UNIT 9: OBSESSIVE COMPULSIVE AND

RELATED DISORDERS*
Structure
9.1 Learning Objectives
9.2 Introduction
9.3 Obsessive Compulsive Disorder
9.3.1 Etiology of Obsessive Compulsive Disorder
9.3.2 Treatment of Obsessive Compulsive Disorder
9.4 Body Dysmorphic Disorder
9.4.1 Etiology and Treatment of Body Dysmorphic Disorder
9.5 Let Us Sum Up
9.6 Key Words
9.7 Answers to Self-Assessment Questions
9.8 Unit End Questions
9.9 References
9.10 Suggested Readings

9.1 LEARNING OBJECTIVES

After studying this Unit, you would be able to,
● Gain knowledge about obsessive-compulsive and related disorders;
● Explain the psychopathology and phenomenology OCD and BDD
with the help of case studies;
● Discuss the bio-psycho-social causal factors implicated in these
disorders;
● Elucidate the treatment of OCD and related disorders.

9.2 INTRODUCTION
One psychiatric disorder, which has probably been extensively studied and
has gained immense curiosity is Obsessive Compulsive Disorder (OCD).
Ever wanted to wash your hands frequently so that you were clean and
tidy? Wanted to keep things neatly arranged in you room and felt annoyed
if things were missing from their place? Had doubts whether the bathroom
geyser switch was left on after leaving the house? Felt the need to itch
and scratch your scalp when feeling tensed? Peeled the skin from your nail
cuticles or surrounding areas? Many of us might have experienced or may
be doing these things. But when are these reasons enough to be worried and
seek professional help to overcome these? In the present Unit, you will be
acquainted about obsessive compulsive and its related disorders.
*
 Tavleen Kaur Kohli1, & M.Manjula2
*
 hD Scholar, 2Professor, Department of Clinical Psychology, National Institute of
P
Mental Health and Neuro Sciences (NIMHANS), Bangalore -560029, Karnataka, India.
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OCD was earlier considered to be an anxiety disorder, however, DSM-5 Obsessive Compulsive and
(APA, 2003) classifies it under the group called Obsessive Compulsive Related Disorders
and Related Disorders (OCRD). OCRD includes a group of disorders,
which has compulsiveness as a prominent characteristic feature in
their psychopathology, with anxiety having no functional relation to
the compulsive symptoms. The disorders that make up OCRD are body
dysmorphic disorder, trichotillomania, excoriation and hoarding disorder.
In this Unit you will learn about two important and commonly seen
disorders, Obsessive Compulsive Disorder (OCD) and Body Dysmorphic
Disorder (BDD).

9.3 OBSESSIVE COMPULSIVE DISORDER

(OCD)
Box 9.1: Arun’s Story
At 9 years of age, Arun was pursuing his studies in school when started
getting repeated, intrusive thoughts of death of family members and would
often go and check his parents room to check whether they were alive
or not. He would often call them when they were not home and would
fear them not being around him. His parents thought this is a normal
childhood fear and that he will grow out of this eventually. As he grew
older he started getting afraid of looking at figures of God, as he would
get abusive words in his mind and thought that he was abusing God. This
led to him avoiding going to the temple. He would close his eyes when
he would cross the small temple at home and would immediately go to
his mother to confirm whether he said something bad about God or not.
This started affecting his studies as whenever he would get these thoughts
while studying he had to stop reading and had to chant mantras twice to
make him feel better. He started becoming overly cautious of not doing
anything immoral. He had strongly held superstitious beliefs, which made
him, pray for hours sitting alone in his room. He would occasionally
go down to play with other children, however, he couldn’t find anyone
who could relate to his thoughts and felt like the odd one out. While he
struggled with these thoughts for years, he only came to seek treatment
when he was 22 years old as his studies were suffering immensely. He
could not clear his exams on two different occasions because of which he
started feeling low, would not get out of his bed for days and would get
thoughts of being worthless.
Obsessive compulsive disorder (OCD) involves the presence of unwanted,
intrusive and repetitive thoughts, images or urges that are accompanied by
compulsive behaviours performed to neutralize the distress associated with
obsessions or to prevent some feared situation from happening.
The persistent, repeated and intrusive thoughts of death of his family
members, getting abusive words in his mind, thoughts of abusing God are
all different types of obsessions that Arun was having. By very nature,
obsessions can be of different types and forms (see box 9.2 below), like
they can come as thoughts, impulses, images that can be highly distressing
to the individual experiencing them. As you saw in Arun’s story, his studies
started getting affected, he reduced his social interaction as he felt like the
“odd one out” and interactions with family were also strained.
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Mental Disorders - I Usually, we find that people who experience obsessions try to resist them
as it causes considerable disturbance and anxiety to them. In doing so they
often tend to engage in behaviours that reduce this distress, these take the
form of compulsions. In Arun’s case he was constantly trying to see whether
his parents were alive or not, chant mantras and he started avoiding going to
temple all together. Compulsions, like obsessions, can also be of different
types (see box 9.2 below), they can either be overt such as doing an action
physically or can be covert such as repeating something in one’s mind
(words, numbers, sentences etc) that reduces their distress momentarily.
While there is a sense of relief from the distress or feared consequence
after performing these compulsions, they can take the form of rigid rules in
which the person feels compelled to perform them which further increases
their distress.
Box 9.2: Different Types of Obsessions and Compulsions
Obsessions Compulsions
●● Contamination ●● Cleaning/Washing
●● Aggressive ●● Checking
●● Sexual ●● Repeating Rituals
●● Hoarding/Saving ●● Ordering/Arranging
●● Religion ●● Counting
●● Symmetry ●● Hoarding/Collecting
●● Somatic ●● Miscellaneous
●● Miscellaneous

A patient with OCD possibly knows that both the obsession and the
compulsion are irrational, hence we call them as ego-dystonic or something
which is unwanted. OCD has a heterogenous presentation among those
diagnosed, characterized by various presentations of obsessions. It has been
found that obsessions related to contamination are present in about more
than half of the people diagnosed with OCD and is considered one of the
most disabling among other presentations of obsessions.
Along with the above mentioned features, the diagnostic criterion for OCD
in DSM-5 mentions that, the obsessions and/or compulsions must be time
consuming (at least an hour per day) and/or cause significant disruption of
one’s socio-occupational functioning. An important aspect of the criteria
is the insight level of the patient which may be either good or satisfactory,
poor, or one where the patient has no insight/delusional convictions (the
patient thinks with utmost certainty that his/her beliefs related to OCD are
entirely true). Having poor or no insight can lead to a poor prognosis as well
as impact a person’s motivation in treatment. Furthermore, the criteria also
emphasize on investigating whether the person has a present or past history
of tic disorder.
Prevalence, Age of Onset, and Gender Differences
The lifetime prevalence of OCD worldwide is estimated to be around 1.5%
for women and around 1% for men. Estimations among adults in USA are
slightly higher, being 2.3% (Fawcett, Power, & Fawcett, 2020; Ruscio, Stein,
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Chiu, & Kessler, 2010). In India the estimate is around 0.8% for adolescents Obsessive Compulsive and
(Jaisoorya, Reddy, Thennarasu, Beena & Jose, 2015) and between 0.5% to Related Disorders
3% in adults (Gururaj et al., 2016). Within India early age of onset of OCD
has been linked with the presence of sexual obsessions, hoarding, repeating
rituals and compulsions involving need to touch (Narayanaswamy et al.,
2012; Rajashekharaiah & Verma, 2016).
Worldwide females have been found to have OCD at slightly higher rates
than males in adulthood, although males are more commonly affected in
childhood. Furthermore younger adults may be more likely to experience
OCD in their lifetime than older adults (Fawcett et al., 2020). What makes
studying about OCD even important is that this is the fourth most common
psychiatric disorder in the world, with disability associated with severe
cases often comparable to the disability associated with schizophrenia and
bipolar disorder (Reddy et al., 2010).
Co-morbidity
Depression and anxiety disorders (panic, generalized anxiety disorder
and social phobia) are the most common co-morbid with patients seeking
treatment for OCD. Other common co-morbid disorders include bipolar
disorder, tic disorders, body dysmorphic disorder, trichotillomania,
hypochondriasis and skin picking disorder. Attention Deficit Hyperactivity
Disorder (ADHD) and Oppositional Defiant Disorder (ODD) are highly co-
morbid in patients with early onset OCD, especially when the onset is in
childhood. Nearly a third of schizophrenia patients report OC symptoms or
OCD. Personality disorders such as obsessivecompulsive, anxiousavoidant,
schizotypal and borderline personality disorder are also relatively commonly
co-morbid with this illness (Reddy, Sundar, Narayanaswamy, & Math,
2017).
Self-Assessment Questions 1
1. Obsessions can take the form of images. True/ False.
2. The onset of OCD mostly is in late adulthood. True/ False.
3. Depression is a common co-morbid condition accompanying OCD.
 True/ False
4. _______ is a form of overt compulsion.
5. Compulsive behaviours are performed with the goal of __________.
9.3.1 Etiology of Obsessive Compulsive Disorder
Genetics: Family and twin studies have shown that genetic factors are
reasonably involved in OCD. They have indicated that not only one but a
number of vulnerability genes are involved in the transmission of OCD from
one family member to another (Cavallini, Pasquale, Bellodi, & Smeraldi,
1999; Nicolini, Kuthy, Hernandez, & Velazquez, 1991). Interestingly, the
family members of patients with OCD having higher number of obsessions
related to checking, symmetry or ordering, were seen to be at a greater risk
of developing OCD themselves, than were relatives of patients with OCD
who had low scores on these obsession domains (Hanna, Fischer, Chadha,
Himle, & Van Etten, 2005).

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Mental Disorders - I Neurobiological Mechanisms: The orbito-frontal system of our brain
connected to the thalamic area, mediated by a neurotransmitter called
glutamic acid is implicated in OCD. While a second loop, connects the
same system via the corpus striatum which controls the amount of activity
within the systems. When this system fails to balance out the over activity in
the orbito-frontal–thalamic loop, an individual keeps repeatedly responding
to his or her environment. This leads to the development of OCD. The
neurotransmitters implicated in this system include serotonin, dopamine
and GABA.
Psychodynamic Models: Freud viewed the development of OCD as a
result of fixation at and regression to the anal-sadistic stage of development.
He proposed that this fixation and regression was a possible consequence of
strict toilet-training in infancy. This behavior had elements of aggression,
and exercise of control over others associated to it. Thus, he called these
patients as having an anal type character represented by traits such as
parsimony, obstinacy, and orderliness. The anal character could then take
on an anal-retentive personality type, manifested as psychological rigidity
as well as an excessive need for control or it could also take the form of an
anal-expulsive personality type.
Karl Abraham (1923) extended his work by proposing that in the anal stage,
one phase has retention as the dominant theme, which becomes the source
of enjoyment, and another phase where sadistic urges towards others take
dominance and the pleasure is received from emptying one’s bowels. Three
ego defense mechanisms usually seen at play in OCD are isolation of affect,
undoing (in the form of compulsions), and reaction formation.
Another psychoanalytic theory conceptualized OCD as a conflict between
the ego and superego as well as that between aggressive, sexual impulses
emerging from the id (Fenichel, 1945). Thus, the repeatedly occurring
obsessions were primarily seen as an expression of unacceptable aggressive
or erotic impulses as well as may be a punishment received by the ever so
strong and harsh superego.
Adler (1964) tried to further these conceptualisations and put forth his
understanding of OCD resulting from the person’s failure of feeling in
control of his or her life situations. He understood compulsions being
unconscious attempts of a person to compensate for this lack of control.
Behavioural Models: To understand the behavioural model of OCD, it is
important to appreciate the Mowrer’s two-stage model of fear and avoidance
(Mowrer, 1947). This model is one of the most important in understanding
the behavioural development and maintenance of OCD. Mowrer proposed
that fear of stimuli (such as thoughts, images or even objects) can be
acquired through the classical conditioning process. There are two stages to
his model where in the first stage, neutral stimuli can become conditioned
stimuli through pairing with another unconditioned stimulus (one that
naturally predicts the fear response). An example of this can be a person
getting contamination obsessions after being seriously ill or experiences
of a family member being diagnosed and suffering from a serious illness.
Another example can be a person having obsessions related doubt after
experiencing an accident at home due to fire/current etc.
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 Obsessive Compulsive and
Related Disorders
The second stage of the model explains fear maintenance. He believed this
happens through operant conditioning processes, i.e. behaviours related to
escape and avoidance. Compulsions, according to this theory thus can be
seen as active avoidance behaviours that are negatively reinforced. They
thus become habitual over time as they are successful in decreasing the fear
and distress caused by the obsessions. The reinforced behaviours (in OCD
compulsions) thus become difficult for extinction (Dollard & Miller, 1950).
Taking forward the example of a person with contamination obsessions, he
or she may engage in excessive hand washing, taking long showers or even
avoiding public washrooms or not going near people who are sick so that
the chance of contamination can be minimised as much as possible.
The theory further proposes that other operant conditioning factors
that maintain OCD are called as safety behaviours, e.g., a person with
contamination related OCD using a cloth to open a restroom door. These
are negatively reinforced as they help in avoiding and escaping from the
anxiety momentarily, however, are seen as important factors that help
maintain or even exacerbate the OCD related symptoms (Deacon & Maack,
2008; Salkovskis, 1991).
Cognitive Models:
Salkovskis’ Cognitive-Behavioral Theory: In 1985, Salkovskis proposed
the appraisals of intrusive thoughts (especially those linked to responsibility)
and not just thoughts themselves as an important cause of compulsions.
The theory suggests that people with OCD view normal intrusive thoughts;
urges or images signifying some harm to himself/herself or another and thus
impose a serious threat. People with OCD also tend to appraise themselves
being responsible for the perceived harm, which possibly only they can
prevent (Salkovskis, 1985). This compels them to perform behaviours to
reduce the harm whenever they experience intrusive thoughts/obsessions.
Rachman’s Theory: Rachman took the previous theory forward and
proposed the presence of two cognitive biases, which increase the likelihood
catastrophic misinterpretations (“some harm will happen to me or my
family and I must prevent it”) of obsessive beliefs. The first bias is a belief
that thinking about an unpleasant situation will make it more likely for it to
occur in reality. For example, “If I get a thought about my mom being in an
accident means she has gotten/or will for sure get into an accident”, whether
or not that is true in reality. The second bias is more deeply rooted in morality.
It says that having an immoral thought is equivalent to immoral actions (e.g.
‘If I get a bad thought, I am a bad person’). Hence with Rachman’s theory,
the phenomenon of thought-action fusion came to life (Rachman, 1998).
This will be discussed in detail later on in this unit. According to Rachman’s
theory, the compulsions are maintained because the person assumes a
heightened sense of responsibility to prevent harm. The heightened sense
of responsibility is influenced by the above said biases in thinking. The
individual is in constant doubt about whether the harm has been reduced
or not. Thus, to remove this doubt the individual constantly engages in the
compulsive act to make sure the harm has been reduced. This phenomenon
can especially be seen in people who have compulsions related to checking.
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Mental Disorders - I Obsessive Compulsive Cognitions Working Group model: A group of
researchers, called the Obsessive Compulsive Cognitions Working Group
(OCCWG) first met each other at the world congress of behavioural
and cognitive therapies, Demark (1995). They collaboratively came
to understand OCD on the basis of three aspects, intrusions (thoughts,
images, urges), appraisals (which are the interpretations one gives to the
intrusions) and finally assumptions or beliefs about the appraisals. They
identified six major belief domains implicated in OCD (OCCWG, 1997)
These are, having an inflated sense of responsibility (“I am responsible to
prevent harm at any cost”), belief that all thoughts are of importance (over
importance of thoughts), overestimation of threat (any situation can be or
become dangerous), importance of controlling thoughts (“it is important for
me to control my thoughts, urges, impulses”), intolerance of uncertainty
(“if I don’t know what is happening some harm is likely to befall”) and
perfectionism (“There is a perfect way to solve all problems and I must be
perfect in doing that or else something bad will happen/I am not capable
enough to shoulder my responsibility”).
Metacognitive Model (Wells & Mathews, 1997): The metacognitive
model of OCD (Wells, 1997) proposed that metacognitive beliefs about
intrusive thoughts lead to maladaptive thinking, which they coined as
the Cognitive Attentional Syndrome (CAS). CAS consists of rumination,
worry, monitoring of threat, as well as overt and covert compulsive rituals.
All these are different ways of dealing with the distress associated with
obsessions. Two domains of metacognitive beliefs proposed were of
beliefs related to the importance of intrusive thoughts/feelings along with
how dangerous these can be if not addressed, along with beliefs related
to a need to perform compulsions. The first belief domain also called as
fusion beliefs, include three important beliefs, these are: thought-event
fusion (presence of a thought can cause events to happen/ belief that event
has already happened); thought-action fusion (presence of thoughts can
make a person engage in unwanted actions) and thought-object fusion
(presence of thoughts/feelings can be transferred into objects). The second
belief domain consists of beliefs about rituals specifically. These are most
often expressed in the form of declarative statements (e.g., “I should/must
clean my hands till I stop thinking about germs/dirt”) or can be seen as one
preparing a plan to monitor their actions better.
Self Assessment Questions 2
1. According to Salkovskis how do individuals appraise obsessive
thoughts?
2. Name the belief domains identified by the OCCWG.
3. What are three types of meta cognitive beliefs?
4. The concept of thought action fusion was first proposed by ________.
Family Involvement in OCD
OCD can lead to many interruptions in daily functioning causing distress
to the entire family. Family accommodation in OCD refers to the changes
that family members get in their own behavours in order to help reduce
the distress of the person suffering from OCD. These behaviours are also
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aimed at helping the person reduce the time taken in prolonged compulsive Obsessive Compulsive and
rituals. Family members have been seen doing the rituals as instructed by Related Disorders
the patient (e.g., patient may ask them to check the light switches, stove etc)
(these are also called as proxy compulsions). They may even sometimes get
cleaning supplies such as soaps or detergents of particular brands to meet
the demands of patients, choose timings of using washrooms according to
the patient’s needs, or even provide reassurance through verbal statements
to make the patient feel at ease. While sometimes the family members
themselves make these accommodations, at times patients demand such
behaviors and can become aggressive or upset when these demands are not
met. In the longer run, however, these are not helpful as patients continue
to avoid confronting their obsessions and don’t learn to tolerate the distress
associated with them. This strengthens their obsessions and the OCD cycle
is maintained. Higher levels of family involvement has been associated
with increased OCD symptoms as well as poor functional and treatment
outcomes (Foa & Kozak,1996).
9.3.2 Treatment of Obsessive Compulsive Disorder
Cognitive Behavioural Therapy (CBT): Behaviour Therapy (BT) and
CBT is often seen as the first line and important treatment in the management
of OCD (Krzyszkowiak, Kuleta-Krzyszkowiak, & Krzanowska, 2019).
The therapy focuses on Exposure and Response Prevention (ERP) as well
as challenging the idiosyncratic beliefs held by patients related to their
obsessions and compulsions (some of which have been mentioned in the
cognitive perspective above).
In ERP sessions, the patients are encouraged to gradually face the anxiety
provoking situations while preventing them from doing any compulsions/
rituals that can neutralize the anxiety. This is done by collaboratively
making hierarchies of feared situations, rated on the basis of the distress it
causes them (termed as Subjective Units of Distress or SUDs). The therapy
also makes use of behavioural experiments to help patients disconfirm their
beliefs and expected consequences of harm. The sessions can range from
13-20 sessions held weekly/bi-weekly, with 3-6 booster sessions offered
every month.
Medication: studies have shown that selective-serotonin reuptake inhibitors
(SSRIs) are effective in management of anxiety in the treatment of OCD.
Other medications often considered in the treatment are serotoninergic
tricyclic antidepressants such as clomipramine (Reddy et al., 2017).

9.4 BODY DYSMORPHIC DISORDER

Ever looked in the mirror and thought, “my forehead is so long”, “My
nose is so crooked”, “my pimples are ugly”, “My eyes are terribly huge/
small”, “my teeth are protruding out”, “what terrible hair”, “I wish I looked
prettier”?
Well, we all have done this sometime or the other. Many of us do not
feel good about how we look and hope to better/change our appearance.
However, how many times would you have engaged in such a behavior?
Now imagine someone engaging in such behaviours and engulfed in such
thoughts 24*7. Will that be distressing?
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Mental Disorders - I Let us see what happened with Anisha (box 9.3) to understand better.
Box 9.3: Anisha’s Story
19-year old Anisha, an undergraduate student came to the hospital after a
suicide attempt. Upon talking to her it was found that she was obsessively
preoccupied with how she looked. For years she referred herself as
the “ugliest duckling of the lot”. When she was 15 years old, she had
developed acne, which was highly distressing for her. From then onwards
she experienced disturbed sleep, felt irritable and low whenever there was
a break out of pimples. She would keep thinking, “If I touch my face and
burst the pimples, they will grow back worse and leave scars on my face. I
cannot deal with my acne.” She said that her face was ugly and the pores
on her skin are overly enlarged. She spends five to seven hours per day
checking her skin in front of the mirror or by opening her front camera
on the phone. She further sometimes washes her face 6-7 times daily. She
believes that, “If I clean my face every hour and keep my skin clean,
the pores will become smaller”, “I need to keep on checking my acne
otherwise I will not be able to manage the situation from getting worse”.
Several times she has scheduled dermatological consultations to ask the
doctor for skin peels and medication. She further consulted the doctor for
a cosmetic surgery, but was told that she did not need that. However, she
continued to believe that her acne was terrible and the skin pores were
enlarged. She feared others would make fun of her just like they did in
school. She became socially withdrawn as she thought “It’s better to be
by myself than go out with others making fun of me”, “If I go out I will
anyway not have a good time so what’s the point”. She would often feel
restless in public places as she believed that others were making fun of her
appearance. After overdosing on her acne medication in despair about
her condition, her family members brought her to the hospital. She further
reported that the doctors were not helping her with further medication
and facial peels which made her think that there is no solution left for her
acne. She felt hopeless and worthless which led to the suicidal attempt.
An Italian psychiatrist by name of Enrico Morselli was the first to talk
about dysmorphophobia in 1891. He believed that this condition is a
“subjective feeling of ugliness or physical defect which the patient feels
is noticeable to others, although the appearance is within normal limits.
The dysmorphophobic patient is really miserable; in the middle of his
daily routines, everywhere and at any time, he is caught by the doubt of
deformity.”
The current conceptualization of Body Dysmorphic Disorder (BDD) is in
line with what he mentioned and includes a preoccupation with appearance,
being excessively self-conscious including disproportionate concerns about
minor flaws as well as excessive and repetitive anxiety-provoking thoughts
about their imagined defects. Patients with BDD often find themselves
engaging in repeated mirror checking, comparing their appearance with
others, overly engaging in grooming themselves and can also resort to skin
picking when feeling distressed. They may seek reassurance from their
family or close friends which can maintain this cycle of preoccupation with
their looks. You may often find patients dealing with these difficulties first
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seeking help from dermatologists and plastic surgeons rather than mental Obsessive Compulsive and
health professionals. Related Disorders

DSM-5 (APA, 2013) also mentions that this preoccupation with appearance
must not be better explained by them having concerns about body fat/weight
and should not amount to an eating disorder. It also requires investigations
to be made for muscle dysmorphia as well as establishing the insight levels
as being good, fair, poor as well as absent insight with or without delusional
beliefs.
To understand the phenomenology of BDD let us look at some important
key elements of the disorder:
● Body image: An individual’s subjective sense of body image majorly
influences their overall quality of life as compared to the objective
‘reality’ of their appearance. Patients with BDD feel extremely
handicapped even though objectively they appear to have a ‘normal’
appearance for others. This discrepancy between their perceived body
image and the true reality leads to stigma experienced by them.
● Body image valence: This refers to how satisfied or dissatisfied one
is with their body image. While some people may not like certain
attributes in their body, they may not value their overall appearance
as much as other aspects such as family, relationships, career etc. For
people with BDD a high level of valence is placed on body image
whether they not only have former but also negatively evaluate their
body image.
● Overvalued ideas and Delusions: People with BDD have extreme
values related to importance of appearance which significantly impacts
their self- concept. However, they are ignorant to the consequences
that come along with it. Other than appearance, some people also
tend to place symmetry or perfectionism as highly important, whereas
others value being socially accepted which they think will happen
only if they have a ‘normal’ appearance. These overvalued ideas and
beliefs can sometimes take the form of rigid, unshakable beliefs and
turn to delusions.
● Metacognitions and Ruminations: Rumination for people with
BDD can take the form of mental imagery and thoughts about being
defective, ugly, thinking about the “why’s” (why am I so ugly?”, “why
did my nose have to be so imperfect?”), the “what’s and what if’s”
(“what will I do if my acne doesn’t get better?”, “What if I never look
better?”), self-punishing thoughts (“you deserve to be laughed upon
as you are so ugly”) reviewing past experiences as well as worrying
about the past and future which further leads to anxiety.
● Shame, Social anxiety and Perfectionism: Body shaming, an
integral phenomenon in BDD can take on a social/external evaluative
form (someone thinking they are inferior, bad or ugly), internal
form (being critical and nagging/punishing oneself), emotional form
(evoking feelings of self-disgust, hate, anger and humiliation) and
a behavioural form (avoidance of people and places, trying to meet
others standards). The fear of being negatively evaluated is often
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Mental Disorders - I present in people with BDD, thus it is not uncommon for them to
report symptoms of social anxiety disorder. People with BDD have
further been found to have perfectionistic standards of appearance and
behavior and are highly critical and harsh in evaluating themselves.
● Safety seeking behaviours and Compulsions: Safety seeking
behaviours are any attempts at reducing harm or a perceived
catastrophic event. People with BDD often find themselves engaging
in safety behaviours such as camouflaging, mirror checking, avoidance
or distracting the attention from specific disliked features of the
body, verifying features directly, using one’s phone or the mirror,
comparisons with others as well as reassurance seeking.
Prevalence, Age of Onset, and Gender Differences
The prevalence in USA has been estimated to be around 1-2% in the general
population. BDD seems to be more frequent among patients seeking cosmetic
treatments with 6-15% of the patients being diagnosed with dermatologic
conditions. Prevalence of BDD in dermatological and plastic surgery
patients have been reported to be 8%–15% (Phillips, Dufresne Jr, Wilkel, &
Vittorio, 2000) and 3%–53% (Aouizerate et al., 2003) respectively. BDD is
a chronic disorder, with an average duration of 15.7 years (Phillips & Diaz,
1997). Milder symptoms however may be episodic and aggravate during
stressful periods. Furthermore, family history data suggest that 6–10% of
first- degree family members have BDD (Richter et al., 2004).
The mean age of onset for BDD is in adolescence (as in the case of OCD),
with community studies indicating a higher prevalence of females with
BDD (Sadock, 2015). Family and twin study data provide preliminary
evidence for genetic susceptibility. Studies also reveal that males are more
likely to be preoccupied with small body build, small penis size, thinning
hair etc. while females could be preoccupied with their weight, breasts,
hips and excessive body hair. Women have also been found to perform
more repetitive and safety behaviors, are more likely to camouflage their
appearance using techniques like mirror- checking, changing their clothes,
picking their skin as well as having an eating disorder. Studies with BDD
patients show an equal sex incidence in people whether they are single or
separated. Commonly seen in adolescents and young adults, this disorder is
rarely seen among the elderly (Veale & Neziroglu, 2010).
Comorbidity
BDD is often under reported or under diagnosed due to shame associated
with the disorder. When patients with BDD do seek help they often presented
with co-morbid conditions such as major depressive disorder, social phobia,
obsessive-compulsive disorder, and substance abuse disorders (Gunstad &
Phillips, 2003).

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 Obsessive Compulsive and
Self-Assessment Questions 3 Related Disorders
1. Compulsive behavior is a phenomenon not seen in BDD.
 True/ False
2. People with BDD can have delusional beliefs. True/ False
3. Males have a higher prevalence rate in BDD as compared to females.
 True/ False
4. Camouflaging one’s perceived flaws shown by people with BDD is
an example of __________ behavior.
5. What are the different ways in which shame can manifest in BDD?
9.4.1 Etiology and Treatment of Body Dysmorphic Disorder
Etiology:
Neurobiological model: Neuroanatomical structures of the limbic system
including amygdala and insula are implicated in BDD. It has been found
that lesions in somatosensory cortex led to loss of perception, while those
of the right temporal lobe are responsible for one experiencing deficits in
their visual field, experiencing mood alterations and can lead to disorders
related to body image. Lesions in the parietal lobe have further been found
to have links for development of BDD (Yaryura-Tobias, Neziroglu, &
Torres-Gallegos, 2002).Abnormalities in serotonergic responses lead to
exaggerated inhibitory response in the fronto-striatal circuits. This is a
neurotransmitter circuit which is involved in reducing anxiety. The changes
seen in the serotonergic system thus may not be involved in someone
developing BDD directly but can result as the system becomes overloaded
as one’s anxiety increases. Hence SRI’s may be involved in the management
of this condition.
Behavioural model: Positive reinforcement of experiences with situations
involving one’s appearance has been found to play an important role in
the development of BDD (Neziroglu, 2004). Especially when these are
encountered early in life, a child may start believing that appearance is of
ultimate importance. Negative experiences further have shown to have an
impact on BDD. Instances of trauma linked to sexual and emotional abuse,
skin conditions like acne/ psoriasis, teasing, neglect, bullying, etc can result
in the person giving over importance to appearance, to the point of creating
distress. Vicarious learning happens when people see others being reinforced
on the basis of their appearance. This can especially be seen by the influence
of television advertisements of beauty products, beauty pageants or movie
actors advocating specific looks via their body type, clothes etc.
Cognitive model: The cognitive model of BDD places importance on a
phenomenon where people start seeing the self as an aesthetic object (Veale,
2002). Seeing oneself in a mirror can often act as a trigger, which is then
described as a self-perceived representation of a person’s appearance than
their true self. Internal triggers include somatic sensations (feeling puffy
under the eyes, tingling sensation in acne prone areas) as well as intrusive
thought (“Why is my nose so crooked?)”. This makes an individual engage
in self – focused attention where he/she becomes excessively aware of one’s
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Mental Disorders - I body image but from an observer’s perspective. The main components of
the self as an aesthetic object are:
● Mental imagery- This is an impression or representation of how they
think they appear to others. It can be negative, recurrent, and vivid
where the perceived distorted and the defective features are severely
highlighted.
● Self - focused attention/ cognitive fusion- An individual with BDD
may compare his/her appearance with others. When someone close is
perceived to be more attractive, the person may switch into a defensive
mode. This will lead to activation of safety seeking behavior, which
protects the individual. He/she may also attempt to escape from the
situation or camouflage themselves/ or their defects and avoid any
perceived threat (e.g., keeping the head down, covering face with
some hair or scarf, avoiding eye contact, wearing excessive makeup
etc.).
● Lack of a self-serving bias- People with BDD may choose to attend
to only those features that they consider to be defective which leads
to an experience of self-depreciation of their appearance.
Each of these components lead to one believing that they are nothing more
than an aesthetic object, eventually raising questions about their body image
and self-concept.
Treatment:
Cognitive behavior therapy (CBT) for BDD: CBT for BDD and has
been shown to be effective for adults. The treatment is focused on trying to
understand the patient’s assigned valence to his/her body image, their self-
appraisals of situations, cognitive biases, safety behavior and avoidance,
which may be maintaining the condition. CBT for BDD uses techniques such
as imagery re-scripting, modifying beliefs and appraisals, working through
attention biases, graded exposure tasks as well behavioural activation (in
cases of depression co-morbid with BDD) in the treatment of BDD.
Medication for BDD: In milder cases of BDD, medication may not be the
first line of treatment. However, if the BDD symptoms worsen or have been
maintained for long enough, then pharmacotherapy may be recommended.
Anti-depressant medication (serotonergic reuptake inhibitor) is often used
in treating moderate to severe BDD.
Self-Assessment Questions 4
1. Serotonergic system is not implicated in the development of BDD.
True/False
2. ________ reinforcement of appearances in childhood can lead to
development of BDD.
3. Lesions in _________ are responsible for loss of perception and are
implicated in body image disorders.
4. According to the cognitive perspective, a person with BDD starts
viewing him or herself as a _______ object.
5. A phenomenon seen in people with BDD, which makes them attend
to their perceived flaws excessively, is called __________.
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 Obsessive Compulsive and
9.5 LET US SUM UP Related Disorders
● ORCDs include OCD, BDD, trichotillomania, hoarding disorder and
excoriation
● Obsessions are repetitive, persistent, intrusive thoughts, images, or
impulses that are distressing, inappropriate, and ego dystonic.
● Compulsions are overt and covert repetitive behaviours that are
performed as lengthy rituals that help neutralise anxiety.
● OCD is the fourth commonest mental disorder with disability in
severe cases, with age of onset in adolescents and a worldwide lifetime
prevalence rate of 1.5% for women and 1% for men.
● The orbito-frontal–thalamic loop along with neurotransmitters
serotonin, dopamine and GABA are primarily implicated in
development of OCD.
● Psychoanalytic view sees development of OCD as a result of fixation
at and regression to the anal-sadistic stage of development. It proposes
two personality types, namely anal retentive and anal expulsive
personality. It also views OCD developing from a conflict between
the ego, superego as well as aggressive and sexual impulses emerging
from the id.
● The behavioural perspective on OCD has focused on the Mowrer’s
two-stage model of fear and avoidance behaviour.
● In the cognitive perspective, Salkovskis proposed phenomenon of
appraisals of intrusive thoughts (responsibility related appraisals),
Rachman proposed cognitive biases lead to catastrophic
misinterpretations of intrusive experiences, the OCCWG proposed six
major belief domains in OCD, and the metacognitive view proposed
importance of metacognitive beliefs.
● BDD involves a preoccupation of a person with appearance, being
excessively self-conscious including disproportionate concerns about
minor flaws as well as excessive and recurrent, anxiety-provoking
thoughts about an entirely imagined defect.
● Key elements identified in the phenomenology of BDD are: body image,
body image valence, overvalued ideas and delusions, ruminations
and meta-cognitions, shame, social anxiety and perfectionism, safety
seeking behaviours and compulsions.
● The mean age of onset for BDD is in adolescence, it seems to be more
frequent among patients seeking cosmetic treatments and in patients
diagnosed with dermatologic conditions.
● The serotonergic system is not implicated in the development of BDD
but could be the result of overloaded systems associated with BDD.
● Behavioural models view positive reinforcement of experiences with
physical appearance to play an important role in the development of
BDD. Instances of trauma linked to sexual and emotional abuse, skin
conditions like acne/ psoriasis, teasing, neglect, bullying etc, as well
as vicarious learning can have a significant impact on development of
BDD.
235
Mental Disorders - I ● The cognitive model of BDD emphasizes on the experience of the self
as an aesthetic object with its main components being mental imagery,
self - focused attention/ cognitive fusion, self-focused attention and
lack of a self-serving bias.
● While therapy, especially CBT appears to be the first line treatment
in both disorders, SSRI’s are also usually considered in treatment of
moderate to severe conditions.

9.6 KEY WORDS

Obsessive compulsive disorder (OCD): involves the presence of unwanted,
intrusive and repetitive thoughts, images or urges that are accompanied by
compulsive behaviours performed to neutralize the distress associated with
obsessions or to prevent some feared situation from happening.
Cognitive attentional Syndrome: consists of rumination, worry, monitoring
of threat, as well as overt and covert compulsive rituals.
Thought-action fusion: presence of thoughts can make a person engage in
unwanted actions.
Body Dysmorphic Disorder (BDD): includes a preoccupation with
appearance, being excessively self-conscious including disproportionate
concerns about minor flaws as well as excessive and repetitive anxiety-
provoking thoughts about their imagined defects.

9.7 ANSWERS TO SELF ASSESSMENT

QUESTIONS
Answers to Self Assessment Questions 1
1. True
2. False
3. True
4. Mental compulsions
5. Reducing anxiety or feared consequences.
Answers to Self-Assessment Questions 2
1. Individuals appraise obsessive thoughts as harm to themselves or
others being a serious risk, and the individual being responsible for
the harm.
2. Inflated responsibility, over importance of thoughts, importance
of controlling thoughts, overestimation of threat, intolerance of
uncertainty, perfectionism
3. Thought-event fusion, thought-action fusion and thought-object
fusion
4. Rachman
Answers to Self-Assessment Questions 3
1. False
2. True
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3. False Obsessive Compulsive and
Related Disorders
4. Safety seeking
5. Social/external evaluative form, internal form (criticism), emotional
form (disgust, anger, humiliation) behavioural form (avoidance)
Answers to Self-Assessment Questions 4
1. True
2. Positive
3. Right temporal lobe
4. Aesthetic object
5. Self-focused attention

9.8 UNIT END QUESTIONS

1. Describe the clinical features, prevalence, age of onset, and gender
differences in obsessive compulsive disorder.
2. Discuss the cognitive models explaining the etiology of OCD.
3. Explain the key elements of body dysmorphic disorder.
4. Discuss the etiology and treatment of body dysmorphic disorder.

9.9 REFERENCES
Alsobrook II, J. P., Leckman, J. F., Goodman, W. K., Rasmussen, S. A.,
& Pauls, D. L. (1999). Segregation analysis of obsessive‐compulsive
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Genetics, 88(6), 669–675.
Aouizerate, B., Pujol, H., Grabot, D., Faytout, M., Suire, K., Braud, C.,
… Tignol, J. (2003). Body dysmorphic disorder in a sample of cosmetic
surgery applicants. European Psychiatry, 18(7), 365–368.
Cavallini, M. C., Pasquale, L., Bellodi, L., & Smeraldi, E. (1999). Complex
segregation analysis for obsessive compulsive disorder and related disorders.
American Journal of Medical Genetics, 88(1), 38–43.
Fawcett, E. J., Power, H., & Fawcett, J. M. (2020). Women are at greater risk
of OCD than men: a meta-analytic review of OCD prevalence worldwide.
The Journal of Clinical Psychiatry, 81(4), 0.
Gunstad, J., & Phillips, K. A. (2003). Axis I comorbidity in body dysmorphic
disorder. Comprehensive Psychiatry, 44(4), 270–276.
Gururaj, G., Varghese, M., Benegal, V., Rao, G. N., Pathak, K., & Singh, L.
K. (2016). NIMHANS Publication No. 130. Bengaluru: National Institute
of Mental Health and Neuro Sciences, 2015–2016.
Hanna, G. L., Fischer, D. J., Chadha, K. R., Himle, J. A., & Van Etten, M.
(2005). Familial and sporadic subtypes of early-onset obsessive-compulsive
disorder. Biological Psychiatry, 57(8), 895–900.
Jaisoorya, T. S., Reddy, Y. J., Thennarasu, K., Beena, K. V., Beena, M.,
& Jose, D. C. (2015). An epidemological study of obsessive compulsive
disorder in adolescents from India. Comprehensive psychiatry, 61, 106-114.
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Mental Disorders - I Krzyszkowiak, W., Kuleta-Krzyszkowiak, M., & Krzanowska, E. (2019).
Treatment of obsessive-compulsive disorders (OCD) and obsessive-
compulsive-related disorders (OCRD). Psychiatria Polska, 53(4), 825–843.
Narayanaswamy, J. C., Viswanath, B., Cherian, A. V., Math, S. B., Kandavel,
T., & Reddy, Y. C. J. (2012). Impact of age of onset of illness on clinical
phenotype in OCD. Psychiatry Research, 200(2–3), 554–559.
Nicolini, H., Kuthy, I., Hernandez, E., & Velazquez, F. (1991). A Family
study of obsessive-compulsive disorder in a Mexican population ((Vol. 49,
p. 477). Univ Chicago Press 5720 S Woodlawn Ave, Chicago, IL 60637.
Phillips, K.A., & Diaz, S. (1997). Gender differences in body dysmorphic
disorder. J Nerv Ment Dis. 185:570–577.
Phillips, K. A., Dufresne Jr, R. G., Wilkel, C. S., & Vittorio, C. C. (2000).
Rate of body dysmorphic disorder in dermatology patients. Journal of the
American Academy of Dermatology, 42(3), 436–441.
Rachman, S. (1998). A cognitive theory of obsessions: Elaborations.
Behaviour Research and Therapy, 36(4), 385–401.
Rajashekharaiah, M., & Verma, P. (2016). Phenomenology of obsessions
and compulsions in Indian patients. International Journal of Contemporary
Medical Research, 3(7), 2139–2143.
Reddy, Y. C. J., Sundar, A. S., Narayanaswamy, J. C., & Math, S. B. (2017).
Clinical practice guidelines for obsessive-compulsive disorder. Indian
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Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2010). The
epidemiology of obsessive-compulsive disorder in the National Comorbidity
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Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-
behavioural analysis. Behaviour Research and Therapy, 23(5), 571–583.
Veale, D., & Neziroglu, F. (2010). Body dysmorphic disorder: A treatment
manual. John Wiley & Sons.
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Neuroanatomical correlates and somatosensorial disturbances in body
dysmorphic disorder. CNS Spectrums, 7(6), 432–434.

9.10 SUGGESTED READINGS

Clark, D. A. (2004). Cognitive-behavioral therapy for OCD. Guilford Press.
Freeston, M. H., Rhéaume, J., & Ladouceur, R. (1996). Correcting faulty
appraisals of obsessional thoughts. Behaviour Research and therapy, 34(5-
6), 433-446.
Himle, M. B., & Franklin, M. E. (2009). The more you do it, the easier it
gets: Exposure and response prevention for OCD. Cognitive and Behavioral
Practice, 16(1), 29-39.
Reddy, Y. C. J., Sundar, A. S., Narayanaswamy, J. C., & Math, S. B. (2017).
Clinical practice guidelines for obsessive-compulsive disorder. Indian
Journal of Psychiatry, 59(Suppl 1), S74.
Rachman, S. (1998). A cognitive theory of obsessions: Elaborations.
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Behaviour Research and Therapy, 36(4), 385–401. Obsessive Compulsive and
Related Disorders
Sharma, E., & Math, S. B. (2019). Course and outcome of obsessive-
compulsive disorder. Indian journal of psychiatry, 61(Suppl 1), S43–S50.
[Link]
Veale, D., & Neziroglu, F. (2010). Body dysmorphic disorder: A treatment
manual. John Wiley & Sons.
Veale, D. (2001). Cognitive–behavioural therapy for body dysmorphic
disorder. Advances in psychiatric treatment, 7(2), 125-132.
Web pages
[Link]
[Link]

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