This document discusses body dysmorphic disorder, hoarding disorder, trichotillomania, excoriation disorder, and obsessive compulsive disorder. It covers the diagnostic criteria and epidemiology of each disorder, potential etiologies related to learning, modeling, life events and cognitive influences, considerations about sex and race, and typical disease course and treatment prognosis. Cognitive behavioral therapy and selective serotonin reuptake inhibitors are often effective treatments.

14. BODY DYSMORPHIC DISORDER (BDD)
• Preoccupation with one or more perceived defects or flaws
in physical appearance that are not observable or appear
slight to others
• Repetitive behaviors (mirror checking, excessive grooming,
reassurance seeking) or mental acts (comparing self to
others) occur in response to the appearance concerns
• The preoccupation causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning

16. HOARDING DISORDER (HD)
• New to DSM-5
• Persistent difficulty discarding or parting with possessions, regardless of
their actual value
• Perceived need to save the items and distress associated with discarding
the items
• Results in an accumulation of possessions that congest and clutter living
areas
• The hoarding causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning (such as an
unsafe home environment)

18. TRICHOTILLOMANIA (TTM)
• Recurrent pulling out of one’s hair, resulting in hair loss
• May pull from any part of body
• Scalp, eyelids, and eyebrows are most common
• Repeated attempts to decrease or stop hair pulling
• The hair pulling causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning

20. EXCORIATION DISORDER (ED)
• New to DSM-5
• Recurrent skin picking resulting in lesions
• May occur on any area of the body
• Most commonly occurs on the face, arms, and hands
• Repeated attempts to stop picking
• The hair pulling causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning

21. EPIDEMIOLOGY OBSESSIVE-COMPULSIVE
DISORDER BODY DYSMORPHIC DISORDER
• 12-month prevalence is 1.2%; lifetime prevalence is 1% (Ruscio et al.,
2010)
• Body dysmorphic disorder is 2.4% (Koran et al., 2008)
• Hoarding disorder; weighted community prevalence is 5.3% (Samuels
et al., 2008)
• Trichotillomania; Community sample 0.6% to 1.2% (Duke et al., 2009) &
Psychiatric setting 3.4% and 4.4%, point and lifetime prevalence
• Excoriation disorder; community sample 1.4% to 5.4% (Hayes et al.,
2009) 4.2% college students using proposed DSM-5 criteria (Odlaug et
al., 2013)

22. ETIOLOGY: LEARNING, MODELING, AND
LIFE EVENTS
• Trauma may be associated with increased symptom severity
in OCD
• In BDD, early sexual, emotional, and physical abuse, as well as
early social interactions, may be associated
• HD may be a conditioned emotional response; anxiety is
avoided by acquisition and hoarding
• TTM and ED have similar environmental risk factors, such as
lack of stimulation or boredom; severe activity restriction has
also been suggested

23. ETIOLOGY: COGNITIVE
INFLUENCES
• A cognitive model of OCD suggests that it is not the content of the
thought, but the interpretation of the thought that leads to preoccupation
and anxiety
• Three types of dysfunctional beliefs have been proposed to contribute to
OCD
a) Overestimated responsibility and exaggerated threat
b) Perfectionism and intolerance of uncertainty
c) Over importance of thoughts and need to control thoughts
• Neurocognitive performance in OCD patients involves impairment in;
a) Executive functioning
b) Strategizing
c) Organizing

24. SEX AND RACIAL/ETHNIC
CONSIDERATIONS
• Men and women are equally likely to suffer from OCD
• Obsessional content in men is more likely to encompass sexual themes,
whereas women were more likely to present with symptoms related to
contamination
• Contamination and checking are OCD themes consistently found across
cultures
• Data suggest lower prevalence of OCD among African Americans; may
reflect lower number of African Americans seeking evidence-based
treatment

25. COURSE AND PROGNOSIS: OCD
• OCD chronic and disabling; rarely remits without
treatment
• Biological and behavioral therapies have been
shown to be effective
• SSRIs (Prozac or Zoloft) also effective
• Exposure with response-prevention (ERP)
• CBT for OCD outperformed control conditions
across 16 RCTs

26. COURSE AND PROGNOSIS: BDD
• BDD typically begins in adolescence, a stage marked
by hormonal changes and accelerated growth
• Also a time of increased peer rejection and ridicule
(also acne)Individual and group CBT are effective
with elements of psychoeducation, cognitive
restructuring, and ERP (relative to controls)

27. COURSE AND PROGNOSIS: HD
• The idea that hoarding develops in response to deprivation (both
emotional and material) has not been supported overall
• Some evidence for high levels of trauma or stressful life events
• Course of HD is typically chronic, with symptoms starting as early as
adolescence but causing impairment later in life
• Treatment is challenging; in OCD patients, the presence of hoarding is
associated with higher dropout rates
• RCTs needed

28. COURSE AND PROGNOSIS: TTM
• TTM may occur at any age, with an average onset of 12.9
years of age
• Course is chronic, with waxing and waning symptom severity
• CBT thought of as treatment of choice; early work with Habit
Reversal Training (HRT)More recently, HRT has been
combined with acceptance and commitment Therapy (ACT)
as well as dialectical behavior therapy (DBT)

29. COURSE AND PROGNOSIS: ED
• Age of onset varies; average is 13.5 years old
• Symptoms appear to be similar regardless of age and culture
• Social, academic, or occupational impairment may be mild to
severe
• Infection or permanent skin damage may occur
• CBT and SRIs shown to be effective
• Habit reversal has been used; ACT and DBT have been added
with promising results