with Christopher Pittenger, MD, Katharine A. Phillips, MD, Carolyn Rodriguez, MD, PhD, and Jon Grant, MD

Obsessive-compulsive and related disorders (OCRDs), a relatively new chapter of disorders in both the DSM-5 and the ICD-11, can significantly impair psychosocial functioning and are associated with elevated rates of suicidality. These disorders include:

  • obsessive-compulsive disorder (OCD)
  • body dysmorphic disorder (BDD)
  • hoarding
  • trichotillomania (pulling out body hair)
  • excoriation (skin picking)
  • substance/medication-induced OCRD
  • OCRD due to another medical disorder, other specified, or unspecified

While most people are familiar with OCD, other psychiatric disorders falling under the OCRD classification – while less prevalent – also need to be considered, especially given research and treatment gaps. In addition, despite their genetic relationship to one another and some overlapping treatment elements, OCRD interventions must be tailored to each disorder.

At a recent symposium at the American Psychiatric Association annual meeting, held online May 1-3, 2021, researchers and clinicians with expertise in both pharmacologic and psychosocial approaches for treating OCRDs discussed first-line treatments and what to do when patients do not respond or engage. They addressed the most common obsessive-compulsive and related disorders: OCD, body dysphoric disorder, and hoarding.

Obsessive-Compulsive Disorder (OCD): DSM-5 Definition and Treatment

“Obsessions can be defined as recurrent and persistent thoughts, images, or urges that produce anxiety or distress,” explained Christopher Pittenger, MD, director of the Yale OCD Research Clinic, in his presentation. Everyone has intrusive thoughts at times but patients who develop OCD will try to neutralize them with other, compensatory thoughts or actions. “This creates a feedback loop where the compulsions ritualize and become stronger every time the patient uses them to obtain relief from their fear,” he said.

Understanding OCD Patterns

Obsessions commonly occur in one of three categories:

  • contamination
  • fear of harm
  • lack of symmetry

Compulsions typically correspond to the obsession. For example, patients who obsess over contamination may compulsively wash their hands, while those who fear harm may compulsively check the locks on their front doors. However, having this diagnosis is not just a matter of a person needing to have things lined up or triple-checked – the OCD brain is much more complicated. According to DSM-5, “compulsions are repetitive behaviors that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.”1 Often, these compulsions take 1 hour or more per day and interfere with the individual’s normal and social functioning.

OCD Combination Therapy

When it comes to OCD treatment, notes Dr. Pittenger, clinicians commonly use a combination of psychotherapy and medication. Many patients find cognitive behavioral therapy (CBT) to be helpful, as this style of talk therapy is well-suited to helping patients break the feedback loop between their obsessions and compulsions. Exposure and Ritual Prevention (ERP) is a specialized form of CBT developed for individuals with OCD.

The most commonly prescribed first-line medications include selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, fluvoxamine, sertraline, paroxetine, citalopram, and escitalopram. However, clomipramine, a tricyclic antidepressant (TCA), was the first FDA-approved medication for OCD in 1989 and was found in a meta-analysis to be more effective than sertraline, fluoxetine, and fluvoxamine.2 While clomipramine may be more effective in treating OCD, its tolerability is limited by adverse effects, and its use should be closely monitored.3

If first-line treatments for OCD do not provide adequate relief, Dr. Pittenger recommends a series  of next steps:

If the failure lies with the therapeutic approach, the patient may benefit from augmentation with another therapy approach, increasing the frequency of sessions, or adding medication.

If the failure is pharmacological, Dr. Pittenger recommends increasing the dosage, switching to another SSRI, switching to clomipramine, adding CBT if not already done, or augmenting the existing regimen with the glutamate modulator riluzole.4

Clinical Takeaway for Treating OCD

Trial an SSRI combined with CBT exposure and ritual prevention; for non-responders, augment the therapy or switch the medication.

Body Dysmorphic Disorder (BDD): Treatment Guidelines are Lacking

Katharine A. Phillips, MD, professor of psychiatry at Weill Cornell Medical College in New York City, defined body dysmorphic disorder (BDD) as a preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others yet cause severe distress to the individual. Patients may engage in repetitive behaviors such as mirror checking or skin picking. The disorder affects 2 to3% of the population and can severely impact quality of life. Individuals diagnosed with BDD suffer from significantly higher levels of suicidality than other psychiatric disorders as well.5

SSRI – CBT Combination Approach

Like OCD, first-line treatments for BDD are SSRIs and CBT, preferably both if symptoms are severe. “CBT should focus on psychoeducation, building a model of the patient’s BDD, and setting values goals,” Dr. Phillips told the APA attendees. “Patients may also benefit from ritual prevention, exposure therapy, and perceptual retraining.”

Most patients will seek some kind of cosmetic treatment, such as plastic surgery; however, these treatments should be discouraged as they are almost never effective and can worsen symptoms. If first-line treatments for BDD are ineffective, Dr. Phillips recommends checking medication adherence, increasing the prescribed dose, or augmenting with another medication.

In severe cases, Dr. Phillip’s research has shown that higher SSRI doses and longer-term treatment may provide the most effective relief.1,6 Augmenting with a low dose of an antipsychotic (eg, lurasidone, aripiprazole) or antianxiety agent (buspirone) may also be effective, especially in patients with severe depression, suicidality, aggression, or agitation, she noted.

Dr. Phillips further emphasizes the need for more research into BDD treatments, as many of her suggestions derive from her clinical experience rather than established treatment guidelines.

Clinical Takeaway for Treating BDD

Trial an SSRI combined with CBT psychoeducation; for non-responders, consider medication adherence or increase/augment medication.

Hoarding Disorder: Connections to ADHD, Treatment Challenges

Carolyn Rodriguez, MD, PhD, director of the Stanford Hoarding Disorders Research Program, defined “hoarding disorder” as persistent difficulty parting with possessions, leading to an accumulation of clutter and a significant amount of distress and impairment. Those who suffer from hoarding disorder are not to be confused with collectors, who typically show pride in their possessions, keep them organized, and only collect one type of item.

Hoarding disorder affects approximately 2 to 6% of the US and European population, according to Dr. Rodriguez. She pointed to several twin studies that found a 50% heritability. In addition, she noted that hoarding can be connected to information processing disorders, including ADHD; these individuals are at a higher risk of developing hoarding disorder.7

CBT & Medication May Break Hoarding Patterns

Like other OCRDs, hoarding disorder is commonly treated with a combination of medication and cognitive behavioral therapy. There are no FDA medications specifically indicated to treat hoarding disorder, however, several studies have found paroxetine, an SSRI, to be effective in 24 to 31% of individuals with hoarding disorder,8 while venlafaxine, a selective norepinephrine reuptake inhibitor (SNRI), has shown to be effective in 32%.9 Stimulants such as atomoxetine and methylphenidate were found to be effective in 25 to 40% of subjects diagnosed with hoarding disorder.10

CBT can help individuals with hoarding disorder break the learned pattern of collecting, saving, and storing items5 while motivational interviewing may help them develop clearer motivations for discarding and not excessively acquiring possessions.

If these treatments are ineffective, Dr. Rodriguez recommends bringing in a professional organizer, cleaning and removal service, or even a court-appointed guardian. It is crucial that interventions preserve the person’s autonomy, however, as forced removal of belongings can lead to suicidal behaviors.

It is worth noting that hoarding disorder can be especially challenging to treat, noted Dr. Rodriguez. People with hoarding disorder will often continue experiencing impairing symptoms even after treatment. They also tend to underutilize treatments and services available to them. A better understanding of what causes attachments to belongings is needed to improve the quality of treatment for this OCRD disorder.

Clinical Takeaway for Treating Hoarding

Trial paroxetine, venlafaxine, or a stimulant, combined with CBT. Be prepared for lack of treatment adherence and/or relapse.

Trichotillomania and Excoriation: The Often-Hidden OCRD Disorders

“Trichotillomania and excoriation, often abbreviated as ‘trich and pick,’ are typically studied together and are characterized by recurrent hair or skin picking that causes significant distress or impairment and cannot be attributed to another disorder,” Jon Grant, MD, professor of psychiatry and behavioral neuroscience at the University of Chicago, told the APA attendees. These OCRD psychiatric disorders are correlated with low self-esteem and increased social anxiety.

OCRD and Job Advancement

Dr. Grant reported that many of his patients fail to pursue job advancement because of their condition. Given the perceived embarrassing nature of these conditions, it is difficult to collect accurate statistics, but approximately 1.7 to 3.1% of the population is estimated to live with trichotillomania or excoriation, he noted. The current vs. lifetime rates suggest that the disorders rarely resolve on their own without treatment. There is no difference in prevalence between men and women with these OCRD disorders but in Dr. Grant’s experience, women tend to seek treatment more often because societal beauty standards make the disorder more disfiguring to women than men.

About 5 to 10% of trichotillomania patients also suffer from trichophagia, meaning they ingest their hair after picking it. This act can lead to life-threatening intestinal blockages. For that reason, Dr. Grant recommends screening patients with trichotillomania for trichophagia even if they tend to find the interaction especially embarrassing.

Antipsychotics, Opioids, and Cannabis for Trichotillomania, Excoriation

Much like the other OCRD conditions described herein, Dr. Grant emphasizes the lack of available research on treatment for trichotillomania and excoriation. In his experience, some types of CBT that focus on habit reversal can help, as can modifying the individual’s environment to reduce triggers.

SSRIs are not typically helpful for treating trichotillomania and excoriation, although low doses of clomipramine may be effective. Olanzapine has shown some effectiveness, however, the side effects are often reported as intolerable, noted Dr. Grant. Naltrexone, an opioid antagonist, may also be effective.

Dr. Grant reported knowledge of a study in progress on cannabinoids that has shown promise for these OCRD conditions, and he expects data to be available shortly. Unfortunately, there is very little information on next-line treatments as first-line treatments are still in development.

Clinical Takeaway for Treating Trichotillomania, Excoriation

Trial CBT focused on habit reversal; consider clomipramine, olanzapine, or naltrexone after weighing risks and benefits to the individual patient.


Last Updated: May 25, 2021