6. Obsessive, Compulsive and Related Disorders
6.1. Obsessive-Compulsive Disorder
6.2. Body Dysmorphic Disorder
6.3. Hoarding Disorder
6.4. Trichotillomania (Hair-Pulling Disorder)
6.5. Excoriation (Skin-Picking) Disorder
6.6. Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
ObSGSSiVG-COmpulsiVG and related disorders include obsessive-compulsive
disorder (OCD), body dysmorphic disorder, hoarding disorder, trichotillomania (hairpulling
disorder), excoriation (skin-picking) disorder, substance/medication-induced obsessive-
compulsive and related disorder, obsessive-compulsive and related disorder due
to another medical condition, and other specified obsessive-compulsive and related disorder
and unspecified obsessive-compulsive and related disorder (e.g., body-focused repetitive
behavior disorder, obsessional jealousy).
OCD is characterized by the presence of obsessions and/or compulsions. Obsessions are recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted, whereas compulsions are repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. Some other obsessive-compulsive and related disorders are also characterized by preoccupations and by repetitive behaviors or mental acts in response to the preoccupations. Other obsessive-compulsive and related disorders are characterized primarily by recurrent body-focused repetitive behaviors (e.g., hair pulling, skin picking) and repeated attempts to decrease or stop the behaviors. The inclusion of a chapter on obsessive-compulsive and related disorders in DSM-5 reflects the increasing evidence of these disorders' relatedness to one another in terms of a range of diagnostic validators as well as the clinical utility of grouping these disorders in the same chapter. Clinicians are encouraged to screen for these conditions in individuals who present with one of them and be aware of overlaps between these conditions. At the same time, there are important differences in diagnostic validators and treatment approaches across these disorders. Moreover, there are close relationships between the anxiety disorders and some of the obsessive-compulsive and related disorders (e.g., OCD), which is reflected in the sequence of DSM-5 chapters, with obsessive-compulsive and related disorders following anxiety disorders.
The obsessive-compulsive and related disorders differ from developmentally normative preoccupations and rituals by being excessive or persisting beyond developmentally appropriate periods. The distinction between the presence of subclinical symptoms and a clinical disorder requires assessment of a number of factors, including the individual's level of distress and impairment in functioning. The chapter begins with OCD. It then covers body dysmorphic disorder and hoarding disorder, which are characterized by cognitive symptoms such as perceived defects or flaws in physical appearance or the perceived need to save possessions, respectively. The chapter then covers trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder, which are characterized by recurrent body-focused repetitive behaviors. Finally, it covers substance/medication-induced obsessive-compulsive and related disorder, obsessive-compulsive and related disorder due to another medical condition, and other specified obsessive-compulsive and related disorder and unspecified obsessive-compulsive and related disorder.
While the specific content of obsessions and compulsions varies among individuals, certain symptom dimensions are common in OCD, including those of cleaning (contamination obsessions and cleaning compulsions); symmetry (symmetry obsessions and repeating, ordering, and counting compulsions); forbidden or taboo thoughts (e.g., aggressive, sexual, and religious obsessions and related compulsions); and harm (e.g., fears of harm to oneself or others and related checking compulsions). The tic-related specifier of OCD is used v^hen an individual has a current or past history of a tic disorder. Body dysmorphic disorder is characterized by preoccupation with one or more perceived defects or flav^s in physical appearance that are not observable or appear only slight to others, and by repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (e.g., comparing one's appearance v^ith that of other people) in response to the appearance concerns. The appearance preoccupations are not better explained by concerns with body fat or weight in an individual with an eating disorder. Muscle dysmoφhia is a form of body dysmorphic disorder that is characterized by the belief that one's body build is too small or is insufficiently muscular. Hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, regardless of their actual value, as a result of a strong perceived need to save the items and to distress associated with discarding them. Hoarding disorder differs from normal collecting. For example, symptoms of hoarding disorder result in the accumulation of a large number of possessions that congest and clutter active living areas to the extent that their intended use is substantially compromised. The excessive acquisition form of hoarding disorder, which characterizes most but not all individuals with hoarding disorder, consists of excessive collecting, buying, or stealing of items that are not needed or for which there is no available space.
Trichotillomania (hair-pulling disorder) is characterized by recurrent pulling out of one's hair resulting in hair loss, and repeated attempts to decrease or stop hair pulling. Excoriation (skin-picking) disorder is characterized by recurrent picking of one's skin resulting in skin lesions and repeated attempts to decrease or stop skin picking. The bodyfocused repetitive behaviors that characterize these two disorders are not triggered by obsessions or preoccupations; however, they may be preceded or accompanied by various emotional states, such as feelings of anxiety or boredom. They may also be preceded by an increasing sense of tension or may lead to gratification, pleasure, or a sense of relief when the hair is pulled out or the skin is picked. Individuals with these disorders may have varying degrees of conscious awareness of the behavior while engaging in it, with some individuals displaying more focused attention on the behavior (with preceding tension and subsequent relief) and other individuals displaying more automatic behavior (with the behaviors seeming to occur without full awareness).
Substance/medication-induced obsessive-compulsive and related disorder consists of symptoms that are due to substance intoxication or withdrawal or to a medication. Obsessive- compulsive and related disorder due to another medical condition involves symptoms characteristic of obsessive-compulsive and related disorders that are the direct pathophysiological consequence of a medical disorder. Other specified obsessive-compulsive and related disorder and unspecified obsessive-compulsive and related disorder consist of symptoms that do not meet criteria for a specific obsessive-compulsive and related disorder because of atypical presentation or uncertain etiology; these categories are also used for other specific syndromes that are not listed in Section Π and when insufficient information is available to diagnose the presentation as another obsessive-compulsive and related disorder. Examples of specific syndromes not listed in Section Π, and therefore diagnosed as other specified obsessive- compulsive and related disorder or as unspecified obsessive-compulsive and related disorder include body-focused repetitive behavior disorder and obsessional jealousy. Obsessive-compulsive and related disorders that have a cognitive component have insight as the basis for specifiers; in each of these disorders, insight ranges from "good or fair insight" to "poor insight" to "absent insight/delusional beliefs" with respect to disorderrelated beliefs. For individuals whose obsessive-compulsive and related disorder symptoms warrant the "with absent insight/delusional beliefs" specifier, these symptoms should not be diagnosed as a psychotic disorder.
The characteristic symptoms of OCD are the presence of obsessions and compulsions (Criterion
A). Obsessions are repetitive and persistent thoughts (e.g., of contamination), images
(e.g., of violent or horrific scenes), or urges (e.g., to stab someone). Importantly, obsessions
are not pleasurable or experienced as voluntary: they are intrusive and unwanted and
cause marked distress or anxiety in most individuals. The individual attempts to ignore or
suppress these obsessions (e.g., avoiding triggers or using thought suppression) or to neutralize
them with another thought or action (e.g., performing a compulsion). Compulsions
(or rituals) are repetitive behaviors (e.g., washing, checking) or mental acts (e.g., counting,
repeating words silently) that the individual feels driven to perform in response to an
obsession or according to rules that must be applied rigidly. Most individuals with OCD
have both obsessions and compulsions. Compulsions are typically performed in response
to an obsession (e.g., thoughts of contamination leading to washing rituals or that something
is incorrect leading to repeating rituals until it feels "just right")・ The aim is to reduce
the distress triggered by obsessions or to prevent a feared event (e.g., becoming ill). However,
these compulsions either are not connected in a realistic way to the feared event (e.g.,
arranging items symmetrically to prevent harm to a loved one) or are clearly excessive
(e.g., showering for hours each day). Compulsions are not done for pleasure, although some
individuals experience relief from anxiety or distress.
Criterion B emphasizes that obsessions and compulsions must be time-consuming (e.g., more than 1 hour per day) or cause clinically significant distress or impairment to warrant a diagnosis of OCD. This criterion helps to distinguish the disorder from the occasional intmsive thoughts or repetitive behaviors that are common in the general population (e.g., double-checking that a door is locked). The frequency and severity of obsessions and compulsions vary across individuals with OCD (e.g., some have mild to moderate symptoms, spending 1-3 hours per day obsessing or doing compulsions, whereas others have nearly constant intmsive thoughts or compulsions that can be incapacitating).
The specific content of obsessions and compulsions varies between individuals. However,
certain themes, or dimensions, are common, including those of cleaning (contamination
obsessions and cleaning compulsions); symmetry (symmetry obsessions and repeating.
ordering, and counting compulsions); forbidden or taboo thoughts (e.g., aggressive, sexual,
or religious obsessions and related compulsions); and harm (e.g., fears of harm to oneself
or others and checking compulsions). Some individuals also have difficulties discarding
and accumulate (hoard) objects as a consequence of typical obsessions and compulsions,
such as fears of harming others. These themes occur across different cultures, are relatively
consistent over time in adults w^ith the disorder, and may be associated v^ith different
neural substrates. Importantly, individuals often have symptoms in more than one
Individuals with OCD experience a range of affective responses when confronted with situations that trigger obsessions and compulsions. For example, many individuals experience marked anxiety that can include recurrent panic attacks. Others report strong feelings of disgust. While performing compulsions, some individuals report a distressing sense of "incompleteness" or uneasiness until things look, feel, or sound "just right." It is common for individuals with the disorder to avoid people, places, and things that trigger obsessions and compulsions. For example, individuals with contamination concerns might avoid public situations (e.g., restaurants, public restrooms) to reduce exposure to feared contaminants; individuals with intrusive thoughts about causing harm might avoid social interactions.
The 12-month prevalence of OCD in the United States is 1.2%, with a similar prevalence internationally (1.1%-1.8%). Females are affected at a shghtly higher rate than males in adulthood, although males are more commonly affected in childhood.
OCD occurs across the world. There is substantial similarity across cultures in the gender distribution, age at onset, and comorbidity of OCD. Moreover, around the globe, there is a similar symptom structure involving cleaning, symmetry, hoarding, taboo thoughts, or fear of harm. However, regional variation in symptom expression exists, and cultural factors may shape the content of obsessions and compulsions.
Males have an earlier age at onset of OCD than females and are more likely to have comorbid tic disorders. Gender differences in the pattern of symptom dimensions have been reported, with, for example, females more likely to have symptoms in the cleaning dimension and males more likely to have symptoms in the forbidden thoughts and symmetry dimensions. Onset or exacerbation of OCD, as well as symptoms that can interfere with the mother-infant relationship (e.g., aggressive obsessions leading to avoidance of the infant), have been reported in the peripartum period.
Suicidal thoughts occur at some point in as many as about half of individuals with OCD. Suicide attempts are also reported in up to one-quarter of individuals with OCD; the presence of comorbid major depressive disorder increases the risk.
OCD is associated with reduced quality of life as well as high levels of social and occupational
impairment. Impairment occurs across many different domains of life and is associated
with symptom severity. Impairment can be caused by the time spent obsessing and
doing compulsions. Avoidance of situations that can trigger obsessions or compulsions
can also severely restrict functioning. In addition, specific symptoms can create specific
obstacles. For example, obsessions about harm can make relationships with family and
friends feel hazardous; the result can be avoidance of these relationships. Obsessions
about symmetry can derail the timely completion of school or work projects because the
project never feels "just right," potentially resulting in school failure or job loss. Health
consequences can also occur. For example, individuals with contamination concerns may
avoid doctors' offices and hospitals (e.g., because of fears of exposure to germs) or develop
dermatological problems (e.g., skin lesions due to excessive washing). Sometimes the
symptoms of the disorder interfere with its own treatment (e.g., when medications are considered
contaminated). When the disorder starts in childhood or adolescence, individuals
may experience developmental difficulties. For example, adolescents may avoid socializing
with peers; young adults may struggle when they leave home to live independently.
The result can be few significant relationships outside the family and a lack of autonomy
and financial independence from their family of origin. In addition, some individuals with
OCD try to impose rules and prohibitions on family members because of their disorder
(e.g., no one in the family can have visitors to the house for fear of contamination), and this
can lead to family dysfunction.
Individuals with body dysmorphic disorder (formerly known as dysmorphophobia) are preoccupied
with one or more perceived defects or flaws in their physical appearance, which
they believe look ugly, unattractive, abnormal, or deformed (Criterion A). The perceived
flaws are not observable or appear only slight to other individuals. Concerns range from
looking "unattractive" or "not right" to looking "hideous" or "like a monster." Preoccupations
can focus on one or many body areas, most commonly the skin (e.g., perceived
acne, scars, lines, wrinkles, paleness), hair (e.g., "thinning" hair or "excessive" body or facial
hair), or nose (e.g., size or shape). However, any body area can be the focus of concern
(e.g., eyes, teeth, weight, stomach, breasts, legs, face size or shape, lips, chin, eyebrows,
genitals). Some individuals are concerned about perceived asymmetry of body areas. The
preoccupations are intrusive, unwanted, time-consuming (occurring, on average, 3-8
hours per day), and usually difficult to resist or control.
Excessive repetitive behaviors or mental acts (e.g., comparing) are performed in response to the preoccupation (Criterion B). The individual feels driven to perform these behaviors, which are not pleasurable and may increase anxiety and dysphoria. They are typically time-consuming and difficult to resist or control. Common behaviors are comparing one's appearance with that of other individuals; repeatedly checking perceived defects in mirrors or other reflecting surfaces or examining them directly; excessively grooming (e.g., combing, styling, shaving, plucking, or pulling hair); camouflaging (e.g., repeatedly applying makeup or covering disliked areas with such things as a hat, clothing, makeup, or hair); seeking reassurance about how the perceived flaws look; touching disliked areas to check them; excessively exercising or weight lifting; and seeking cosmetic procedures. Some individuals excessively tan (e.g., to darken "pale" skin or diminish perceived acne), repeatedly change their clothes (e.g., to camouflage perceived defects), or compulsively shop (e.g., for beauty products). Compulsive skin picking intended to improve perceived skin defects is common and can cause skin damage, infections, or ruptured blood vessels. The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion C); usually both are present. Body dysmoφhic disorder must be differentiated from an eating disorder.
Muscle dysmorphia, a form of body dysmoφhic disorder occurring almost exclusively in males, consists of preoccupation with the idea that one's body is too small or insufficiently lean or muscular. Individuals with this form of the disorder actually have a normal- looking body or are even very muscular. They may also be preoccupied with other body areas, such as skin or hair. A majority (but not all) diet, exercise, and/or lift weights excessively, sometimes causing bodily damage. Some use potentially dangerous anabolicandrogenic steroids and other substances to try to make their body bigger and more muscular. Body dysmorphic disorder by proxy is a form of body dysmorphic disorder in which individuals are preoccupied with defects they perceive in another person's appearance. Insight regarding body dysmorphic disorder beliefs can range from good to absent/ delusional (i.e., delusional beliefs consisting of complete conviction that the individual's view of their appearance is accurate and undistorted). On average, insight is poor; onethird or more of individuals currently have delusional body dysmorphic disorder beliefs.
Individuals with delusional body dysmorphic disorder tend to have greater morbidity in some areas (e.g., suicidality), but this appears accounted for by their tendency to have more severe body dysmorphic disorder symptoms.
Many individuals with body dysmorphic disorder have ideas or delusions of reference,
believing that other people take special notice of them or mock them because of how they
look. Body dysmorphic disorder is associated with high levels of anxiety, social anxiety,
social avoidance, depressed mood, neuroticism, and perfectionism as well as low extroversion
and low self-esteem. Many individuals are ashamed of their appearance and their
excessive focus on how they look, and are reluctant to reveal their concerns to others. A
majority of individuals receive cosmetic treatment to try to improve their perceived defects.
Dermatological treatment and surgery are most common, but any type (e.g., dental,
electrolysis) may be received. Occasionally, individuals may perform surgery on themselves.
Body dysmorphic disorder appears to respond poorly to such treatments and
sometimes becomes worse. Some individuals take legal action or are violent toward the
clinician because they are dissatisfied with the cosmetic outcome.
Body dysmorphic disorder has been associated with executive dysfunction and visual processing abnormalities, with a bias for analyzing and encoding details rather than holistic or configurai aspects of visual stimuli. Individuals with this disorder tend to have a bias for negative and threatening interpretations of facial expressions and ambiguous scenarios.
The point prevalence among U.S. adults is 2.4% (2.5% in females and 2.2% in males). Outside the United States (i.e., Germany), current prevalence is approximately 1.7%-1,8%, with a gender distribution similar to that in the United States. The current prevalence is 9%-15% among dermatology patients, 7%-8% among U.S. cosmetic surgery patients, 3%- 16% among international cosmetic surgery patients (most studies), 8% among adult orthodontia patients, and 10% among patients presenting for oral or maxillofacial surgery.
Body dysmorphic disorder has been reported internationally. It appears that the disorder may have more similarities than differences across races and cultures but that cultural values and preferences may influence symptom content to some degree. Taijin kyofusho, included in the traditional Japanese diagnostic system, has a subtype similar to body dysmorphic disorder: shubo-kyofu ("the phobia of a deformed body").
Females and males appear to have more similarities than differences in terms of most clinical features— for example, disliked body areas, types of repehtive behaviors, symptom severity, suicidality, comorbidity, illness course, and receipt of cosmetic procedures for body dysmorphic disorder. However, males are more likely to have genital preoccupations, and females are more likely to have a comorbid eating disorder. Muscle dysmorphia occurs almost exclusively in males.
Rates of suicidal ideation and suicide attempts are high in both adults and children/adolescents with body dysmorphic disorder. Furthermore, risk for suicide appears high in adolescents. A substantial proportion of individuals attribute suicidal ideation or suicide attempts primarily to their appearance concerns. Individuals with body dysmorphic disorder have many risk factors for completed suicide, such as high rates of suicidal ideation and suicide attempts, demographic characteristics associated with suicide, and high rates of comorbid major depressive disorder.
Nearly all individuals with body dysmorphic disorder experience impaired psychosocial
functioning because of their appearance concerns. Impairment can range from moderate
(e.g., avoidance of some social situations) to extreme and incapacitating (e.g., being completely
housebound). On average, psychosocial functioning and quality of life are markedly
poor. More severe body dysmorphic disorder symptoms are associated with poorer
functioning and quality of life. Most individuals experience impairment in their job, academic,
or role functioning (e.g., as a parent or caregiver), which is often severe (e.g., performing
poorly, missing school or work, not working). About 20% of youths with body
dysmorphic disorder report dropping out of school primarily because of their body dysmorphic
disorder symptoms. Impairment in social functioning (e.g., social activities, relationships,
intimacy), including avoidance, is common. Individuals may be housebound
because of their body dysmorphic disorder symptoms, sometimes for years. A high proportion
of adults and adolescents have been psychiatrically hospitalized.
The essential feature of hoarding disorder is persistent difficulties discarding or parting
with possessions, regardless of their actual value (Criterion A). The term persistent indicates
a long-standing difficulty rather than more transient life circumstances that may lead
to excessive clutter, such as inheriting property. The difficulty in discarding possessions
noted in Criterion A refers to any form of discarding, including throwing away, selling,
giving away, or recycling. The main reasons given for these difficulties are the perceived
utility or aesthetic value of the items or strong sentimental attachment to the possessions.
Some individuals feel responsible for the fate of their possessions and often go to great
lengths to avoid being wasteful. Fears of losing important information are also common.
The most commonly saved items are newspapers, magazines, old clothing, bags, books,
mail, and paperwork, but virtually any item can be saved. The nature of items is not limited
to possessions that most other people would define as useless or of limited value.
Many individuals collect and save large numbers of valuable things as well, which are often
found in piles mixed with other less valuable items.
Individuals with hoarding disorder purposefully save possessions and experience distress when facing the prospect of discarding them (Criterion B). This criterion emphasizes that the saving of possessions is intentional, which discriminates hoarding disorder from other forms of psychopathology that are characterized by the passive accumulation of items or the absence of distress when possessions are removed.
Individuals accumulate large numbers of items that fill up and clutter active living areas to the extent that their intended use is no longer possible (Criterion C). For example, the individual may not be able to cook in the kitchen, sleep in his or her bed, or sit in a chair. If the space can be used, it is only with great difficulty. Clutter is defined as a large group of usually unrelated or marginally related objects piled together in a disorganized fashion in spaces designed for other purposes (e.g., tabletops, floor, hallway). Criterion C emphasizes the ''active" living areas of the home, rather than more peripheral areas, such as garages, attics, or basements, that are sometimes cluttered in homes of individuals without hoarding disorder. However, individuals with hoarding disorder often have possessions that spill beyond the active living areas and can occupy and impair the use of other spaces, such as vehicles, yards, the workplace, and friends' and relatives' houses. In some cases, living areas may be uncluttered because of the intervention of third parties (e.g., family members, cleaners, local authorities). Individuals who have been forced to clear their homes still have a symptom picture that meets criteria for hoarding disorder because the lack of clutter is due to a third-party intervention. Hoarding disorder contrasts with normative collecting behavior, which is organized and systematic, even if in some cases the actual amount of possessions may be similar to the amount accumulated by an individual with hoarding disorder. Normative collecting does not produce the clutter, distress, or impairment typical of hoarding disorder.
Symptoms (i.e., difficulties discarding and/or clutter) must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, including maintaining a safe environment for self and others (Criterion D). In some cases. particularly when there is poor insight, the individual may not report distress, and the impairment may apparent only to those around the individual. Hov^ever, any attempts to discard or clear the possessions by third parties result in high levels of distress.
Other common features of hoarding disorder include indecisiveness, perfectionism, avoidance, procrastination, difficulty planning and organizing tasks, and distractibility. Some individuals with hoarding disorder live in unsanitary conditions that may be a logical consequence of severely cluttered spaces and/or that are related to planning and organizing difficulties. Animal hoarding can be defined as the accumulation of a large number of animals and a failure to provide minimal standards of nutrition, sanitation, and veterinary care and to act on the deteriorating condition of the animals (including disease, starvation, or death) and the environment (e.g., severe overcrowding, extremely unsanitary conditions). Animal hoarding may be a special manifestation of hoarding disorder. Most individuals who hoard animals also hoard inanimate objects. The most prominent differences between animal and object hoarding are the extent of unsanitary conditions and the poorer insight in animal hoarding.
Nationally representative prevalence studies of hoarding disorder are not available. Community surveys estimate the point prevalence of clinically significant hoarding in the United States and Europe to be approximately 2%-6%. Hoarding disorder affects both males and females, but some epidemiological studies have reported a significantly greater prevalence among males. This contrasts with clinical samples, which are predominantly female. Hoarding symptoms appear to be almost three times more prevalent in older adults (ages 55-94 years) compared with younger adults (ages 34-44 years).
Hoarding appears to begin early in life and spans well into the late stages. Hoarding symptoms may first emerge around ages 11-15 years, start interfering with the individual's everyday functioning by the mid-20s, and cause clinically significant impairment by the mid-30s. Participants in clinical research studies are usually in their 50s. Thus, the severity of hoarding increases with each decade of life. Once symptoms begin, the course of hoarding is often chronic, with few individuals reporting a waxing and waning course. Pathological hoarding in children appears to be easily distinguished from developmentally adaptive saving and collecting behaviors. Because children and adolescents typically do not control their living environment and discarding behaviors, the possible intervention of third parties (e.g., parents keeping the spaces usable and thus reducing interference) should be considered when making the diagnosis.
Temperamental. Indecisiveness is a prominent feature of individuals with hoarding disorder
and their first-degree relatives.
Environmental. Individuals with hoarding disorder often retrospectively report stressful and traumatic life events preceding the onset of the disorder or causing an exacerbation.
Genetic and physiological. Hoarding behavior is familial, with about 50% of individuals who hoard reporting having a relative who also hoards. Twin studies indicate that approximately 50% of the variability in hoarding behavior is attributable to additive genetic factors.
While most of the research has been done in Western, industrialized countries and urban communities, the available data from non-Western and developing countries suggest that hoarding is a universal phenomenon with consistent clinical features.
The key features of hoarding disorder (i.e., difficulties discarding, excessive amount of clutter) are generally comparable in males and females, but females tend to display more excessive acquisition, particularly excessive buying, than do males.
Clutter impairs basic activities, such as moving through the house, cooking, cleaning, personal
hygiene, and even sleeping. Appliances may be broken, and utilities such as water
and electricity may be disconnected, as access for repair work may be difficult. Quality of
life is often considerably impaired. In severe cases, hoarding can put individuals at risk for
fire, falling (especially elderly individuals), poor sanitation, and other health risks. Hoarding
disorder is associated with occupational impairment, poor physical health, and high
social service utilization. Family relationships are frequently under great strain. Conflict
with neighbors and local authorities is common, and a substantial proportion of individuals
with severe hoarding disorder have been involved in legal eviction proceedings, and
some have a history of eviction.
The essential feature of trichotillomania (hair-pulling disorder) is the recurrent pulling out of one's own hair (Criterion A). Hair pulling may occur from any region of the body in which hair grows; the most common sites are the scalp, eyebrows, and eyelids, while less common sites are axillary, facial, pubic, and peri-rectal regions. Hair-pulling sites may vary over time. Hair pulling may occur in brief episodes scattered throughout the day or during less frequent but more sustained periods that can continue for hours, and such hair pulling may endure for months or years. Criterion A requires that hair pulling lead to hair loss, although individuals with this disorder may pull hair in a widely distributed pattern (i.e., pulling single hairs from all over a site) such that hair loss may not be clearly visible. Alternatively, individuals may attempt to conceal or camouflage hair loss (e.g., by using makeup, scarves, or wigs). Individuals with trichotillomania have made repeated attempts to decrease or stop hair pulling (Criterion B). Criterion C indicates that hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The term distress includes negative affects that may be experienced by individuals with hair pulling, such as feeling a loss of control, embarrassment, and shame. Significant impairment may occur in several different areas of functioning (e.g., social, occupational, academic, and leisure), in part because of avoidance of work, school, or other public situations.
Hair pulling may be accompanied by a range of behaviors or rituals involving hair. Thus,
individuals may search for a particular kind of hair to pull (e.g., hairs with a specific texture
or color), may try to pull out hair in a specific way (e.g., so that the root comes out intact),
or may visually examine or tactilely or orally manipulate the hair after it has been
pulled (e.g., rolling the hair between the fingers, pulling the strand between the teeth, biting
the hair into pieces, or swallowing the hair).
Hair pulling may also be preceded or accompanied by various emotional states; it may be triggered by feelings of anxiety or boredom, may be preceded by an increasing sense of tension (either immediately before pulling out the hair or when attempting to resist the urge to pull), or may lead to gratification, pleasure, or a sense of relief when the hair is pulled out. Hair-pulling behavior may involve varying degrees of conscious awareness, with some individuals displaying more focused attention on the hair pulling (with preceding tension and subsequent relief), and other individuals displaying more automatic behavior (in which the hair pulling seems to occur without full awareness). Many individuals report a mix of both behavioral styles. Some individuals experience an "itch-like" or tingling sensation in the scalp that is alleviated by the act of pulling hair. Pain does not usually accompany hair pulling.
Patterns of hair loss are highly variable. Areas of complete alopecia, as well as areas of thinned hair density, are common. When the scalp is involved, there may be a predilection for pulling out hair in the crown or parietal regions. There may be a pattern of nearly complete baldness except for a narrow perimeter around the outer margins of the scalp, particularly at the nape of the neck ("tonsure trichotillomania"). Eyebrows and eyelashes may be completely absent.
Hair pulling does not usually occur in the presence of other individuals, except immediate family members. Some individuals have urges to pull hair from other individuals and may sometimes try to find opportunities to do so surreptitiously. Some individuals may pull hairs from pets, dolls, and other fibrous materials (e.g., sweaters or carpets). Some individuals may deny their hair pulling to others. The majority of individuals with trichotillomania also have one or more other body-focused repetitive behaviors, including skin picking, nail biting, and lip chewing.
In the general population, the 12-month prevalence estimate for trichotillomania in adults and adolescents is l%-2%. Females are more frequently affected than males, at a ratio of approximately 10:1. This estimate likely reflects the true gender ratio of the condition, although it may also reflect differential treatment seeking based on gender or cultural attitudes regarding appearance (e.g., acceptance of normative hair loss among males). Among children with trichotillomania, males and females are more equally represented.
Trichotillomania appears to manifest similarly across cultures, although there is a paucity of data from non-Westem regions.
Most individuals with trichotillomania admit to hair pulling; thus, dermatopathological diagnosis is rarely required. Skin biopsy and dermoscopy (or trichoscopy) of trichotillomania are able to differentiate the disorder from other causes of alopecia. In trichotillomania, dermoscopy shows a range of characteristic features, including decreased hair density, short vellus hair, and broken hairs with different shaft lengths.
Trichotillomania is associated with distress as well as with social and occupational impairment.
There may be irreversible damage to hair growth and hair quality. Infrequent medical
consequences of trichotillomania include digit purpura, musculoskeletal injury (e.g.,
carpal tunnel syndrome; back, shoulder and neck pain), blepharitis, and dental damage
(e.g., worn or broken teeth due to hair biting). Swallowing of hair (trichophagia) may lead
to trichobezoars, with subsequent anemia, abdominal pain, hematemesis, nausea and
vomiting, bowel obstruction, and even perforation.
The essential feature of excoriation (skin-picking) disorder is recurrent picking at one's
own skin (Criterion A). The most commonly picked sites are the face, arms, and hands, but
many individuals pick from multiple body sites. Individuals may pick at healthy skin, at
minor skin irregularities, at lesions such as pimples or calluses, or at scabs from previous
picking. Most individuals pick with their fingernails, although many use tweezers, pins,
or other objects. In addition to skin picking, there may be skin rubbing, squeezing, lancing,
and biting. Individuals with excoriation disorder often spend significant amounts of time
on their picking behavior, sometimes several hours per day, and such skin picking may
endure for months or years. Criterion A requires that skin picking lead to skin lesions, although
individu^als with this disorder often attempt to conceal or camouflage such lesions
(e.g., with makeup or clothing). Individuals with excoriation disorder have made repeated
attempts to decrease or stop skin picking (Criterion B).
Criterion C indicates that skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The term distress includes negative affects that may be experienced by individuals with skin picking, such as feeling a loss of control, embarrassment, and shame. Significant impairment may occur in several different areas of functioning (e.g., social, occupational, academic, and leisure), in part because of avoidance of social situations.
Skin picking may be accompanied by a range of behaviors or rihials involving skin or scabs. Thus, individuals may search for a particular kind of scab to pull, and they may examine, play with, or mouth or swallow the skin after it has been pulled. Skin picking may also be preceded or accompanied by various emotional states. Skin picking may be triggered by feelings of anxiety or boredom, may be preceded by an increasing sense of tension (either immediately before picking the skin or when attempting to resist the urge to pick), and may lead to gratification, pleasure, or a sense of relief when the skin or scab has been picked. Some individuals report picking in response to a minor skin irregularity or to relieve an uncomfortable bodily sensation. Pain is not routinely reported to accompany skin picking. Some individuals engage in skin picking that is more focused (i.e., with preceding tension and subsequent relief), whereas others engage in more automatic picking (i.e., when skin picking occurs without preceding tension and without full awareness), and many have a mix of both behavioral styles. Skin picking does not usually occur in the presence of other individuals, except immediate faniily members. Some individuals report picking the skin of others.
In the general population, the lifetime prevalence for excoriation disorder in adults is 1.4% or somewhat higher. Three-quarters or more of individuals with the disorder are female. This likely reflects the true gender ratio of the condition, although it may also reflect differential treatment seeking based on gender or cultural attitudes regarding appearance.
Excoriation disorder is associated with distress as well as with social and occupational impairment.
The majority of individuals with this condition spend at least 1 hour per day
picking, thinking about picking, and resisting urges to pick. Many individuals report
avoiding social or entertainment events as well as going out in public. A majority of individuals
with the disorder also report experiencing work interference from skin picking on
at least a daily or weekly basis. A significant proportion of students with excoriation disorder
report having missed school, having experienced difficulties managing responsibilities
at school, or having had difficulties studying because of skin picking. Medical complications
of skin picking include tissue damage, scarring, and infection and can be life-threatening.
Rarely, synovitis of the wrists due to chronic picking has been reported. Skin picking
often results in significant tissue damage and scarring. It frequently requires antibiotic treatment
for infection, and on occasion it may require surgery.
The essential features of substance/medication-induced obsessive-compulsive and related disorder are prominent symptoms of an obsessive-compulsive and related disorder (Criterion A) that are judged to be attributable to the effects of a substance (e.g., drug of abuse, medication). The obsessive-compulsive and related disorder symptoms must have developed during or soon after substance intoxication or withdrawal or after exposure to a medication or toxin, and the substance/medication must be capable of producing the symptoms (Criterion B). Substance/ medication-induced obsessive-compulsive and related disorder due to a prescribed treatment for a mental disorder or general medical condition must have its onset while the individual is receiving the medication. Once the treatment is discontinued, the obsessive-compulsive and related disorder symptoms will usually improve or remit within days to several weeks to 1 month (depending on the half-life of the substance/medication). The diagnosis of substance/medication-induced obsessive-compulsive and related disorder should not be given if onset of the obsessive-compulsive and related disorder symptoms precedes the substance intoxication or medication use, or if the symptoms persist for a substantial period of time, usually longer than 1 month, from the time of severe intoxication or withdrawal. If the obsessive-compulsive and related disorder symptoms persist for a substantial period of time, other causes for the symptoms should be considered. The substance/medication-induced obsessive- compulsive and related disorder diagnosis should be made in addition to a diagnosis of substance intoxication only when the symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to warrant independent clinical attention
Obsessions, compulsions, hair pulling, skin picking, or other body-focused repetitive behaviors can occur in association with intoxication with the following classes of substances: stimulants (including cocaine) and other (or unknown) substances. Heavy metals and toxins may also cause obsessive-compulsive and related disorder symptoms. Laboratory assessments (e.g., urine toxicology) may be useful to measure substance intoxication as part of an assessment for obsessive-compulsive and related disorders.
In the general population, the very limited data that are available indicate that substanceinduced obsessive-compulsive and related disorder is very rare.