Hoarding Disorder

People with hoarding disorder have persistent difficulty getting rid of or parting with possessions due to a perceived need to save the items. Attempts to part with possessions creates considerable distress and leads to decisions to save them. The resulting clutter disrupts the ability to use living spaces. To be diagnosed as hoarding disorder, the hoarding must cause significant distress or significant impairment in social, academic, occupational, or other important areas of functioning (including maintaining a safe environment for oneself and others).

Hoarding is not the same as collecting. Collectors typically acquire possessions in an organized, intentional, and targeted fashion. Possessions do not accumulate to the point where they cause problems for oneself or other people or cause safety risks. In contrast to the organization and display of possessions seen in collecting, disorganized clutter that compromises the use of active living areas is a hallmark of hoarding disorder. For example, the kitchen may become so filled up with magazines or books that it is difficult or unsafe to cook there. Other rooms may be so cluttered that it is challenging or even unsafe to walk through them.

Hoarding disorder currently affects approximately 2.5% of the population. Hoarding behavior typically begins relatively early in life and increases in severity with each decade, especially after age 30. The prevalence and clinical features of hoarding disorder appear to be similar across countries and cultures, and it appears to occurs with about equal frequency in men and women. Most people with hoarding disorder excessively acquire possessions, most often by excessively buying things.

Cognitive-behavioral therapy (CBT) is the first-line treatment for hoarding disorder. Treatment begins with psychoeducation, goal setting, and motivational interviewing to explore and resolve ambivalence about discarding, and not excessively acquiring new possessions. Core treatment elements include practice in resisting acquisition of new possessions, sorting through possessions, decision-making, and discarding possessions. Cognitive techniques focus on modifying dysfunctional beliefs about possessions. Medication has not been well studied as a treatment for hoarding disorder. Limited preliminary data suggest that some patients may benefit from an SSRI such as paroxetine (Paxil) or an SNRI such as venlafaxine (Effexor).

Body Dysmorphic Disorder

Individuals with body dysmorphic disorder (BDD) are preoccupied with what they perceive as flaws in their physical appearance. The perceived flaws are actually not noticeable or appear only slight to other people, but the person with BDD sees them as ugly or abnormal. In other words, people with BDD have distorted body image. BDD is not the same as the typical concerns many people have about their appearance. To be diagnosed as BDD, the preoccupation with perceived defects or flaws in one’s appearance must cause significant emotional distress or significant interference in social, academic, occupational, or other important areas of functioning.

Body dysmorphic disorder also involves repetitive behaviors, also known as compulsions or rituals, (such as checking mirrors or seeking reassurance about how one looks, or repetitive thoughts, such as comparing one’s appearance with other people).

The preoccupations can focus on one or many body areas, most commonly the skin, hair, or nose. The preoccupations and behaviors are intrusive, unwanted, and time-consuming (occurring, on average, for three to eight hours per day). The individual feels driven to perform the repetitive behaviors and usually has difficulty resisting or controlling them. The appearance preoccupations cause significant distress or problems in daily activities such as work or social interactions. This can range from avoiding some social situations to being completely isolated and housebound because they think they’re so ugly. Body dysmorphic disorder is associated with high levels and rates of anxiety, social anxiety, social avoidance, depressed mood, low self-esteem, and suicidal thinking and behavior.

Many individuals seek and receive cosmetic treatment, such as dermatologic treatment or surgery, to try to fix their perceived defects. However, cosmetic treatment is almost never helpful, and it can make appearance concerns even worse.

People with body dysmorphic disorder usually don’t realize that their concerns about their appearance are distorted. And many individuals with body dysmorphic disorder mistakenly believe that other people take special notice of them or mock them because of how they look.

BDD currently affects an estimated 2% to 3% of people. It typically begins before age 18 and affects both men and women.

Muscle dysmorphia, a form of body dysmorphic disorder, is more common in males. It consists of preoccupation with the idea that one’s body is too small or not muscular enough. Individuals with this form of the disorder actually have a normal-looking body or are even very muscular. A majority (but not all) diet, exercise, and/or lift weights excessively.

A class of medications known as selective serotonin-reuptake inhibitors (SSRIs) are a first-line treatment for body dysmorphic disorder. They appear to be more effective than other types of medication. SSRIs available in the U.S. are fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), fluvoxamine (Luvox), and paroxetine (Paxil). Citalopram (Celexa), another SSRI, is not recommended because BDD often requires relatively high SSRI doses, and the maximum dose of citalopram that can be used (the dosing limit is firmer than for other SSRIs) is often too low to effectively treat BDD. Clomipramine (Anafranil) is an SRI (not an SSRI) that is also effective for BDD.

Effective SSRI doses for BDD are similar to those used for OCD; effective doses are often higher than those used for depression and some other mental health disorders. It often takes six to twelve weeks for improvement in BDD symptoms to occur. An SSRI/SRI should be tried for at least 12 weeks, reaching a high enough dose during that time and being sure to take the medication every day. If BDD doesn’t improve enough, it may help to take a dose that is higher than the manufacturer’s maximum dose (but this should not be done with clomipramine or citalopram).

For most people, SSRIs cause no side effects or only minimal side effects that often improve with time. If side effects occur, they can often be addressed with various strategies so they are tolerable or resolve. SSRI/SRIs are not addicting or habit forming.

If a good trial of an SSRI/SRI isn’t adequately helpful, BDD symptoms may improve by adding certain other medications to the SSRI/SRI. Alternatively, patients who do not improve sufficiently with one SSRI/SRI medication may improve with another one.

Cognitive-behavioral therapy (CBT) that includes exposure and response (ritual) prevention as well as cognitive therapy is the other first-line treatment for BDD. CBT must be tailored to BDD’s unique symptoms. There is more research evidence supporting the effectiveness of CBT than there is for other kinds of therapy.

Patients learn cognitive therapy techniques to help them develop more accurate and helpful appearance-related thoughts and beliefs. Treatment also includes ritual prevention (for example, no longer excessively checking mirrors) and gradual exposure to feared and avoided situations, which are often social situations. CBT for BDD also involves mirror retraining and approaches to improve self-esteem. The patient and therapist work collaboratively together, and patients are asked to do things that are challenging but doable. Practicing learned skills between treatment sessions with the therapist is essential.

Patients with mild to moderate BDD symptoms should be treated with either CBT or an SSRI/SRI medication, or both treatments, depending on patient preference, the presence or absence of associated psychiatric conditions, treatment availability, and other considerations. Severe BDD should be treated with both CBT and an SSRI/SRI concurrently.

Trichotillomania (Hair-Pulling Disorder)

Trichotillomania, or hair-pulling disorder, consists of repeatedly pulling out one’s own hair, most commonly from the scalp, eyebrows, and eyelids. Many people twist and play with their hair or bite their hair, but these behaviors are not the same as trichotillomania. To be diagnosed as trichotillomania, the hair pulling must result in hair loss, the person must have attempted to decrease or stop pulling, and the hair pulling must cause significant distress or significant problems with life functioning. The person may avoid work, school, or other public situations. To be diagnosed as trichotillomania, the hair pulling or hair loss must not be caused by another medical condition (such as a dermatologic condition) or another mental disorder that can involve hair pulling. For example, some people with body dysmorphic disorder pull out facial or body hair because they think it looks ugly. In such cases, body dysmorphic disorder is diagnosed rather than trichotillomania.

The distress caused by the hair pulling can include feeling a loss of control, embarrassment, and shame. Hair pulling may be preceded or accompanied by various emotions such as feelings of anxiety or boredom. It may also be triggered by an increasing sense of tension and may lead to a sense of relief after the pulling, or it may be a more automatic behavior.

In the general population, trichotillomania affects an estimated 1%-2% of adults and adolescents in a given year, and in adults it is more common among females. It usually begins around puberty. Trichotillomania may fluctuate in severity over time, but it usually continues if it is not treated.

The first-line therapy is a type of cognitive behavioral therapy (CBT) called habit reversal therapy (or habit reversal training). This treatment helps patients to identify triggers of pulling and enhances awareness of pulling. Habit reversal therapy also helps patients gain more control over the behavior – for example, by doing other things with their hands (like knitting or squeezing a spongy ball) rather than pulling their hair.

Glutamate inhibitors/modulators are the first-line medications for trichotillomania. N-acetylcysteine (NAC), which is available as a supplement, or memantine (Namenda) are usually the ones that are used. These medications usually have few or no side effects. Selective serotonin-reuptake inhibitors (SSRIs) may also be helpful for some people (see the OCD or body dysmorphic disorder section for more information about SSRIs).

Excoriation (Skin-Picking) Disorder

A person with excoriation (skin-picking) disorder repeatedly picks at their own skin, to the point of causing skin lesions. Although many people occasionally pick at their skin, skin picking is given a diagnosis of excoriation (skin-picking) disorder when the picking causes skin lesions, the person has repeatedly tried to decrease or stop the picking without success, and the behavior causes significant distress or significant problems with work, social interactions, or other activities. Also, for this diagnosis to be made, the skin picking should not be caused by a medical problem (such as a dermatologic condition). Finally, to be diagnosed as excoriation disorder, the skin picking must not be due to another mental disorder that can involve skin picking. For example, many people with body dysmorphic disorder pick their skin because they think that their skin (for example, blemishes or spots) looks ugly, and they’re trying to make their skin look better. In such cases, body dysmorphic disorder is diagnosed rather than excoriation disorder.

Excoriation (skin-picking) disorder can cause feelings of a loss of control, embarrassment, and shame, and it can lead to avoidance of social situations. The behavior may be triggered by feelings of anxiety or boredom. It may be preceded by an increasing sense of tension and may lead to a sense of relief after the picking, or it may be a more automatic behavior.

In the general population, the current prevalence of excoriation disorder in adults is estimated to be approximately 2%. It is much more common among women than men. It most often begins in adolescence, and it may fluctuate in severity over time, but it is usually chronic if not treated.

The first-line therapy is a type of cognitive behavioral therapy (CBT) called habit reversal therapy (or habit reversal training). This treatment helps patients to identify stressors and triggers of skin picking and enhance awareness. Habit reversal therapy also helps patients gain more control over the behavior – for example, by doing other things with their hands (like knitting or making a fist) rather than picking.

Glutamate inhibitors/modulators are the first-line medications for trichotillomania (hair-pulling disorder). N-acetylcysteine (NAC), which is available as a supplement, or memantine (Namenda) are the ones that are usually used. These medications usually have few or no side effects. Selective serotonin-reuptake inhibitors (SSRIs) may also be helpful for some people (see the OCD section or the body dysmorphic disorder section for more information about SSRIs).

Olfactory Reference Disorder

Olfactory reference disorder (also known as olfactory reference syndrome) consists of preoccupation with the inaccurate belief that one emits a foul or offensive body odor. In reality, the odor is not detectable or is only slight, but most people with olfactory reference disorder don’t realize this. For olfactory reference disorder to be diagnosed, the preoccupation must cause significant distress or significant impairment in functioning -- for example, interference with social interactions, relationships, academics, work, or other important aspects of functioning.

Preoccupations often focus on having bad breath or emitting a sweaty odor or an odor that smells like flatulence/feces, urine, or a genital odor. The preoccupation typically triggers repetitive behaviors (rituals, compulsions), such as excessive showering or toothbrushing or excessively checking one’s body or clothes for odor. In addition, most people with olfactory reference disorder try to hide or cover up the perceived odor -- for example, with perfume, deodorant, mouthwash, or chewing gum.

Most people with this disorder mistakenly believe that certain comments or behaviors of other people are a reaction to the perceived odor -- for example, comments like “let's get some fresh air,” or someone touching their nose. Depression and suicidal thinking are common. In more severe cases, people with olfactory reference disorder may not socialize, work, or even leave their house because they think they smell so bad.

Many people with olfactory reference disorder seek non-mental health treatment for their body odor concerns from doctors such as dermatologists, gastroenterologists, and gynecologists. But such treatment (for example, a tonsillectomy or prescription mouthwash for perceived bad breath) appears to be ineffective for olfactory reference disorder.

Treatment with a selective serotonin-reuptake inhibitor (SRI) is a first-line treatment for olfactory reference disorder. SSRIs available in the U.S. are fluoxetine (Prozac), sertraline (Zoloft), escitalopram (Lexapro), fluvoxamine (Luvox), and paroxetine (Paxil). Citalopram (Celexa), another SSRI, is not recommended because olfactory reference disorder may require a relatively high SSRI dose, and the maximum dose of citalopram that can be used (the dose limit is firmer than for other SSRIs) may be too low to effectively treat this disorder. Clomipramine (Anafranil) is an SRI (not an SSRI) that may also be effective.

An SSRI/SRI should be tried for at least 12 weeks, reaching a high enough dose during that time and being sure to take the medication every day. If symptoms don’t improve enough, it may help to take a dose that is higher than the manufacturer’s maximum dose (but this should not be done with clomipramine or citalopram).

If an SSRI/SRI doesn’t sufficiently improve symptoms, a medication known as an atypical neuroleptic, such as aripiprazole (Abilify), can be added to the SSRI/SRI. In more severe cases, an atypical neuroleptic should be added at the beginning of treatment, in combination with the SSRI/SRI. Patients who don’t improve sufficiently with one SSRI/SRI medication or one atypical neuroleptic may improve with a different one.

Cognitive-behavioral therapy (CBT) that includes exposure and response (ritual) prevention as well as cognitive therapy is the other first-line treatment for olfactory reference disorder. CBT must be tailored to olfactory reference disorder’s unique symptoms. Patients learn cognitive therapy techniques to help them develop more accurate and helpful body odor-related thoughts and beliefs. Ritual prevention (for example, no longer excessively laundering clothes) and gradual exposure to feared and avoided situations (which are often social situations) are other key elements of the treatment. CBT for olfactory reference disorder also involves approaches to improve self-esteem. The patient and therapist work collaboratively together, and patients are asked to do things that are challenging but doable. Practicing learned skills between treatment sessions with the therapist is essential.

Patients with mild to moderate symptoms should be treated with either medication (an SSRI/SRI), therapy (cognitive-behavioral therapy), or both. Severe olfactory reference disorder should be treated with both an SSRI/SRI and cognitive-behavioral therapy concurrently. In addition, when symptoms are severe, an atypical neuroleptic medication should be used along with an SSRI from the beginning of treatment.