Trichophagy (hair mouthing) → risk of trichobezoar, obstruction.

  • Often denied and camouflaged; may coexist with other self-injury (nail biting, head banging).

• Ms. C vignette: pulling since age 11 → bald patches hidden, urge irresistible, anxiety if resisted, sessions $10\text{–}60$ min.

• Excoriation (Skin-Picking) Disorder intro

  • Recurrent skin picking → lesions; attempts to stop fail; causes distress/impairment; recognized as separate Dx in DSM-5.

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• Skin-picking details

  • Sites: face (most), hands, arms, legs (see Fig 9-2).

  • Consequences: scarring, infections, need for grafts/surgery.

  • Psychological cycle: tension → picking → relief → guilt/embarrassment.

  • Avoidance: make-up, bandages, clothing; $87\%$ embarrassed, $58\%$ social avoidance, $15\%$ suicidal ideation, $12\%$ attempts.

• Ms. J vignette: picks face thrice daily, scars, infection, withdrawn; onset age 11.

Page 13

• Figure 9-2: clinical image of chin lesions.

• Secondary OCD-related diagnoses

  • OCD or related disorder due to medical condition.

  • Substance-induced obsessive-compulsive or related disorder.

Page 14

• Other Specified OCD-Related Disorder

  • Used for: atypical presentations; syndromes not listed; insufficient information.

  • Example: Olfactory Reference Syndrome (ORS)

  • False belief of foul body odor → washing/changing clothes.

  • Predominantly males, mean onset $25$ yrs.

  • Must rule out neurologic/sinus causes; can reach delusional intensity.

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• Diagnosis overview

  • OCD: clinical history; note compulsions often not logically related/excessive; assess avoidance.

  • BDD: preoccupation plus compulsive appearance behaviors; distress/impaired function.

  • HD: accumulation of valueless items, clutter, distress; insight specifier (good/fair/poor/absent).

  • Hair-Pulling: repetitive pulling not for cosmetics.

  • Excoriation: recurrent picking w/ lesions, attempts to stop, distress; rule out medical/ substance causes.

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• Differential diagnosis – medical

  • PANDAS: post-streptococcal basal ganglia inflammation.

  • Basal ganglia diseases (Sydenham chorea, Huntington) resemble OCD.

  • New-onset OCD after $\ge 30$ yrs → consider neurologic work-up.

  • Trichotillomania vs alopecia areata/tinea capitis → biopsy.

  • Skin picking vs dermatologic pruritus (e.g., scabies), Prader–Willi.

Page 17

• Table 9-4 (OCD DSM-5 vs ICD-10) – key elements summarized:

  • Requires obsessions and/or compulsions, $\ge 1$ hr/day or major distress.

  • Excludes other disorders/substances.

  • Specifiers: tic-related; insight (good/fair, poor, absent/delusional); predominant type (ICD-10).

Page 18

• Tourette disorder relationship

  • $\approx90\%$ have compulsive symptoms; $2/3$ meet OCD criteria.

  • Premonitory urges mimic obsessions; complex tics resemble compulsions.

• Psychiatric differentials

  • Obsessive-compulsive personality disorder: traits but no true obsessions/compulsions.

  • GAD worries ≠ irrational/ego-dystonic.

  • Depression/mania ruminations mood-congruent.

  • Psychotic disorders lack insight; broader symptom profile.

  • BDD may be delusional → add delusional disorder, somatic type.

Page 19

• Table 9-5 DSM-5 vs ICD-10 criteria for BDD – key points captured earlier (preoccupation + repetitive behaviors, distress, specifiers for muscle dysmorphia & insight).

• Additional differential notes

  • Avoidant personality & social phobia: embarrassment, but less intense.

  • Hoarding in ASD, psychosis, Alzheimer, Prader–Willi.

  • Skin-picking as response to contamination obsession vs standalone disorder.

  • Factitious dermatitis: bizarre, geometric lesions; healthy adjacent skin (Fig 9-3).

Page 20

• Table 9-6 DSM-5 vs ICD-10 for HD – essentials summarized: difficulty discarding, clutter, distress, specifiers (excessive acquisition, insight).

• Normal vs pathological behaviors: appearance concern, pandemic cleanliness, occasional hair removal/scab picking, hobby collecting – distinguished by distress & impairment.

Page 21

• Table 9-7 DSM/ICD criteria for Hair-Pulling: recurrent pulling → loss, attempts to stop, distress; preceded by tension in ICD-10.

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• Table 9-8 DSM/ICD criteria for Excoriation: recurrent picking → lesions, attempts to stop, distress.

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• Comorbidity

  • OCD: major depression $67\%$ lifetime, social phobia $25\%$, alcohol use, GAD, specific phobia, panic, EDs, personality d/o, suicidality. Tourette $5\text{–}7\%$; tics $20\text{–}30\%$.

  • BDD: depression $75\%$ lifetime, suicidal ideation $80\%$, OCD $\approx33\%$, panic attacks $30\%$, substance use, low self-esteem.

  • HD: comorbid OCD, GAD, MDD.

  • Hair-Pulling: excoriation common, mood/anxiety, OCD; medical sequelae (trichobezoar).

  • Excoriation: hair-pulling, OCD, BDD, mood/anxiety.

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• Course & Prognosis

  • OCD: usually chronic; good outcomes possible with treatment.

  • BDD: chronic; earlier onset & severity predict worse.

  • HD: symptoms start youth, meet criteria in 30s, worsen each decade.

  • Hair-Pulling: limited data; often chronic, some remit.

  • Excoriation: chronic with fluctuations; help-seeking hindered by shame.

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• Treatment – OCD

  • Pharmacotherapy: clomipramine & SSRIs (high-dose, $\ge12$ wk trial). Maintain dose $1\text{–}2$ yrs; taper slowly. Augmentation: risperidone, aripiprazole (esp. tics); other agents (memantine, riluzole, ketamine, lamotrigine, NAC).

  • Psychotherapy: exposure & response prevention (ERP) cornerstone; cognitive & mindfulness elements; family sessions.

  • Combined Tx often superior; choice of first-line based on age, severity, comorbidity.

  • Other somatic: neurosurgery (cingulotomy, capsulotomy), deep brain stimulation; TMS investigational; ECT ineffective.

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• Treatment – BDD

  • SSRIs effective, often high dose/long duration; buspirone augmentation anecdotal; limited support for antipsychotic augmentation; MAOIs occasionally helpful.

  • Plastic surgery: $7\text{–}8\%$ of cosmetic pts may have BDD; unrealistic expectations → legal action/depression; psychotherapy preferred.

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• Treatment – Hoarding

  • CBT tailored: decision-making training, exposure to discarding, cognitive restructuring; office + in-home sessions; therapist guides skills & beliefs; goal = livable space.

  • Pharmacology: limited, SSRIs or venlafaxine small benefit.

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• Treatment – Hair-Pulling

  • Pharmacologic: NAC $1200\text{–}2400$ mg/day promising; SSRIs inconsistent; consider dopamine blockers in refractory.

  • Behavioral: Habit Reversal Training (awareness, competing response, social support) + stimulus control; augmentations (ACT, DBT, CT) show benefit.

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• Treatment – Excoriation

  • Limited data; SSRIs (fluoxetine) superior to placebo.

  • Lamotrigine mixed; NAC and antipsychotics anecdotal.

  • Non-pharm: HRT, brief CBT.

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• Epidemiology

  • OCD lifetime prevalence $2\text{–}3\%$; more females in community, equal clinically; mean onset $19$ yrs.

  • BDD point prevalence $1.7\text{–}2.4\%$; onset adolescence; equal gender in clinics.

  • HD point prevalence $\approx1.5\%$; prevalence rises with age; treatment seekers avg age $50$; M:F $\approx1$.

  • Hair-Pulling point $0.5\text{–}2\%$ among students; onset menarche; adult F:M $4:1$.

  • Excoriation point $1.4\text{–}5.4\%$; mean onset $12$ yrs; F predominance.

Page 31

• Etiology overview – OCD

  • Neurocircuitry: cortico–striatal–thalamic–cortical (CSTC) loops; regions – anterior cingulate, orbitofrontal cortex, striatum (Fig 9-4).

  • Cognitive findings: inflexibility, habit dominance, executive deficits.

  • Neurochemistry: serotonergic (SRI response), dopaminergic (augmentation), glutamatergic, GABAergic.

  • Genetic susceptibility: twin/family data; stronger in childhood-onset.

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• Etiology – BDD

  • Executive & visual processing deficits; CSTC & visual circuits implicated; genetic ties to OCD; etiology unclear.

• Etiology – Hoarding

  • Neuropsych deficits: spatial planning, working memory, inhibition.

  • Neuroanatomy: ventromedial prefrontal/anterior cingulate, medial temporal.

  • Dopaminergic role suggested; genetic influence from twin data.

• Etiology – Hair-Pulling

  • Working memory & visuo-spatial learning deficits; CSTC habit circuits, reward & affect regions; genetic susceptibility; candidate genes preliminary.

• Etiology – Excoriation

  • Motor impulsivity overlap with OCD; CSTC plus other regions; dopaminergic involvement; genetic susceptibility, shared with other body-focused behaviors.

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• Figure 9-4 referenced: multiple brain regions (ACC, OFC, striatum, etc.) in OCD pathophysiology.

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• Clinical implications / ethical & practical considerations

  • Importance of accurate insight assessment to avoid misdiagnosis (e.g., delusional vs psychotic disorders).

  • Risks: infection, self-injury, suicide, social/occupational dysfunction.

  • Ethical duty to screen for medical mimics (e.g., streptococcal PANDAS, dermatologic conditions).

  • Practical: high doses & long trials of SRIs; gradual tapering to prevent relapse; combined therapy often optimal.

  • Public health: recognition of HD hazards (fires, structural collapse) and legal/eviction issues.

  • Cosmetic medicine interface: surgeons must screen for BDD to prevent iatrogenic harm.

Page 35

• Numeric/Statistical recap (selected highlights)

  • Adult OCD obsessions: contamination $45\%$, pathologic doubt $42\%$.

  • Pediatric compulsions: washing $85\%$, repeating $51\%$.

  • BDD insight: reasonable $\approx25\%$, absent $\approx33\%$.

  • Excoriation embarrassment $87\%$, suicidal attempt $12\%$.

  • OCD meds: fluoxetine $\approx80$ mg, sertraline $\approx200$ mg typical; ERP & SRI each first-line; combined superior.

(End of detailed study notes.)