Advocacy Action Center for Members: Federal Policy Updates. Log in to view > Advocacy Action Center for Members Federal Policy Updates Obsessive-Compulsive Disorder, Hoarding Disorder, Body Dysmorphic Disorder, Trichotillomania (Hair-Pulling Disorder), Excoriation (Skin-Picking) Disorder, and Olfactory Reference Disorder People with obsessive-compulsive disorder have obsessions (persistent, recurring, unwanted thoughts and urges) and compulsions (repetitive behaviors or mental acts) that the individual feels driven to perform in response to an obsession. Other obsessive-compulsive related disorders primarily involve recurring body-focused repetitive behaviors (such as hair-pulling) and repeated attempts to stop the behavior. Related disorders described below include hoarding disorder, body dysmorphic disorder, trichotillomania (hair-pulling disorder), excoriation (skin-picking) disorder, and olfactory reference disorder. Obsessive-Compulsive Disorder (OCD) Obsessive-compulsive disorder (OCD) is a disorder in which people have obsessions, which are recurring, unwanted and unpleasant thoughts, ideas, urges, or images. To get rid of the thoughts, people with OCD feel driven to do something repetitively (i.e., perform a compulsion, also called a ritual). The obsessions and compulsions -- such as hand washing/cleaning, checking on things, and mental acts like counting -- are problematic. They are time consuming (for example, take more than an hour a day), cause significant emotional distress, or significantly interfere with a person’s daily activities such as social interactions. Many people without OCD have distressing thoughts or repetitive behaviors. However, these are not time consuming, distressing, or impairing. For people with OCD, thoughts are persistent and intrusive, and the repetitive behaviors are rigid (it feels as though they must be done). Not performing the behaviors (compulsions, rituals) commonly causes great distress. For example, the person may fear that dire consequences will occur to self or loved ones if the behaviors are not completed. Most people with OCD know or suspect that their obsessional thoughts are not realistic or true, but they nonetheless have difficulty disengaging from the obsessive thoughts or stopping the compulsive behaviors. OCD currently affects 1-2% of people in the United States, and, among adults, slightly more women than men are affected. OCD often begins in childhood, adolescence, or early adulthood. Obsessions are unwanted, intrusive, recurrent, and persistent thoughts, urges, or images that cause distressing emotions such as anxiety, fear, or disgust. Most people with OCD recognize that these thoughts are a product of their mind and that they are excessive or unreasonable. However, the distress that these intrusive thoughts cause cannot be resolved by logic or reasoning. Most people with OCD try to ease the distress of the obsessional thinking by doing compulsions. For example, if they worry that they will be contaminated by touching things like doorknobs, they may compulsively and excessively wash their hands. They may also try to ignore or suppress the obsessions or distract themselves with other activities. Examples of common content of obsessional thoughts: Fear of contamination by people or the environment. Disturbing sexual thoughts or images. Religious, often blasphemous, thoughts or fears. Fear of perpetrating aggression or being harmed (self or loved ones). Extreme worry something is not complete. Extreme concern with order, symmetry, or exactness. Fear of losing or discarding something important. Can also be seemingly meaningless thoughts, images, sounds, words or music. Compulsions are repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession. The behaviors typically prevent or reduce a person's distress related to an obsession temporarily, and they are then more likely to do the same in the future. Compulsions may be excessive responses that are directly related to an obsession (such as excessive hand washing due to the fear of contamination) or actions that are completely unrelated to the obsession. In the most severe cases, a constant repetition of rituals may fill the day, making a normal routine impossible. Examples of compulsions: Excessive or ritualized hand washing or showering. Repeated cleaning of household objects. Excessively ordering or arranging things in a particular way. Repeatedly checking locks, switches, appliances, doors, etc. Frequently seeking approval or reassurance. Rituals related to numbers, such as counting, repeating, or doing things a certain number of times (for example, three times). People with OCD may also avoid certain people, places, or situations that cause them distress and trigger obsessions and/or compulsions. For example, they may avoid going out of the house because they obsess about contaminating the house and family members when they return. Avoiding these things may further impair their ability to function in life and may be detrimental to other areas of mental or physical health. Patients with OCD who receive appropriate treatment usually experience improvement in OCD symptoms as well as increased quality of life and improved functioning. Treatment usually improves an individual's ability to function at school and work, develop and enjoy relationships, and pursue leisure activities. Cognitive Behavioral Therapy A type of cognitive-behavioral therapy (CBT) known as exposure and response (ritual) prevention (ERP) is the first-line therapy for OCD. There is more research evidence supporting the effectiveness of ERP for OCD than there is for other kinds of therapy. During treatment sessions, patients are gradually exposed to feared and avoided situations or images related to their obsessions (exposure) without performing their rituals (ritual prevention). For example, a patient who checks the stove 30 times before leaving the house to prevent a fire learns to gradually cut back on the number of times they check before leaving. By staying in a feared situation without doing their rituals and without anything terrible happening, patients learn that their fearful thoughts are just thoughts and that the feared outcome doesn’t occur, even without the rituals. People learn that they can cope with their thoughts without relying on ritualistic behaviors, and their anxiety decreases over time. Using evidence-based guidelines, therapists and patients collaborate to develop an exposure plan that gradually moves from lower-anxiety situations to higher-anxiety situations. Exposures are performed both in treatment sessions and at home. The patient and therapist work collaboratively together, and patients are asked to do things that are challenging but doable. It can be helpful to add cognitive approaches (for example, cognitive restructuring) to exposure and response (ritual) prevention when treating OCD. A class of medications known as selective serotonin-reuptake inhibitors (SSRIs) are the other first-line treatment for OCD. Many research studies have shown that these medications are usually effective for OCD, and that they are 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 OCD 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 OCD. Clomipramine (Anafranil) is an SRI (not an SSRI) that is also effective for OCD. The SSRIs/SRIs are also used to treat depression, anxiety disorders, body dysmorphic disorder, some eating disorders, and many other mental health conditions. Effective SSRI doses for OCD are often higher than those used to treat depression and some of these other disorders. It often takes six to twelve weeks for improvement in OCD 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 OCD 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, OCD 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. Patients with mild to moderate OCD symptoms should be treated with either therapy (CBT/ERP) or medication (an SSRI/SRI), or both treatments, depending on patient preference, the presence or absence of associated psychiatric conditions, treatment availability, and other considerations. Severe OCD should be treated with both CBT/ERP and an SSRI/SRI concurrently. Read more on psychiatric medications. Neuromodulation Treatment Some newer studies suggest that transcranial magnetic stimulation (TMS) (combined with exposure and ritual prevention) can be effective for OCD. TMS uses magnetic fields to stimulate nerve cells in the brain. It is usually well tolerated. Deep brain stimulation, which involves an implanted device in the brain, has data to support efficacy, but it is invasive and complex to manage, and there are limited providers and hospital systems trained to offer this treatment and provide the long-term support needed by patients who are treated with DBS. How to Support a Loved One Who Is Struggling with OCD For people with OCD who live with family, friends, or caregivers, enlisting their support to help with exposure and ritual prevention practice at home is often recommended. In fact, the participation of family or friends may improve the likelihood of treatment success. It is important that family and friends not accommodate the patient’s OCD (for example, it is best to not help the patient do rituals or avoid healthy activities). A therapist can help family members or friends to support their loved one without accommodating their OCD symptoms. Maintaining a healthy lifestyle by itself is not sufficient treatment for OCD. SSRI/SRI medications and/or cognitive-behavioral therapy (exposure and response/ritual prevention) are needed. But maintaining a healthy lifestyle may help in coping with OCD and has many health benefits. Getting enough good-quality sleep, eating healthy food, exercising, and spending time with others can help to improve overall mental and physical health. Also, using relaxation techniques (when not doing exposure exercises) such as meditation, yoga, visualization, and massage might help with easing the stress and anxiety that OCD causes. Related Disorders Hoarding Disorder 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 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 (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 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 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. Physician Review Katharine Phillips,, M.D., DLFAPA More on Obsessive-Compulsive and Related Disorders Anxiety Disorders Association of America OCD Hoarding Find a therapist Find a therapist International OCD Foundation Find help: therapists, clinics, support groups, organizations OCD in Kids Find help: therapists, clinics, support groups, organizations Mental Health Care Works Supporting Someone with OCD Supporting Someone with OCD Medical leadership for mind, brain and body. Residents & Medical Students Patients and Families Advocacy & APAPAC Diversity & Health Equity Research & Registry Advocacy & APAPAC Meetings & Events Search Directories & Databases Residents & Medical Students Medical Students Patients and Families What is Psychiatry? 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