ADD5107- Week 5 Discussion 1: Panic Attack Versus Panic

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CHAPTER 5

Obsessive– Compulsive and Related Disorders

Quick Guide to the Obsessive– Compulsive and Related Disorders

Patients who are preoccupied with obsessional ideas or certain repetitive behaviors may qualify for the disorders listed here. As in earlier chapters, the page number following each item indicates where a more detailed discussion begins.

Obsessive– compulsive disorder. These patients are bothered by repeated thoughts or behaviors that appear senseless, even to them (p. 200).

Body dysmorphic disorder. In this disorder, physically normal patients believe that parts of their bodies are misshapen or ugly (p. 204).

Hoarding disorder. An individual accumulates so many objects (perhaps of no value) that they interfere with life and living (p. 207).

Trichotillomania (hair- pulling disorder). Pulling hair from various parts of the body is often accompanied by feelings of “tension and release” (p. 210).

Excoriation (skin- picking) disorder. Patients so persistently pick at their skin that they trau- matize it (p. 212).

Obsessive– compulsive and related disorder due to another medical condition. Obsessions and compulsions can be caused by various medical conditions (p. 215).

Substance/medication- induced obsessive– compulsive and related disorder. Various sub- stances can lead to obsessive– compulsive symptoms that don’t fulfill criteria for any of the above-mentioned disorders (p. 214).

Other specified, or unspecified, obsessive– compulsive and related disorder. Use one of these categories to code disorders with prominent obsessive– compulsive symptoms that do not fit neatly into any of the groups above (p. 216).

Morrison, James. DSM-5® Made Easy : The Clinician's Guide to Diagnosis, Guilford Publications, 2014. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/capella/detail.action?docID=1682559. Created from capella on 2023-08-08 21:12:40.

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Introduction

This chapter—new to the DSMs—pulls together disorders that have in common intrusive thoughts and time- consuming, repetitive behaviors: skin picking, hoarding, checking for body defects, and of course the classic component symptoms of obsessive– compulsive disorder (OCD). These behaviors aren’t all unwanted—at least not at first, as with the pursuit of physical perfection (body dysmorphic disorder) or an accumu- lation of goods (hoarding). However they begin, the behaviors eventually become symptoms— burdensome to those whose once voluntary acts have morphed into duties that are performed at the cost of anxiety and distress.

A number of other features bind together this seemingly disparate collection of conditions: onset when young, similar comorbidity, a family history of OCD, similar treatment response, and hints of dysfunction in the frontostriatal brain circuitry (cau- date hyperactivity).

F42.2 [300.3] Obsessive– Compulsive Disorder

Obsessions are recurring thoughts, beliefs, or ideas that dominate a person’s mental content. They persist despite the fact that the person may believe they are unrealistic and tries to resist them. Compulsions are acts (either physical or mental) performed repeatedly in a way that the person may realize is neither appropriate nor useful. So why do them? For the most part, the aim is to neutralize the obsessional thinking. Note, then, that repeated thoughts can themselves sometimes be compulsions, if their purpose is to reduce the obsessional anxiety.

Compulsions can be comparatively simple, such as uttering or thinking a word or phrase of protection against an obsessive thought. But some are almost unbelievably complex. For instance, some elaborate dressing, bedtime, or washing rituals, if not per- formed exactly as specified by intricate rules, must be repeated until the patient gets it right. Of course, that sort of behavior can soak up hours every day.

Most patients have both obsessions and compulsions, which usually result in anxi- ety and dread. And most patients recognize them as being irrational and want to resist. OCD comprises four major symptom patterns, whose features sometimes overlap.

•• The most common is a fear of contamination that leads to excessive handwash- ing.

•• Doubts (“Did I turn off the cooktop?”) lead to excessive checking: The patient returns repeatedly to be sure that the cooktop is well and truly cold.

•• Obsessions without compulsions constitute a less common pattern.

•• Obsessions and compulsions slow some patients down to the point that it can take them hours just to finish breakfast or other daily routines.

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Obsessions about symmetry (putting things into a specific order, counting things) and forbidden thoughts (sacrilegious ideas, sexual taboos) also commonly occur.

One feature that helps classify patients with OCD is their degree of insight. Most patients are pretty well aware that their behavior is odd or peculiar; in fact, they are often embarrassed by it and try to hide it. But others— perhaps 10–25% of all patients with OCD—either have never recognized the irrationality of their behavior or have now to some degree lost that insight. Poor insight often indicates a worse prognosis. A few patients have so little that they are actually delusional; however, their OCD can be distinguished from delusional disorder by the presence of their obsessions (you don’t need to give them an additional psychotic diagnosis). Note that children often don’t have the experience to judge the reasonableness of their own behavior; therefore, insight specifiers often don’t apply to them.

OCD is clinically important because it is usually chronic and often debilitating. Though symptoms may wax and wane, it puts patients at risk for celibacy or marital dis- cord and interferes with performance at school and work. Comorbidity is the rule, with two- thirds of patients experiencing major depression. Perhaps 15% attempt suicide.

Men and women are about equally likely to be affected by OCD. Its prevalence, which may be as high as 2% in the general population, is reported to be greater in higher socioeconomic classes and in individuals of high intelligence. OCD is strongly familial (risk for first- degree relatives is 12%, about six times normal) and probably at least in part inherited. However, it is still unclear how genetics and environmental influences interact.

OCD typically begins in adolescence (males) or young adult life (females), but it often takes a decade or more before patients come to clinical attention. When it begins before puberty, compulsions may start first, often accompanied by tics and comorbid disorders.

Tic Specifier

DSM-5 has added a new specifier concerning a patient’s experience with chronic (but not transient) tic disorder. These patients, usually male, tend to have a very early onset of OCD—often before the age of 11. They are especially likely to obsess over issues of exactness and symmetry; their compulsions concern ordering and arranging things. Some studies seem to suggest that a chronic tic disorder may reduce patients’ response to antidepressant medications (though not to cognitive- behavioral therapy), and that antipsychotic drugs may help. However, it isn’t clear that the history of tics denotes a patient who is more seriously ill. The tic specifier will apply to about a fourth of patients with OCD.

The December 2008 issue of The Atlantic reported asking for a term that would describe the irresistible impulse to rearrange that which someone else has already loaded into a dishwasher. Numerous readers suggested “obsessive compulsive dishorder.”

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Essential Features of Obsessive– Compulsive Disorder The patient has distressing obsessions or compulsions (or both!) that occupy so much time they interfere with accustomed routines.

The Fine Print Obsessions are recurring, unwanted ideas that intrude into awareness; the patient usually tries to suppress, disregard, or neutralize them.

Compulsions are repeated physical (sometimes mental) behaviors that follow rules (or respond to obsessions) in an attempt to alleviate distress; the patient may try to resist them. The behaviors are unreasonable, meaning that they don’t have any realistic chance of helping the obsessional distress.

The D’s: • Distress or disability (typically, the obsessions and/or compulsions occupy an hour a day or more or cause work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, “normal” superstitions and rituals that don’t actually cause distress or disability, depressive and psychotic disorders, anxiety and impulse- control disorders, Tourette’s disorder, obsessive– compulsive personality disorder)

Coding Notes Specify degree of insight:

With good or fair insight. The patient realizes that the OCD thoughts and behav- iors are definitely (or probably) not true.

With poor insight. The patient thinks that the OCD concerns are probably true. With absent insight/delusional beliefs. The patient strongly believes that the

OCD concerns are true.

Specify if:

Tic- related. The patient has a lifetime history of a chronic tic disorder.

Leighton Prescott

Pausing for a moment, Leighton Prescott leaned forward to straighten a stack of jour- nals on the interviewer’s desk. The chapped skin on the backs of his hands was the color of dusty bricks. Apparently satisfied, he resumed his narrative.

“I would get this feeling that there could be semen on my hands and that it might be transferred to a woman and get her pregnant, even if I only shook hands with her. So I started washing extra carefully each time I masturbated.”

Leighton was a 23-year-old graduate student in plant physiology. Though he was enormously bright and dedicated to science, his grades had slipped badly over the past few months. He attributed this to the handwashing rituals. Whenever he had the

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thought that he might have contaminated his hands with semen, he felt compelled to scrub them vigorously.

A year earlier, this had only meant 3 or 4 minutes with a bar of soap and water as hot as he could stand it. Soon he required a nail brush; still later he was brushing his hands and wrists as well. Now an elaborate ritual had evolved. First he scraped under his nails with a blade; then he used the brush on them. He then lathered surgical soap up to his elbows and scrubbed with a different brush for 15 minutes per arm. Then he would have to start over with his nails, because semen he had scrubbed off his arms might have lodged under them. If he had the thought that he had not performed one of the steps exactly right, he would have to start all over again. In recent weeks this had become the norm.

“I know it seems crazy,” he said with a glance at his hands. “I’m a biologist. That part of me knows that spermatozoa can’t live longer than a few minutes on the skin. But if I don’t wash, the pressure just builds up and up, until I have to wash— washing is the only thing that relieves the anxiety.”

Leighton didn’t think he was depressed, though he was appropriately concerned about his symptoms. His sleep and appetite had been normal; he had never felt guilty or suicidal.

“Just stupid, especially when my girl stopped seeing me. I used the bathroom in a restaurant where I took her to eat. After 45 minutes, she had to send the manager in for me.” He laughed without much humor. “She said she might see me again, if I’d clean up my act.”

Evaluation of Leighton Prescott

Leighton’s obsessions and compulsions (criterion A) both easily fulfilled the require- ments for OCD. He tried to suppress the recurrent thoughts about contamination, which he recognized were the unreasonable products of his own mind (good insight). He felt compelled to ward off these ideas by repetitive handwashing, which he acknowl- edged was grossly excessive. By the time he came for help, his symptoms occupied several hours each day, interfered with his schooling and social life, and caused him severe distress (B). He had no other identifiable mental disorder that might account for his symptoms (D).

An important step in evaluating anyone for OCD is to determine whether the patient’s focus of concern is pathological. For example, someone who lives in a ghetto or a war zone might be prudent to triple-lock the doors and frequently check security. Had Leighton been excessively concerned about numerous real-life problems (such as pass- ing his exams or succeeding with his girlfriend), he might instead warrant a diagnosis of generalized anxiety disorder.

Though repetitive behavior is also characteristic of Tourette’s disorder and tem- poral lobe epilepsy, patients with other medical conditions rarely present with obses- sions or compulsions (C). However, occasionally a person will develop obsessions or compulsions as a result of substance use.

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Inquire carefully about past or present tics, reported in about one- quarter of all patients with OCD. Not only is there a relationship between OCD and Tourette’s dis- order, but an outsized percentage of patients with OCD (though not Leighton) report a history of chronic tics.

Obsessional thinking or compulsive behavior can be found in a variety of other mental disorders. People may obsessively pursue any number of activities, such as gam- bling, drinking, and sex. The differential diagnosis also includes body dysmorphic dis- order (the patient obsesses about body shape) and illness anxiety disorder (the focus is health). Patients with psychotic disorders sometimes maintain their obsessional ideas to a delusional degree. And of course there is something a bit obsessive in the eating behaviors of patients with anorexia nervosa and bulimia nervosa.

Perhaps 20% of patients with OCD have premorbid obsessional traits. Because of its name, obsessive– compulsive personality disorder (see p. 558) can be confused with OCD. Patients with only the personality disorder may not have obsessions or compulsions at all. They are perfectionistic and become preoccupied with rules, lists, and details. These people may accomplish tasks slowly because they keep checking to be sure it is being performed exactly right, but they do not have the desire to resist these behaviors. OCD and obsessive– compulsive personality disorder can coexist, in which case the OCD is often extra severe. Some clinicians believe that the border zone between OCD and schizotypal personality disorder is also a common problem in dif- ferential diagnosis.

Leighton’s clinician needs to ensure that he doesn’t have one of the (numerous) other conditions that often accompany OCD. Besides the two personality disorders just men- tioned, I’d especially check for mood disorders (either depressive or bipolar) and anxiety disorders (generalized anxiety disorder, social anxiety disorder, and panic disorder).

Although most patients with OCD recognize that their obsessions and compul- sions are unreasonable or excessive, some lose insight as the illness wears on. Leighton recognized that he was being unreasonable; we’ll code him accordingly. With a GAF score of 60, his diagnosis would be the following:

F42.2 [300.3] Obsessive– compulsive disorder, with good insight

As many as half of patients with OCD have an accompanying mood disorder. Some only show their obsessional symptoms when they are in the midst of a severe depression. Patients with OCD are also highly likely to have an accompanying anxiety disorder. (Indeed, OCD was itself classified as an anxiety disorder in earlier DSMs.)

F45.22 [300.7] Body Dysmorphic Disorder

Patients with body dysmorphic disorder (BDD) worry that there is something wrong with the shape or appearance of a body part—most often breasts, genitalia, hair, or the

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nose or some other portion of the face. The ideas these patients have about their bodies are not delusional; as in illness anxiety disorder, they are overvalued ideas. At one time the disorder was called dysmorphophobia; although some clinicians may still call it that, it isn’t a phobia at all (irrational fear doesn’t really enter into it).

This disorder can be devastating. Although they frequently request medical pro- cedures (such as dermabrasion) or plastic surgery to correct their imagined defects, patients are often dissatisfied with the results. For that reason, surgery is usually contraindicated in these patients. They may also seek reassurance (which helps only briefly), try to hide their perceived deformities with clothing or body hair, or avoid social situations; some even become housebound. The preoccupation causes clinically important distress of other sorts— depressed mood, for example, even suicide ideas and attempts. Insight varies, though it’s mostly poor.

In the general population, the rate of BDD is probably about 2%. It may account for as many as 10% of patients who consult a dermatologist and a third of patients seek- ing rhinoplasty. Though patients with BDD are relatively young (it tends to begin dur- ing the teen years), incidence may peak again after menopause. Although the question is not settled, men and women are probably about equally affected. However, males are more often concerned about genitals and hair.

Essential Features of Body Dysmorphic Disorder In response to a miniscule, sometimes invisible physical flaw, the patient repeatedly checks in a mirror, asks for reassurance, or picks at patches of skin—or makes mental comparisons with other people.

The Fine Print The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood and psychotic disorders, anorexia nervosa or other eating disorders, OCD, illness anxiety disorder, ordinary dissatisfaction with personal appearance)

Coding Notes Specify if:

With muscle dysmorphia. These people believe that their bodies are too small or lack adequate musculature.

Specify degree of insight:

With good or fair insight. The patient realizes that the BDD thoughts and behav- iors are definitely (or probably) not true.

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With poor insight. The patient thinks that the BDD concerns are probably true. With absent insight/delusional beliefs. The patient strongly believes that the

BDD concerns are true.

Muscle Dysmorphia Specifier

The muscle dysmorphia specifier for BDD is found almost exclusively in men. Such a man believes that he is too small or slightly built. As a result, he will often take dieting or weight lifting to extremes, and may misuse anabolic steroids or other drugs. (These patients may also be concerned about other body features—skin, hair, or whatever.)

Cecil Crane

Cecil Crane was only 24 when he was referred. “He came in here last week asking for a rhinoplasty,” said the plastic surgeon on the telephone, “but his nose looks perfect to me. I told him that, but he insisted there was something wrong with it. I’ve seen this kind of patient before—if I operate, they’re never satisfied. It’s a lawsuit waiting to hap- pen.”

When Cecil appeared a few days later, he had the most beautiful nose the clinician had ever seen, apart from one or two Greek statues. “What seems to be wrong with it?”

“I was afraid you’d ask that,” said Cecil. “Everybody says that.” “But you don’t believe it?” “Well, they look at me funny. Even at work—I sell suits at Macy’s—I sometimes

feel that the customers notice. I think it’s this bump here.” Viewed from a certain angle, the area Cecil pointed out bore the barest suggestion

of a convexity. He complained that it had cost him his girlfriend, who always said it looked fine to her. Weary of Cecil’s trying to look at his profile in every mirror he passed and banging on about plastic surgery all the time, she’d finally sought greener pastures.

Cecil felt unhappy, though not depressed. He admitted that he was making a mess of his life, but he had nevertheless maintained his interests in reading and going to the movies. He thought his sex interest was good, though he’d had no chance to test it since the departure of his girlfriend. His appetite was good, and his weight was about average for his height. His flow of thought was unremarkable; its content, aside from his concern for his nose, seemed quite ordinary. He even admitted that it was possible that his nose was less ugly than he feared, though he thought that unlikely.

Cecil couldn’t say exactly when his worry about his nose began. It may have been about the time he started shaving. He recalled frequently gazing at a silhouette of his profile that had been cut from black paper during a seashore vacation with his family. Although numerous relatives and friends had remarked that it was a good likeness, something about the nose had bothered him. One day he had taken it down from the wall and, with a pair of scissors, he’d tried to put it to rights. Within moments the nose lay in snippets on the kitchen table, and Cecil was grounded for a month.

“I sure hope the plastic surgeon is a better artist than I am,” he commented.

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Evaluation of Cecil Crane

The criteria for BDD are straightforward. Cecil was preoccupied with his flawless nose (criterion A), which caused him enough distress to seek surgery—and lose his girl- friend (C). More than one person had tried to assure him that his nose was rather ordi- nary, so his distress evidently exceeded normal concerns regarding appearance. And he appeared to need the constant checking in the mirror (B). Despite the full range of symptoms, there are several disorders in the differential diagnosis to consider.

In illness anxiety disorder, it isn’t appearance that preoccupies the patient; rather, it is fear of having a disease. In anorexia nervosa, patients have distorted self-image, but only in the context of concern about overweight. In the somatic type of delusional disorder, patients lack insight that their complaints might be unreasonable, whereas Cecil was willing to entertain the notion that others might see his nose differently. (However, some patients with BDD completely lack insight; then the differentiation turns on the content of the delusion, which in delusional disorder will involve the func- tion of or sensations in body parts, not their appearance.) Complaints from patients with schizophrenia about appearance are often bizarre (one woman reported that when she looked into the mirror, she noticed that her head had been replaced by a mushroom). In gender dysphoria, patients’ complaints are limited to the conviction that they should have been born the opposite sex.

None of these was the focus of Cecil’s concern (D, E). However, his clinician would do well to look carefully for social phobia, obsessive– compulsive disorder, and major depressive disorder, all of which can be comorbid with body dysmorphic disor- der. Pending investigation for these disorders, Cecil’s full diagnosis would be as given below, with a GAF score of 70:

F45.22 [300.7] Body dysmorphic disorder, with fair insight

F42.3 [300.3] Hoarding Disorder

Over a thousand years ago, the Beowulf legend referred to a hoard as a mass of some- thing valuable (especially money or other treasure) laid by for future use. Nowadays, we stand this definition on its head to mean worthless stuff that’s kept beyond all practical use.

The motivations behind hoarding can be varied. Some people believe their things are valuable when they’re not. Others may be imitating behavior they’ve encountered in family members (a genetic component is also suspected). Still others apparently feel comforted by the presence of things they’ve grown used to having, or that they think they may need later. Whatever the instigation, a hoarder’s living space becomes clut- tered, perhaps eventually filling up completely. (If living areas remain habitable, it’s probably because someone else tidies up the mess.) One social consequence of hoarding is that children dread having visitors to the home; they sure don’t learn the basics of housekeeping there! There are now online support groups for hoarders’ children, who

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are otherwise left with their own hopeless attempts at coping with the unsanitary, the unsightly, and the unsafe.

A condition that’s said to affect 2–5% of the general population, hoarding disorder is new in DSM-5. It was once considered a possible variant of OCD, but in fact not even 20% of hoarders meet OCD criteria—partly because they don’t consider their symptoms to be intrusive, unpleasant, or distressing. Indeed, distress often develops only when they are forced to get rid of the stuff they’ve so laboriously brought home.

Hoarding disorder comprises several special types: people who hoard books, or animals (think a houseful of cats), or food that is—ugh!—way past its pull date. Animal hoarders also save other things, which may at least have the advantage of better sanita- tion. The disorder begins young and worsens with time, so that it is more often found among older adults; males may outnumber females. It appears to be strongly hereditary.

Essential Features of Hoarding Disorder These patients are in the grip of something powerful: the overwhelming urge to accumulate stuff. They experience trouble—indeed, distress—when trying to discard their possessions, even those that appear to have little value (sentimental or other- wise). As a result, things pile up, cluttering up living areas to render them unusable.

The Fine Print The D’s: • Duration (not stated, other than “persistent”) • Distress or disability (work/ educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood and psychotic disorders, dementia, OCD, normal col- lecting

Coding Notes Specify if:

With excessive acquisition. If symptoms are accompanied by excessive collecting, buying, or stealing of items that are not needed or for which there is no space available.

Specify degree of insight:

With good or fair insight. The patient realizes that these thoughts and behav- iors cause problems.

With poor insight. The patient mostly believes that hoarding isn’t a problem. With absent insight/delusional beliefs. The patient strongly believes that hoard-

ing isn’t a problem.

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Langley Collyer

More than half a century later, the Collyer case remains celebrated in the annals of hoarding.

Though well educated (Columbia University) and a talented pianist, Langley Col- lyer probably never held gainful employment. He and his older brother, Homer, lived in the Harlem house left them by their parents, an obstetrician and his wife who were first cousins. Trained as a lawyer, Homer worked for a time, but his vision deteriorated and he suffered from arthritis. So, as they grew older, the brothers lived on their inherited money. They didn’t require much: They had no gas, electricity, or telephone service. Even the water was eventually turned off. For decades, they essentially camped out indoors.

Langley would walk miles to the store for supplies that he’d bring home in a wagon, pulled along by a string. On these journeys, he also collected much of the debris that ultimately invaded their living space. Though he wore clothes long out of fashion, Lang- ley was not completely asocial. As reported from accounts of those who knew him, he was pleasant, at times grateful for company. He even admitted that he was too reclusive.

In 1947, at age 61, Langley died, crushed under the weight of the booby trap he’d designed and installed over a period of years to prevent criminals from stealing the brothers’ possessions. Finding the doorways stuffed with 10-foot-high walls of bailed newspaper and other debris, police had to chop their way in. It took them over 2 weeks to find Langley’s body, which lay just 10 feet from where Homer had subsequently also died—of starvation.

After the bodies had been removed, the house was cleared of its holdings. Workers found dressmaker’s dummies, sheets of Braille, a doll carriage, bicycles, a photograph of Mickey Rooney, old advertisements, firearms and ammunition, parts for old radios, chunks of concrete, and shoelaces. The brothers had stored some of their body waste in jars. There was a two- headed baby preserved in formaldehyde (probably an artifact from their father’s medical practice), a canoe, a dismantled Model T automobile, two pipe organs, thousands of empty tin cans, and 14 pianos. There were also tons of news- papers, saved so that Homer could catch up on the news, once he regained his sight. In all, the house eventually yielded 180 tons of junk, with everything covered in decades of dust.

Evaluation of Langley Collyer

The analysis of Langley’s condition requires a little forgiveness. That’s because, candidly, we must infer one criterion important for hoarding disorder: that no other medical dis- order could better explain the symptoms (criterion E). Langley and Homer famously refused to seek medical attention; hence Homer’s crippling arthritis and, perhaps, his blindness. But Langley eschewed alcohol and drugs, and he appeared well enough for decades until the very end of his life—when it all came, quite literally, crashing down.

Hoarding can occur as a symptom of OCD, but as with most patients who hoard,

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we have no evidence of actual obsessions or (other) compulsions (F). Although there is no evidence for another mental disorder, neither have we positive evidence that Lang- ley did not suffer from, say, major depressive disorder (it and OCD are often comorbid with hoarding disorder).

As for the other requirements of the syndrome, Langley was undeniably a collector whose accumulated tonnage didn’t just impinge upon but engulfed the living space of the two hermit brothers (A, B, C). It imperiled their own health and that of any public service personnel who might be required to enter to give assistance; failing to maintain a safe environment satisfies the stress or impairment requirement (D).

In the absence of direct testimony from Langley, we cannot know how deeply he understood his condition, so we must ignore the insight specifiers. However, we can probably agree that his collecting habits qualify for the specifier with excessive acquisi- tion—as is the case in the vast majority of hoarders. Although we are no longer able to code something on the order of “personality disorder, diagnosis deferred,” if Langley were a living patient I’d make some sort of note in my summary to that effect—to alert me, or some other clinician down the road, that there was more diagnostic work to be done. I’d give him a GAF score of 60.

F42.3 [300.3] Hoarding disorder, with excessive acquisition

F63.3 [312.39] Trichotillomania (Hair- Pulling Disorder)

Trichotillomania comes from the Greek meaning “passion for pulling hair.” As with pyromania and kleptomania, many such patients (but not all) feel a mounting tension until they succumb to the urge. Then, when they pull out the hair, they experience release. Usually beginning in childhood, hair- pullers repeatedly extract their own hair, beards, eyebrows, or eyelashes. Less often, they will pull hair from armpits, the pubic area, or other body locations. They usually don’t report pain associated with the hair pulling, although they may note a tingling sensation.

Some people put the hair into their mouths, and about 30% swallow it. If the hair is long, it can accumulate in the stomach or intestines as a bezoar (hairball) that may require surgical removal. Patients may be referred to mental health professionals by dermatologists, who note patchy hair loss.

Onset of trichotillomania is usually in childhood or adolescence. (When it begins in an adult, it may be associated with psychosis.) The condition tends to wax and wane, but is usually chronic.

Trichotillomania is embarrassing to patients, who tend to be secretive, so it’s unclear just how common it is. Some hair pulling can be found in up to 3% of the adult population, especially women, though far fewer (probably under 1%) meet full criteria for the disorder. It is far more common in females than in males, and it is especially common in people with intellectual disability. Hair pullers also tend to crack their knuckles, bite their nails, or excoriate themselves.

The feeling of tension before hair pulling, and release or relief of stress afterwards,

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still characterizes many sufferers (though it is no longer a requirement for diagnosis). But patients who have the “tension and release” aspect of hair pulling may be in for a more severe course of the illness than those who don’t report this feature.

Essential Features of Trichotillomania Repeated pulling out of the patient’s own hair results in bald patches and attempts to control the behavior.

The Fine Print The D’s: • Duration (“recurrent”) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, mood and psychotic disorders, body dysmorphic disorder, OCD, ordinary grooming)

Rosalind Brewer

“I don’t know why I do it, I just do it.” Rosalind Brewer had been referred to the mental health clinic by her dermatologist. “I get to feeling sort of uptight, and if I just pop one little strand loose, somehow it relieves the tension.” She selected a single strand of her long blonde hair, twined it neatly twice around her forefinger, and tweaked it out. She gazed at it a moment before dropping it onto the freshly vacuumed carpet.

Rosalind had been pulling out her hair for nearly half her 30 years. She thought it had started during her sophomore or junior year in high school, when she was studying for final exams. Perhaps the tingling sensation on her scalp had helped her stay awake; she didn’t know. “Now it’s a habit. I’ve always only pulled the hairs from the very top of my head.”

The top of Rosalind’s head bore a round, almost bald spot about the size of a sil- ver dollar. Only a few broken hairs and a sparse growth of new hair sprouted there. It looked like a tiny tonsure.

“It used to make my mom really angry. She said I’d end up looking like Dad. She’d order me to stop, but you know kids. I used to think I had her by the short hairs.” She laughed a little. “Now that I want to stop, I can’t.”

Rosalind had sucked her thumb until the age of 8, but otherwise her childhood hadn’t been remarkable. Her physical health was good; she had no other compulsive behaviors or obsessive thinking. She denied using drugs or alcohol. Although she had no significant symptoms of depression, she admitted that her hair pulling was a serious problem for her. She could wear a hairpiece to hide her bald spot, but the knowledge that it was there had kept her from forming any close relationships with men.

“It’s bad enough looking like a monk,” Rosalind said. “But this thing has got me living like one, too.”

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Evaluation of Rosalind Brewer

Rosalind’s symptoms of repeated hair pulling (criterion A) included the classic “tension and release” that used to be required for a diagnosis of trichotillomania, but now is only a frequent feature. She had no evidence of a dermatological disorder or other general medical condition (D) that might explain the condition (she was referred by a derma- tologist). The mental conditions that might be confused with trichotillomania would include OCD, in which compulsions are performed not as an end to themselves, but as a means of preventing anxiety. Hair pulling is sometimes found in body dysmorphic disorder, but all would agree that Rosalind had a cosmetic flaw. Factitious disorder, another possibility, would be ruled out because Rosalind gave no indication that she wanted to be a patient. She had no psychosis or other evident mental disorder (espe- cially mood disorder, E), except for her distress (C) at her inability to stop (B).

With a GAF score of 70, her complete diagnosis would be straightforward:

F63.3 [312.39] Trichotillomania

F42.4 [698.4] Excoriation (Skin- Picking) Disorder

Excoriation (skin- picking) disorder usually begins by adolescence, though sometimes later. These patients spend much time— perhaps hours each day— digging at their skin. Most will focus on head or face; fingernails tend to be the instruments of choice, though some people employ tweezers. Tension prior to the act, as with other disorders of impulse such as pyromania, is a frequent finding in these patients. Then the act of picking may yield gratification; subsequent embarrassment or shame can delay treat- ment. Infections are common, sometimes producing ulceration. Patients may use cos- metics to conceal the scarring and excoriations; some will avoid social events as a result.

Other consequences can be dire. One patient picked so persistently at his neck and scalp that he picked right through his skull and developed an epidural abscess. The resultant quadriplegia resolved only partially; confined to a wheelchair, he ultimately resumed picking. Of course, this is the extreme; however, scarring and less harmful infections are common. Many patients will expend an hour or more each day engaged in picking behavior or its consequences.

A third of patients with excoriation disorder currently have some other mental disorder, most notably trichotillomania, a mood disorder, or OCD; some bite their nails. Nearly half of patients with body dysmorphic disorder also pick at themselves. Excoria- tion is found in people with developmental disabilities, especially in those with Prader– Willi syndrome (see sidebar, p. 215).

For a “new” disorder (though it was described as early as 1889, its DSM-5 listing is its first appearance as an official mental disorder), excoriation disorder is surprisingly common; its prevalence is probably 2% or more. It tends to begin in adolescence and runs a chronic course. By a large majority, these patients tend to be female; many have relatives similarly afflicted.

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Essential Features of Excoriation (Skin- Picking) Disorder The patient frequently tries to stop the repeated digging, scratching, or picking at skin, which has caused lesions.

The Fine Print The D’s: • Duration (recurring) • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use and physical disorders, psychotic disorders, OCD, body dysmorphic disorder, stereotypic movement disorder)

Brittany Fitch

The evidence was stark: Brittany Fitch’s face was replete with pits and scars. A few of her lesions were still inflamed, and one on her forehead had scabbed over. She’d cov- ered her fingernails with tape.

When she was 11, Brittany had developed acne, which her mother would “relieve” by squeezing the pustules and blackheads. Brittany endured long minutes standing with her head wedged into a corner, her mother’s muscular fingers digging away “as if for gold,” Brittany would recall years later. Released at last, she’d run to the bathroom and dab cool water on her smarting, spotted face. She’d hated her mother.

Now in college, Brittany had taken over the squeezing and picking job, though she knew it only led to more damaged skin. Several times a week she’d attack herself, usu- ally just a few minutes at a time, but longer if she was alone in the bathroom. She felt drawn to mirrors to inspect, to criticize her face; those inspections, inevitably, ushered in further bouts of destruction. Because she felt ashamed of the damage she’d wreaked, she avoided dating. It had been 6 months since she’d attended a play or a concert, even by herself.

“I hope you can help me,” she said with a wry smile. “More than anything, I want to stop being my mother.”

Evaluation of Brittany Fitch

Brittany’s condition isn’t hard to diagnose. The spots and scars (criterion A) and the taped fingernails (B) told much of the story, and her clinic visit testified to the distress her symptoms were causing (C). The most important question at this point would be this: Could another mental (or medical) disorder explain her symptoms? For that, her clinician would have to dig a little deeper, so to speak, into her history to make sure she didn’t have OCD (E). Of course she didn’t have body dysmorphic disorder: Her skin condition was perfectly evident to anyone who looked.

As long as her clinician could find no evidence of a medical condition (such as scabies or some other dermatological disease) or a substance use disorder (such as use of cocaine or methamphetamines, in which the sensation of bugs crawling on or under

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the skin can precipitate picking, D), Brittany’s diagnosis seems secure. I would base her GAF score (60) on the degree of social disability she experienced.

F42.4 [698.4] Excoriation disorder

Substance/Medication- Induced Obsessive– Compulsive and Related Disorder

Reports link obsessive– compulsive symptoms to use of codeine, cocaine, ecstasy, and methamphetamine. If these criteria look an awful lot like those for substance- induced anxiety disorders, it’s because the two sections were one and the same in DSM-IV. That’s one reason I’ve elected not to include an additional vignette here. The other is that these conditions are probably vanishingly rare.

A principal example is the foraging behavior noted in users of crack cocaine. For a few hours at most, heavy users will inspect the carpet or bare floor looking for bits of the drug they might have dropped. It always occurs as a withdrawal phenomenon, and though they realize it is in vain, they feel helpless to resist.

Essential Features of Substance/Medication- Induced Obsessive– Compulsive and Related Disorder

The use of some substance appears to have caused obsessions, compulsions, hoard- ing, hair pulling, excoriation, or other recurring symptoms concerning the patient’s own body.

The Fine Print For tips on identifying substance- related causation, see sidebar, page 95.

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (ordinary substance intoxication or withdrawal, delirium, physi- cal disorders, OCD, anxiety disorders)

Coding Notes Specify:

With onset during {intoxication}{withdrawal}. This gets tacked on at the end of your string of words.

With onset after medication use. You can use this in addition to other specifiers.

For specific coding procedures, see Tables 15.2 and 15.3 in Chapter 15.

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F06.8 [294.8] Obsessive– Compulsive and Related Disorder Due to Another Medical Condition

Occasionally you’ll encounter obsessive– compulsive symptoms that are associated with another medical condition. Of course, association doesn’t prove causation, but an etio- logical relationship has been claimed for Japanese B encephalitis and arachnoid cyst, among others.

Obsessive– compulsive symptoms are also found with Sydenham’s chorea, which results from streptococcus infection in children. Much has been written about the pediatric autoimmune neuropsychiatric disorders associated with streptococcal infec- tion (PANDAS), in which young children develop obsessions and compulsions as well as tics and other symptoms, but without the motor disorder of chorea. After years of study, a lot still isn’t known— including whether PANDAS is an actual entity, and whether the alleged association is even genuine. (In 2013, a young man was arrested for planning to bomb his own high school near Portland, Oregon. In his defense, he cited OCD due to PANDAS.)

Prader–Willi syndrome is a rare (about 1 in 50,000) disorder associated with a portion of DNA mission from chromosome 15. The condition may be identified at birth with genetic testing of markedly hypotonic babies. Though some individuals with this syndrome have borderline normal intelligence, mild to moderate intellectual disability is common. Patients typically have short stature and hypogonadism; insatiable appetite often results in severe obesity. Some have mood symptoms and problems with impulse control. Patients with Prader–Willi have also been reported to have hoarding behavior, foraging for food, skin picking, and obsessions with cleanliness—almost a clean sweep of the disorders this chapter comprises.

Essential Features of Obsessive– Compulsive and Related Disorder Due to Another Medical Condition

A physical condition appears to have caused a patient to have obsessions, compul- sions, hoarding, hair pulling, excoriation, or other recurrent symptoms concerning the patient’s own body.

The Fine Print For pointers on deciding when a physical condition may have caused a mental disor- der, see sidebar, page 97.

The D’s: • Distress or disability (work/educational, social, or personal impairment) • Differential diagnosis (substance use disorders, delirium, mood and anxiety disor- ders, OCD)

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Coding Notes Depending on presentation, specify:

With appearance preoccupations. For symptoms similar to body dysmorphic dis- order.

With obsessive– compulsive disorder-like symptoms. With hoarding symptoms. With hair- pulling symptoms. With skin- picking symptoms.

F42.8 [300.3] Other Specified Obsessive– Compulsive and Related Disorder

This category (which you use, remember, when a patient has obsessive– compulsive features but doesn’t fully qualify for a diagnosis, and you want to say why) might be appropriate in several situations, including these:

Symptoms similar to body dysmorphic disorder, but with actual flaws. The flaws are there, all right, but the concern seems excessive.

Obsessional jealousy. Without qualifying for any other mental disorder, the patient is distressed (or impaired) by a partner’s infidelity; as a result, repetitive behavior or thoughts occur.

Symptoms similar to body dysmorphic disorder, but without repetitive behav- iors.

F42.9 [300.3] Unspecified Obsessive– Compulsive and Related Disorder

The patient has obsessions or compulsions or other behaviors that belong in this chap- ter, and you don’t care to explain yourself.

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