What do Obsessive Compulsive disorder Body Dysmorphic Disorder in hoarding disorder have in common?

By Audrey R. Kraynak & Shelley R. Hart

Obsessive–compulsive and related disorders (OCRD) result in potentially disabling conditions that trap individuals in endless cycles of repetitive thoughts and behaviors (Katz, 2012). OCRD differ from developmentally normative preoccupations and rituals in that the obsessions or rituals are excessive and persist beyond developmentally appropriate stages (American Psychiatric Association [APA], 2013a). Currently, OCRD is considered to be a neuropsychological disorder based on research suggesting that it results from abnormal connections in the communication loop involving the orbitofrontal cortex, anterior cingulate cortex, caudate nucleus, and thalamus, as well as basal ganglia (Carter, Aldridge, Page, & Parker, 2009). Other studies suggest that a low level of the neurotransmitter serotonin or the hormone vasopressin is associated with OCRD (Ben-Joseph, 2012; Keeley, Storch, Dhungana, & Giffken, 2007).

In the DSM-5, the OCRD chapter lists nine disorders: obsessive–compulsive disorder (OCD), body dysmorphic disorder (BDD), hoarding disorder, trichotillomania (hair pulling), excoriation (skin-picking), substance/medication-induced OCRD, OCRD due to another medical disorder, other specified OCRD, and unspecified OCRD (APA, 2013a). Common to these disorders is the presence of obsessions, compulsions, or both. Obsessions are defined as recurrent and distressing thoughts, fears, or images that the person cannot control. The obsessions produce anxiety or nervousness that leads to an urgent need to perform compulsive behaviors. The compulsive behaviors (i.e., rituals or routines) are performed to avoid or make the obsessive thoughts go away. Some of the more common obsessions involve fears such as fear of dirt or germs, causing harm, making a mistake, thinking sinful or evil thoughts, as well as a need for order, symmetry, and exactness or constant reassurance. For individuals with BDD, recurring negative thoughts regarding their appearance are present (Neziroglu & Slavin, 2012). Specific obsessions may call forth compulsive behaviors such as repeatedly bathing or washing hands, refusing to shake hands or touch doorknobs or other objects, repeatedly checking things such as locks or appliances, being stuck on words, recurrent images or thoughts that may interfere with sleep, constantly counting while performing routine tasks, arranging things in a specific way, eating foods in a specific order, or searching for ways to eliminate or disguise the body “flaw.” Furthermore, the obsessions and compulsions must cause significant distress or impairment, are not attributable to the physiological effects of a substance or another medical condition, and are not better explained by symptoms of another mental disorder.

According to DSM-5, the prevalence of any OCRD in the United States ranges from 1% to 6% (APA, 2013a). Estimates suggest that approximately 2 to 3 million adults living in the United States have an OCRD with prevalence rates ranging from 1% to 4%. The prevalence rates for the general population suggest that 2.4% of individuals with BDD and 1.4% with excoriation disorder may be affected (Duckworth & Friedman, 2012; Keeley et al., 2007; Kessler, Berglund, Demler, Jin, & Walters, 2005; Shunfeld, 2013). For children and adolescents, estimates suggest that approximately 1 in 200 exhibit symptoms of OCD (Stewart, 2012), while specific estimates for other OCR disorders are not broken down by age (Neziroglu & Slavin, 2012). Gender-related rates suggest that more women are diagnosed with OCD, BDD, trichotillomania, and excoriation than men. In contrast, men may be more likely to exhibit hoarding symptoms (APA, 2013a). Although the median age of onset is 18 to 19 years of age, 80% of individuals have symptoms that began before this time (Kessler et al., 2005). Typically, children with OCD are diagnosed between the ages of 7 and 12 years, while for several of the disorders, symptoms are more likely to present during adolescence. The exception is hoarding, which tends to be two times more prevalent in the 55 and older age group than in the 34- to 40-year-old group (APA, 2013a; Ben-Joseph, 2012; Frost, Steketee, & Tolin, 2011; Stewart & Murphy, 2010). Some evidence exists for a genetic component. Swedo, Rapoport, Leonard, Lenane, and Cheslow (1989) found that 25% of the subjects in their study had a first-degree relative with OCD, while Adams (2004) reported that there is a higher occurrence of OCD in identical twins. Other research has found that children with early onset of OCD symptoms were more likely to have blood relatives who also had an OCRD (APA, 2013a).

The different OCRD diagnoses may coexist with each other as well as with other disorders (APA, 2013a). The more common comorbid diagnoses include major depression or anxiety disorders, which together account for approximately two thirds of the coexisting conditions (APA, 2013a). This comorbidity can negatively impact the course of treatment (Pallant, Grasi, Sarrecchia, Cantisani, & Pelligrini, 2011). The OCRD chapter includes a comprehensive discussion of differential diagnostic features to help to distinguish OCRD from other disorders such as psychotic disorders, eating disorders, and some medical disorders. In addition, the chapter distinguishes OCRD from an obsessive–compulsive personality disorder; the latter involves a pattern of excessive perfectionism and rigid control, but lacks the intrusive thoughts, images, urges, or repetitive behaviors that are performed in response to the intrusive thoughts.

CHANGES FROM DSM-IV-TR AND RATIONALE FOR THE CHANGES

The major change is the new, independent chapter that groups nine disorders under the diagnostic category of OCRD. According to the DSM-5 OCRD Work Group, the disorders now grouped within the OCRD category share a set of common characteristics that includes obsessive thoughts and compulsive behaviors, preoccupations accompanied by repetitive behaviors or mental acts, or recurrent body-focused repetitive behaviors (APA, 2013a; Frost et al., 2011; Hollander, Braun, & Simeon, 2008). Moreover, the work group felt that these nine disorders were related to each other in terms of “diagnostic validators as well as clinical usefulness,” and urged clinicians to screen carefully for these conditions (APA 2013a, p. 235).

To create this new category of OCRD, several disorders were moved and several others created. Moving OCD, which was formerly located within the DSM-IV-TR anxiety disorders category, creates consistency with the International Classification of Mental Disorders (APA, 2000, 2013a, 2013b; Hollander et al., 2008). In addition, two other disorders were moved to the OCRD chapter due to the presence of common characteristics: BDD from the DSM-IV-TR somatoform category and trichotillomania from the impulse control disorders not elsewhere classified category. Hoarding disorder is a new diagnosis in DSM-5. Previously, it was one symptom of obsessive–compulsive personality disorder; however, the OCRD Work Group reported that available data provided evidence of diagnostic validity and clinical utility supporting the creation of an independent disorder rather than a variant of another disorder (APA 2013b; Grohol, 2013). Excoriation (skin-picking) disorder is also new to DSM-5. Again, evidence to support the prevalence and diagnostic utility, particularly in terms of treatment, were cited (APA, 2013c). Finally, consistent with other diagnoses in the DSM-5, new OCRD diagnoses include substance/medication-induced OCRD and OCRD due to another medical condition. Other specified OCRD and unspecified OCRD were added to include conditions whose symptoms do not meet criteria for a specific OCRD because of atypical presentation or uncertain etiology. Other specified OCRD is diagnosed when body-focused repetitive behavior disorders, obsessional jealousy, or other syndromes are present (APA, 2013a, 2013b). Table 1 describes the OCRD and outlines changes made in the DSM-5.

Table 1 Brief Description of Changes to Obsessive–Compulsive and Related Disorders

Several modifications were also made to the DSM-5 OCRD specifier labels. The DSM-IV-TR OCD specifier label was modified from “with poor insight” to three levels of insight for any of the OCRD containing a cognitive component: OCD, BDD, and hoarding disorder (Grohol, 2013; APA, 2013a). These specifiers are: “good or fair insight,” “poor insight,” and “absent insight/delusional.” An individual with good or fair insight recognizes that the OCD beliefs are either definitely or probably not true. In contrast, an individual with “poor insight” thinks the beliefs are probably true, while the individual with absent insight/delusional beliefs perceives them as definitely true. When evidence suggesting absent insight/delusional beliefs is present, the recommended diagnosis is that of a relevant OCRD rather than schizophrenia or another psychotic disorder (APA, 2013a, 2013b; Grohol, 2013).

In addition to expansion of the specifier pertaining to insight, new specifiers (“tic-related” and “with excessive acquisition”) have been added specifically for OCD and hoarding, respectively. The Work Group recommended the addition of “tic-related” because of the clinical importance of identifying individuals with either a current or past comorbid tic disorder (APA 2013a, 2013b; Grohol, 2013). Estimates suggest that up to 30% of individuals with OCD have a lifetime tic disorder (APA, 2013a). Those with a history of tic disorders differ from those with no history of a tic disorder with respect to the themes and course of their OCD symptoms, as well as pattern of family transmission (APA, 2013a). For the hoarding category, the specifier “with excessive acquisition” was added to reflect the excessive buying or acquisition of free items as well as difficulties discarding or parting with possessions that distinguish 80% to 90% of hoarders from collectors (APA 2013a, 2013b).

POSSIBLE CONSEQUENCES OF THE DSM-5 CHANGES

The creation of the new diagnostic category of OCRD did not occur without debate or controversy. The controversies centered on the possibility of over-diagnosing or falsely diagnosing mental health disorders and whether specific disorders should be included in the category (Cool, 2013; Odlaug & Grant, 2010; Walton, 2012). According to Frances (2009, 2010), creating new diagnostic options incorrectly pathologizes normal behavior or unnecessarily medicalizes normal mental processes. Nordletten and Mataix-Cols (2012) investigated concerns that collecting might be pathologized as hoarding due to the overlap in several core features. They recommended that the diagnosis of hoarding be made only when all of the diagnostic criteria are met. Moreover, these two investigators reported that collecting does not cause significant distress or impairment, nor is it accompanied by clutter, which is found with hoarders. In addition, there is debate concerning whether pediatric autoimmune neuropsychiatric disorder associated with strep (PANDAS) or pediatric autoimmune neuropsychiatric syndrome should be included as an OCRD due to another medical condition. Strep A infections have been noted to produce sudden onset of OCRD symptoms, as do other immune system diseases (APA, 2013a; National Institute of Health, 2012; Stewart & Murphy, 2010). Finally, Odlaug and Grant (2010) suggested that excoriation is more like a substance abuse disorder than an OCRD because skin picking is rarely driven by obsessive thoughts, is pleasurable, and is not as successfully treated by typical OCRD treatments such as selective serotonin-reuptake inhibitors (SSRI) and exposure therapy as other OCRD.

Several benefits accrue from recognizing DSM-5 OCRD diagnoses as legitimate disorders as well as specifying the degree of insight (and, in the case of OCD, the presence or absence of tic-related behaviors). Greater awareness of the symptoms of each disorder can lead to more effective screening and assessment as well as earlier treatment (Cool, 2013). Earlier and more effective treatment can help to alleviate the distress and impairment created by the individual's obsessions or compulsions. Moreover, insurance companies may be more likely to fund treatment now that OCRD have become independent diagnostic entities. With respect to research, more specific criteria can enhance sample selection and contribute to the growing body of knowledge regarding OCRD.

Implications for School Psychology

While not the most prevalent of the ORCDs, OCD is likely the most familiar. According to March and Benton (2007), in any average size elementary school, four or five students could have OCD, while in a medium to large high school, 20 students might be expected to struggle with the challenges of OCD. Two age ranges appear to be associated with the onset of symptoms: 8 to 12 year olds, and late adolescence to early adulthood (APA, 2013a; International OCD Foundation, 2012a, 2012b). More prevalent is BDD (2.4%), with the most common age of onset between 12 to 13 years and two thirds demonstrating an onset prior to age 18 (APA, 2013a). Thus, it is likely that a school psychologist may encounter students with difficulties due to an OCRD.

Recognizing OCRD can be difficult because youth may not disclose their obsessive thoughts or engage in the compulsive behaviors at school or in front of friends or family (Ben-Joseph, 2012). Possible behavioral indicators in the school setting include difficulty attending or concentrating due to recurrent thoughts that can affect completion of both in-class work as well as homework, rituals involving counting during routine tasks, arranging things in a specific way, being stuck on words, a sudden drop in test grades, and holes made by frequently erasing through test papers or homework. While screening for possible disorders, school psychologists may want to ask parents about the presence of tantrums to determine if anger management difficulties are related to the child's attempts to engage the parent in rituals or repetitive behavior such as repeating strange phrases or answering the same question(s) repeatedly. Other possible indicators of OCRD, which may be likely to surface in the home setting, include the presence of raw or chapped hands from frequent washing, use of high amounts of soap or paper towels, unexplained high utility bills, significant amounts of time spent getting ready for bed or falling asleep, and frequent checking regarding the health of family members (Katz, 2012; Massachusetts General Hospital, 2013).

Given the possible effect of OCRD on school functioning, it is possible that a student with one of these disorders may meet the IDEA criteria for emotional disturbance (ED). These disorders might be considered consistent with several ED characteristics, most notably criterion (b), inappropriate types of behaviors or feelings under normal circumstances (although there may be occurrences when (a), inability to learn that cannot be explained by intellectual, sensory, or health factors and (c), physical fears apply). However, ED eligibility is more restrictive than DSM-5 criteria and will require the IEP team to determine that the characteristic associated with OCRD has been present for a long period of time, to a marked degree, and that it significantly as well as adversely affects the student's educational performance.

OCRD can affect the child's physical health, academic progress, and social development as well as the family's ability to function effectively (Stewart, 2012). The child may be socially isolated or have difficulty engaging positively with peers or adults. Friendship patterns may be affected as a result of time spent on obsessions/compulsions and embarrassment (Zasio, 2009). Moreover, these students may feel like they are going “crazy” because their thinking differs from friends and family members (Stewart, 2012). Individuals with OCRD can experience stress, which results from hiding rituals or from difficulty leaving the family home to live independently (APA, 2013a). It has been suggested that symptoms of OCD exhibited at home are often more intrusive than at school, which is stressful for the family and leaves family members feeling powerless to change the rigid behavioral patterns exhibited by the child (Massachusetts General Hospital, 2013).

The school psychologist may play an important part in helping the family secure a diagnosis, investigate support via special education (e.g., evaluation for an ED eligibility determination), and obtain effective clinical and academic interventions for the child (Ben-Joseph, 2012). Without treatment, remission rates tend to be low. Moreover, treatment can be complicated by the presence of other disorders. Knowledge of the diagnostic criteria and differential indicators can help the school psychologist ask pertinent questions to build a thorough history of symptoms that can be shared with a medical doctor or clinician. If medication is prescribed, the school psychologist can contribute information about the effectiveness of the medication in the school setting or monitor for side effects (Massachusetts General Hospital, 2013). Additional roles may include educating teachers, educational personnel, and parents about OCRD and helping both educational personnel and parents implement appropriate accommodations and interventions for the student to help reduce the distress and embarrassment typically experienced by an individual with OCRD.

Audrey R. Kraynak, PhD, NCSP, ABSNP, is a consultant to the Ohio Center for DeafBlind Education, a state trainer for INSITE, and is currently serving as past president of the Ohio Council on Family Relations. Shelley R. Hart, PhD, NCSP, is an assistant professor in the department of child development at California State University, Chico. She is also a contributing editor for Communiqué

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