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i
ADVANCE PRAISE FOR COMPLEXITIES

IN OBSESSIVE-C OMPULSIVE
AND RELATED DISORDERS
“Dr. Storch and colleagues and all of the chapter authors have given us an amazing overview of the
relationship OCD has to other conditions, how it is best treated outside of the standard one-on-one
session, and what we have to look forward to in the future of OCD and Related Disorders Care.
This book is a welcome addition to the library of anyone treating OCD and Related Disorders, and
will likely be dog-eared from continued use as a reference both in and out of sessions.”
—Patrick B. McGrath, PhD, Head of Clinical Services, NOCD
“This is an exceptional and much-needed compilation, compulsory for anyone wishing to keep
abreast of the most recent advances in the field of OCD and related disorders. The authors suc-
cessfully synthesize emerging research and concepts into practical treatment implications and
recommendations, no small feat given the complexity of the data and the disorders.”
—Rachel A. Davis, MD, Associate Professor of Psychiatry and
Vice Chair for Clinical Affairs, Medical Director, OCD and
Neuromodulation Programs, University of Colorado
Anschutz Medical Campus
“Complexity is part and parcel of the clinical expression of OCD and related disorders. This text
is a must-read for clinicians, researchers, and students alike who will work with these patients in
practice or in research settings and presents latest innovations in treatment science and practice.
Storch, Abramowitz and McKay, world leading authorities in the field of OCRDs, have compiled
the most comprehensive volume to date on this topic, delivering novel, practical solutions to com-
plex clinical issues.”
—Lara J. Farrell, PhD, Associate Professor,
School of Applied Psychology, Griffith University, Australia
“For a clinician with extensive experience in treating complex cases of OCD, this book is a treat. It
offers a timely and indispensable road map for the complex and changing landscape of OCRD and
its borderlands. Offering new insight for experienced clinicians and a comprehensive overview for
researchers and students at once is simply brilliant.”
—Bernhard Weidle, MD, PhD,
Norwegian University of Science and Technology
“Storch, Abramowitz, and McKay have teamed up with a host of excellent clinical researchers
to assemble a truly comprehensive collection of chapters that explain OCD and multiple related
disorders. The authors do a fine job of pointing out the similarities and differences among these de-
bilitating conditions and pointing to the clinical implications of the research findings. Well done!”
—Gail Steketee, PhD,
Professor and Dean Emerita, Boston University
“A much-needed and invaluable compendium that expertly fills a gap in the literature. Unique and
impressive in its scope, this one-stop reference guide provides excellent coverage of key issues,
nuances and challenges in a murky field of complex conditions. A ‘must-have’ for the clinician’s
bookshelf.”
—Aureen Pinto Wagner, PhD, Director,
The Anxiety Wellness Center, Cary, NC
ii
“This is a must-have resource for any clinician, researcher, educator, and trainee working with
Obsessive-Compulsive or related disorders (OCRDs). Authored by a who’s who of leading author-
ities, this book brings much needed clarity to the DSM-5 conceptualization of OCRDs through
careful description of the unique and overlapping clinical features and highly pragmatic as-
sessment and treatment guidelines for over a dozen, often poorly understood, yet surprisingly
common, OCD-related clinical presentations, including hoarding, body dysmorphia, hairpulling,
skinpicking, sensory intolerance, Tourette’s disorder, as well as OCD complicated by trauma, sub-
stance use, and autism.”
—John Piacentini, PhD, ABPP, Director, UCLA Child OCD,
Anxiety and Tic Disorders Program and Center for Child
Anxiety, Resilience, Education and Support (CARES)
“Hurrah! The formidable trio of Storch, Abramowitz and McKay have done it again! This book
provides an engaging up-to-date resource by leading global experts on Obsessive-Compulsive and
Related Disorders. It seamlessly incorporates advances in science that inform best practices for
assessment and management of these disorders. With pearls of wisdom throughout, this book
deserves to be front and center in bookshelves of everyone working with OCRD.”
—S. Evelyn Stewart, MD, Professor of Psychiatry,
University of British Columbia, Scientific & Clinical
Advisory Board Member, International OCD Foundation,
Founding Director-British Columbia Children’s
Hospital Provincial OCD Program
“Organized by three of the most prolific scholars from the field of obsessive-compulsive and related
disorders, this paragon of knowledge brings together basic concepts and complex problems into an
undisputable masterpiece. It is an essential item in the bookshelf of any mental health clinician.”
—Prof. Leonardo F. Fontenelle, MD, PhD, Federal University of
Rio de Janeiro, Brazil, Monash University, Australia
“As a clinician who specializes in the treatment of OCD and related disorders, I often feel as if I am
one unanswered question away from dramatically reducing someone’s suffering. People with these
conditions rarely fit perfectly into one simple category for which a manual would spell out the
whole treatment approach. Storch, Abramowitz, and McKay, to whom I have grown accustomed
turning to for answers, have pulled together the most comprehensive collection of studies possible
in Complexities in Obsessive-Compulsive and Related Disorders. This will be the first place I look
when I think ‘what about . . . ?’ and it will be required reading for anyone I train.”
—Jon Hershfield, MFT, Director of the Center
for OCD and Anxiety at Sheppard Pratt
“Creation of a new diagnostic category called Obsessive-Compulsive Related Disorders (OCRD)
was based, in part, on the premise that a group of disorders characterized by compulsive-like be-
havior might share common biological underpinnings and respond similarly to treatment. Perhaps
hair pulling, skin picking, checking for physical deformities, and hoarding possessions are be-
havioral variants of some common mechanism that also drives the hand washing and door-lock
checking characteristic of OCD. In fact, the extent to which these disorders share anything more
than topography is still unknown and the implications for treatment and prevention have yet to be
determined. That is why this book is so timely. Storch, Abramowitz, and McKay have assembled
an all-star cast to tackle the subject. Clinicians take note, this is not an ivory tower compilation in-
tended only for scientific investigators. This book provides highly useful clinical information that
can inform the implementation of treatment. Descendants of Copernicus may someday discover
OCD is not the center of the OCRD universe, but, for now, it provides a practical theme for a book
that will enlighten readers about clinical conditions the editors rightly contend have been ‘misun-
derstood, misdiagnosed, and mistreated.’ ”
—C. Alec Pollard, PhD, Director, Center for OCD & Anxiety-Related
Disorders, Saint Louis Behavioral Medicine Institute,
Professor Emeritus of Family and Community Medicine,
Saint Louis University School of Medicine
iii
Complexities in Obsessive-
Compulsive and Related
Disorders
Advances in Conceptualization
and Treatment
EDITED BY ERIC A. STORCH,
J O N AT H A N S . A B R A M O W I T Z ,
AND
D E A N M C K AY
1
iv
1
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the University’s objective of excellence in research, scholarship, and education
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Published in the United States of America by Oxford University Press

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© Oxford University Press 2022
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You must not circulate this work in any other form

and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data

Names: Storch, Eric A., editor. | Abramowitz, Jonathan S., editor. |
McKay, Dean, 1966– editor.
Title: Complexities in obsessive-compulsive and related disorders :
advances in conceptualization and treatment /
[edited by] Eric A. Storch, Jonathan S. Abramowitz, and Dean McKay.
Description: New York, NY : Oxford University Press, [2022] |
Includes bibliographical references and index.
Identifiers: LCCN 2021016363 (print) | LCCN 2021016364 (ebook) |
ISBN 9780190052775 (hardback) | ISBN 9780190052799 (epub) | ISBN 9780190052805
Subjects: LCSH: Compulsive behavior. | Obsessive-compulsive disorder.
Classification: LCC RC533 .C658 2022 (print) |
LCC RC533 (ebook) | DDC 616.85/227—dc23
LC record available at https://lccn.loc.gov/2021016363
LC ebook record available at https://lccn.loc.gov/2021016364
DOI: 10.1093/med-psych/9780190052775.001.0001
9 8 7 6 5 4 3 2 1
Printed by Integrated Books International, United States of America

v
To Ellie, Noah, Maya, and Jill for their love and being life co-pilots.
EAS
To Stacy, Emily, and Miriam with all my love.

JA
To my loving wife Dawn, and our wonderful daughter Rebecca.

DM
vi
vi
CONTENTS
Contributors ix
1. Introduction: What Is Obsessive-Compulsive Disorder? What Is Not? And
Why This Book? 1
Jonathan S. Abramowitz, Dean McKay, and Eric A. Storch
2. Body Dysmorphic Disorder 15
Sophie C. Schneider, Amita Jassi, Lauren Peile, D. Luis Ordaz,
and Eric A. Storch
3. Hair-Pulling Disorder 32
Kara N. Kelley, Devin Dattolico, Caroline Strang, and Martha J. Falkenstein
4. Excoriation Disorder 44
Hae-Joon Kim, Kelsey L. Luks, Ana Rabasco, Justyna Jurska, and
Margaret Andover
5. Hoarding Disorder 63
Blaise Worden and David F. Tolin
6. Misophonia: An Obsessive-Compulsive Disorder? 87
Lisa Clark and Dean McKay
7. Orthorexia Nervosa and the Use of Exposure and Response Prevention to
Treat Eating-Related Obsessions and Compulsions 103
Hana F. Zickgraf
8. Sensory Processing and Intolerance in Obsessive-Compulsive Disorder 125
Katherine A. Collins, Stephanie J. Grimaldi, and Emily R. Stern
9. Incompleteness, Not Just Right Experiences, and Reward Sensitivity in
Obsessive-Compulsive Disorder 142
Charlene Minaya and Dean McKay
10. The Hunt for “Perfect” Jolly Green (Cannabis): Examining the
Complex Relationship Between Obsessive-Compulsive Disorder
and Substance Use 155
Charlene Minaya and Dean McKay
11. Stress, Trauma, and Obsessive-Compulsive and Related Disorders 173
Jennifer Forte, Christal L. Badour, C. Alex Brake, Jordyn M. Tipsword, and
Thomas G. Adams, Jr.
vi
viii Contents
12. Tourette’s Disorder 201

Kesley Ramsey and Joseph F. McGuire
13. Pediatric Acute-Onset Neuropsychiatric Syndrome: Diagnostic
and Therapeutic Considerations with Abrupt-Onset Obsessive-
Compulsive Disorder 231
Kirti Saxena, Sherin Kurian, Johanna Saxena, and Eyal Muscal
14. Perinatal and Postpartum Obsessive-Compulsive Disorder 249
Nichole Fairbrother, Fiona L. Challacombe, Fanie Collardeau, and
Thanh Thuy Truong
15. The Inhibitory Learning Approach to Exposure and Response
Prevention for Obsessive-Compulsive Disorder 270
Samantha N. Hellberg, Heidi J. Ojalehto, Jennifer L. Buchholz, and
Jonathan S. Abramowitz
16. Childhood Obsessive-Compulsive and Related Disorders 285
Andrew G. Guzick, Sophie C. Schneider, and Eric A. Storch
17. Technology-Based Psychotherapies for Obsessive-Compulsive Disorder 311
Terri L. Fletcher, Anthony H. Ecker, Derrecka M. Boykin, Darius B. Dawson,
Fenan Rassu, and Natalie E. Hundt
18. Co-occurrence of Obsessive-Compulsive Disorder and Autism Spectrum
Disorder: Differentiation, Assessment, and Treatment 332
Saashi A. Bedford, Michelle Hunsche, and Connor M. Kerns
19. Acceptance and Commitment Therapy for Obsessive-Compulsive and
Related Disorders 352
Jennifer Krafft, Julie M. Petersen, and Michael P. Twohig
20. Couple-Based Cognitive-Behavioral Therapy for Obsessive-Compulsive
Disorder 370
Jennifer L. Buchholz, Jonathan S. Abramowitz, Samantha N. Hellberg, and
Heidi J. Ojalehto
21. Advances in Treating Obsessive-Compulsive Related Disorders Other than
OCD? 384
Abel S. Mathew, Ivar Snorrason, Martha J. Falkenstein, and Han-Joo Lee
22. Distress Tolerance 407
Shannon M. Blakey and Megan K. Lanier
23. Prevention of Obsessive-Compulsive Disorder 424
Shiu F. Wong, John H. Riskind, and Frederick Aardema
Index 443
x
x Contributors
Natalie E. Hundt, PhD Heidi J. Ojalehto, BS

Michael E. DeBakey VA University of North Carolina at
Medical Center Chapel Hill
Michelle Hunsche, MA D. Luis Ordaz, PhD
University of British Columbia Baylor College of Medicine
Amita Jassi, BSc, DClinPsy Lauren Peile, DClinPsych, BSc (Hons)
South London and Maudsley Psychology
NHS Trust South London and Maudsley
NHS Trust
Justyna Jurska, MA
Fordham University Julie M. Petersen, MS
Utah State University
Kara N. Kelley, BA
American University Ana Rabasco, MA
Fordham University
Connor M. Kerns, PhD
University of British Columbia Kesley Ramsey, PhD
Johns Hopkins University School of
Hae-Joon Kim, MA
Medicine
Fordham University
Fenan Rassu, PhD
Jennifer Krafft, MS
Utah State University
Medicine
Sherin Kurian, PhD
John H. Riskind, PhD
Baylor College of Medicine
George Mason University
Megan K. Lanier, BS
Johanna Saxena, BS, BA
Duke University
Han-Joo Lee, PhD
Kirti Saxena, MD
University of Wisconsin-Milwaukee
Kelsey L. Luks, MS
Sophie C. Schneider, PhD
Fordham University
Abel S. Mathew, MS
Ivar Snorrason, PhD
University of Wisconsin-Milwaukee
Massachusetts General Hospital
Joseph F. McGuire, PhD
Emily R. Stern, PhD
New York University School of
Medicine
Medicine
Dean McKay, PhD
Eric A. Storch, PhD
Fordham University
Charlene Minaya, BA
Caroline Strang, PhD
Fordham University
Scripps College
Eyal Muscal, MD, MS
Jordyn M. Tipsword, MS
University of Kentucky
xi
Contributorsxi
David F. Tolin, PhD Shiu F. Wong, PhD

The Institute of Living Concordia University
Thanh Thuy Truong, MD Blaise Worden, PhD
Baylor College of Medicine Institute of Living/Hartford Hospital
Michael P. Twohig, PhD Hana F. Zickgraf, PhD
Utah State University University of South Alabama
ix
CONTRIBUTORS
Frederick Aardema, PhD Fanie Collardeau, MSc, PhD

University of Montreal Candidate
University of Victoria
Jonathan S. Abramowitz, PhD
UNC-Chapel Hill Katherine A. Collins, MSW, PhD
Nathan S. Kline Institute for
Thomas G. Adams, Jr., PhD
Psychiatric Research
Devin Dattolico, BS
Margaret Andover, PhD
McLean Hospital
Fordham University
Darius B. Dawson, PhD
Christal L. Badour, PhD
Anthony H. Ecker, PhD
Saashi A. Bedford, MSc
University of British Columbia
Nichole Fairbrother, PhD
Shannon M. Blakey, PhD
University of British Columbia
Durham VA Health Care System
Martha J. Falkenstein, PhD
Derrecka M. Boykin, PhD
McLean Hospital/Harvard
Medical School
C. Alex Brake, PhD
Terri L. Fletcher, PhD
Warren Alpert Medical School of
Brown University
Jennifer Forte, BA
Jennifer L. Buchholz, MA
Binghamton University
University of North Carolina at
Chapel Hill Stephanie J. Grimaldi, MA
Hofstra University
Fiona L. Challacombe, PhD,
DClinPsy Andrew G. Guzick, PhD
King’s College London Baylor College of Medicine
Lisa Clark, BS Samantha N. Hellberg, BA
Fordham University UNC Chapel Hill
xi
1
Introduction
What Is Obsessive-Compulsive Disorder? What Is Not?
And Why This Book?
J O N AT H A N S . A B R A M O W I T Z , D E A N M C K AY, A N D
ERIC A. STORCH ■
Obsessive-compulsive disorder (OCD) was once considered a rare and untreat-

able condition (Kringlen, 1965). Over the past half-century, however, a dramatic
surge in clinical research has led not only to a clearer understanding of this
problem but also to the realization that it is fairly common, afflicting up to about
3% of the population (i.e., Adam et al., 2012; Ruscio et al., 2010). Further, research
has shown that those with OCD have high rates of disability and occupational
and social role dysfunction (Markarian et al., 2010). When the prevalence and
functional impairment are considered together with the anxiety and distress that
individuals with OCD experience, one recognizes that this condition represents a
significant public health concern. With this in mind, the present volume focuses
on advances and emerging clinical implications in the field of OCD and related
disorders with respect to assessment, treatment, treatment augmentation, and
basic science.
WHAT IS OCD?
OCD is classified in the DSM-5 (American Psychiatric Association, 2013) as an

obsessive-compulsive and related disorder (OCRD) and characterized by obsessions
or compulsions. Obsessions are persistent intrusive thoughts, ideas, images, or
doubts that are experienced as senseless or unacceptable (e.g., the idea that one
could murder loved ones in their sleep). Such intrusions evoke subjective distress
2
2 C omple x ities in O C R D s
in the form of fear, doubt, or guilt and are not simply everyday worries about
work, relationships, or finances. Although highly person-specific, obsessions usu-
ally focus on the following general themes: aggression and violence, responsibility
for harm or mistakes, contamination, sex, religion, the need for exactness or com-
pleteness, and concerns about serious illnesses. Most people with OCD report
multiple types of obsessions.
Because individuals with OCD perceive their obsessions as unpleasant and
unwanted, they attempt to control these thoughts (and reduce the associated
distress) by avoiding trigger stimuli (e.g., knives, in the case of violence-related
obsessions). If such stimuli cannot be avoided, the person might perform com-
pulsive rituals—behavioral or mental acts that are completed according to
self-generated “rules.” These rituals are deliberate, yet senseless or excessive
in relation to the obsessional fear they aim to neutralize (e.g., checking the
roadway for 30 minutes to be sure one hasn’t hit a pedestrian without realizing
it). As with obsessions, rituals are highly individualized. Common rituals in-
clude excessive washing and cleaning, checking, seeking reassurance, counting,
and repeating routine actions (e.g., going through doorways). Rituals can also
be covert, such as excessive prayer and using “good” words or phrases to neu-
tralize “bad” thoughts (e.g., thinking a happy thought to “undo” the effect of
number 13). A hallmark of OCD is therefore that obsessions and compulsions
are functionally related: Obsessions provoke subjective distress, and rituals are
performed to reduce this distress.
Individuals with OCD display a range of insight into the senselessness of
their symptoms: Some acknowledge the irrationality of their obsessions and
compulsions, and others are firmly convinced that these symptoms are real-
istic. Often, the degree of insight varies across time and obsessional themes.
For example, one person might recognize her obsessional thoughts of harm
as senseless yet have poor insight into the irrationality of her contamination
obsessions.
PREVALENCE, COURSE, ASSOCIATED FEATURES,

AND TREATMENT
The lifetime prevalence of OCD in the general adult population is between 2%

and 3% (e.g., Kessler et al., 2005). Symptoms typically develop gradually, often
beginning in childhood; a noteworthy exception is the abrupt onset sometimes
observed during the perinatal period (e.g., Fairbrother & Abramowitz, 2007).
Left untreated, OCD usually follows a chronic course with waxing and waning
symptoms over time, often dependent upon levels of stress (e.g., Skoog & Skoog,
1999). Most people with OCD also suffer from depressive and anxiety symptoms,
which can exacerbate obsessional problems and attenuate response to treatment
(e.g., Abramowitz & Foa, 2000).
3
Introduction3
CLASSIFICATION OF OCD AND THE OCRDS
OCD as an Anxiety Disorder
Through DSM-IV-TR, OCD was considered an anxiety disorder along with

social and specific phobias, panic disorder and agoraphobia, posttraumatic
stress disorder (PTSD), and generalized anxiety disorder (GAD). Indeed, at
a descriptive level, OCD symptoms are similar to the main features of these
conditions: excessive and irrational fear, apprehension, and avoidance beha-
vior. Although not mentioned in DSM, “rituals” such as checking for safety
(in PTSD), asking for reassurance (in GAD), and seeking repeated medical
evaluations (in panic disorder) also appear in both OCD and the anxiety
disorders. But OCD and the anxiety disorders are also all maintained by the
same psychological mechanisms involving (a) overestimates of the likelihood
and severity of threat and (b) escape and avoidance behaviors that reduce
anxiety in the short term but prevent long-term fear extinction. Moreover,
these conditions all respond to a specific intervention that promotes fear
extinction—exposure therapy (Abramowitz, Deacon, & Whiteside, 2011;
Barlow, 2004).
OCD in the DSM-5
Some of the DSM-5 architects, however, felt that OCD was incorrectly classified
as an anxiety disorder because it bears even greater similarity to disorders—
including hoarding, trichotillomania, body dysmorphic disorder (BDD), and
compulsive skin picking— that appear to share “compulsive behavior and
failures in behavioral inhibition” (Fineberg et al., 2011, p. 21). These authors
(e.g., Fineberg et al., 2011; Hollander et al., 2005) provided the following
arguments for moving OCD out of the anxiety disorders and creating the new
OCRD classification in DSM-5:
(a) The distinguishing features of OCD and the other OCRDs are repetitive
thoughts and behaviors and a failure of behavior inhibition,
(b) OCD and the OCRDs overlap in demographic features such as their age
of onset, comorbidity, and family loading,
(c) OCD and the OCRDs share brain circuitry and neurotransmitter
abnormalities, and
(d) OCD and the OCRDs share similar treatment response profiles.
This shift has implications for how clinicians and scientists understand, treat, and
study OCD and the other OCRDs. Thus, it is worth taking a closer look at these
arguments.
4
EVALUATING ARGUMENTS FOR THE

OCRD CLASSIFICATION
Repetitive Thoughts and Behaviors Are Distinguishing Features

of OCD and the OCRDs
The DSM-5 labels OCD and the other OCRDs as “characterized by preoccupa-
tions and by repetitive behaviors or mental acts in response to the preoccupations”
and “recurrent body-focused repetitive behaviors (e.g., hair pulling, skin picking)
and repeated attempts to decrease or stop the behaviors” (American Psychiatric
Association, 2013, p. 235). Thus, the unifying factor among the OCRDs appears to
be repetitive thoughts and behaviors that the person cannot stop.
To be sure, the OCRDs have repetitive thinking and/or repetitive behavior in
common. But such a description of the form of observable signs and symptoms is
only one way to think about how mental health problems may relate to one another.
Another perspective focuses on the function of the repetitive behavior. In OCD, repet-
itive rituals are performed in response to obsessional thoughts that are misinterpreted
as danger signals. Rituals thus function as a “safety behaviors” in that they provide a
temporary escape from distress and are negatively reinforced. This is an important
mechanism by which OCD is maintained. But is it present in the other OCRDs?
The answer is generally not. Hair pulling disorder (HPD) and skin picking
disorder (SPD) are characterized by repetitive behavior, yet these behaviors are
distinct from rituals in OCD. First, there are no obsessional fears in HPD and
SPD; thus there is no safety behavior function. Second, urges to pull and pick are
precipitated by feelings of general tension, depression, anger, boredom, frustra-
tion, indecision, or fatigue (Diefenbach et al., 2002), and the behavior leads to
pleasurable feelings (Grant & Potenza, 2004; Schreiber et al., 2011), which is not
observed with rituals in OCD (Stanley et al., 1992). Even the excessive acquisition
behavior in hoarding disorder—if one could call this repetitive—is not motivated
by intrusive obsessive fears but rather by beliefs about the potential usefulness
of possessions and other exaggerated cognitions about loss or sentimentality.
Moreover, excessive saving does not result in an escape from obsessional anxiety
in the way that OCD rituals do and thus cannot be conceptualized as “compul-
sive” or “ritualistic” in the OCD sense. BDD, on the other hand, is the one OCRD
that does conform to the OCD functional template. As with obsessions, the
appearance-related preoccupations in BDD are intrusive and anxiety-provoking;
and as with rituals in OCD, the repetitive checking and other appearance-related
behaviors in BDD have an anxiety-reduction function (Phillips et al., 2010).
The logical and scientific problem with grouping the OCRDs together on the
basis of the mere presence of repetitive behaviors and thoughts is easy to spot if
we consider the following absurdity:
• Vomiting is a symptom of bulimia nervosa.

• Vomiting is a symptom of salmonella poisoning.
5
Introduction5
• Therefore, bulimia and salmonella poisoning are part of the same family
of disorders.
Obviously bulimia and salmonella are not related, and we would not put them in
the same diagnostic class. It is similarly easy to see how, however, from this per-
spective, repetitive hair pulling and skin picking could end up seeming as if they
are related to OCD. On the other hand, a functional approach provides better
resolution and reveals that of the OCRDs, only BDD actually “works” like OCD.
Moreover, both OCD and BDD are more similar to anxiety disorders than to the
other OCRDs. Both respond to a similar treatment (exposure and response pre-
vention [ERP]) that is based on this functional perspective. From this viewpoint,
skin picking and hair pulling operate quite differently from OCD, BDD, and anx-
iety disorders and also respond to different treatment approaches, as we will dis-
cuss later in this chapter.
The OCRDs Overlap in Terms of Their Demographic

Features
Age of Onset
Although OCD may begin at any age, it has a mean age of onset in early adulthood
(e.g., Anholt et al., 2014; Antony et al., 1998). The other OCRDs also typically have
their onset in adolescence through early adulthood and follow similar courses
(e.g., Bjornsson et al., 2013; Flessner et al., 2010; Grisham et al., 2006; Odlaug &
Grant, 2012; Wilhelm et al., 1999). Yet similarity in age of onset and course is not
a persuasive argument for grouping DSM disorders together: Indeed, most mood,
anxiety, somatic symptom, dissociative, sexual, sleep, personality, substance-
related, psychotic, and eating disorders also begin during this time of life! Thus,
the fact that the OCRDs share these nonspecific characteristics does not indicate
the presence of a unique relationship.
Comorbidity
Are the OCRDs highly comorbid with one another, and is this a compelling
reason to group them together? Again, the answer is “no” to both questions.
Studies fail to support the claim of high comorbidity; Bienvenu et al. (2000),
for example, found that while the comorbidity rate between OCD and BDD
was 15%, it was only 4% with HPD. Other studies have reported largely
similar results (Jaisoorya et al., 2003; Lovato et al., 2012), suggesting that
other than BDD, the OCRDs are quite uncommon among people with OCD.
Interestingly, 13% of OCD patients meet criteria for GAD, 20.8% for panic
disorder, 16.7% for agoraphobia, 36% for social phobia, and 30.7% for specific
phobias (Nestadt et al., 2001). Thus, using the DSM-5 committee’s own rea-
soning, OCD is 5-to 10-fold more closely related to the anxiety disorders than
to most of the OCRDs!
6
There’s also a logical problem with using comorbidity to group disorders into
categories: Comorbidity does not indicate etiologically meaningful relationships
among disorders. Substance use disorders and PTSD, for example, are highly co-
morbid (Kramer et al., 2014), yet they are not part of the same diagnostic cate-
gory. Similarly, at least half of OCD sufferers also meet criteria for depression, yet
this does not mean depression should be part of the OCRDs.
Family Patterns
Proponents of the OCRD approach assert that if OCRDs occur frequently in
relatives of people with OCD, then such disorders share a common genetic eti-
ology. Research, however, does not support this claim. Bienvenu et al. (2000), for
example, found that the lifetime prevalence of HPD in first-degree relatives of
adults with OCD was only 1%. In contrast, the rates of anxiety disorders among
first-degree relatives of people with OCD are far higher than the rates of OCRDs
among relatives of OCD sufferers (e.g., Bienvenu et al., 2000; Nestadt et al., 2001).
So, the assertion that familial pattern represents a valid basis for grouping to-
gether the OCRDs again more strongly supports the notion that OCD should be
grouped with the anxiety disorders.
The OCRDs Have Overlapping Neurobiological Etiologies

Brain Structure and Function
Neuroimaging studies sometimes (but not always) find that individuals with and
without OCD show differences in variables related to brain structure and func-
tion (for a review and consensus statement see Bandelow et al., 2016). Much less
brain imaging research, however, has been conducted with the other OCRDs, yet
the few comparisons to healthy control groups also show some differences (e.g.,
Buchanan et al., 2013; Chamberlain et al., 2008; Grant et al., 2013; Mataix‐Cols
et al., 2011). OCRD proponents interpret these findings to suggest a common
causal brain abnormality or deficit across the OCRDs (e.g., Fineberg et al., 2011).
Examination of the evidence (and logic), however, indicates no basis for such
causal inferences, or for using brain imaging studies as a basis for grouping the
OCRDs together.
An important limitation of most brain imaging studies is that they are correla-
tional and therefore can merely detect associations between an OCRD diagnosis
and brain structure or function. But one cannot infer the presence of abnormal-
ities from such studies any more than one could infer that, say, an association
between anorexia nervosa and being female means that being female is abnormal.
That is, just because a variable is correlated with the symptoms of a mental dis-
order does not imply this variable indicates an “abnormality” with etiological sig-
nificance. It is equally plausible that the observed differences in brain structure
and function between OCRDs and controls are the result of having an OCRD, or
that OCRDs and the observed differences in brain-related variables are caused by
other variables.
7
Introduction7
It’s important to point out that although brain imaging is an important tool
for studying brain–behavior relationships, brain scans are not snapshots of the
brain’s real-time functioning (Roskies, 2007). Rather, they are highly processed
representations of the brain’s activities. Thus, whereas the conclusion that people
with OCRDs show enhanced activation in the basal ganglia relative to controls ac-
curately characterizes the brain imaging data, statements such as the abnormally
high activity shows that OCD is a disorder of the basal ganglia go beyond the
data. Despite three decades of brain imaging studies, there have been no major
advances in determining the causes of OCD (Bandelow et al., 2016, 2017).
Neurotransmitters
The most consistent (yet still overstated) neurobiological finding in OCD is that
medication using serotonin reuptake inhibitors (SRIs; e.g., fluoxetine, sertraline)
can be effective (Greist et al., 1995). This, and a small literature comparing sero-
tonergic and non-serotonergic processes in OCD patients (Insel et al., 1985), led
to the “serotonin hypothesis” that OCD is caused by abnormalities in the seroto-
nergic system (Barr et al., 1993; Zohar et al., 2004). Yet it is a logical error to use
the effectiveness of SRIs to infer that an abnormally functioning serotonin system
is the cause of OCD/OCRDs. For one thing, the serotonin hypothesis was derived
from the effectiveness of serotonin medications (making the argument circular). It
also is an example of “reasoning backward from what helps,” a logical error exem-
plified by the following: “When I take aspirin, my toothache goes away; therefore
the toothache was caused by abnormally low aspirin levels.”
Neurotransmitter models of OCRDs could be supported by evidence from ex-
perimental studies showing differences in serotonin functioning between indi-
viduals with and without OCD, or by studies in which neurotransmitters are
manipulated leading to increased symptom expression. Yet despite a consider-
able amount of energy (and money) devoted to biological marker and challenge
studies in OCD, there are no consistent findings (Bandelow et al., 2017; Barr et al.,
1993; Koo et al., 2010; Zohar et al., 2004). A further problem is that virtually no
neurotransmitter research has been conducted on OCRDs other than OCD.
There is no doubt that the signs and symptoms of the OCRDs involve the brain
and neurotransmitter systems at some level. Yet evidence that OCRDs are caused
by abnormally functioning systems is absent. Therefore, the appeal to a common
neurobiological etiology as a basis for grouping the OCRDs is unjustified.
OCD and the OCRDs Share Similar Treatment

Response Profiles
Treatment response is a pivotal test of the OCRD category’s validity since ef-
fective treatment is the ultimate goal of identifying and classifying mental
disorders. The DSM-5 claims there is “clinical utility” (p. 235) in grouping
OCRDs together because they respond preferentially to SRIs. This argument,
however, is only useful in delineating a class of OCRDs if three conditions
8
are met: (a) preferential response to SRIs is observed uniformly among the
OCRDs, (b) preferential response to SRIs is only observed among the OCRDs,
and (c) SRIs are the best treatment for the OCRDs. We consider these
conditions next.
Is There a Uniform Response to SRIs Across the OCRDs?

Numerous placebo-controlled studies indicate the efficacy of SRIs for OCD (Eddy
et al., 2004; Greist et al., 1995) and BDD (Phillips et al., 2002). Yet SRI response
in the other OCRDs is inconsistent. Bloch et al. (2007) found that SRIs were gen-
erally no more effective than placebo in the treatment of HPD, and patients with
hoarding disorder were about 50% less likely than those with OCD to respond to
SRIs (Bloch et al., 2014). Only two placebo-controlled studies have been published
for SPD, one showing significant reduction with fluoxetine on only one of three
outcome measures (Simeon et al., 1997), and the other finding that citalopram
was no more effective than placebo (Arbabi et al., 2008). The only conclusion that
can be drawn from these data is that the OCRDs do not show a uniform response
to SRIs.
Is a Preferential Response to SRIs Only Observed Among

the OCRDs?
The previous problem aside, numerous controlled studies show that SRIs are
efficacious in the treatment of unipolar depressive disorders (e.g., Fournier
et al., 2010; Schatzberg & Nemeroff, 2013) and anxiety disorders such as so-
cial anxiety disorder (Hedges et al., 2007). Thus, because SRIs help numerous
conditions, even if the OCRDs all responded preferentially to these agents
(which they don’t), it would not call for grouping these disorders together based
on SRI response.
Are SRIs the Best Treatment for OCRDs?

A meta-analysis of 13 randomized controlled trials directly comparing SRIs and
cognitive-behavioral therapy (CBT) (mainly using ERP) for OCD revealed that
CBT is at least as effective (if not more so) than SRIs (Romanelli et al., 2014).
No studies to date have compared SRIs with CBT in an exclusively hoarding
disorder sample. In BDD, although larger effect sizes and more consistently
positive findings are reported in studies of CBT (usually ERP) compared to
those evaluating SRIs, there are no direct comparison studies (Ipser et al., 2009;
Williams et al., 2006). Similarly, the skin-picking treatment literature indicates
greater consistency in response to CBT (e.g., habit reversal training) than to
SRIs (e.g., Grant et al., 2012), although there are as yet no direct comparison
studies. Finally, in HPD, Bloch et al.’s (2007) meta-analysis revealed that habit
reversal training had a larger effect size on hair-pulling symptoms than did
SRIs. Thus, research suggests that SRIs are not the most effective treatment for
any of the OCRDs.
9
Introduction9
CONCLUSIO NS
The scientific evidence suggests CBT is at least as effective as SRIs across the
OCRDs. A noteworthy aspect of CBT interventions apparently overlooked by the
DSM-5 is that these treatments are derived from specific models of psychopa-
thology that have a sound empirical basis. The use of ERP for OCD and BDD,
for example, originated from experimental research demonstrating that these
conditions are characterized by conditioned fear that is maintained by anxiety-
reduction strategies that impede long-term fear extinction (e.g., Rachman &
Hodgson, 1980; Veale & Riley, 2001)—which happen to be the same processes
that maintain the anxiety disorders (e.g., Barlow, 2004). The use of habit reversal
training for SPD and HPD is also guided by research on the function of these
behaviors and their controlling variables (e.g., Grant et al., 2012). This is in contrast
to SRI medications, which were discovered serendipitously and which gave rise to
(circular) theories about serotonin (which have also turned out to be invalid),
primarily on the basis of treatment response (Whitaker, 2011). All of this leaves
pharmacotherapy response of little value in classifying mental disorders, whereas
response to CBT—because it targets specific processes—has a better chance of
helping to identify useful boundaries and classes of disorders. Thus, if we consider
CBT response as a litmus test of the OCRD approach, the only conclusion to be
drawn is that whereas OCD and BDD overlap and could be considered “related,”
hoarding disorder, HPD, and SPD would not fit into the same category. Moreover,
OCD and BDD fit best with the anxiety disorders.
WHY THIS BOOK?
The scientific difficulties we’ve noted with the OCRD classification aside, the last
decade has witnessed a dramatic surge in research on OCRDs, some of which
were understudied. And this has also led to more people seeking help for these
and other putatively related problems. We view these consequences as posi-
tive outcomes resulting from the OCRD classification. Yet they have come at a
price: Many researchers and clinicians assume that because disorders such as
HPD, hoarding disorder, and SPD are classified as OCRDs, they have overlapping
mechanisms and respond to the same treatments. This, however, is not the case.
Moreover, although the DSM-5 is most closely aligned with a medical model in
which psychiatric disorders are considered brain diseases that require medication,
research on the psychological mechanisms and treatments for these problems has
eclipsed any advances in biological approaches—especially when it comes to un-
derstanding the nuances and complexities that often present barriers to success-
fully treating these problems. These fast-moving clinical and research advances
set the stage for this book, which aims to bring together state-of-the-art practical
implications and research advances under one cover.
10
The volume is organized into four sections. Chapters in the first section cover
the phenomenology and assessment of putative OCRDs (other than OCD) to pro-
vide the reader with a comprehensive understanding of psychological mechanisms
of these conditions. The second section comprises chapters addressing additional
mental and behavioral health problems that remain under-researched yet are often
considered related to OCD in one way or another. The focus of the third section is
complex presentations of these conditions, including co-occurring problems (e.g.,
trauma, substance abuse, autism spectrum symptoms) and special populations
(e.g., postpartum onset, pediatric acute onset). Finally, section four covers novel
applications of existing interventions (e.g., the use of technology, involving a
partner in treatment). We believe these various sets of chapters provide unique
and up-to-date collections of material to help clinicians and researchers apply
psychological approaches to understanding, assessing, and treating a collection of
problems that are often misunderstood, misdiagnosed, and mistreated in clinical
practice.
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15
Body Dysmorphic Disorder

S O P H I E C . S C H N E I D E R , A M I TA J A S S I , L A U R E N P E I L E ,
D. LUIS ORDAZ, AND ERIC A. STORCH ■
CLINICAL PRESENTATION
Core Symptoms
Body dysmorphic disorder (BDD) affects approximately 1.9% of adults and 1.7% to
2.2% of adolescents (Schneider et al., 2017; Veale et al., 2016). Individuals with BDD
believe that some aspect of their appearance is unattractive, abnormal, or deformed,
despite these flaws being unobservable or appearing minimal to others (American
Psychiatric Association, 2013). These appearance preoccupations are intrusive, dis-
tressing, and time-consuming; 1 hour per day is an accepted indication of clinical
levels of BDD symptoms (Phillips, 2005), but many individuals with BDD spend
much of their waking lives focused on their appearance. In response to appearance
concerns, individuals with BDD perform repetitive behaviors or mental acts such as
mirror checking, excessive grooming, or seeking reassurance from others, and often
avoid situations in which their appearance may be evaluated by others (American
Psychiatric Association, 2013). In the short term the behaviors function to improve,
hide, examine, or distract from the body area of concern, yet they usually worsen
preoccupation and distress over time (Didie et al., 2010). These behaviors are often
time-consuming and can even be harmful; for example, skin picking and abrasive
skin care procedures can cause infection and permanent damage. Although any part
of the body can be a focus of concern, the most common body areas of concern in-
volve the face, skin, and hair (Phillips et al., 2006a; Schneider et al., 2019a).
In clinical samples, BDD is associated with high levels of interference with occu-
pational and academic achievement, many individuals with BDD are single or un-
employed, and some have been housebound or hospitalized due to BDD (Phillips
et al., 2005). Research in community samples support the negative impacts of
BDD. This includes interference with dating, socializing, work, and school (Koran
et al., 2008), lower incomes, lower marriage rates and higher divorce rates, higher
16
unemployment, and higher rates of plastic surgery (Rief et al., 2006), and poorer
quality of life and higher psychopathology in adolescents (Schneider et al.,
2017) and adults (Schneider et al., 2019b).
Diagnostic Classification
BDD was initially classified as a somatoform disorder in DSM-IV due to the focus
on unexplained physical symptoms (American Psychiatric Association, 1994);
however, this approach was criticized due to the low association between BDD
and other somatoform disorders (Cororve & Gleaves, 2001). BDD is now clas-
sified as an obsessive-compulsive or related disorder in both DSM-5 (American
Psychiatric Association, 2013) and ICD-11 (World Health Organization, 2018),
a category that includes OCD, hoarding disorder, body- focused repetitive
behaviors (e.g., trichotillomania and excoriation) and, in ICD-11, olfactory ref-
erence disorder and hypochondriasis. This reclassification is in large part due to
shared features with obsessive-compulsive disorder (OCD), including obsessive
concerns and repetitive behavioral responses to these concerns, elevated comor-
bidity in clinical samples, familial aggregation of the disorder, and similarities in
treatment response (Abramowitz & Jacoby, 2015; Bienvenu et al., 2012; Kelly &
Phillips, 2011; Phillips et al., 2010). However, further research is needed to fully
evaluate the associations of BDD with other obsessive-compulsive and related
disorders.
Gender Differences
BDD affects 1.6% of males compared to 2.1% of females (Veale et al., 2016). Many
core features of BDD are similar in males and females (Perugi et al., 1997; Phillips
et al., 2006b; Schneider et al., 2019b). However, some presenting features may
differ by sex; males may be more likely to be concerned about their genitals, body
build, and thinning hair, whereas females may be more likely to report concern
about weight, breasts/chest, hips, buttocks, thighs, legs, and other hair concerns
(Perugi et al., 1997; Phillips & Diaz, 1997; Phillips et al., 2006b; Schneider et al.,
2019a). Some BDD-related behaviors may also differ by sex, with men more likely
to lift weights than females, and females more likely to camouflage their appear-
ance concerns, pick their skin, and check the mirror excessively than men (Perugi
et al., 1997; Phillips & Diaz, 1997; Phillips et al., 2006b).
Muscle Dysmorphia
Muscle dysmorphia is a subtype of BDD involving unrealistic concerns that

the individual is insufficiently muscular (American Psychiatric Association,
2013) and is characterized by behaviors intended to increase muscularity and
17
Body Dysmorphic Disorder17
reduce body image–related distress. Such behaviors can include intense exercise,
dietary control, anabolic steroid use, mirror checking, and avoidance strategies
(Murray & Baghurst, 2013). Muscle dysmorphia primarily affects males and may
be associated with poorer quality of life, greater suicidality, and higher frequency
of substance use disorder compared to males with BDD who do not experience
muscle dysmorphia (Pope et al., 2005). Male bodybuilders are at increased risk of
muscle dysmorphia symptoms compared to other non-bodybuilding weightlifters
(Mitchell et al., 2017). There is debate regarding the classification of muscle
dysmorphia, with specific classifications under consideration being obsessive-
compulsive spectrum disorders, eating disorders, and addictive disorders (dos
Santos Filho et al., 2015; Foster et al., 2015; Murray & Touyz, 2013), and further
research is needed to understand the presentation and classification of muscle
dysmorphia in males and females.
ASSESSMENT
It is vital that clinicians directly assess for core BDD symptoms as they are rarely
disclosed during routine clinical assessment (Schneider & Storch, 2017). Across
four studies, routine clinical intake interviews detected just 3% of the cases sub-
sequently identified using BDD-specific questionnaires or interviews (Conroy
et al., 2008; Dyl et al., 2006; Grant et al., 2001; Veale et al., 2015). Lack of BDD
disclosure may be due to feelings of embarrassment, poor insight, fear of nega-
tive judgments about BDD symptoms, and feeling the provider would not under-
stand (Conroy et al., 2008; Veale et al., 2015). Fortunately, including even basic
questions asking about BDD symptomology can greatly enhance symptom dis-
closure (Phillips, 2005).
Interview Measures
A face-to-face semistructured interview with a trained mental health professional

is the gold-standard method to assess BDD and associated disorders (Phillips &
Feusner, 2010). The most widely used measure in research studies is the Yale-
Brown Obsessive-Compulsive Scale Modified for Body Dysmorphic Disorder
(BDD- YBOCS; Phillips et al., 2014). This 12- item semistructured interview
assesses the nature of BDD-related preoccupations, repetitive behaviors, insight,
and avoidance. The Structured Clinical Interview for DSM-5 (SCID-5; First et al.,
2015) enhanced version also can be used to diagnose BDD.
Questionnaire Measures
Although questionnaire measures cannot provide a diagnosis of BDD, they can

provide valuable information about BDD symptom severity and can be used as
18
the first step in a diagnostic process. The most commonly used screening tool is
the Body Dysmorphic Disorder Questionnaire (Phillips, 2005), which includes
up to 13 items assessing DSM-IV BDD criteria (which are very similar to DSM-
5 criteria), body areas of concern, and the nature of BDD-related interference.
Severity of dysmorphic concern can be assessed using the seven-item Dysmorphic
Concern Questionnaire (Oosthuizen et al., 1998) or the 19-item Body Image
Concern Inventory (Littleton et al., 2005). BDD symptoms can also be assessed
using the nine-item Cosmetic Procedure Screening Questionnaire (Veale et al.,
2012) or the 10-item Appearance Anxiety Inventory (Veale et al., 2014b). The
DSM-5 introduced the five-item Body Dysmorphic Disorder Dimensional Scale
(LeBeau et al., 2013) that is useful for assessing key symptoms such as duration of
preoccupation, distress, control, avoidance, and interference. Each of these meas-
ures can be quickly administered without requiring clinician training and can be
used to detect high BDD symptom levels and to track symptom change over time.
Assessment in Young People
It is important to assess BDD symptoms in young people as subclinical BDD phe-

nomena typically develop at 13 years of age, with mean onset at 16 years (Bjornsson
et al., 2013; Marques et al., 2011). Although most core BDD symptoms are sim-
ilar between youth and adults (Phillips et al., 2006a; Schneider & Storch, 2017), it
can be challenging to detect BDD in young people as appearance concerns may
be overlooked as normative in this age group, and young people with BDD have
particularly poor insight into their appearance concerns (Phillips et al., 2006a). It
may be helpful to include parents in the assessment process and to pay close at-
tention to more objective BDD symptoms, such as length of time thinking about
appearance, specific BDD-related compulsive behaviors, and types of avoidance.
Where possible, youth versions of assessment measures should be used, such as
the Body Dysmorphic Disorder-Adolescent Version (Phillips, 2005) and the Body
Image Questionnaire-Child and Adolescent Version (Veale, 2009). If this is not
possible and a measure is used that was developed in an adult population, special
attention should be paid to ensuring that all terminology used is properly under-
stood by the young person.
Assessment of Muscle Dysmorphia
Currently there is no interview specifically developed and validated for the detec-
tion of muscle dysmorphia, although the BDD-YBOCS has been successfully used
in the past to assess for muscularity concerns (Pope et al., 2005). When conducing
a clinical interview, clues to the presence of a muscularity-focused BDD presen-
tation may include health and fitness behaviors that are causing problems such as
injuries due to overexercising, financial difficulties due to overspending on fitness,
failing to carry out other important duties due to exercising, or irrational beliefs
19
related to muscularity and self-worth (Parent, 2013). When assessing for anabolic
steroid use, it is also important to address motivations for use, as appearance-
related motives may be more indicative of muscle dysmorphia than performance-
related motives (Murray et al., 2016).
Several questionnaires exist that provide a valid assessment of the symptoms of
muscle dysmorphia, including the 27-item Muscle Dysmorphia Inventory (Rhea
et al., 2004), the 13-item Muscle Dysmorphic Disorder Inventory (Hildebrandt
et al., 2004), and the 19-item Muscle Appearance Satisfaction Scale (Mayville
et al., 2002). Additionally, the 15-item Drive for Muscularity Scale (McCreary &
Sasse, 2000) can be used to assess muscularity-oriented behaviors and body image
concerns. The 15-item Muscularity-Oriented Eating Test (Murray et al., 2019) is
a newly validated single-construct measure that can be used to assess eating pa-
thology related to muscularity concerns.
Differential Diagnosis
BDD is characterized by high levels of comorbidity; only 8% of adults with BDD

report no prior or current comorbid diagnoses (Gunstad & Phillips, 2003). The
most common lifetime comorbid disorders are major depressive disorder (75%),
substance use disorders (48%), social anxiety disorder (39%), OCD (33%), eating
disorders (33%), avoidant personality disorder (23%), and panic disorder (20%;
Phillips et al., 2005). Individuals with BDD often present for treatment of co-
morbid disorders without disclosing their BDD, even when BDD is the most in-
terfering disorder (Schneider & Storch, 2017). Even when BDD symptoms are
disclosed, the overlap with symptoms of better-recognized disorders can lead to
misdiagnosis (e.g., confusing social withdrawal due to BDD with symptoms of
social anxiety disorder, or attributing obsessive exercising associated with muscle
dysmorphia to an eating disorder). For a useful overview see Phillips and Feusner
(2010) or Schneider and Storch (2017).
TREATMENT WITH COGNITIVE-B EHAVIORAL THERAPY
The Cognitive-Behavioral Model
Cognitive-behavioral therapy (CBT) for BDD is guided by the cognitive-behavioral

model of BDD; the most recent model (Fang & Wilhelm, 2015) integrates sev-
eral previous cognitive-behavioral models for the etiology or maintenance of this
condition (Neziroglu et al., 2004; Veale, 2004; Veale et al., 1996; Wilhelm et al.,
2010). The model suggests that although everyone experiences negative thoughts
about appearance, people with BDD have unhelpful responses to these thoughts
that maintain them over time. In addition, biological and cognitive characteris-
tics such as selective attention and excessive focus on disliked features are char-
acteristic of BDD sufferers (Beilharz et al., 2017; Li et al., 2015; Toh et al., 2017).
20
This drives attention toward disliked appearance features, exacerbating negative

perceptions of appearance and maladaptive behavioral responses.
Maladaptive beliefs about appearance are central to these models, including
high self-standards for beauty, overvaluing of appearance, negative interpreta-
tion biases in facial expressions, and detecting threat in social situations. These
cognitions and corresponding core beliefs about the self (e.g., unattractive people
are unlovable) lead to distress, predominantly feelings of anxiety and disgust.
Attempts to regulate these negative emotional states through social avoidance or
other self-defeating strategies (such as ritualistic or repetitive behaviors) nega-
tively reinforce and strengthen maladaptive thoughts.
The development and maintenance of maladaptive cognitions in BDD is
attributed to factors such as cultural beliefs about appearance, experiences of
bullying or abuse, high rejection sensitivity, intolerance of uncertainty, perfec-
tionism, or fear of negative evaluation (Fang & Wilhelm, 2015; Li et al., 2013;
Neziroglu et al., 2008). Potential triggers include changes to appearance (such as
those during puberty or other ageing), negative comments by others, stress, or
low mood.
Core Treatment Elements

Goal Setting and Psychoeducation
Following assessment of BDD and related symptoms, it is necessary to focus
on building a foundation of shared understanding and therapeutic alliance for
CBT. Due to shame or stigma, individuals may be disclosing their appearance
concerns and behaviors for the first time, and thus a therapeutic alliance is crucial.
Establishing an individual’s desire for psychological change will guide the degree
of motivation-enhancing techniques offered in treatment.
Individuals with BDD often believe that their appearance concerns are re-
alistic and their distress is due to their disfigured appearance (Didie et al.,
2010); thus, they may be skeptical that CBT will benefit them. Motivational
interviewing strategies (Miller & Rollnick, 2002) are a helpful adjunct to CBT,
generating a curious and nonjudgmental therapeutic stance. Exploration of
how current BDD-related behavior relates to expressed treatment goals may
invite alternative ways forward and can be revisited throughout treatment, es-
pecially given that insight into appearance concerns should improve over the
treatment period. Establishing concrete goals provides structure for tracking
progress and ensuring that CBT remains meaningful and motivating for the
individual.
Before embarking on CBT, individuals are provided with a general explana-
tion of BDD and the cognitive-behavioral model of BDD. Material includes how
perceptual distortions contribute to the cycle of BDD, illustrated through con-
crete examples and encouraging consideration of the role such mechanisms play
in their own BDD. Information about the effective CBT treatment available aims
to clarify expectations and nurture hope.
21
Shared Formulation and Cognitive Restructuring

Applying the cognitive-behavioral model to an individual’s experience highlights
the role of psychological factors in maintaining their distress. Even where there
are “delusional” beliefs about physical appearance (i.e., the individual totally
lacks insight into the unrealistic nature of their BDD concerns), an individual
may concede that CBT has something to offer by reducing distress or problematic
behaviors. Behavior change over time may generate some acceptance of psycho-
logical explanations and subsequently further reduction in beliefs and behaviors.
Cognitive restructuring guides the identification, tracking, and labeling of, and
reflection on, negative thoughts about appearance. Following the recognition of
cognitive mechanisms (e.g., “all or nothing” thinking and “mind-reading”) and
the distress and self-defeating behavior they elicit, alternative perspectives may be
considered and more functional thoughts and beliefs emerge. However, caution
should be taken that cognitive restructuring techniques do not become a method
of self-reassuring.
Exposure and Additional Strategies

Exposure seeks to demonstrate that the anxiety associated with feared situations
is tolerable and will decrease over time. It is usually graded, although this is not
always essential (Davies & Craske, 2015), and follows a collaboratively generated
hierarchy of feared situations and stimuli. Rituals or safety behaviors used during
exposure should be gradually reduced when paired with exposure to triggers as
these preserve the excessive focus on appearance concerns and inhibit habituation
to anxiety. Tasks should be repeated both in and outside of the CBT sessions with
reliable recording of in-task anxiety ratings along with the predicted and actual
outcomes of exposure.
Exposure work in BDD can be integrated with cognitive techniques including
explicit gathering of evidence for and against negative thoughts about appearance
in order to develop insight and address cognitive distortions, as well as atten-
tional strategies to shift focus toward the “bigger picture” (e.g., focus on other
sights and sounds, holistic processing of appearance). Attentional retraining
helps individuals to shift from narrow, critical, self-focused attention to broader,
nonjudgmental appraisals that enhance self-acceptance. For example, in mirror
retraining the therapist models this to the patient by verbalizing neutral, nonjudg-
mental descriptions of their own image in the mirror, standing at arm’s distance
and taking care to scan from head to toe, giving equal time and attention to each
feature. Patients then try this for themselves, being coached as they do so to resist
problematic rituals or habitual negative statements. Practicing this regularly at
home helps to normalize appearance perceptions.
There may be a need to directly address BDD behaviors such as seeking cos-
metic procedures, self- surgery, skin picking, or hair pulling. Habit reversal
techniques may be helpful adjuncts to CBT for skin picking and hair pulling
(Teng et al., 2006). Further psychoeducation and motivational techniques may
be used to target beliefs about surgery, which is typically associated with poor
outcomes for those with BDD (Bowyer et al., 2016). CBT components associated
2
with depressive symptoms such as activity scheduling and cognitive restructuring

of negative thoughts may also prove beneficial.
Modifications to CBT for young people include use of developmentally ap-
propriate psychoeducation and concepts, including parents to support exposure
practice (e.g., with concrete rewards) and to reduce family accommodation of
rituals, and increased emphasis on behavioral, rather than cognitive, strategies.
Awareness raising within the system around the young person should be included
to increase overall support. Such modifications are necessary to ensure that the
information presented is engaging and comprehensible for the young person.
Risk Assessment and Management

The high level of suicidality in individuals experiencing BDD (Albertini & Phillips,
1999; Mataix-Cols et al., 2015; Phillips et al., 2006a) requires consideration when
delivering CBT with this group. Other risks include self-surgery or debt from
expensive procedures. A thorough assessment process, within an open and non-
judgmental environment where thoughts and behaviors can be disclosed, is vital.
Risk monitoring and management is key during treatment, and a team approach,
drawing on the skills and resources of medical colleagues as necessary, can help
overcome some of the challenges and make it possible for CBT to continue with
close monitoring of potential risks.
Evidence Supporting CBT
The evidence base for CBT consists of case studies, case series, small open trials,
a limited number of randomized controlled trials, and a meta-analysis that in-
cluded seven of these trials. The majority of outcome research studies have
been conducted with adults, with early trials comparing CBT to waitlist control
(Rosen et al., 1995; Veale et al., 1996; Wilhelm et al., 2014) and more recently
credible psychological control treatments such as anxiety management (Enander
et al., 2016; Veale et al., 2014a; Wilhelm et al., 2019). There has only been one
randomized controlled trial involving young people comparing CBT to weekly
psychoeducation and telephone support (Mataix-Cols et al., 2015).
A meta-analysis synthesizing the data from seven randomized controlled trials
(n = 299) found that CBT outperformed waitlist or a psychological placebo in
reducing BDD symptoms with an overall large effect size (Cohen’s d for the differ-
ence in severity decrease between groups = 1.22) at the end of treatment (Harrison
et al., 2016). There were no significant predictors of outcomes in the meta-analysis
(Harrison et al., 2016); however, a more recent study found that better treatment
outcomes were associated with higher motivation to change, greater treatment
expectancies, and better insight at baseline (Greenberg et al., 2019). This recent
study is the largest single randomized trial of CBT for BDD, and 83% to 85% of
those randomized to CBT responded to treatment—that is, their BDD-YBOCS
severity score reduced by 30% or more (Wilhelm et al., 2019). Interestingly,
a significant number of participants who were randomized to the supportive
23
psychotherapy condition also responded to treatment, and the response rate did
not differ between groups at one of the study sites (69% CBT vs. 45% supportive
psychotherapy). Thus, although CBT is still the supported treatment modality,
supportive therapy may provide meaningful benefits for a minority of adults with
BDD. This highlights the need to identify the active components of psychological
treatments for BDD.
Follow-up studies generally support the durability of CBT treatment effects.
Improvements are maintained at 2-to 4-month follow-up, and there are additional
benefits seen in depression reduction and insight improvement (Harrison et al.,
2016). Krebs et al. (2017) conducted a 12-month follow-up for 30 adolescents in-
volved in the randomized controlled trial by Mataix-Cols et al. (2015). They found
that further improvements were made following active treatment; 50% responded
(at least 30% reduction in BDD-YBOCS symptom severity) and 23% remitted to
treatment (no longer met diagnostic criteria for BDD) by the end of the follow-up
period. This finding was echoed in a naturalistic 2-year follow-up of internet-
delivered CBT. In the initial trial among 96 self-referring adults, 54% of the CBT
group responded to treatment (at least 30% reduction in BDD-YBOCS symptom
severity) compared to a 6% response in the supportive therapy group (Enander
et al., 2016). Examining long-term follow-up in 88 of these participants, Enander
et al. (2019) found that 40% kept their response status, 29% had a delayed response
to treatment (responded to treatment in the follow-up period), 21% remained
non-responders, and 10% relapsed. This indicates that half of the participants
maintained or made further gains in the follow-up period. These studies taken
together indicate the durability of effects and that further gains can be made in the
time following treatment, perhaps indicating use of CBT learning by participants
beyond the active treatment phase. However, there is significant room to improve
treatment response using CBT.
TREATMENT WITH PHARMACOTHER APY
Recommended Treatment Approach
Pharmacotherapy is also an evidence-based treatment for BDD and, where pos-

sible, should be used in conjunction with CBT. Selective serotonin reuptake
inhibitors (SSRIs) are typically used as the first-line pharmacological treatment
for BDD (Hong et al., 2019). SSRIs have been found to be effective in reducing
core BDD symptoms and associated depressive symptoms for this population and
can be particularly useful for more severe presentations of BDD and suicidality
(Phillips & Hollander, 2008). There is insufficient evidence to recommend one
type of SSRI over another; thus, SSRI dosing recommendations are informed by
treatment strategies for OCD. Several SSRI trials may be necessary to find one
that is effective for an individual. In such cases, it is advised to try each SSRI one
by one, allowing ample time (e.g., 12 to 16 weeks) for symptom reduction be-
fore trying another medication (Hong et al., 2019). Relatively high doses of SSRIs
24
may be required to see treatment effects, so a maximum tolerable dosing strategy

may be indicated. When first-line SSRIs are not effective, it may be appropriate
to try the tricyclic antidepressant clomipramine or a second-generation antipsy-
chotic (Hong et al., 2019). Such medications may prove effective yet are reserved
as second-line medications due to the higher potential for side effects.
Evidence for Pharmacotherapy
There are relatively few pharmacotherapy studies for BDD. Phillipou

et al. (2016) identified three randomized controlled trials using fluoxetine,
clomipramine, and desipramine, with response rates ranging from 18% to
70%. Open-label trials have also provided support for pharmacotherapy using
citalopram, escitalopram, and fluvoxamine (Phillips, 2006; Phillips et al., 1998;
Phillips & Najjar, 2003). In the largest study to date, 67% of 100 adults with
BDD responded (BDD-YBOCS severity reduction of at least 30%) to open-
label escitalopram (Phillips et al., 2016). In treatment responders, continued
escitalopram delayed time to relapse and rates of relapse (18% medication vs.
40% placebo) and was associated with further reductions in BDD symptom se-
verity. There are few studies examining the effectiveness of pharmacotherapy
for BDD in children and adolescents, though SSRIs are still considered to be
effective in this population (Phillips & Hollander, 2008). In a case series of 33
children and adolescents, 53% of individuals treated with an SSRI showed im-
provement in BDD symptoms based on a measure of global improvement in
symptoms (Albertini & Phillips, 1999).
While pharmacotherapy for BDD has growing evidence, this treatment ap-
proach is not without its drawbacks. A common barrier to medication manage-
ment is side effects. Medication management for BDD often requires higher dosing
than for other psychiatric conditions, which can lead to greater side effects. Side
effects of SSRIs can include gastrointestinal problems, sleep and weight distur-
bance, and sexual dysfunction, while clomipramine can cause cardiac side effects
(Hong et al., 2019). Additionally, it is often recommended that patients remain
on medication to prevent relapse, and there is a lack of information on how to
withdraw from medication and the risk of relapse. Pharmacotherapy has prom-
ising evidence, yet further research is needed that can provide clear treatment
recommendations, such as optimal selection and dosing of SSRIs, best-practice
management for individuals taking multiple psychotropic medications, and how
best to reduce side effects.
DIRECTIONS FOR FUTURE TREATMENT RESEARCH
Across CBT studies there is substantial variation in the number of treatment

sessions, inclusion of specific CBT skills, and use of non-CBT skills. Given the
evidence of treatment response to non-exposure treatments such as supportive
25
psychotherapy (Wilhelm et al., 2019) and meta-cognitive therapy (Rabiei et al.,

2012), there is a need to dismantle and critically evaluate CBT programs to iden-
tify the important treatment components. Further, modifications of treatment
delivery format such as online CBT (Enander et al., 2016) and telephone CBT
(Turner et al., 2009) may have great potential to reach those who struggle to ac-
cess face-to-face CBT. Given that response rates appear to be lower among youth
with BDD compared to adults, careful attention should be paid to developmental
considerations in treatment (Turner & Cadman, 2017).
Emerging research has identified a range of potential cognitive mechanisms
implicated in the etiology of maintenance of BDD symptoms. A recent review
found that those with BDD differed from healthy controls regarding selective at-
tention, interpretation biases, and memory deficits (Johnson et al., 2018). BDD
is characterized by visual processing abnormalities including face recognition,
emotion identification, object recognition, and gestalt processing (Beilharz et al.,
2017). Differences to healthy controls include a dominance of detailed local pro-
cessing over global processing and associated changes in brain activation in visual
regions (Beilharz et al., 2017). Perceptual mirror retraining and self-exposure
are part of efficacious CBT packages (Wilhelm et al., 2010); however, these
components have not been examined independently, so it is unclear how much
they contribute to CBT outcomes.
Buhlmann et al. (2011) examined the effect of emotional recognition training
in 34 individuals with BDD and found an improvement in recognition of neutral
and scared expressions in the training condition relative to the non-training con-
dition. Although this was a one-session training session and looked at the imme-
diate effects of training, this type of intervention shows promise for an approach
targeting potential cognitive mechanisms or processes in the treatment of BDD.
Further research is needed to establish if such emotion recognition training and
other programs targeting the information processes, attentional biases, and basic
visual processing abnormalities can diminish these deficits in the long term, and
if this leads to BDD symptom reduction.
CONCLUSIO N
BDD affects approximately 2% of the population and involves excessive preoccu-

pation with perceived defects in appearance that appear slight or are not observ-
able to others. BDD is associated with high comorbidity, significant interference
in functioning, and suicidality. Stigma, poor insight, and limited understanding
of BDD contribute to low treatment-seeking and high rates of misdiagnosis, so
clinicians have a vital role in identifying BDD and providing access to treatment.
CBT and pharmacotherapy are both evidence-supported treatments for BDD,
but there are substantial gaps in the evidence base regarding treatment selec-
tion, predictors of treatment, and improving treatment outcomes. Sustained re-
search and clinical efforts are needed to reduce the burden of this misunderstood
disorder.
26
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32
Hair-Pulling Disorder
K A R A N . K E L L E Y, D E V I N D AT T O L I C O , C A R O L I N E S T R A N G ,
AND MARTHA J. FALKENSTEIN ■
Trichotillomania (TTM), otherwise known as hairpulling disorder, is

characterized by the recurrent pulling of one’s hair, resulting in hair loss and signif-
icant distress or impairment (American Psychiatric Association, 2013). Existing
data show that individuals with TTM may be less likely to seek treatment and ex-
perience higher levels of disability and lower life satisfaction compared to controls
(Woods et al., 2001). TTM can also result in a variety of physical consequences,
including hair loss, scalp irritation, and follicle damage.
Appropriate treatment for TTM has long been a complex topic of research.
The etiology of TTM remains poorly understood, and behavioral and pharma-
cological treatments currently have no standardized best practice. Traditional
treatment has several limitations that fail to account for the motivation and
maintenance of pulling behaviors. Given the highly idiosyncratic nature of TTM,
conceptualizations of the condition and approaches to treatment have evolved in
numerous ways over recent years. Unique treatment strategies paired with aspects
of traditional treatment have emerged as a novel way to tackle some of the com-
plexities of TTM. These recent developments in treatment aim to improve the
quality of life for those with TTM who are non-responders or prone to relapse.
This chapter discusses various theoretical models of TTM and developments in
behavioral and pharmacological treatments.
TREATMENT STRATEGIES
Treatment strategies for TTM have evolved greatly throughout the years. Habit
reversal training (HRT) has been considered the gold standard in TTM treat-
ment; however, not all individuals respond to HRT. In recent years, HRT has been
paired with third-wave cognitive therapies to address mechanisms of TTM that
HRT may not have been fully targeting. This evolution of behavioral treatments
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Jane stretched that ship to the limit. The Imp bobbed far behind.
Territory unreeled under her. The Stormbird loomed large again.
Both ships were goin’ their limit. The race settled down to a question
of which ship had the more speed and power and stamina, and the
victor would be decided by a very narrow margin. Jane kept the
throttle wide, and waited for the Alton to do its stuff—and it did.
Slowly she drew up. She kept the Alton on a level with the
Stormbird’s tail for a hundred miles. Then slowly the differences in
the ships began to tell. The Alton crept up. An inch. Another inch.
Another inch—forward always, at a mad airspeed, the motor blasting
like a demon loose out of hell, the whole ship shaking, the wires
screaming. The earth spun and veered. Another inch—another. Little
by little the Alton crept up on the Stormbird until, prop even with
prop, they drove ahead without either gainin’ a mite.
Once again the Stormbird began to slip back; and Jane—yes!—
tossed Mr. Stud Walker an ironic kiss!
Jane kept that ship howlin’. On she went. On. The skies began to
darken. The air got a little bumpy. The visibility dropped. The exhaust
tubes of the planes, white-hot, spouted orange fire. And Jane drove
on. Little by little, again, the Alton took its margin of lead.
What was that? Water! Long Island Sound! Only a few miles
away was the finish field!
Jane kept the plane drivin’. The Stormbird howled on the Alton’s
tail. Both planes were crazy flyin’ things—crazy.
Then the field, the big square! Closer and closer! Jane stepped
down to it, slowin’ as little as possible. Down she swooped, and the
ground swung up at her. She felt the trucks touch. She zipped across
the sand; she ground looped; she trundled back. And as she came to
a stop, and the crowd started for her, the Stormbird dropped out of
the sky.
Jane jumped out of her plane. She knew Ned wasn’t seriously
hurt, but he needed help, and to the first man she saw she shouted:
“Get a doctor!” Then, with reporters mobbin’ her, she just smiled,
gave her name and that of the plane, and waited until a fat man with
an official badge, head of the Committee, came up to her. Then she
said pertly:
“Well, I guess I won, didn’t I?”
The Committeeman was flabbergasted. He hadn’t expected to
see a girl. Reporters were yowlin’ for Jane’s name, and facts about
her, knowin’ that a girl hadn’t been scheduled to pilot the Alton, and
sensin’ a big story. The Committeeman muffed a few words, not
knowin’ what to do or say, but seein’ plain enough that she had got
to the field first.
Then a man in leather tunic and with goggle-prints around his
eyes came pushin’ through the crowd, with four other
Committeemen, all lookin’ indignant and outraged. That guy was
Walker—Walker was howlin’.
“There she is!” he yelped. “This race is bein’ run on the square,
ain’t it? Well, you can’t rate her winner. She isn’t the pilot that
belongs to that ship. Her name is Alton—the pilot registered for this
plane is named Knight!”
The Committeeman got red-faced and mad and still more
dignified. They waved a hand for silence and bellowed to the
reporters, after a hot and fast conference among themselves:
“The Alton is not the winner of this race. The Alton is not the
winner! It is disqualified because of irregularities. The official winner
of the race is the Stormbird, with Walker pilotin’!”
“Just a minute!” Jane spoke up, pert and clear. “Where are the
irregularities? The Alton has come through clean, without any. The
pilot of this ship is supposed to be Knight, and it wins the race
because my name is Knight!”
That’s a poser.
“I intended to fly this ship all along!” Jane declared. “And I win the
race—”
“Your name is Knight?” the Committeemen demanded in one big
voice.
“Yes, indeed,” said Jane. “Mrs. Ned Knight. It has been that since
last evenin’. So there!”
Whenever I see Jane comin’ onto the testin’ field of the big, boomin’,
prosperous Alton factory, to take a little sky-spin with her husband, I
size her up and sigh and tell myself all over again that that girl sure
looks right in a flyin’ suit!
THE END
Transcriber’s Note: This story appeared in the August 1928 issue

of Adventure magazine.
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Complexities in Obsessive Compulsive and Related Disorders Advances in Conceptualization and Treatment Eric A Storch Editor Full Chapter PDF

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Complexities in Obsessive Compulsive and Related Disorders Advances in Conceptualization and Treatment Eric A Storch Editor Full Chapter PDF

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Complexities in Obsessive Compulsive

and Related Disorders: Advances in

Language Intervention Strategies in Aphasia and Related

Aphasia and Related Neurogenic Communication Disorders

Treatment of Language Disorders in Children (CLI) 2nd

Neurology and Pregnancy: Neuro-Obstetric Disorders 1st

Unified Protocols for Transdiagnostic Treatment of

Unified Protocol for Transdiagnostic Treatment of

Cognitive Behavioral Treatment of Borderline

Articulation and Phonological Disorders: Speech Sound

ADVANCE PRAISE FOR COMPLEXITIES

EDITED BY ERIC A. STORCH,

Published in the United States of America by Oxford University Press

© Oxford University Press 2022

All rights reserved. No part of this publication may be reproduced, stored in

You must not circulate this work in any other form

Library of Congress Cataloging-​in-​Publication Data

Printed by Integrated Books International, United States of America

To Stacy, Emily, and Miriam with all my love.

To my loving wife Dawn, and our wonderful daughter Rebecca.

12. Tourette’s Disorder 201

Natalie E. Hundt, PhD Heidi J. Ojalehto, BS

David F. Tolin, PhD Shiu F. Wong, PhD

Frederick Aardema, PhD Fanie Collardeau, MSc, PhD

Obsessive-​compulsive disorder (OCD) was once considered a rare and untreat-

OCD is classified in the DSM-​5 (American Psychiatric Association, 2013) as an

PREVALENCE, COURSE, ASSOCIATED FEATURES,

The lifetime prevalence of OCD in the general adult population is between 2%

CLASSIFICATION OF OCD AND THE OCRDS

OCD as an Anxiety Disorder

Through DSM-​IV-​TR, OCD was considered an anxiety disorder along with

OCD in the DSM-​5

EVALUATING ARGUMENTS FOR THE

Repetitive Thoughts and Behaviors Are Distinguishing Features

• Vomiting is a symptom of bulimia nervosa.

The OCRDs Overlap in Terms of Their Demographic

The OCRDs Have Overlapping Neurobiological Etiologies

OCD and the OCRDs Share Similar Treatment

Is There a Uniform Response to SRIs Across the OCRDs?

Is a Preferential Response to SRIs Only Observed Among

Are SRIs the Best Treatment for OCRDs?

WHY THIS BOOK?

10 C omple x ities in O C R D s

12 C omple x ities in O C R D s

14 C omple x ities in O C R D s

Body Dysmorphic Disorder

16 C omple x ities in O C R D s

Muscle dysmorphia is a subtype of BDD involving unrealistic concerns that

Body Dysmorphic Disorder17

A face-​to-​face semistructured interview with a trained mental health professional

Although questionnaire measures cannot provide a diagnosis of BDD, they can

18 C omple x ities in O C R D s

Assessment in Young People

It is important to assess BDD symptoms in young people as subclinical BDD phe-

Assessment of Muscle Dysmorphia

Body Dysmorphic Disorder19

BDD is characterized by high levels of comorbidity; only 8% of adults with BDD

TREATMENT WITH COGNITIVE-​B EHAVIORAL THERAPY

The Cognitive-​Behavioral Model

Cognitive-​behavioral therapy (CBT) for BDD is guided by the cognitive-​behavioral

20 C omple x ities in O C R D s

This drives attention toward disliked appearance features, exacerbating negative

Core Treatment Elements

Library of Congress Cataloging-in-Publication Data

Obsessive-compulsive disorder (OCD) was once considered a rare and untreat-

OCD is classified in the DSM-5 (American Psychiatric Association, 2013) as an

Through DSM-IV-TR, OCD was considered an anxiety disorder along with

OCD in the DSM-5

10 C omple x ities in O C R D s

12 C omple x ities in O C R D s

14 C omple x ities in O C R D s

16 C omple x ities in O C R D s

Body Dysmorphic Disorder17

A face-to-face semistructured interview with a trained mental health professional

18 C omple x ities in O C R D s

Body Dysmorphic Disorder19

TREATMENT WITH COGNITIVE-B EHAVIORAL THERAPY

The Cognitive-Behavioral Model

Cognitive-behavioral therapy (CBT) for BDD is guided by the cognitive-behavioral

20 C omple x ities in O C R D s

Body Dysmorphic Disorder21

22 C omple x ities in O C R D s

Body Dysmorphic Disorder23

Pharmacotherapy is also an evidence-based treatment for BDD and, where pos-

24 C omple x ities in O C R D s

Body Dysmorphic Disorder25

psychotherapy (Wilhelm et al., 2019) and meta-cognitive therapy (Rabiei et al.,

26 C omple x ities in O C R D s

Abramowitz, J. S., & Jacoby, R. J. (2015). Obsessive-compulsive and related disorders: A

Body Dysmorphic Disorder27

28 C omple x ities in O C R D s

Body Dysmorphic Disorder29

30 C omple x ities in O C R D s

an obsessive-compulsive spectrum grouping of disorders be included in DSM-V?

Body Dysmorphic Disorder31

Trichotillomania (TTM), otherwise known as hair- pulling disorder, is