Learning Objectives
- Describe how obsessive compulsive disorder presents.
- Describe how body dysmorphic disorder presents.
- Describe how hoarding disorder presents.
Obsessive-Compulsive Disorder
Obsessive-compulsive disorder, more commonly known as OCD, requires the presence of obsessions, compulsions, or both. Obsessions are defined as repetitive and persistent thoughts, urges, or images. These obsessions are intrusive, time-consuming (i.e., take more than an hour a day), and unwanted, often causing significant distress or impairment in an individual’s daily functioning. Common obsessions are contamination (dirt on self or objects), errors of uncertainty regarding daily behaviors (locking the door, turning off appliances), thoughts of physical harm or violence, and orderliness, to name a few (Cisler, Adams, et al., 2011; Yadin & Foa, 2009). Often the individual will try to ignore these thoughts, urges, or images. When they are unable to ignore them, the individual will engage in compulsory behaviors to gain temporary relief from the distress or anxiety.
Compulsions are time-consuming, repetitive behaviors or mental acts that an individual performs in response to an obsession. Common examples of compulsions are checking (e.g., repeatedly checking if the stove is turned off even though the first four-times they checked it was), counting (e.g., flicking the lights off and on exactly five times), hand washing, symmetry, fears of harm to self or others, or repeating specific words (APA, 2022). These compulsive behaviors essentially alleviate the anxiety associated with the obsessive thoughts. For example, an individual may feel as though their hands are dirty after using utensils at a restaurant. They may obsess over this thought for some time, impacting their ability to interact with others or complete a specific task. This obsession will ultimately lead to the individual performing a compulsion where they will wash their hands with extremely hot water to rid all the germs, or even wash their hands a specified number of times if they also have a counting compulsion. At this point, the individual’s anxiety should be temporarily relieved.
These obsessions and compulsions are more excessive than the typical “cleanliness” as they consume a large part of the individual’s day. Additionally, they cause significant impairment in one’s daily functioning. Given the example above, an individual with a fear of contamination may refuse to eat at restaurants, or they may bring their utensils from home. The frequency and severity of the obsessions and compulsions varies by patient, with some having mild to moderate symptoms and only spending 1-3 hours a day obsessing or engaging in compulsive behaviors, while other patients present with severe symptoms and have nearly constant intrusive thoughts or compulsions that can become incapacitating (APA, 2022).
Body Dysmorphic Disorder
Body dysmorphic disorder is another obsessive disorder; however, the focus of the obsessions is with perceived defects or flaws in one’s physical appearance. A key feature of these obsessions is that they are not observable or appear slight to others. An individual who has a congenital facial defect or a burn victim who is concerned about their scars are not examples of an individual with body dysmorphic disorder. The obsessions related to one’s appearance can run the spectrum from feeling “unattractive” to “looking hideous.” While any part of the body can be a concern for an individual with body dysmorphic disorder, the most commonly reported areas are skin (acne, wrinkles, skin color), hair (particularly thinning or excessive body hair), and nose (size or shape; APA, 2022). Interestingly, the disorder can occur by proxy meaning the individual is not concerned with their own defects but those of another person, often a spouse or partner but at times, a parent, child, sibling, or stranger.
Due to the distressing nature of the obsessions regarding one’s body, individuals with body dysmorphic disorder also engage in compulsive behaviors that take up a considerable amount of time in their day. For example, they may repeatedly compare their body to other people’s bodies in the general public; frequently look at themselves in the mirror; engage in excessive grooming, which includes using make-up to modify their appearance. Some individuals with body dysmorphic disorder will go as far as having numerous plastic surgeries in attempts to obtain their “perfect” appearance.
While most of us are guilty of engaging in some of these behaviors, to meet criteria for body dysmorphic disorder, one must spend a considerable amount of time preoccupied with their appearance (i.e., on average 3-8 hours a day), as well as display significant impairment in social, occupational, or other areas of functioning. Some individuals excessively tan, change their clothes repeatedly, or compulsively shop such as for beauty products. Camouflaging perceived defects is a common behavior and could involve applying makeup, adjusting a hat or one’s clothes, or covering the forehead or eyes with one’s hair, all to hide or cover the perceived defect or problem area (APA, 2022).
As the DSM-5-TR notes, body dysmorphic disorder has been associated with, “abnormalities in emotion recognition, attention, and executive function, as well as information-processing biases and inaccuracies in interpretation of information and social situations” (APA, 2022, pg. 273). These individuals tend to express a bias for negative and threatening interpretations of facial expressions and situations that would be classified as ambiguous, for instance.
9.1.2.1. Muscle dysmorphia. While muscle dysmorphia is not a formal diagnosis, it is a common type of BDD, particularly within the male population. Muscle dysmorphia refers to the belief that one’s body is too small or lacks the appropriate amount of muscle definition (Ahmed, Cook, Genen & Schwartz, 2014). While the severity of BDD between individuals with and without muscle dysmorphia appears to be the same, some studies have found higher use of substance abuse (i.e., steroid use), poorer quality of life, and increased reports of suicide attempts in those with muscle dysmorphia (Pope, Pope, Menard, Fay Olivardia, & Philips, 2005). The DSM-5-TR instructs clinicians to specify if body dysmorphic disorder occurs with muscle dysmorphia.
9.1.2.2. Insight specifiers. Those diagnosed with body dysmorphic disorder vary in the degree of insight they have about the accuracy of their body dysmorphic disorder beliefs, ranging from good to absent/delusional. On average, insight is poor and at least one-third of those diagnosed with the disorder display absent/delusional insight. Mental health professionals would indicate the degree of insight regarding body dysmorphic disorder beliefs using with good or fair insight, with poor insight, or with absent insight/delusional beliefs. See page 272 of the DSM-5-TR for more information. Note that the insight specifier is used with OCD and hoarding disorders as well.
Hoarding Disorder
In hoarding disorder, the key feature is the persistent over-accumulation of possessions (APA, 2022). While we all obtain items throughout life, individuals with hoarding disorder continue to accumulate items without discarding possessions, regardless of their value or sentiment. This lack of discarding occurs over a long period and is not explained by a recent significant stressor (e.g., lost house in fire, so now keeps everything). For example, last week’s newspaper would likely have no relevance to you or possibly any historical value, but those with hoarding disorder would keep this newspaper despite the lack of value or sentiment.
The most commonly hoarded items are newspapers, magazines, clothes, bags, books, mail, and paperwork (APA, 2022). While these items may be stored in attics and garages, individuals with a hoarding disorder also have these items cluttering their living space, sometimes to the extent that they are unable to utilize their furniture because it is covered in stuff. Cognitive factors contributing to the need to hold onto these non-sentimental items are fear of losing valuable information and fear of being wasteful. When asked to “clean out” their house or get rid of these items, individuals with hoarding disorder experience significant distress. Individuals with hoarding disorder display indecisiveness, avoidance, procrastination, perfectionism, difficulty planning and organizing tasks, and are easily distractible.
One’s hoarding behaviors also impacts their daily functioning and causes impairment in social and occupational functioning. It can lead to low quality of life and in extreme cases, place the individual at risk for figure, falling, poor sanitation, and other health risks. Family relationships are often strained and conflict with neighbors and local authorities is common (APA, 2022).
Key Takeaways
You should have learned the following in this section:
- As part of OCD, obsessions are repetitive and persistent thoughts, urges, or images while compulsions are repetitive behaviors or mental acts that an individual performs in response to an obsession.
- Body dysmorphic disorder is characterized by obsessions over perceived defects or flaws in one’s physical appearance.
- Muscle dysmorphia refers to the belief that one’s body is too small or lacks the appropriate amount of muscle definition and is a type of body dysmorphic disorder common to men.
- Hoarding disorder is characterized by accumulating items without discarding possessions, regardless of their value or sentiment.
Review Questions
- Define obsessions and compulsions. Provide a list of examples of each thought/behavior.
- What is body dysmorphic disorder? Give examples of characteristics that would not be consistent with a body dysmorphic disorder diagnosis.
- Many of us save items throughout our lifetime that remind us of specific events. How is this different from hoarding?
