Obsessive-Compulsive and

Related Disorders
Muhammad Behroze Khan
Internee
Centre for Psychotherapy and
Psychiatry
 Introduction
• Obsessive-compulsive disorders (OCD), a type of anxiety
disorder in which people suffer from recurrent, unwanted
thoughts or ideas (obsessions);
• Engage in repetitive, irrational behaviors or mental acts
(compulsions);
• or both.
• Among people with OCDs, carrying out compulsive behavior
tends to ease feelings of anxiety while repressing compulsive
behavior causes stress (Sudak 2012; Veale 2014; Yip 2014;
Nicholas 2009; Mayo Clinic 2013).
 Diagnostic Criteria of OCD
A. Presence of obsessions, compulsions, or both:
Obsessions are defined by (1) and (2):

– 1. Recurrent and persistent thoughts, urges, or images that are

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

– 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or

mental acts (e.g., praying, counting, repeating words silently) that
the individual feels driven to perform in response to an obsession
or according to rules that must be applied rigidly.

– 2. The behaviors or mental acts are aimed at preventing or reducing

anxiety or distress, or preventing some dreaded event or situation;
however, these behaviors or mental acts are not connected in a
realistic way with what they are designed to neutralize or prevent,
or are clearly excessive
B. The obsessions or compulsions are time consuming (e.g., take
more than 1 hour per day) or cause clinically significant
distress or impairment in social, occupational, or other
important areas of functioning.

C. The obsessive-compulsive symptoms are not attributable to

the physiological effects of a substance (e.g., a drug of abuse,
a medication) or another medical condition.

D. The disturbance is not better explained by the symptoms of

another mental disorder.
Specify if:

• With good or fair insight:

– The individual recognizes that obsessive-compulsive disorder beliefs
are definitely or probably not true or that they may or may not be
true.
• With poor insight:
– The individual thinks obsessive-compulsive disorder beliefs are
probably true.
• With absent insight/delusional beliefs:
– The individual is completely convinced that obsessive-compulsive
disorder beliefs are true.
 Prevalence
• The 12-month prevalence of OCD in the United States is 1.2%,
with a similar prevalence internationally (1.1%-1.8%).

• Females are affected at a slightly higher rate than males in

adulthood, although males are more commonly affected in
childhood.
 Development
• In the United States, the mean age at onset of OCD is 19.5
years, and 25% of cases start by age 14 years. Onset after age
35 years is unusual but does occur.

• The onset of symptoms is typically gradual; however, acute

onset has also been reported.

• If OCD is untreated, the course is usually chronic, often with

waxing and waning symptoms.

• Some individuals have an episodic course, and a minority have

a deteriorating course.
• Without treatment, remission rates in adults are low (e.g.,
20% for those reevaluated 40 years later).

• Onset in childhood or adolescence can lead to a lifetime of

OCD.

• However, 40% of individuals with onset of OCD in childhood

or adolescence may experience remission by early adulthood.
 Causes of OCD
• Despite a wealth of research, the exact causes of OCD have
not been identified.
Genetic causes
• The rate of OCD among first-degree relatives of adults with
OCD is approximately two times that among first-degree
relatives of those without the disorder;
• However, among first-degree relatives of individuals with
onset of OCD in childhood or adolescence, the rate is
increased 10-fold.

Physiological Cause
• Dysfunction in the orbitofrontal cortex, anterior cingulate
cortex, and striatum have been most strongly implicated.
• Imbalances in the brain chemicals serotonin and glutamate
may play a part in OCD.
Autoimmune causes
• Some rapid-onset cases of OCD in children might be
consequences of Group A streptococcal infections, which
cause inflammation and dysfunction in the basal ganglia.
• These cases are grouped and referred to as pediatric
autoimmune neuropsychiatric disorders associated with
streptococcal infections (PANDAS).
• In recent years, however, other pathogens, such as the
bacteria responsible for Lyme disease and the H1N1 flu virus,
have also been associated with the rapid onset of OCD in
children.
Environmental Cause
• Traumatic Brain Injury (TBI) in adolescents and children has
also been associated with an increased risk of onset of
obsessive-compulsions.
• One study found that 30% of children aged 6 to 18 years who
experienced a TBI developed symptoms of OCD within 12
months of the injury.
• Physical and sexual abuse in childhood and other stressful or
traumatic events have been also associated with an increased
risk for developing OCD.
 Differential Diagnosis
Anxiety Disorders
• The recurrent thoughts that are present in generalized anxiety
disorder (i.e., worries) are usually about real-life concerns,
whereas the obsessions of OCD usually do not involve real-life
concerns and can include content that is odd or irrational in
nature.
• Moreover, compulsions are often present and usually linked
to the obsessions.
• Individuals with specific phobia can have a fear reaction to
specific objects or situations; the feared object is usually
much more limited to that specific object, and rituals are not
present.
Eating Disorder
• OCD can be distinguished from anorexia nervosa in that in
OCD the obsessions and compulsions are not limited to
concerns about weight and food.

Tics and Stereotyped Movements

• Tics and stereotyped movements are typically less complex
than compulsions and are not aimed at neutralizing
obsessions.
• However, distinguishing between complex tics and
compulsions can be difficult.
• Whereas compulsions are usually preceded by obsessions, tics
are often preceded by premonitory sensory urges.
Psychotic Disorders
• Some individuals with OCD have poor insight or even
delusional OCD beliefs.
• However, they have obsessions and compulsions
(distinguishing their condition from delusional disorder) and
do not have other features of schizophrenia or schizoaffective
disorder (e.g., hallucinations or formal thought disorder).
Other Compulsive Behavior
• Certain behaviors are sometimes described as ''compulsive,"
including sexual behavior (in the case of paraphilias),
gambling (i.e., gambling disorder) and substance use (e.g.,
alcohol use disorder).
• However, these behaviors differ from the compulsions of OCD
in that the person usually derives pleasure from the activity
and may wish to resist it only because of its harmful
consequences.
OCPD and OCD
• Obsessive-compulsive personality disorder is not
characterized by intrusive thoughts, images, or urges or by
repetitive behaviors that are performed in response to these
intrusions;
• Instead, OCPD involves an enduring and pervasive
maladaptive pattern of excessive perfectionism and rigid
control.
• If an individual displays symptoms of both OCD and obsessive-
compulsive personality disorder, both diagnoses can be given.
 Body Dysmorphic Disorder
A. Preoccupation with one or more perceived defects in
physical appearance that are not observable or appear slight
to others.

B. At some point during the course of the disorder, the individual

has performed repetitive behaviors (e.g., mirror checking,
excessive grooming, skin picking, reassurance seeking) or
mental acts (e.g., comparing his or her appearance with that
of others) in response to the appearance concerns.
C. The preoccupation causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.

D. The appearance preoccupation is not better explained by

concerns with body fat or weight in an individual whose
symptoms meet diagnostic criteria for an eating disorder.

Specify if:
With muscle dysmorphia: The individual is preoccupied with the
idea that his or her body build is too small or insufficiently
muscular. This specifier is used even if the individual is
preoccupied with other body areas, which is often the case.
 Prevalence
• 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%.
• 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), and
• 10% among patients presenting for oral or maxillofacial
surgery.
 Development and Course
• Two-thirds of individuals have disorder onset before age 18.
• Subclinical body dysmorphic disorder symptoms begin, on
average, at age 12 or 13 years.
• Subclinical concerns usually evolve gradually to the full
disorder, although some individuals experience abrupt onset
of body dysmorphic disorder.
• The disorder appears to usually be chronic, although
improvement is likely when evidence-based treatment is
received.
• Individuals with disorder onset before age 18 years are more
likely to attempt suicide.
 Risk Factors
Environmental.
• Body dysmorphic disorder has been
associated with high rates of childhood
neglect and abuse.
Genetic and physiological.
• The prevalence of body dysmorphic disorder is
elevated in first-degree relatives of individuals
with obsessive-compulsive disorder (OCD).
 Differential Diagnosis
Normal appearance concerns and clearly noticeable
physical defects
• Body dysmorphic disorder differs from normal appearance
concerns in being characterized by excessive appearance-
related preoccupations and repetitive behaviors that are time-
consuming, are usually difficult to resist or control, and cause
clinically significant distress or impairment in functioning.
• Physical defects that are clearly noticeable (i.e., not slight) are
not diagnosed as body dysmorphic disorder.
Major depressive disorder.
• The prominent preoccupation with appearance and excessive
repetitive behaviors in body dysmorphic disorder differentiate
it from major depressive disorder.
• However, major depressive disorder and depressive
symptoms are common in individuals with body dysmorphic
disorder, often appearing to be secondary to the distress and
impairment that body dysmorphic disorder causes.
• Body dysmorphic disorder should be diagnosed in depressed
individuals if diagnostic criteria for body dysmorphic disorder
are met.
Social Anxiety disorder
• Social anxiety are common in body dysmorphic disorder.

• Body dysmorphic disorder includes prominent appearance-

related preoccupation, which may be delusional, and
repetitive behaviors,

• In social anxiety the concerns are about perceived appearance

defects and the belief or fear that other people will consider
these individuals ugly or reject them because of their physical
features.
Psychotic Disorders
• Many individuals with body dysmorphic disorder have
delusional appearance belief, which is diagnosed as body
dysmorphic disorder, with absent insight/ delusional beliefs,
not as delusional disorder.
• Appearance-related ideas or delusions of reference are
common in body dysmorphic disorder; however, unlike
schizophrenia or schizoaffective disorder, body dysmorphic
disorder involves prominent appearance preoccupations and
related repetitive behaviors, and disorganized behavior and
other psychotic symptoms are absent
 Hoarding Disorder
A. Persistent difficulty discarding or parting with possessions,
regardless of their actual value.
B. This difficulty is due to a perceived need to save the items
and to distress associated with discarding them.
C. The difficulty discarding possessions results in the
accumulation of possessions that congest and clutter active
living areas and substantially compromises their intended
use. If living areas are uncluttered, it is only because of the
interventions of third parties (e.g., family members, cleaners,
authorities).
D. The hoarding causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning (including maintaining a safe environment for
self and others).
E. The hoarding is not attributable to another medical condition
(e.g., brain injury, cerebrovascular disease, Prader-Willi
syndrome).
F. The hoarding is not better explained by the symptoms of
another mental disorder (e.g., obsessions in obsessive-
compulsive disorder, delusions in schizophrenia or another
psychotic disorder, cognitive deficits in major neurocognitive
disorder, restricted interests in autism spectrum disorder).
 Associated Features
• 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).
• Animal hoarding may be a special manifestation of hoarding
disorder.
 Development and Course
• 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.

• 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.
 Risk Factors
Temperamental
• Indecisiveness is a prominent feature of individuals with
hoarding disorder and their first-degree relatives.
Environmental
• Individuals with hoarding disorder often retrospectively
report stressful and traumatic life events preceding the onset
of the disorder.
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.
 Differential Diagnosis
Other Medical Conditions
• Hoarding disorder is not diagnosed if the symptoms are
judged to be a direct consequence of another medical
condition (Criterion E), such as traumatic brain injury,
cerebrovascular disease, infections of the central nervous
system (e.g., herpes simplex encephalitis), and conditions
such as Prader-Willi syndrome.

• Damage to the anterior ventromedial prefrontal and cingulate

cortices has been particularly associated with the excessive
accumulation of objects.
Neurodevelopmental disorders
• Hoarding disorder is not diagnosed if the accumulation of
objects is judged to be a direct consequence of a
neurodevelopmental disorder, such as autism spectrum
disorder or intellectual disability.

Schizophrenia spectrum and other psychotic disorders

• Hoarding disorder is not diagnosed if the accumulation of
objects is judged to be a direct consequence of delusions or
negative symptoms in schizophrenia spectrum and other
psychotic disorders
Major depressive episode.
• Hoarding disorder is not diagnosed if the accumulation of objects is
judged to be a direct consequence of psychomotor retardation,
fatigue, or loss of energy during a major depressive episode.

Obsessive Compulsive Disorder

• In OCD, the behavior is generally unwanted and highly distressing,
and the individual experiences no pleasure or reward from it.
Excessive acquisition is usually not present; if excessive acquisition
is present, items are acquired because of a specific obsession.
• Individuals who hoard in the context of OCD are also more likely to
accumulate bizarre items, such as trash, feces, urine, nails, hair,
used diapers, or rotten food.
• Accumulation of such items is very unusual in hoarding disorder.
Trichotillomania (Hair-Pulling Disorder)
A. Recurrent pulling out of one’s hair, resulting in hair loss.
B. Repeated attempts to decrease or stop hair pulling.
C. The hair pulling causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.
D. The hair pulling or hair loss is not attributable to another
medical condition (e.g., a dermatological condition).
E. The hair pulling is not better explained by the symptoms of
another mental disorder (e.g., attempts to improve a
perceived defect or flaw in appearance in body dysmorphic
disorder).
 Prevalence
• In the general population, the 12-month prevalence estimate
for trichotillomania in adults and adolescents is l%-2%.

• Females are more frequently affected than males, at a ratio of

approximately 10:1.
 Development and Course
• Hair pulling may be seen in infants, and this behavior typically
resolves during early development.

• Sites of hair pulling may vary over time. The usual course of
trichotillomania is chronic, with some waxing and waning if
the disorder is untreated.

• Symptoms may possibly worsen in females accompanying

hormonal changes (e.g., menstruation, perimenopause).
 Risk Factors
Genetic and Physiological Factor
• There is evidence for a genetic vulnerability to
trichotillomania. The disorder is more common in individuals
with obsessive-compulsive disorder (OCD) and their first-
degree relatives than in the general population.
 Differential Diagnosis
Normative hair removal/manipulation
• Trichotillomania should not be diagnosed when hair removal
is performed specially for cosmetic reasons (i.e., to improve
one's physical appearance).
• Many individuals twist and play with their hair, but this
behavior does not usually qualify for a diagnosis of
trichotillomania.
• Some individuals may bite rather than pull hair; again, this
does not qualify for a diagnosis of trichotillomania.
Other obsessive-compulsive and related disorders
• Individuals with OCD and symmetry concerns may pull out
hairs as part of their symmetry rituals, and individuals with
body dysmorphic disorder may remove body hair that they
perceive as ugly or abnormal; in such cases a diagnosis of
trichotillomania is not given.

Neurodevelopmental disorders
• In neurodevelopmental disorders, hair pulling may meet the
definition of stereotypies (e.g., in stereotypic movement
disorder). Tics (in tic disorders) rarely lead to hair pulling.
Psychotic disorder
• Individuals with a psychotic disorder may remove hair in
response to a delusion or hallucination.
• Trichotillomania is not diagnosed in such cases.

Other Medical Conditions

• Trichotillomania is not diagnosed if the hair pulling or hair loss
is attributable to another medical condition (e.g.,
inflammation of the skin or other dermatological conditions).
• Other causes of scarring alopecia or non-scarring alopecia
should be considered in individuals with hair loss who deny
hair pulling.
• Skin biopsy can be used to differentiate individuals with
trichotillomania from those with dermatological disorders.
 Excoriation (Skin picking Disorder)
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. The skin picking causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
D. The skin picking is not attributable to the physiological effects
of a substance (e.g., cocaine) or another medical condition (e.g.,
scabies).
E. The skin picking is not better explained by symptoms of
another mental disorder.
 Prevalence
• In the general population, the lifetime prevalence for
excoriation disorder in adults is 1.4% or somewhat higher.
• Three-quarters or more of individuals with the disorder are
female.
 Development and Course
• Individuals with excoriation disorder may present at various
ages, the skin picking most often has onset during
adolescence, commonly coinciding with or following the onset
of puberty.
• The disorder frequently begins with a dermatological
condition, such as acne.
• Sites of skin picking may vary over time.
• The usual course is chronic, with some waxing and waning if
untreated.
 Risk Factors
Genetic and physiological
• Excoriation disorder is more common in individuals with
obsessive-compulsive disorder (OCD) and their first-degree
family members than in the general population.
 Differential Diagnosis
Psychotic disorder
• Skin picking may occur in response to a delusion (i.e.,
parasitosis) or tactile hallucination (i.e., formication) in a
psychotic disorder.
• In such cases, excoriation disorder should not be diagnosed.

Somatic symptom and related disorders.

• Excoriation disorder is not diagnosed if the skin lesion is
primarily attributable to deceptive behaviors in factitious
disorder.
Other obsessive-compulsive and related disorders
• Excessive washing compulsions in response to contamination
obsessions in individuals with OCD may lead to skin lesions,
and skin picking may occur in individuals with body
dysmorphic disorder who pick their skin only because of
appearance concerns; in such cases, excoriation disorder
should not be diagnosed.

Other disorders
• Excoriation disorder is not diagnosed if the skin picking is
primarily attributable to the intention to harm oneself that is
characteristic of non-suicidal self-injury.
Other medical conditions.
• Excoriation disorder is not diagnosed if the skin picking is
primarily attributable to another medical condition.
• For example, scabies is a dermatological condition invariably
associated with severe itching and scratching.
• However, excoriation disorder may be precipitated by an
underlying dermatological condition. For example, acne may
lead to some scratching and picking, which may also be
associated with comorbid excoriation disorder.
• The differentiation between these two clinical situations (acne
with some scratching and picking vs. acne with comorbid
excoriation disorder) requires an assessment of the extent to
which the individual's skin picking has become independent
of the underlying dermatological condition.
 Treatment of OCD
• Cognitive Behavioral Therapy is the most effective treatment
for obsessive-compulsive disorder and generally involves two
components:
Exposure and response prevention
• Which requires repeated exposure to the source of your
obsession, as explained above.
Cognitive therapy
• A big part of cognitive therapy for OCD is teaching you healthy
and effective ways of responding to obsessive thoughts,
without turn to compulsive behavior.
Medications
• Certain psychiatric medications can help control the
obsessions and compulsions of OCD.
• Most of these drugs belongs to a class of anti-depressant
group called SSRI’s.
• However some of these drugs belongs to a class of Tricyclic
anti- depressants.
• Antidepressants approved by the Food and Drug
Administration (FDA) to treat OCD include:
• Clomipramine (Anafranil) for adults and children 10 years and
older
• Fluoxetine (Prozac) for adults and children 7 years and older
• Fluvoxamine for adults and children 8 years and older
• Paroxetine (Paxil, Pexeva) for adults only
• Sertraline (Zoloft) for adults and children 6 years and older
Family Therapy
• Since OCD often causes problems in family life and social
adjustment, family therapy can help promote understanding
of the disorder and reduce family conflicts. It can also
motivate family members and teach them how to help their
loved one with OCD.

Group Therapy.
• Through interaction with fellow OCD sufferers, group therapy
provides support and encouragement and decreases feelings
of isolation.