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Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive Disorder  |  Body Dysmorphic Disorder  |  Body Focused Repetitive Behaviors (Hair-Pulling and Skin-Picking)  | Resources

Once included under the umbrella of anxiety disorders, obsessive-compulsive and related disorders now compose their own standalone category according to the American Psychiatric Association. These diagnoses include obsessive-compulsive disorder (recurring mental intrusions possibly accompanied by repetitive behaviors), body dysmorphic disorder (preoccupation with physical defects), hair-pulling disorder (trichotillomania), skin-picking disorder (excoriation), and hoarding disorder (difficulty discarding possessions).


What are the similarities and differences between these conditions?

OCD specifically refers to bothersome mental intrusions, often including pictures, vague feelings, or thoughts that are somewhat unusual in nature. People with OCD may or may not engage in internal or external behaviors while attempting to dismiss thoughts (e.g., hand washing or counting). Body dysmorphic disorder is specific to disproportionate concerns over physical flaws. Hair-pulling and skin-picking disorders are considered Body Focused Repetitive Behaviors (BFRBs) and involve repeated actions that damage physical appearance. Patients with hoarding disorder experience great distress when disposing of items and, as a result, allow an excessive amount of objects to accumulate. These conditions frequently share symptoms, have a similar course, and co-occur.


How do I know if I have a problem?

If these habits cause significant distress or emotional pain, consume extensive periods of time during the week, trigger frequent distraction, and/or cause problems in your personal or professional relationships, you likely meet the threshold for a diagnosable condition and could benefit from treatment.


How do you treat these problems?
Most frequently, clients meet once a week and complete exercises independently between sessions. Depending on availability, our therapists may be able to offer intensive treatment. During an intensive treatment, a client attends 1-2 daily sessions with one or more clinicians for a specified number of weeks. This form of concentrated treatment may be preferred by clients who have difficulty completing exercises independently, have not responded to previous treatment, will be in New York for only a limited amount of time, or whose schedule is more compatible with a shortened treatment window due to personal or professional commitments.

How often do clients meet for therapy? Can I accelerate the treatment schedule?

People are anxious about things that are personally relevant to their concerns. Depending on your personality, you may worry about being rejected, making mistakes, not achieving success, getting sick, or being abandoned. Furthermore, when you are anxious, you may avoid or leave situations that make you anxious or try to compensate by trying to be overly controlling, overly concerned about approval or by trying to be perfect. These individual concerns that you have and your style of coping with anxiety may actually make you more vulnerable to anxiety.


Is there evidence that CBT works?
A comprehensive review of 16 trials for OCD, found that participants treated with CBT experienced large improvements to symptoms (Olatunji et al., 2013). Analyses of CBT for skin-picking and hair-pulling also found large improvements to symptoms (Selles et al., 2016; McGuire et al., 2014). A review of CBT for hoarding found that therapy regularly improved symptoms although the magnitude of improvement varied (Tolin et al., 2015).

Obsessive-Compulsive Disorder

What is Obsessive-Compulsive Disorder?

People with obsessive compulsive disorder (OCD) have obsessions and/or compulsions. Obsessions are thoughts, mental pictures, or impulses that are upsetting and continue to return. Compulsions are actions that a person feels he or she needs to mitigate strong feelings of discomfort or prevent something bad from happening. Most people with OCD suffer from both obsessions and compulsions. Common obsessions include fears of getting a disease (e.g. AIDS or cancer), coming in contact with harmful substances (e.g., asbestos or pesticides), hurting or killing someone (e.g., stabbing your child or running into a pedestrian), forgetting to do something (e.g., turning off stove or locking front door), and fears of doing something embarrassing or immoral (e.g., shouting obscenities or racial slurs). Common compulsions include excessive washing or cleaning, checking, repeating actions a set number of times, arranging objects in a set pattern or order, and counting or another form of mental distraction, as well as many others. OCD is a common problem. During any 6 month period over 4 million people in the United States suffer from OCD. One person in every 40 will have OCD at some point during their life. OCD can cause severe problems and suffering. People with OCD may spend several hours a day performing rituals, making it difficult to attend to work or take care of a family. Many people with OCD also avoid places or situations that make them uncomfortable. Some become homebound. Often they enlist loved ones to help them perform their rituals.


What is the cause of Obsessive-Compulsive Disorder?

The exact cause of OCD is not known. Family members of people with OCD often have OCD and other anxiety problems. However, genes alone do not explain OCD. Learning and life stress also appear to contribute to the disorder.


How does Obsessive Compulsive-Disorder develop?
Studies show that 90% of people have thoughts similar to those that trouble people with OCD. However, people with OCD appear to be more upset by these thoughts and respond differently than other people. Often the thoughts that worry people with OCD go against their beliefs and values. For example, a very religious man may fear he will commit blasphemy, or a loving mother may fear she will harm her child. Because these thoughts are upsetting, people with OCD quite logically attempt to avoid them or force the intrusions to go away. Unfortunately, psychologists have found that compulsive attempts to avoid or reduce thoughts often increase their intensity and ensure their steady return. However, these mental tricks or actions frequently provide relief in the short run. Therefore, under the assumption that their efforts are working, people with OCD continue steadfast attempts. Over time, the requirements of completing rituals can take over their lives.

How exactly do people with OCD think about their thoughts differently?

People with OCD often have specific beliefs about their intrusive thoughts or images, such as the following: “I need to stop this thought right now”; “If this thought doesn’t stop, I will lose control”; “If I have this thought again, something terrible will happen”; “These thoughts show that I am evil”; “No one else thinks like this”; “If this thought doesn’t go away immediately, there must be something wrong with me.” Many of these thoughts are types of “fusion metacognitions,” faulty beliefs about thoughts or the thinking process itself. 

Fusion metacognitions include: 
  • Thought-action fusion – The belief that the presence of a bad thought will make one perform a terrible behavior, or that thoughts and behaviors are morally equivalent. (Example: “If I have the thought about pushing someone into the subway, I will do it.” or “Having that thought makes me an awful person, even if I don’t do it.”)
  • Thought-event fusion – The belief that a thought will cause external events to occur. (Example: “If I think about a homeless person, I will lose all my money.”)
  • Thought-object fusion – The belief that thoughts and feelings will be transferred to and from objects. (“If I touch that door handle, the next person who touches it will become contaminated.”)


How does cognitive-behavioral treatment for OCD work?
People with OCD are afraid that if they let themselves think their feared thoughts without doing any compulsions they will get more and more anxious and they won't be able to stand it. They often worry that they might go crazy. Cognitive-behavioral treatment is aimed at helping you learn that you can control your anxiety without compulsions. You will learn coping strategies like relaxation exercises and ways of thinking that can help you feel less anxious. You will also learn that if you face your fears rather than avoid them they will go away. This may be hard to believe, but it's true. Your therapist will help you gradually face the things that you fear most, until you are confident that you can handle your fears without compulsions. Cognitive-behavioral treatment for OCD usually takes about 20 sessions. Treatment may take longer for people with severe symptoms.

How effective is cognitive-behavioral treatment for OCD?

A comprehensive review of 16 trials for OCD, found that participants treated with CBT experienced large improvements to symptoms (Olatunji et al., 2013). Following successful treatment, patients usually feel much more in control of their lives and better able to enjoy them. Improvements may include less distress related to intrusions and less time spent struggling with them, less time devoted to rituals, as well as greater freedom to enjoy activities in their personal and professional life.

Medications for OCD

Medications are compatible with therapy, and many people choose to consult with a psychiatrist or physician for medications to assist in their OCD treatment. Often, medications prescribed for OCD target increased levels of the chemical serotonin in the brain. While studies have shown that medication alone can improve symptoms, these symptoms often return to prior levels once medication is discontinued.

Body Dysmorphic Disorder

What is Body Dysmorphic Disorder?

Body Dysmorphic Disorder (BDD) is an obsessive preoccupation with perceived defects or subtle imperfections in physical appearance that can begin in childhood and become more pronounced during adolescence and adulthood. Generally individuals with BDD view themselves as unattractive or disfigured. The preoccupation causes excessive distress and may interfere with academic, employment, or social functioning. In some extreme scenarios, individuals may go to great lengths to avoid interacting with others (quit their job, divorce their spouse, or seldom leave their home). Most notably, individuals find themselves spending a lot of time and energy thinking about, monitoring, masking, avoiding or attempting to improve their physical appearance. Some individuals may find the intensity of their obsession increases and decreases with little or no warning. Alternatively, they may find their obsession shift from one region of the body to another which can lead to further distress. Approximately 5-40% of individuals receiving treatment for anxiety or depression and 6-15% evaluated for cosmetic surgery or dermatology services have been identified with BDD. While it is not entirely understood what triggers the onset of BDD, environment and genetics likely influence symptoms. BDD is thought to occur equally in men and women.


Common physical appearance obsessions:

  • Acne
  • Body or facial hair
  • Thinning hair on head
  • Scars or markings on skin
  • Moles
  • Coloring of skin complexion
  • Wrinkles
  • Facial Asymmetry
  • Shape or size of facial features, various body parts, or muscles


 Common repetitive behaviors:

  • Frequent checking of the "defective" region(s) in mirrors or windows for reassurance about or an attempt to correct the perceived defect
  • Avoid examination of "defective" regions
  • Excessive grooming
  • Covering up "defective" region using make-up, hari products, clothing, or positioning body in a particular way
  • Isolating self from others for fear others will see "defects"
  • Skin picking
  • Constant comparison between self and others physical appearance

Cognitive behavior therapy

Cognitive behavior therapy, including exposure and response prevention and challenging distorted beliefs about physical appearance, have been identified in research studies to improve overall body image by reducing obsessions, repetitive behaviors and overall distress associated with BDD. Clinical trials have also found medication combined with cognitive behavior therapy to be effective.  

What are hair-pulling and skin-picking disorders?

Hair-pulling and skin-picking, also referred to as trichotillomania and excoriation, refer to repetitive actions performed on the body. Some individuals report discomfort or a strong urge to perform an action and feel a sense of relief or gratification after doing so. Common hair pulling sites include the scalp, eyelashes, eyebrows and pubic area. Skin-picking sites include unobstructed areas, such as the face and hands, as well as many other areas of the body. Despite the emphasis on picking or pulling in their names, behaviors may include touching, rubbing, folding, playing, or chewing/eating.


Who suffers from BFRBs?

Body focused repetitive behaviors have been found to occur across many age groups, with onset often occurring between nine and thirteen years old. The lifetime prevalence rates are between 0.6% and 3.4% and more frequently occurs in females than males. Adults with BFRBs may also experience anxiety, obsessive–compulsive disorder, post traumatic stress disorder, depression, and eating disorders. It is not entirely understood how they develop, but it is believed that both biological and environmental elements contribute to these conditions.


What happens before a repetitive behavior?

Pulling, picking, or playing behaviors often occur in two ways. They might be a focused behavior in response to an internal or external event. Some individuals may perform them in response to emotions such as anxiety, sadness, shame, boredom, or anger. They might, instead, occur automatically without thought. For example, if you visit a coffee shop or library, you will often notice people absent-mindedly touching their hair or face while they read. Some people may notice only midway through or well after the episode has stopped. Physical positions (e.g., having one’s hand close to hair or face) or situations prompts (e.g., brushing hair, applying make-up in a mirror, reading, or lying in bed) can trigger the behavior.


What are Common Symptoms and Medical Issues of BFRBs?

Common external symptoms include:
  • Bald spots on scalp or other areas of body
  • Sparse eyebrows or eyelashes
  • Skin lesions
  • Efforts to hide symptoms, such as makeup, wigs, hats, pencils, and false eyelashes.
Possible medical issues include:
  • Carpal Tunnel Syndrome
  • Infections
  • Permanent hair loss
  • Intestinal hair balls (life-threatening) 


    How Do We Treat BFRBs?

    Cognitive behavior therapy (CBT) is problem-focused, goal-oriented and proactive treatment approach, with particular emphasis on the present and future. Subsets of CBT, Habit Reversal Training and Comprehensive Behavioral Treatment, were specifically designed to treat BFRBs. Therapists employ a variety of techniques to help clients challenge beliefs and behaviors that are not serving them well. Examples include awareness training or mindfulness skills, making environmental changes to discourage unhelpful behaviors, formulating alternative beliefs, disputing erroneous beliefs, and/or facing challenging situations that one typically avoids.



    Recommended resources and readings: 

     Blog posts on OCD by Dr. Leahy: 

       Clinician books about cognitive behavior therapy: 

         Sample chapters from Guilford Press:


           For further information or to schedule an appointment, please call :

          The American Institute for Cognitive Therapy,
          136 East 57th St., Suite 1101 
          NYC, NY 10022.

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