Until relatively recently, obsessive-compulsive disorder (OCD) was classified as an anxiety disorder. However, as we have learned more about OCD and other related disorders like hoarding disorder, trichotillomania (hair pulling), and excoriation disorder (skin picking), experts have realized that it deserves its own category.
As a result, the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) published in 2013 moved OCD out from under the anxiety umbrella and gave it its own category: “Obsessive-compulsive and related disorders.”
This new classification is a major step in spreading awareness and improving education about these highly misunderstood mental health conditions. We spoke with Dr. Nicholas Farrell, licensed clinical psychologist and Regional Clinical Director at NOCD, to better understand the similarities between OCD and its related disorders, and how this new classification better allows us to address and treat the people who have them.
An important note here: while some use the term “OCD spectrum disorders,” the category is actually titled “obsessive-compulsive and related disorders.” While “spectrum” is generally used to talk about this group, it’s important to recognize that these are individual conditions that, while certainly related, are distinct from one another.
What makes a condition related to OCD?
OCD is a condition that is defined by the presence of obsessions, compulsions, or both.
- Obsessions are repetitive and intrusive thoughts, images, urges, or feelings. These thoughts are often distressing and can cause significant distress and anxiety.
- Compulsions are physical or mental behaviors that people with OCD may perform in an attempt to temporarily relieve the distress and anxiety that their obsessions can bring. Some compulsions are done ritualistically and repetitively as a way to prevent something bad from happening based on their intrusive fears.
Obsessions and compulsions related to OCD can cause significant distress or impairment to the lives of people struggling with this disorder. People with OCD often recognize that their obsessions don’t line up with their values, intentions, usual way of thinking, or even reality, bringing intense doubt and/or anxiety. Compulsions are also often repetitive and can significantly impact people’s quality of life; for example, someone may compulsively avoid certain situations or carry out time-consuming, disruptive rituals in an attempt to ease their anxiety.
Because OCD can be so debilitating, it’s important to understand how it works to help people find hope. This is why it is so significant that OCD now has its own category in the DSM-5. While anxiety is certainly a significant aspect in OCD, classifying it as an anxiety disorder doesn’t necessarily capture the obsessive and repetitive nuances and idiosyncrasies of this condition. Categorizing OCD and its related disorders in its own separate category allows us to better understand the nature of these conditions and how they can be best addressed with treatment.
So what is the common thread between OCD and its related disorders trichotillomania (hair pulling), excoriation disorder (skin picking), hoarding disorder, and body dysmorphic disorder?
One of the biggest reasons that OCD and its related disorders were placed in their own category is because they seem to share a similar neurocircuitry, Dr. Farrell explains. When examining brain scans, neuroscientists found that similar parts of the brain were activated among patients with OCD and its related disorders, indicating similarities between the ways these conditions affect the brain.
In addition to shared neurobiology, there are also conceptual similarities between OCD and its related conditions.
Dr. Farrell explains that in each of these related disorders, “there’s a highly repetitive nature to the behavior, a strong sense of feeling compelled to engage in the behavior, and the relief usually from some unwanted or emotional state that is achieved via engagement in the behavior.” They all share an element of unhelpful, seemingly uncontrollable thought processes and compulsive, repetitive behaviors that can negatively affect one’s quality of life when left untreated.
Take hoarding disorder, for example. Many people with hoarding disorder tend to overestimate the likelihood that something bad will happen if they throw away an object that they own, even if it seemingly has little value on its own. This can be compared to patients with OCD, who often fear that something bad may happen if they don’t engage in their ritualistic compulsions.
Someone with hoarding disorder may also be concerned that they can’t tolerate the emotional impact of throwing away something that holds a lot of sentimental value to them, even if that sense of value isn’t shared by other people. The struggle to handle those emotional impacts can be similar to how someone with OCD might feel as though they can’t tolerate the distress that comes from their obsessions without engaging in their compulsive behaviors to feel better.
Similar comparisons can also be made between OCD and body-focused repetitive behaviors like trichotillomania and excoriation disorder. People who deal with trichotillomania and skin-picking disorder repetitively pick at their hair or their skin, often in response to tension or stress. Though these acts are voluntary, they’re often preceded by a feeling of physical tension called a premonitory urge that’s hard to resist—some people report that it feels similar to how we feel before we sneeze.
Finally, body dysmorphic disorder also has similar symptoms of obsessive thoughts and compulsions—though in this case, they are all related to one’s own body. People with body dysmorphic disorder will often have obsessive and persistent thoughts about flaws that they perceive in their own body, and engage in compulsive behaviors like avoidance and seeking reassurance from their friends and family.
What is included among “OCD and related disorders”?
In addition to OCD itself, the category of ‘OCD and related disorders” in the DSM-5 also includes trichotillomania (hair pulling), excoriation disorder (skin picking), hoarding disorder, and body dysmorphic disorder.
Trichotillomania
Trichotillomania is also sometimes referred to as “hair-pulling disorder.” People with trichotillomania experience a recurring urge to pull at their hair, which can lead to significant hair loss. Trichotillomania is considered a body-focused repetitive disorder (BFRB). The urge to pull hair is often linked to stress or boredom, and people with trichotillomania often report feeling a physical urge that is relieved when they finally pull.
Excoriation disorder
Excoriation disorder, casually known as skin-picking or more scientifically as dermatillomania, is another body-focused repetitive disorder, this time involving repetitive picking and pulling of the skin. People with skin picking disorder may repeatedly pick at their skin despite repeated attempts to stop the habit, and it can cause significant skin damage as well as significant distress and negative impacts on one’s quality of life.
Hoarding disorder
Hoarding disorder is a mental health condition in which people accumulate large amounts of material possessions and have a hard time getting rid of them. People with hoarding disorder will often feel as though they need to save these items in case they need them for the future, and they will also often like to acquire items with seemingly little or no worth in the chance that they’ll need them later, or due to a strong emotional attachment to them. This can lead to extreme amounts of clutter in their home that can ultimately impact the health, wellness, and safety of everyone who lives there.
Body dysmorphic disorder
Body dysmorphic disorder is a mental health condition that is defined by a preoccupation with one’s perceived physical flaws that are not apparent to others. People with body dysmorphic disorder will often obsess over these “flaws,” sometimes performing repetitive behaviors like grooming, reassurance seeking, mirror checking, or comparing their appearance to others. They will often hide themselves by “camouflaging” these so-called flaws or just stop going out in public whatsoever.
Are all OCD-related disorders treated the same?
No—just as each of these disorders is unique, the treatment for OCD and its related disorders will change based on the condition itself. However, treatments for each kind of OCD-related disorder do share some common ground.
“The most evidence-based treatments for obsessive-compulsive spectrum disorders are all behavioral in nature,” explains Dr. Farrell. For each of these related disorders, therapists generally prefer to use a form of treatment within the category of cognitive behavioral therapy (CBT).
Cognitive-behavioral therapies (CBT) are structured forms of psychotherapy that are used to change unhelpful behaviors and thoughts. In these kinds of treatments, therapists place an emphasis on changing behaviors and helping patients address the causes of their distress rather than avoiding them or participating in unhelpful behaviors that can reinforce unhealthy thought processes.
The goals of CBT are generally to help patients become more aware of their unhelpful and/or negative thought processes so that they can deal with those thoughts in a more effective and healthy way, leading to more positive feelings and helpful behaviors. This makes CBT especially useful for people dealing with ongoing mental health conditions like OCD and its related disorders.
With that said, there are also many different kinds of CBT, and each condition is best addressed by a specific kind. In other words, the CBT approach that is used for OCD looks different than the ones used for body dysmorphic disorder, as well as those used for hoarding disorder, and so on.
- ERP is the best treatment for OCD. Exposure and response prevention (ERP) is considered the “gold standard” for OCD treatment. In ERP, a trained therapist works with someone with OCD to face their biggest triggers in a safe, gradual, and intentional way. They then help therapy members learn to sit with that anxiety and distress rather than engaging in compulsive behaviors, which only temporarily alleviate distress, and actually reinforce anxiety and fear.
- HRT or ComB are used to treat BFRBs like trichotillomania and skin picking disorder. Habit reversal training (HRT) is a form of CBT that involves tracking the triggers and feelings that cause people to engage in their repetitive body grooming behaviors. Under the guidance of a therapist, patients then learn to engage in alternative healthier responses to replace the damaging behavior. In cases like trichotillomania and skin picking disorder, this means that patients can learn to satisfy their premonitory urge without damaging their skin or hair. Comprehensive Behavioral (ComB) treatment, on the other hand, is a multi-faceted approach to BFRBs that combines various therapeutic techniques, including HRT, to address the root causes of BFRBs and implement behavioral interventions.
- CBT or cognitive rehabilitation are used to treat hoarding disorder. In patients with hoarding disorder, CBT is used to help them change their relationship with their material possessions, reduce the anxiety they may feel when discarding those items, and ultimately improve their quality of life. Additionally, some people with hoarding disorder may find that cognitive rehabilitation therapies are helpful. This kind of treatment involves addressing their thought patterns and decision-making skills to better manage their relationship with their items.
- ERP or CBT are used for body dysmorphic disorder. ERP is also frequently involved in treatment for BDD, but it is not typically the only form of therapy that is used. People with BDD generally respond well to a varied range of CBT modalities and techniques: ERP, cognitive restructuring, and perceptual training techniques are often used in BDD treatment, and may be supplemented with medication. When people also have a co-occurring Eating Disorder, Family-Based Treatment may also be used.
In addition to CBT, people struggling with these conditions can also benefit from medication to help them better deal with their condition. Serotonergic classes of medicines, like SSRIs (selective serotonin reuptake inhibitors) and SNRIs (serotonin-norepinephrine reuptake inhibitors), are most commonly used across the board for OCD and other OCD-related disorders. These medications work by acting on the neurotransmitters in your brain that carry signals between your brain cells, often relieving symptoms to a degree that actually makes therapeutic approaches like ERP more effective for some people.
Where to seek help for OCD spectrum disorders
Grouping OCD with related disorders like BFRBs, hoarding disorder, and body dysmorphic disorder rather than anxiety disorders was an enormous step in helping patients and providers understand the unique nuances of these conditions, allowing people to gain holistic, evidence-based care for their mental health struggles.
If you are dealing with OCD or a related disorder and are looking for answers, know that you are not alone. There is help and hope out there, and it starts with evidence-based treatment. NOCD’s clinical team includes therapists who are specially trained in ERP to help patients with OCD and many related disorders.
NOCD therapists also treat OCD-related conditions including hoarding disorder and body-focused repetitive disorders like trichotillomania and excoriation disorder. If you are interested in learning how NOCD can help you, I encourage you to read more about NOCD’s holistic and accessible approach to helping people with OCD and related disorders live life on their own terms.