PsyDactic
A resource for psychiatrists and other medical or behavioral health professionals interested in exploring the neuroscientific basis of psychiatric disorders, psychopharmacology, neuromodulation, and other psychiatric interventions, as well as discussions of pseudoscience, Bayesian reasoning, ethics, the history of psychiatry, and human psychology in general.
This podcast is not medical advice. It strives to be science communication. Dr. O'Leary is a skeptical thinker who often questions what we think we know. He hopes to open more conversations about what we don't know we don't know.
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PsyDactic
Those other obsessive and compulsive disorders
My last three episodes focussed on classical cases of Obsessive Compulsive Disorder, but the DSM 5 has included a few other related diagnoses in the same chapter including body dysmorphic disorder (BDD), hoarding disorder, trichotillomania, and excoriation disorder. Each of these have distinct obsessional components and compulsions, age of onset, degree of insight, and chronic course. Hence, they get their own diagnostic category.
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References and readings (when available) are posted at the end of each episode transcript, located at psydactic.buzzsprout.com. All opinions expressed in this podcast are exclusively those of the person speaking and should not be confused with the opinions of anyone else. We reserve the right to be wrong. Nothing in this podcast should be treated as individual medical advice.
Welcome to PsyDactic - Residency Edition - Your podcast resource to survive and thrive in your psych residency.
I am Dr. O, and as of this recording I am a 2nd Year Resident in the National Capital Consortium Psychiatry Residency Program. However, make no mistake, I do not speak for this program, nor do I speak for the Department of Defense or the Federal Government or anyone else for that matter. What I say is my opinion, and I reserve the right to be wrong, so trust me at your own risk. It’s a risk some are willing to take.
References and recommended readings can be found at the end of the show transcript, located at psydactic.buzzsprout.com.
Before I get started here, I want to turn you on to another resource out there for psych residents and med studs. It’s called bullet psych located at www.bulletpsych.com, and it gives you the option of signing up for a free daily email stream of content in bite sized chunks to learn about psychiatric disorders. It’s created by a fellow residency colleague of mine, Dr. Marcus Hunt, and for those of you, like me, who tend to fall asleep after reading about 3 paragraphs, it may be just the thing for you. It is concise, well-organized, and somehow still manages to give a good thorough treatment of its subject. So try googling bullet psych and see where it takes you. By the way, Dr. Hunt is not paying me to say this, I do it of my own free will and admiration.
Now getting back to my meager attempts to impart knowledge:
My last three episodes focussed on classical cases of Obsessive Compulsive Disorder, but the DSM 5 has included a few other related diagnoses in the same chapter including body dysmorphic disorder (BDD), hoarding disorder, trichotillomania, and excoriation disorder. Each of these have distinct obsessional components and compulsions, age of onset, degree of insight, and chronic course. Hence, they get their own diagnostic category.
Something else I failed to give sufficient attention to in previous episodes is the presence of tics in patients with OCD. Nearly a third of patients diagnosed with OCD will have comorbid tics at least some time during their life. It is an interesting finding that points to a common pathway shared between OCD and at least some kinds of tics, so it is good to screen patients with OCD for tics and patients with tics for OCD.
Also, I want to highlight the high rates of suicidal ideation and suicide attempts among patients with obsessive compulsive related disorders. The rates of suicide attempts can be as high as 1 in 10. Comorbid disorders can greatly increase that risk, so please don’t fail to do a thorough risk assessment for your OCD patients.
Now, let’s start reviewing the rest of the OCD chapter.
In body dysmorphic disorder or BDD, patients obsess over what they perceive to be flaws in their appearance. Other people are likely not even to notice these flaws, or would characterize them as minor. These patients are compelled to do something about this flaw, like excessive grooming, trying to cover it up or hide it, and having surgery to fix it. In the absence of these correcting or hiding behaviors, they may instead spend ridiculous amounts of time in mental gymnastics, comparing themselves to other people, or some ideal of perfection that they can never reach. Now, most humans have identified deficiencies in their own appearance (I have many, to include annoyingly asymmetric ear placement that makes my glasses sit crooked), and there is a huge cosmetic and plastic surgery industry that takes advantage of our need to do something about our appearance. However, these behaviors normally enhance social functioning and make us feel better about ourselves. In BDD, the sufferer must be experiencing significant distress or dysfunction as a result of their obsession and compulsion. They spend excessive amounts of time trying to change or hide their appearance or at least wishing they could do so. They may have had multiple surgeries or expensive cosmetic procedures.
If you are going to diagnose someone with BDD who has problems with their overall body shape or habitus, then be sure to rule out eating disorders, which may better explain a patient’s symptoms. Wanting to change one’s appearance to look more like another gender is also not dysmorphia, especially because for patients with BDD, changing their appearance often does not improve their self-image, but a gender transition is therapeutic.
The DSM would like providers to also specify the level of insight that a patient appears to have regarding the veracity of their beliefs about themselves. Do they think that others would notice the deficiency? Do they know it is unreasonable to be so obsessed about it? If their primary concern is whether they appear muscular enough, this should also be specified. Imagine a bodybuilder who looks in the mirror and sees noodle arms in the place of his or her bulging biceps.
Patients with BDD are highly unlikely to walk into your office. They are far more likely to have regular visits with their dermatologist or plastic surgeon.
Treatment is similar across the OCD spectrum disorders. Forming a strong alliance with the patient, specific cognitive behavioral therapies, and SSRIs are the primary starting points. SSRIs may be particularly helpful in the presence of comorbid depression, which is very common. Also, from a psycho-educational perspective, it is imperative to disclose to a BDD patient that attempts to change their appearance with procedures or surgery rarely improves symptoms and may exacerbate them.
The next disorder to discuss is Hoarding disorder.
Hoarding disorder is an obsessional disorder that results in the accumulation of possessions that usually add little or no value to someone’s life. Someone with a hoarding disorder over values what they have. They feel the need to keep it and will experience distress if required to part with their stuff. The rate of accumulation depends on the rate of acquisition minus the rate of disposition. Just because someone has a hard time throwing things out, doesn’t mean they will necessarily have piles of things at home. To get a diagnosis of hoarding disorder possessions need to clutter living areas such that the areas cannot be used for its intended purpose anymore. That may help to explain why this disorder has a higher prevalence in those over the age of 55. For one, it is chronic and so as people age, their numbers in the population have time to accumulate. They also have had plenty of time to make piles and to be diagnosed. Also, the disorder often starts gradually and worsens over time, so those over 55 may have more obvious dysfunction than they did when their house was a mess, but still manageable.
Just like with all DSM disorders, the appearance of hoarding disorder in a patient may be better explained by something else. A neurocognitive impairment may result in someone who buys excessive amounts of things and never gets rid of them, but they are not necessarily hoarding. Someone with executive functioning difficulties of any variety, for example those seen in ADHD, may not be able to organize themselves well enough to manage their stuff, but they would not necessarily be opposed to help getting rid of it.
Patients with hoarding disorder are also not super likely to self-refer to your office. Public health officials will often be involved with the patient and families may be concerned for their loved one’s health and safety. CBT focusing on the patient’s symptoms and SSRIs remain the first line for this as well as the other obsessive compulsive spectrum disorders. Motivating the patient to participate in treatment may be a big challenge. They may need special skills training to help them better organize their home.
The next two disorders, trichotillomania and excoriation disorder, are so similar that to discuss them separately I could just discuss one of them and then record the word excoriation disorder over the word trichotillomania and replace the words hair pulling with skin picking and be done with it. Both appear most commonly around puberty and have a high female to male ratio. Excoriation disorder female to male ratio is about 3 to 1, while trichotillomania may be as high as 10:1. That might have something to do with societal expectations for short hair in males making hair pulling less convenient overall. Also, if you notice hair loss in your patient due to hair pulling, then ask if they also pick their skin and do a skin exam, because these disorders are highly comorbid. You should also be screening for both OCD and MDD as well in these patients.
Trichotillomania is one of the coolest sounding names in the DSM. Typical patients are adolescent females. The diagnosis is straightforward. The patient must be pulling out hair and this must result in measurable hair loss. The patient must also have multiple unsuccessful attempts to stop doing this, and there must be significant distress or dysfunction associated with it. As always, you should rule out substance use (like cocaine) or other medical conditions (like pica) that may better explain their symptoms, if they are eating their hair. Also ask about postprandial fullness, abdominal pain, nausea, vomiting, anorexia, and weight loss. If present then it is reasonable to get abdominal plain-films and refer to GI for possible endoscopy, ultrasound, or CT scan. What you are looking for is a trichobezoar, or massive hairball in their GI tract.
If you want to know the sites where hair pulling is most common then just think about the sites where hair grows most dense and is most accessible. The scalp, eyebrows, eyelashes and finally the pubic area. This makes sense in humans. A chimp would have far more options.
Excoriation disorder is similar, but without hairballs. It is manifested by skin picking (most commonly on the face and extremities) that results in skin lesions. Places that are more often exposed, like the hands and fingers, are convenient sites. The patient must also have multiple unsuccessful attempts to stop doing this, and there must be significant distress or dysfunction associated with it. As always, you should rule out substance use (like stimulants) or other medical conditions (like scabies, or eczema) that may better explain their symptoms.
Evidence-based, specific treatments for hair pulling and skin picking disorders don’t really exist. Because these were considered just manifestations of OCD for so long, the first line treatments for these disorders are the same as those for OCD which I’ve discussed in detail in the last episode. Stress seems to exacerbate symptoms, so psychotherapies focusing on alternative stress management strategies may help reduce symptom burden.
Before I end my series on OCD and related disorders, I want to leave you with something important, something you are not likely to forget. I was recently reading a 2021 article called, “When self-harm is about preventing harm: emergency management of obsessive–compulsive disorder and associated self-harm,” by Palmonbini et al in the BJPsych Bulletin. They describe a patient who has compulsively harmed themselves in response to obsessions of contamination. I’ll quote the patient here, “I can feel contamination under my skin that is hurting people, and I have been trying to get it out. I used to use soaps and bleaches, but they didn’t work, so I now use corrosive alkali to try to remove the contamination. I needed to go to the shop to buy more when the police stopped me. I’m scared the staff will get contaminated too, and I don’t want them to touch me.”
I highly recommend you continue to read this article, and I’m not going to review it in its entirety here. Instead, I use it as a segue to discuss a phenomenon I saw occurring during this apparently never-ending COVID-19 pandemic. There are many who to some degree or other deny the pandemic even exists. Yet, there are others ready to cash in on other people’s excessive fears. All sorts of devices and concoctions were developed to sell to the public, reporting that they could protect someone or their loved ones from COVID-19 contamination. Most of these are not new, but just rebranded. These things may purport to use magnetic energies, UV light, homeopathic magic, or some secret blend of herbs or other more caustic or toxic substances. I suspect most of these things do nothing at all, but some could be harmful, contain substances like bleach, iodine, or even pharmaceuticals like ivermectin. Others might give high doses of radiation that could later result in cancer.
I wonder about both developers and consumers of these products. On social media, the developers are often portrayed as pandemic carpet-baggers, ready to cash in on other people's suffering. I expect many or most of them are. But maybe some of them have obsessions of contamination and compulsions and develop these substances to protect themselves and others. The consumers of these products are often portrayed as scientific ignoramuses or conspiracy theory consumers who are ready to believe anything attributed to Q-anon or some other anti-establishment or prophetic source. Many or even most of them may actually be suffering from mental illness, either a delusional disorder or an obsessive compulsive disorder. Some may think, I know this stuff probably doesn’t work, but I’m compelled to use it anyway.
What I am trying to sell you here is that, yes, these products are repugnant, and yes, we need a better accountability system to deal with their producers and advertisers, but at the core of many of these products may be a level of mental dysfunction that is not well understood, and we need to be careful that we are not simply stigmatizing and punishing the mentally ill.
In my most recent episodes, I reviewed the identification and diagnosis of obsessive and compulsive related disorders and their treatments, which really lack much specificity and need more development. I hope also to have inspired the listener to have more sympathy for these patients and the broad levels of dysfunction they may experience, including potentially harming themselves to prevent harm to others.
I am Dr. O, and this has been an episode of Psydactic - Residency edition.
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