VIII.

OBSESSIVE-COMPULSIVE AND RELATED

DISORDERS
● OBSESSIVE-COMPULSIVE DISORDER
- Persistent and recurrent thoughts, urges or images (obsessions)
- Repetitive behaviors and mental acts (compulsions)

● BODY DYSMORPHIC DISORDER

- Preoccupations, behaviors and mental acts about perceived flaws or defects in one’s
physical appearance that are not observable or appear slight to others, and by repetitive
behaviors or mental acts in response to the appearance concerns

● HOARDING DISORDER
- Difficulty discarding or parting with possessions, due to a strong perceived need to save
the items and to distress associated with discarding; possessions clutter living areas
until use is compromised

● TRICHOTILLOMANIA (HAIR-PULLING DISORDER)

- Recurrent pulling out of one’s hair resulting in hair loss, and repeated attempts to
decrease or stop hair pulling

● EXCORIATION (SKIN PICKING) DISORDER

- Recurrent picking of one’s skin resulting in skin lesions and repeated attempts to
decrease or stop skin picking

- The body-focused repetitive behaviors are not triggered by obsessions; however, they
may be preceded or accompanied by various emotional states, such as feelings of
anxiety or boredom, or an increasing sense of tension (urge, “itch”)
- May lead to gratification, pleasure, or a sense of relief when the hair is pulled out or the
skin is picked (powerful negative reinforcement)

OBSESSIVE-COMPULSIVE DISORDER

- Presence of obsessions, compulsions, or both

- OBSESSIONS:
- Recurrent and persistent thoughts, urges or images
- Experienced as intrusive and unwanted
- Cause anxiety or distress
 - The individual attempts to ignore or suppress the thoughts, urges, or images, or
to neutralise them with some other thought or action (compulsion)
- Often appear unreasonable or ridiculous
- Most common dimensions:
- Contamination
- Sexual, aggressive, religious (acceptable/taboo thoughts)
- Symmetry / exactness
- Harm
Contamination:
- Thought that there exist contaminants, such as germs and viruses, present throughout
the environment that can cause harm (being infected, become ill, die)
- Garbage
- Animals
- Public places
- Bodily fluids
- …
- Sympathetic magic beliefs (implausible beliefs about how contagion is transmitted, e.g.,
belief that contaminated objects retain their contagion for an indefinite period of time and
are able to transmit contamination permanently and absolutely)

Sexual, aggressive, religious (unacceptable/taboo thoughts)

- E.g., sexual thoughts about friends, family, or children; thoughts of violent sexual
behavior; thoughts of engaging in homosexual activity, thoughts of sex with animals
- E.g., image of stabbing or pushing one’s child down the stairs; thought of punching a
stranger; thought of hurting or killing one’s self
- E.g., urge to shout blasphemy in a church, thoughts of having inadvertently offended a
deity

Symmetry / exactness
- E.g., urge to have books arranged by size or colour, to write perfectly-shaped letters, to
have pens arranged on one’s desk in the “right” position and in the “right” number, to
perform movements in a symmetrical manner
- May have magical (superstitious) thinking: someone will get hurt if thighs are not “in the
right place”

Harm
- Causing harm to or negligence or carelessness, e.g., image or thought of having hit a
cyclist while driving, thought of one’s own house burning down
- Accompanied by excessive doubt or uncertainty, poor confidence in memory, inflated
sense of responsibility

- COMPULSIONS:
- Repetitive behaviors or mental acts, that the individual feels driven to perform in
response to obsessions or according to rules that must be applied rigidly
 - 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 neutralise or prevent, or are clearly excessive
- May involve complex behavioral rituals
- Viewed as irrational, absurd, illogical
- It is extremely difficult to resist the impulse
- May relieve anxiety, but are not pleasurable !
- Most common:
- Cleaning/washing
- Checking
- Repeating
- Counting
- Ordering/arranging
NB: Compulsive gambling or eating are NOT considered as compulsions, as they are often
associated with pleasant emotions.

- The obsessions or compulsions are time-consuming (e.g., take more that 1 hour a day)
or cause clinically significant distress, or impairment in social, occupational, or other
important areas of functioning

Examples:
- Obsessions of having being contaminated after having been in the same room where someone
sneezed → showering for 3 hours, wash all clothes and home
- Obsession of one’s house on fire (harm) → checking gas stove 35 times
- Obsession of having sinned (religious) → excessive, ritualised praying or confession
- Obsession of pushing a stranger in front of a train (aggressive) → count to 23
- Obsession of stabbing one’s child (aggressive) → repeat “he’s ok” or tap the table 4+4 times
- Obsession of mother ill with cancer (harm) → arrange books by colour

- See themselves as “ugly” or even “disfigured” or monstrous

- Women focus on skin, hair, legs, breast
- Perceived deficits in more than one body part (e.g., nose, eyes)
- The preoccupations are intrusive, unwanted, time-consuming
- Average time spent thinking about their appearance is 3-8 hours per day; ¼
spend more than 8 hours a day
- Individuals report having only limited control or no control over their concerns
- It is possible to specify if:
- With muscle dysmorphia
- The individual is preoccupied with the idea that his or her body build is too
small or insufficiently muscular. The 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 not be true
- With poor insight: The individual thinks that the body dysmorphic disorder
beliefs are probably true
- With absent insight/delusional beliefs: The individual is completely
convinced that the body dysmorphic disorder beliefs are true
- About ⅓-½ of individuals with body dysmorphic disorder have poor-absent insight
- Respond to SSRI monotherapy as robustly as BDD patients with
nondelusional concerns
- Preoccupation is not limited to weight or body shape
- Onset in late adolescence (mean age 16-17 years)
- Mostly gradual, evolving from subclinical concerns (12-13 years)
- Tends to become chronic if not treated
- Slightly higher prevalence among women
- Lifetime prevalence is about 2% in general population; 5-7% of individuals who undergo
cosmetic medical treatment/plastic surgery
- About 20% attempt suicide
- May be unable to work and housebound
- Almost all affected individuals have a comorbid mental disorder
- Major depressive disorder (about ⅓ of individuals with BDD)
- OCD (about ⅓ of individuals with BDD)
- Social anxiety
- Substance use
- Personality disorders

Causes of Body Dysmorphic Disorder: behavioral and cognitive factors

● Focus on details of physical aspect
○ Affected individuals can accurately see and process their physical features (not a
problem of perception, but focus on a certain body aspect)
○ Focus on details, do not consider the whole
○ Distorted beliefs about the importance of aspect (e.g., self-worth depends
exclusively on appearance)

HOARDING DISORDER

Persistent difficulty discarding or parting with obsessions, regardless of their actual

value.
- This difficulty is due to a perceived need to save the items and to distress
associated with discarding them
- 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)
- The hoarding cases clinically significant distress or impairment in social,
occupational, or other important areas of functioning (including maintaining a
safe environment for self and others)
- Most objects (but not necessarily all) are worthless and are not needed
- Most commonly saved items are newspapers, magazines, odd clothing, bags,
books, mail, paperwork
- Strong resistance to efforts to get rid of possessions (selling, giving away,
throwing away, recycling)
- Perceived utility or aesthetic value of the items or strong sentimental attachment
to the possessions; fear of losing important information
- Hoarding is not just collecting (which is systematic and organised)
- It is possible to specify:
- With excessive acquisition: if difficulty discarding possessions is
accompanied by excessive acquisition of items that are not needed or for
which there is no available space
- Approximately 80-90% of individuals with hoarding disorder
display excessive acquisition (excessive buying, acquisition of free
items, stealing)
- With good or fair insight: the individual recognizes that hoarding-related
beliefs and behaviors (pertaining to difficulty discarding items, clutter, or
excessive acquisition are problematic)
- With poor insight: the individual is mostly convinced that hoarding-related
beliefs and behaviors are not problematic despite evidence to the
contrary
- With absent insight/delusional beliefs: the individual is completely
convinced that hoarding-related beliefs and behaviors are not problematic
despite evidence to the contrary
- About 66% of affected individuals are not aware of the severity of their condition
- About ¼ meet the diagnostic criteria for OCD
- Severe consequences:
- Living conditions below decency standards
- Negative impact on interpersonal relationships
- Poor physical health
- Many become unable to work
- About 10% are threatened with eviction
- Usually begins in childhood or early adolescence (ages 11-15)
- Progressively increasing severity, clinically significant impairment by the
mid-30s
- Lifetime prevalence is about 1.5-5%
 - Chronic course
- Equally common among men and women
- Almost three times more prevalent in older adults (age 55+ years) compared with
younger adults (35-45 years)
- About 75% of individuals with hoarding disorder have a comorbid mood or
anxiety disorder (about 50% have major depressive disorder)
- About ⅓ hoard animals (that often do not receive proper care) in addition to
inanimate objects

Causes of Obsessive-compulsive disorders

● Evolutionary point of view
○ Adaptive to stockpile vital resources for times when supplies are scarce
○ Animal models of hoarding behaviour can offer insights into the brain regions
associated with hoarding
● Cognitive behavioral factors
○ Poor organizational abilities (attention and classification problems, poor decision-
making abilities)
○ Unusual beliefs about possessions and their importance
■ Responsibility, comfort, objects as a core of identity
○ Avoidance behaviours
■ Anxiety generalized by the idea of getting rid of objects leads to avoid
organising the chaos
● Neurobiological factors
○ Hyperactivity of some brain areas/networks
■ Orbitofrontal cortex
■ Anterior cingulate
■ Caudate nucleus
■ Cortico-striatal-thalamic-cortical model
● Genetic factors
○ 30-50% of variance is accounted for by genetic factors
○ Shared genetic vulnerability
■ Individuals with body dysmorphic disorder and hoarding disorder often
have a family history of OCD
■ OCD is associated with multiple genes, with most having a modest
association with OCD and each making small, incremental contributions
to the risk of developing the disorder
● Serotonin-related polymorphisms (5-HTTLPR and HTR2A)
● In males only, polymorphisms involved in catecholamine
modulation (COMT and MAO-A)
● Dopamine? Glutamate?

Treatment for OCD and related disorders

● Medications
○ Antidepressants
 ■ SSRIs and clomipramine (tricyclic)
■ Significant improvement is observed after 6-12 weeks
■ 30-50% do not show clinically significant improvement
■ High relapse rates when medication is discontinued
■ Most individuals continue to experience mild symptoms during treatment

Exposure and response prevention (ERP)

○ Developed for OCD and adapted for body dysmorphic disorder and hoarding
disorder
○ Exposure hierarchy approach
■ E.g., lowest: walk into a public restroom; middle: touch pedestrian
crossing button; highest: touch a public restroom door handle without
washing
○ Refrain from engaging in compulsions
○ Not performing the ritual exposes the person to the full force of anxiety provoked
by the stimulus, and to its natural dissipation
○ Exposure results in the extinction of the conditioned response (anxiety)
○ ERP is highly effective for both adult patients and children/adolescents (¾ show
significant improvement)
○ Improvement is maintained at follow-ups
○ More effective than medication
○ Remission is rarely complete: mild symptoms often persist
○ About 25% of clients refuse ERP treatment

ERP for body dysmorphic disorder

● Exposure may involve interacting with people who could be critical of their appearance,
or wearing clothes that highlight the perceived defect
● Clients are required to refrain from engaging in self-reassuring activities (e.g., looking at
mirrors)
● Supplements with cognitive restructuring (challenge the belief that self-worth depends on
appearance)
● 50-80% of patients improve significantly
● Long-term effectiveness

ERP for hoarding disorder

● Exposure involves getting rid of objects
● Clients are required to refrain from engaging in rituals that reduce anxiety (e.g., counting
objects)
● Importance of facilitating insight to promote change
● In-home visits (in vivo exercises)

Cognitive therapy
● Challenging beliefs about anticipated consequences of not engaging in
compulsions, and challenging exaggerated sense of responsibility
 ● Usually also involves exposure
● Effectiveness similar to ERP’s

Deep brain stimulation

● For severe, refractory OCD (about 10% of patients)
● Goal: to modulate abnormal activity and synaptic connectivity in circuits involving
the Orbitofrontal cortex (OFC), anterior cingulate cortex (ACC) and striatum
● Nucleus accumbens, subthalamic nucleus (modulator of basal ganglia)