1. Chapter 8: Obsessive-Compulsive and Related Disorders

2. Obsessive-Compulsive and related disorders include obsessive-compulsive disorder (OCD), body dysmorphic disorder, hoarding disorder, trichotillomania (hairpulling disorder), excoriation (skin-picking) disorder, substance/medication-induced obsessive- compulsive and related disorder, obsessive-compulsive and related disorder due to another medical condition, and other specified obsessive-compulsive and related disorder and unspecified obsessive-compulsive and related disorder (e.g., body-focused repetitive behavior disorder, obsessional jealousy).

3. OCD is characterized by the presence of obsessions and/or compulsions.
Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, whereas compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.

4. Examples:
a. Endless hand washing.
b. Checking re-checking doors if they're locked.
c. Elaborate dressing rituals.
-The patient is trying to resist this, but because of long period of disorder, resistance may decrease.
-As a result, The patient will have much difficulties in social relationship.
-The patient is neurotic (because the patient believes that these ideas are not true and silly).

5. Obsession compulsion: repetitive acts or rituals to release tension or relieve anxiety.
-The patient carries out these acts even if he recognizes that they are inappropriate or foolish.
Some other obsessive-compulsive and related disorders are also characterized by preoccupations and by repetitive behaviors or mental acts in response to the preoccupations. Other obsessive-compulsive and related disorders are characterized primarily by recurrent body-focused repetitive behaviors (e.g., hair pulling, skin picking) and repeated attempts to decrease or stop the behaviors.

6. Obsessive-Compulsive Disorder Diagnostic Criteria
Obsessions are defined by (1) and (2):
1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
Compulsions are defined by (1) and (2):

7. 1. Repetitive behaviors (e. g
1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.

8. Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
D. The disturbance is not better explained by the symptoms of another mental disorder.

9. Specify if:
With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks obsessive-compulsive disorder beliefs are
probably true.
With absent insight/delusional beliefs: The individual is completely convinced that
obsessive-compulsive disorder beliefs are true.

10. Prevalence
The 12-month prevalence of OCD in the United States is 1.2%, with a similar prevalence internationally (1.1%-1.8%). Females are affected at a shghtly higher rate than males in adulthood, although males are more commonly affected in childhood

11. Development and Course -Usually starts in adolescence.
-Chronic disorder and the patient may not present to psychiatrist for years.
-About 30% of patients: good improvement, 30-40%: mild
improvement, and the rest: chronic or worse.
-Some patients may have depression, suicide or addiction.

12. Risk and Prognostic Factors
Temperamental. Greater internalizing symptoms, higher negative emotionality, and behavioral inhibition in childhood are possible temperamental risk factors.
Environmental. Physical and sexual abuse in childhood and other stressful or traumatic events have been associated with an increased risk for developing OCD.
Genetic and physiological. The rate of OCD among first-degree relatives of adults with OCD is approximately two times that among first-degree relatives of those without the disorder; however, among first-degree relatives of individuals with onset of OCD in childhood or adolescence, the rate is increased 10-fold. Familial transmission is due in part to genetic factors (e.g., a concordance rate of 0.57 for monozygotic vs for dizygotic twins).

13. Suicide Risk
Suicidal thoughts occur at some point in as many as about half of individuals with OCD. Suicide attempts are also reported in up to one-quarter of individuals with OCD; the presence of comorbid major depressive disorder increases the risk.

14. Treatment:
1-Drugs:
-Anfranil (Clomipramin): Drug of choice (6-12months).
2-Behavioral therapy:
-Effective in 60-70% of patients (may be treatment of choice).
-Techniques used: Desensitization, thought stopping, flooding and implosion therapy.
Aversive conditioning: means giving a painful shock or loud noise when thought occurs.
-Some use response preventing as: forcibly stopping the patient from responding to obsession.
3-Psychodynamic psychoanalytic therapy:
-Aims to help the patient get insight into his aggressive impulses and strengthens ego to deal with aggression in mature ways.

15. Body Dysmorphic Disorder
Body dysmorphic disorder is characterized by preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear only slight to others, and by repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (e.g., comparing one's appearance with that of other people) in response to the appearance concerns.

16. Diagnostic Criteria
A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

17. Specify if:
With muscle dysmorphia: The individual is preoccupied with the idea that his or her
body build is too small or insufficiently muscular. This specifier is used even if the individual is preoccupied with other body areas, which is often the case.
Indicate degree of insight regarding body dysmorphic disorder beliefs (e.g., “I look ugly” or “I look deformed”).
With good or fair insight: The individual recognizes that the body dysmorphic disorder beliefs are definitely or probably not true or that they may or may not be true.
With poor insight: The individual thinks that the body dysmorphic disorder beliefs are probably true.
With absent insight/delusionai beliefs: The individual is completely convinced that the body dysmorphic disorder beliefs are true.

18. Development and Course
The mean age at disorder onset is years, the median age at onset is 15 years, and the most common age at onset is years. Two-thirds of individuals have disorder onset before age 18.
-Complication: Plastic surgeries without any need.

19. Risk and Prognostic Factors
Environmental. " Body dysmorphic disorder has been associated with high rates of childhood neglect and abuse.
Genetic and physiological. The prevalence of body dysmorphic disorder is elevated in first-degree relatives of individuals with obsessive-compulsive disorder (OCD).
Suicide Risk
Rates of suicidal ideation and suicide attempts are high in both adults and children/adolescents with body dysmorphic disorder.

20. Comorbidity
Major depressive disorder is the most common comorbid disorder, with onset usually after that of body dysmorphic disorder. Comorbid social anxiety disorder (social phobia), OCD, and substance-related disorders are also common.
Treatment:
-Patients refuse psychotherapy despite their severe suffering and insist on having plastic surgeries so it is important for plastic surgeon to refer them to psychiatrist or psychologist.
-Meds. may relief symptoms (anti-anxiety, anti-depression).
-Long-term psychotherapy is recommended.

21. Hoarding Disorder
Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value, as a result of a strong perceived need to save the items and to distress associated with discarding them. Hoarding disorder differs from normal collecting

22. Diagnostic Criteria
A. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
B. This difficulty is due to a perceived need to save the items and to distress associated with discarding them.
C. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).
D. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

23. E. The hoarding is not attributable to another medical condition (e. g
E. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).
F. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).

24. Risk and Prognostic Factors
Temperamental. Indecisiveness is a prominent feature of individuals with hoarding disorder and their first-degree relatives.
Environmental. Individuals with hoarding disorder often retrospectively report stressful and traumatic life events preceding the onset of the disorder or causing an exacerbation.
Genetic and physiological. Hoarding behavior is familial, with about 50% of individuals who hoard reporting having a relative who also hoards. Twin studies indicate that approximately 50% of the variability in hoarding behavior is attributable to additive genetic factors.

25. Comorbidity
Approximately 75% of individuals with hoarding disorder have a comorbid mood or anxiety disorder. The most common comorbid conditions are major depressive disorder (up to 50% of cases), social anxiety disorder (social phobia), and generalized anxiety disorder.
Approximately 20% of individuals with hoarding disorder also have symptoms that meet diagnostic criteria for OCD.

26. Trichotillomania (Hair-Pulling Disorder)
Trichotillomania (hair-pulling disorder) is characterized by recurrent pulling out of
one's hair resulting in hair loss, and repeated attempts to decrease or stop hair pulling.
Excoriation (skin-picking) disorder is characterized by recurrent picking of one's skin resulting in skin lesions and repeated attempts to decrease or stop skin picking. The body focused repetitive behaviors that characterize these two disorders are not triggered by obsessions or preoccupations; however, they may be preceded or accompanied by various emotional states, such as feelings of anxiety or boredom.

27. Diagnostic Criteria
A. Recurrent pulling out of one’s hair, resulting in hair loss.
B. Repeated attempts to decrease or stop hair pulling.
C. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition).
E. The hair pulling is not better explained by the symptoms of another mental disorder
(e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder).

28. Prevalence
In the general population, the 12-month prevalence estimate for trichotillomania in adults and adolescents is l%-2%. Females are more frequently affected than males, at a ratio of approximately 10:1.
Development and Course
Hair pulling may be seen in infants, and this behavior typically resolves during early development.
Onset of hair pulling in trichotillomania most commonly coincides with, or follows the onset of, puberty. Sites of hair pulling may vary over time. The usual course of trichotillomania is chronic, with some waxing and waning if the disorder is untreated. Symptoms may possibly worsen in females accompanying hormonal changes (e.g., menstruation, perimenopause).
For some individuals, the disorder may come and go for weeks, months, or years at a time. A minority of individuals remit without subsequent relapse within a few years of onset.

29. Risk and Prognostic Factors
Genetic and physiological. There is evidence for a genetic vulnerability to trichotillomania.
The disorder is more common in individuals with obsessive-compulsive disorder (OCD) and their first-degree relatives than in the general population.
Comorbidity
Trichotillomania is often accompanied by other mental disorders, most commonly major depressive disorder and excoriation (skin-picking) disorder.

30. Treatment
-Anti-anxiety, anti-depression or anti-psychotic.
-Behavioral therapy (Biofeedback).
-Individual or group psychotherapy.

31. Excoriation (Skin-Picking) Disorder Diagnostic Criteria
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
D. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies).
E. The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury).

32. Prevalence
In the general population, the lifetime prevalence for excoriation disorder in adults is 1.4% or somewhat higher. Three-quarters or more of individuals with the disorder are female.
Risk and Prognostic Factors
Genetic and physiological. Excoriation disorder is more common in individuals with obsessive-compulsive disorder (OCD) and their first-degree family members than in the general population.

33. Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
Substance/medication-induced obsessive-compulsive and related disorder consists of symptoms that are due to substance intoxication or withdrawal or to a medication. Diagnostic Criteria A. Obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of the obsessive-compulsive and related disorders predominate in the clinical picture. B. There is evidence from the history, physical examination, or laboratory findings of both (1)and (2): 1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication. 2. The involved substance/medication is capable of producing the symptoms in Criterion A.

34. C. The disturbance is not better explained by an obsessive-compulsive and related disorder that is not substance/medication-induced. Such evidence of an independent obsessive- compulsive and related disorder could include the following:
The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non-substance/medication-induced obsessive-compulsive and related disorder (e.g., a history of recurrent non-substance/medicationrelated episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturiiance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

35. Specify if:
With onset during intoxication: If the criteria are met for intoxication with the substance and the symptoms develop during intoxication.
With onset during withdrawal: If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal.
with onset after medication use: Symptoms may appear either at initiation of medication or after a modification or change in use.

36. Obsessive-Compulsive and Related Disorder Due to Another Medical Condition
Obsessive- compulsive and related disorder due to another medical condition involves symptoms characteristic of obsessive-compulsive and related disorders that are the direct pathophysiological consequence of a medical disorder.
Diagnostic Criteria
A. Obsessions, compulsions, preoccupations with appearance, hoarding, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of obsessive-compulsive and related disorder predominate in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.

37. C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

38. Other Specified Obsessive-Compulsive and Related Disorder
Other specified obsessive-compulsive and related disorder and unspecified obsessive-compulsive and related disorder consist of symptoms that do not meet criteria for a specific obsessive-compulsive and related disorder because of atypical presentation or uncertain etiology
This category applies to presentations in which symptoms characteristic of an obsessive compulsive and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the obsessive-compulsive and related disorders diagnostic class. The other specified obsessive-compulsive and related disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific obsessive-compulsive and related disorder.

39. Unspecified Obsessive-Compulsive and Related Disorder
This category applies to presentations in which symptoms characteristic of an obsessive compulsive and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the obsessive-compulsive and related disorders diagnostic class. The unspecified obsessive-compulsive and related disorder category is used in situations in which the clinician chooses not to specify the reason that the criteria are not met for a specific obsessive-compulsive and related disorder, and includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).