With the publication of the DSM-5, the organization of anxiety disorders and OCRDs was significantly revised [1]. Specifically, the creation of the OCRDs class in DSM-5 involved the following reclassifications and changes: OCD was moved from the anxiety disorders, BDD from the somatoform disorders, and hair-pulling disorder (previously trichotillomania) from the impulse control disorders; hoarding was distinguished as a separate diagnosis, rather than a symptom of OCD; and exco- riation (skin-picking) disorder was added as a new diagnosis, not previously included in the DSM.
As noted, OCD was previously classified as an anxiety disorder (alongside spe- cific phobias, panic disorder, social anxiety disorder, and generalized anxiety disor- der) due to the considerable overlap between their conceptual models and empirically supported treatments. Generally, anxiety disorders and OCD both involve chronic, impairing affective states of fear, anxiety, and distress and functionally related behaviors, including avoidance of feared stimuli and safety behaviors aimed to reduce perceived threat and distress. However, some research suggests that OCD might be better conceptualized along a spectrum of related conditions that are char- acterized by the repeated, compulsive nature of behavioral symptoms rather than cognitive-affective symptoms [7, 8]. Thus, this reconceptualization switched the unifying emphasis from a functional model centered around affectively motivated avoidance and impairment to one focused on observable, recurrent behavioral symptoms. Such repetitive actions were hypothesized to more precisely indicate shared neurobiological diatheses, and thus this new categorization was suggested to have greater utility to clinical practice (e.g., indicating optimal treatments) as well as research aimed to advance our understanding of the causal mechanisms of OCRDs.
Broadly, the OCRDs are characterized by compulsive cognitive and/or behav- ioral phenomena. However, the function of these behaviors may differ considerably across OCRDs and include symptoms that involve anxiety or distress or yield grati- fication and positive reinforcement. This discrepancy is best evidenced in consider- able research highlighting the functional overlap between the phenomenology of several OCRDs (e.g., skin-picking and hair-pulling disorder) and addictive spectrum concerns [9, 10]. As can be noted in reviewing the ORCD class in the sections that
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follow, several conditions share greater conceptual and treatment overlap with shared cognitive-behavioral mechanistic and maintenance processes (e.g., anxiety disorders, OCD, BDD), while other OCRDs present more specialized consider- ations and distinctive conceptual models and treatments (e.g., hair-pulling, skin- picking, hoarding disorder).
Diagnostic Criteria
First, a few common diagnostic criteria present transdiagnostically across OCRDs in the DSM-5 [1]. The central symptoms of each disorder must be causing substan- tial distress or impairment across multiple meaningful domains of functioning (e.g., socially, at work or school, in one’s ability to perform daily activities). Research has supported that many OCRD symptoms are highly prevalent and occur on a spectrum of severity within the population (e.g., intrusive thoughts, body image concerns, hair pulling, skin picking) [e.g., 11–14]. This impairment criterion is thus particu- larly important in distinguishing clinical phenomena that warrant intervention.
Additionally, OCRD symptoms must not be the result of a diagnosed medical con- dition (e.g., neurological disorder, dermatological condition, specific disease) or the result of substance use behavior (e.g., cocaine). Similarly, primary symptoms must not be more robustly explained by or attributed to another psychological condition.
This last distinction can be particularly challenging in terms of differential diagno- sis within the OC spectrum or between OCRDs, anxiety disorders, and other condi- tions (e.g., psychosis, eating disorders). As such, considerations and tools are provided below (see Differential Diagnoses) for anxiety-related conditions that are commonly misdiagnosed or co-occur with OCRDs.
Obsessive-Compulsive Disorder (OCD)
OCD is characterized by the presence of either obsessions or compulsions that cause significant distress and impairment across several domains of functioning (e.g., occupational, interpersonal) [1]. Obsessions are defined as recurring thoughts, urges, or images, which lead to anxiety or distress (e.g., the fear that one has been contaminated by germs, an image of hitting a pedestrian while driving). If it is not possible to avoid obsessional thoughts, individuals with OCD attempt to eliminate, reduce, neutralize, or suppress these intrusive cognitions, either with another thought (e.g., a prayer to keep a loved one safe) or action (e.g., handwashing).
Compulsions are repetitive mental or physical actions that the individual engages in following an obsession or in adherence to specific rules. These behaviors are per- formed in order to alleviate distress (e.g., anxiety) or to prevent feared outcomes (e.g., checking the locks repeatedly to prevent a break-in). As such, compulsions are time-consuming, impairing behaviors that are either not directly connected with feared outcomes (e.g., compulsive counting to prevent a disaster from impacting
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one’s family) or are excessive in response to actual threat (e.g., washing hands for 30 minutes after cooking with raw meat). Further, compulsions may be overt or covert, involving either observable behaviors (e.g., reassurance seeking, cleaning, ordering) or internalized mental acts (e.g., counting, praying, reviewing one’s actions to assure that something was done properly). In this way, despite the DSM-5 criteria that requires only obsessions or compulsions be present to meet criteria for OCD, research indicates that 96% of individuals with OCD report both obsessions and compulsions [15]. For this reason, it is particularly important to comprehen- sively assess for covert rituals if a client presents with significant obsessions without overt compulsions.
Insight Criterion An insight criterion is also included for OCD in DSM-5. This specifier identifies the individual as possessing (1) good or fair, (2) poor, or (3) absent insight. In the case of good or fair insight, a client will identify that obsessive beliefs and intrusive thoughts are definitively or likely not true (e.g., viewing them as unreasonable or senseless; e.g., a woman with distressing intrusive thoughts about accidentally poisoning her children with chemicals may believe that it is unlikely that using more detergent than recommended will harm her children, but she thinks it is “better to be safe than sorry”). For an individual with poor insight, obsessive beliefs and intrusive thoughts are reported to likely be true; however, these individuals are able to recognize that there is a chance that these beliefs are inaccurate. Lastly, a client with absent insight will present with a solid conviction that obsessions and beliefs are true and accurate (e.g., “I had this thought because I certainly made a mistake that will poison my children”). In these cases, intrusive thoughts may present as delusional beliefs, and individuals may appear out of touch with reality. Of note, poor insight in OCD is fairly uncommon and absent or delu- sional insight even less so [16].
Subtypes and Symptom Dimensions As mentioned, the presentation of obsessions and compulsions in OCD is highly idiosyncratic and can shift over time. Although subtypes of OCD are not formally included in the DSM-5, research suggests that obsessions tend to cohere along four primary themes including (1) fears of germs, contamination, and illness, (2) responsibility for causing harm or making a mistake, (3) thoughts about unacceptable or taboo topics (i.e., sexual, violent, immoral, or blasphemous themes), or (4) a need for symmetry, order, and exactness [4, 17].
Within these four dimensions, obsessions and compulsions are coupled together in thematic content. For example, an intrusive thought regarding contamination (e.g.,
“The toilet in the public restroom is covered with germs that will spread HIV/
AIDs”) is typically linked with a compulsion aimed to prevent getting sick and reduce resulting anxiety (e.g., washing one’s hands for 15 minutes to eliminate the perceived contaminant). However, obsessions and compulsions can couple across symptom dimensions; for instance, an individual may wash his hands to rid himself of sin following an unwanted blasphemous thought. This unique heterogeneity in OCD underscores the need for careful, comprehensive assessment as further described below (see Considerations for Assessment and Diagnosis).
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Prevalence and Course OCD is estimated to impact 1–2% of the US population in a given year, with parallel estimates internationally [18, 19]. Symptoms typically onset around age 20, with the first onset of symptoms possible but rare in pediatric populations or in individuals over the age of 35 [19–21]. The prevalence rates of OCD are similar across men and women; however, symptoms typically onset earlier in men (resulting in more boys with OCD compared to girls) [22]. In general, symp- toms onset gradually; yet, in certain circumstances (e.g., perinatal OCD), a rapid onset of severe symptoms can occur [23]. The severity of symptoms tends to oscil- late over time, with a long-term trend toward worsening severity and impairment without treatment [24]. Despite several highly effective, empirically supported treatments (e.g., exposure therapy), the majority of individuals with OCD do not receive treatment, and clients suffer for on average 10–17 years prior to receiving care [25]. Moreover, full remission rates in the community remain quite low [20, 26]. Collectively, these factors highlight the considerable impairment, disability, and distress associated with OCD.
Body Dysmorphic Disorder (BDD)
In terms of diagnostic criteria and presentation, BDD mostly closely aligns with OCD within the OCRD spectrum. In order to meet criteria for BDD, an individual must report marked concerns with at least one perceived fault or problem with their physical appearance [1]. This reported physical defect must either be unobservable to others or deemed excessive and disproportionate to the flaw. In response to this appearance-centered distress, individuals with BDD engage in repetitive physical (e.g., mirror checking, reassurance seeking) and/or mental (e.g., comparing his or her appearance with that of others) behaviors. Additionally, individuals with BDD engage in patterns of avoidance (e.g., of having their photograph taken, leaving the house to interact with others) aimed to prevent or reduce distress. As noted for OCD, these intrusive cognitions, rituals, and avoidance cause substantial distress as well as impairment in various domains of functioning (e.g., social interactions, workplace performance).
Muscle Dysmorphia In DSM-5, a specifier was included to identify individuals specifically preoccupied with weight and shape concerns centered on muscularity (a subtype that otherwise can be overlooked or mistaken for an eating disorder). This symptom presentation is far more common in men but can also present in women [27, 28].
Insight Criterion As in OCD, an insight criterion (with the same three categories) is included in the DSM-5 definition of BDD. Clients with BDD are more likely than those with OCD to report poor or absent insight [16], endorsing statements with conviction such as “My nose looks dreadful and is severely deformed.” Thus, low insight in the treatment of BDD can present a challenge (as discussed further in the Treatment Implications section below).
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Prevalence and Course BDD is estimated to affect 2% of the population, with higher rates observed among clients seeking medical or surgical treatment that impacts physical appearance (i.e., cosmetic surgery, dermatology) [29, 30]. In most cases, BDD onsets during adolescence (e.g., 12–17 years old) and progresses gradu- ally over time [31]. However, the discrete trigger endorsed for BDD onset is often either unidentifiable or related to more diffuse, interpersonal events that contribute to a sensitized awareness of one’s appearance, such as bullying or teasing [32].
Although BDD presents across the lifespan, its presentation among geriatric popu- lations is lacking. Extant research supports that the prevalence and clinical charac- teristics of BDD are overall similar across men and women; however, men and women tend to differ in their body area of primary concern [27, 33]. Specifically, women are more likely to be preoccupied with their breasts/chest, skin, buttocks, thighs/legs, hips, toes, and excessive body/facial hair, while men are more likely to focus on body build, genitals, and hair thinning/balding.
Hoarding Disorder
To meet criteria for hoarding disorder, an individual must experience considerable difficulty with the disposal of possessions [1]. This difficulty arises from a strongly held desire to save items, and attempts to discard possessions elicit considerable distress (e.g., anxiety, anger). This distress is typically present for the majority of possessions and is the not the result of the specific monetary or sentimental value attached to a single item. In fact, individuals may acquire possessions without func- tional, monetary, or sentimental value (e.g., broken appliances, used food contain- ers), due to a diverse number of reasons for saving [34]. The inability to discard possessions results in substantial clutter and impairment in daily activities. If the removal of items does occur, it usually is done by the intervention of others such as family members or authorities. Hoarding is considered of clinical significance if it is causing impairment in daily life activities and hindering functioning in interper- sonal, workplace, or other meaningful domains. Of note, hoarding may uniquely result in impaired safety both for oneself and others (e.g., neighbors, children, pets) in the immediate living environment due to excessive clutter [35].
Excessive Acquisition Criterion Within DSM-5, it is possible to specify whether an individual presents with excessive acquisition (i.e., excessive buying or collect- ing). It is more common for women to engage in compulsive buying of items, whereas the excessive acquisition of free items tends to be similar in men and women [36]. This criterion may indicate overall clinical severity, given the relation- ship between compulsive buying and hoarding symptom severity [37, 38].
Insight Criterion The degree of insight (good or fair, poor, absent) in hoarding disorder can vary considerably between individuals. Although these three insight categories overlap with OCD and BDD, insight for hoarding disorder focuses on whether the individual recognizes the degree to which hoarding symptoms are caus-
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ing problems and impairment. For example, an individual with poor or absent insight will hold a strong conviction that the excessive acquisition and inability to discard possessions are not a source of impairment.
Prevalence and Course In comparison with OCD, accurate prevalence estimates of hoarding disorder are lacking, with best estimates indicating that 2–6% of the US population is impacted by this condition [39]. Although symptoms typically begin in adolescence, similar to other OCRDs, individuals typically are diagnosed and present for treatment significantly later in life [40]. Further, individuals with hoarding symptoms are less to likely to present for treatment than other OCRDs (or they present for delayed treatment), given that treatment seeking is typically due to extrinsic motivations (e.g., encouragement to seek care by loved ones or due to legal ramifications) [41, 42]. This also contributes to the challenging nature of treating hoarding, as discussed in Treatment Implications below. Those with severe hoarding symptoms often struggle with additional impairments in interper- sonal domains (e.g., conflict with family members, neighbors) as well as physical health consequences (e.g., due to the impact of clutter on sleep, movement, hygiene, etc.) [35].
Hair-Pulling Disorder (HPD)
To meet criteria for HPD, an individual must demonstrate repetitive, hair-pulling behavior that they are unable to control or stop, resulting in substantial hair loss [1].
The hair pulling must cause significant distress or impairment (e.g., social, per- sonal, occupational, physical). Hair pulling must not solely occur as a means to improve physical appearance (e.g., cosmetic behavior) or correct a perceived blem- ish (e.g., as in BDD, to be discussed further in Differential Diagnosis) or as the result of another medical or psychological condition.
Prevalence and Course Recent estimates suggest that HPD impacts approxi- mately 1–2% of the population [18, 19, 21]. The majority of individuals affected by HPD are women. It remains unclear the extent to which this gender discrep- ancy is inflated due to gender differences in cultural attitudes around hair loss and appearance or genetic/biological sex differences in the etiology of HPD. Hair pulling is fairly common in early developmental stages and typically extinguishes on its own [43, 44]. Moreover, as previously noted, it is not uncommon for indi- viduals to engage in forms of hair removal (e.g., tweezing, physical pulling) for cosmetic purposes. When hair pulling persists and leads to significant physical consequences or distress, however, it is likely to result in a diagnosis of HPD. Although HPD typically onsets in adolescence, symptoms can onset at any age [45]. The severity of symptoms may oscillate over time, but typically do not fully remit without treatment [46]. Individuals with severe symptoms may experi- ence significant physical health consequences (e.g., permanent hair follicle destruction) as a result of chronic hair pulling [47].
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Skin-Picking (Excoriation) Disorder (SPD)
The criteria for SPD closely parallel those of HPD and are new to DSM-5 [1]. An individual with SPD experiences excessive, repeated skin picking that they are unable to control, reduce, or cease on their own. Importantly, the behavior causes considerable distress, physical health consequences (e.g., tissue damage, infection), or impairments in relationships, work, school, or other domains of functioning.
Clients often present for treatment due to physical ramifications of picking, medical advice, or parental intervention.
Prevalence and Course SPD (i.e., excoriation, disorder) is estimated to impact 1–2% of the population, with community estimates suggesting a higher prevalence around 5% [12, 48]. As with HPD, rates are much higher among women than men.
However, again the extent to which this represents a true biological versus cultural difference in prevalence remains unknown. Although SPD can onset at any age, symptoms often present earlier than other OCRDs in childhood or adolescence [49].
It is also common for skin picking to follow the onset of a dermatological condition, such as acne or a rash, and then to persist [50]. As with HPD, over time these behav- iors become chronic and more severe, leading to impairment, and it is uncommon for symptoms to remit without treatment. Moreover, individuals may also experi- ence significant health consequences (e.g., scarring, damaged tissue, infection) and necessitate medical intervention as a result of excoriation [51].