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lation strategy aimed to reduce or alleviate generalized distress (e.g., feeling bored or anxious) or from thoughts and feelings of disgust, imperfection, or not- just-right experiences regarding one’s hair or skin (e.g., searching for a gray or coarse hair that does not belong). However, hair pulling and skin picking may also generate and be reinforced by positive affective experiences, and it is not uncom- mon for individuals to have mixed feelings about their pulling/picking behaviors.
For instance, while clients may be distressed by the loss of their hair or damage to their skin, they may also report gratification and pleasure when engaging in hair pulling and skin picking that maintain the behavior [64]. Finally, in some instances, hair pulling and skin picking may not be clearly linked to specific cognitive-affec- tive motivations and may present as a more automatic behavior (i.e., pulling/pick- ing without conscious awareness).
Therefore, due to the functional differences in the conceptual models of hoard- ing, HPD, and SPD, differential approaches for conceptualization and treatment are necessary (e.g., skills training for decision-making in hoarding) and will be dis- cussed in Treatment Implications below.
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Cues/Triggers
A multitude of external (e.g., situations, activities, objects, etc.) and internal (e.g., thoughts, emotions) antecedents may trigger OCRD symptoms. Thus, a comprehen- sive functional assessment should begin by obtaining a complete list of cues/trig- gers to aid in developing a cognitive-behavioral treatment plan (e.g., exposures to feared stimuli, habit reversal training). First, across OCRDs, certain external situa- tions, activities, objects, or places may trigger symptoms. For instance, symptoms may be triggered by seeing a potential weapon or using a public restroom (OCD), seeing one’s image in the mirror or being in locations like the gym or the beach (BDD), seeing an item on sale at the grocery store or receiving a new stack of mail (hoarding disorder), or using tweezers or talking on the phone (HPD/SPD).
Assessing each of these external triggers, therefore, provides clinicians with treat- ment targets to help clients manage these challenging situations.
Internal experiences can also serve as potent triggers. First, as noted in the cognitive- behavioral model of OCRDs, cognitions play a role by triggering affec- tive reactions (e.g., anxiety, disgust, or guilt/shame). Internal triggers can include intrusive images or doubts about being responsible for harm such as causing a fire (OCD), thoughts about how deformed a body part is (BDD), fears of losing impor- tant things and beliefs such as “I might need this one day” (hoarding disorder), and perfectionistic cognitions or rationalizations about pulling/picking (HPD/SPD).
Second, although most commonly considered in anxiety disorders such as panic disorder, bodily sensations and emotional reactions can also serve as internal cues among the OCRDs including anxiety-related sensations interpreted as inappropri- ate, unwanted sexual arousal in OCD, physiological tension or boredom leading to hair pulling, or a tactile sensation (e.g., skin crawling) leading to skin picking.
Behavioral Symptoms and Consequences
Compulsions/Rituals Compulsions represent a unique behavioral symptom of OCRDs (which map onto other safety behaviors in other anxiety disorders). As previously described, compulsions may present as overt (e.g., external, observable behaviors) or covert (internal, mental rituals), and covert rituals can be more subtle and difficult to recognize or assess. Further, compulsions may be used before, during, or after being exposed to a feared stimulus in order to prevent, neutralize, escape, or eliminate a feared outcome or perceived wrongdoing.
In OCD, compulsions are most often functionally linked to obsessions along the four symptom dimensions discussed (e.g., fears about causing harm and checking, concerns about becoming ill and repeated washing, not-just-right feelings and ordering or counting, unacceptable thoughts about taboo topics and repeated attempts to replace thoughts with “good” ones) [4]. However, it is important to ensure that one understands the specific link between an individual client’s compul- sions and their fears (e.g., are they washing their hands because they fear them-
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selves getting sick or others; are they checking the locks on their front door because they fear theft or an attack). In BDD, rituals may be both directly targeted to change physical appearance (e.g., time-consuming makeup routines, repeated medical pro- cedures) or to reduce distress induced by appearance-related thoughts (e.g., seeking reassurance about physical appearance, checking the mirror). Further, compulsions in BDD may also overlap with symptoms of other OCRDs (e.g., hair pulling, skin picking) or eating disorders (e.g., eating or exercise rituals aimed to change per- ceived defects in weight/shape), and it is thus helpful to fully assess the purpose of these behaviors in clarifying appropriate diagnoses and treatment.
As highlighted throughout this chapter, it is necessary for the clinician to assess both the types of compulsions present for a given client and the purpose of these compulsions; that is, how is the compulsion linked to feared stimuli and obses- sions, and why does the individual feel driven to engage in compulsions (e.g., what about the ritual feels better to do it this way, or what do they fear will occur if they refrain from engaging in the compulsion?). Such questions are critical to understanding the nature of the individual’s symptoms, as well as for pinpointing how to design and implement evidence-based techniques to be most useful for an individual.
Hair-Pulling and Skin-Picking Behaviors As with OCD and BDD, it is useful for clinicians to gather detailed information about the form and function of hair-pulling and skin-picking behaviors, including detailed information about the pulling/pick- ing behaviors themselves (e.g., what parts of the body individuals pick/pull from, a description of each step in the process), the individual’s experience of what happens if they try to resist performing the behavior, as well as emotions or thoughts the individual experiences before, during, and after picking/pulling (e.g., loss of con- trol, embarrassment, shame, relief, pleasure). It can be especially useful, given the guilt and shame clients feel about their hair-pulling or skin-picking behaviors [73], to normalize both the positive and negative aspects of picking or pulling so that clients feel more comfortable in disclosing their symptoms.
Avoidance Avoidance is a hallmark feature and often a primary maintaining factor of symptoms across anxiety-related conditions and OCRDs. Most individuals with these disorders will engage in avoidance in an effort to prevent feared internal or external triggers and other symptoms. The avoidance may be behavioral or experi- ential (e.g., avoidance of internal experiences like strong emotions or physical sen- sations) [74, 75] and as such may be overt or covert. First, across the OCRDs, a diverse array of specific situations or activities (e.g., being at parties in BDD, using cleaning products in OCD, discarding items in hoarding disorder, going swimming where others may see hair loss in HPD), places (e.g., public transportation, hospi- tals, public restrooms), people (e.g., homeless individuals, attractive individuals), or other objects or behaviors (e.g., saying certain words, taking photographs) may be avoided. Further, avoidance of internal experiences can be subtle and thus difficult for both the individual and the clinician to identify. Such internal avoidance efforts may include efforts to suppress, distract, or “white knuckle” to avoid experiencing
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feared emotions or sensations. As discussed, avoidance serves as one of the primary maintaining factors of anxiety and OCRD-related symptoms by impeding naturalis- tic corrective learning and opportunities for the individual to be exposed to experi- ences that challenge and change core dysfunctional beliefs that underlie symptoms.
As such, it is necessary to assess the breadth of forms maladaptive avoidance is taking, as well as the function of each avoidance behavior in relation to other symp- toms: what does the avoidance behavior look like, how is it causing interference, and what is it accomplishing or preventing?
Interpersonal Factors
Finally, it is critical to assess the extent to which environmental contexts and inter- personal factors are contributing to symptom severity and maintenance. Across anxiety-related conditions, symptom accommodation by loved ones is very preva- lent [76]. Specifically, well-intentioned family members, partners, or close friends often contribute to the maintenance of symptoms by engaging in avoidance, safety behaviors, or rituals (especially in OCD and BDD) with or for the individual. Family may also develop independent patterns of avoidance aimed to prevent or reduce the chance of their loved one becoming anxious, particularly if they themselves become highly upset by their loved one’s distress or symptoms. Although intentioned to sup- port their loved ones, these behaviors paradoxically contribute to the maintenance and exacerbation of symptoms. Further, patterns of accommodation (e.g., assisting a client with OCD with checking rituals to ensure that doors are locked, providing reassurance repeatedly to a client with BDD that their hair looks fine) can facilitate relational distress over time. Comprehensively assessing the ways in which inter- personal dynamics are contributing to symptoms is thus essential for informing either individual- or couple-/family-based (where possible) treatment approaches to target core symptoms and maximize treatment gains [77, 78].
Empirically Validated Assessment Measures
Clinician-Administered, Structured Interviews
There are three structured clinical interviews that have been updated for the diag- nosis of DSM-5 anxiety disorders and OCRDs: the Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5) [79], the Structured Clinical Interview for DSM-5 (SCID-5) [80], and the Mini-International Neuropsychiatric Interview, version 7 (MINI) [81]. In addition, several clinical interviews have been empirically validated for more fine-tuned assessment of specific OCRDs. Due to the hetero- geneity of symptom presentations in OCRDs, these assessments are particularly useful for enriching case-specific conceptualizations and informing treatment planning.
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Anxiety Disorders Interview Schedule for DSM-5 (ADIS-5) The ADIS-5 is a semi-structured, clinician-administered interview for anxiety and related disorders [79]. The ADIS-5 facilitates differential diagnostics across anxiety, OC, trauma- and stress-related, mood (e.g., depression), and somatoform disorders (e.g., illness anxiety disorder). Given the high rates of comorbidity within and between anxiety and OCRDs, as well as with other forms of psychopathology (e.g., substance use, depression), such an assessment is particularly useful.
In line with the demand for more dimensional methods of assessment and diagnosis, the ADIS-5 can assess central, common features of psychopathology in a dimensional fashion (e.g., assessing severity from 0 to 8 rather than the dichotomous presence or absence of symptoms). Further, the clinician can gather data regarding the functional nature and specific manifestation of symp- toms (e.g., situations avoided, content of anxiety cognitions). The ADIS has strong reliability and specificity in identifying certain diagnoses [82]. The main limitation of the ADIS-5 is that it can be particularly time-consuming. However, specific modules may be utilized as needed for a more efficient assessment (e.g., of OCD).
Structured Clinical Interview for DSM Axis I Disorders (SCID-5) The SCID-5 is also a semi-structured interview, typically administered by a clinician, with good psychometric support [83, 84]. The SCID provides a more comprehensive and inclusive assessment of DSM-5 disorders. However, qualitative information on the person-specific presentation of symptoms is lost. As such, the SCID may be best used as an initial assessment of psychiatry history and followed by more specific, detailed assessments of present diagnostic concerns.
Mini-International Neuropsychiatric Interview (MINI) The MINI is a brief, structured interview that, similar to the SCID, assesses the presence of DSM diagnoses [81, 85]. The MINI can be administered in 15–20 minutes and thus provides a highly time-efficient option. Further, the MINI has similar validity and reliability to the SCID [86]. However, given its brevity, this measure may best be administered for brief screening (e.g., to rule in/out diagnoses) in tandem with clinician- administered or self-report measures that provide more detailed information.
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) The Y-BOCS is the gold standard interview assessment of OCD symptom severity [87]. The measure pro- vides a comprehensive checklist to assess the primary obsessions and compulsions which will serve as core targets for treatment. Questions assess the time occupied, interference, distress, resistance, and degree of control for both obsessions and com- pulsions (assessed separately). Supplemental questions assess insight, as well as the severity of common features in OCD (e.g., avoidance, inflated responsibility, doubt- ing) that may be important treatment considerations. The Y-BOCS demonstrates good validity and reliability and can be administered and scored with relative ease [88, 89].
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Although the Y-BOCS provides specificity regarding symptoms, it fails to capture functional relationships among symptoms that are critical to identify and target in treat- ment. Specifically, obsessions and compulsions are assessed as distinct from one another, and the links between the individual’s obsessions (e.g., about causing harm to one’s family) and compulsions (e.g., repeatedly checking the stove and locks) are not assessed.
It also does not equally capture the full spectrum of OCD symptoms (e.g., mental rituals are underrepresented) and consists of items (e.g., compulsive self-harm, hair pulling, eating behaviors) that may contribute to misdiagnosis without sufficient training.
The Y-BOCS has been adapted for the assessment of BDD (BDD-YBOCS) [90]
and hair pulling (Yale-Brown Obsessive-Compulsive-Scale-Trichotillomania;
Y-BOCS-TM) [91]). Additionally, it has been adapted for SPD, although psycho- metric data for this modification is lacking (The Yale-Brown Obsessive-Compulsive Scale for Neurotic Excoriation; YBOCS-NE [92]). Overall, the structure of these additional versions is similar to original Y-BOCS, and the symptoms assessed have been modified for the primary symptoms of BDD, HPD, and SPD.
Hoarding Rating Scale-Interview (HRS-I) The HRS-I is a commonly used and validated clinical interview to assess hoarding symptoms [93]. The measure is brief (five items), is easy to administer, and assesses the severity of clutter, excessive acquisition, difficulty discarding, distress, and impairment. The HRS-I demon- strates strong internal consistency, reliability, and validity [94] and has cut scores for use in clinical and nonclinical populations. Of note, the measure does not collect qualitative information necessary for a comprehensive case conceptualization (e.g., specific content of symptom-related cognitions, level of insight).
Trichotillomania Severity Scale (TSS) The TSS was created by the National Institute of Mental Health (NIMH) [95] and has been used to monitor hair-pulling severity [96]. The TSS was developed based on the Y-BOCS-TM and consists of five items that assess the duration, impairment, distress, resistance, and control of HPD symptoms. Psychometric validation of the TSS is not available.
Self-Report Measures
A number of self-report assessments are available and psychometrically validated for the assessment of OCRDs. The focus of this section is on OC-specific measures, but given the high rates of comorbidity and conceptual overlap between anxiety and OCRDs, transdiagnostic self-report assessments may also be useful (e.g., Overall Anxiety Severity and Impairment Scale, OASIS [97]). Overall, self-report assess- ments provide a quick, accessible, and structured way to assess initial symptoms and track symptom severity over the course of treatment.
Dimensional Obsessive-Compulsive Scale (DOCS) The DOCS consists of 20 items, divided into 4 subscales that correspond to OC symptom dimensions consis- tently identified and discussed above: (a) contamination, (b) responsibility for harm and mistakes, (c) symmetry/ordering, and (d) unacceptable thoughts [98]. Given
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symptom heterogeneity in OCD, each subscale details examples of obsessions and compulsions that highlight the form and function of intrusive thoughts, rituals, and avoidance. For each subscale, five items are completed to assess the severity of symptoms (over the past month). Given empirical support for conceptualizing the mechanisms and treatment of OCD based on symptom dimensions, the DOCS is best scored and interpreted based on its subscales [4, 17]. The DOCS subscales have demonstrated excellent reliability (α = 0.94–0.96) and validity [98].
Body Dysmorphic Symptom Scale (BDD-SS) The BDD-SS assesses the presence and severity of BDD symptoms across seven symptom clusters: (1) checking, (2) grooming, (3) behaviors aimed to change weight or shape, (4) hair pulling/skin picking, (5) avoidance, (6) medical behaviors (e.g., surgery), and (7) cognitive symptoms [99]. The BDD-SS can be summed for an overall symptom severity rat- ing, or a composite score of the quantity of symptoms present can be generated (range 0–54). Preliminary psychometric results provide excellent support for the BDD-SS [99], and it demonstrates robust change to treatment [100–102].
Saving Inventory-Revised (SI-R) The SI-R is a measure of hoarding symptom severity, which consists of 26 items that assess hoarding symptoms along 3 concep- tually meaningful subscales: difficulty discarding, acquisition problems, and exces- sive clutter [37]. Psychometric data supports good internal consistency and reliability for the SI-R [37, 103]. The SI-R demonstrates strong divergent validity (i.e., low correlations with measures of OCD symptom severity), suggesting it may be useful for distinguishing between these two conditions.
Skin Picking Scale (SPS) The SPS is a brief measure that assesses SPD severity with six items that assess the (1) frequency of urges to engage in skin picking, (2) intensity of these urges, (3) time spent picking, (4) picking-related interference, (5) distress associated with picking behavior, and (6) avoidance [104]. The SPS is used as an index of clinical severity, with a clinical cutoff of 7. The SPS has good psychometric support [104]. The SPS may be coupled with the Skin Picking Impact Scale (SPIS), which is a 28-item assessment of functional consequences associated with SPD [105, 106].
Massachusetts General Hospital Hairpulling Scale (MGH-HPS) The MGH-HPS is a brief (seven items) measure of the severity, frequency, and distress associated with hair pulling [107]. The MGH-HPS demonstrates good internal consistency, reliability, and validity [108, 109]. Further supporting its utility, the MGH-HPS is sensitive to symptom change in effective treatments for HPD [110, 111].
Differential Diagnosis
As illustrated in the initial sections of this chapter, anxiety and OCRDs share both considerable overlap and several critical distinctions. In order to best devise an evidence- based treatment plan for a given individual, it is necessary to comprehen-
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sively assess and accurately diagnose the psychological conditions present. This process often involves differentiating between anxiety, OCRDs, and related disor- ders, to arrive at the most accurate conceptualization of the individual’s presenting concerns. For example, within OCRDs several specific behavioral symptoms (e.g., hair pulling) appear in multiple different diagnoses (e.g., BDD, HPD). However, the function of the symptom and its context within the broader network of symptoms will lead to different diagnoses and empirically supported interventions (e.g., expo- sure vs. habit reversal training). It is also often the case that anxiety, OCRDs, and related conditions (e.g., depression, eating disorders, substance use disorders) co- occur [5], in which case delineating which condition(s) are primary (i.e., central to presenting concerns, distress, or impairment; motivating treatment seeking) as well as identifying all conditions that are current sources of distress can be important for ordering and integrating of evidence-based treatment approaches.
In the following section, we will thus discuss specific considerations for differ- entiating within OCRDs and between OC and anxiety spectrum disorders that dem- onstrate significant overlap in symptom presentation or function. We will focus on specific distinctions that tend to be most challenging or relevant to clinical practice.
Within OC Spectrum Disorders
OCD vs. BDD Given the overlap in the form and function of symptoms between OCD and BDD [112], these diagnoses are sometimes misdiagnosed. In both cases, central symptoms involve intrusive, distressing thoughts and rituals aimed to reduce anxiety (as well as disgust, guilt/shame). Perhaps most important to this diagnostic distinction is the content of intrusive thoughts and symptoms. In OCD, the topics of intrusive thoughts can be quite diverse. In BDD, on the other hand, the content of intrusions, distress, and associated compulsions is more restricted and revolves spe- cifically around the perception of a physical defect in one’s appearance. BDD and OCD often co-occur [33] and share many risk and maintenance factors; as such, an individual with obsessions and compulsions both about physical appearance and other obsessional fears (e.g., contamination concerns) should be diagnosed and treated for both conditions.
BDD vs. Hair-Pulling and Skin-Picking Disorders A particularly difficult chal- lenge can be differentiating between BDD and HPD or SPD, given the potential for symptoms of hair pulling or skin picking to present in either condition. In BDD, individuals may engage in hair pulling or skin picking as rituals in order to alleviate distress associated with a perceived problem with the appearance of one’s hair, skin, or other physical concerns [113]. In this way, the behavior is functionally linked with other primary BDD symptoms, such as the cognitive (e.g., intrusive thoughts about one’s appearance) and affective (e.g., anxiety, dis- gust) responses. However, in HPD or SPD, the hair pulling or skin picking, respec- tively, represents the core symptom of the disorder. Furthermore, the behavior is not motivated by a desire to change one’s appearance in HPD and SPD and may not be specifically tied to particular cognitions. In HPD and SPD, symptoms are
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