181CHAPTER 7
Other Obsessive-Compulsive and Related Disorders in DSM-5
This chapter addresses four diagnostic categories in the DSM-5 chapter on obsessive-compulsive and related disorders (OCRDs): substance/medication-induced OCRD, OCRD due to another medical condition, other specified OCRD, and unspecified OCRD (American Psychiatric Association 2013).
Both the “substance/medication-induced” category and the “due to another medical condition” category are used in the disorder chapters throughout DSM-5. To ensure accurate diagnosis and treatment, it is critically important to consider whether a substance, a medication, or a nonpsychiatric medical condition is responsible for presenting symptoms—for example, whether cocaine use or scabies is the cause of compulsive skin picking.
Furthermore, many presenting conditions have similarities to an OCRD but do not quite meet the diagnostic criteria for the disorders discussed in earlier chapters in this book. Presentations such as these that cause clinically significant distress or impairment in functioning are diagnosed as “other specified 182OCRD” (when the clinician briefly describes the presenting symptoms) or as “unspecified OCRD” (when the clinician does not describe the presenting symptoms). These two categories are equivalent to the “not otherwise specified” category in previous editions of DSM. The “other specified” and “unspecified” categories are also used across DSM-5, for other diagnostic classes of disorders.
One example of an “other specified OCRD” is body-focused repetitive behavior disorder, which is characterized by repetitive behaviors, such as lip biting, that are not covered by other DSM-5 categories of body-focused repetitive behaviors (i.e., trichotillomania [hair-pulling disorder] or excoriation [skin-picking] disorder). Another example of an “other specified OCRD” is olfactory reference syndrome (jikoshu-kyofu), which involves distressing or impairing preoccupation with emitting an offensive or foul-smelling body odor, which other people cannot perceive. As these and other specified OCRDs are better studied and better understood, they may be included in future editions of DSM as separate diagnostic entities.
Because the OCRD chapter is new to DSM-5, these four diagnoses are new to the nomenclature, although they are analogous to conditions in DSM-IV (American Psychiatric Association 1994). In this chapter we discuss diagnostic criteria for these categories and examples of these presentations. We also consider key aspects of assessment and management.
Substance/Medication-Induced OCRD
Diagnostic Features
Substance/medication-induced OCRD is diagnosed when OCRD symptoms are clinically assessed as having a causal relationship to substance use, withdrawal from a substance, or use of a medication. It may be difficult to determine with certainty that the symptoms are due to a substance or medication; the diagnostic criteria focus largely on a temporal relationship between use of the substance or medication and development of OCRD-like symptoms as well as whether the substance or medication is known to be capable of producing the OCRD symptoms.
Diagnostic criteria for substance/medication-induced OCRD are shown in Box 7–1. The wording of the criteria is very similar to that used for substance/medication-induced diagnoses in other chapters of DSM-5 (e.g., substance/medication-induced anxiety disorder). However, the criteria include some features that are specific to OCRDs; most notably, Criterion A focuses on obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of the OCRDs, which 183must predominate in the clinical picture. Criterion B states that there is evidence from the history, physical examination, or laboratory findings that these symptoms developed during or soon after substance intoxication or withdrawal or after exposure to a medication, and that the involved substance/medication is capable of producing the OCRD-like symptoms.
BOX 7–1. DSM-5 Diagnostic Criteria for Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
A. Obsessions, compulsions, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of the obsessive-compulsive and related disorders predominate in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings of both (1) and (2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or withdrawal or after exposure to a medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.
C. The disturbance is not better explained by an obsessive-compulsive and related disorder that is not substance/medication-induced. Such evidence of an independent obsessive-compulsive and related disorder could include the following:
The symptoms precede the onset of the substance/medication use; the symptoms persist for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication; or there is other evidence suggesting the existence of an independent non-substance/medication-induced obsessive-compulsive and related disorder (e.g., a history of recurrent non-substance/medication-related episodes).
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Note: This diagnosis should be made in addition to a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to warrant clinical attention.
Coding note: The ICD-9-CM and ICD-10-CM codes for the [specific substance/medication]-induced obsessive-compulsive and related disorders are indicated in the table below. Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. If a mild substance use disorder is comorbid with the substance-induced obsessive-compulsive and related disorder, the 4th position character is “1,” and the clinician should record “mild [substance] use disorder” before the substance-induced obsessive-compulsive and related disorder (e.g., “mild cocaine 184use disorder with cocaine-induced obsessive-compulsive and related disorder”). If a moderate or severe substance use disorder is comorbid with the substance-induced obsessive-compulsive and related disorder, the 4th position character is “2,” and the clinician should record “moderate [substance] use disorder” or “severe [substance] use disorder,” depending on the severity of the comorbid substance use disorder. If there is no comorbid substance use disorder (e.g., after a one-time heavy use of the substance), then the 4th position character is “9,” and the clinician should record only the substance-induced obsessive-compulsive and related disorder.
Specify if (see Table 1 in the [DSM-5] chapter “Substance-Related and Addictive Disorders” for diagnoses associated with substance class):
With onset during intoxication: If the criteria are met for intoxication with the substance and the symptoms develop during intoxication.
With onset during withdrawal: If criteria are met for withdrawal from the substance and the symptoms develop during, or shortly after, withdrawal.
With onset after medication use: Symptoms may appear either at initiation of medication or after a modification or change in use.
Criterion C indicates that the disturbance is not better explained by an OCRD that is not substance/medication-induced; this criterion provides guidelines to determine this, again with a focus on a temporal association between the clinical symptoms and use of a medication or substance. These guidelines are not meant to be exhaustive, however. It is useful to consider temporal relationships; for example, if symptoms preceded use of a medication or substance, it is very unlikely that the medication or substance is causing the symptoms. However, clinicians should consider all other available evidence as well.
Criterion D notes that the disturbance does not occur exclusively during the course of a delirium, and Criterion E indicates that the disturbance must 185cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
A DSM-5 “note” emphasizes that this diagnosis should be made in addition to a diagnosis of substance intoxication or substance withdrawal only when the symptoms in Criterion A predominate in the clinical picture and are sufficiently severe to warrant clinical attention. The manual also provides three specifiers: with onset during intoxication, with onset during withdrawal, and with onset after medication use.
Assessment and Treatment
The literature on the prevalence, psychobiology, and management of substance/medication-induced OCRD is sparse. Nevertheless, case reports indicate that obsessions, compulsions, hair pulling, skin picking, and other body-focused repetitive behaviors can occur in association with intoxication with stimulants (including cocaine) and other substances, as well as various toxins (Fried 1994; Laplane et al. 1989; Martin et al. 1998). The association between stimulant abuse and stereotypic behaviors (also known as “punding”) has long been described, and such behaviors may include skin picking. Toxins that have been associated with obsessive-compulsive-like behavior include carbon monoxide.
These observations are consistent with the known pathophysiology of OCRDs. Stimulants act to increase dopaminergic neurotransmission, and in animal models they induce stereotypic behavior such as abnormal grooming and picking (Ridley 1994), which has similarities to certain repetitive behaviors in humans, including body-focused repetitive behaviors such as skin picking. Carbon monoxide may lead to basal ganglia lesions, and corticostriatal circuitry is thought to mediate obsessive-compulsive symptoms (Laplane et al. 1989).
Thus, it is appropriate for clinicians to consider routinely whether substances or medications are causing OCRD symptoms. In our clinical experience, it is more common to conclude that the relevant substance/medication plays an exacerbating role rather than a causal one; for example, patients with obsessive-compulsive disorder (OCD) may note that their symptoms worsen when they use cocaine.
When a substance/medication-induced OCRD is diagnosed, assessment and treatment should target the relevant substance/medication. For example, severity of cocaine use can be ascertained using standardized substance use scales. Laboratory assessment, such as a urine toxicology screening, may be useful. Substance use–focused psychotherapy or medication can be initiated. When a substance/medication is thought to be primarily responsible for presenting symptoms, it is more appropriate to directly target the substance or medication use rather than instituting a serotonin reuptake inhibitor (SRI), cognitive-behavioral therapy (CBT), or other treatment for an OCRD. However, 186when a substance/medication is thought to play an exacerbating role in precipitating or perpetuating an OCRD, clinicians may need to focus treatment on both the substance use and the OCRD itself.
A key debate in the literature regards the relationship between prescription psychostimulants, such as methylphenidate, and subsequent onset of tics. One early view was that because psychostimulants have dopaminergic effects, and because tics are mediated by this neurotransmitter system, tics may be an adverse effect of psychostimulants. A contrasting later view is that the emergence of tics in patients with attention-deficit/hyperactivity disorder (ADHD) after appropriate treatment with medications such as methylphenidate merely reflects the high comorbidity of ADHD with tic disorder. Reviews of the literature support this contemporary view (Madruga-Garrido and Mir 2013); the current consensus is that methylphenidate and other prescription stimulants not only do not exacerbate or reactivate tics but may actually improve tics in patients with comorbid ADHD and tic disorder.
OCRD Due to Another Medical Condition
Diagnostic Features
OCRD due to another medical condition is diagnosed when a nonpsychiatric medical disorder is thought to be the cause of OCRD symptoms. It is worth noting a difference in nomenclature between DSM-IV and DSM-5: DSM-IV referred to nonpsychiatric medical conditions as “general medical conditions,” whereas DSM-5 refers to them as “other medical conditions,” based on the fact that psychiatric disorders are themselves medical conditions.
The diagnostic criteria for OCRD due to another medical condition are presented in Box 7–2. The wording of these criteria is very similar to wording used in analogous “due to another medical condition” diagnoses in other DSM-5 chapters. The criteria also have some similarities to those for substance/medication-induced OCRD. Criterion A emphasizes that obsessions, compulsions, preoccupations with appearance, hoarding, hair pulling, skin picking, other body-focused repetitive behaviors, or other symptoms characteristic of the OCRDs predominate in the clinical picture. Criterion B emphasizes the need for evidence that the presenting symptoms are a direct pathophysiological consequence of a medical condition, based on the history, physical examination, or laboratory findings. Criteria C, D, and E indicate that the disturbance is not better explained by another mental disorder, does not occur exclusively during the course of a delirium, and causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. DSM-5 provides several specifiers: with obsessive-compulsive disorder–like symptoms, with appearance preoccupations, with 187hoarding symptoms, with hair-pulling symptoms, and with skin-picking symptoms.
BOX 7–2. DSM-5 Diagnostic Criteria for Obsessive-Compulsive and Related Disorder Due to Another Medical Condition
A. Obsessions, compulsions, preoccupations with appearance, hoarding, skin picking, hair pulling, other body-focused repetitive behaviors, or other symptoms characteristic of obsessive-compulsive and related disorder predominate in the clinical picture.
B. There is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition.
C. The disturbance is not better explained by another mental disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Specify if:
With obsessive-compulsive disorder–like symptoms: If obsessive-compulsive disorder–like symptoms predominate in the clinical presentation.
With appearance preoccupations: If preoccupation with perceived appearance defects or flaws predominates in the clinical presentation.
With hoarding symptoms: If hoarding predominates in the clinical presentation.
With hair-pulling symptoms: If hair pulling predominates in the clinical presentation.
With skin-picking symptoms: If skin picking predominates in the clinical presentation.
Coding note: Include the name of the other medical condition in the name of the mental disorder (e.g., 294.8 [F06.8] obsessive-compulsive and related disorder due to cerebral infarction). The other medical condition should be coded and listed separately immediately before the obsessive-compulsive and related disorder due to the medical condition (e.g., 438.89 [I69.398] cerebral infarction; 294.8 [F06.8] obsessive-compulsive and related disorder due to cerebral infarction).
In some cases, the cause of the OCRD-like symptoms can be determined with reasonable certainty—for example, when excoriation occurs in response to pruritus caused by eczema. In other cases, however, it may be difficult to determine with certainty whether a medical illness is the cause of OCRD-like symptoms. Guidelines that may assist in determining such an etiological relationship include the presence of a clear temporal association between the 188onset, exacerbation, or remission of the medical condition and the OCRD symptoms; the presence of features that are atypical of a primary OCRD (e.g., atypical age at onset or course); and evidence in the literature that a known physiological mechanism (e.g., striatal damage) causes OCRD symptoms.
Assessment and Treatment
The literature on the prevalence, psychobiology, and treatment of OCRD due to another medical condition is once again fairly sparse. Nevertheless, case reports indicate that obsessions, compulsions, preoccupations with appearance, hoarding, hair pulling, skin picking, or other body-focused repetitive behaviors can occur as a result of a range of medical disorders (Laplane et al. 1989; Mataix-Cols et al. 2010; Stein et al. 2010). These observations are consistent with the known pathophysiology of some OCRDs; for example, a range of neurological conditions may lead to lesions in corticostriatal circuitry and so precipitate obsessive-compulsive symptoms. There are reports of OCD precipitated by cerebral anoxia, with subsequent basal ganglia damage (Laplane et al. 1989). One published report describes a case of body dysmorphic disorder (BDD)–like symptoms associated with onset of subacute sclerosing panencephalitis (Salib 1988). A degenerative disorder, such as neurocognitive disorder associated with frontotemporal lobar degeneration of Alzheimer’s disease, can cause hoarding behavior; in such cases, hoarding disorder should not be diagnosed. Skin excoriation or skin picking may be caused by a dermatological condition, such as scabies, or any medical condition that causes pruritus, and thus excoriation (skin-picking) disorder should not be diagnosed in such instances. Similarly, trichotillomania (hair-pulling disorder) should not be diagnosed if the hair pulling is attributable to a medical condition involving inflammation of the skin, such as seborrheic dermatitis or tinea capitis.
Thus, it is appropriate for clinicians to consider routinely whether a nonpsychiatric medical condition is the cause of OCRD symptoms. When OCRD due to another medical condition is diagnosed, assessment and treatment should target the relevant medical condition. For example, if stroke is thought to be the cause of hoarding symptoms, the standard medical evaluation and management of stroke should follow, including appropriate behavioral interventions to address hoarding symptoms.
A key debate in this literature concerns the question of whether OCRDs can be attributed to group A streptococcal infection. It is well established that Sydenham’s chorea is a neurological manifestation of rheumatic fever, results from infection with group A Streptococcus, and is often accompanied by motor features (e.g., choreas) and psychiatric symptoms (e.g., obsessions, compulsions, tics). Individuals with Sydenham’s chorea who present with such 189symptoms should be diagnosed with an OCRD due to another medical condition (assuming all diagnostic criteria are met). Assessment and treatment should be targeted at the underlying group A streptococcal infection.
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) has been proposed as another postinfection autoimmune disorder characterized by the sudden onset of obsessions, compulsions, or tics, in the absence of chorea, carditis, or arthritis, following infection with group A Streptococcus (Swedo et al. 1998). A range of evidence supports the existence of such an entity, and from a clinical perspective it may be useful to ask patients about the relationship of throat infections to onset of OCD and perhaps also to other OCRD symptoms and to manage relevant group A streptococcal infections when they appear to play a substantial clinical role (Swedo and Grant 2005). Although not all published data are entirely consistent, in selected individuals, and in consultation with infectious disease specialists, such management may include the use of prophylactic antibiotic treatments.
Indeed, there is ongoing controversy as to whether neuropsychiatric symptoms are limited specifically to either OCRD symptoms or group A Streptococcus. Recent work has proposed an expanded clinical entity, pediatric acute-onset neuropsychiatric syndrome (PANS), or idiopathic childhood acute neuropsychiatric symptoms (CANS), with a broad range of neuropsychiatric symptoms (e.g., obsessive-compulsive behaviors, aggressiveness, anxiety, anorexia) that have been suggested to be precipitated by a number of infectious agents and other factors (Singer et al. 2012). The pathogenesis of acute onset of OCD and possibly other OCRDs in children requires additional research; it may involve both constitutional and environmental factors. Although there is an absence of consensus on diagnostic criteria and treatment interventions for PANDAS, PANS, and CANS, clinicians should remain aware of these entities so that appropriate cases may be referred to specialized centers for comprehensive medical assessment and treatment.
Other Specified OCRD
Diagnostic Features
The “other specified OCRD” category is used when symptoms characteristic of an OCRD predominate in the clinical picture and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning but full diagnostic criteria for disorders in the OCRD chapter of DSM-5 are not met (see Box 7–3).
This category applies to presentations in which symptoms characteristic of an obsessive-compulsive and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the obsessive-compulsive and related disorders diagnostic class. The other specified obsessive-compulsive and related disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific obsessive-compulsive and related disorder. This is done by recording “other specified obsessive-compulsive and related disorder” followed by the specific reason (e.g., “body-focused repetitive behavior disorder”).
Examples of presentations that can be specified using the “other specified” designation include the following:
1. Body dysmorphic–like disorder with actual flaws: This is similar to body dysmorphic disorder except that the defects or flaws in physical appearance are clearly observable by others (i.e., they are more noticeable than “slight”). In such cases, the preoccupation with these flaws is clearly excessive and causes significant impairment or distress.
2. Body dysmorphic–like disorder without repetitive behaviors: Presentations that meet body dysmorphic disorder except that the individual has not performed repetitive behaviors or mental acts in response to the appearance concerns.
3. Body-focused repetitive behavior disorder: This is characterized by recurrent body-focused repetitive behaviors (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors. These symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning and are not better explained by trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, stereotypic movement disorder, or nonsuicidal self-injury.
4. Obsessional jealousy: This is characterized by nondelusional preoccupation with a partner’s perceived infidelity. The preoccupations may lead to repetitive behaviors or mental acts in response to the infidelity concerns; they cause clinically significant distress or impairment in social, occupational, or other important areas of functioning; and they are not better explained by another mental disorder such as delusional disorder, jealous type, or paranoid personality disorder.
5. Shubo-kyofu: A variant of taijin kyofusho (see “Glossary of Cultural Concepts of Distress” in the [DSM-5] Appendix) that is similar to body dysmorphic disorder and is characterized by excessive fear of having a bodily deformity.
6. Koro: Related to dhat syndrome (see “Glossary of Cultural Concepts of Distress” in the [DSM-5] Appendix), an episode of sudden and intense anxiety that the penis (or the vulva and nipples in females) will recede into the body, possibly leading to death.
1917. Jikoshu-kyofu: A variant of taijin kyofusho (see “Glossary of Cultural Concepts of Distress” in the [DSM-5] Appendix) characterized by fear of having an offensive body odor (also termed olfactory reference syndrome).
Reprinted from American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA, American Psychiatric Association. Copyright 2013, American Psychiatric Association. Used with permission.
This category allows clinicians to indicate that a clinically significant entity is present and to communicate the specific reason that the presentation does not meet the criteria for any specific DSM-5 OCRD. This is done by recording “other specified OCRD,” followed by the specific reason (e.g., “body dysmorphic–like disorder without repetitive behaviors”).
DSM-5 provides a number of examples of other specified OCRD. However, these examples are not meant to be exhaustive; any clinical presentation that fulfills the guidelines may be diagnosed as other specified OCRD.
Body Dysmorphic-Like Disorder With Actual Flaws
Body dysmorphic–like disorder with actual flaws is similar to BDD except that the defects or flaws in physical appearance are clearly observable by others. BDD, in contrast, is diagnosed when the defects or flaws in appearance are nonexistent or only slight (even though the individual with BDD thinks—inaccurately—that the defects/flaws are clearly observable by others). The appearance flaws of body dysmorphic–like disorder with actual flaws may have any number of causes, such as a medical illness or treatment for an illness (e.g., chemotherapy), surgery, an accident, or a congenital deformity. In some cases the appearance “flaws” may reflect a normal variation of appearance (such as baldness due to aging). As is the case for all types of other specified OCRD, the symptoms must be excessive (the concept of “excessiveness” is inherent to all OCRDs) and must cause clinically significant distress or impairment in psychosocial functioning.
Body Dysmorphic–Like Disorder Without Repetitive Behaviors
Body dysmorphic–like disorder without repetitive behaviors is similar to BDD except that the individual has not performed repetitive behaviors (such as mirror checking, excessive grooming, skin picking, or reassurance seeking) or mental acts (such as comparing) in response to preoccupation with nonexistent or slight appearance defects at any point during the course of the disorder. For the diagnostic criteria for BDD to be met, DSM-5 requires the presence of such repetitive behaviors (Criterion B), whereas DSM-IV did not. Virtually all individuals who meet DSM-5 Criteria A, C, and D for BDD also meet Criterion B, but a very small proportion do not; such individuals should be diagnosed with this form of other specified OCRD.
192Body-Focused Repetitive Behavior Disorder
Body-focused repetitive behavior disorder is characterized by recurrent behaviors (e.g., nail biting, lip biting, cheek chewing, nose picking) and repeated attempts to decrease or stop the behaviors. This disorder is similar to trichotillomania (hair-pulling disorder) and excoriation (skin-picking) disorder in that the symptoms are purely motoric; they are not triggered by a cognition. As with all “other specified” OCRDs, the diagnosis requires that the symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. This criterion helps to ensure that normal habits that are not clinically significant are not diagnosed as a mental disorder. For this diagnosis to be made, the behaviors also must not be better explained by another DSM-5 mental disorder such as trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, or stereotypic movement disorder.
Obsessional Jealousy
Obsessional jealousy is characterized by nondelusional preoccupation with a partner’s perceived infidelity. The preoccupations may lead to repetitive behaviors or mental acts in response to the infidelity concerns, such as repeatedly searching for “evidence” of infidelity, repeatedly checking on the whereabouts of the partner, or seeking reassurance that the infidelity is not occurring. Furthermore, the symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Finally, these preoccupations are not better explained by another mental disorder such as delusional disorder, jealous type or paranoid personality disorder. It is also important to exclude medical factors that may precipitate jealous preoccupations, such as cerebral infarcts or brain tumors (Kuruppuarachchi and Seneviratne 2011).
Shubo-Kyofu
Shubo-kyofu is characterized by excessive fear of having a bodily deformity. It is very similar to BDD. According to the traditional Japanese diagnostic system, shubo-kyofu is considered a subtype of taijin kyofusho, a cultural syndrome characterized by interpersonal fear and avoidance that overlaps with—but is broader than—social anxiety disorder (social phobia). Many presentations of shubo-kyofu are likely the same disorder as BDD, although taijin kyofusho is more prominently characterized by concerns about offending others, whereas BDD typically focuses more on fear of being rejected by others because of the perceived appearance defects.
193Koro
Koro is another culturally bound syndrome, one that occurs primarily in men in epidemics in Southeast Asia. Koro is characterized by an acute fear that the penis (labia, nipples, or breasts in women) is shrinking or retracting and will disappear into the abdomen. This fear is often accompanied by a belief that death will result from these symptoms. Koro has some similarities to BDD but also differs from it in a number of ways: koro involves a fear that disappearance of the penis will result in death; is usually brief in duration; usually occurs, as epidemic, in a particular geographical area; and often responds to reassurance. Concerns that do not involve these characteristics and that instead focus on the appearance of the penis (e.g., its “small” size) may be more appropriately diagnosed as BDD.
Jikoshu-Kyofu
Jikoshu-kyofu is a subtype of taijin kyofusho that denotes fear of emitting a foul or offensive body odor that cannot, however, be detected by others. DSM-5 notes that jikoshu-kyofu is also termed olfactory reference syndrome (ORS). DSM-5 emphasizes the Japanese cultural variant of this syndrome, perhaps because this condition has been better recognized in Japanese psychiatry than in non-Japanese psychiatry. However, ORS has been reported around the world, and nearly as many cases have been reported from Canada and Nigeria as from Japan (Feusner et al. 2010). Other sizable case series are from the United States and Saudi Arabia (Feusner et al. 2010; Phillips and Menard 2011).
The most common concerns focus on emitting bad breath or a sweaty odor, and the most common sources of body odor are the mouth, armpits, genitals, anus, and feet (Phillips and Menard 2011). The false belief that one emits a foul or offensive body odor usually leads to repetitive behaviors or mental acts in response to the odor concerns. The most common behaviors are smelling oneself to check for body odor, excessive showering, excessive clothes changing, seeking reassurance about the perceived body odor, eating unusual diets (e.g., to minimize perceived halitosis or flatulence), and excessive tooth brushing (to decrease perceived halitosis) (Phillips and Menard 2011). The preoccupation must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Furthermore, although not specified by DSM-5, the body odor concerns should not be better explained by another medical condition (e.g., frontal tumors and temporal lobe seizures may be associated with olfactory hallucinations). According to DSM-5, the clinical presentation of individuals with ORS who have absent insight may meet diagnostic criteria for delusional disorder. However, it seems likely that the delusional and nondelusional forms of ORS 194actually constitute the same disorder (although research is needed to determine whether this is actually the case).
Assessment and Treatment
The literature on the prevalence, psychobiology, and treatment of other specified OCRDs varies by the type of other specified OCRD. Body dysmorphic–like disorder with actual flaws can be assessed with some existing measures for BDD (those that focus on preoccupation with appearance flaws as well as resulting distress or impairment in functioning, but do not require that the appearance defect[s] are nonexistent or only slight). However, there is a dearth of treatment literature for this clinical presentation. It is unknown whether SRIs might be useful, although it is reasonable to think that they might be, because SRIs decrease obsessions/preoccupations in both BDD and OCD. CBT approaches for BDD would probably need to be modified, however. Cognitive restructuring and other cognitive techniques, response prevention for rituals if present, and certain other components of CBT for BDD might be useful; however, exposure exercises would probably need to be modified. For example, when designing exposures, the clinician would need to keep in mind that other people might actually take special notice of or mock an individual with clearly observable physical flaws, whereas in BDD this does not actually occur (even though most patients with BDD think it does).
The literature on DSM-IV-defined BDD is applicable to body dysmorphic–like disorder without repetitive behaviors, because this disorder was diagnosed as BDD in DSM-IV. Screening, diagnostic, and symptom severity measures for DSM-IV BDD, as well as treatments that are recommended for BDD (see Chapter 3, “Body Dysmorphic Disorder”), should be used for these patients.
Although the treatment of body-focused repetitive behavior disorder has not been studied, until such evidence becomes available these patients should be approached similarly to those with trichotillomania (hair-pulling disorder) or excoriation (skin-picking) disorder. Clinical experience suggests that such patients may respond to standard behavioral interventions developed for these conditions (i.e., habit reversal training).
There is an accumulating case literature on obsessional jealousy (Agarwal et al. 2008; Parker and Barrett 1997). It is reasonable to use standard OCD symptom severity scales, such as the Yale-Brown Obsessive Compulsive Scale, to assess jealous preoccupations and accompanying repetitive behaviors or mental acts. Anecdotal reports suggest that patients with obsessional jealousy may respond to SRIs or to cognitive-behavioral interventions (Cobb and Marks 1979; Stein et al. 1994). With individuals with no insight (who are convinced that their belief about infidelity is true), it may be useful to begin with an approach that conceptualizes obsessional jealousy as lying on the 195OCRD spectrum, which may be useful in assessing and treating patients. However, clinicians should have a relatively low threshold for replacing or augmenting SRIs with antipsychotic agents, which clinical experience suggests may also be useful for such patients.
Similar considerations may apply to olfactory reference syndrome. Measures that assess ORS are available (www.bodyimageprogram.com). Multiple case reports that focus on treatment have been published, many of which suggest that SRI monotherapy may improve ORS symptoms; others describe response to non-SRI antidepressants, antipsychotics, or a combination of an antidepressant and an antipsychotic (Feusner et al. 2010; Phillips et al. 2006). Our clinical practice is to begin treatment with an SRI, even for patients with delusional beliefs. If response is inadequate after dosages typically used for BDD and OCD are reached, we consider adding an antipsychotic. Indeed, because the majority of individuals with ORS have no insight (i.e., they are completely convinced that they really do smell bad; Phillips and Menard 2011), it would seem reasonable for clinicians to have a low threshold for augmenting SRIs with antipsychotic agents.
There are also anecdotal reports of individuals with ORS responding to cognitive-behavioral interventions, with a focus on exposure and response prevention (Stein et al. 1998). In our clinical experience, because the majority of patients with ORS have delusional beliefs about body odor, motivational interviewing and cognitive approaches are often needed in addition to behavioral interventions. Thus, we suggest a CBT approach that is more similar to that used for BDD than OCD. However, research on the most effective treatment approach for these very ill patients is greatly needed.
A substantial proportion of patients with ORS seek and receive treatment from nonpsychiatric health professionals for their perceived body odor—for example, tonsillectomy, gastrointestinal medication, or electrolysis of the axillae (Phillips and Menard 2011). Available data (while limited), as well as case reports and series, suggest that such treatment is not effective for ORS (Phillips et al. 2006).
Unspecified OCRD
The category of “unspecified OCRD” is similar to the other specified OCRD category except that the clinician chooses not to specify the reason diagnostic criteria for an OCRD are not met—that is, the clinician does not note one of the examples discussed here or another reason. Thus, this diagnosis is used when patients have symptoms characteristic of an OCRD that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, the symptoms do not meet the full diagnostic criteria for any disorder in the DSM-5 chapter on OCRDs, and the clinician 196does not note information about presenting symptoms. Unspecified OCRD includes presentations in which there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).
Key Points
All patients who present with symptoms characteristic of an obsessive-compulsive and related disorder (OCRD) should be evaluated for the presence of substances/medications that may cause or exacerbate these symptoms.
All patients who present with symptoms characteristic of an OCRD should be evaluated for the presence of nonpsychiatric medical conditions that may cause or exacerbate these symptoms.
When an underlying substance/medication or nonpsychiatric medical disorder is found to cause or exacerbate an OCRD-like presentation, an appropriate assessment and management plan, based on clinical judgment, should be put in place.
For body dysmorphic–like disorder without repetitive behaviors, treatments that are used for body dysmorphic disorder should be implemented. However, the treatment literature is relatively sparse for other examples of other specified OCRD. In such cases, the assessment and treatment suggestions in this chapter may be helpful, in combination with clinical judgment and knowledge of the most relevant similar OCRD, when formulating an assessment and treatment plan.
References
Recommended Readings
Ecker W: Non-delusional pathological jealousy as an obsessive-compulsive spectrum disorder: cognitive-behavioural conceptualization and some treatment suggestions. J Obsessive Compuls Relat Disord 1:203–210, 2012
Feusner JD, Phillips KA, Stein DJ: Olfactory reference syndrome: issues for DSM-V. Depress Anxiety 27:592–599, 2010
Phillips KA, Menard W Olfactory reference syndrome: demographic and clinical features of imagined body odor. Gen Hosp Psychiatry 33:398–406, 2011198