Abstract
This chapter presents an overview of the nature, assessment, and treatment of obsessive-compulsive and related disorders (OCRD), including obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), hoarding disorder (HD), hair-pulling disorder (HPD), and skin-picking disorder (SPD). Specifically, we review the DSM-V diagnostic criteria, epidemiology and impact, clinical features and course, and etiological insights for each of these disorders in turn. Next, we discuss key points to consider when making a differential diagnosis with disorders outside the OCRD category. From there, we turn to a discussion of the assessment and treatment of these disorders using pharmacological, cognitive-behavioral, and neuromodulation interventions. Future directions in the research on OCRDs then follows.
Introduction
This chapter presents an overview of the nature, assessment, and treatment of obsessive-compulsive and related disorders (OCRDs), including obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), hoarding disorder (HD), hair-pulling disorder (HPD), and skin-picking disorder (SPD). Specifically, we review the DSM-V diagnostic criteria, epidemiology and impact, clinical features and course, and etiological insights for each of these disorders in turn. Next, we discuss key points to consider when making a differential diagnosis with disorders outside the OCRD category. From there, we turn to a discussion of the assessment and treatment of these disorders using pharmacological, cognitive-behavioral, and neuromodulation interventions. Future directions in the research on OCRDs then follows.
The Spectrum of Obsessive-Compulsive and Related Disorders
Diagnostic Criteria
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) was the first version of the DSM to classify obsessive-compulsive and related disorders (OCRDs) in a newly created category, including obsessive-compulsive disorder (OCD), body dysmorphic disorder (BDD), hoarding disorder (HD), hair-pulling disorder (HPD; i.e., trichotillomania), and skin-picking disorder (SPD; i.e., excoriation). The core symptoms of OCRDs include preoccupation/obsessional thinking patterns and repetitive behaviors/compulsions (American Psychiatric Association, 2013). Across disorders, difficulties inhibiting behavioral responses may result in the manifestation of a variety of clinical symptoms such as repeated checking, acquisition of items, hair pulling, skin picking, or repetitive mental rituals. The rationale for grouping the OCRDs together was based upon common symptoms (i.e., repetitive thoughts and/or behaviors), associated features (e.g., age of onset, comorbidity patterns, heredity), etiology (i.e., neurobiological and neurotransmitter abnormalities), and similar treatment response profiles. (For comprehensive reviews on the development of this diagnostic class, see Abramowitz & Jacoby, 2015; Phillips et al., 2010).
Obsessive-Compulsive Disorder
Previously included within the anxiety disorders category in DSM-IV, OCD is the flagship disorder of the OCRDs in DSM-V. OCD is characterized by unwanted intrusive thoughts, images, or impulses (i.e., obsessions) that cause significant distress and anxiety. The content of patients’ obsessions can be very heterogeneous, including fears of contamination, doubts about making a mistake, unwanted aggressive or sexual impulses, or a need for symmetry. Moreover, the content of obsessions is typically incongruent with the person’s belief system and not in line with how the individual sees him/herself (i.e., ego-dystonic). In response to obsessions, individuals with OCD engage in ritualistic compulsions (both covert mental rituals and overt behaviors) in order to reduce the anxiety triggered by the obsessional thoughts. Such compulsions may include checking for signs of harm, repeating/arranging rituals, washing/cleaning, and/or praying. Additionally, patients often rely on avoidance in order to escape distressing obsessions and time-consuming compulsions. In order to receive a diagnosis of OCD, the level of obsessions and/or compulsions must be severe enough to cause marked distress or interferences in functioning (American Psychiatric Association, 2013).
Body Dysmorphic Disorder
BDD is a distressing preoccupation with one or more perceived flaws in physical appearance that are slight or unobservable. BDD is also associated with repetitive behaviors (e.g., mirror checking, excessive grooming or make-up use, skin picking in response to appearance concerns, touching/measuring body parts, and reassurance seeking) or mental acts (e.g., comparing one’s appearance with that of others) in response to the body image concerns. These behaviors take up significant time and interfere with other social/work/school/role obligations (American Psychiatric Association, 2013). BDD was moved from the somatoform disorders in DSM-IV to the OCRD section in DSM-V; however, the diagnostic criteria were essentially unchanged.
Hoarding Disorder
HD is characterized by persistent difficulty discarding or parting with possessions (regardless of their actual value), which often results in the amassing of possessions that fill up and clutter living areas of the home, car, or workplace to the extent that their intended use is no longer possible. If living areas are uncluttered, to meet criteria for HD, this must be due to interventions of a third party (e.g., family member or authority; American Psychiatric Association, 2013). Hoarding is also associated with distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). Hoarding was previously listed as a symptom of obsessive-compulsive personality disorder (OCPD) and often considered as a symptom of OCD, although research strongly suggests it is distinct from OCD (e.g., Mataix-Cols et al., 2010), supporting its separation as a new diagnosis included in DSM-V.
Hair Pulling and Skin-Picking Disorders
Finally, HPD and SPD both involve repetitive grooming behaviors. Research suggests that these problems frequently co-occur, have substantial similarities in symptom presentation and course of illness, and may have common risk factors (e.g., genetic vulnerabilities; Snorrason, Belleau, & Woods, 2012). HPD was previously classified as an impulse control disorder in DSM-IV and is characterized by the recurrent pulling out of one’s hair (e.g., using fingernails and tweezers to pull hairs from their head, face, and pubic or other areas), with repeated attempts to stop hair pulling, resulting in measurable hair loss. While not a criterion for DSM-V, patients sometimes report feeling tension prior to or during pulling (i.e., a premonitory urge) and experiencing pleasure, relief, or gratification while pulling. In order to meet diagnostic criteria for HPD, the pulling behavior and/or the significant loss of hair must lead to significant distress or impairment in social, work, or role functioning.
Similarly, SPD is a new diagnosis in DSM-V and is characterized by recurrent skin picking (e.g., using fingernails or other implements to pick at the face, arms, legs, or other areas) that results in visible tissue damage and at times scarring. As a result of the skin picking and damage, patients with SPD also experience significant distress and/or functional impairment due to problems socially, at work/school, or at home.
Epidemiology and Impact
Each of the OCRDs has a significant public health impact. First, OCD is a substantial impairing and burdensome psychiatric condition, with a lifetime prevalence of approximately 2 percent in the population. It is identified as one of the top ten causes of health-related disability worldwide among all medical and psychiatric conditions due to the extreme distress patients experience, the amount of time the disorder consumes, as well as its relatively early onset and chronic course. Next, large population-based surveys have found the current prevalence rates for BDD to be approximately 1.7 to 2.4 percent (e.g., Buhlmann et al., 2010). Increased rates of cosmetic surgery, hospitalization, suicidal ideation, and suicide attempts due to appearance concerns are reported by these patients (e.g., Buhlmann et al., 2010). Thus, BDD is not only a commonly occurring disorder but also one that is associated with significant morbidity and mortality.
Although there have been only a few studies to date investigating the prevalence rates of HD by DSM-V criteria, preliminary estimates indicate that HD occurs at a prevalence of approximately 4–5 percent in the general population (Steketee & Frost, 2014). HD is associated with a considerable public health burden, especially in regard to the commonly hazardous living conditions that result. In extreme cases, the hoarded material has endangered the lives of not only the individual with HD but also neighbors (e.g., been a cause of fires).
Finally, large epidemiological studies of HPD and SPD have not been conducted; however, in the general population, SPD has reported prevalence rates ranging from 1.4 percent to 5.4 percent and HPD around 0.6 percent (Grant & Chamberlain, 2016; Grant et al., 2012). Patients with HPD and SPD report social, occupational, and academic impairment, financial burdens, as well as additional medical or mental health concerns (such as depression and anxiety), which they attribute to hair pulling and skin picking (Grant & Chamberlain, 2016). Additionally, HPD has the potential for mortality from trichobezoars (i.e., a buildup of ingested hair in the gastrointestinal system, often requiring surgical intervention), whereas severe skin picking can lead to infections which also may require surgery.
Clinical Features and Course
OCD is a heterogeneous disorder in which symptom expression may include a broad array of obsessions/compulsions that tend to vary within and across the following four types of symptom clusters or dimensions: (1) contamination/decontamination-related obsessions and washing/cleaning rituals, (2) responsibility for harm/doubting obsessions and checking rituals, (3) need for symmetry and ordering/arranging rituals, and (4) autogenous/unacceptable/“taboo” thoughts (e.g., related to violence, religion, sex, immorality, etc.) and covert mental neutralizing.
DSM-V also includes two clinical specifiers of OCD, including (a) the degree of insight patients have into their obsessive beliefs (ranging from good/fair insight to absent insight/delusional beliefs), and (b) whether the OCD is tic-related (i.e., whether the individual has a history of a tic disorder). The majority of patients with OCD have good insight regarding their obsessions (Phillips et al., 2012); in other words, they acknowledge that the obsessions and/or compulsions are unreasonable or excessive (e.g., “I know that I most likely won’t contract AIDS if I use this public restroom, but the thought of having the disease is so horrible that I think it’s better to be safe than sorry”). Poor insight is correlated with worse symptom severity and treatment outcomes.
Like all OCRDs, OCD tends to be chronic in nature without treatment and has a waxing and waning course that tends to correspond with general life stressors. Approximately half of OCD cases begin in childhood (ages 8–12); however, symptoms may also onset in late teens and early adulthood. The male to female ratio of OCD is approximately 1:1 in adults; however, girls have a later mean age of onset, resulting in more boys with pediatric OCD.
BDD is typified by a preoccupation with perceived appearance defects, with patients reporting that their appearance is ugly, abnormal, or deformed. Perceived defects can involve any area of the body, and hair preoccupations are the most common areas of concern (Bjornsson, Didie, & Phillips, 2010). Patients with BDD often attempt to hide or camouflage their perceived defects and frequently compare their appearance to others. Many will seek consultation or request clinical procedures from dermatologists and/or cosmetic surgeons. DSM-V specifiers for BDD include whether there is muscle dysmorphia (i.e., the preoccupation with the idea that one’s body build lacks muscular tone) and/or limited insight. The degree of insight is often compromised in BDD, and patients may be quite delusional regarding their body image (Phillips et al., 2012). In comparing patients with BDD and delusional insight to nondelusional patients with BDD, research has shown that when controlling for symptom severity, the two groups differ only in terms of educational attainment, suggesting that BDD’s delusional and nondelusional forms have many more similarities than differences and constitute the same disorder. BDD typically onsets during early adolescence, has a waxing and waning symptom course, and estimates of the male to female gender ratio range from 1:1 to 2:3 (Bjornsson et al., 2010).
For HD, DSM-V also includes two clinical specifiers to provide additional information about the hoarding diagnosis, including whether there is excessive acquisition (i.e., collecting of items) and/or limited insight. Patients with hoarding may or may not have issues with severe domestic squalor (i.e., unsanitary conditions in the home) due to their hoarding symptoms (e.g., accumulating spoiled food). Hoarding disorder most commonly onsets in adolescence and, in the majority of patients, before age twenty. HD has a chronic course with very little waxing and waning of symptoms (Steketee & Frost, 2014). Stressful and traumatic events are common in patients with HD, and relationship changes and interpersonal violence are temporally associated with symptom onset or exacerbation. The gender ratio of HD is inconsistently reported in the literature but appears to occur in an approximately 1:1 male: female ratio or be slightly more prevalent in men.
Patients with HPD and SPD often pull hair/pick skin from primarily one site on the body, but this site can change over time. Individuals with both disorders tend to pull hair and pick skin with imperfections; specifically, patients with HPD often seek to pull hairs that are “different” from other hairs (e.g., coarse, curly, or gray hairs), and patients with SPD target bumps/blemishes on the skin. Of note, HPD and SPD are similar to the other OCRDs (i.e., OCD, BDD) in the shared difficulty resisting or inhibiting repetitive maladaptive behaviors. However, the repetitive behaviors in HPD/SPD are not solely performed with the desire to reduce or avoid distress/anxiety (i.e., negative reinforcement; although individuals do at times report the urge to pull/pick in order to regulate emotions), but these behaviors are also associated with positive reinforcement (e.g., gratification).
Hair pulling and skin picking behavior can occur within the context of a BDD diagnosis, with approximately one-third of patients with BDD reporting skin-picking or hair-pulling symptoms. Thus, it is important to conduct a functional assessment to determine whether the picking/pulling is only performed in order to improve the appearance of a perceived defect (vs. to regulate emotions, derive pleasure, etc.). HPD and SPD tend to onset in adolescence, with an average age of onset of 11.8 years old, but these conditions have been seen in patients as young as 1-year-old. While longitudinal data is lacking, cross-sectional studies suggest that both disorders are chronic, with waxing and waning symptom severity (Grant & Chamberlain, 2016).
Etiological Insights
In general, research supports the idea that OCRDs run in families and there is likely a genetic component in the development of each of the disorders. Several genes have been implicated as potentially conferring risk for OCD and/or related disorders in human studies, or in the context of animal models (e.g., SLC1A1, OLIG2, SAPAP have been studied as candidate genes in OCRD genetic studies; e.g., Stewart et al., 2013). Still, there is no single gene or genetic make-up that has been shown to cause any of the OCRDs, indicating that psychosocial variables (cognitive processes or temperamental antecedents such as perfectionism) and life stressors also play a developmental role (Phillips et al., 2010).
Findings from functional brain imaging studies support a neurobiological model for the pathophysiology of OCD, which involves hyperactivity in the frontostriatal system (Dougherty et al., 2018). Specifically, the orbitofrontal and anterior cingulate cortex, caudate nucleus, and the thalamus have all been implicated as nodes in this hyperactive circuit; activity within these regions has been observed to be elevated during resting or neutral states, increased during symptom provocation, and attenuated following successful treatment. Moreover, OCD has been characterized by fear extinction abnormalities (evidenced by elevated psychophysiological responding during extinction recall relative to healthy controls), with identifiable neurobiological correlates as measured by functional brain imaging (e.g., reduced activation in the ventromedial prefrontal cortex; Milad et al., 2013). Additional neurobiological research implicates dysfunctional serotonergic and dopaminergic systems in OCRDs.
Differential Diagnosis
OCRDs share similarities with many other diagnoses and diagnostic groups in the DSM-V. Thus, several important differential diagnoses are discussed in this section. Specifically, important similarities and distinctions in symptom functionality to consider when making a diagnosis will be briefly reviewed. A number of the differences between the OCRDs and the differential diagnoses discussed as follows have to do with the ego-dystonic versus ego-syntonic nature of the disorder. In general, the OCRDs tend to be ego-dystonic disorders, indicating that the obsessional beliefs are incompatible with the patient’s self-identity or image.
Tic Disorders
OCRDs and tic disorders (e.g., Tourette’s disorder) both exhibit repetitive behaviors in response to a trigger and OCRDs commonly co-occur with tic disorders. However, in tic disorders, repetitive behaviors are usually exhibited to alleviate unpleasant sensations/premonitory urges, rather than obsessional thoughts. In general, OCRD-related rituals reduce anxiety, whereas tics reduce physical tension. Patients are often unaware of their tics, and they can have limited premeditation or thought processes involved in tic behaviors. OCRDs, on the other hand, typically involve a conscious link between the cognitive process of obsessions and compulsive behavior. This distinction becomes more difficult to determine, however, in the case of complex tics with multiple processes that may appear goal-directed as opposed to sudden, rapid, simple tic processes.
Hypochondriasis/Illness Anxiety Disorder.
Similar to compulsions in OCRDs, individuals with illness anxiety disorder (IAD; or “hypochondriasis”) frequently engage in behaviors (such as reassurance seeking or body scanning) to reduce anxiety associated with the belief that they may have a disease or illness (Abramowitz, Schwartz, & Whiteside, 2002). Patients with IAD have thematically limited fears around disease and have less insight into the psychological cause of their distress than individuals with OCD, for instance, who are often eager to consider the irrationality of their obsessions. Patients with IAD have conviction about the feared disease and thus believe that any compulsive behaviors are justified. Additionally, patients with IAD are often worried about diffuse internal bodily sensations (e.g., headaches as potential signs of cancer), while patients with OCD are typically less preoccupied by physical sensations and have more varied obsessions and compulsions (e.g., sex, violence, harm, etc.).
Obsessive-Compulsive Personality Disorder (OCPD)
OCPD shares a preoccupation with perfection, order, and mental/interpersonal control with some of the OCRDs. Rigid behavior seen in OCPD, however, is usually as a result of a firmly held ego-syntonic belief (i.e., beliefs that are in line with the person’s sense of self), rather than an intrusive unwanted (i.e., ego-dystonic) thought (Fineberg, Kaur, Kolli, Mpavaenda, & Reghunandanan, 2015). For instance, patients with OCPD may engage in ordering and arranging behaviors but describe such tasks as enjoyable and consistent with being an orderly person. Moreover, unlike OCD, repetitive behaviors in OCPD are not aimed at lowering obsession-related distress. For example, someone with OCPD might report that they need to maintain a certain routine because it is the “correct” and desirable thing to do rather than due to intrusive thoughts about something bad happening if they were to deviate from their routine.
Schizophrenia/Psychotic Disorders
Bizarre content of repetitive thoughts and overvalued ideas are present in both psychotic disorders and OCRDs (Kozak & Foa, 1994). Thus, obsessions (as seen in OCD) and delusions (as seen in psychotic disorders) may not be categorically distinct, but rather may exist on a continuum and vary by degree of insight (i.e., lower insight in psychotic disorders). However, distinctions can also be made, as the presence of compulsions or neutralizing behaviors indicates a diagnosis of OCD rather than a psychotic disorder, and other symptoms of psychosis (e.g., loose associations, negative symptoms) must additionally be present to diagnose schizophrenia.
Autism Spectrum Disorders (ASD)
ASD and OCRDs are similarly characterized by repetitive thoughts (i.e., fixated interests in ASD and obsessions in OCD) and strict adherence to routines and rituals. Furthermore, co-morbid OCD is common in ASD (Wu, Rudy, & Storch, 2014). However, when individuals with ASD become fixated on certain interests, they tend to enjoy the content of a particular topic (e.g., trains, dinosaurs). This is in contrast to obsessions and rituals and routines in OCD that are usually ego-dystonic (Wu et al., 2014). Similarly, an individual with ASD may engage in repetitive behaviors such as opening and closing a door repeatedly because he enjoys it, or it is calming, or in order to communicate something (e.g., that he wants to leave). In contrast, a patient with OCD may open and close the door a targeted number of times in order to neutralize an unwanted obsessional thought (e.g., about catastrophic consequences if the door is not closed in a way that is “just right”).
Evaluation
Semi-Structured Diagnostic Interviews
The use of structured diagnostic interviews for the assessment OCRDs is common in research studies (but less common outside of a research setting). These interviews facilitate diagnostic decisions by utilizing specific questions to assess symptoms according to DSM criteria. The Structured Clinical Interview for DSM-V (SCID-5; First, Williams, Karg, & Spitzer, 2015) is a commonly used semi-structured clinical interview, which contains modules for OCD as well as the other OCRDs (BDD, HD, HPD, SPD as optional modules). The SCID is divided into sections by disorders and detailed questions regarding each disorder are administered as clinically indicated. These interviews usually take between 60 and 120 minutes to administer.
Clinician-Rated Symptom Severity Instruments
Individuals trained in the use of clinician-rated assessments utilize semi-structured interviews to gather severity ratings of OCRD-related distress and impairment. The gold standard clinician-rated instrument for assessing OCD symptom severity is the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989). The Y-BOCS examines the severity of obsessions and compulsions over the past week via the following five parameters: (a) the amount of time they occupy, (b) the degree to which they cause impairment in work, school, relationships, and activities, (c) the amount of distress they cause, (d) the frequency that patients attempt to disregard obsessions and refrain from compulsions, and (e) the level of control over these symptoms. Items are rated on a 5-point Likert scale from 0 (no symptomatology) to 4 (extreme symptomatology). Total scores on the Y-BOCS range from 0 to 40, and higher scores indicate greater symptom severity.
The Yale-Brown Obsessive-Compulsive Scale Modified for BDD (BDD-YBOCS) is an adapted version of this measure for BDD (Phillips et al., 1997). The BDD-YBOCS examines the severity of obsessional preoccupations about perceived appearance flaws (items 1–5), severity of BDD-related repetitive behaviors (e.g., comparing, mirror checking, camouflaging; items 6–10), insight into appearance beliefs (item 11), and avoidance due to BDD (item 12). Scores on the BDD-YBOCS range from 0 to 48, and higher scores indicate greater symptom severity.
Self-Report Instruments
In addition to clinician-rated measures, patient self-report measures are frequently used and provide several advantages in OCRD assessment: they can be completed quickly and independently of clinician time and thus are useful screening tools or markers of progress over treatment, and patients may feel more comfortable completing measures independently rather than in response to a clinician. Thus, used in conjunction with clinician-rated measures, self-report forms may add additional information to the clinical picture.
First, the Obsessive-Compulsive Inventory-Revised (OCI-R; Foa et al., 2002) is an eighteen-item measure of the degree to which patients are bothered or distressed by OCD symptoms in the past month (e.g., “I am upset by unpleasant thoughts that come into my mind against my will”). The OCI-R includes six dimensions: (1) Washing, (2) Checking/Doubting, (3) Obsessing, (4) Mental Neutralizing, (5) Ordering, and (6) Hoarding.1 The BDD-Symptom Scale (BDD-SS; Wilhelm, Greenberg, Rosenfield, Kasarskis, & Blashill, 2016) rates the severity of specific BDD symptoms and associated thoughts, feelings, and behaviors including: checking rituals, grooming rituals, shape/weight-related rituals, hair pulling/skin picking rituals, surgery/dermatology seeking rituals, avoidance, and BDD-related cognitions. The Saving Inventory–Revised (SI-R; Frost, Steketee, & Grisham, 2004) is a twenty-three-item self-report assessment of hoarding symptoms across three subscales: difficulty discarding, acquisition, and clutter. The Massachusetts General Hospital Hairpulling Scale (MGH-HPS; Keuthen et al., 1995) consists of seven items of HPD symptom severity in the past week, including frequency and intensity of urges to pull, perceived control over urges, frequency of hair pulling, attempts to resist and control over hair pulling, and associated distress. Finally, the Skin Picking Scale – Revised (SPS-R; Snorrason, Ólafsson, et al., 2012) is an eight-item self-report measure of skin-picking disorder severity in the past week, with items assessing the frequency and intensity of urges to pick one’s skin; time spent and control over skin picking; associated distress, impairment, and avoidance; and resulting skin damage.
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