Chapter 6
Obsessive-Compulsive and Related Disorders

The term obsessive-compulsive disorder (OCD) refers to unwanted and repeated mental rituals, including thoughts, feelings, ideas, sensations, or observable behaviors (i.e., obsessions) that make an individual feel driven to do something (i.e., compulsions; National Library of Medicine, 2013; Stein, 2002). Examples of obsessions include excessive counting, skin picking, ruminating about physical flaws, and hoarding (see Table 6.1). Rituals are very common among individuals diagnosed with OCD and may include frequent checking of doors or locks, recurrent hand washing, or avoidance of certain situations. An example would be a person who has persistent and uncontrollable thoughts that he is soiled, polluted, or otherwise unclean. To mitigate stress, he washes his hands numerous times throughout the day, gaining temporary relief from these thoughts. For his behavior to be considered an OCD, it must be disruptive to his everyday functioning, such as washing to the point of excessive irritation of his skin.

Table 6.1 Common Obsessions and Compulsions

Obsessions	Commonly Associated Compulsions
Fear of contamination	Washing, cleaning
Need for symmetry, precise arranging	Ordering, arranging, balancing, straightening until “just right”
Unwanted sexual or aggressive thoughts or images	Checking, praying, “undoing” actions, asking for reassurance
Doubts (e.g., gas jets off, doors locked)	Repeated checking behaviors
Concerns about throwing away something valuable	Hoarding

Disorders listed in this chapter have the common feature of obsessive preoccupation and engagement in repetitive behaviors. These disorders are considered similar enough to be grouped in the same diagnostic classification but distinct enough to subsist as separate disorders. Some of the disorders in this chapter have historically been included as part of what was considered the “obsessive-compulsive spectrum.”

Major Changes From DSM-IV-TR to DSM-5

OCD, previously classified in the DSM-IV-TR as an anxiety disorder, is now the first disorder listed in a stand-alone chapter in the DSM-5 titled Obsessive-Compulsive and Related Disorders. The fundamental features of obsession and compulsion, rather than anxiety, served as the driving force for moving OCD and other related disorders to a separate chapter (APA, 2013a). This also follows revisions within ICD-10-CM that classifies OCD separately from anxiety disorder. As with the ICD-10-CM, which keeps OCD and anxiety disorder in the same larger category, the sequential order of this chapter reflects the close relationship between OCD and anxiety disorder. Separating obsession and compulsion from anxiety received more support from psychiatrists than other mental health professionals, as only 40% to 45% of other mental health professionals supported the move (Mataix-Cols, Pertusa, & Leckman, 2007). Some counselors opposed the move because treatment protocols are similar for anxiety and obsessive-compulsive and related disorders and, just like anxiety and depression, comorbidity is more often the rule than the exception (Stein et al., 2010).

New disorders in this chapter include hoarding disorder, excoriation (skin-picking) disorder, substance/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. The DSM-IV-TR diagnosis of trichotillomania is now termed trichotillomania (hair-pulling disorder) and has been moved from a DSM-IV-TR classification of impulse-control disorders to obsessive-compulsive and related disorders in DSM-5 (APA, 2013a).

Aside from moving OCD out of the anxiety chapter and adding new diagnoses, most changes to this section are semantic. For example, the DSM-5 has modified the word impulse to the word urge. This change more accurately reflects the origin of obsessive disorders (i.e., behaviors that can be modified as opposed to an irresistible compulsion). The word impulse seems to have a strong biological component, thus insinuating that these disorders are involuntary. This modification is backed by numerous studies that demonstrated that obsessive-compulsive and related disorders can be treated and, in many cases, extinguished (Simpson et al., 2008; Tenneij, Van Megen, Denys, & Westenberg, 2005; Tolin, Maltby, Diefenbach, Hannan, & Worhunsky, 2004; Tundo, Salvati, Busto, Di Spigno, & Falcini, 2007).

Other semantic changes include amending references to inappropriate behaviors or feelings to unwanted behaviors or feelings. The reason for this change is culturally based, because cultural norms regarding appropriate versus inappropriate behaviors are very different. Finally, the new diagnostic classifications of obsessive-compulsive and related disorders have removed the criterion that people must recognize their obsessions or compulsions as unreasonable or excessive. Although people must realize the obsessive thoughts, mental images, or urges are a product of their own minds, it is no longer required that they understand the behavior or mental rituals are excessive.

Differential Diagnosis

As with anxiety disorders, the decision of APA (2013a) to cluster obsessive-compulsive and related disorders within one chapter, separate from anxiety and trauma and stressor-related disorders, influences differential diagnosis. Stein et al. (2011) posited that clinical attention should focus on the discernment of disorders enumerated within this chapter. One way to differentiate OCD is the common feature of obsessive preoccupation and repetitive behaviors. Once this has been established, counselors can then distinguish between the disorders in this chapter.

Note

To help differentiate between obsessive-compulsive and related disorders and anxiety disorders, counselors can ask clients, “Do you ever have thoughts or images that you can't get out of your mind?” and “Are there things that you can't resist doing over and over again?”

Differential diagnosis of obsessive-compulsive and related disorders is challenging because of comorbidity with other diagnoses. It is not uncommon for individuals diagnosed with an obsessive-compulsive or related disorder to also exhibit symptoms of depressive and anxiety disorders; somatoform disorder; hypochondrias; eating disorder; impulse-control disorder, especially kleptomania; and ADHD (Pallanti, Grassi, Sarrecchia, Cantisani, & Pellegrini, 2011). There is also a significant amount of literature dedicated to comorbidity between OCD and Tourette's syndrome. In a clinical population of children ages 7 to 18 years diagnosed with Tourette's syndrome, approximately 30% also met diagnostic criteria for OCD (Sukhodolsky et al., 2003). In terms of commonality, counselors should look for mood disorders, specifically depression, social and simple phobias, eating disorders, panic disorder, and Tourette's syndrome. Counselors should be aware that comorbidity with schizophrenia and other psychotic disorders is relatively uncommon; in cases in which a client is unable to recognize that the obsession is a product of his or her own mind, the obsession may be better classified as a delusion. In that case, a schizophrenia spectrum or other psychotic disorder may be a more appropriate diagnosis.

Etiology and Treatment

Exact etiology for obsessive-compulsive and related disorders has not been determined. However, there is a considerable amount of research that suggests abnormalities in serotonin (5-HT) and dopamine neurotransmission are responsible for mental rituals and compulsive behaviors (Bloch et al., 2006; Greist, Jefferson, Kobak, Katzelnick, & Serlin, 1995; Kobak, Greist, Jefferson, Katzelnick, & Henk, 1998). Twin studies have suggested a strong genetic influence (van Grootheest, Cath, Beekman, & Boomsma, 2005), and a considerable amount of literature supports the idea that obsessive-compulsive and related disorders are stress responsive, meaning symptoms increase with stress. However, stress in and of itself is not seen as an etiologic factor (Abramowitz, Khandker, Nelson, Deacon, & Rygwall, 2006; Lin et al., 2007).

The most commonly reported treatment for obsessive-compulsive and related disorders involves a combination of psychopharmacological treatments and psychotherapy (Simpson et al., 2008; Tenneij et al., 2005; Tolin et al., 2004). In some trials, CBT has been identified as more effective than drug treatment (Blatt, Zuroff, Bondi, & Sanislow, 2000; Melville, 2013) or as a suitable replacement once medication has reduced symptomatology (Tundo et al., 2007). The International Obsessive-Compulsive Disorder Foundation (IOCDF; 2012) specifically recommends exposure and response prevention (ERP), a type of CBT, citing that ERP may reduce symptoms by 60% to 80% if clients are active participants in treatment (Melville, 2013). ERP confronts thoughts, images, objects, and situations that make a person experience anxiety and uses “response prevention” to encourage clients to choose not to engage in a compulsive behavior.

Implications for Counselors

The ability for counselors to recognize obsessive-compulsive and related disorders is important because studies have indicated that nearly one in 100, approximately 2 to 3 million adults, currently have OCD (IOCDF, 2012; Kessler, Chiu, Demler, & Walters, 2005). Numbers for children are also alarming, with nearly 1 in 200, or 500,000 children and adolescents, diagnosed with OCD (Ruscio, Stein, Chiu, & Kessler, 2008). These numbers only apply to OCD and do not include other related disorders. Rates of BDD among community samples are between 0.7% and 1.1% of the general population (Phillips, 2004). Hoarding affects 4% of the general population (Samuels et al., 2008). Trichotillomania affects 2.5 million individuals within the United States (Diefenbach, Reitman, & Williamson, 2000), and 3.8% of college psychology students exhibited signs of excoriation (Misery et al., 2012).

To help readers better understand changes from the DSM-IV-TR to the DSM-5, the rest of this chapter outlines each disorder within the Obsessive-Compulsive and Related Disorders chapter of the DSM-5. Readers should note that we have focused on major changes from the DSM-IV-TR to the DSM-5; however, this is not a stand-alone resource for diagnosis. Although a summary and special considerations for counselors are provided for each disorder, when diagnosing clients, counselors need to reference the DSM-5. It is essential that the diagnostic criteria and features, subtypes and specifiers (if applicable), prevalence, course, and risk and prognostic factors for each disorder are clearly understood prior to diagnosis.

300.3 Obsessive-Compulsive Disorder (F42)

I couldn't do anything without counting. It invaded every aspect of my life and really bogged me down. I would wash my hair three times as opposed to once because 3 was a good luck number and 1 wasn't. It took me longer to read because I'd count the lines in a paragraph. When I set my alarm at night, I had to set it to a number that wouldn't add up to a “bad” number. —Cathey

Obsessive-compulsive disorder is characterized by “recurrent, persistent, and intrusive anxiety-provoking thoughts or images (obsessions) and subsequent repetitive behaviors (compulsions)” (den Braber et al., 2008, p. 91). These thoughts, beliefs, ideas, or mental rituals dominate an individual's life. Compulsions are the acts that relieve this distress and can be simple (e.g., thinking of a word) or extraordinarily complex (e.g., engaging in an elaborate washing routine that takes hours to complete). Most individuals have both obsessions and compulsions, although it is not unheard of for clients to report obsessions only. Once considered a rare and eccentric disorder, OCD has risen considerably in visibility since the NIMH conducted a study in 1988 that recognized a 2.5% lifetime prevalence of OCD in the U.S. population (Karno, Golding, Sorenson, & Burnam, 1988). There have been no major changes to this disorder in the DSM-5.

Essential Features

The most common pattern of obsessions and compulsions is a fear of contamination, which causes excessive washing of an individual's hands or body (Morrison, 2006). Also common are persistent doubts such as “Did I lock the door?” that lead a person to repetitively check the locks. There is also a strong need to have things in a particular order, which causes significant distress when objects are perceived as disorganized. These thoughts and behaviors significantly influence clients' lives, sometimes to the point of interfering with work, school, family relationships, or social obligations. Individuals exhibiting symptoms of OCD often realize that these thoughts and behaviors are irrational and often have a strong desire to resist the obsessive thoughts and compulsive behaviors. Because of a lack of cognitive awareness, children have never been required to recognize obsessive-compulsive behaviors as unreasonable.

Special Considerations

Having some degree of obsessive thoughts or compulsive behaviors is not rare; in fact, 70% to 80% of the general population may experience some features of OCD (den Braber et al., 2008). A clinical diagnosis of OCD, however, requires substantial distress or impairment. Counselors should pay close attention to whether the symptoms significantly interfere with a person's daily routine. For example, clients can have a fear of blurting out obscenities or insults, but until this fear prevents them from engaging in activities of daily living or from engaging in a regular routine at work, home, or school or in social situations, it cannot be diagnosed as OCD.

Counselors should be aware that the level of insight among adults, and even children, varies considerably. There is a specifier with poor insight that can be applied to this diagnosis, but it is not unusual for adults to vary considerably in their ability to recognize a mental ritual or behavior as unreasonable. This is particularly common when the disorder coexists with another psychological disorder such as MDD or social anxiety disorder. Because avoidance of certain situations, such as one that might make an individual dirty, is common, evading objects or scenarios that provoke obsessions or compulsions may begin to seem ordinary as opposed to excessive (Morrison, 2006; National Library of Medicine, 2013). Counselors who work with individuals diagnosed with OCD must be on the lookout for situations that restrict functioning severely.

Cultural Considerations

OCD is more common among individuals with higher socioeconomic status and higher levels of intelligence. Culturally appropriate ritualistic behavior, such as rituals to ward off bad luck, may have distinct parallels to OCD but are not indicative of OCD unless the behavior exceeds cultural norms. Counselors must be sure they are familiar with the cultural context of the client before determining that a ritualistic behavior is obsessive-compulsive. OCD will typically manifest before the age of 25, with symptoms becoming more prevalent as the individual ages (Morrison, 2006). Many clients will report that obsessive hand washing, for example, began with a 3- to 4-minute wash routine using only soap. Gradually, however, clients may report that they began to use nail brushes, surgical soap, and washing for 15 minutes per arm numerous times per day.

Gender does not seem to be an indicator of prevalence. In children, however, OCD is more common in boys than in girls. Whereas the DSM-5 (APA, 2013a) states the age of onset is earlier for boys, research has indicated a wider age of onset, with symptoms appearing between ages 6 and 15, and women typically experience symptoms between the ages of 20 and 29 years (Mancebo et al., 2008). Familial patterns for OCD are higher in first-generation biological relatives than in the general population. Pathophysiologic findings provide evidence of a familial pattern with OCD; studies of monozygotic twins have revealed concordance rates as high as 87% and nearly half that for dizygotic twins (den Braber et al., 2008). Symptoms may fluctuate and increase with emotional stressors. For example, during flu season, a client may experience constant worry about becoming contaminated and exhibit persistent OCD symptoms, but these symptoms may decrease or even disappear during the summer months.

Differential Diagnosis

Counselors must be sure to distinguish OCD from anxiety disorder due to another medical condition. For example, counselors working with children experiencing a sudden onset of obsessions, compulsions, or tics need to work with a medical professional to rule out pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections. If a substance is the source of the obsession or compulsion, counselors need to rule out substance/medication-induced anxiety disorder. Counselors should be aware that OCD could occur within the context of other psychological disorders. However, if content is distinctly related to another disorder, such as fixation with one's appearance as in BDD or preoccupation with a fear-based object or situation as in specific phobia or social anxiety disorder, OCD cannot be diagnosed unless there are symptoms that are unrelated to the other disorder. In this case, both disorders would be diagnosed. Finally, an important criterion that distinguishes OCD from psychotic disorders is the ability of the individual to recognize, at some point, that the obsessions or compulsions are unreasonable. Although levels of insight occur on a continuum, counselors who detect a presence of psychotic features should consider assessing for schizophrenia spectrum and other psychotic disorder instead of or in addition to OCD.

Note

As many as half of individuals diagnosed with OCD have a comorbid psychiatric disorder. It is not uncommon for clients to display only OCD symptoms when they are experiencing a major depressive episode. Counselors should be careful to assess for accompanying disorders.

Coding, Recording, and Specifiers

There is only one diagnostic code for OCD: 300.3 (F42). However, there are two specifiers. The first specifier indicates the client's current level of insight (with good or fair insight, with poor insight, or with absent insight/delusional beliefs). The second specifier, tic-related, denotes whether an individual has a current or past history of a tic disorder. These specifiers do not have specific codes associated with them.

Note

The same diagnostic code is used for both OCD and hoarding. Hoarding is a new disorder in the DSM-5 and is not listed specifically as a diagnosable disorder in the ICD. Therefore, the DSM-5 uses the same diagnostic code for OCD.

Case Example

Anuj is a 15-year-old Indian American boy who lives with his mother in a lower-middle-class neighborhood bordering a major metropolitan area. He is an only child and attends the 10th grade at a local public high school. Anuj recently had a full physical for school and the doctor reported no medical problems. His mother states that Anuj has a great deal of difficulty concentrating on and completing any of his schoolwork.

Anuj reports he is constantly distracted by powerful and strange thoughts, such as counting how many times he blinks and how many steps it takes to get to the hallway. He feels compelled to avoid stepping on any floor tiles with dirt on them because he does not want to get germs on his feet. The possibility that germs could be on door handles or windows also forces him to avoid touching them unless he first uses a cloth (which he always carries with him) to clean them off. In fact, if he misplaces or forgets to bring a clean cloth with him, he feels a great deal of anxiety, feels paralyzed, and may get physically ill.

Anuj realizes that his behavior does not make sense, and it frustrates him that he cannot overcome these powerful thoughts. His compulsive behaviors have become increasingly frequent over the past 2 years, although he has always had a lot of unusual fears and behaviors associated with cleanliness. Other classmates make fun of him and call him crazy.

Anuj has been staying home from school because he is embarrassed and upset with himself. His mother is concerned about his absences from school but does not know how to make him go to school. His teachers are concerned about his absences and poor academic performance. They support Anuj as much as they can, but they do not understand his behavior either.

Diagnostic Questions

1. Do Anuj's presenting symptoms meet the criteria for an OCD? If so, which disorder?
2. Based on the disorder identified in Question 1, which symptom(s) led you to select that diagnosis?
3. What would be the reason(s) a counselor may not diagnose Anuj with the disorder identified in Question 1?
4. Would Anuj be more accurately diagnosed with obsessive-compulsive personality disorder? If so, why? If not, why not?
5. What rule-outs would you consider for Anuj's case?
6. What other information may be needed to make an accurate clinical diagnosis?]

300.7 Body Dysmorphic Disorder (F45.22)

You could say that all my life I've been semi-obsessed with being perfect. I often did not think I looked pretty enough. What's amazing to me is, I know that I am very attractive, and yet, whenever I glance at myself in public or something, I kind of see everything wrong with me. It's very frightening. Most of all, I fear that people are judging me for the imagined flaws that I see staring back at me. —Ester

Body dysmorphic disorder (BDD), previously included in the somatoform disorders section of the DSM-IV-TR, involves excessive concern with how one looks, specifically with the shape or appearance of one's body or a specific body part. Common concerns often involve breasts, genitalia, hair, nose, or some other portion of the face. Distress is not focused on worry about the presence of an unknown medical condition, as with illness anxiety disorder (previously known as hypochondriasis), or excessive concern with body weight, as with eating disorder. Historically, this disorder was referred to as dysmorphophobia, but this term was changed in the DSM-IV because it implies a phobia rather than an OCD. Because individuals diagnosed with BDD do not present with persistent and irrational fear of their body or body part, a more accurate term is dysmorphia, which refers to preoccupation rather than irrational fear.

Note

When working with clients who have concerns about their bodies, counselors should carefully consider whether a delusional disorder, illness anxiety disorder, or feeding or eating disorder is present.

Essential Features

Common concerns for individuals with BDD are skin imperfections such as wrinkles, scars, or acne. Hair concerns can be due to the lack of hair or too much hair. Individuals may also obsess about their weight, height, or the shape of a body part. Although most individuals can point out some feature of their appearance that they would like to change, BDD is a devastating disorder in which individuals repeatedly obsess about their body or a part of their body. For example, they will spend hours a day engaged in activities to camouflage their “defect” or repeatedly check themselves in a mirror. It is not uncommon for some clients to seek out surgical interventions to correct perceived flaws; however, these individuals seldom feel satisfied with the results of surgery and often attempt other surgical procedures or look for other ways in which they can modify the perceived imperfection (Nietzel, Speltz, McCauley, & Bernstein, 1998).

BDD is an underrecognized yet relatively common disorder affecting 2.5% of women and 2.2% of men in the general population (Bjornsson, Didie, & Philips, 2010; Koran, Abujaoude, Large, & Serpe, 2008). Prevalence of BDD in clinical settings is high, including 9% to 12% of individuals in dermatological settings and up to 53% of clients seen by cosmetic surgeons. There have been no major changes to this disorder.

Special Considerations

BDD is associated with increased occupational and social impairment, hospitalization, and suicide attempts. Counselors should not assume BDD is simply a symptom of depression. Although this diagnosis often coexists with depression, it should always be considered a stand-alone diagnosis if diagnostic criteria are met (Phillips, 1999).

Cultural Considerations

BDD usually begins in early adolescence, with an age onset of 16 to 22 years (Mancebo et al., 2008). This diagnosis affects males and females equally but with different manifestations. Phillips and Diaz (1997) identified males as more likely to be preoccupied with their physique, genitals, and loss of hair. Females are more likely to have a comorbid eating disorder, hide perceived defects with various camouflaging techniques, frequently check mirrors, and pick their skin as a symptom of BDD. In terms of psychosocial functioning, males fared worse than females and were more likely to be unemployed and receiving disability payments. The DSM-5 states that “the disorder may have more similarities than differences across races and cultures but that cultural values and preferences may influence symptom content to some degree” (APA, 2013a, p. 245).

Differential Diagnosis

For a diagnosis of BDD, the symptoms must represent disproportionate concerns about real or imagined flaws related to one's appearance (APA, 2013a). Counselors should consider the degree to which one's concern with appearance may be culturally or developmentally expected (even if unhealthy). Counselors must rule out eating disorders when a client is only concerned with weight and feeling “fat.” Counselors should also strongly consider depressive, anxiety, psychotic, and other obsessive-compulsive related disorders such as OCD (Frances, 2013). Ensuring that the client's obsessions and symptomatology focus only on appearance will help ensure accurate diagnosis (APA, 2013a).

Coding, Recording, and Specifiers

There is only one diagnostic code for BDD: 300.7 (F45.22). However, there are two specifiers, the first of which indicates extreme preoccupation with one's body build and the second an individual's level of insight. Counselors should use the specifier with muscle dysmorphia if clients are significantly troubled by the idea that their body build is too small. This specifier is also used if the clients are preoccupied with other body areas, such as one's breasts. Counselors should indicate current insight (with good or fair insight, with poor insight, or with absent insight/delusional beliefs) specifiers assessing the degree to which clients accept their beliefs as true.

Case Example

Becca, a 32-year-old single Hispanic woman, had been obsessed with her “huge” nose and “acne-scarred” skin since junior high school. She reported being “absolutely convinced” that she looked “deformed and atrocious.” When others tried to tell her she was pretty, she would not budge. Becca was convinced that others talked about her “hideous” nose and “grotesque” skin. Because of her self-loathing, Becca became severely depressed. She could not work or leave home. She has a history of two suicide attempts and was hospitalized after both attempts.

Although her friends and family strongly advised against it, Becca received two rhinoplasties for a nose that outwardly appeared normal. She also received a course of isotreninoin (Accutane). These treatments left Becca even more obsessed with her appearance and feeling more depressed because her “last hopes” had not cured her perceived ugliness.

Diagnostic Questions

1. Do Becca's presenting symptoms meet the criteria for BDD? Which symptom(s) led you to select that diagnosis?
2. What rule-outs would you consider for Becca's case?
3. What course of treatment would you recommend for Becca?

300.3. Hoarding Disorder (F42)

I've always had trouble throwing things away. Magazines, newspapers, old clothes. What if I need them one day? I don't want to risk throwing something out that might be valuable. The large piles of stuff in our house keep growing so it's difficult to move around and sit or eat together as a family. My wife is upset and embarrassed, and we get into horrible fights. I'm scared when she threatens to leave me. My children won't invite friends over, and I feel guilty that the clutter makes them cry, but I get so anxious when I try to throw anything away. I don't know what's wrong with me, and I don't know what to do. —Ben

Hoarding is defined as “persistent difficulty discarding or parting with possessions, regardless of their actual value” (APA, 2013a, p. 247). Historically referred to as pathological or compulsive hoarding, this disorder has extremely detrimental emotional, social, and financial effects on individuals and their loved ones. Because of their avoidance of or difficulty with getting rid of possessions, individuals diagnosed with hoarding disorder are consumed with fears related to losing important information or objects of emotional significance (IOCDF, 2012).

Major Changes From DSM-IV-TR to DSM-5

Hoarding, commonly associated with OCD and previously listed in the DSM-IV-TR as one of eight concurrent criteria for obsessive-compulsive personality disorder (OCPD), is now a stand-alone diagnosis in the DSM-5. The DSM-5 Task Force decided to include hoarding as a discrete disorder because individuals with hoarding symptoms may not display any other symptoms of OCD and are often nonresponsive to traditional treatments for OCD or OCPD, such as exposure therapy or psychopharmaceutical treatments (see Pertusa et al., 2010; Samuels et al., 2008). Moreover, correlational studies only identified a small to moderate relationship between hoarding and OCD (Abramowitz, Wheaton, & Storch, 2008; Wu & Watson, 2005). Two strong indicators that hoarding is a distinct disorder rather than a component of OCD are that hoarding is the only OCD symptom that increases with age and that distress and disability often appear late in the course of the disorder (Ayers, Saxena, Golshan, & Wetherell, 2010).

Essential Features

Individuals with hoarding disorder typically have living spaces and personal surroundings cluttered to the point of being useless for their intended purpose (e.g., a bathroom or bedroom). Hoarding behaviors often cause a considerable amount of distress for the individual and family members, caregivers, neighbors, and friends who attempt to clear spaces. It is important to note that diagnostic criteria for hoarding, like other obsessive-compulsive and related disorders, include symptoms that cause significant impairment in social, occupational, or other essential areas of functioning.

Prevalence of hoarding among the general population is 2% to 5%, with older adults more likely to exhibit hoarding behaviors. Hoarding typically manifests in childhood with symptoms worsening as clients become older. Some researchers claim that as the geriatric population increases, so will the number of adults diagnosed with a hoarding disorder (Ayers et al., 2010). Symptoms often are associated with other psychological disorders such as depression, anxiety, and substance abuse. Although epidemiological research is limited, some researchers have identified a familial pattern (Samuels et al., 2008).

Special Considerations

A client's ability to maintain a safe living environment, free of any public health consequences, is often a major indicator for counselors considering this diagnosis. Counselors should not diagnose hoarding simply because a person owns an abnormal amount of things. Counselors should keep in mind the following three behaviors regarding hoarding: (a) acquisition of numerous possessions, many of little value; (b) difficulty discarding these possessions; and (c) significant difficulty organizing possessions. In contrast to people with hoarding problems, people who collect items often keep their property well organized. Collectors often display items for others to appreciate, whereas those with hoarding disorder overrun living areas with items and can create problems such as financial obligations of paying for storage space.

When collecting behaviors lead to health or safety problems or cause significant distress, hoarding becomes a diagnosable disorder. For example, a major feature of hoarding is the large amount of disorganized clutter that creates chaos in the home or office. Individuals diagnosed with hoarding disorder often have rooms that can no longer be used as they were intended, moving through the home is challenging, exits are blocked, and life inside the home becomes difficult (Frances, 2013; Morrison, 2006). Counselors should pay close attention to health and safety concerns, especially in older adult clients. Client safety (e.g., falling over items in one's home or illnesses due to contaminated food or infestation) is the number one concern for counselors working with individuals diagnosed with a hoarding disorder.

Cultural Considerations

It is not uncommon for individuals who hoard to have a history of trauma or have experienced significantly stressful life events (Hartl, Duffany, Allen, Steketee, & Frost, 2005; Samuels et al., 2008). Some studies have linked symptom onset or exacerbation to traumatic events. Although some researchers have identified material deprivation (e.g., lack of money, food, adequate clothing, or shelter during their lifetime) as an environmental risk factor, general consensus among scholars is that there is no clear link between a lack of material items and hoarding disorder (Landau et al., 2011). People with hoarding disorder are typically older, yet most have trouble discarding items early on in their lives. They are also less likely to be married, which may relate to functional impacts associated with the disorder.

Differential Diagnosis

Researchers have identified important phenomenological differences between hoarding and prototypical OCD symptoms, which can help counselors differentiate between hoarding disorder and OCD (Landau et al., 2011). Thoughts associated with hoarding are not intrusive, and typically no ritualistic attributes are associated with hoarding behaviors. Researchers have also discovered that failure to discard possessions is more of a passive behavior than an active attempt to neutralize unwanted thoughts, images, or impulses (Pertusa et al., 2010; Steketee & Frost, 2003). Counselors must be sure to rule out MDD, schizophrenia, or any neurocognitive disorder such as ASD because the presentation of any one of these could result in an inability for a client to be able to get rid of objects or clear clutter (APA, 2013a; Frances, 2013). Hoarding is often comorbid with ADHD-inattentive type (Hartl et al., 2005).

Coding, Recording, and Specifiers

There is only one diagnostic code for hoarding disorder: 300.3 (F42). Because hoarding is not directly mentioned in either the ICD-9 or the ICD-10, the diagnostic code for OCD is used. There are two specifiers, the first of which indicates extreme hoarding and the second an individual's level of insight. Counselors should use the with excessive acquisition specifier if attainment of items is extreme and individuals are unable to discard large numbers of possessions. In addition, counselors should use insight specifiers (e.g., with good or fair insight, with poor insight, or with absent insight/delusional beliefs) to indicate the degree to which the individual is able to understand the hoarding beliefs and behaviors as problematic. These specifiers do not have specific codes associated with them.

Diagnostic Criteria for Hoarding 300.3 (F42)

1. Persistent difficulty discarding or parting with possessions, regardless of their actual value.
2. This difficulty is due to a perceived need to save the items and to distress associated with discarding them.
3. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).
4. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).
5. The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome).
6. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, restricted interests in autism spectrum disorder).

   Specify if:

   With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space.

   Specify if:

   With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic.

   With poor insight: The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

   With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary.

From Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013, p. 247. Copyright 2013 by the American Psychiatric Association. All rights reserved. Reprinted with permission.

Case Example

Barrett, an articulate 69-year-old Caucasian male retiree, first came to the attention of the Community Services Board when a neighbor complained to the police about the mounds of trash she could see through his windows. A staff person from the Fire Department visited Barrett but was unable to investigate the complaint because he would not allow the investigator to enter his home. The fire official was able to persuade Barrett to meet with a case manager from Adult Protective Services, who evaluated Barrett and found him to be competent and able to refuse services. Over the next 10 years, neighbors complained about Barrett's hoarding behavior approximately every 2 years. Complaints included references to a car that was so stuffed full of things that it was unsafe to drive, rodents on the property, and trash piled up in the backyard.

When Barrett was not seen at his volunteer job for several days, his supervisor requested that police check on his welfare. Police found Barrett unconscious in a corner of his bedroom where he had landed after tripping over a pile of papers. Barrett was hospitalized and received treatment for an infection of both legs. During this time, the fire marshal condemned his home. In the hospital, a counselor met with Barrett to help him cope with being removed from his home and begin exploring a plan for moving forward.

Diagnostic Questions

1. Do Barrett's presenting symptoms meet the criteria for an OCD? If so, which disorder?
2. Based on the disorder identified in Question 1, which symptom(s) led you to select that diagnosis?
3. What would be the reason(s) a counselor may not diagnose Barrett with OCD or OCPD?
4. Would Barrett be more accurately diagnosed with an anxiety disorder? If so, why and which one? If not, why not?
5. What rule-outs would you consider for Barrett's case?
6. What other information may be needed to make an accurate clinical diagnosis?

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

I eat my hair. I know I am a freak, but I don't even realize I am doing it. I just pull at my hair and, one day, just started swallowing it. I have tried to stop, but I cannot. Even the thought of trying to stop again makes my heart start racing. —Allyia

Previously identified in the DSM-IV-TR as an impulse-control disorder, trichotillomania (TTM), or hair-pulling disorder, is characterized by the compulsive urge to pull out, and sometimes ingest, one's own hair (APA, 2013a). TTM leads to noticeable hair loss and, as characteristic of all obsessive-compulsive and related disorders, causes distress or functional impairment (APA, 2013a; Chamberlain, Menzies, Sahakian, & Fineberg, 2007). The ICD-10 classifies TTM as a habit and impulse disorder in the section on disorder of adult personality and behavior. Both the ICD and the DSM describe TTM as recurrent and noticeable by others.

Essential Features

Hair pulling often occurs without focused attention, meaning individuals are typically not aware they are doing it (APA, 2013a). This is different from OCD, in which people may have a high level of insight into their behavior (Chamberlain et al., 2007). Hair pulling occurs in response to a wide range of negative moods, such as anger, boredom, sadness, or stress. Although there were not many changes to this disorder, aside from moving it from the Impulse-Control Disorders Not Elsewhere Classified chapter in the DSM-V-TR to the new Obsessive-Compulsive and Related Disorders chapter, the DSM-5 includes a new criterion that addresses attempts to resist hair pulling.

The hallmark feature of TTM is pleasure, gratification, or relief experienced by the client as a result of pulling out one's hair (APA, 2013a; Chamberlain et al., 2007). In the ICD-10, this disorder is described as “preceded by mounting tension [that] is followed by a sense of relief” (WHO, 2010, p. 87). It is the defining characteristic of relief, as opposed to pleasure, that caused this disorder to be recategorized. Impulse disorders, such as pyromania and kleptomania, give pleasure to the person and are not typically carried out for the purpose of relief (Gershuny et al., 2006; Stein, Chamberlain, & Fineberg, 2006). Prevalence of TTM is 1% to 2% of adults and adolescents in the general population (APA, 2013a).

Special Considerations

Counselors should be aware that the reference to “mania” in trichotillomania implies an interest or enthusiasm for the hair-pulling behavior. Since this is not the case, a more neutral reference to “hair-pulling disorder” has been included in the DSM-5. The typical age of onset is between 12 and 13, and the disorder affects mostly females (APA, 2013a; Chamberlain et al., 2007). Cases of TTM in toddlers and young children, referred to as pediatric TTM, have been reported with onset between the age of 18 months and 4 years. Pediatric TTM is often short term (Tolin, Franklin, Diefenbach, Anderson, & Meunier, 2007). Behavior therapy, CBT, and selective serotonin reuptake inhibitors have been found to be effective for the treatment of TTM (Blatt et al., 2000; Chamberlain et al., 2007; Melville, 2013).

Cultural Considerations

Unfortunately, little is known regarding cultural considerations and features of TTM.

Differential Diagnosis

A TTM diagnosis should not be made if there is a preexisting dermatological problem, another medical condition, or if the hair pulling is in response to a delusion, hallucination, or another mental health disorder (APA, 2013a; Chamberlain et al., 2007). TTM has a high rate of comorbidity, with some studies reporting up to 60% of individuals diagnosed with TTM having another mental health disorder (see Chamberlain et al., 2007). It is not uncommon for individuals also to be diagnosed with MDD, GAD, social phobia, OCD, or other impulse-control disorder and substance use disorder.

Coding, Recording, and Specifiers

There is only one diagnostic code for TTM (hair-pulling) disorder: 312.39 (F63.3). There are no specifiers for this disorder. Counselors should note that the original DSM-5 mistakenly published the code 312.39 (F63.2) for TTM (hair-pulling disorder). This is incorrect, and the code of 312.39 (F63.3) should be used.

698.4 Excoriation (Skin-Picking) Disorder (L98.1)

First it was occasional picking at scabs and acne on my face. Then I started just sitting at home picking at my fingers and arms. Now, I spend hours nearly every day obsessed with picking the skin on my face, arms, and hands. I think about it all the time. I can't even go to work sometimes because I am either embarrassed about the scabs and scars on my skin or because I am so consumed with the need to keep picking at myself. —Meagan

Excoriation (skin-picking) disorder is characterized by repetitive and compulsive picking of skin, resulting in tissue damage (Odlaug & Grant, 2010). Sometimes called neurotic excoriation, compulsive skin-picking, dermatillomania, or psychogenic skin-picking, symptoms of excoriation can also include skin rubbing, squeezing, lancing, and biting (APA, 2013a; Stein et al., 2010). Individuals with excoriation disorder may use their fingers, fingernails, tweezers, or other objects. These individuals spend a considerable amount of time picking, and the disorder can continue for months or years. This disorder may be accompanied by a range of behaviors or rituals, typically does not occur in the presence of others, and has the potential to cause significant distress in several areas of functioning (APA, 2013a).

Major Changes From DSM-IV-TR to DSM-5

Excoriation disorder is new to the DSM-5; symptoms of it were previously classified by clinicians as impulse-control disorder NOS because there was no other appropriate diagnostic classification. As the DSM-5 was being developed, there were serious deliberations as to whether this disorder should be included as an impulse-control disorder or as a body-focused repetitive behavioral disorder (Stein et al., 2010). Before inclusion in the DSM-5, excoriation was considered clinically similar to substance abuse or impulse-control disorders, rather than a disorder related to obsessive-compulsive behavior. However, similar to TTM, the core feature of excoriation is repetitive feelings of tension, anxiety, or agitation immediately preceding the picking episode (i.e., obsessive) and feelings of relief during or following picking (i.e., compulsive). Thus, the diagnosis was included within the Obsessive-Compulsive and Related Disorders chapter.

The DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group determined there was clinical utility in conceptualizing excoriation as part of the OCD spectrum because of comorbidity of excoriation and OCD and treatment approaches that have been strongly influenced by research on OCD (Stein et al., 2010).

Essential Features

Six core features characterize excoriation: (a) recurrent and repetitive picking resulting in noticeable tissue damage; (b) intrusive urges to pick skin; (c) feelings of tension, anxiety, or agitation immediately preceding the picking episode; (d) feelings of pleasure, relief, or satisfaction during or after picking; (e) the picking cannot be accounted for by another medical (e.g., scabies, eczema) or mental disorder (e.g., cocaine or amphetamine use disorders); and (f) the individual suffers significant distress or social or occupational impairment as a result of the picking behavior (APA, 2013a). Clients most frequently report picking at the face, but the fingers, arms, torso, hands, legs, back, and stomach are also common areas for picking.

Special Considerations

Counselors should be sensitive to the needs of clients who engage in skin picking. This behavior may result in skin discoloration or scarring. In more serious cases, severe tissue damage and visible disfigurement can result. Although skin picking is typically not related to other physical or mental disorders, it is essential for counselors to help clients identify whether picking is a symptom of another problem, for example, dermatological disorders, autoimmune problems, BDD, or psychosis. Because clients are often embarrassed about their problem, they may avoid treatment (Flessner & Woods, 2006). In a study of 31 patients with pathological skin picking, only 14 (45%) had ever sought treatment, and only six of the 31 had ever received dermatological treatment. The largest concern for counselors is significant medical complications such as scarring and infection. As with TTM, common interventions include behavioral approaches (i.e., habit reversal) and psychopharmaceutical treatments.

Note

Clients are typically embarrassed about hair-pulling or skin-picking disorders. Therefore, if you do not see evidence of the disorder, you are not likely to hear about associated symptoms.

Cultural Considerations

Age of onset is bimodal, beginning in either young adulthood or between the ages of 30 and 45. Mostly identified in females, prevalence rates of excoriation range from 1.4% to 5.4% in the general population (Odlaug & Grant, 2010).

Differential Diagnosis

Comorbidity is not uncommon. For example, in an examination of clients with BDD, 44.9% reported skin-picking behaviors (Grant, Menard, & Phillips, 2006). Also common is the existence of another body-focused repetitive behavior, such as excessive washing seen in individuals diagnosed with OCD. Somatic symptoms, such as a factitious disorder, should be ruled out as should any other substance/medication-induced disorder (APA, 2013a).

Coding, Recording, and Specifiers

There is only one diagnostic code for excoriation (skin-picking) disorder, 698.4 (L98.1), and there are no specifiers for this disorder. Readers will note the ICD-10-CM code for excoriation begins with an “L” as opposed to the commonly seen “F.” The reason is because the ICD-10 classifies excoriation under other disorders of skin and subcutaneous tissue, not elsewhere classified (WHO, 2007).

Case Example

Adrianne, a 38-year-old European American single woman, picks her arms on a daily basis. Although she had previously picked at her face, particularly her nose, her arms have been her main focus for the past 2 years. Her picking sometimes lasts as long as 3 hours each day and is so intense that her arms are scarred and covered with scabs. Touching her arms creates an irresistible urge to pick. Sometimes when she walks and her hands touch her thighs she has to stop what she is doing and pick.

Adrianne started picking her face when she was 14 years old. Because of the time she spent picking, she missed a significant amount of high school and could not graduate. Since then, because of the facial scarring, Adrianne started focusing on her arms. Scarring and the consistent bleeding caused Adrianne to avoid going out in public, working, or socializing. She lives alone at home on medical disability. She had never sought help for her picking until just recently when she was hospitalized for septicemia, a life-threatening infection as a result of skin picking.

Diagnostic Questions

1. Do Adrianne's presenting symptoms meet the criteria for excoriation (skin-picking) disorder?
2. Which symptom(s) led you to agree with this diagnosis?
3. What rule-outs would you consider for Adrianne's case?
4. What other information may be needed to make an accurate clinical diagnosis?

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder

Substance/medication-induced obsessive-compulsive and related disorder is characterized by obsessive-compulsive symptoms as a direct result of substance use (APA, 2013a). For an individual to meet the criteria for substance/medication-induced obsessive-compulsive and related disorder, symptoms must have occurred during or soon after substance or medication intoxication or withdrawal; must be in excess of what is expected during intoxication or withdrawal for the specific substance; and must subside after the effects of the medication, treatments, or substance have been removed.

Major Changes From DSM-IV-TR to DSM-5

The DSM-IV-TR included a specifier with obsessive-compulsive symptoms in the diagnoses of substance-induced anxiety disorder, but the DSM-5 now classifies this as a distinct disorder given that obsessive-compulsive and related disorders are now a distinct category. This change is consistent with the intent of DSM-IV-TR and reflects the recognition that substances, including medications, can present with symptoms similar to primary obsessive-compulsive and related disorders.

Special Considerations

Counselors should ensure that the substance or medication deemed to be responsible for symptoms directly caused the disturbance; this effect does not only occur when the individual is experiencing delirium (APA, 2013a). Moreover, the symptoms must in some way result in clinically significant distress or impairment to functioning.

Coding, Recording, and Specifiers

Similar to all substance/medication-induced disorders in the DSM-5, the ICD-9-CM and ICD-10-CM codes are used. An extensive coding chart for substance/medication-induced obsessive-compulsive and related disorder can be found on page 258 in the DSM-5. As with all substance/medication-induced disorders, the name of the substance causing the symptoms is used to identify the appropriate code and is included within the written name of the disorder, for example, 292.89 (F15.288) amphetamine-induced obsessive-compulsive and related disorder.

Three different types of substances are classified as applicable to obsessive-compulsive and related disorders. These are amphetamines/stimulants, cocaine, or other/unknown substance. Specifiers indicating with onset during intoxication, with onset during withdrawal, or with onset after medication use can be indicated after the code and name but, as with all specifiers in this chapters, do not have specific codes associated with them (APA, 2013a). Counselors using the ICD-10-CM diagnostic codes should note specific coding procedures when there is a comorbid substance use disorder present for the same class of substance. For example, if a mild substance use disorder is comorbid with the substance/medication-induced obsessive-compulsive related disorder, the fourth position character should be a “1”; if the comorbid substance use disorder is considered heavy, the fourth position character should be a “2.” If there is no comorbid disorder, the fourth position character should be a “9” and only the substance-induced obsessive-compulsive and related disorder would be recorded (APA, 2013a).

Note

Counselors should reference page 482, Table 1, Diagnoses Associated With Substance Class, in the Substance-Related and Addictive Disorders chapter of the DSM-5 to fully understand which mental health diagnoses are associated with specific substances classes.

294.8 Obsessive-Compulsive and Related Disorder Due to Another Medical Condition (F06.8)

Medical conditions can cause the development of an obsessive-compulsive or related disorder, but symptoms must cause clinically significant distress in order to be diagnosed. Symptoms can include a wide range of obsessive-compulsive features (e.g., obsessions, compulsions, preoccupation with appearance, hoarding, skin picking), but there is direct pathophysiological evidence of a medical condition. The characteristic features of obsessive-compulsive and related disorder due to another medical condition is that symptoms are not better explained by another obsessive-compulsive related disorder and are deemed to be the result of direct pathophysiological consequence of a medical condition (APA, 2013a).

Major Changes From DSM-IV-TR to DSM-5

Obsessive-compulsive and related disorder due to another medical condition is now a distinct disorder. It was previously a specifier in the diagnoses of anxiety disorder due to a general medical condition in the DSM-IV-TR. This reflects the recognition that medical conditions can present with symptoms similar to OCD.

Essential Features

A medical condition, as evidenced by laboratory findings, physical examination from a medical professional, or physical health history, must be present when diagnosing a client with obsessive-compulsive and related disorder due to another medical condition. Furthermore, the condition cannot be better explained by another medical condition or use of a substance/medication. As with any obsessive-compulsive and related disorder, symptoms must cause significant impairment to social, occupational, or other essential areas of functioning.

Special Considerations

Two medical conditions that are of significance are (a) pediatric autoimmune neuropsychiatric disorder associated with streptococcal infections (PANDAS), with the rapid onset of OCD symptoms or tics as a result of strep throat or scarlet fever; and (b) pediatric acute-onset neuropsychiatric syndrome (PANS), a broader condition similar to PANDAS but not related to a strep infection (APA, 2013a). Clients with a history of these disorders are prone to obsessive-compulsive traits.

Cultural Considerations

There is limited information on cultural considerations for this disorder because these are typically relevant to the underlying medical illness rather than the psychiatric diagnosis. However, as with any medical disorder, counselors should consult with health professionals for information related to the development and course of the medical disorder as it relates to the client's cultural background.

Differential Diagnosis

It is especially important for counselors to rule out differential diagnoses, such as a primary diagnosis of OCD or an illness anxiety disorder (i.e., hypochondriasis), and consult with a physician to determine physiological etiology before using the diagnosis of obsessive-compulsive and related disorder due to another medical condition.

Coding, Recording, and Specifiers

There is only one diagnostic code for obsessive-compulsive and related disorder due to another medical condition: 294.8 (F06.8). When coding this disorder, counselors should be sure to indicate the medical condition alongside the diagnosis (e.g., obsessive-compulsive and related disorder due to PANDAS). There are five specifiers associated with this diagnosis that are relatively self-explanatory because they relate to the diagnoses found within this chapter. These include with obsessive-compulsive disorder–like symptoms, with appearance preoccupations, with hoarding symptoms, with hair-pulling symptoms, and with skin-picking symptoms. There are no specific codes assigned to these specifiers.

Note

Proper recording procedures should include the separate coding and listing of the medical condition immediately before the obsessive-compulsive and related disorder due to another medical condition diagnosis.

Other Specified and Unspecified Obsessive-Compulsive and Related Disorders

The other specified obsessive-compulsive and related disorder (300.3 [F42]) category, along with the unspecified criterion, replaces the NOS category in the DSM-IV-TR. This disorder may include conditions such as body-focused repetitive behavior disorder and obsessional jealousy. Body-focused repetitive behavior disorder, for example, is characterized by recurrent behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors. Obsessional jealousy is characterized by nondelusional preoccupation with a partner's perceived infidelity.

The other specified obsessive-compulsive and related disorder category is used in situations in which the counselor chooses to communicate the specific reason that the presentation does not meet the criteria for any specific anxiety disorder (e.g., “body dysmorphic-like disorder with actual flaws”; APA, 2013a, p. 263). The example given would indicate BDD, except the client's preoccupation involves a physical imperfection that is evident to other persons. When coding other specified obsessive-compulsive and related disorder, counselors will use one diagnostic code, 300.3 (F42), being sure to indicate the specific reason for choosing this diagnosis in the name. If the counselor chooses not to specify the reason the criteria are not met, then the unspecified obsessive-compulsive and related disorder (300.3 [F42]) category is used. In either case, symptoms cause clinically significant impairment or distress. This diagnosis is also commonly used when counselors are unable to distinguish whether a medical illness or substance has played a causal role in the manifestation of obsessive-compulsive symptoms.

Note

The diagnostic code for specified and unspecified obsessive-compulsive and related disorder is the same.