No full-text available
To read the full-text of this research,
you can request a copy directly from the authors.
Symptom Profiles in Pediatric Obsessive Compulsive Disorder (OCD): The Effects of Comorbid Grooming Conditions
Abstract
This study sought to examine possible differences in phenomenological features and/or symptom severity of children diagnosed with obsessive-compulsive disorder (OCD) and a comorbid grooming condition (i.e., skin picking and trichotillomania). A total of 202 children receiving a primary diagnosis of OCD were classified into two distinct groups: (1) OCD alone (n=154) and (2) OCD plus a comorbid grooming condition (OCD+grooming; n=48). Analyses revealed that those children presenting with a comorbid grooming condition demonstrated different symptom profiles than those with OCD alone. In addition, parents of these children were more likely to report the presence of tactile/sensory sensitivity than those in the OCD alone group. However, no differences were found with respect to symptom severity via self-report (e.g., OCI) or semi-structured interview (e.g., CY-BOCS). Possible clinical and treatment implications, future areas of research, and limitations to the present study are discussed.
... In contrast, OCD cases had higher scores than the HC but not the OPD cases on the CBCL Externalizing Problems, Attention-Deficit/Hyperactivity Problems, Oppositional Defiant Problems, and Conduct Problems scales. Consistent with previous studies of comorbidity in pediatric OCD, OCD cases had a higher prevalence than the OPD cases of anxiety disorders, tic disorders, and trichotillomania [48,49]. In assessing the sensitivity and specificity of the OCI-CV with a ROC analysis to predict current OCD among all participants, the optimal cut-score was 11 with an AUC of 0.88. ...
... Although the original study of the OCI-R identified an optimal cut-score of 21 for discriminating between OCD cases and non-anxious controls, subsequent studies have recommended cut-scores ranging between 14 to 36 for various populations [52]. Although our results indicate that the OCI-CV is an effective instrument for discriminating between OCD cases and HC and between OCD cases and OPC cases, additional interviews and measures are necessary for screening youth for OCD in a clinical setting laden with other severe psychiatric disorders, including ASD, ADHD, anxiety disorders, depressive disorders, tic disorders, hoarding disorder, and psychotic disorders [1,6,7,27,28,[48][49][50][51][52]. ...
The study assessed the ability of the Obsessive-Compulsive Inventory-Child Version (OCI-CV) to detect pediatric obsessive-compulsive disorder (OCD) using receiver operating characteristic analyses. The sample consisted of 114 cases with current OCD, 340 cases with other psychiatric disorders (OPD), and 301 healthy controls (HC) ages 7 to 18 years. All 755 participants were assessed with two semi-structured interviews and seven rating scales. In a comparison of current OCD cases and all other participants, the optimal OCI-CV cut-score was 11 with an area under the curve (AUC) of .88. In a comparison of current OCD cases and OPD cases, the optimal OCI-CV cut-score was 11 with an AUC of .82. In a comparison of current OCD cases and HC, the optimal OCI-CV cut-score was 10 with an AUC of .94. The results indicate that the OCI-CV provides an effective screen for pediatric OCD using empirically derived cut-scores.
... This paper indicates that pathologic grooming behaviors are transmitted in families of patients with OCD and can be considered part of a familial OCD spectrum [24]. In a sample of pediatric patients with OCD, Flessner et al [25] observed high comorbidity with grooming behaviors, with distinct characteristics, and suggested that the identification of this patient subgroup calls for specific changes in treatment manuals. Knowledge of this putative specific OCD subgroup could guide future OCD treatment practices, such as including habit reversal techniques in cognitive-behavioral therapy, as well as encouraging researchers to evaluate specific pharmacologic agents (such as modulators of the dopaminergic system) in clinical trials [26,27]. ...
... Fontenelle et al found that the prevalence of PSP and trichotillomania was 13.3% and 6.6%, respectively [21], whereas Matsunaga et al found that 12% of their patients exhibited self-injurious behaviors (including PSP) and 5% had trichotillomania [22]. In another study, Flessner et al [25] studied a sample of pediatric patients with OCD and found that 21.3% also had GDs (15.9% with PSP and 5.3% with trichotillomania). Our results differ from those of a study conducted by Grant et al [23], who identified ICDs in only 11% of their sample, 7.8% with PSP, and 1% with trichotillomania. ...
The objective of this study was to compare patients with obsessive-compulsive disorder (OCD) associated with pathologic skin picking (PSP) and/or trichotillomania, and patients with OCD without such comorbidities, for demographic and clinical characteristics. We assessed 901 individuals with a primary diagnosis of OCD, using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) Axis I disorders. Diagnoses of PSP and trichotillomania were made in 16.3% and 4.9% of the sample, respectively. After the logistic regression analysis, the following factors retained an association with OCD-PSP/trichotillomania: younger (odds ratio [OR] = 0.979; P = .047), younger at the onset of compulsive symptoms (OR = 0.941; P = .007), woman (OR = 2.538; P < .001), with a higher level of education (OR = 1.055; P = .025), and with comorbid body dysmorphic disorder (OR = 2.363; P = .004). These findings support the idea that OCD accompanied by PSP/trichotillomania characterizes a specific subgroup.
... In addition, it appears that comorbid tic disorders and grooming disorders (ie, trichotillomania, excoriation), which commonly co-occur with OCD, increase the likelihood of experiencing sensory phenomena. 2,44,46 This finding indicates that OCD, tic disorders, and grooming disorders may share overlapping neural substrates that potentially underlie abnormalities in sensation. ...
Objective: Childhood anxiety and obsessive-compulsive disorder (OCD) are defined by fear, worry, and uncertainty, but there is also evidence that affected children possess exteroceptive sensory abnormalities. These sensory features may often instigate symptoms and cause significant distress and functional impairment. In addition, a purported class of conditions known as "sensory processing disorders" may significantly overlap with childhood anxiety and OCD, which provides further support for a connection between abnormal sensation and fear-based psychopathology. Method: The current review was conducted to synthesize and to critically evaluate the existing research on exteroceptive sensory abnormalities in childhood anxiety and OCD. Because of the paucity of research in this area, studies with adult populations were also briefly reviewed. Results: The review found significant support for the notion that sensory abnormalities are common in children with anxiety disorders and OCD, but there are significant limitations to research in this area that prevent firm conclusions. Conclusion: Potential avenues for future research on sensory features of pediatric anxiety and OCD are discussed.
... In addition, it appears that comorbid tic disorders and grooming disorders (ie, trichotillomania, excoriation), which commonly co-occur with OCD, increase the likelihood of experiencing sensory phenomena. 2,44,46 This finding indicates that OCD, tic disorders, and grooming disorders may share overlapping neural substrates that potentially underlie abnormalities in sensation. ...
Objective:
Childhood anxiety and obsessive-compulsive disorder (OCD) are defined by fear, worry, and uncertainty, but there is also evidence that affected children possess exteroceptive sensory abnormalities. These sensory features may often instigate symptoms and cause significant distress and functional impairment. In addition, a purported class of conditions known as "sensory processing disorders" may significantly overlap with childhood anxiety and OCD, which provides further support for a connection between abnormal sensation and fear-based psychopathology.
Method:
The current review was conducted to synthesize and to critically evaluate the existing research on exteroceptive sensory abnormalities in childhood anxiety and OCD. Because of the paucity of research in this area, studies with adult populations were also briefly reviewed.
Results:
The review found significant support for the notion that sensory abnormalities are common in children with anxiety disorders and OCD, but there are significant limitations to research in this area that prevent firm conclusions.
Conclusion:
Potential avenues for future research on sensory features of pediatric anxiety and OCD are discussed.
... The existing literature also suggests that comorbid OCRDs impact the clinical presentation and functioning of individuals with OCD. Flessner et al 18 reported high comorbidity in a pediatric OCD sample with grooming behaviors and suggested that this subgroup may require modified treatment. Although empirical study is needed, more sessions of exposure response prevention and possibly additional treatment targeting the comorbid disorder (eg, also using habit reversal for body-focused repetitive behaviors [BFRBs]) may be required. ...
Background:
Trichotillomania (TTM), obsessive-compulsive disorder (OCD), and skin-picking disorder (SPD) frequently occur together and share overlapping phenomenology, pathophysiology, and possible genetic underpinnings. This study sought to identify factors that predict OCD and SPD in hair pullers.
Methods:
Five hundred fifty-five adult female hair pullers were recruited from specialty clinics and assessed using standardized, semi-structured interviews and self-reports. Clinical predictors and multivariate models were evaluated using logistic regression modeling.
Results:
Hair pullers met criteria for OCD (18.9%), SPD (19.5%), or chronic skin picking (CSP) (5%), or both comorbid diagnoses, respectively. In the final multivariate model for OCD, family history of OCD and an eating disorder diagnosis were associated with an increased risk of OCD in TTM. A nail-biting diagnosis was associated with a decreased risk of OCD in TTM. In the final multivariate model for SPD/CSP, only family history of OCD was associated with an increased risk of SPD/CSP in TTM.
Conclusions:
Identification of factors predicting OCD and SPD in TTM provides evidence for the relatedness of these disorders and supports their collective classification as obsessive-compulsive and related disorders (OCRDs) in DSM-5. The findings of this study further underscore the importance of assessing for comorbid OCRDs and family histories of OCRDs in clinical practice.
... Much of the current excoriation disorder research has been based on previous research conducted on trichotillomania. Excoriation disorder and trichotillomania are body-focused repetitive behaviors (BFRB) under the same DSM-5 classification, and the etiologies behind both disorders might be similar (Flessner, Berman, Garcia, Freeman, & Leonard, 2009). Most theorists suggest that excoriation disorder is rooted in both biological and psychological factors (Grant et al., 2012). ...
... Buna karşılık OKB'li hastaların %1.4-9 arasında değişen oranlarda trikotillomani tanı ölçütlerini karşıladığı bildirilmiştir (12). Obsesif kompulsif bozukluğu olan 202 çocuktan 48'inin (%28) ebeveynlerinde trikotillomani, deri yolma gibi bozukluklar olduğu bildirilmiştir (13). Hana (1997), trikotillomanili çocukların %45'inde eşik altı OKB semptomlarının bulunduğunu bildirmiştir (14). ...
Trichotillomania is defined as significant hair loss due to individuals' repetitive self-pulling of hair. It is a chronic disorder that leads to significant distress and functional impairment and is often difficult to treat. Although it has been recognized for a long time, it has attracted less attention from scholars compared to other psychiatric disorders. Despite the fact that it is classified as an impulse control disorder, there is still a debate on how it should be classified. Research regarding etiology and treatment of trichotillomania has increased over last twenty years. It has been mentioned that its etiology is based on evolutional, genetic, neurophysiological and neurocognitive factors. Although robust evidence is not available, drugs such as clomipramine and selective serotonin reuptake inhibitors (SSRIs) or cognitive behavioral therapy are promising treatments. Habit Reversal Training (HRT), as a cognitive behavioural technique, has the highest rate of success in treating trichotillomania. However, not revealing the the habit of pulling hair or not coming forward to seek help due to embarrassment is an obstacle to running large scale controlled experiments. A series of multicentered, coordinated large scale studies are needed to explore the etiology of the disorder, reach an agreement on its classification and defining the best approach and algorithms for the treatment. In this review it is aimed to summarise the latest research and progress in etiology, classification and treatment of trichotillomania.
... In other work, prominent hoarding in childhood was the only symptom dimension linked to OCD persistence in adulthood [8]. However, although rates of hoarding in our study were similar to rates of hoarding reported in other pediatric OCD samples [27,28], no participants (or parents) identified hoarding as their principal symptom. This finding is consistent with studies of hoarding that report a very gradual course of symptoms [29]that peaks in middle to late-adulthood [30]. ...
Objective:
This study assesses the long-term course of treatment-seeking youth with a primary diagnosis of DSM-IV OCD.
Method:
Sixty youth and their parents completed intake interviews and annual follow-up interviews for 3 years using the youth version of the Longitudinal Interval Follow-up Evaluation (Y-LIFE) and Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Remission was defined as no longer meeting DSM-IV criteria for OCD for 8 weeks or more, and recurrence was defined as meeting full criteria for OCD for 4 consecutive weeks after having achieved symptom remission. Remission rates for youth were compared to rates of adults participating in the same study.
Results:
The probability of achieving partial remission of OCD was 0.53 and the probability of achieving full remission was 0.27. Among the 24 youth participants who achieved remission, 79% stayed in remission throughout the study (mean of 88 weeks of follow-up) and 21% experienced a recurrence of symptoms. Better functioning at intake and a shorter latency to initial OCD treatment were associated with faster onset of remission (P<.001).
Conclusions:
Remission is more likely among youth versus adults with OCD. Treatment early in the course of illness and before substantial impact on functioning predicted a better course.
Despite obsessive-compulsive disorder (OCD) being a recognizable psychiatric disorder, certain presentations of OCD are still highly stigmatized and misidentified by healthcare professionals. Namely, aggressive obsessions, which include ego-dystonic, intrusive thoughts and fears of accidentally or intentionally harming the self or others, are vastly under researched. With current prevalence estimates for aggressive obsessions in pediatric OCD ranging anywhere from 30.8% to 86%, the primary aim of the current meta-analysis was to provide the first meta-analytic estimate of the worldwide prevalence of aggressive obsessions among youth with OCD. A secondary goal of this study was to quantify sources of heterogeneity that contribute to the variability in prevalence estimates to date. A systematic review was conducted in Covidence using the following online databases: PsycINFO, PubMed, and CINAHL. Of the 4218 articles imported and screened, 831 received a full-text review, with 27 studies (N = 3428) ultimately coded. Using a random-effects model, the aggregate lifetime prevalence rate of aggressive obsessions was found to be 65.1% CI95% [57.3%, 72.2%], with prediction intervals ranging from 43.9% to 81.7%, and a current prevalence rate of 61.9% CI95% [56.4%, 67.0%], with prediction intervals ranging from 37.0% to 81.8%. The presence of comorbidities and the type of diagnostic measure utilized were found to be significant moderators for current estimates. With over half of youth experiencing aggressive obsessions in their lifetime, continuing education is required for healthcare professionals to be able to identify and properly treat this common, but often overlooked, symptom dimension.
The aim of this study was to develop and validate The Early Life Experiences and Coping strategies scale for Adult with Obsessive-Compulsive Disorder. A culturally sensitive therapeutic screening tool, designed to identify the impacts of early life factors, including parenting styles, childhood traumas and maladaptive coping strategies on the development of obsessive-compulsive tendencies in young adults specifically in the context of Pakistani Culture. The development of "ELE-CSS" followed a rigorous methodology, utilizing a mix method approach, dividing the study into five phases, that included purposive sampling in which interview were conducted from eight OCD diagnosed Patients. Succeeded by expert's content validation by clinical psychologist. The semi structured interview questions were designed in accordance to research's objective, these questions included adverse childhood experiences, parenting styles, coping strategies and family histories. Preliminary set of 29 items were refined by expert evaluation, that was finalized for pilot study (N = 62) and explanatory factor analysis. Factor analysis identified three principal factors: "Emotional Neglect, Parental Rejection and childhood stress, Parental Control, Trauma and Avoidance and perfectionistic parenting and Coping Strategies for Illness Symptoms culminating in a 21-item scale. The scale exhibited exceptional reliability (Cronbach's alpha = 0.71) and test-retest stability, affirming its efficacy as a tool for screening out early life experiences that had an effect on Obsessive Compulsive tendencies etiology. Moreover, evaluations of convergent and divergent validity demonstrated the scale's precision. This tool would have great clinical Implications.
Skin‐centered body dysmorphic disorder (BDD) and excoriation disorder (ED) are categorized under Obsessive Compulsive and Related Disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5) and are characterized by excessive or inappropriate skin picking. Patients with skin‐centered BDD and ED often first present to dermatology. These conditions are important to recognize and appropriately diagnose, as perpetuation of the disorder is inevitable without appropriate psychiatric treatment. These conditions are associated with increased morbidity and BDD is associated with increased suicide risk. This review aims to present a combined dermatologic and psychiatric approach to diagnosing, differentiating, and managing skin‐centered BDD and ED. Patient presentation, DSM‐5 criteria, and management approaches are reviewed.
This article is protected by copyright. All rights reserved.
The association between Tourette Syndrome (TS) and body-focused repetitive behaviors (BFRBs), including skin picking disorder (SPD), hair pulling disorder (HPD) and pathological nail biting (PNB) is rarely studied, especially in TS pediatric samples, even though TS and BFRBs share many characteristics. This study therefore sought to determine the prevalence rates and predictors of SPD, HPD and PNB in a pediatric TS sample. Data from 739 child and adolescent participants who completed validated instruments to assess for tic severity and various other comorbidities were used to calculate prevalence rates for each of the BFRBs. Clinical and demographic predictors were determined via regression modelling. The prevalence rates for SPD, HPD and PNB were 5.8%, 2.4% and 6.0%, respectively. The presence of PNB and worst ever tic severity predicted the presence of SPD. Worst ever tic severity and the presence of SPD were the only significant predictors of HPD and PNB, respectively. When distress was dropped as a diagnostic requirement for the BFRBs, the prevalence for SPD, HPD and PNB increased to 18.4%, 7.6% and 11.8%, respectively, while the predictors were generally the same. The prevalence rates for SPD, HPD and PNB were similar to estimated rates in the general population. However, their association with tic severity suggests a relationship between BFRBs and TS. These findings suggest that more research is needed to further elucidate the nature of the relationship between TS and BFRBs, especially in pediatric populations.
Anxiety disorders are one of the most common psychiatric conditions observed in children and adolescents worldwide, and can lead to significant impairments in academic, social, and family functioning. Child anxiety disorders frequently predict the development of other psychiatric disorders in later adolescence and adulthood, including subsequent anxiety disorders, conduct disorder, substance use disorders, and major depressive disorder. This chapter provides an overview of the etiology and clinical characteristics of anxious youth, as well as of evidence-based cognitive behavioral treatments for anxiety disorders in children and adolescents. Clinical descriptions are provided of separation anxiety disorder, generalized anxiety disorder, social phobia, panic disorder, specific phobia, obsessive-compulsive disorder, and posttraumatic stress disorder. An outline of the main components of treatment for childhood anxiety disorders is provided. Furthermore, current research on the efficacy and effectiveness of cognitive behavioral therapy for anxious youth is reviewed. The chapter concludes with a discussion of innovative adaptations of cognitive behavioral treatments for anxious children and adolescents.
Touch is an understudied sensory modality that has a significant neuroregulatory impact on social and emotional behavior relevant to psychiatric conditions. In particular, the sense of touch has a profound impact on early social development and bonding which makes it particularly relevant for neurodevelopmental disorders such as autism spectrum disorder (ASD). This chapter reviews behavioral and neural studies of touch in two categories of psychiatric diagnosis: ASD and obsessive compulsive (OCD) and related disorders. In ASD, altered tactile perception seems to be heavily weighted toward affective, rather than discriminative touch, and relates significantly to core symptoms including social deficits and repetitive behaviors. In OCD and related disorders, body-focused repetitive behaviors are significant and debilitating clinical symptoms that often involve affective dysfunction of the somatosensory system, including diminished nociception and/or altered reward response to tactile stimuli. Animal models suggest the involvement of serotonergic, dopaminergic, and oxytocin neurotransmitters/neuropeptides and neuroimaging studies implicate the interface of sensory systems with networks for affect and arousal in both classes of psychiatric conditions, but much more research is needed to clarify the role of touch in these clinical conditions. In addition, our understanding of other psychiatric conditions such as psychotic disorders and mood disorders would benefit substantially from more research on the role of touch in their development and clinical presentation.
ZET: Trikotillomani: Tanı, farmakoterapive kognitif davranışçı terapisi Trikotillomani, tekrarlayan saç yolmalar sonucu belirgin saç kaybına yol açan, süregen gidişli, kişinin işlevselliğinin tüm alanlarını olumsuz etkileyen, tedavisi güç bir bozuk-luktur. Uzun yıllardır bilinmesine rağmen diğer psikiyatrik bozukluklarla karşılaştırıldığında daha az ilgi çekmiştir. Dürtü kontrol bozuklukları tanı kategorisi altında sınıflan-dırılmasına karşın, sınıflama konusunda tartışmalar halen devam etmektedir. Trikotillomani, etyolojisi ve tedavisine yönelik çalışmalar son 20 yılda artmıştır. Etyolojik katkıda bulunan etkenler olarak evrimsel, genetik, nörofizyolojik ve nörokognitif faktörler bildirilmiştir. Trikotillomani tedavisi ile ilgili çalışmalar henüz yeterli kanıt düzeyine ulaşmamış-tır. Yeterli kanıt olmamasına karşın, etkili tedaviler olarak başta SSRI'lar ve klomipramin olmak üzere antidepresan-larla tedavi ve kognitif davranışçı terapiler bildirilmektedir. Kontrollü çalışmalar sonucunda ağırlıklı olarak "Alışkanlığı Tersine Çevirme Eğitimi (Habit Reversal Training, HRT)" olmak üzere kognitif ve davranışçı terapiler trikotillomani tedavisinde etkin tedaviler olarak gözükmektedir. Yolma davranışlarının gizlenmesi ya da utanma nedeniyle teda-viye başvurunun sınırlı olması geniş kontrollü çalışmaların yapılabilmesini engellemektedir. Çok merkezli, koordine geniş çalışmalar etyolojinin aydınlatılması, sınıflama tar-tışmalarının sona erdirilmesi, en uygun tedavi yaklaşımları ve algoritmaların geliştirilmesi için gerekmektedir. Bu göz-den geçirmede trikotillomani etyolojisi, sınıflaması, tedavisi konusunda son gelişmelerin özetlenmesi amaçlanmıştır. Anahtar sözcükler: Trikotillomani, HRT, kognitif davranışçı terapiler, farmakoterapi Kli nik Psikofarmakoloji Bülteni 2011;21(3):268-77 ABS TRACT: Diagnosis, pharmacotherapy and cognitive behavioral therapy of trichotillomania Trichotillomania is defined as significant hair loss due to individuals' repetitive self-pulling of hair. It is a chronic disorder that leads to significant distress and functional impairment and is often difficult to treat. Although it has been recognized for a long time, it has attracted less attention from scholars compared to other psychiatric disorders. Despite the fact that it is classified as an impulse control disorder, there is still a debate on how it should be classified. Research regarding etiology and treatment of trichotillomania has increased over last twenty years. It has been mentioned that its etiology is based on evolutional, genetic, neurophysiological and neurocognitive factors. Although robust evidence is not available, drugs such as clomipramine and selective serotonin reuptake inhibitors (SSRIs) or cognitive behavioral therapy are promising treatments. Habit Reversal Training (HRT), as a cognitive behavioural technique, has the highest rate of success in treating trichotillomania. However, not revealing the the habit of pulling hair or not coming forward to seek help due to embarrassement is an obstacle to running large scale controlled experiments. A series of multi-centered, coordinated large scale studies are needed to explore the etiology of the disorder, reach an agreement on its classification and defining the best approach and algorithms for the treatment. In this review it is aimed to summarise the latest research and progress in etiology, classification and treatment of trichotillomania.
Epidemiologic studies show that by late adolescence OCD has a lifetime prevalence of 2% to 3%. The age of onset is earlier in boys than in girls, and has a first peak around puberty and another in early adulthood. The natural course of the disorder is fairly stable, with a complete remission rate of 10% to 15%, although fluctuations in symptom level may make short-term apparent outcome unreliable. Comorbid conditions include depression, movement disorders, and anxiety disorders. Although the prevalence of OC symptoms and of OCD are not different for boys and girls, there may be gender differences in the symptom types. The boundary of the diagnosis of OCD is not always easy to determine, and individuals may meet threshold and subthreshold criteria at different times.
The current study examined the frequency and associated distress of both hairpulling and skin picking behaviors in 1,324 college students using the Massachusetts General Hospital Hairpulling Scale (MGHHS) and Skin Picking Scale (SPS). In this sample, many participants reported significant distress secondary to both hairpulling and skin picking. Participants who endorsed relatively frequent hairpulling or skin picking (N = 72) were scheduled for a follow-up testing session to further assess the relationship between these behaviors and measures of affective distress. Compared to a control sample, the follow-up sample endorsed significantly more symptoms of anxiety and stress reactivity, and had higher scores on a measure of obsessive-compulsive symptoms.
Very few of the emotional disorders described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) are as devastating as obsessive-compulsive disorder (OCD). Individuals suffering
from OCD are likely to have difficulty with work or school, falter in maintaining social and emotional relationships, and
struggle with daily life events that others take for granted. They are more likely than patients with other anxiety disorders
to suffer fromsevere depression, require inpatient treatment, and undergo psychosurgery (Barlow, 1988). Additionally, the
psychopathology in OCD is among the most complex of the emotional disorders. Intense and often senseless and bizarre thoughts
that run contrary to the individual's logic, sense of self, and core values come to mind, often at the worst possible times.
More overt, yet equally impairing signs of OCD include profound avoidance and performance of senseless and excessive compulsive
rituals that can dominate the sufferer's day.
Trichotillomania, characterized by an irresistible urge to pull one's hair, may be more prevalent than previously believed. Despite increasing attention devoted to this topic in the recent literature, there are few studies based on large samples that are potentially generalizable to a community population.
Surveys addressing clinical profile, comorbidity, and treatment history were mailed to all responders to a nationally distributed magazine article on trichotillomania. Out of 772 surveys sent, 123 completed surveys were returned.
While there was a predominance of females in the whole sample, female-to-male prevalence was lower in children than adults. Onset was predominantly in childhood (mean age = 11 years), most frequently in middle childhood and least frequently before age 6. Subjects pulled hair from a variety of sites, including scalp, eyelashes, eyebrows, pubic region, face, and body, but the highest incidence and severity involved scalp hair. Children under 6 were more likely than other age groups to pull scalp hair and possibly less likely to pull other hair. In adults, symptom profile was not associated with age at onset. While subjects reported high rates of comorbid conditions in both self and family, trichotillomania was reportedly formally diagnosed in only 40% of the subjects. Although subjects reported a range of treatments, the majority (58%) reported no treatment history. Finally, only minimal improvement was reported for all modalities, with no significant difference in response to psychotherapy, behavior therapy, clomipramine, or fluoxetine.
Trichotillomania is a chronic illness that may be difficult to treat. Controlled studies on comorbidity, epidemiology, treatment-seeking patterns, and long-term treatment response are needed.
To describe the history, factor structure, reliability, and validity of the Multidimensional Anxiety Scale for Children (MASC).
In two separate school-based population studies, principal-components factor analysis was used, first, to test a theory-driven factor structure, and second, to develop an empirically derived factor structure for the MASC. In a separate study using a clinical population, test-retest reliability at 3 weeks and 3 months, interrater concordance, and convergent and divergent validity were examined.
The final version of the MASC consists of 39 items distributed across four major factors, three of which can be parsed into two subfactors each. Main and subfactors include (1) physical symptoms (tense/restless and somatic/autonomic), (2) social anxiety (humiliation/rejection and public performance fears), (3) harm avoidance (perfectionism and anxious coping), and (4) separation anxiety. The MASC factor structure, which presumably reflects the in the vivo structure of pediatric anxiety symptoms, is invariant across gender and age and shows excellent internal reliability. As expected, females show greater anxiety on all factors and subfactors than males. Three-week and 3-month test-retest reliability was satisfactory to excellent. Parent-child agreement was poor to fair. Concordance was greatest for easily observable symptom clusters and for mother-child over father-child or father-mother pairs. Shared variance with scales sampling symptom domains of interest was highest for anxiety, intermediate for depression, and lowest for externalizing symptoms, indicating adequate convergent and divergent validity.
The MASC is a promising self-report scale for assessing anxiety in children and adolescents.
Eleven chronic hair pullers, 11 subjects with obsessive-compulsive disorders (OCD), and 11 subjects with a non-OCD anxiety disorder were assessed with structured interviews and the Child Behavior Checklist (CBCL). Only 4 hair pullers (36%) reported both rising tension and relief with hair pulling. Each group had significantly more internalizing than externalizing symptoms on the CBCL. Seven hair pullers (64%) had a lifetime history of at least one other axis I diagnosis. The results provide further evidence that trichotillomania in referred children and adolescents is usually a chronic disorder often associated with internalizing symptoms and psychiatric comorbidity. Rising tension followed by relief with hair pulling may be an unnecessary restriction in the diagnosis of childhood trichotillomania.
Epidemiologic studies show that by late adolescence OCD has a lifetime prevalence of 2% to 3%. The age of onset is earlier in boys than in girls, and has a first peak around puberty and another in early adulthood. The natural course of the disorder is fairly stable, with a complete remission rate of 10% to 15%, although fluctuations in symptom level may make short-term apparent outcome unreliable. Comorbid conditions include depression, movement disorders, and anxiety disorders. Although the prevalence of OC symptoms and of OCD are not different for boys and girls, there may be gender differences in the symptom types. The boundary of the diagnosis of OCD is not always easy to determine, and individuals may meet threshold and subthreshold criteria at different times.
A hypothesis that eating disorders are a phenomenological variant of obsessive-compulsive disorder (OCD) has been proposed. This study was conducted to determine whether anorexia nervosa and bulimia, the two main eating disorders, are familial and whether the risk for obsessive-compulsive spectrum disorders (OCD and tic disorders) is higher in families of patients with eating disorders.
The morbidity risk for obsessive-compulsive spectrum disorders in first-degree relatives of 136 female probands with eating disorders (84 with anorexia nervosa, 52 with bulimia) was compared to that for first-degree relatives of 72 female comparison subjects.
The morbidity risk for obsessive-compulsive spectrum disorders was significantly higher among the 436 relatives of the eating disorder probands than among the 358 relatives of the comparison subjects (9.69% versus 0%). This finding was independent of any comorbid diagnosis of an obsessive-compulsive spectrum disorder in the eating disorder probands. The eating disorder group and the comparison group did not differ in familial risk for eating disorders and tic disorders.
To better understand the genetic components of eating disorders, these disorders should be considered as part of the obsessive-compulsive spectrum of disorders.
Psychogenic excoriation (PE), characterized by excessive scratching or picking of the skin, is not yet recognized as a symptom of a distinct DSM-IV disorder. It is a chronic disorder with a high rate of psychiatric comorbidity. The purpose of this study was to compare patients diagnosed with PE and patients with another dermatological disease in terms of comorbid psychiatric disorders. Thirty-one consecutive subjects were recruited from an outpatient dermatology clinic. The control group was composed of 31 patients with chronic urticaria. All subjects were interviewed using the Structured Clinical Interview for DSM-III-R (SCID-I), Beck Depression Inventory (BDI), Hamilton Anxiety Rating Scale (HARS), and Yale-Brown Obsession and Compulsion Scale (Y-BOCS) and also completed a semistructured questionnaire. Current major depressive syndrome was the most common psychiatric disorder in the PE group. There was a statistically significant difference between the two groups in terms of current major depressive syndrome (PE group 58.1%, control group 6.5%, P<.01). In the PE group, 45.2% of subjects were diagnosed with obsessive compulsive disorder (OCD), while the rate of OCD was only 3.7% in the control group (P <.01). The PE group scored significantly higher on the BDI, HARS, and Y-BOCS. The results of this study point to the close relationship of PE to depression and OCD.
In this study, the authors collected data on the demographic characteristics, phenomenology, and social and economic impact of skin picking. A total of 92 participants completed an anonymous, Internet-based survey through a link to the Trichotillomania Learning Center's home page. Results indicated that skin pickers experienced social, occupational, and academic impairment, a number of medical or mental health concerns, and financial burdens, which they attributed to skin picking. Results also revealed moderate, statistically significant relationships between skin picking severity and symptoms of depression, anxiety, and experiential avoidance. Subsequent mediational analyses demonstrated that the relationship between skin picking severity and symptoms of anxiety and depression was partially mediated by experiential avoidance. Implications, conclusions, and future areas of research are discussed.
Objective: Chronic hair pulling and trichotillomania are putative obsessive-compulsive spectrum disorders. This study determined the prevalence of hair Pulling in an inpatient obsessive-compulsive disorder (OCD) population and compared clinical characteristics and treatment response between subgroups with and without comorbid hair-pulling. Method: Patients with severe DSM-TV-diagnosed OCD (N = 154) who were consecutively admitted to an OCD residential treatment facility between August 2000 and July 2003 were included. Clinician-rated (Yale-Brown Obsessive Compulsive Scale) and patient-rated (Massachusetts General Hospital Hairpulling Scale, Beck Depression Inventory, and Posttraumatic Diagnostic Scale) measures were administered at index evaluation. OCD patients with and without moderate to severe hair pulling were statistically compared on clinical and treatment characteristics and treatment response. Results: Of the OCD subjects, 18.8% (N = 29) endorsed any hair pulling, 15.6% (N = 24) had moderate to severe hair pulling, and 7.8% (N = 12) had severe hair pulling comparable to that of a specialty trichotillomania clinic population. OCD patients with moderate to severe hair pulling were more likely to be women (p <.001), endorse > I comorbid tic (p <.05), and have earlier-onset OCD (p =.001). This cohort also had fewer contamination obsessions (p =.04) and checking compulsions (p =.04) and was more likely to be receiving stimulant (p =.006) or venlafaxine (p =.02) medication than those patients without hair pulling. Posttraumatic Diagnostic Scale scores were nearly significantly higher in the OCD + hair pulling group (p =.08). 0 CD treatment response was unaffected by the presence of comorbid hair pulling. Conclusion: Hair pulling is a highly common comorbidity in severe OCD. Women and early-onset OCD patients appear to be more vulnerable to comorbid hair pulling. OCD sufferers with comorbid hair pulling also exhibit an increased risk for tics and may present with different OCD symptomatology.
Context:
The empirical literature on treatment of obsessive-compulsive disorder (OCD) in children and adolescents supports the efficacy of short-term OCD-specific cognitive-behavior therapy (CBT) or medical management with selective serotonin reuptake inhibitors. However, little is known about their relative and combined efficacy.
Objective:
To evaluate the efficacy of CBT alone and medical management with the selective serotonin reuptake inhibitor sertraline alone, or CBT and sertraline combined, as initial treatment for children and adolescents with OCD.
Design, setting, and participants:
The Pediatric OCD Treatment Study, a balanced, masked randomized controlled trial conducted in 3 academic centers in the United States and enrolling a volunteer outpatient sample of 112 patients aged 7 through 17 years with a primary Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of OCD and a Children's Yale-Brown Obsessive-Compulsive Scale (CY-BOCS) score of 16 or higher. Patients were recruited between September 1997 and December 2002.
Interventions:
Participants were randomly assigned to receive CBT alone, sertraline alone, combined CBT and sertraline, or pill placebo for 12 weeks.
Main outcome measures:
Change in CY-BOCS score over 12 weeks as rated by an independent evaluator masked to treatment status; rate of clinical remission defined as a CY-BOCS score less than or equal to 10.
Results:
Ninety-seven of 112 patients (87%) completed the full 12 weeks of treatment. Intent-to-treat random regression analyses indicated a statistically significant advantage for CBT alone (P = .003), sertraline alone (P = .007), and combined treatment (P = .001) compared with placebo. Combined treatment also proved superior to CBT alone (P = .008) and to sertraline alone (P = .006), which did not differ from each other. Site differences emerged for CBT and sertraline but not for combined treatment, suggesting that combined treatment is less susceptible to setting-specific variations. The rate of clinical remission for combined treatment was 53.6% (95% confidence interval [CI], 36%-70%); for CBT alone, 39.3% (95% CI, 24%-58%); for sertraline alone, 21.4% (95% CI, 10%-40%); and for placebo, 3.6% (95% CI, 0%-19%). The remission rate for combined treatment did not differ from that for CBT alone (P = .42) but did differ from sertraline alone (P = .03) and from placebo (P<.001). CBT alone did not differ from sertraline alone (P = .24) but did differ from placebo (P = .002), whereas sertraline alone did not (P = .10). The 3 active treatments proved acceptable and well tolerated, with no evidence of treatment-emergent harm to self or to others.
Conclusion:
Children and adolescents with OCD should begin treatment with the combination of CBT plus a selective serotonin reuptake inhibitor or CBT alone.
This study evaluated the effectiveness of variations of two treatments, attention reflection and aversive taste treatment, previously found to be successful for managing trichotillomania and simultaneous thumb sucking in an 18-month-old boy. Results indicate that a modified attention reflection procedure decreased both behaviors. However, an aversive taste treatment applied to the thumb only when preceded by hair pulling decreased thumb sucking and eliminated hair pulling. The discriminative effects of punishment and considerations for treating habits in small children when a targeted covarying behavior is developmentally normal are discussed.
Over the past 15 yrs, it has been increasingly recognized that a wide range of psychiatric and neuropsychiatric disorders might be related to obsessive–compulsive disorder (OCD), and thus, together, may form a family of related disorders often referred to as obsessive–compulsive (or OCD) spectrum disorders. Disorders frequently proposed to be OCD spectrum disorders include the somatoform disorders, body dysmorphic disorder, and hypochondriasis; the eating disorders; the impulse control disorders and possible impulse control disorders such as compulsive buying, repetitive self-mutilation, severe nail biting, and compulsive skin picking; the paraphilias and nonparaphilic sexual addictions; and Tourette's syndrome and other movement disorders. In this chapter, the authors review the evidence supporting the grouping of these conditions into a family of OCD-related disorders and discuss the theoretical and clinical implications of such a grouping. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Currently there is no gold standard treatment outcome measure for trichotillomania (TTM), a disorder characterized by repetitive hair pulling resulting in noticeable hair loss. The goal of the current study was to evaluate the psychometric properties of TTM measures of differing assessment methods: self-report, clinician-rated summary scales, and clinician-rated global severity scales. Data collected from 28 patients with TTM indicated mixed psychometric properties for current scales. Internal consistency was strong for self-report but not clinician-rated summary scales. One clinician-rated summary scale total and subjective ratings of hair loss demonstrated good interrater agreement. Although convergent validity was good within measurement type, self-report did not correlate with clinician-rated global severity scales, perhaps because of absence of hair loss severity assessment on the self-report measure. A multimethod assessment including one of each type of measure reviewed in this paper, along with self-monitoring and measures of hair loss severity, is recommended for a comprehensive best practice approach to TTM assessment.
Obsessive-compulsive disorder (OCD) is an anxiety disorder with an often chronic course that is estimated to have a lifetime
prevalence rate of 1.9–3% in the United States (American Psychiatric Association, 2000). However, a substantially greater
percentage of the population has symptoms that overlap with OCD and may be included within the so-called obsessive-compulsive
spectrumdisorders (OCSDs).OCD and OCSDs are characterized by obsessions, defined as recurrent and intrusive thoughts, impulses,
or images that cause marked distress, and/or compulsions, which are repetitive behaviors performed in response to an obsession
(American Psychiatric Association, 2000; Hollander & Wong, 1995a). As is shown in Figure 5.1, OCSDs may be subdivided into
three basic clusters: (1) neurological disorders with repetitive behaviors, (2) impulse control disorders, and (3) body image,
body sensation, and body weight concern disorders.
Our objective was to determine the efficacy of fluoxetine in the treatment of pathologic skin picking in a double-blind, placebo-controlled, parallel trial.
Twenty-one adults with chronic pathologic skin picking agreed to participate and received 10 weeks of placebo or fluoxetine with a flexible dosing schedule up to 80 mg/day. Three skin-picking measures were employed: the Clinical Global Impression-Improvement (CGI-I) scale, the Skin Picking Treatment Scale (SPTS), and a visual analog scale of self-rated change (VAS). In addition, depression, anxiety, and obsessions-compulsions were rated using the Hamilton Rating Scale for Depression (HAM-D), the Hamilton Rating Scale for Anxiety (HAM-A), the Spielberger State-Trait Anxiety Inventory (STAI), and the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) for the duration of the study.
Seventeen subjects (6 treated with fluoxetine and 11 treated with placebo) completed the trial, at a mean fluoxetine dose of 55 mg/day. Fluoxetine was significantly superior to placebo in the treatment of skin picking according to two of the three measures for the completer analysis and to one of the three measures for the intent-to-treat analysis. Neither baseline level nor change in depression, anxiety, or obsessive-compulsive symptoms was significantly related to change in skin picking.
This first controlled trial of the treatment of pathologic skin picking suggests that fluoxetine may be of therapeutic benefit. Larger controlled studies are warranted.
Surprisingly, only 3 self-report measures that directly assess pediatric obsessive-compulsive disorder (OCD) have been developed. In addition, these scales have typically been developed in small samples and fail to provide a quick assessment of symptoms across multiple domains. Therefore, the current paper presents initial psychometric data for a quick assessment of pediatric OCD across multiple symptom domains, a child version of the Obsessive Compulsive Inventory (the OCI-CV). Data from a sample of over 100 youth ages 7 to 17 with a primary DSM-IV diagnosis of OCD support the use of the 21-item OCI-CV. Results support the use of the OCI-CV as a general index of OCD symptom severity and in 6 symptom domains parallel to those assessed by the revised adult version of the scale (OCI-R). The OCI-CV showed strong retest reliability after approximately 1.5 weeks in a subsample of 64 participants and was significantly correlated with clinician-rated OCD symptom severity and parent and child reports of dysfunction related to OCD. Significantly stronger correlations with self-reported anxiety than with depressive symptoms provide initial support for the divergent validity of the measure. Finally, preliminary data with 88 treatment completers suggest that the OCI-CV is sensitive to change.
This article describes the development and initial psychometric properties of the Milwaukee Inventory for the Dimensions of Adult Skin picking (MIDAS), a measure designed to assess "automatic" and "focused" skin picking. Data were collected from 92 participants who completed an anonymous internet-based survey. Results of an exploratory factor analysis revealed a two-factor solution. Factors 1 ("focused" picking scale) and 2 ("automatic" picking scale) each consisted of 6 items, and preliminary data demonstrated adequate internal consistency, good construct validity, and good discriminant validity. The MIDAS provides researchers with a reliable and valid assessment of "automatic" and "focused" skin picking.
Trichotillomania, a disorder of hair pulling, has been considered a rare condition. Estimations of the prevalence of this disorder have been based largely on clinical experience, and there have been no estimates of its prevalence based on data collected from a large, nonclinical population.
2579 freshman college students at two state universities and one liberal arts college were asked to provide written responses to questions designed to practically apply DSM-III-R criteria for trichotillomania and estimate the prevalence of trichotillomania in this population.
2534 students (97.9% of the study population) responded. We found a 0.6% lifetime prevalence of DSM-III-R trichotillomania for both male and female respondents. Hair pulling resulting in visible hair loss, but failing to meet full DSM-III-R criteria, was identified in 1.5% of males and 3.4% of females.
Trichotillomania may not be as rare as previously suspected and may affect males as often as females.
This study was constructed to detail the demographic and phenomenological features of chronic hair pullers as well as to assess psychiatric comorbidity in a sizable study group.
Subjects were drawn from an outpatient population of chronic hair pullers who had been referred to a trichotillomania clinic or had responded to a newspaper advertisement announcing a treatment study of adults who pull out their hair. Sixty adult chronic hair pullers completed a semistructured interview that focused on their hair-pulling behavior and demographic characteristics and that incorporated screening questions for DSM-III-R axis I disorders. The data were tabulated to derive a comprehensive picture of this group.
The typical subject was a 34-year-old woman who had pulled hair from two or more sites for 21 years. All subjects described either tension before or relief/gratification after pulling hair from the primary site, but 17% (N = 10) failed to describe both of these characteristics and thus failed to fulfill the DMS-III-R criteria for trichotillomania. Forty-nine subjects (82%) qualified for past or current axis I diagnoses other than trichotillomania. Several characteristics of the study group suggested phenomenological differences between obsessive-compulsive disorder and trichotillomania.
Adult trichotillomania is a chronic disorder, frequently involving multiple hair sites, and is associated with high rates of psychiatric comorbidity. Its relation to obsessive-compulsive disorder requires further clarification. The tension-reduction requirement in DSM-III-R for the diagnosis of trichotillomania may be overly restrictive.
To investigate the incidence, transition probabilities, and risk factors for obsessive-compulsive disorder (OCD) and subclinical OCD in adolescents.
A two-stage epidemiological study originally designed to investigate depression was conducted between 1987 and 1989 in the southeastern United States. For the screening, a self-report depressive symptom questionnaire was administered to a community sample of 3,283 adolescents. In the diagnostic stage, the Schedule for Affective Disorders and Schizophrenia for School-Age Children was administered to 488 mother-child pairs. Baseline screening and diagnostic data from the first year the subject completed an interview and follow-up diagnostic data from subsequent years were used.
The 1-year incidence rates of OCD and subclinical OCD were found to be 0.7% and 8.4%, respectively. Transition probabilities demonstrated a pattern of moving from more severe to less severe categories. Of those with baseline OCD, 17% had the diagnosis of OCD at follow-up; 62% moved to the referent group. Of those with baseline subclinical OCD, 1.5% had OCD at follow-up and 75% moved to the referent group. Black race (odds ratio [OR] = 23.38), age (OR = 4.02), desirable life events (OR = 0.78), undesirable life events (OR = 1.21), and socioeconomic status (OR not estimable) were significant predictors of incident OCD. Age (OR = 2.30), desirable life events (OR = 0.92), and undesirable life events (OR = 1.13) were significantly associated with incident subclinical OCD.
An initial diagnosis of subclinical OCD was not significantly predictive of a diagnosis of OCD at 1-year follow-up. The overall morbidity remained higher at follow-up in the baseline OCD group than in the baseline subclinical OCD group. The baseline subclinical OCD group was more dysfunctional at follow-up than was the baseline referent group. Further research concerning differences in symptomatology and impairment between OCD and subclinical OCD is warranted.
To examine the full spectrum of psychiatric comorbidity in juvenile obsessive-compulsive disorder (OCD) in a naturalistic manner when no exclusionary criteria are used for sample selection.
Consecutive referrals to a specialized pediatric OCD clinic were evaluated by means of structured diagnostic interviews and rating scales. No exclusionary criteria were used for sample selection. Findings were compared with those of previously published reports of juvenile OCD.
Compared with previous studies, our sample of juveniles with OCD had high rates of comorbidity not only with tic, mood, and anxiety disorders but also with disruptive behavior disorders.
Our findings indicate that in the naturalistic setting, juvenile OCD is heavily comorbid with both internalizing and externalizing disorders. The presence of such a complex comorbid state has important clinical and research implications and stresses the relevance of limiting exclusionary criteria in studies of juvenile OCD.
To evaluate the reliability and validity of a semistructured measure of obsessive-compulsive symptom severity in children and adolescents with obsessive-compulsive disorder (OCD).
Sixty-five children with OCD (25 girls and 40 boys, aged 8 to 17 years) were assessed with the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). Interrater agreement was assessed by four raters in a subsample (n = 24). Discriminant and convergent validity were assessed by comparing CY-BOCS scores to self-ratings of depression, anxiety, and obsessive-compulsive symptoms.
Internal consistency was high, measuring .87 for the 10 items. The intraclass correlations for the CY-BOCS Total, Obsession, and Compulsion scores were .84, .91, and .68, suggesting good to excellent interrater agreement for subscale and total scores. The CY-BOCS Total score showed a significantly higher correlation with a self-report of obsessive-compulsive symptoms (r = .62 for the Leyton survey) compared with the Children's Depression Inventory (r = .34) and the Children's Manifest Anxiety Scale (r = .37) (p = .02 and .05, respectively).
The CY-BOCS yields reliable and valid subscale and total scores for obsessive-compulsive symptom severity in children and adolescents with OCD. Reliability and validity appear to be influenced by age of the child and the hazards associated with integrating data from parental and patient sources.
The prevalence of skin-picking and its associated characteristics were documented in a nonclinical sample of 105 college students. Subjects completed a self-report skin-picking inventory and several paper-and-pencil scales. Students who endorsed skin-picking were compared to a clinical sample of self-injurious skin-pickers (n = 31) reported on previously. Of the student subjects, 78.1% (n = 82) endorsed some degree of skin-picking and four subjects satisfied criteria for severe, self-injurious picking. Student subjects significantly differed from the clinical sample-of self-injurious skin-pickers in the duration, focus, and extent of picking, techniques used, reasons for picking, associated emotions, and picking sequelae.
The familial relationship between obsessive-compulsive disorder (OCD) and "obsessive-compulsive spectrum" disorders is unclear. This study investigates the relationship of OCD to somatoform disorders (body dysmorphic disorder [BDD] and hypochondriasis), eating disorders (e.g., anorexia nervosa and bulimia nervosa), pathologic "grooming" conditions (e.g., nail biting, skin picking, trichotillomania), and other impulse control disorders (e.g., kleptomania, pathologic gambling, pyromania) using blinded family study methodology.
Eighty case and 73 control probands, as well as 343 case and 300 control first-degree relatives, were examined by psychiatrists or Ph.D. psychologists using the Schedule for Affective Disorders and Schizophrenia-Lifetime Anxiety version. Two experienced psychiatrists independently reviewed all diagnostic information and made final consensus diagnoses using DSM-IV criteria.
Body dysmorphic disorder, hypochondriasis, any eating disorder, and any grooming condition occurred more frequently in case probands. In addition, BDD, either somatoform disorder, and any grooming condition occurred more frequently in case relatives, whether or not case probands also had the same diagnosis.
These findings indicate that certain somatoform and pathologic grooming conditions are part of the familial OCD spectrum. Though other "spectrum" conditions may resemble OCD, they do not appear to be important parts of the familial spectrum.
Psychogenic excoriation (also called neurotic excoriation, acne excoriée, pathological or compulsive skin picking, and dermatotillomania) is characterised by excessive scratching or picking of normal skin or skin with minor surface irregularities. It is estimated to occur in 2% of dermatology clinic patients and is associated with functional impairment, medical complications (e.g. infection) or substantial distress. Psychogenic excoriation is not yet recognised in the DSM. We propose preliminary operational criteria for its diagnosis that take into account the heterogeneity of behaviour associated with psychogenic excoriation and allow for subtyping along a compulsivity-impulsivity spectrum. Psychiatric comorbidity in patients with psychogenic excoriation, particularly mood and anxiety disorders, is common. Patients with psychogenic excoriation frequently have comorbid disorders in the compulsivity-impulsivity spectrum, including obsessive-compulsive disorder, body dysmorphic disorder, substance use disorders, eating disorders, trichotillomania, kleptomania, compulsive buying, obsessive-compulsive personality disorder, and borderline personality disorder. There are few studies of the pharmacological treatment of patients with psychogenic excoriation. Case studies, open trials and small double-blind studies have demonstrated the efficacy of selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors in psychogenic excoriation. Other pharmacological treatments that have been successful in case reports include doxepin, clomipramine, naltrexone, pimozide and olanzapine. There are no controlled trials of behavioural or psychotherapeutic treatment for psychogenic excoriation. Treatments found to be effective in case reports include a behavioural technique called 'habit reversal'; a multicomponent programme consisting of self-monitoring, recording of episodes of scratching, and procedures that produce alternative responses to scratching; and an 'eclectic' psychotherapy programme with insight-oriented and behavioural components.
Although trichotillomania and pathological skin-picking are both characterized by repetitive self-injurious stereotypic behaviors, the former is classified as an impulse control disorder, while the latter is not given a specific diagnostic category in the Diagnostic and Statistical Manual of Mental Disorders (4th edition) [APA, 1994]. There are, however, few empirical data on phenomenological similarities and differences between these disorders. Patients with trichotillomania and pathological skin-picking were compared in terms of several demographic (age, gender), clinical (comorbid axis I and II disorders), and personality variables.
Trichotillomania and pathological skin-picking were very similar in demographics, psychiatric comorbidity, and personality dimensions. Dissociative symptoms may be more common in trichotillomania than in pathological skin-picking. These data support the concept of phenomenological overlap between trichotillomania and pathological skin-picking. Future work to assess the implications of overlap for clinical evaluation and intervention in the two conditions may be useful. Depression and Anxiety 15:83–86, 2002.
Hoarding occurs relatively frequently in obsessive-compulsive disorder (OCD), and there is evidence that patients with hoarding symptoms have more severe OCD and are less responsive to treatment. In the present study, we investigated hoarding symptoms in 126 subjects with OCD. Nearly 30% of the subjects had hoarding symptoms; hoarding was twice as prevalent in males than females. Compared to the 90 non-hoarding subjects, the 36 hoarding individuals had an earlier age at onset of, and more severe, obsessive-compulsive symptoms. Hoarders had greater prevalences of symmetry obsessions, counting compulsions, and ordering compulsions. Hoarders also had greater prevalences of social phobia, personality disorders, and pathological grooming behaviors (skin picking, nail biting, and trichotillomania). Hoarding and tics were more frequent in first-degree relatives of hoarding than non-hoarding probands. The findings suggest that the treatment of OCD patients with hoarding symptoms may be complicated by more severe OCD and the presence of co-occurring disorders. Hoarding appears to be transmitted in some OCD families and may differentiate a clinical subgroup of OCD.
Severe skin picking (SP) is a repetitive, intentionally performed behavior that causes noticeable tissue damage and results in clinically significant distress or impairment. To date, SP has received little attention in the psychiatric literature. This study was conducted to further investigate SP and its characteristics in a German student population. The participants (N = 133) completed various self-report questionnaires. More than 90% (n = 122) reported occasional SP, with six students (4.6%) endorsing significant impairment from recurrent, self-injurious SP. SP was triggered by specific cutaneous stimuli, situations, and emotions. The students primarily squeezed (85%) and scratched (77.4%) the skin, with a primary focus on the face (94.7%) and cuticles (52.6%). About 20% (n = 26) ate the picked tissue afterward. Results suggest SP is an underrecognized problem that occurs on a continuum ranging from mild to severe with generally stable clinical characteristics across cultures.
Evaluated the concurrent validity of the Anxiety Disorders Interview Schedule for the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV], American Psychiatric Association, 1994): Child and Parents Versions (ADIS for DSM-IV-C/P; Silverman & Albano, 1996) social phobia, separation anxiety disorder (SAD), generalized anxiety disorder (GAD), and panic disorder diagnoses. Children referred to an outpatient anxiety disorder clinic (N = 186; ages 8 to 17), and their parents completed the Multidimensional Anxiety Scale for Children (MASC; March, 1998) and the ADIS-C/P interview. There was no convergence between MASC scores and ADIS-C/P GAD diagnoses. However, there was strong correspondence between ADIS-C/P social phobia, SAD, and panic disorder diagnoses and the empirically derived MASC factor scores corresponding to these disorders. These results provide support for the concurrent validity of the anxiety disorders section of the ADIS-C/P.
The purpose of this study was to discriminate subtypes of obsessive-compulsive disorder (OCD) in a clinical sample of children and adolescents. Sixty OCD patients were assessed in two outpatient psychiatric clinics; 15 patients had a lifetime history of tics and 45 patients had no tic history. Interviews were conducted with the patients and their parents by a child psychiatrist using the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). The symptom checklist of the CY-BOCS was used to categorize obsessions and compulsions. Discriminant function analysis was used to compare the two groups in their symptomatology. There was no difference between the two groups in seven obsession categories. However, there was a significant difference between the two groups in seven compulsion categories. Ordering, hoarding, and washing compulsions were more common in those with no tic history. The results indicate that tic-related OCD may be differentiated from non-tic-related OCD early in life by the presence or absence of certain compulsive symptoms.
Family studies of Obsessive-Compulsive (OCD) indicate there is substantial heterogeneity in the familiality of the disorder. This study was done to determine whether there are differences between familial and sporadic probands with early-onset OCD in obsessive-compulsive (OC) symptom categories and comorbid psychiatric diagnoses.
We ascertained 50 OCD probands ranging in age from 10 to 19 years with an onset of OC symptoms before age 15 years. All probands were directly assessed with semistructured diagnostic interviews; their first-degree and second-degree relatives were directly or indirectly assessed with similar diagnostic instruments. Descriptive data were compared in 33 familial and 17 sporadic OCD probands using logistic regression to control for age, gender, and age at onset of OC symptoms.
Ordering compulsions were significantly more common in the familial OCD probands. Aberrant grooming behaviors were significantly more frequent in the familial subgroup with skin picking contributing significantly to that difference. Anxiety disorders other than OCD were also significantly more frequent in the familial subgroup with phobic disorders contributing significantly to that difference.
The results indicate that familial and sporadic forms of early-onset OCD may be differentiated by ordering compulsions, aberrant grooming behaviors, and anxiety disorders other than OCD.
Chronic hair pulling and trichotillomania are putative obsessive-compulsive spectrum disorders. This study determined the prevalence of hair pulling in an inpatient obsessive-compulsive disorder (OCD) population and compared clinical characteristics and treatment response between subgroups with and without comorbid hair pulling.
Patients with severe DSM-IV-diagnosed OCD (N = 154) who were consecutively admitted to an OCD residential treatment facility between August 2000 and July 2003 were included. Clinician-rated (Yale-Brown Obsessive Compulsive Scale) and patient-rated (Massachusetts General Hospital Hairpulling Scale, Beck Depression Inventory, and Posttraumatic Diagnostic Scale) measures were administered at index evaluation. OCD patients with and without moderate to severe hair pulling were statistically compared on clinical and treatment characteristics and treatment response.
Of the OCD subjects, 18.8% (N = 29) endorsed any hair pulling, 15.6% (N = 24) had moderate to severe hair pulling, and 7.8% (N = 12) had severe hair pulling comparable to that of a specialty trichotillomania clinic population. OCD patients with moderate to severe hair pulling were more likely to be women (p < .001), endorse > 1 comorbid tic (p < .05), and have earlier-onset OCD (p = .001). This cohort also had fewer contamination obsessions (p = .04) and checking compulsions (p = .04) and was more likely to be receiving stimulant (p = .006) or venlafaxine (p = .02) medication than those patients without hair pulling. Posttraumatic Diagnostic Scale scores were nearly significantly higher in the OCD + hair pulling group (p = .08). OCD treatment response was unaffected by the presence of comorbid hair pulling.
Hair pulling is a highly common comorbidity in severe OCD. Women and early-onset OCD patients appear to be more vulnerable to comorbid hair pulling. OCD sufferers with comorbid hair pulling also exhibit an increased risk for tics and may present with different OCD symptomatology.
Cognitive behaviour therapy is effective for obsessive-compulsive disorder and for obsessive-compulsive spectrum disorders such as trichotillomania. Unfortunately, many people with these disorders, especially those living in rural areas, have limited access to treatment. Telephone-administered cognitive behaviour therapy may help address this problem. In a recent study of telephone treatment for obsessive-compulsive disorder, we found that such treatment was often effective (42% in remission at post-treatment, and 47% in remission at 12-week follow-up). This article presents 2 case reports of the same treatment, applied to obsessive-compulsive spectrum disorders (trichotillomania and compulsive skin picking). Treatment was associated with symptom reduction for both participants, although one subsequently relapsed. Possible reasons for relapse are discussed. The findings encourage further studies to identify the characteristics of people most likely to benefit from telephone treatment for spectrum disorders.
The effectiveness of a deliberately limited version of Acceptance and Commitment Therapy (ACT) for chronic skin picking was evaluated in a pair of multiple baseline across participants designs. Self-monitoring of skin picking showed that four of the five participants reached near zero levels of picking by post-treatment, but these gains were not fully maintained for three of the four participants at follow-up. The findings of the self-reported skin picking were generally corroborated by ratings of photographs of the damaged areas and by ratings on a validated measure of skin picking severity. All participants rated the intervention as socially acceptable, and reductions were found on measures of anxiety, depression, and experiential avoidance for most participants as a result of the intervention. Results support the construction of more comprehensive ACT protocols for skin picking.
Little is known about impulse control disorders (ICDs) in individuals with obsessive compulsive disorder (OCD). Although studies have examined ICD comorbidity in OCD, no previous studies have examined clinical correlates of ICD comorbidity in a large sample of individuals with a primary diagnosis of OCD. We examined rates and clinical correlates of comorbid ICDs in 293 consecutive subjects with lifetime DSM-IV OCD (56.8% females; mean age=40.6+/-12.9 years). Comorbidity data were obtained with the Structured Clinical Interview for DSM-IV. ICDs were diagnosed with structured clinical interviews using DSM-IV criteria. OCD severity was assessed with the Yale-Brown Obsessive-Compulsive Scale. Quality of life and social/occupational functioning were examined using the Quality of Life Enjoyment and Satisfaction Questionnaire and the Social and Occupational Functioning Assessment Scale. All variables were compared in OCD subjects with and without lifetime and current ICDs. Forty-eight (16.4%) OCD subjects had a lifetime ICD, and 34 (11.6%) had a current ICD. Skin picking was the most common lifetime (10.4%) and current (7.8%) ICD, followed by nail biting with lifetime and current rates of 4.8% and 2.4%, respectively. OCD subjects with current ICDs had significantly worse OCD symptoms and poorer functioning and quality of life. These preliminary results suggest that there is a low prevalence of ICDs among individuals with OCD, although certain ICDs (skin picking) appear to be more common.
Obsessive-compulsive disorder (OCD) is a distressing and functionally impairing disorder that can emerge as early as age 4. Cognitive behavior therapy (CBT) for OCD in youth shows great promise for amelioration of symptoms and associated functional impairment. However, the empirical evidence base for the efficacy of CBT in youth has some significant limitations, particularly as related to treating the very young child with OCD. This report includes a quantitative review of existing child CBT studies to evaluate evidence for the efficacy of CBT for OCD. It identifies gaps in the literature that, when addressed, would enhance the understanding of effective treatment in pediatric OCD. Finally, it presents a proposed research agenda for addressing the unique concerns of the young child with OCD.
In study 1, 46 children and adolescents with trichotillomania who sought treatment at 2 specialty outpatient clinics were assessed. Most children reported pulling hair from multiple sites on the body, presented with readily visible alopecia, reported spending 30-60 minutes per day pulling or thinking about pulling, and reported experiencing significant distress about their symptoms. Most were described by their parents as having significant problems in school functioning. Few children met criteria for obsessive-compulsive disorder or tic disorder. Child and family rates of other forms of psychopathology were high. In study 2, 22 of these children were enrolled in an open trial of individual cognitive behavioral therapy with particular attention to relapse prevention. Trichotillomania severity decreased significantly and 77% of children were classified as treatment responders at post-treatment and 64% at 6-month follow-up.
The relationship of pathological skin picking to obsessive-compulsive disorder Assessment of trichotillomania: A psychometric evaluation of hair-pulling scales
- Ba Cullen
- Jf Samuels
- Gj Bienvenu
- M Grados
- Hoehn
- R Saric
- J Hahn
Cullen BA, Samuels JF, Bienvenu GJ, Grados M, Hoehn-Saric R, Hahn J, et al. The relationship of pathological skin picking to obsessive-compulsive disorder. Journal of Nervous & Mental Disease 2001;189:193–195. [PubMed: 11277358] Diefenbach GJ, Tolin DF, Crocetto J, Maltby N, Hannan S. Assessment of trichotillomania: A psychometric evaluation of hair-pulling scales. Journal of Psychopathology and Behavioral Assessment 2005;27:169–178
Reply to Abramowitz and Deacon: beyond Anxiety: etiological and functional overlaps between OCD and OC spectrum disorders
- Hollander
Hollander, E., & Yeh, C. (2005). Reply to Abramowitz and Deacon: beyond Anxiety: etiological and functional overlaps between OCD and OC spectrum disorders. In: J. S. Abramowitz & A. C. Houts (Eds.), Concepts and controversies in obsessive-com-pulsive disorder (pp. 137–140). New York, NY, US: Springer Science + Business Media.
Examining the incremental validity of criteria B and C for trichotillomania in children and adolescents. Poster presented at the association for behavioral and cognitive therapies annual conference in Orlando
- C A Conelea
- M R Walter
- C A Flessner
- D W Woods
- M E Franklin
- N J Keuthen
Conelea, C. A., Walter, M. R., Flessner, C. A., Woods, D. W., Franklin, M. E., & Keuthen, N. J. (2008). Examining the incremental validity of criteria B and C for trichotillomania in children and adolescents. Poster presented at the association for behavioral and cognitive therapies annual conference in Orlando.
Children's Depression Inventory. North Tonawanda, NY: Multi-Health Systems
- M Kovacs
Kovacs, M. Children's Depression Inventory. North Tonawanda, NY: Multi-Health Systems; 1992.
The Milwaukee Dimensions of Adult Skin Picking Scale (MIDAS): Initial development and psychometric properties Treating trichotillomania in a toddler: Variations on effective treatments
- Mw Walther
- Ca Flessner
- Ca Conelea
- Dw Woods
- Ki Dittmer
- Kp Ray
Walther MW, Flessner CA, Conelea CA, Woods DW. The Milwaukee Dimensions of Adult Skin Picking
Scale (MIDAS): Initial development and psychometric properties. Journal of Behavior Therapy and
Experimental Psychiatry. in press
Watson TS, Dittmer KI, Ray KP. Treating trichotillomania in a toddler: Variations on effective treatments.
Child & Family Behavior Therapy 2000;22:29–40.