Clinical Features

OCD is a clinically heterogeneous disorder with various presentations of obsessions and/or compulsions. Although individuals do not need to endorse both obsessions and compulsions to meet diagnostic criteria (APA, 2013), 96% of outpatients with OCD report experiencing both, whereas 2% endorse predominant obsessions and 2% report predominant compulsions (Foa & Kozak, 1995). Among this large sample of individuals from the DSM-IV field trials, the most common obsession reported was contamination (37.8%), followed by fear of harming self or others (23.6%) and symmetry (10%). The most common compulsions reported were checking (28.2%) and cleaning/washing (26.6%). Other obsessions included somatic, religious, and sexual obsessions, whereas other compulsions included repeating, mental rituals, ordering, and counting.

A meta-analysis of factor analytic studies of OCD symptom categories revealed four factors, which explained nearly 80% of the variance in 17 studies of adults with OCD (Bloch, Landeros-Weisenberger, Rosario, Pittenger, & Leckman, 2008). The four factors included symmetry (symmetry obsessions and repeating, counting, and ordering compulsions), cleaning (contamination obsessions and cleaning compulsions), forbidden thoughts (aggressive, religious, and sexual obsessions), and hoarding (hoarding obsessions and compulsions). Often, obsessions and compulsions are functionally related (e.g., contamination fears accompanied by cleaning rituals or self-doubt and dread accompanied by repetitive checking; Turner & Beidel, 1988). For instance, strong associations exist between some similar obsessions and compulsions (e.g., contamination obsessions and cleaning compulsions), whereas others are less specific (e.g., checking compulsions are related to a variety of obsessions) (Bloch et al., 2008).

OCD is a debilitating disorder with significant functional impairment and reduced quality of life (Norberg, Calamari, Cohen, & Riemann, 2008). In fact, a recent review found that quality of life in OCD is significantly lower than quality of life in community controls and individuals with other psychiatric and medical disorders (Macy et al., 2013). Unfortunately, despite the associated impairment and distress, few individuals with the disorder initiate treatment (Levy, McLean, Yadin, & Foa, 2013).

Clinically, BDD is marked by preoccupation with physical appearance that results in repetitive behavioral or mental acts. On average, preoccupation is focused on five to seven areas of the body (Phillips, Menard, Fay, & Weisberg, 2005). Although the clinical presentation in men and women is more similar than different, implicated body regions differ significantly (Phillips, Menard, & Fay, 2006). Men are more likely to be preoccupied with body build, genitals, and hair thinning or balding, whereas women are more likely to be preoccupied with a wider variety of body areas (i.e., skin, stomach, weight, breasts, buttocks, thighs, legs, hips, toes, and excessive body or facial hair). Repetitive or safety behaviors in response to body preoccupation may include comparison to others, camouflaging (i.e., using body posture or position, clothes, and makeup, among others, to hide the perceived defect), mirror checking, grooming, reassurance seeking, dieting, and tanning (Phillips et al., 2005).

Individuals with BDD endorse high rates of both suicidal ideation and suicide attempts due to appearance concerns (Rief, Buhlmann, Wilhelm, Borkenhagen, & Brähler, 2006). For instance, in a sample of 200 individuals with BDD, 81.3% of treated subjects and 71.2% of untreated subjects endorsed suicidal ideation, and over a quarter of all subjects had attempted suicide (Phillips et al., 2005). Further, individuals with the disorder are more likely to be divorced, unmarried, unemployed, and have lower incomes than individuals without the disorder (Rief et al., 2006) and may be housebound, miss work and school, drop out of school, and receive disability (Phillips et al., 2005). Despite the associated distress and impairment, few individuals with BDD disclose their body image concerns to clinicians, most often due to feelings of embarrassment or fears of being negatively evaluated (Conroy et al., 2008). Instead, many individuals with the disorder receive nonpsychiatric treatment (i.e., dermatology and cosmetic surgery) (Phillips et al., 2005).

The typical clinical presentation of HD involves an individual who has significant difficulty parting with possessions and associated distress and impairment. Over two-thirds of individuals with the disorder may also exhibit excessive acquisition of items, which has been found to be a clinical predictor of distress and/or impairment (Timpano et al., 2011). Individuals with the disorder most frequently accumulate items through purchase (64.4%) and obtaining free things (53.4%); however, a subsample of those who engage in excessive acquisition may also steal (25.3%). Clinically significant hoarding may lead to work impairment, eviction from the home, and/or removal of others from the home, and is a significant public health burden (Tolin, Frost, Steketee, Gray, & Fitch, 2008).

The hallmark symptom of TTM is clinically significant hair pulling. Individuals usually pull hair from multiple sites, most frequently being the scalp, followed by eyelashes, eyebrows, and pubic hair (Flessner, Woods, Franklin, Keuthen, & Piacentini, 2009). Although it is not necessary for diagnosis, many adults with the disorder report an urge, need, or drive to pull hair, as well as a sense of gratification or relief during or after pulling (Lochner et al., 2012). Most individuals pull out single hairs (68%); however, some may pull out clumps (5%), or a combination of single hairs and clumps (27%) (Christenson, MacKenzie, & Mitchell, 1991). Additionally, individuals may target specific types of hair based on thickness, texture, or color and may manipulate hair after it is pulled (e.g., suck on hairs or scrape off roots) (Walsh & McDougle, 2001). Finally, individuals with TTM may express associated negative affective states, including feeling unattractive (87%), secretiveness (83%), shame (75%), irritability (71%), low self-esteem (77%), and depressed mood (81%) (Stemberger, Thomas, Mansueto, & Carter, 2000).

ED describes clinically significant picking of the skin that results in skin lesions. An examination of 60 individuals with pathologic skin picking suggests that the disorder is time-consuming and associated with various complications (Odlaug & Grant, 2008). Results of this study also suggest that individuals often begin picking in response to triggers, such as feel (55%) or sight (26.7%) of the skin, boredom/downtime (25%), and stress (20%). The face and head (60%) are the most common sights for picking, followed by the legs and feet (33.3%), arms (30%), torso (23.3%), and hands and fingers (21.7%). Most individuals (68.8%) pick from multiple sites of the body, often switching areas in order for other sites to heal. In fact, 35% of this sample experienced infections requiring antibiotics as a result of skin picking.

Diagnostic Considerations

The National Comorbidity Survey Replication (NCS-R; Kessler et al., 2004) found that 90% of individuals with a lifetime diagnosis of OCD met criteria for an additional DSM-IV disorder (Ruscio, Stein, Chiu, & Kessler, 2010). The most common comorbid disorders were anxiety disorders (75.8%), followed by mood disorders (63.3%), impulse-control disorders (55.9%), and finally substance use disorders (38.6%). Within anxiety disorders, the highest comorbidity rates were found for lifetime social phobia (43.5%), specific phobia (42.7%), and separation anxiety disorder (37.1%); whereas major depressive disorder (40.7%) was the most frequent comorbid mood disorder. Another study that examined a wider variety of DSM-IV disorders also found high rates of lifetime anxiety and depression comorbidity, as well as high rates of lifetime comorbid obsessive-compulsive personality disorder (24.7%) in individuals with OCD (Pinto, Mancebo, Eisen, Pagano, & Rasmussen, 2006).

In a sample of 200 individuals with BDD, lifetime comorbidity was compared in treated and untreated individuals (Phillips et al., 2005). Comorbidity rates were highest for mood (88.1% in treated individuals and 75.8% in untreated individuals), anxiety (73.1% and 62.1%, respectively), substance use (50.0% and 43.9%, respectively), and personality disorders (47.9% and 39%, respectively). The highest rate of comorbidity for both samples was major depression (75.4% and 72.7%, respectively); however, rates were relatively high for social phobia (40.3% and 34.8%, respectively) and avoidant personality disorder (26.9% and 22.0%, respectively), which are likely related to appearance concerns associated with BDD.

Literature on the comorbidity rates of HD is sparse, likely due to its introduction as a stand-alone disorder in the DSM-5. However, one recent study did examine current comorbidity of HD (defined by the then-proposed DSM-5 criteria) in 217 individuals with the diagnosis (Frost, Steketee, & Tolin, 2011). Major depression was the most common comorbid mood disorder (50.7%); however, comorbidity rates were also high for attention-deficit/hyperactivity disorder inattentive type (27.8%), generalized anxiety disorder (24.4%), social phobia (23.5%), and OCD (18%).

Similarly, research examining comorbidities of TTM is limited. A recent review suggests mood, anxiety, and substance use disorders are the most commonly identified comorbidities (Duke, Keeley, Geffken, & Storch, 2010). In addition, TTM is related to skin-picking disorder (Snorrason, Belleau, Woods, 2012), which is discussed in more detail next.

Although no literature exists at this time that examines comorbidities of DSM-5 ED, earlier studies examining pathologic skin picking do exist. In one study, comorbidity was examined in a small sample (n = 60) of individuals who engaged in pathologic skin picking, defined similarly to the DSM-5 criteria (with the exception of inclusion of preoccupation, tension, and relief criteria). Results found that 38.3% of individuals met current criteria for an additional DSM-IV disorder, whereas 56.7% met lifetime criteria for another disorder (Odlaug & Grant, 2008). Specifically, 36.7% of individuals met current criteria for TTM (with a similar rate for lifetime diagnosis [38.3%]), 15.0% met criteria for current OCD (16.7% for lifetime), and 15.0% met current criteria for major depressive disorder (31.7% for lifetime). Indeed, the comorbidity of TTM and skin-picking disorder appears to be high, with an average of 20.8% of TTM outpatient samples endorsing skin picking, and an average of 15.5% of skin-picking disorder outpatient samples endorsing TTM, indicating relatedness between the two disorders (Snorrason et al., 2012).

Epidemiology

Due to the recent advent of the DSM-5, current epidemiological studies reflect diagnoses largely based on DSM-IV-TR criteria. Diagnostic changes introduced in the DSM-5, as well as inclusion of new disorders, will likely generate new research that may elucidate changes in prevalence rates reflective of new diagnostic criteria. Thus, epidemiological data reflected here are based on DSM-IV-TR criteria and in samples of U.S. adults, unless otherwise noted.

Although over one-fourth of individuals report experiencing obsessions or compulsions at some point in their lives, meeting diagnostic criteria for OCD occurs in a much smaller percentage of individuals (Ruscio et al., 2010). Specifically, the 12-month prevalence rate of OCD is 1.2% and the lifetime prevalence rate is 2.3%. As a result, OCD is a relatively rare disorder.

In a nationally representative study, the point prevalence of BDD was 2.4% (Koran, Abujaoude, Large, & Serpe, 2008); however, rates vary widely depending on the setting. In one study, 1.8% of outpatient adults met criteria for BDD (van der Meer et al., 2012), whereas rates in inpatient samples range from 13.1% to 16% (Conroy et al., 2008; Grant, Kim, & Crow, 2001).

Using the DSM-IV hoarding criterion of obsessive-compulsive personality disorder (i.e., being “unable to discard worn-out or worthless objects even when they have no sentimental value”) (APA, 1994), the weighted community prevalence was 5.3% (Samuels et al., 2008). Similarly, in a large German community sample, 5.8% of individuals endorsed current hoarding according to (then proposed) DSM-V criteria (Timpano et al., 2011).

In a community sample, 0.6% of individuals met DSM-IV-TR criteria for TTM; however, the prevalence increased to 1.2% when the prior diagnostic criteria of building tension or release were ignored (Duke, Bodzin, Tavares, Geffken, & Storch, 2009), suggesting that the DSM-5 criteria may be less restrictive and produce larger prevalence rates. Among a psychiatric inpatient sample, the point prevalence of TTM was 3.4% and the lifetime prevalence was 4.4% (Grant, Levine, Kim, & Potenza, 2005). Interestingly, a similar rate of TTM (3.9%) was found for a sample of college students; however, the latter rate was based on a modified self-report measure of the clinical interview administered to the inpatient sample (Odlaug & Grant, 2010).

Although ED was not an official diagnosis within the DSM-IV-TR (APA, 2000), prevalence rates based on various diagnostic criteria do exist. For instance, in non-clinical community samples, 1.4% to 5.4% of individuals endorsed clinically significant skin picking with associated distress or impairment (Hayes, Storch, & Berlanga, 2009). In a recent study examining prevalence based on (then proposed) DSM-5 criteria, 4.2% of college students met diagnostic criteria for ED (Odlaug et al., 2013).

Psychological and Biological Assessment

Various clinician-administered measures for the assessment of OCD exist. For instance, the Anxiety Disorders Interview Schedule for DSM-IV (ADIS-IV; Brown, DiNardo, & Barlow, 1994) and the Structured Clinical Interview for DSM-IV-TR Axis I Disorders (SCID-CV; First, Spitzer, Gibbon, & Williams, 1996) are semistructured diagnostic interviews that assess for OCD and other disorders. Additionally, the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman et al., 1989a; Goodman et al., 1989b) is considered the “gold standard” for assessing OCD symptom severity and now includes a revised second edition (Y-BOCS-II; Storch, Rasmussen, et al., 2010). The Y-BOCS-II is a semi-structured, clinician-administered measure that assesses for the frequency and severity of OCD symptoms over the past week, with good to excellent psychometric properties (Storch, Larson, et al., 2010; Storch, Rasmussen, et al., 2010).

Although OCD is typically assessed using semi-structured clinical interviews, various self-report measures with established reliability and validity exist, including the Y-BOCS-Self Report (Baer, Brown-Beasley, Sorce, & Henriques, 1993; Steketee, Frost, & Bogart, 1996) and Obsessive-Compulsive Inventory (OCI; Foa et al., 2002). Finally, behavioral avoidance tests (BATs), or observational tasks in which individuals are exposed to feared stimuli while rating their distress, have recently been used to assess OCD (Grabill et al., 2008). Specifically, BATs are often administered before treatment to assess the severity of avoidance and distress, and after treatment to assess functional change. Although BATs provide additional clinical information, they are generally considered an adjunct to traditional clinical interviewing, providing particularly helpful information for development of exposure hierarchies. For recent comprehensive reviews of assessment measures for OCD, see Benito and Storch (2011) and Grabill et al. (2008).

Although the SCID-CV (First et al., 1996) screens for BDD, more thorough assessments are needed for diagnosis. For example, the BDD Examination (BDDE; Rosen & Reiter, 1996), a 34-item semi-structured clinical interview, is designed specifically to diagnosis BDD. The BDDE has acceptable reliability and validity, and measures not only the various aspects of preoccupation, but also the level of conviction the individual holds regarding the perceived defect (Cororve & Gleaves, 2001). In addition, the Y-BOCS (Goodman et al., 1989a; Goodman et al., 1989b) was modified for the assessment of BDD (Y-BOCS-BDD; Phillips et al., 1997); however, the measure has been criticized for a narrow focus of obsessive compulsive type symptomatology (Rosen & Reiter, 1996).

The majority of current measures that assess for hoarding are based on DSM-IV-TR criteria (APA, 2000), which conceptualized hoarding as a symptom of OCD or a criterion of obsessive-compulsive personality disorder (Frost, Steketee, & Tolin, 2012). Although hoarding subscales exist on some measures of OCD, more recent measures designed specifically for hoarding have been created and may more accurately assess the diagnostic criteria of the disorder. For instance, the Hoarding Rating Scale-Interview (HRS-I; Tolin, Frost, & Steketee, 2010) is a five-item semi-structured clinical interview used to assess compulsive hoarding and related impairment and distress. The HRS-I exhibits excellent reliability, is sensitive to treatment changes, and can distinguish individuals with hoarding from both OCD patients without hoarding and community controls (Tolin et al., 2010). Additionally, the Saving Inventory–Revised (SI-R; Frost, Steketee, & Grisham, 2004) is a 23-item self-report measure that assesses for clutter, difficulty discarding, and excessive acquisition, which exhibits appropriate reliability and validity. For more comprehensive reviews of assessment of hoarding, see Frost et al. (2012) and Frost and Hristova (2011).

Although no gold standard assessment for TTM exists, there are some measures designed to assess for the disorder (Duke et al., 2010). Measures with acceptable psychometric properties include the Massachusetts General Hospital Hairpulling Scale (MGH-HPS; Keuthen et al., 1995; O’Sullivan et al., 1995), a seven-item self-report scale, and the Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A; Flessner, Woods, Franklin, Cashin, & Keuthen, 2008), a 15-item scale that provides two distinct scale scores (i.e., automatic pulling and focused pulling scores).

There does not appear to be an assessment measure yet developed for the DSM-5 diagnosis of ED; however, some measures do assess for factors related to earlier conceptualizations of skin picking. For instance, the Skin Picking Scale (SPS; Keuthen et al., 2001) is a six-item self-report measure modeled after the original Y-BOCS (Goodman et al., 1989a; Goodman et al., 1989b); however, the measure only assesses for severity of skin picking. Further, similar to the MIST-A (Flessner et al., 2008), the Milwaukee Inventory for the Dimensions of Adult Skin Picking (MIDAS; Walther, Flessner, Conelea, & Woods, 2009) is a reliable and valid assessment of automatic and focused skin picking for individuals who engage in the behavior. Even so, assessment of ED is currently lacking due to the recent advent of the disorder in the latest DSM-5. Clinical interviews or self-report measures that assess for the presence of DSM-5 criteria are of particular need.