Chapter 6

OBSESSIVE COMPULSIVE DISORDER (300.3) This is also referred to as OCD. It involves having intrusive images, thoughts, or impulses that cause a great degree of emotional distress. The distress can be anxious distress; however, disgust and guilt can also be a part of the emotional response. In order to cope with the emotional distress, the patient will perform some type of ritual (overt or covert). The ritual will reduce the emotional response intensity and decrease the likelihood of acting on the image or thought. This is called “thought-action fusion.” The patient will usually know the futility of doing the ritual but cannot stop engaging in the behavior. According to the DSM-V, the patient can have obsessions and/or compulsions. There are those who just have obsessions and are referred to as “pure obsessionals.” Obsessions have to do with aggression, harm, symmetry, and cleanliness. Patients will respond with rituals, such as cleaning, arranging, and counting. The definition of obsessions includes recurrent and persistent impulses, images, and thoughts that are intrusive and cause distress. They cannot be exaggerations of real life problems but must be out of the ordinary. The person will attempt to neutralize, suppress or ignore the obsession without success. The person realizes that these are not delusional but are just made 96 up in their own mind. Compulsions are the mental acts or repetitive behaviors that the individual feels they must do to quell the thoughts related to an obsession. The behaviors or mental acts tend to reduce the patient’s stress and will decrease the tendency to carry out the obsession. They may or may not be directly related to the obsession, as in compulsive washing in order to stave off contamination. The symptoms seen in OCD cannot be explained by another mental illness, substance use, or a medical condition. The first medical line of treatment involves SSRI therapy, which reduces obsessions and associated anxiety. Cognitive-behavioral therapy can be used, which consists of exposure and response prevention methods. Psycho-education and relaxation training (PRT) is used to treat children with the disorder. Behavior therapy and family-based therapy will decrease OCD in children; however, individual CBT does not seem to be helpful in these kids. Family members often feel confused and angry about these symptoms, especially in kids, so parent management therapy along with CBT will reduce the symptomatology better than CBT alone. Deep brain stimulation will improve some aspects of the disorder. Without treatment, the patient can have a severely affected quality of life in many life areas. The compulsions are often time-consuming and will impact the level of functioning. Severely affected patients will spend hours a day doing their rituals and will be perceived as eccentric or odd. The patient will be reluctant to get treatment as they feel their behavior is shameful or embarrassing. Family members suffer, which is why family-focused cognitive behavioral therapy (FCBT) will usually be more beneficial than individual CBT. BODY DYSMORPHIC DISORDER (300.7) This is also referred to as BDD. It is a DSM-V diagnoses that involves having anxiety or distress due to a perceived physical anomaly, such as a scar, a certain physical feature, or the shape/size of a body part. While most individuals will have a degree of dissatisfaction with their appearance at times, people with BDD will have ongoing and intrusive thoughts about their 97 flaw, which may be exceedingly minor and will be something others are not concerned with or don’t notice. It is different from distorted body image seen in eating disorders, which is more related to total body mass rather than a specific area. Individuals with an eating disorder may be preoccupied with certain areas of their body that they don’t like, but the focus is regarding the mass of the area as it relates to the total body mass. BDD patients will be concerned about body mass but only related to certain things like a lack of muscle definition in an area or in the entire body. There is self-consciousness, distress, and avoidance of social situations and/or intimacy because of their perceptions, which lead to depression, social isolation, and suicidality. The patient will often undergo unnecessary cosmetic surgery, skin procedures, or dental procedures to correct the perceived flaw. Unfortunately, they are rarely satisfied with the results because of ongoing perceptual problems. Some believe that this disorder is actually part of OCD; however, the DSM-V classifies this as a discrete disorder under the umbrella of OCD-related disorders. There are four diagnostic criteria for body dysmorphic disorder with four different specifiers. The major criteria include the following: 1. Being preoccupied with a physical feature they perceive as flawed, which is not concerning to others. 2. Having repetitive behavior focusing on the perceived anomaly, like examining oneself in the mirror or trying to hide the flaw. They constantly seek reassurance about their appearance but aren’t satisfied with the responses they get. 3. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. 4. The appearance preoccupations are not restricted to concerns with body fat or weight and the patient does not meet the criteria for an eating disorder. 98 Specifiers include the following: A. Dysmorphia—obsession regarding musculature, in which there is a fixation about one or more muscle groups. B. Good or fair insight—the patient will be able to be distracted from their preoccupation and have a good prognosis. C. Poor insight with the patient needing constant reassurance with brief moments of insight. D. Absent insight or delusional—the patient is convinced of their defect and will not respond to surgical intervention or reassurance. The average age of onset of BDD is 16 years; although it is often seen in kids who develop the disorder at around puberty (aged 12-13 years). The prevalence of body dysmorphic disorder in the US is about 2.5 percent in males and 2.2 percent in females. Risk factors for BDD are child abuse, a history of sexual trauma, bullying, and hormonal imbalances. The main comorbidities are depression, OCD, and substance abuse. They may use substances to self-medicate and may be so depressed as to be suicidal. While BDD is chronic, it responds favorably to treatment. CBT is effective as it challenges the patient’s irrational beliefs and perceptions regarding their bodily features. They are somewhat resistant to starting treatment as they don’t see their beliefs as irrational. SSRIs are a good first-line therapy for the treatment of this disorder. There are several things to rule out as part of diagnosing BDD. These include OCD, somatic anxiety, eating disorders, major depressive disorder, psychotic disorders, and anxiety disorders. There are several rarer disorders that can mimic BDD, such as gender dysmorphia, body identity integrity disorder, dysmorphic concern, and olfactory reference syndrome. 99 HOARDING DISORDER (300.3) Hoarding disorder is a diagnosis given to persons who have distress over discarding any items and who excessively save most items. They cannot part with anything so that they have excessive clutter to such a degree that they create safety and health risks in their home. It is a bigger thing than clutter and collecting. These patients have roomfuls of stuff that have very little value and have little room to maneuver in their home. Tables, sinks, and even chairs/couches are unusable. They often do not invite guests over and people do not feel comfortable in the hoarder’s home. Their home is often a safety issue. Typical symptoms include the following: A. Severe anxiety over the idea of discarding possessions. B. Inability to discard possessions and things. C. Having limited living space in their home. D. Using common areas of the home as storage spaces. E. Loneliness F. Social isolation and withdrawal G. Depression H. Disorganization I. Fear or embarrassment about having visitors to their home J. Being indecisive as to where to put things The DSM-V diagnostic criteria include the following: A. Persistence in having a difficulty parting with possessions that have negligible value. B. Distress associated with getting rid of items and/or perceiving the need to save items. C. Distress resulting in the accumulation of possessions that clutter the home excessively. D. The hoarding causes distress and/or impairment in several areas of life functioning. 100 E. The disorder is not attributable to another medical condition, such as brain injury or stroke. F. The hoarding cannot be explained by symptoms of another mental disorder. They often buy things that are not necessary and that they don’t have the space for. The hoarder may have good insight or poor insight into their problem. About 80-90 percent of these patients engage in excessive shopping and buy unnecessary items. The disease affects about 2-6 percent of individuals, usually common in older adults, although it starts to cause impairment in the patient’s 30s. About 20 percent of patients will have true OCD and are likely to hoard strange things, like trash, nails, hair, and feces. About 57 percent will have depression, 29 percent will have social phobia, and 28 percent will have ADHD. People with hoarding disorder generally don’t think they have a serious problem and will only go for treatment when they are pushed by family members or at risk of eviction. As hoarding can create risks to health, the goal is to attain reduction in physical harm. Treatment often involves a team of nurses, psychologists, and social workers as well as support groups, psychotherapy, and medications. CBT given to a group of individuals with a hoarding problem to decrease the symptoms. Hoarders who do not get treated have limited mobility and a low quality of life. The stuff takes over their living space and their lives. They live a lonely existence with decreased interaction between themselves and other people. Things that tend to get saved include magazines, newspapers, clothing, books, bags, and paperwork. They have health problems related to unsanitary conditions and unstable structures of their homes. They often violate fire and safety codes so they run the risk of being evicted. TRICHOTILLOMANIA (312.39) This is the DSM-V diagnosis given to people who recurrently pull their hair out. They feel compelled to pull out hair from their head or body, resulting in significant impairment. It is classified as a body-focused repetitive behavior. It is related to conditions of self-grooming, 101 which includes picking, pulling, scraping, or biting the hair, skin, or nails, resulting in damage to body areas. The person with trichotillomania has the overwhelming urge to pull hair out of their eyelashes, eyebrows, and head. They have tension that can only be relieved by pulling hair out. Some do the behavior directly because of stress, while others have the subconscious urge to do this behavior. The ratio of females to males with this disorder is 10:1 with prevalence of about 1-2 percent of Americans. It usually starts at puberty or just past puberty at 12-13 years. Typical symptoms include the following: A. Constant twist or pulling hair B. Bald patches on the head or eyebrows C. Uneven appearance to the hair D. Denying that hair pulling is taking place E. Bowel obstruction from hair swallowing F. Tension preceding hair pulling G. Other self-injurious behaviors H. Poor self-image I. Feeling anxious, sad or depressed While most people pull their hair from their scalps, some patients with trichotillomania will pull hair from their eyelashes, eyebrows, beard, genital area, or moustache. The diagnosis is made using these diagnostic criteria: A. Recurrent pulling out of hair, resulting in hair loss. B. Having repeated attempts to reduce or stop hair pulling. C. Having extreme distress or impairment from the behavior. D. Hair pulling is not secondary to another medical condition. E. Hair pulling cannot be explained by another mental disorder. 102 These people experience increased stress in their everyday lives that is compounded by embarrassment over their behavior that, in turn, affects their activities of daily living. They may fear social situations because of their appearance or inability to control their behavior in public. They do, however, manage to avoid doing the behaviors in public except with close family members. Hair pulling can extend to pulling hair from toys or pets. Swallowing hair is not uncommon. There is no single cause to trichotillomania but a number of factors may contribute to the onset of the disorder. Scientists have identified individuals with some type of genetic predisposition to the disorder and there is an increased risk of trichotillomania in people with OCD or who have first-degree relatives with OCD. Other factors that may play a role in getting the disorder include chemical imbalances in the brain, hormonal changes in puberty, poor coping skills, or similar factors that lead to self-injurious behavior. Comorbidities with trichotillomania include major depressive disorder, excoriation disorder, and obsessive-compulsive disorder. About a third of all patients will have some type of anxiety disorder, while 1 in 5 will also have a substance use disorder. If the hair pulling or manipulation is intended to make the individual appear better (according to them), it is not trichotillomania. Some OCD patients will pull hair to make their appearance symmetrical and this is not trichotillomania. Other things that are not trichotillomania involve those who pull hair because of body dysmorphic disorder or psychotic disorders with delusions about their hair. Certain substances and neurodevelopmental disorders can lead to hair pulling as well. The treatment for trichotillomania involves managing what is a chronic condition. Medications and psychotherapy together can be used to aid recovery. There are many tips and tricks for relaxation and distraction that abort the hair pulling behavior. These are employed to decrease hair pulling. The medications used are the same ones employed in the treatment of OCD, including fluoxetine, sertraline, fluvoxamine, paroxetine, clomipramine, lithium, and valproate. SSRIs are used first, followed by mood stabilizers if more treatment is needed. 103 EXCORIATION DISORDER (698.4) Excoriation disorder goes by the medical name of dermatillomania and is a skin-picking disorder associated with the impulse to pick at the skin, even when it causes damage. It is similar to trichotillomania and sometimes coexists with it. While both are obsessive-compulsive disorders, they share similarities with substance abuse disorders. While there have been many psychological and medical theories behind excoriation disorder, it is now recognized as an organically-caused mental disorder of the obsessive-compulsive classification. The major symptom is the compulsion to squeeze, pick at, or scratch a part of the skin when experiencing anxiety or stress. There may be a perceived defect there but this is not a requirement. Most sufferers scratch their face but other areas seen are the extremities and scalp. Some will switch areas to allow formerly scratched areas to heal. Most patients pick with their fingers; however, needles and tweezers can be used. Patients with excoriation disorder will feel embarrassed, guilty, helpless, and ashamed of their urges; however, they cannot stop them. About 15 percent have been hospitalized in the past for psychiatric reasons and 11 percent have had prior suicide attempts. Like trichotillomania, the behavior is triggered by depression or anxiety, which decreases the heightened level of arousal. In addition, the mean age at onset of excoriation disorder is during adolescence when acne breaks out. Another peak age is 30-45 years of age but this is less commonly seen. Some argue that excoriation disorder isn’t a separate disorder but is just a facet of OCD or body dysmorphic disorder. Others say it is just a bad habit and not a disorder. The reason why it is listed as a separate OCD-related disorder is that there are no obsessions and no concern over a bodily abnormality. Patients also refer to skin-picking as pleasurable and they experience a release and a sense of pleasure, which is similar to an addiction disorder. There is now a specifier on the DSM-V to include individuals who have good to fair insight into their condition (and a better prognosis), poor insight (and a worse prognosis), or absent insight (the worst prognosis as they are convinced their behaviors are appropriate). There may or may 104 not be anxiety with this disorder, which makes it not an anxiety disorder but an OCD-related disorder. The patient must have recurrent skin picking that leads to skin lesions and repeated attempts to stop the behavior. The estimated prevalence of the disorder is 1-5 percent of the general population with only about 1-2 percent truly meeting all the criteria for the disorder, including suffering distress or problems in several life areas. Many will have the disorder around adolescence or before with a marked preponderance of females with the disorder. Childhood traumatic experiences are linked to the disorder and it persists after the “era” of acne goes away. There is a great deal of comorbidity with excoriation disorder, particularly mood and anxiety disorders. OCD is a common comorbidity and about 40 percent will have some type of drug or alcohol use disorder. About half of people with body dysmorphic disorder have skin picking. It is also linked slightly to trichotillomania. Patients with developmental disabilities often have skin-picking disorder as well particularly Prader-Willi syndrome. The neurotransmitter dopamine is felt to be linked to skin-picking as drugs that enhance dopamine (like methamphetamine and cocaine) will increase skin picking behaviors, while drugs that block dopamine and naltrexone will decrease skin picking. Only about a third of patients seek treatment for the disorder with SSRI drugs being the first line of defense against the disease. Other drugs, like naltrexone (which blocks dopamine), tricyclic antidepressants, and atypical neuroleptic drugs have been tried successfully for skin-picking behaviors. Topiramate is used for those with Prader-Willi syndrome who pick their skin. SUBSTANCE/MEDICATION-INDUCED OBSESSIVE-COMPULSIVE AND RELATED DISORDER This is the name for any OCD symptoms that are secondary to taking a drug. This is a relatively rare disorder that usually causes things like hair-pulling or skin-picking in predisposed individuals. If the person meets the criteria for OCD before taking the substance, it isn’t substance-induced OCD. There is a specifier that includes “with onset during intoxication”, 105 meaning that the onset is immediately after taking the drug. It can also occur during drug withdrawal, which is an anxious time for many people. There are just a few drugs that are recognized as causing substance-induced OCD. These are methamphetamine, amphetamine, and cocaine. There is a category for “other” or “unknown” drugs but this would be quite rare. OBSESSIVE-COMPULSIVE AND RELATED DISORDER DUE TO ANOTHER MEDICAL CONDITION This is a new category for the DSM-V. Most OCD conditions caused by a medical disorder involve things like excoriation disorder and trichotillomania. Organic disorders that can cause skin-picking behaviors include anemia, liver disease, kidney failure, allergic skin reactions, acne, and other skin disorders. Compulsive hair pulling can come secondary to a fungal infection of the scalp, scalp acne, psoriasis, seborrheic dermatitis, and other scalp conditions. Oddly enough, a streptococcal infection in kids can trigger a disease called PANDAS, which leads to the sudden onset of OCD and other neuropsychiatric symptoms. Wilson’s disease is an inherited disorder that results in liver disease and various psychiatric disorders, including OCD. Chelation therapy will help control the behaviors and other problems linked with this disease. 106 KEY TAKEAWAYS • Typical OCD is manifest as having obsessions (though