OBSESSIVE-COMPULSIVE AND RELATED

DISORDERS
According to the American Psychiatric Association (APA), the
publisher of the DSM-5, the major change for obsessive-
compulsive disorder is the fact that it and related disorders
now have their own chapter. They are no longer considered
“anxiety disorders.” This is due to increasing research evidence
demonstrating common threads running through a number of
OCD-related disorders — obsessive thoughts and/or repetitive
behaviors.
Disorders in this chapter include obsessive-compulsive
disorder, body dysmorphic disorder and trichotillomania (hair-
pulling disorder), as well as two new disorders: hoarding
disorder and excoriation (skin-picking) disorder.
OBSESSIVE-COMPULSIVE DISORDER
Obsessions:
OCD obsessions are repeated, persistent and unwanted urges
or images that cause distress or anxiety. You might try to get rid
of them by performing a compulsion or ritual. These obsessions
typically intrude when you're trying to think of or do other
things.
 Obsessions often have themes to them, such as:
 Fear of contamination or dirt
 Having things orderly and symmetrical
 Aggressive or horrific thoughts about harming yourself or
others
 Unwanted thoughts, including aggression, or sexual or
religious subjects
OBSESSIVE-COMPULSIVE DISORDER
Examples of obsession signs and symptoms include:
 Fear of being contaminated by shaking hands or by touching
objects others have touched
 Doubts that you've locked the door or turned off the stove
 Intense stress when objects aren't orderly or facing a certain
way
 Images of hurting yourself or someone else
 Thoughts about shouting obscenities or acting
inappropriately
 Avoidance of situations that can trigger obsessions, such as
shaking hands
 Distress about unpleasant sexual images repeating in your
mind
OBSESSIVE-COMPULSIVE DISORDER
Compulsions:
OCD compulsions are repetitive behaviors that you feel driven to
perform. These repetitive behaviors are meant to prevent or reduce
anxiety related to your obsessions or prevent something bad from
happening. However, engaging in the compulsions brings no pleasure
and may offer only a temporary relief from anxiety.
 You may also make up rules or rituals to follow that help control your
anxiety when you're having obsessive thoughts. These compulsions
are often not rationally connected to preventing the feared event.
 As with obsessions, compulsions typically have themes, such as:
 Washing and cleaning
 Counting
 Checking
 Demanding reassurances
 Following a strict routine
 Orderliness
OBSESSIVE-COMPULSIVE AND RELATED
DISORDERS
Examples of compulsion signs and symptoms
include:
 Hand-washing until your skin becomes raw
 Checking doors repeatedly to make sure they're
locked
 Checking the stove repeatedly to make sure it's off
 Counting in certain patterns
 Silently repeating a prayer, word or phrase
 Arranging your canned goods to face the same way
 INSIGHT & TIC SPECIFIERS FOR OBSESSIVE-
COMPULSIVE AND RELATED DISORDERS
The old DSM-IV specifier with poor insight has been modified from being a black-
and-white specifier, to allowing for some degrees on a spectrum of insight:
 Good or fair insight
 Poor insight
 Absent insight/delusional obsessive-compulsive disorder beliefs (i.e.,
complete conviction that obsessive-compulsive disorder beliefs are true)
These same insight specifiers have been included for body dysmorphic disorder
and hoarding disorder as well. “These specifiers are intended to improve
differential diagnosis by emphasizing that individuals with these two disorders
may present with a range of insight into their disorder-related beliefs, including
absent insight/delusional symptoms,” according to the APA.

This change also emphasizes that the presence of absent insight/delusional

beliefs warrants a diagnosis of the relevant obsessive-compulsive or related
disorder, rather than a schizophrenia spectrum and other psychotic disorder.
 BODY DYSMORPHIC DISORDER
Body dysmorphic disorder in the DSM-5 remains largely unchanged
from DSM-IV, but does include one additional criterion. This criterion
describes repetitive behaviors or mental acts in response to
preoccupations with perceived defects or flaws in physical appearance.
It was added to the DSM-5, according to the APA, to be consistent with
data indicating the prevalence and importance of this symptom.
 A with muscle dysmorphia specifier has been added to reflect the
research data, suggesting this is an important distinction to make for
this disorder.
 The delusional variant of body dysmorphic disorder (which identifies
individuals who are completely convinced that their perceived defects
or flaws are truly abnormal appearing) is no longer coded as both
delusional disorder, somatic type, and body dysmorphic disorder.
Instead, it gets the new “absent/delusional beliefs” specifier.
BODY DYSMORPHIC DISORDER
Signs and symptoms of body dysmorphic disorder include:
 Preoccupation with your physical appearance with extreme self-
consciousness
 Frequent examination of yourself in the mirror, or the opposite, avoidance of
mirrors altogether
 Strong belief that you have an abnormality or defect in your appearance that
makes you ugly
 Belief that others take special notice of your appearance in a negative way
 Avoidance of social situations
 Feeling the need to stay housebound
 The need to seek reassurance about your appearance from others
 Frequent cosmetic procedures with little satisfaction
 Excessive grooming, such as hair plucking or skin picking, or excessive
exercise in an unsuccessful effort to improve the flaw
 The need to grow a beard or wear excessive makeup or clothing to
camouflage perceived flaws
 Comparison of your appearance with that of others
 Reluctance to appear in pictures
HOARDING DISORDER
Hoarding disorder graduates from being listed as just one symptom
of obsessive-compulsive personality disorder in the DSM-IV, to a full-
blown diagnostic category in the DSM-5. After the DSM-5 OCD
working group examined the research literature on hoarding, they
found little support to suggest this was simply a variant of a
personality disorder, or a component of another mental disorder.
 Hoarding disorder is characterized by the persistent difficulty
discarding or parting with possessions, regardless of the value
others may attribute to these possessions, according to the APA’s
new criteria:
 The behavior usually has harmful effects — emotional, physical,
social, financial, and even legal — for the person suffering from
the disorder and family members. For individuals who hoard, the
quantity of their collected items sets them apart from people with
normal collecting behaviors. They accumulate a large number of
possessions that often fill up or clutter active living areas of the
home or workplace to the extent that their intended use is no
longer possible.
HOARDING DISORDER
 Symptoms of the disorder cause clinically significant distress or
impairment in social, occupational or other important areas of
functioning including maintaining an environment for self and/or
others. While some people who hoard may not be particularly distressed
by their behavior, their behavior can be distressing to other people, such
as family members or landlords.
 Hoarding disorder is included in DSM-5 because research shows that it
is a distinct disorder with distinct treatments. Using DSM-IV, individuals
with pathological hoarding behaviors could receive a diagnosis of
obsessive-compulsive disorder (OCD), obsessive-compulsive personality
disorder, anxiety disorder not otherwise specified or no diagnosis at all,
since many severe cases of hoarding are not accompanied by obsessive
or compulsive behavior. Creating a unique diagnosis in DSM-5 will
increase public awareness, improve identification of cases, and
stimulate both research and the development of specific
treatments for hoarding disorder.
HOARDING DISORDER

 This is particularly important as studies show

that the prevalence of hoarding disorder is
estimated at approximately two to five percent
of the population. These behaviors can often
be quite severe and even threatening. Beyond
the mental impact of the disorder, the
accumulation of clutter can create a public
health issue by completely filling people’s
homes and creating fall and fire hazards
HOARDING DISORDER
 Hoarding affects emotions, thoughts and behavior. Signs and
symptoms of hoarding may include:
 Cluttered living spaces
 Inability to discard items
 Keeping stacks of newspapers, magazines or junk mail
 Moving items from one pile to another, without discarding anything
 Acquiring unneeded or seemingly useless items, including trash or
napkins from a restaurant
 Difficulty managing daily activities, including procrastination and
trouble making decisions
 Difficulty organizing items
 Shame or embarrassment
 Excessive attachment to possessions, including discomfort letting
others touch or borrow possessions
 Limited or no social interactions
TRICHOTILLOMANIA (HAIR-PULLING DISORDER)

This disorder remains largely unchanged from the DSM-

IV, although the name has been updated to add “Hair-
pulling disorder” (we guess because people didn’t know
whattrichotillomania actually meant).
TRICHOTILLOMANIA (HAIR-PULLING DISORDER)

Signs and symptoms of trichotillomania often include:

 Repeatedly pulling your hair out, typically from your scalp, eyebrows
or eyelashes, but can be from other body areas, and sites may vary
over time
 An increasing sense of tension before pulling, or when you try to
resist pulling
 A sense of pleasure or relief after the hair is pulled
 Shortened hair or thinned or bald areas on the scalp or other areas
of your body, including sparse or missing eyelashes or eyebrows
 Preference for specific types of hair, rituals that accompany hair
pulling or patterns of hair pulling
 Biting, chewing or eating pulled-out hair
 Playing with pulled-out hair or rubbing it across your lips or face
EXCORIATION (SKIN-PICKING) DISORDER
Excoriation (skin-picking) disorder is a new disorder added to the
DSM-5. It is estimated that between 2 and 4 percent of the
population could be diagnosed with this disorder, and there exists a
large research base that supports this new diagnostic category.
Resulting problems may include medical issues such as infections,
skin lesions, scarring and physical disfigurement.
 According to the APA, this disorder is characterized by constant
and recurrent picking at your skin, resulting in skin lesions.
“Individuals with excoriation disorder must have made repeated
attempts to decrease or stop the skin
picking, which must cause clinically significant distress or
impairment in social, occupational or other important areas of
functioning. The symptoms must not be better explained by
symptoms of another mental disorder.”
EXCORIATION (SKIN-PICKING) DISORDER
Specific DSM-5 criteria for excoriation disorder are as
follows:
 Recurrent skin-picking, resulting in lesions
 Repeated attempts to decrease or stop skin picking
 The skin picking causes clinically significant distress or
impairment in important areas of functioning
 The skin picking cannot be attributed to the physiologic
effects of a substance or another medical condition
 The skin picking cannot be better explained by the
symptoms of another mental disorder
OTHER SPECIFIED AND UNSPECIFIED OBSESSIVE-
COMPULSIVE AND RELATED DISORDERS
DSM-5 includes the diagnoses other specified obsessive-
compulsive and related disorders. These disorders can
include conditions such as body-focused repetitive behavior
disorder and obsessional jealousy, or unspecified
obsessive-compulsive and related disorder.
 Body-focused repetitive behavior disorder, for instance, is
characterized by recurrent behaviors other than hair
pulling and skin picking (e.g., nail biting, lip biting, cheek
chewing) and repeated attempts to decrease or stop the
behaviors.
 Obsessional jealousy is characterized by nondelusional
preoccupation with a partner’s perceived infidelity.