Obsessive-Compulsive and Related Disorders (OCRDs)
*(DSM-5 Classification)*
A group of psychiatric conditions characterized by obsessions (intrusive thoughts/urges) and/or compulsions (repetitive behaviors/mental acts), with significant distress or functional impairment.
DSM-5 Disorders in This Category
1. Obsessive-Compulsive Disorder (OCD)
- Obsessions: Recurrent, intrusive thoughts (e.g., contamination, harm).
- Compulsions: Repetitive behaviors (e.g., washing, checking) or mental acts (e.g., counting) aimed at reducing anxiety.
- Insight Levels:
- Good insight (knows beliefs are unrealistic)
- Poor insight (uncertain about reality)
- Absent insight/delusional (firmly believes obsessions are true)
2. Body Dysmorphic Disorder (BDD)
- Preoccupation: Perceived flaws in appearance (often minor/nonexistent).
- Behaviors: Excessive mirror-checking, skin-picking, seeking cosmetic procedures.
- Related to: Eating disorders, social anxiety.
3. Hoarding Disorder
- Symptoms: Persistent difficulty discarding possessions, regardless of value.
- Consequences: Cluttered living spaces, distress, safety risks.
4. Trichotillomania (Hair-Pulling Disorder)
- Urge: Recurrent pulling of hair (scalp, eyebrows, etc.), leading to hair loss.
- May Include: Ritualistic behaviors (e.g., examining the root).
5. Excoriation (Skin-Picking) Disorder
- Repetitive: Picking at skin, causing lesions.
- Common Sites: Face, arms, hands.
6. Other OCRDs:
- Substance/Medication-Induced OCRD
- OCRDs Due to Another Medical Condition
- Other Specified/Unspecified OCRDs
Shared Features Across OCRDs
✔ Repetitive behaviors (compulsions, picking, hoarding).
✔ Cognitive distortions (e.g., overestimation of threat in OCD).
✔ Shame/secrecy (especially BDD, hoarding).
✔ High comorbidity with anxiety, depression, and tic disorders.
Etiology (Causes & Risk Factors)
- Genetic: Higher risk if family history (especially OCD, BDD).
- Neurobiological: Dysregulation in cortico-striato-thalamo-cortical (CSTC) circuits (OCD).
- Environmental: Trauma, streptococcal infections (PANDAS/PANS in pediatric OCD).
- Psychological: Maladaptive coping, perfectionism.
Diagnosis & Assessment
1. Clinical Interviews:
- Yale-Brown Obsessive Compulsive Scale (Y-BOCS) for OCD severity.
- Body Dysmorphic Disorder Questionnaire (BDDQ).
2. Differential Diagnosis:
- OCD vs. GAD: OCD has specific compulsions.
- BDD vs. Eating Disorders: Focus on appearance, not weight.
- Hoarding vs. Collecting: Hoarding lacks organization/value.
3. Medical Workup:
- Rule out thyroid disorders, autoimmune encephalitis, or stimulant abuse.
Treatment Approaches
1. Psychotherapy (First-Line)
- Exposure & Response Prevention (ERP) (Gold standard for OCD).
- Cognitive Behavioral Therapy (CBT) (For BDD, hoarding).
- Habit Reversal Training (HRT) (For trichotillomania, excoriation).
2. Medications
- SSRIs (Fluoxetine, Fluvoxamine, Sertraline) – High doses often needed.
- Clomipramine (TCA for treatment-resistant OCD).
- Augmentation Strategies:
- Antipsychotics (e.g., Risperidone for OCD with poor insight).
- N-acetylcysteine (NAC) for skin-picking/hair-pulling.
3. Emerging/Alternative Treatments
- Deep Brain Stimulation (DBS) for severe, treatment-resistant OCD.
- Psychedelics (Psilocybin research for OCD).
Prognosis & Challenges
- OCD: Chronic but manageable with therapy (40-60% respond to SSRIs/ERP).
- BDD: Often underdiagnosed; high suicide risk.
- Hoarding: Harder to treat due to low insight.
Key Patient Education Points
- OCD is not about cleanliness – It’s about anxiety relief.
- BDD is not vanity – It’s a distorted self-perception.
- Hoarding is not laziness – It’s a brain-based difficulty discarding.
Differential Diagnosis Table
| Disorder | Core Symptom | Misdiagnosed As |
|---|---|---|
| OCD | Intrusive thoughts + rituals | Anxiety, psychosis |
| BDD | Fixation on appearance flaw | Vanity, social anxiety |
| Hoarding | Can’t discard items | Diogenes syndrome, OCD |
| Trichotillomania | Hair-pulling | Dermatological condition |