Obsessive Compulsive Related disorders

OCD Related disorders are a group of conditions which share common symptoms, yet differ in important ways. Accurate diagnosis guides effective treatment. 

• Body Dysmorphic Disorder
• Excoriation Disorder (Skin Picking)
• Hoarding Disorder
• Obsessive Compulsive Disorder
• Trichotillomania

Body Dysmorphic Disorder (BDD) is part of the “Obsessive Compulsive Related Disorders” according to the Diagnostic and Statistical Manual for Mental Disorders-Fifth Edition (DSM-5). BDD is characterized by an intense preoccupation with a particular aspect(s) of physical appearance in a normal appearing person. Although individuals can become preoccupied with any aspect of their appearance, concern with facial features is the most common. Patients may complain, for example, that their nose is too large nose, their hairline is receding, or they have facial blemishes. 

Individuals with BDD often feel a sense of shame or embarrassment about their concerns or worry that others will perceive their behavior as vain. As a result, they often do not reveal their distress and symptoms to others. With the right questions, BDD can be relatively clear to identify. 

BDD is associated with depression, hopelessness, shame, disgust, anger, and anxiety.  Suicidal thoughts are unfortunately common in BDD (up to 80-90% experience thoughts at some point during their illness).  

Many individuals with BDD have a strong belief that their appearance is flawed rather than the concern being a result of a psychological disorder. Often the belief is so strong that it is called an  “overvalued idea," meaning that the belief does not easily change with evidence that contradicts it. Professionals at our Institute have developed an interview based questionnaire (“The Overvalued Ideas Scale”) to evaluate the strength of the belief. High OVI can alter the treatment plan, requiring a slower pace, more cognitive therapy, and motivational interviewing techniques before behavioral therapy (exposure and response prevention) can be successfully implemented. 

BDD is often accompanied by other psychiatric conditions, such as depression and social anxiety. 

Some Common Symptoms of Body Dysmorphic Disorder

• Mirror checking or mirror avoidance 
• Deliberate camouflaging or hiding the perceived defect (e.g. wearing excessive makeup, hats, baggy clothing)
• Comparing self to others (e.g. in magazines, with one’s old photographs, social media)
• Checking appearance in different lightings and settings (selfies using cell phone camera)
• Attempts to improve body part (e.g. skin peels, frequent haircuts, teeth whitening)
• Reassurance Seeking  - questioning family or friends about appearance, with the purpose of seeking reassurance.
• Avoidance of social situations (parties, crowded places, classroom or lecture setting, weddings)
• Avoidance of getting photograph taken
• Avoidance of getting flushed or sweating
• Vacillating between wanting to hide/blend in and the desire to be noticed and complimented
• Skin picking (attempting to remove acne, scars, bumps); often leading to skin irritation, infection
• Repeatedly consulting with medical professionals, such as cosmetic surgeons or dermatologists 

What is Excoriation (Skin-Picking) Disorder?

Excoriation disorder is characterized by recurrent skin picking resulting in mild to severe damage to the skin. It is part of the “Obsessive Compulsive Related Disorders” according to the Diagnostic and Statistical Manual for Mental Disorders-Fifth Edition (DSM-5). Skin picking is one of the “Body Focused Repetitive Behaviors (BFRBs), along with hair pulling, nail biting, skin biting. A large majority of people engage in occasional picking of skin such as cuticles, dry skin, mosquito bites, or a pimple that doesn’t seem to go away. Skin picking, when it turns into a recurrent interfering psychological illness, causes distress, interference in life, and difficulty stopping despite repeated attempts to do so. Distress may be characterized as a feeling of loss of control, embarrassment or shame. Skin picking may be triggered by many different beliefs and feelings. Skin picking may lead to gratification, pleasure, or a sense of relief when the skin area has been picked. Some individuals who pick seek to remove or improve perceived or real imperfections in their skin. When the main focus of skin picking is to improve physical appearance accompanied by a significant distress about one’s looks, then a diagnosis of Body Dysmorphic Disorder may be considered instead. 

What are common symptoms of Excoriation (Skin-Picking) Disorder?

1. Recurrent picking of one's skin

2. Repeated attempts to decrease or stop skin picking. 

3. An urge to pick followed by a sense of relief or gratification after picking.

4. Picking may be triggered by negative emotions such as anxiety, boredom, and restlessness. Positive emotions, such as excitement may also trigger urges to pick. 

5. A sensory sensation in the area, such as tingling, tightening, or itching sensation that triggers the picking. 

6. The picking can occur from any region and may include more than one area. Common sites are the face, arms, hands (including around fingernails), and legs. 

7. Individuals may pick at healthy skin or at minor skin irregularities, such as pimples, calluses, mosquito bites, acne, or at scabs from previous picking. 

8. Individuals may pick with their fingernails, tweezers, pins, or other objects. 

9. In addition to skin picking, there may be skin rubbing, squeezing, lancing, and biting.

10. Individuals may frequently rub hands over certain skin areas to check for irregular texture of skin, such as bumpiness or dryness. Use of the mirror to check may occur also.

11. A belief that skin should be smooth, unflawed, or look a certain way. 

12. A belief that picking will improve or “fix” the skin imperfections. 

13. A feeling of shame and/or embarrassment over the scars/scabs from picking may result in avoidance of certain activities in which the skin would be exposed (swimming, wearing shorts etc.) or hiding the skin with long shirts or pants.

14. Infections and long term scars may occur.

Hoarding disorder is a complex psychological disorder that can significantly disrupt a person’s life. Hoarding is a persistent difficulty discarding possessions due to a perceived need to save and a significant distress at the idea of throwing items out. Often the items may seem of little value to others, but have purpose and meaning to the individual with hoarding. Objects may be acquired actively from excessive shopping or passively, such as newspapers, magazines, grocery bags and other items which naturally enter into a person's daily life. 

The collecting of objects leads to an excessive amount of clutter in the home. Often areas in the home can no longer be used in a functional way, such as the kitchen counters, sink, stove, and kitchen table. Hoarding can range from mild to severe, with milder clutter hidden in private areas of the home. In severe cases, it may be difficult to walk in the home with only narrow pathways to maneuver around and many spaces in the home becoming unusable over time. 

Individuals with hoarding collect things for many reasons:

1. For their sentimental value.  

2. The belief that the item may come of use in the future. 

3.  A belief that the items are unique or special in some way.

4. A desire not to waste and make full use of the item.

5. A feeling of safety and emotional security surrounded by one's possessions.

Hoarding symptoms may also occur within the context of other conditions, such as Attention Deficit Hyperactivity Disorder (ADHD), depression, as well as neurobiological conditions, including Alzheimer’s Disorder and Dementia. Individuals with hoarding may also struggle with organization, decision making, planning, and procrastination.

Hoarding behavior can often lead to other problems, including interpersonal difficulties, family tension, poor self-esteem, difficulty with decision-making skills, occupational issues, and even legal issues. Due to the clutter, it is difficult for the individual to invite family and friends to the home. In addition, there are physical risks, such as falls and fires within the home environment.  

Hoarding vs. Collecting

Common symptoms of hoarding disorder include collecting and saving items that others may think of having none to little value. It is different from an individual who is a collector. A collector takes pride in their collections and typically displays them in an organized way. A collector is typically selective about the items he/she will acquire, thinking about whether buying an additional item to add to the collection will be worthwhile. They will also be comfortable sharing their collection with others. For example, someone who collects antique perfume bottles may have them on a shelf and can tell others some information about their collection. 

Someone who suffers from hoarding, on the other hand, is unable to display or categorize their items. The items are mixed into unorganized piles without the intent to display the items. He/she may be embarrassed by their items and be unable to invite people into their home.  Hoarding disorder also leads to clutter which may take up functional/useful space in the home. Individuals struggling with hoarding disorder may suffer rom depression and social isolation. 

Obsessive Compulsive Disorder (OCD) is a complex neuropsychiatric disorder. It is characterized by persistent, intrusive thoughts called “obsessions” and/or urges to perform certain repetitive strange seeming behaviors called “compulsions.” OCD is not simply a single, identifiable disorder. It is frequently a ‘masked’ disorder, mixed with other symptoms. One can suffer from thoughts alone, the behaviors alone, or both.

Obsessions are  

• Recurrent and persistent thoughts, impulses, or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress.
• The thoughts, impulses, or images are not simply excessive worries about real-life problems.
• The person attempts to ignore or suppress such thoughts, impulses, or images, or to neutralize them with some other thought or action.
• The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion). In other words, the individual does not truly believe in the thought, but is unable to erase it from his/her mind. 

Compulsions are:

• Repetitive "motor" behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession, or according to rules that must be applied rigidly. Mental compulsions are more discreet because they are invisible. 
• The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive.

The Following are Some Common Types of Obsessions:

• Aggressive (e.g. urge to stab, push someone onto railroad tracks)
• Contamination (e.g. germs, sticky substances, household cleaners)
• Morbid (e.g. urge to harm oneself or others, thoughts of death, disease, tragedies)
• Religious (e.g. blasphemous thoughts against God, being possessed by the devil)
• Sexual (e.g. believing one is homosexual, thoughts of having sex with animals)
• Reviewing of conversations (e.g. trying to recall exactly what was said in a discussion)
• Need to know (e.g. pondering over questions that intrude into the mind and are of no relevance to the present functioning of the person)
• Somatic (e.g. being overly concerned with having an illness such as AIDS, over focus on certain bodily functions such as swallowing, breathing)
• Right and wrong (e.g. a need to know when thoughts are right, and if they are wrong, the need to stop doing other activities until one gets the right thought)

The Following are Some Common Types of Compulsions:

Mental Compulsions:

• Counting (e.g. devising games in the mind for sentences, objects, or situations to end up in a certain number or some combination of a favored number)
• List making (e.g. making mental lists of activities, shopping items, trip itineraries, and continuously reviewing or revising them)
• Praying (e.g. saying prayers mechanically and without conviction, engaging in the practice of litanies, or rosary praying, with the aim of accumulating a large quantity of daily prayers without religious finality)

Motor Compulsions:

• Aggressive (e.g. verbal or physical)
• Physiological (e.g. defecating, spitting, drinking, swallowing, eating)
• Movement (e.g. touching, squeezing, jumping, throat clearing, rocking, exercising)
• Cleaning/washing (e.g. excessive showering, handwashing, grooming, housecleaning)
• Checking (e.g. locks, appliances, for accidents while driving, reviewing work to correct mistakes)
• Repeating (e.g. rewriting, rereading, standing up several times until it “feels right”)
• Counting (e.g. similar to an ideational compulsion, but overtly counting and devising number configurations)
• Ordering/arranging (e.g. wanting objects in a certain place and noticing if they are slightly altered, organizing clothes in closet according to color, shape, or size, labeling cupboards)
• Hoarding/collecting (e.g. piling up newspapers, filing articles, keeping junk mail, magazines, saving shopping bags, garbage)
• Need to ask, tell, or confess (e.g. urge to ask for information, providing information that others do not ask for, seeking reassurance, providing information in different ways to make sure that it is understood)
• Retracing (e.g. exiting a room the same way one entered it, driving back on the same streets as one took to get to work, getting into bed the same way as getting out of bed)
• Somatic (e.g. taking one’s pulse or blood pressure continuously, checking body for signs of illness, excessively performing breast examinations)

Trichotillomania is characterized by the repetitive pulling on one’s hair resulting in noticeable hair loss. Patients typically experience an increasing sense on tension immediately before pulling out the hair or when attempting to resist the behavior. Pleasure, gratification or relief is felt upon hair pulling.

What are symptoms of Trichotillomania?

Common symptoms and behaviors of trichotillomania include recurrent pulling out of one’s hair as well as repeated attempts to decrease or stop hair pulling. The pulling can occur from any region and may vary, but common sites are the scalp, eyebrows, eyelashes, pubic region, face, body, and legs. Avoidance of situations in which others might notice the hair loss, such as getting hair cuts or going swimming, is also common. Trichotillomania is often associated with difficulties in family and/or other interpersonal relationships as well as other mental disorders such as depression, and excoriation (skin-picking) disorder. Children/adolescents may begin pulling after experiencing problems with their friends.