OCD

Diagnostic Criteria for OCD

A. Presence of obsessions, compulsions, or both:

�Obsessions (must include 1 and 2):

1. Recurrent and persistent thoughts, urges, or images that are intrusive, unwanted, and
cause anxiety/distress.
2. The person tries to ignore, suppress, or neutralize them (e.g., by performing a
compulsion).

�Compulsions (must include 1 and 2):

1. Repetitive behaviors (e.g., handwashing, checking, ordering) or mental acts (e.g.,

praying, counting, repeating words) that the person feels driven to perform.
2. These behaviors/mental acts aim to reduce distress or prevent a dreaded event.
However:
o They are not realistically connected to what they are intended to prevent, or
o They are clearly excessive.

Note: Young children may not be able to explain the purpose of their
compulsions.

B. The obsessions/compulsions are time-consuming (e.g., >1 hour/day) or cause clinically

significant distress/impairment in functioning.

C. The symptoms are not attributable to substances or another medical condition.

D. The disturbance is not better explained by another mental disorder (e.g., GAD, BDD,
hoarding, trichotillomania, excoriation disorder, psychotic disorders, autism spectrum
disorder, eating disorders, etc.).

Specifiers

 Insight specifier:
o With good or fair insight: Recognizes beliefs are definitely/probably not true
(or may/may not be true).
o With poor insight: Thinks beliefs are probably true.
o With absent insight/delusional beliefs: Completely convinced beliefs are
true.
 Tic-related specifier: If there is a current or past history of a tic disorder.

Obsessive-Compulsive Disorder (OCD)

What is OCD?

Obsessive-compulsive disorder is a condition where a person experiences repeated and

unwanted thoughts, ideas, or urges called obsessions. These thoughts create anxiety, and to
reduce this anxiety, the person feels forced to carry out certain actions or rituals, which are
called compulsions. For example, a person may have a constant fear of germs and may wash
their hands again and again even though they know it is unnecessary. Obsessions are mental
events, while compulsions are behaviors. People with OCD usually know their thoughts and
actions are not logical, but they still feel unable to control them.

Epidemiology

OCD is one of the most common psychiatric disorders, affecting about two to three percent of
the general population. Studies show that it is equally common in men and women, but
during adolescence, boys are affected more often than girls. The average age of onset is
around twenty years, with men developing it slightly earlier than women. Most cases begin
before the age of twenty-five, and it is rare for OCD to start after the age of thirty-five.
People with OCD often find it hard to maintain close relationships, and many remain single.
The condition has been observed across different cultures and countries, showing similar
prevalence rates.

Comorbidity

OCD often occurs alongside other mental health disorders. Depression is very common,
affecting more than half of all people with OCD. Social anxiety disorder is also seen
frequently, and many patients may suffer from other anxiety disorders, panic disorder, or
eating disorders. Alcohol use problems and certain personality disorders are also linked with
OCD. In some cases, patients may have a history of tics, and a smaller percentage may even
develop Tourette’s disorder, which has a close connection with OCD symptoms.

Causes of OCD

Biological Factors

Research suggests that changes in the brain and neurotransmitters play an important role in
OCD. The chemical messenger serotonin is thought to be particularly involved, because
medicines that increase serotonin levels, such as SSRIs or clomipramine, have been found
effective in reducing symptoms. Brain imaging studies show overactivity in areas like the
orbitofrontal cortex, caudate nucleus, and thalamus. Genetics also play a role, as the risk of
developing OCD is several times higher in close relatives of patients. In rare cases, infections
such as streptococcal throat infection in children can trigger OCD-like symptoms, a condition
known as PANDAS.

Behavioral Factors

From a learning perspective, OCD develops when neutral situations or objects become linked
with fear. For example, if touching a doorknob is once associated with germs, it may later
cause anxiety whenever touched. To reduce this anxiety, the person may wash their hands,
and because the washing temporarily lowers the fear, it becomes a repeated and fixed pattern.
Over time, these avoidance behaviors turn into compulsions that are hard to stop.

Psychosocial Factors

OCD must be distinguished from obsessive-compulsive personality disorder, which is more

about perfectionism and strict attention to detail. Stressful events in life, such as pregnancy,
childbirth, or conflicts in relationships, may trigger or worsen OCD. Family members often
unknowingly support the illness by participating in or allowing rituals, which increases stress
in the household and makes recovery harder. Patients may also resist treatment because of
unconscious emotional factors or because their symptoms provide secondary benefits, such as
gaining care and attention.

Psychodynamic View

According to Freud’s classical psychoanalytic theory, OCD was described as obsessive-

compulsive neurosis and was linked to early childhood development, particularly the anal
stage. Patients often feel both love and hate toward the same person or object, which creates a
state of ambivalence and leads to rituals or doubts. A common feature in OCD is magical
thinking, where the person believes that simply thinking about something can make it
happen. For instance, a patient may fear that having an aggressive thought could cause harm
to others. Many OCD symptoms, such as the need for cleanliness or fear of contamination,
are explained as defenses against unconscious conflicts and unacceptable impulses.

Differential Diagnosis of OCD

Anxiety Disorders

OCD can sometimes look like other anxiety disorders, because people may show repeated
thoughts, avoidant behaviors, and frequent requests for reassurance. However, there are key
differences. In generalized anxiety disorder, the worries are usually related to real-life
concerns, such as finances or health, whereas in OCD the obsessions are often odd, irrational,
or even magical in nature. Compulsions are also a hallmark of OCD, and they are usually
linked directly to the obsessions. Specific phobia also involves strong fear of certain objects
or situations, but the fear is usually much more limited and rituals are absent. In social
anxiety disorder, the anxiety is specifically tied to social situations or performance, and the
avoidance is mainly to prevent embarrassment, not to neutralize intrusive thoughts.

Major Depressive Disorder

It is also important to distinguish OCD from major depressive disorder. In depression,

patients may experience rumination, which means repeatedly thinking about sad or hopeless
topics. However, these ruminations are usually mood-related, not intrusive, and are not
experienced as foreign or distressing in the same way obsessions are. Moreover, depressive
ruminations are not accompanied by compulsions, which makes them different from OCD
symptoms.

Other Obsessive-Compulsive and Related Disorders

Several other conditions can resemble OCD but have their own distinct features. In body
dysmorphic disorder, the obsessions and compulsions revolve only around appearance. In
trichotillomania, the compulsive act is limited to hair pulling, without obsessions. Hoarding
disorder is focused on the inability to discard possessions and the distress linked to losing
them. However, when hoarding behaviors are driven by typical OCD obsessions, such as fear
of harm or a need for completeness, then the correct diagnosis is OCD.

Eating Disorders

In anorexia nervosa and other eating disorders, the repetitive behaviors and obsessive
thoughts are limited to concerns about weight and food. In contrast, OCD obsessions and
compulsions are not restricted to these themes, which helps in differentiating the two
conditions.

Tics and Stereotyped Movements

Tics are sudden, repetitive, and nonrhythmic movements or sounds, such as eye blinking or
throat clearing. Stereotyped movements are repetitive and nonfunctional actions, such as head
banging or body rocking. These are usually simpler than compulsions and are not performed
to neutralize anxiety-provoking thoughts. The difference can sometimes be tricky to see,
especially with complex tics, but compulsions are usually preceded by obsessions, while tics
are often preceded by a sensory urge. Some individuals may have both OCD and a tic
disorder, in which case both diagnoses are made.

Psychotic Disorders

Some people with OCD may have very poor insight, even to the point of having delusional
beliefs about their obsessions. However, unlike psychotic disorders such as schizophrenia,
OCD still involves obsessions and compulsions as the central features. These patients do not
usually show hallucinations, disorganized speech, or other symptoms of psychosis. For such
cases, the specifier ―with absent insight/delusional beliefs‖ can be added, rather than
diagnosing a psychotic disorder.
Other Compulsive-like Behaviors

Certain behaviors such as compulsive gambling, substance use, or excessive sexual behaviors
may be described as ―compulsive.‖ However, these are not the same as OCD compulsions
because they are usually pleasurable at the time and are resisted only due to their harmful
consequences. In contrast, OCD compulsions are performed to reduce distress or anxiety, not
for pleasure.

Obsessive-Compulsive Personality Disorder (OCPD)

Although OCD and obsessive-compulsive personality disorder share similar names, they are
quite different. OCPD does not involve intrusive obsessions or compulsive rituals. Instead, it
is a long-term personality style marked by perfectionism, rigidity, and an excessive need for
control. A person can have both OCD and OCPD, but the features of each are distinct.

Diagnostic Criteria for Body Dysmorphic Disorder (BDD)

A. Preoccupation with one or more perceived defects or flaws in physical appearance that are
not observable or appear slight to others.

B. At some point during the disorder, the individual has performed repetitive behaviors or
mental acts in response to the appearance concerns, such as:

 Mirror checking
 Excessive grooming
 Skin picking
 Reassurance seeking
 Comparing appearance with others

C. The preoccupation causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

D. The preoccupation is not better explained by concerns about body fat or weight in
individuals who meet diagnostic criteria for an eating disorder.

Specifiers

 With Muscle Dysmorphia: Preoccupation that the body build is too small or
insufficiently muscular (even if other body areas are also a concern).

Insight Specifier
  With good or fair insight: Recognizes beliefs are definitely or probably not true, or
may or may not be true.
 With poor insight: Thinks beliefs are probably true.
 With absent insight/delusional beliefs: Completely convinced beliefs are true.

Body Dysmorphic Disorder (BDD): Overview

Etiology (Causes)

The exact cause of BDD is not known. However, research suggests that biological,
psychological, and cultural factors all play a role. BDD often co-occurs with depression and
OCD, and patients may respond to medications that target serotonin. This points toward
serotonin dysregulation as a possible factor. Family history of mood disorders and OCD also
increases risk. Social and cultural pressures—such as strict beauty standards—can strongly
influence individuals who are already vulnerable. From a psychodynamic view, BDD may
represent displacement of hidden emotional or sexual conflicts onto a body part, through
defense mechanisms like repression, distortion, or projection.

Development and Course

BDD typically begins in adolescence. The average onset is at age 16–17, with most cases
starting around 12–13 years. Symptoms often begin subtly and worsen over time, although
sometimes onset can be sudden. The disorder tends to be chronic, but improvement is
possible with treatment. Early-onset cases (before age 18) often have higher comorbidity and
gradual progression. BDD is also seen in older adults, though less studied.

Risk and Prognostic Factors

 Environmental: Childhood trauma, neglect, abuse, and bullying (especially

appearance-related teasing) are strongly linked with BDD.
 Genetic and Physiological: First-degree relatives of people with OCD have higher
rates of BDD, and twin studies estimate heritability at 37–49%, possibly higher in
women. Some genetic vulnerability is shared with OCD, while some is unique to
BDD.

Culture-Related Diagnostic Issues

BDD is found across cultures. Core features like distress, repetitive behaviors, and
impairment are consistent worldwide, but the specific appearance concerns vary by
culture. For example:
  In Japan, concerns may center on eyelids or involve shubo-kyofu, a subtype of taijin
kyofusho (fear of deformity).
 In Western cultures, muscle dysmorphia (fear of being too small or weak) is
common.
Cultural beauty ideals (e.g., pale skin, slimness, hairlessness) shape the focus of
preoccupation.

Sex- and Gender-Related Issues

BDD affects men and women equally, but differences exist:

 Men: More likely to have muscle dysmorphia, preoccupation with genitals, thinning
hair, or body build. They also have higher rates of comorbid substance use disorders.
 Women: More likely to focus on weight, breasts, hips, legs, buttocks, or excess
body/facial hair. They more often have comorbid eating disorders.
Despite these differences, both genders show similar severity, distress, suicidality, and
cosmetic surgery-seeking.

Differential Diagnosis of Body Dysmorphic Disorder (BDD)

Normal Appearance Concerns vs. BDD

Almost everyone worries about their looks sometimes, but in BDD the concern is excessive,
intrusive, and time-consuming (often hours per day). People with normal concerns may
dislike a feature but can move on with daily life. In BDD, the preoccupation dominates life
and causes distress or impairment. Importantly, if a visible defect is actually noticeable to
others, the diagnosis of BDD is not given.

Eating Disorders

Both BDD and eating disorders involve dissatisfaction with appearance, but the focus differs:

 In anorexia nervosa or bulimia, the main concern is weight and body fat, linked to
drive for thinness.
 In BDD, the preoccupation can involve any body part (e.g., skin, nose, hair,
muscles).
BDD can co-occur with eating disorders, especially in women, but if the concern is
exclusively weight-related, then an eating disorder is diagnosed instead of BDD.
Obsessive-Compulsive Disorder (OCD) and Related Disorders

OCD and BDD share repetitive thoughts and behaviors, but in BDD these are limited to
appearance. For example, mirror checking and grooming rituals are directly tied to how
someone looks.

 Excoriation disorder: Involves skin picking without appearance obsessions. If skin

picking happens because of a perceived defect (e.g., ―my skin looks ugly‖), then it is
BDD.
 Trichotillomania: Involves pulling hair for tension relief, not because of perceived
ugliness. But if the hair-pulling is driven by belief that hair looks bad, BDD should be
diagnosed.

Illness Anxiety Disorder (Hypochondriasis)

In illness anxiety disorder, the focus is on fear of having a medical illness (e.g., cancer,
HIV). In BDD, the concern is about looking abnormal or ugly, not about being sick. For
example, someone with BDD may think their nose is deformed, while someone with illness
anxiety worries that their nose lump is cancer.

Major Depressive Disorder

Depressed individuals often feel unattractive, but their thoughts are mood-congruent and not
usually obsessive. They don’t spend excessive time checking mirrors or performing rituals. In
BDD, the appearance preoccupation is specific, repetitive, and linked to compulsive
behaviors.

Anxiety Disorders

Social anxiety disorder can overlap with BDD since both involve fear of embarrassment and
avoidance of social situations. However, in social anxiety, the fear is about negative
judgment of behavior (e.g., ―I’ll say something stupid‖), while in BDD it is about looking
deformed or ugly.
In specific phobia, fear is tied to one stimulus (like heights or spiders), but in BDD it is
centered on body appearance, not external objects.

Psychotic Disorders

BDD with absent insight can look delusional, because the person is convinced their
perceived defect is real. However, unlike schizophrenia or schizoaffective disorder, BDD
does not involve hallucinations, disorganized thinking, or other psychotic features. The
key difference is that BDD symptoms are always centered on appearance.

Other Compulsive or Addictive Behaviors

Behaviors like gambling, substance use, or compulsive sexual behavior may look repetitive,
but they are usually performed for pleasure or reward, not to reduce distress about
appearance. In BDD, rituals are unwanted, repetitive, and driven by anxiety.

Obsessive-Compulsive Personality Disorder (OCPD)

Despite the similar name, OCPD is very different. OCPD involves a pervasive personality
style of perfectionism, rigidity, and control, but without intrusive thoughts or repetitive
rituals. In BDD, the problem is focused on appearance, not a general lifestyle pattern. Both
disorders can co-occur, but they are distinct.

Culture-Specific Syndromes

Some syndromes resemble BDD but differ in focus:

 Koro (South & East Asia): Fear of genital retraction into the body, not appearance-
based.
 Olfactory Reference Syndrome: Preoccupation with having a foul body odor rather
than a visual defect.
 Taijin Kyofusho (Japan/Korea): A subtype involves fear of offending others due to
supposed deformity, overlapping with BDD.

Diagnostic Criteria for Hoarding Disorder

A. Persistent difficulty discarding or parting with possessions, regardless of their actual
value.

B. The difficulty arises from a perceived need to save items and from the distress associated
with discarding them.

C. The difficulty discarding possessions leads to accumulation of clutter that congests and
clutters active living areas and substantially compromises their intended use.

 If living areas are uncluttered, it is only because of the intervention of third parties
(e.g., family, cleaners, authorities).
D. The hoarding causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning (including maintaining a safe living
environment).

E. The hoarding is not attributable to another medical condition (e.g., brain injury,
cerebrovascular disease, Prader-Willi syndrome).

F. The hoarding is not better explained by another mental disorder, such as:

 Obsessions in OCD
 Decreased energy in Major Depressive Disorder
 Delusions in Schizophrenia or other Psychotic Disorders
 Cognitive deficits in Major Neurocognitive Disorder
 Restricted interests in Autism Spectrum Disorder

Specifiers

 With Excessive Acquisition: If the difficulty discarding is also accompanied by

excessive acquiring of items not needed or for which there is no available space.

Insight Specifiers

 With good or fair insight: Recognizes that hoarding beliefs and behaviors are
problematic.
 With poor insight: Mostly convinced that hoarding beliefs/behaviors are not
problematic despite evidence to the contrary.
 With absent insight/delusional beliefs: Completely convinced that hoarding
beliefs/behaviors are not problematic despite evidence to the contrary.

Etiology

The exact cause of hoarding disorder is not fully understood. However, research suggests that
it often runs in families—around 80% of individuals with hoarding disorder report having at
least one first-degree relative with similar behaviors. Brain studies show reduced metabolism
in the posterior cingulate and occipital cortex, which may explain difficulties with attention,
decision-making, and organization seen in hoarders. Genetic studies also point to possible
links with chromosomes 4q, 5q, and 17q, as well as the COMT gene on chromosome
22q11.21, which may increase susceptibility to hoarding behaviors.

Associated Features

People with hoarding disorder often struggle with indecisiveness, procrastination,

perfectionism, avoidance, and difficulty organizing tasks. Many live in unsafe or unsanitary
conditions due to extreme clutter. A special form, called animal hoarding, involves keeping
large numbers of animals without providing proper nutrition, sanitation, or care. This usually
leads to severe overcrowding and poor living conditions. Those who hoard animals often
hoard objects as well, but they tend to have even poorer insight into their condition.

Risk and Prognostic Factors

 Temperamental: Indecisiveness is a key feature, often present in both individuals

with hoarding disorder and their relatives.
 Environmental: Stressful or traumatic life events may trigger or worsen hoarding.
 Genetic and Physiological: More than half of individuals report a family history of
hoarding. Twin studies suggest that about 50% of hoarding behavior is genetic,
while the rest is due to environmental influences.

Culture-Related Issues

Hoarding disorder has been observed across cultures, including in low- and middle-income
countries. While cultural values (such as thrift and saving items) may influence what is
considered ―normal,‖ the diagnosis should only be made when the behavior leads to distress,
clutter, or impairment in daily functioning.

Sex- and Gender-Related Issues

Both men and women show similar difficulties with clutter and discarding items. However,
women tend to show more excessive acquisition behaviors, especially compulsive buying,
compared to men.

Functional Consequences

Hoarding can severely affect daily life. Clutter makes it hard to move through the home,
cook, clean, or even sleep. Essential repairs may be impossible if repair workers cannot
access utilities, leading to broken appliances or disconnected water/electricity. Severe
hoarding increases risks of fire, falls, poor sanitation, and health hazards. Socially,
hoarding often damages family relationships, causes conflict with neighbors, and may even
lead to legal problems or eviction.
Differential Diagnosis

 Other Medical Conditions: Hoarding may result from brain injury, stroke,
infections, or genetic conditions like Prader-Willi syndrome. In these cases, hoarding
behavior appears only after the illness and may lack emotional attachment to items.
 Neurodevelopmental Disorders: Conditions like autism or intellectual disability can
involve collecting behaviors, but if hoarding is directly due to these disorders, a
separate hoarding diagnosis is not made.
 Schizophrenia Spectrum and Psychotic Disorders: If hoarding is caused by
delusions or negative symptoms of psychosis, it should not be diagnosed as hoarding
disorder.
 Major Depressive Episode: During depression, clutter may build up due to fatigue or
low energy, not because of distress about discarding items.
 Obsessive-Compulsive Disorder (OCD): In OCD, hoarding may result from
obsessions (e.g., contamination fears) or rituals (e.g., keeping items to avoid harm).
Unlike hoarding disorder, these behaviors are usually unwanted and distressing, not
rewarding. Items hoarded in OCD are often bizarre (e.g., trash, rotten food), unlike in
hoarding disorder. If hoarding occurs independently from OCD symptoms, both
disorders can be diagnosed.
 Neurocognitive Disorders: Hoarding-like behaviors may occur in dementia (e.g.,
frontotemporal degeneration, Alzheimer’s disease). In such cases, hoarding begins
after cognitive decline and is often accompanied by other symptoms like disinhibition,
self-neglect, or unsafe living conditions.

Diagnostic Criteria Trichotillomania (DSM-5-TR,

F63.3)
A. Recurrent pulling out of one’s hair, resulting in hair loss.

 Hair can be pulled from any site (most often scalp, eyebrows, eyelashes, beard, pubic
region, arms, legs).
 Patterns may vary: focused pulling (deliberate, to relieve tension) or automatic pulling
(outside of awareness, often during sedentary activities).
 The degree of hair loss can range from subtle thinning to complete bald patches.

B. Repeated attempts to decrease or stop hair pulling.

 Individuals are often distressed about the behavior and make efforts to control it.
 Attempts usually fail, leading to guilt, shame, and secrecy.

C. The hair pulling causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

 Examples: avoiding social interactions due to visible hair loss, wearing hats or wigs to
cover bald spots, decreased work/school performance due to time spent pulling.
 Emotional impact: embarrassment, low self-esteem, depression, anxiety.
D. The hair pulling or hair loss is not attributable to another medical condition.

 Must rule out dermatologic or medical causes (e.g., alopecia areata, tinea capitis,
trichorrhexis nodosa, thyroid disease).

E. The hair pulling is not better explained by another mental disorder.

 Must differentiate from:

o Body dysmorphic disorder (BDD): pulling to improve a perceived flaw.
o Psychotic disorders: pulling in response to delusional beliefs.
o Stereotypic movement disorder: repetitive movements without the
distress/compulsion component.

Trichotillomania (Hair-Pulling Disorder)

Epidemiology

The true prevalence of trichotillomania is likely underestimated, as many individuals conceal

the behavior due to shame and embarrassment. The disorder tends to fall into two main
categories. The more serious, chronic form begins in early to mid-adolescence and often
persists throughout life if untreated. In the general population, lifetime prevalence rates range
from 0.6 to 3.4 percent. Females are disproportionately affected, with some studies reporting
a female-to-male ratio as high as 10 to 1, although men may be underrepresented because
they are more likely to hide the behavior. This chronic form is often seen in individuals who
are the only child or the eldest child in their family. A second, childhood-onset form is also
recognized. It appears more equally across boys and girls, tends to be less severe, and is
usually transient.

An important clinical feature is trichophagia, or the chewing and swallowing of pulled hair.
Around 35 to 40 percent of patients engage in this behavior at some point, and approximately
one-third of them develop dangerous trichobezoars (hairballs) in the gastrointestinal tract,
which can cause obstruction, ulceration, or even perforation.

Development and Course

Hair pulling may be observed in infants, but in most cases, it resolves spontaneously during
early development. The typical onset of trichotillomania occurs around or after puberty,
which coincides with the period when symptoms are most likely to become chronic. The
disorder usually follows a long-term course with waxing and waning patterns. Some
individuals may experience symptom-free intervals lasting weeks, months, or years, while
others struggle with persistent urges. A minority of patients achieve remission within a few
years of onset without relapse.

The location of hair pulling often shifts over time. Commonly affected sites include the scalp,
eyelashes, eyebrows, and other body hair. In females, symptoms may worsen before
menstruation, although pregnancy does not consistently influence the course.
Risk and Prognostic Factors

There is clear evidence of a genetic vulnerability in trichotillomania. The condition is more

frequently observed in individuals with obsessive-compulsive disorder (OCD) and among
their first-degree relatives compared to the general population. Environmental stressors and
traumatic life events are frequently reported as triggers or factors that worsen symptoms.
Temperamental traits, such as difficulty regulating emotions and tendencies toward
impulsivity, also increase the risk of persistent hair pulling.

Culture-Related Diagnostic Issues

Trichotillomania appears to manifest similarly across cultures and ethnic groups, suggesting
that its clinical features are universal. While research is limited in non-Western populations,
the available evidence indicates that severity, symptom expression, and associated behaviors
remain largely consistent across cultural contexts.

Differential Diagnosis

Trichotillomania must be distinguished from several other conditions. Normal grooming and
cosmetic practices, such as plucking or shaving, should not be mistaken for the disorder, nor
should casual habits like twisting or playing with hair. Similarly, biting hair without pulling
does not qualify.

It must also be differentiated from other obsessive-compulsive and related disorders. For
example, in OCD, hair may be removed as part of a symmetry ritual, and in body dysmorphic
disorder, hair may be plucked in response to perceived flaws in appearance. In these cases,
the behavior is driven by obsessions rather than the urge–tension–relief cycle characteristic of
trichotillomania.

In children with intellectual disability or autism spectrum disorder, hair pulling may occur as
a stereotypic movement, but here it is not driven by urges and should be diagnosed as
stereotypic movement disorder. Psychotic disorders can also involve hair removal,
particularly when motivated by delusional or hallucinatory experiences.

Medical conditions such as alopecia areata, androgenic alopecia, and various forms of
scarring alopecia must be excluded through careful dermatological assessment. Dermoscopy
or biopsy may be required in unclear cases. Finally, substance use, particularly stimulants,
may exacerbate hair pulling, but it rarely serves as the primary cause of the persistent
disorder.
Diagnostic Criteria – Excoriation (Skin-Picking)
Disorder
A. Recurrent skin picking resulting in skin lesions.

B. Repeated attempts to decrease or stop skin picking.

C. The skin picking causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning.

D. The skin picking is not attributable to the physiological effects of a substance (e.g.,
cocaine) or another medical condition (e.g., scabies).

E. The skin picking is not better explained by the symptoms of another mental disorder (e.g.,
delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived
defect in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or
nonsuicidal self-injury).

Excoriation (Skin-Picking) Disorder

Etiology

The exact cause of excoriation disorder is not known, but several theories have been
suggested. Psychodynamic explanations propose that skin-picking may represent repressed
rage toward authoritarian parents, with patients unconsciously expressing defiance through
self-destructive acts. Others view the behavior as a stress-relief mechanism, often triggered
by events such as marital conflicts, bereavement, or unwanted pregnancies. Psychoanalytic
theory also emphasizes the skin as an erotic organ, with picking considered a form of
unconscious erotic gratification.

From a biological perspective, abnormalities in serotonin, dopamine, and glutamate

metabolism have been implicated, although more research is needed. Many individuals also
report beginning to pick during dermatological conditions like acne, and the behavior often
persists even after the skin condition resolves.

Prevalence

Population studies suggest that 2.1% of adults currently meet criteria for excoriation
disorder, while about 3.1% report lifetime prevalence. Women are more frequently
affected, with nearly three-quarters of cases found in females in community samples.

Development and Course

Excoriation disorder can begin at different ages, but onset is most common during
adolescence, often coinciding with puberty or the presence of acne. The sites of picking may
shift over time. The disorder typically follows a chronic course, with waxing and waning of
symptoms if left untreated. In some individuals, it occurs in episodes lasting weeks, months,
or years.

Risk and Prognostic Factors

 Genetic and Physiological: Evidence suggests a heritable component, as the disorder

is more common in individuals with OCD and their first-degree relatives.
 Environmental: Stressful life events may act as triggers or worsen symptoms.

Culture-Related Diagnostic Issues

Though limited data exist across cultures, the clinical features appear similar worldwide.
Studies in both the U.S. and other countries report comparable severity, behaviors, and
impact.

Diagnostic Markers

Most individuals openly admit to picking, so skin biopsy is rarely needed. However, in
uncertain cases, dermatopathology may show characteristic features that support the
diagnosis.

Functional Consequences

Excoriation disorder significantly impairs functioning. Most patients spend at least one hour
daily picking, resisting urges, or thinking about picking. This leads to social avoidance
(avoiding public places, events, or interactions) and occupational impairment (missed
school, difficulty concentrating, or poor work performance).

Medical complications are common and include tissue damage, scarring, infections, and in
severe cases, life-threatening conditions. Rarely, chronic picking has caused complications
such as wrist synovitis.

Differential Diagnosis

 Psychotic Disorders: If picking is due to delusions (e.g., parasitosis) or tactile

hallucinations (formication), excoriation disorder is not diagnosed.
 Other OCD-Related Disorders: Skin picking due to contamination fears in OCD or
appearance concerns in body dysmorphic disorder should not be classified as
excoriation disorder.
 Neurodevelopmental Disorders: In Prader-Willi syndrome or stereotypic movement
disorder, picking may occur as part of early-onset repetitive self-injurious behavior.
 Dermatitis Artefacta: When patients deny responsibility for self-induced lesions, the
diagnosis may be malingering or factitious disorder if deception is evident. Without
deception, excoriation disorder is diagnosed.
 Other Mental Disorders: Skin picking as a method of nonsuicidal self-injury
should not be classified as excoriation disorder.
 Other Medical Conditions: Dermatological illnesses (e.g., scabies, acne) may cause
scratching, but excoriation disorder is diagnosed only when the picking continues
beyond the skin condition itself.
 Substance/Medication-Induced Disorders: Stimulants like cocaine may induce skin
picking. In such cases, the correct diagnosis is substance/medication-induced
obsessive-compulsive and related disorder, not excoriation disorder.