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Whats the difference between BDD and hypochondriasis?

Whats the difference between BDD and hypochondriasis?


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I'm a new psychiatry trainee. I've run through the literature available to me (plus google), and the descriptions of body dysmorphic disorder (BDD) and hypochondriasis seem too similar. Here's what I've understood so far:

Hypochondriasis represents a general anxiety of disease/symptoms whereas BDD happens to revolve around a single issue. The former is more about somatic symptoms whereas the latter is about physical appearances. But I wonder if this understanding is correct and whether there is a clearer differentiation.


DSM-5 is the go to book for psychiatric dignoses and I would strongly recommend you pick up a copy if you are studying Psychiatry.

I am going to split my answer in 3 as you are talking about two different disgnoses and the 3rd part will be making a comparison between the two.

Hypochondriasis

The more recently approved Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains many revisions, but few are as sweeping as those involving somatoform disorders. In the updated edition, hypochondriasis and several related conditions have been replaced by two new, empirically derived concepts: Somatic Symptom Disorder and Illness Anxiety Disorder. They differ markedly from the somatoform disorders in DSM-IV.

To meet the diagnostic criteria for Somatic Symptom Disorder under DSM-5 (Page 311), patients must have:

The Somatic Symptom Disorder is considered persistant if it is characterised by severe symptoms, marked impairment, and long duration (more than 6 months).

The DSM also goes on to say that there are 3 levels of severity, which are:

  • Mild if only one of the symptoms specified in Criterion B is fulfilled.
  • Moderate If two or more of the symptoms specified in Criterion B are fulfilled.
  • Severe If two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).

Patients with illness anxiety disorder may or may not have a medical condition but have heightened bodily sensations, are intensely anxious about the possibility of an undiagnosed illness, or devote excessive time and energy to health concerns, often obsessively researching them. Like people with somatic symptom disorder, they are not easily reassured. Illness anxiety disorder can cause considerable distress and life disruption, even at moderate levels.

In DSM-5 Page 315 it states that the diagnostic critera for Illness Anxiety Disorder is

  1. Preoccupation with having or acquiring a serious illness.
  2. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.
  3. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.
  4. The individual performs excessive health-related behaviours (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).
  5. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time.
  6. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalised anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.

The DSM goes on to say that there are two types of Illness Anxiety Disorder

  • Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used.
  • Care-avoidant type: Medical care is rarely used.

Diagnostic Features

Most individuals with hypochondriasis are now classified as having somatic symptom disorder; however, in a minority of cases, the diagnosis of illness anxiety disorder applies instead…

Body Dysmorphic Disorder (BDD)

In DSM-5, BDD is described under Obsessive Compulsive Disorders.

BDD as described in DSM-5

  1. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others.
  2. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.
  3. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  4. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder.

Diagnostic Features

Individuals with body dysmorphic disorder (formerly known as dysmorphophobia) are preoccupied with one or more perceived defects or flaws in their physical appearance, which they believe look ugly, unattractive, abnormal, or deformed…

Comparison between Hypochondriasis and BDD

When you compare the two within the DSM they do differ as you suggest where Hypochondriasis is more about somatic symptoms as it is about perception of illness whereas BDD is about physical appearances. However when you look at the International Statistical Classification of Diseases (ICD) produced by the World Health Organisation, which is linked to in the DSM with the ICD codes at the top of each Diagnostic Criteria (for example 300.82 (F45.1) for Somatic Symptom Disorder - see image above), the 10th revision ICD code - ICD-10 - which is in brackets, refers to Section F45 of the ICD and this adds to the definitions.

F45 - Somatoform disorders

The main feature is repeated presentation of physical symptoms together with persistent requests for medical investigations, in spite of repeated negative findings and reassurances by doctors that the symptoms have no physical basis. If any physical disorders are present, they do not explain the nature and extent of the symptoms or the distress and preoccupation of the patient.

F45.2 - Hypochondriacal disorder

The essential feature is a persistent preoccupation with the possibility of having one or more serious and progressive physical disorders. Patients manifest persistent somatic complaints or a persistent preoccupation with their physical appearance. Normal or commonplace sensations and appearances are often interpreted by patients as abnormal and distressing, and attention is usually focused upon only one or two organs or systems of the body. Marked depression and anxiety are often present, and may justify additional diagnoses.

Body dysmorphic disorder
Dysmorphophobia (nondelusional)
Hypochondriacal neurosis
Hypochondriasis
Nosophobia

Excl.:
delusional dysmorphophobia (F22.8)
fixed delusions about bodily functions or shape (F22.-)

When reading this it confuses things as F45.2 considers BDD to be a somatic disorder as it is about perception rather than fact, however in my view, as psychiatry uses the DSM to distinguish between the two, in a psychiatric sense you get a definitive answer which you already have.

With psychosomatic disorders your mind can make your body act like it actually has the medical problem or make an actual problem like pain worse, where as in BDD your mind cannot alter the physical shape of the body.


The Connection Between Body Dysmorphic Disorder and Low Self-Esteem

Hemera/Thinkstock

We live in a society and culture that is constantly telling us that we are not good enough the way we are. We’re too fat or too skinny.

Our skin isn’t smooth enough, our pores are too big and we have too many wrinkles and blemishes. We need to have whiter teeth and shinier hair.

If we’re being told every day that we don’t look attractive enough naturally and need to fix certain parts of our bodies to be acceptable, it might start to become a challenge for people to have a healthy self-esteem.

This Article

And if many people are struggling with self-esteem issues, it can be difficult to draw the line between normal body image concerns and mental illnesses like body dysmorphic disorder.

For example, if I can hold down a full-time job and have a decent social life, but I think every day about how disgusting my stomach looks, and stare at my stomach every time I walk by a mirror or window and think about how much better I would look with a thinner stomach, is that normal?

Is it normal to feel so negatively toward certain body parts, yet still be able to get through life (maybe dragging a little)?

Is it only a disorder when you’re unable to work and have relationships with other people because of that preoccupation? Experts explain the link between low self-esteem and body dysmorphic disorder, and the differences that separate the two.

Body dysmorphic disorder (BDD) is officially defined as “a preoccupation with a defect in appearance,” according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). The manual has three major requirements in order for a person to be considered to have BDD:

1) “The defect is either imagined, or, if a slight physical anomaly is present, the individual’s concern is markedly excessive.”

2) “The preoccupation must cause significant distress or impairment in social, occupational, or other important areas of functioning.”

3) “The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)."

Karen Hylen, a primary therapist at Summit Malibu, a treatment facility for addictions and other disorders, said in an email that BDD is considered to be a somatoform disorder.

“This means that the person has the symptoms of a medical illness, but those symptoms cannot be explained by an actual physical illness,” Hylen said.

“BDD patients have an obsessive preoccupation with their physical appearance and usually a specific, imaginary defect on their body that they focus their attention entirely on. They often have a relentlessly negative view of themselves and how others view them, and regularly turn to cosmetic surgery in an effort to ‘fix themselves.’”

She said BDD and low self-esteem go together.

“You cannot have one without the other unless the person has gone through extensive therapy and treatment to reverse their negative, ruminating thoughts about themselves,” Hylen said.

“BDD is a lifelong disorder, but it can be managed with professional intervention.”

She said especially in today’s world, it can be challenging to decide when a person is suffering from more than low self-esteem unless a person has proper knowledge of the disorder.

“Low self-esteem is prevalent among Americans because of the ridiculous standards of beauty we have set for ourselves,” Hylen said.

“However, someone with BDD’s symptoms are exponentially worse than someone who simply has low self-esteem.”

People with low self-esteem might engage in some compulsive behaviors and have negative feelings toward their bodies or different body parts, but unless these thoughts and feelings take over to the point of causing a major disruption in everyday living, it’s not considered a disorder.

“A ‘normal’ person may spend a lot of time in front of the mirror putting on make-up, fixing their hair, and making a big effort to look their best before they go out in public,” Hylen said.

“They may not be happy with the end result, but they still engage in these activities. They will complain about how they look in pictures, or be shy, but they don’t disengage from reality.”

“Someone with BDD constantly obsesses about their appearance, spends hours in front of the mirror, throws fits because they don’t look how they want, [seeks] constant validation about their looks, turns to surgery as a way to change their bodies, focus on one or two specific imaginary defects on their bodies, and are never satisfied – no matter what – with just being themselves,” Hylen added.

Natascha Santos, a certified bilingual school psychologist and behavior therapist who specializes in obsessive compulsive disorder and body dysmorphic disorder, said in an email that people with BDD often have depression, which is associated with low self-esteem. Many BDD sufferers also have suicidal thoughts.

“With low self-esteem and overvalued ideation on this perceived/imagined body defect, they really believe that there is something wrong with the body part of concern,” Santos said.

Laura Cipullo, a registered dietician, certified diabetes educator and nutritionist, said in an email that some people recovering from eating disorders suffer from BDD, and even more suffer from low self-esteem.

“While there is no clinical definition of low self-esteem, it is generally defined as an absence of a sense of contentment and self-acceptance that stems from a person's appraisal of their own worth, significance, attractiveness, competence and ability to satisfy their aspirations,” Cipullo said.

“Those struggling with low self-esteem often take things very personally, have difficulty in social interactions, are unable to accept compliments, and have pessimistic tendencies. Low self-esteem puts one at greater risk for an eating disorder.”

She agreed that BDD and low self-esteem almost always are present together.

“Several studies have been conducted finding those suffering from BDD also experience lower self-esteem compared to those not suffering from the disorder,” Cipullo said.

“It is unclear at this time whether poor self-esteem predisposes one to BDD and/or is a consequence of the disorder, but a correlation definitely seems present.”

She added that today it might be easier to become obsessed over appearances if a person already has low self-esteem, since there is such an overall focus on physical beauty. However, it’s important to note that BDD is not something that will go away on its own usually, and it’s a disorder unlike low self-esteem, but treatment is available, such as cognitive behavioral therapy.

“BDD is not a disorder of vanity,” Cipullo said. “BDD is a serious mental disorder affecting both men and women.”

Stacey Rosenfeld, a licensed clinical psychologist, said in an email that low self-esteem is fairly common, especially in women, and that it’s even normal for women to be dissatisfied with their bodies in today’s society.

“However, when it goes beyond a fleeting thought or feeling and becomes a preoccupation that seems to be more important than anything else, that
is likely BDD,” Rosenfeld said.

“Plenty of people dislike aspects of their appearance, but in general feel good about themselves. They're able to look at the big picture. For those w/BDD, the focus becomes incredibly narrowed.”

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder: Fourth Edition: Text Revision. Arlington, VA: American Psychiatric Association, 2000.
http://www.psych.org/practice/dsm

Hylen, Karen. Email interview. April 24, 2012.
http://www.summitmalibu.com

Santos, Natascha. Email interview. April 24, 2012. http://nataschasantos.com/about

Cipullo, Laura. Email interview. April 25, 2012.
http://lauracipullollc.com

Rosenfeld, Stacey. Email interview. April 25, 2012. http://www.staceyrosenfeld.com

Reviewed April 26, 2012
by Michele Blacksberg RN
Edited by Jody Smith


Hypochondriasis and somatization: two distinct aspects of somatoform disorders?

We investigated boundaries and overlap between somatization and hypochondriasis on different levels of psychopathology: (1) comorbidity between hypochondriasis and somatization on the level of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV American Psychiatric Association, 1994): (2) comorbidity with other mental disorders (3) differences in clinical characteristics: and (4) overlap on the level of psychometric measures. The sample consisted of 120 psycho somatic inpatients. Somatoform, hypochondriacal, and depressive symptomatology, cognitions about body and health, and further aspects of general symptomatology were investigated. Diagnoses of Axis I and II were based on DSM-IV Our results suggest a large overlap on the level of DSM-IV-diagnoses: only 3 of 31 hypochondriacal patients had no multiple somatoform symptoms, while 58 of 86 patients with multiple somatoform symptoms had no hypochondriasis. However, the overlap between hypochondriacal and somatization symptomatology on the level of psychometric measurement is only moderate, indicating that hypochondriasis is a markedly distinct aspect of somatoform disorders.


What is Anorexia?

Anorexia is an eating disorder whereby the patients deliberately and without objectively apparent reasons drastically reduce their weight.

It may be a temporary disorder, but it is possible to become chronic and lead to a life-threatening condition.

Weight loss is achieved through strict low-calorie diets, vomiting, laxatives, excessive training. Very often the weight loss is drastic within a few months. Characteristically, patients perceive they are fat, despite the abnormally low body weight.

Anorexia mainly affects girls in puberty and young women. Less than 5% of the patients are male.

Symptoms of anorexia are:

  • Weight loss – a reduction of more than 15% of the normal for the age and height
  • Body mass index (BMI) below 17.5
  • Adolescent developmental disorders – secondary amenorrhea, etc.
  • Constipation – caused by the reduced amount of food
  • Cachexia, dry skin, hypotension, decreased body temperature, decreased heartbeat, disorders of the body’s water-balance, osteoporosis, etc.
  • Patients often lie about their feeding and weight.

The disease is caused by the interaction of mental, family, social and cultural factors. The causative factors include:

  • Genetic factors – in patients with family history the development of anorexia is 10 times more likely
  • Psychiatric factors – depression, panic disorder, abuse, and abnormality in sexual behavior often precede anorexia
  • Personal characteristics – in patients with anorexia, tendencies towards perfectionism, decreased initiative, and social fear are often observed.
  • Socio-cultural factors – cult to perfect appearance
  • Biological factors- perinatal hypoxia, premature birth, etc.

Diagnosis is based on:

  • Physical examination
  • Psychological evaluation
  • Laboratory tests – complete blood count, analysis of the electrolytes and protein, etc.

The therapy of the disease includes three main directions:

  • Rehabilitation and diet therapy
  • Psychotherapy
  • Work with the family to build an appropriate and supportive environment for the patient.

Complete remission occurs in 50% of the patients, in 30% occurs improvement in the symptom.


How Hypochondriasis and OCD Are Similar

Though the differences between OCD and hypochondriasis exceed the similarities, there are some characteristics that remain similar between the two. Important similarities are listed below.

Ways of Reducing Anxiety

Just as people with OCD often use compulsions or rituals, such as counting, checking, ordering or washing, to reduce anxiety related to obsessions, people with hypochondriasis will often try to reduce anxiety about their health by taking their pulse or checking their blood pressure. People with hypochondriasis may also frequently seek reassurance from doctors, family or friends to reduce anxiety about their health.

Impact on Life, Relationships, and Work

For both those who are living with OCD and those with hypochondriasis, the distress and worry are often so intense that there is a severe impact on interpersonal relationships and/or performance at school or work.

Safety Behaviors

Whether a person has OCD or hypochondriasis, safety behaviors, such as checking or seeking reassurance, are used to prevent a feared outcome, or to reduce distress and anxiety. The safety behaviors feel good and are therefore used again and again.

Safety behaviors actually maintain the fear and anxiety they are supposed to prevent because they keep the person from having new experiences that could help disprove their worries. For example, constantly running to the doctor for reassurance at the first sign of a stomachache does not allow a person with hypochondriasis to learn that dangerous symptoms often go away on their own.

For someone with OCD, constantly ordering shirts in the closet to prevent the death of a loved one will never allow them to learn that their loved one will be OK despite having not performed the ritual. For this reason, psychological therapies for both OCD and hypochondriasis specifically target these kinds of rituals and compulsions.

A Word From Verywell

Only a qualified mental health professional should diagnose a complex illness, such as OCD or hypochondriasis. Extensive assessment is often required to arrive at the correct diagnosis. The treatment you receive is very much tied to your diagnosis, so it is essential that you are diagnosed correctly.

If you feel that you are experiencing symptoms of either OCD or hypochondriasis, speak with your family doctor or a mental health professional.


What is Somatization Disorder?

Somatization disorder is defined as the presence of physical complaints over a period longer than 6 months that cannot be explained by a particular disease. Patients with somatic disorders have actual complaints, the brain perceives them as real, but they do not respond to organ pathology.

Somatization disorder occurs more common in women, in elderly people, and in individuals with low socio-economic status. About 50% of the individuals with this disorder suffer from other disorders such as anxiety, depression, etc.

Symptoms of somatization disorder are diverse and vary from patient to patient. Some of the most commonly reported symptoms are pain, fatigue, loss of appetite, and other gastrointestinal problems. Complaints usually remain for a long time, with one patient being able to alternate several different complaints over time. Regardless of the type and severity of the symptoms, no specific medical reason for their occurrence can be identified.

It is assumed that chronic stress is the main triggering factor of the somatization disorder.

The diagnosis of the somatization disorder is performed with the involvement of various medical specialists. In some individuals, multiple examinations and tests are needed in order to explain the symptoms and exclude other diseases.

The treatment of somatization disorder is done with medications and/or psychotherapy. The treatment is based on the severity and type of the symptoms and the age of the patient. The best therapeutic effect is achieved with the simultaneous use of pharmacotherapy and psychotherapy.


Abstract

Background/Objective

Unwanted mental intrusions (UMIs) are the normal variants of obsessions in Obsessive-Compulsive Disorder (OCD), preoccupations about defects in Body Dysmorphic Disorder (BDD), images about illness in Hypochondriasis (HYP), and thoughts about eating in Eating Disorders (EDs). The aim was to examine the similarities and differences in the functional links of four UMI contents, adopting a within-subject perspective. Method: 438 university students and community participants (Mage = 29.84, SD = 11.41 70.54% women) completed the Questionnaire of Unpleasant Intrusive Thoughts (QUIT) to assess the functional links (emotions, appraisals, and neutralizing/control strategies) of the most upsetting UMIs with OCD, BDD, HYP and EDs-contents. Results: HYP-related intrusions caused the highest emotional impact, OCD-related intrusions were the most interfering, and EDs-related intrusions interfered the least. The four UMI were equally ego-dystonic. Women appraised OCD-related intrusions more dysfunctionally, but men appraised the four intrusive contents similarly. All UMI instigated the urge to “do something”, to keep them under control and/or neutralizing them. Conclusions: Similarities among the functional links of intrusions related to OCD, BDD, HYP and EDs contents support their transdiagnostic nature and they might contribute to understanding common factors in these disorders.


Case description

Ms A, a 32-year-old single white female, was referred by her dermatologist to a BDD specialty clinic. She lived alone, was not involved in a romantic relationship, and had no children. Despite having completed college, she was employed as a part-time clerk in a clothing boutique. Ms A attributed her difficulties with obtaining full-time work to interference she experienced from intrusive thoughts and compulsive behaviors related to her appearance concerns.

Ms A looked normal but had been preoccupied with the appearance of her skin (minor blemishes and “uneven” skin tone) since age 13. She reported thinking about her appearance for at least 7 to 8 hours a day, and she worried that other people would notice her or judge her negatively because her skin looked so “ugly.” For 5 to 6 hours a day, Ms. A checked her skin in mirrors and other reflecting surfaces, picked her skin, and compared her skin with that of other people. She spent thousands of dollars a year on skin-care products, and she frequently bought special lighting and mirrors to better examine her skin.

Because she was so preoccupied with, and distressed by, her skin, Ms A was often late for work, and her productivity suffered, which resulted in conflicts with her supervisor. She often got “stuck” in the mirror at work, examining her skin. Because Ms A was so embarrassed about how she looked, and feared that other people would judge her negatively (eg, as �normal looking” and “hideous”), Ms A avoided all contact with friends and saw her family only on special occasions. Ms A reported feeling anxious and depressed over her skin. She also expressed passive suicidal ideation because she thought her skin looked so ugly.

Ms A had seen several dermatologists for treatment to improve her skin's appearance. Her compulsive skin picking was intended to improve perceived skin flaws by “smoothing” her skin and removing tiny blemishes. However, because her skin picking was difficult to control and occurred for several hours a day, this behavior caused skin irritation and slight redness and scarring. Ms A had undergone three dermatologic procedures but continued to be “obsessed” with improving the quality of her skin. “I just want to look normal!” she stated. Ms A reported that the dermatologic procedures had done little to change her perception of her skin's appearance and made her feel even more anxious and preoccupied. This was the first time Ms A had sought mental health treatment for her skin concerns. In the past, she had been reluctant to discuss her concerns with a mental health clinician for fear that she would be perceived as “superficial” or “vain.”


Symptoms of Body Dysmorphic Disorder

People who have body dysmorphic disorder are preoccupied or obsessed with one or more perceived flaws in their appearance. This preoccupation or obsession typically focuses on one or more body areas or features, such as their skin, hair, or nose. However, any body area or part can be the subject of concern.

The Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines the criteria for a diagnosis of body dysmorphic disorder.   BDD is not classified as an eating disorder in the DSM-5. Instead, it is listed under the category of "Obsessive-Compulsive and Related Disorders." The DSM-5 lists the following diagnostic criteria:

  • Preoccupation with one or more perceived defects in appearance that are not noticeable to others and are not truly disfigured.
  • At some point, the person suffering has performed repetitive actions or thoughts in response to the concerns. This may be something like continuously comparing his/her appearance to that of others, mirror checking, or skin picking.
  • This obsession causes distress and problems in a person’s social, work, or other areas of life.
  • This obsession isn’t better explained as a symptom of an eating disorder (although some people may be diagnosed with both).

Muscle dysmorphia or a preoccupation with the idea that your muscles are too small is considered a subtype of body dysmorphic disorder.


Understanding the Differences Between Impulsivity and Compulsivity

• Differences and similarities between impulsivity and compulsivity.
• Characteristics of impulsivity and compulsivity.
• Factors that contribute to impulsivity and those that contribute to compulsivity.
• Treatment approaches for impulsivity and compulsivity..

Who will benefit from reading this article?
Psychiatrists, primary care physicians, neurologists, nurse practitioners, and other health care professionals. Continuing medical education credit is available for most specialists. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing board.

Dr Berlin is assistant professor and Dr Hollander is Esther and Joseph Klingenstein Professor and chair, department of psychiatry at Mount Sinai School of Medicine in New York Dr Hollander is also director of the Seaver and New York Autism Center of Excellence at Mount Sinai.

Dr Berlin reports no conflicts of interest concerning the subject matter of this article Dr Hollander reports that he has received research grants from Solvay, Abbott, Ortho-McNeil, and Somaxon.

Impulsivity and compulsivity are natural behaviors controlled by brain mechanisms that are essential for survival in all species. Understanding these brain mechanisms may lead to targeted treatment strategies for these symptom domains when impulsivity and compulsivity become dysfunctional. Pathological impulsivity and compulsivity characterize a broad range of mental disorders and are the core and most debilitating symptoms, at least phenotypically, in some of the disorders in which these behaviors occur. These illnesses, some of which are highly heritable, are currently classified across several DSM-IV-TR diagnostic categories. Obsessive-compulsive spectrum disorders include obsessive-compulsive disorder (OCD), body dysmorphic disorder, trichotillomania, Tourette syndrome, and hypochondriasis. Disorders that involve deficits in impulse control include pathological gambling, externalizing disorders such as attention-deficit/hyperactivity disorder (ADHD), personality disorders such as borderline personality disorder, and substance and behavioral addictions.

Impulsivity versus compulsivity

The concept of impulsivity has many different aspects and definitions, but in general it covers a wide range of “actions that are poorly conceived, prematurely expressed, unduly risky, or inappropriate to the situation and that often result in undesirable outcomes,” or more simply put, a tendency to act prematurely and without foresight. 1 Moeller and colleagues 2 defined impulsivity as “a predisposition toward rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions to the impulsive individual or to others.” However, impulsivity is not always unplanned for example, some pathological gamblers plan in advance to pursue their impulsive behavior. Impulsive behaviors can be conceptualized as the core symptoms of a broad range of psychiatric disorders that are often comorbid with one another, including cluster B personality disorders, impulse control disorders, and bipolar disorder (Figure 1 restricted. Please see print version for content.).

In contrast, compulsivity refers to repetitive behaviors that are performed according to certain rules or in a stereotypical fashion. 3 Compulsivity is a tendency to repeat the same, often purposeless acts, which are sometimes associated with undesirable consequences. Impulsivity and compulsivity may be viewed as diametrically opposed, or alternatively, as similar, in that each implies a dysfunction of impulse control. 4 Each involves alterations within a wide range of neural processes including, for example, attention, perception, and coordination of a motor or cognitive response. Objective neurocognitive tests hold potential for elucidating the mechanisms by which pharmacological agents exert their beneficial clinical effects and for predicting clinical outcomes. 5,6 Using sensitive and domain-specific neurocognitive tasks, we may also be able to divide impulsivity and compulsivity into separate and quantifiable neuro-biologically specific domains. 7

Disorders characterized by impulsivity include impulse control disorders in DSM-IV-TR, representing a failure to resist aggressive impulses (as in intermittent explosive disorder) and urges to steal (kleptomania), set fires (pyromania), gamble (pathological gambling), and pull one’s hair (trichotillomania). However, behaviors characteristic of these disorders may also manifest as symptoms of another mental disorder. A number of other disorders are not included as a distinct category but are categorized as impulse control disorders not otherwise specified in DSM-IV-TR. These include sexual compulsions, compulsive shopping, skin picking, and Internet addiction. Impulse control disorders share the feature of the irresistible urge to act in a given way and may be considered as a subset of the obsessive-compulsive spectrum of disorders.

The obsessive-compulsive spectrum is a dimensional model of risk avoidance in which impulsivity and compulsivity represent polar opposite psychiatric spectrum complexes that can be viewed along a continuum of compulsive and impulsive disorders. Patients on the compulsive end of the spectrum tend to have an exaggerated sense of threat from the outside world and engage in rituals/routines, such as obsessive-compulsive behaviors, to neutralize the threat or reduce the harm. This end point marks compulsive or risk-aversive behaviors characterized by overestimation of the probability of future harm, as exemplified by OCD. However, some compulsive patients pursue unrewarding rituals for short-term gains (relief of tension) despite negative long-term consequences. Generally, however, OCD rituals are not pleasurable activities engaged in for their own sake but are neutral or often irritating and unpleasant behaviors that are performed to reduce anxiety.

Patients on the impulsive end of the spectrum tend to underestimate the harm that is associated with behaviors such as aggression, excessive gambling, or self-injury. This end point designates impulsive action generally characterized by a lack of consideration of the negative results of such behavior and is exemplified by borderline and antisocial personality disorders. 8 Some impulsive patients do recognize and assess the harm associated with the impulsive behavior but nonetheless engage in it because they find that the thrill or arousal they experience in response to the behavior outweighs the negative consequences.

Impulsive behaviors generally have an element of pleasure, at least initially, although they may lose their pleasurable quality over time. Some patients with impulse control disorders may engage in the behavior to increase arousal, but there may be a compulsive component to their behavior in which they continue to engage in the behavior to decrease dysphoria. So, in general, while compulsivity may be driven by an attempt to alleviate anxiety or discomfort, impulsivity may be driven by the desire to obtain pleasure, arousal, or gratification. Both types of behaviors share the inability to inhibit or delay repetitive behaviors. 9 Over time, impulsive behaviors may become compulsive (driven behaviors without arousal) and compulsive behaviors may become impulsive (reinforced habits).

Contributing factors

There are many contributing factors to impulsivity and compulsivity, such as genes, gender, environment, psychiatric disorders, and substance abuse. The neurobiology of impulsivity and compulsivity may involve inhibitory neurotransmitters such as serotonin and γ-aminobutyric acid (GABA) excitatory neurotransmitters such as glutamate, norepinephrine, and dopamine and prefrontal cortex and/or limbic dysfunction. Convergent evidence suggests that a failure in top-down cortical control mechanisms that leads to striatal overdrive may constitute a unifying pathophysiological model underpinning an “impulsive-compulsive spectrum” of mental disorders. 7 Increased frontal lobe activity may characterize the compulsive disorders, such as OCD. In contrast, decreased frontal lobe activity may characterize the impulsive disorders, such as pathological gambling and borderline personality disorder. 9

Impulsive and compulsive features may present at the same time or at different times during the same illness. 10 Although both compulsive and impulsive disorders may be related to prefrontal cortex dysfunction, compulsive disorders would be related to hyperactivity and impulsive disorders to hypoactivity of the prefrontal cortex. Compulsiveness appears to be associated with increased frontal lobe activity, while impulsiveness may be associated with reduced frontal lobe activity.

Treatment targets

The impulse control disorders can be conceptualized in addictive, affect-driven, and compulsive models (Figure 2). Targeted treatments of impulsivity in impulse control disorders can influence the motivational circuitry, or work via addictive, affect-driven, and compulsive systems. Treatments should also target comorbid bipolar spectrum, ADHD, and compulsive and addictive

disorders for maximal anti-impulsive effects (Figure 3). There is some evidence that different symptom dimensions within the impulse control disorders are particularly responsive to different medication classes. 11,12 It is therefore important to individualize treatment decisions based on the limited evidence base and the patient’s presenting problems, history, and comorbid conditions.

For example, a patient with borderline personality disorder with prominent cognitive/perceptual distortion may respond to neuroleptics, while a patient with depressed mood may respond best to antidepressants. Some symptom dimensions (eg, antisocial traits) may be less responsive to medication, and some classes of medication, including the benzodiazepines, do not appear particularly effective for the treatment of impulse control disorders and should generally be avoided. 13

There may be several unique developmental trajectories to impulsivity and compulsivity (eg, ADHD, bipolar spectrum, trait impulsivity, obsessive-compulsive personality disorder) and various routes to altering motivational circuitry, such as modulators of cortico-striatal-limbic circuits. We suggest that core symptoms within disorders should be treated and appropriate

outcome measures should be used to determine targeted treatment response. Interventions should be directed at the brain circuitry that modulates core symptoms, which may be shared across disorders rather than DSM diagnoses. 14

Although the neurobiological basis of OCD (symptoms and related cognitive impairments) is unclear, lesion, functional neuroimaging, and neuropsychological studies have suggested that structural and functional dysfunction of limbic or affective cortico-striato-thalamocortical circuitry, which includes the orbitofrontal cortex, plays a key role. 15-18 These circuits, first identified in nonhuman primates, have also been identified in human lesion and imaging studies of patients who have OCD. 19-23

Treatment approaches

Intervention can occur at the symptom, syndrome, or behavioral level. Effective treatment of impulsivity and compulsivity depends on determining the cause(s) of these behaviors and selecting treatments accordingly. Pharmacological and nonpharmacological treatment, such as behavioral strategies aimed at reducing impulsive and compulsive behavior, may be most effective for the long-term treatment of the underlying chronic or recurrent illness.

There is no standardized treatment for complex disorders involving impulsivity, although a range of different medication classes have been investigated. 13 Pharmacological treatments may reduce impulsivity and normalize arousal by decreasing dopaminergic activity, enhancing serotonergic activity, shifting the balance of amino acid neurotransmitter from excitatory (glutamatergic) toward inhibitory (GABAergic) transmission, lowering glutamatergic conduction, and/or reducing or stabilizing nonadrenergic effects. Medications used to treat disorders involving impulsivity, including impulse control disorders and cluster B personality disorders, which have been shown to be effective in some clinical trials, include SSRIs, lithium, and anticonvulsants. 14,24-31 Cognitive-behavioral therapy (CBT) and psychodynamically informed psychotherapy have a useful role in the management of a number of impulse control disorders. More specific details of the pharmacotherapeutic and psychotherapeutic approaches to each of the individual impulse control disorders can be found elsewhere. 32

With regard to compulsive behavior, the most common treatment approaches for OCD are pharmacological and psychological. CBT was the first psychological treatment for which empirical support was obtained. A recent review compared psychological treatments with treatment as usual and found that psychological treatments derived from cognitive-behavioral models are effective for adults with OCD. 33

On the basis of the hypothesized underlying neurobiology of OCD and observed treatment effects, SSRIs are considered first-line treatment for OCD. However, SSRIs are often associated with delayed onset of therapeutic effect (8 to 12 weeks), only partial symptom reduction, and response failure or intolerability in 40% to 60% of patients. Pharmacological options for SSRI-
refractory cases include increasing drug dosage, changing to another SSRI or clomipramine, combining SSRIs, or changing the mode of drug delivery. Augmentation with second-generation
antipsychotics appears promising, as well as augmentation or monotherapy with some of the anticonvulsants. 34-36

Alternative interventions

Some patients with OCD remain refractory to all standard pharmacological and psychological treatments. Several alternative medical interventions have been considered for these severe cases, including ablative neurosurgery and brain stimulation techniques such as electroconvulsive therapy, transcranial magnetic stimulation (TMS), and deep brain stimulation (DBS-the nonablative neurosurgical procedure). Studies that explore these techniques for OCD treatment are limited by small sample sizes and scarcity of double-blind trials, and none of these alternative interventions are FDA-approved for treatment of OCD. However, given the promising efficacy findings thus far, reversibility, noninvasiveness or minimal invasiveness, tolerability, and possibility of double-blind trials, additional research should be conducted with TMS and DBS to refine these techniques, better establish their efficacy, and offer more options to patients who have exhausted all other available treatments. 37

Patients with comorbid disorders

Clinicians should also identify comorbid conditions and associated symptoms related to brain systems, because these can also influence treatment choice and response. For example, mood stabilizers, traditionally used to treat bipolar disorder, can be effective for other disorders, including impulse control disorders.

When treating patients at risk for bipolar disorder, SSRI-induced manic behaviors could emerge in pathological gamblers who have a history of, or are at risk for, mania or hypomania. 24 Thus, mood stabilizers such as lithium or valproate may be better treatment options for patients with comorbid impulse control disorder and bipolar disorder. Personality disorders with aggressive behavior and emotionally unstable character disorder with a disturbance of mood swings respond to lithium. A variety of personality factors and comorbid conditions such as premenstrual syndrome, bulimia, agoraphobia, major affective disorder (eg, bipolar II), and hypersomnia, which are overrepresented in patients with borderline personality disorder, often complicate the clinical picture. Depending on a mix of these factors, certain drugs may need to be avoided, nonstandard drug combinations may be needed, or safer but less effective drugs may need to replace more effective drugs whose abuse by suicidal patients may have more dangerous consequences. 38

OCD is heterogeneous in terms of types of obsessions and compulsions, heritability, and comorbid conditions, which probably reflect heterogeneity in the underlying pathology. 18 Accordingly, there are many disorders known as obsessive-compulsive spectrum disorders that share features with OCD, including trichotillomania and body dysmorphic disorder. 39,40

The apparent association between altered serotonergic function and OCD has guided attention toward the possible role of serotonergic function in the underlying cause of trichotillomania. 41 Some investigators have postulated that patients with trichotillomania who engage primarily in hair pulling, where their attention is focused on the hair pulling, are more phenomenologically similar to individuals with compulsions in OCD than those with automatic hair pulling that occurs outside conscious awareness, and thus they may be more responsive to pharmacological interventions found to be effective for OCD. 42-43 A number of investigations of the use of antidepressants with specific inhibition of serotonin reuptake (ie, fluoxetine and clomipramine) have yielded mixed results. 44-48 Naltrexone, an opioid antagonist, has been found to be superior to placebo in reducing trichotillomania symptoms. 49 Also, augmentation of SSRIs with atypical neuroleptics may be beneficial, and olanzapine may be effective as a mono-therapy for trichotillomania, as well as CBT. 50-55

Body dysmorphic disorder is a relatively common and often disabling somatoform disorder that may be an obsessive-compulsive spectrum disorder because of its similarity to OCD. 40 There is some evidence for familial aggregation and genetic links with OCD. 56 Although body dysmorphic disorder is still difficult to treat, success has been demonstrated for serotonin reuptake inhibitors and CBT. 57 A clear role for the serotonin system is evidenced by the specificity of therapeutic response to serotonergic antidepressants. 58 Higher doses of SSRIs and longer treatment trials than those used for many other psychiatric disorders, including depression, may be needed to effectively treat body dysmorphic disorder. CBT, using techniques such as cognitive restructuring, behavioral experiments, response (ritual) prevention, and exposure, also appears beneficial and is currently considered the psychotherapy of choice for body dysmorphic disorder. 59

In general, evidence suggests that mood stabilizers appear to be effective for treating the symptom domains of impulsivity and compulsivity across a wide range of psychiatric disorders and for impulse control and cluster B personality disorders in particular. We suggest that clinicians target and treat core symptoms of impulsivity and compulsivity based on the underlying neurobiology of these behaviors instead of the overall diagnosis, while taking into account comorbid disorders, associated symptoms, developmental trajectory, and family history.


What is Anorexia?

Anorexia is an eating disorder whereby the patients deliberately and without objectively apparent reasons drastically reduce their weight.

It may be a temporary disorder, but it is possible to become chronic and lead to a life-threatening condition.

Weight loss is achieved through strict low-calorie diets, vomiting, laxatives, excessive training. Very often the weight loss is drastic within a few months. Characteristically, patients perceive they are fat, despite the abnormally low body weight.

Anorexia mainly affects girls in puberty and young women. Less than 5% of the patients are male.

Symptoms of anorexia are:

  • Weight loss – a reduction of more than 15% of the normal for the age and height
  • Body mass index (BMI) below 17.5
  • Adolescent developmental disorders – secondary amenorrhea, etc.
  • Constipation – caused by the reduced amount of food
  • Cachexia, dry skin, hypotension, decreased body temperature, decreased heartbeat, disorders of the body’s water-balance, osteoporosis, etc.
  • Patients often lie about their feeding and weight.

The disease is caused by the interaction of mental, family, social and cultural factors. The causative factors include:

  • Genetic factors – in patients with family history the development of anorexia is 10 times more likely
  • Psychiatric factors – depression, panic disorder, abuse, and abnormality in sexual behavior often precede anorexia
  • Personal characteristics – in patients with anorexia, tendencies towards perfectionism, decreased initiative, and social fear are often observed.
  • Socio-cultural factors – cult to perfect appearance
  • Biological factors- perinatal hypoxia, premature birth, etc.

Diagnosis is based on:

  • Physical examination
  • Psychological evaluation
  • Laboratory tests – complete blood count, analysis of the electrolytes and protein, etc.

The therapy of the disease includes three main directions:

  • Rehabilitation and diet therapy
  • Psychotherapy
  • Work with the family to build an appropriate and supportive environment for the patient.

Complete remission occurs in 50% of the patients, in 30% occurs improvement in the symptom.


Hypochondriasis and somatization: two distinct aspects of somatoform disorders?

We investigated boundaries and overlap between somatization and hypochondriasis on different levels of psychopathology: (1) comorbidity between hypochondriasis and somatization on the level of diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV American Psychiatric Association, 1994): (2) comorbidity with other mental disorders (3) differences in clinical characteristics: and (4) overlap on the level of psychometric measures. The sample consisted of 120 psycho somatic inpatients. Somatoform, hypochondriacal, and depressive symptomatology, cognitions about body and health, and further aspects of general symptomatology were investigated. Diagnoses of Axis I and II were based on DSM-IV Our results suggest a large overlap on the level of DSM-IV-diagnoses: only 3 of 31 hypochondriacal patients had no multiple somatoform symptoms, while 58 of 86 patients with multiple somatoform symptoms had no hypochondriasis. However, the overlap between hypochondriacal and somatization symptomatology on the level of psychometric measurement is only moderate, indicating that hypochondriasis is a markedly distinct aspect of somatoform disorders.


The Connection Between Body Dysmorphic Disorder and Low Self-Esteem

Hemera/Thinkstock

We live in a society and culture that is constantly telling us that we are not good enough the way we are. We’re too fat or too skinny.

Our skin isn’t smooth enough, our pores are too big and we have too many wrinkles and blemishes. We need to have whiter teeth and shinier hair.

If we’re being told every day that we don’t look attractive enough naturally and need to fix certain parts of our bodies to be acceptable, it might start to become a challenge for people to have a healthy self-esteem.

This Article

And if many people are struggling with self-esteem issues, it can be difficult to draw the line between normal body image concerns and mental illnesses like body dysmorphic disorder.

For example, if I can hold down a full-time job and have a decent social life, but I think every day about how disgusting my stomach looks, and stare at my stomach every time I walk by a mirror or window and think about how much better I would look with a thinner stomach, is that normal?

Is it normal to feel so negatively toward certain body parts, yet still be able to get through life (maybe dragging a little)?

Is it only a disorder when you’re unable to work and have relationships with other people because of that preoccupation? Experts explain the link between low self-esteem and body dysmorphic disorder, and the differences that separate the two.

Body dysmorphic disorder (BDD) is officially defined as “a preoccupation with a defect in appearance,” according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). The manual has three major requirements in order for a person to be considered to have BDD:

1) “The defect is either imagined, or, if a slight physical anomaly is present, the individual’s concern is markedly excessive.”

2) “The preoccupation must cause significant distress or impairment in social, occupational, or other important areas of functioning.”

3) “The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa)."

Karen Hylen, a primary therapist at Summit Malibu, a treatment facility for addictions and other disorders, said in an email that BDD is considered to be a somatoform disorder.

“This means that the person has the symptoms of a medical illness, but those symptoms cannot be explained by an actual physical illness,” Hylen said.

“BDD patients have an obsessive preoccupation with their physical appearance and usually a specific, imaginary defect on their body that they focus their attention entirely on. They often have a relentlessly negative view of themselves and how others view them, and regularly turn to cosmetic surgery in an effort to ‘fix themselves.’”

She said BDD and low self-esteem go together.

“You cannot have one without the other unless the person has gone through extensive therapy and treatment to reverse their negative, ruminating thoughts about themselves,” Hylen said.

“BDD is a lifelong disorder, but it can be managed with professional intervention.”

She said especially in today’s world, it can be challenging to decide when a person is suffering from more than low self-esteem unless a person has proper knowledge of the disorder.

“Low self-esteem is prevalent among Americans because of the ridiculous standards of beauty we have set for ourselves,” Hylen said.

“However, someone with BDD’s symptoms are exponentially worse than someone who simply has low self-esteem.”

People with low self-esteem might engage in some compulsive behaviors and have negative feelings toward their bodies or different body parts, but unless these thoughts and feelings take over to the point of causing a major disruption in everyday living, it’s not considered a disorder.

“A ‘normal’ person may spend a lot of time in front of the mirror putting on make-up, fixing their hair, and making a big effort to look their best before they go out in public,” Hylen said.

“They may not be happy with the end result, but they still engage in these activities. They will complain about how they look in pictures, or be shy, but they don’t disengage from reality.”

“Someone with BDD constantly obsesses about their appearance, spends hours in front of the mirror, throws fits because they don’t look how they want, [seeks] constant validation about their looks, turns to surgery as a way to change their bodies, focus on one or two specific imaginary defects on their bodies, and are never satisfied – no matter what – with just being themselves,” Hylen added.

Natascha Santos, a certified bilingual school psychologist and behavior therapist who specializes in obsessive compulsive disorder and body dysmorphic disorder, said in an email that people with BDD often have depression, which is associated with low self-esteem. Many BDD sufferers also have suicidal thoughts.

“With low self-esteem and overvalued ideation on this perceived/imagined body defect, they really believe that there is something wrong with the body part of concern,” Santos said.

Laura Cipullo, a registered dietician, certified diabetes educator and nutritionist, said in an email that some people recovering from eating disorders suffer from BDD, and even more suffer from low self-esteem.

“While there is no clinical definition of low self-esteem, it is generally defined as an absence of a sense of contentment and self-acceptance that stems from a person's appraisal of their own worth, significance, attractiveness, competence and ability to satisfy their aspirations,” Cipullo said.

“Those struggling with low self-esteem often take things very personally, have difficulty in social interactions, are unable to accept compliments, and have pessimistic tendencies. Low self-esteem puts one at greater risk for an eating disorder.”

She agreed that BDD and low self-esteem almost always are present together.

“Several studies have been conducted finding those suffering from BDD also experience lower self-esteem compared to those not suffering from the disorder,” Cipullo said.

“It is unclear at this time whether poor self-esteem predisposes one to BDD and/or is a consequence of the disorder, but a correlation definitely seems present.”

She added that today it might be easier to become obsessed over appearances if a person already has low self-esteem, since there is such an overall focus on physical beauty. However, it’s important to note that BDD is not something that will go away on its own usually, and it’s a disorder unlike low self-esteem, but treatment is available, such as cognitive behavioral therapy.

“BDD is not a disorder of vanity,” Cipullo said. “BDD is a serious mental disorder affecting both men and women.”

Stacey Rosenfeld, a licensed clinical psychologist, said in an email that low self-esteem is fairly common, especially in women, and that it’s even normal for women to be dissatisfied with their bodies in today’s society.

“However, when it goes beyond a fleeting thought or feeling and becomes a preoccupation that seems to be more important than anything else, that
is likely BDD,” Rosenfeld said.

“Plenty of people dislike aspects of their appearance, but in general feel good about themselves. They're able to look at the big picture. For those w/BDD, the focus becomes incredibly narrowed.”

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorder: Fourth Edition: Text Revision. Arlington, VA: American Psychiatric Association, 2000.
http://www.psych.org/practice/dsm

Hylen, Karen. Email interview. April 24, 2012.
http://www.summitmalibu.com

Santos, Natascha. Email interview. April 24, 2012. http://nataschasantos.com/about

Cipullo, Laura. Email interview. April 25, 2012.
http://lauracipullollc.com

Rosenfeld, Stacey. Email interview. April 25, 2012. http://www.staceyrosenfeld.com

Reviewed April 26, 2012
by Michele Blacksberg RN
Edited by Jody Smith


Abstract

Background/Objective

Unwanted mental intrusions (UMIs) are the normal variants of obsessions in Obsessive-Compulsive Disorder (OCD), preoccupations about defects in Body Dysmorphic Disorder (BDD), images about illness in Hypochondriasis (HYP), and thoughts about eating in Eating Disorders (EDs). The aim was to examine the similarities and differences in the functional links of four UMI contents, adopting a within-subject perspective. Method: 438 university students and community participants (Mage = 29.84, SD = 11.41 70.54% women) completed the Questionnaire of Unpleasant Intrusive Thoughts (QUIT) to assess the functional links (emotions, appraisals, and neutralizing/control strategies) of the most upsetting UMIs with OCD, BDD, HYP and EDs-contents. Results: HYP-related intrusions caused the highest emotional impact, OCD-related intrusions were the most interfering, and EDs-related intrusions interfered the least. The four UMI were equally ego-dystonic. Women appraised OCD-related intrusions more dysfunctionally, but men appraised the four intrusive contents similarly. All UMI instigated the urge to “do something”, to keep them under control and/or neutralizing them. Conclusions: Similarities among the functional links of intrusions related to OCD, BDD, HYP and EDs contents support their transdiagnostic nature and they might contribute to understanding common factors in these disorders.


Case description

Ms A, a 32-year-old single white female, was referred by her dermatologist to a BDD specialty clinic. She lived alone, was not involved in a romantic relationship, and had no children. Despite having completed college, she was employed as a part-time clerk in a clothing boutique. Ms A attributed her difficulties with obtaining full-time work to interference she experienced from intrusive thoughts and compulsive behaviors related to her appearance concerns.

Ms A looked normal but had been preoccupied with the appearance of her skin (minor blemishes and “uneven” skin tone) since age 13. She reported thinking about her appearance for at least 7 to 8 hours a day, and she worried that other people would notice her or judge her negatively because her skin looked so “ugly.” For 5 to 6 hours a day, Ms. A checked her skin in mirrors and other reflecting surfaces, picked her skin, and compared her skin with that of other people. She spent thousands of dollars a year on skin-care products, and she frequently bought special lighting and mirrors to better examine her skin.

Because she was so preoccupied with, and distressed by, her skin, Ms A was often late for work, and her productivity suffered, which resulted in conflicts with her supervisor. She often got “stuck” in the mirror at work, examining her skin. Because Ms A was so embarrassed about how she looked, and feared that other people would judge her negatively (eg, as �normal looking” and “hideous”), Ms A avoided all contact with friends and saw her family only on special occasions. Ms A reported feeling anxious and depressed over her skin. She also expressed passive suicidal ideation because she thought her skin looked so ugly.

Ms A had seen several dermatologists for treatment to improve her skin's appearance. Her compulsive skin picking was intended to improve perceived skin flaws by “smoothing” her skin and removing tiny blemishes. However, because her skin picking was difficult to control and occurred for several hours a day, this behavior caused skin irritation and slight redness and scarring. Ms A had undergone three dermatologic procedures but continued to be “obsessed” with improving the quality of her skin. “I just want to look normal!” she stated. Ms A reported that the dermatologic procedures had done little to change her perception of her skin's appearance and made her feel even more anxious and preoccupied. This was the first time Ms A had sought mental health treatment for her skin concerns. In the past, she had been reluctant to discuss her concerns with a mental health clinician for fear that she would be perceived as “superficial” or “vain.”


Symptoms of Body Dysmorphic Disorder

People who have body dysmorphic disorder are preoccupied or obsessed with one or more perceived flaws in their appearance. This preoccupation or obsession typically focuses on one or more body areas or features, such as their skin, hair, or nose. However, any body area or part can be the subject of concern.

The Diagnostic & Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines the criteria for a diagnosis of body dysmorphic disorder.   BDD is not classified as an eating disorder in the DSM-5. Instead, it is listed under the category of "Obsessive-Compulsive and Related Disorders." The DSM-5 lists the following diagnostic criteria:

  • Preoccupation with one or more perceived defects in appearance that are not noticeable to others and are not truly disfigured.
  • At some point, the person suffering has performed repetitive actions or thoughts in response to the concerns. This may be something like continuously comparing his/her appearance to that of others, mirror checking, or skin picking.
  • This obsession causes distress and problems in a person’s social, work, or other areas of life.
  • This obsession isn’t better explained as a symptom of an eating disorder (although some people may be diagnosed with both).

Muscle dysmorphia or a preoccupation with the idea that your muscles are too small is considered a subtype of body dysmorphic disorder.


Understanding the Differences Between Impulsivity and Compulsivity

• Differences and similarities between impulsivity and compulsivity.
• Characteristics of impulsivity and compulsivity.
• Factors that contribute to impulsivity and those that contribute to compulsivity.
• Treatment approaches for impulsivity and compulsivity..

Who will benefit from reading this article?
Psychiatrists, primary care physicians, neurologists, nurse practitioners, and other health care professionals. Continuing medical education credit is available for most specialists. To determine whether this article meets the continuing education requirements of your specialty, please contact your state licensing board.

Dr Berlin is assistant professor and Dr Hollander is Esther and Joseph Klingenstein Professor and chair, department of psychiatry at Mount Sinai School of Medicine in New York Dr Hollander is also director of the Seaver and New York Autism Center of Excellence at Mount Sinai.

Dr Berlin reports no conflicts of interest concerning the subject matter of this article Dr Hollander reports that he has received research grants from Solvay, Abbott, Ortho-McNeil, and Somaxon.

Impulsivity and compulsivity are natural behaviors controlled by brain mechanisms that are essential for survival in all species. Understanding these brain mechanisms may lead to targeted treatment strategies for these symptom domains when impulsivity and compulsivity become dysfunctional. Pathological impulsivity and compulsivity characterize a broad range of mental disorders and are the core and most debilitating symptoms, at least phenotypically, in some of the disorders in which these behaviors occur. These illnesses, some of which are highly heritable, are currently classified across several DSM-IV-TR diagnostic categories. Obsessive-compulsive spectrum disorders include obsessive-compulsive disorder (OCD), body dysmorphic disorder, trichotillomania, Tourette syndrome, and hypochondriasis. Disorders that involve deficits in impulse control include pathological gambling, externalizing disorders such as attention-deficit/hyperactivity disorder (ADHD), personality disorders such as borderline personality disorder, and substance and behavioral addictions.

Impulsivity versus compulsivity

The concept of impulsivity has many different aspects and definitions, but in general it covers a wide range of “actions that are poorly conceived, prematurely expressed, unduly risky, or inappropriate to the situation and that often result in undesirable outcomes,” or more simply put, a tendency to act prematurely and without foresight. 1 Moeller and colleagues 2 defined impulsivity as “a predisposition toward rapid, unplanned reactions to internal or external stimuli without regard to the negative consequences of these reactions to the impulsive individual or to others.” However, impulsivity is not always unplanned for example, some pathological gamblers plan in advance to pursue their impulsive behavior. Impulsive behaviors can be conceptualized as the core symptoms of a broad range of psychiatric disorders that are often comorbid with one another, including cluster B personality disorders, impulse control disorders, and bipolar disorder (Figure 1 restricted. Please see print version for content.).

In contrast, compulsivity refers to repetitive behaviors that are performed according to certain rules or in a stereotypical fashion. 3 Compulsivity is a tendency to repeat the same, often purposeless acts, which are sometimes associated with undesirable consequences. Impulsivity and compulsivity may be viewed as diametrically opposed, or alternatively, as similar, in that each implies a dysfunction of impulse control. 4 Each involves alterations within a wide range of neural processes including, for example, attention, perception, and coordination of a motor or cognitive response. Objective neurocognitive tests hold potential for elucidating the mechanisms by which pharmacological agents exert their beneficial clinical effects and for predicting clinical outcomes. 5,6 Using sensitive and domain-specific neurocognitive tasks, we may also be able to divide impulsivity and compulsivity into separate and quantifiable neuro-biologically specific domains. 7

Disorders characterized by impulsivity include impulse control disorders in DSM-IV-TR, representing a failure to resist aggressive impulses (as in intermittent explosive disorder) and urges to steal (kleptomania), set fires (pyromania), gamble (pathological gambling), and pull one’s hair (trichotillomania). However, behaviors characteristic of these disorders may also manifest as symptoms of another mental disorder. A number of other disorders are not included as a distinct category but are categorized as impulse control disorders not otherwise specified in DSM-IV-TR. These include sexual compulsions, compulsive shopping, skin picking, and Internet addiction. Impulse control disorders share the feature of the irresistible urge to act in a given way and may be considered as a subset of the obsessive-compulsive spectrum of disorders.

The obsessive-compulsive spectrum is a dimensional model of risk avoidance in which impulsivity and compulsivity represent polar opposite psychiatric spectrum complexes that can be viewed along a continuum of compulsive and impulsive disorders. Patients on the compulsive end of the spectrum tend to have an exaggerated sense of threat from the outside world and engage in rituals/routines, such as obsessive-compulsive behaviors, to neutralize the threat or reduce the harm. This end point marks compulsive or risk-aversive behaviors characterized by overestimation of the probability of future harm, as exemplified by OCD. However, some compulsive patients pursue unrewarding rituals for short-term gains (relief of tension) despite negative long-term consequences. Generally, however, OCD rituals are not pleasurable activities engaged in for their own sake but are neutral or often irritating and unpleasant behaviors that are performed to reduce anxiety.

Patients on the impulsive end of the spectrum tend to underestimate the harm that is associated with behaviors such as aggression, excessive gambling, or self-injury. This end point designates impulsive action generally characterized by a lack of consideration of the negative results of such behavior and is exemplified by borderline and antisocial personality disorders. 8 Some impulsive patients do recognize and assess the harm associated with the impulsive behavior but nonetheless engage in it because they find that the thrill or arousal they experience in response to the behavior outweighs the negative consequences.

Impulsive behaviors generally have an element of pleasure, at least initially, although they may lose their pleasurable quality over time. Some patients with impulse control disorders may engage in the behavior to increase arousal, but there may be a compulsive component to their behavior in which they continue to engage in the behavior to decrease dysphoria. So, in general, while compulsivity may be driven by an attempt to alleviate anxiety or discomfort, impulsivity may be driven by the desire to obtain pleasure, arousal, or gratification. Both types of behaviors share the inability to inhibit or delay repetitive behaviors. 9 Over time, impulsive behaviors may become compulsive (driven behaviors without arousal) and compulsive behaviors may become impulsive (reinforced habits).

Contributing factors

There are many contributing factors to impulsivity and compulsivity, such as genes, gender, environment, psychiatric disorders, and substance abuse. The neurobiology of impulsivity and compulsivity may involve inhibitory neurotransmitters such as serotonin and γ-aminobutyric acid (GABA) excitatory neurotransmitters such as glutamate, norepinephrine, and dopamine and prefrontal cortex and/or limbic dysfunction. Convergent evidence suggests that a failure in top-down cortical control mechanisms that leads to striatal overdrive may constitute a unifying pathophysiological model underpinning an “impulsive-compulsive spectrum” of mental disorders. 7 Increased frontal lobe activity may characterize the compulsive disorders, such as OCD. In contrast, decreased frontal lobe activity may characterize the impulsive disorders, such as pathological gambling and borderline personality disorder. 9

Impulsive and compulsive features may present at the same time or at different times during the same illness. 10 Although both compulsive and impulsive disorders may be related to prefrontal cortex dysfunction, compulsive disorders would be related to hyperactivity and impulsive disorders to hypoactivity of the prefrontal cortex. Compulsiveness appears to be associated with increased frontal lobe activity, while impulsiveness may be associated with reduced frontal lobe activity.

Treatment targets

The impulse control disorders can be conceptualized in addictive, affect-driven, and compulsive models (Figure 2). Targeted treatments of impulsivity in impulse control disorders can influence the motivational circuitry, or work via addictive, affect-driven, and compulsive systems. Treatments should also target comorbid bipolar spectrum, ADHD, and compulsive and addictive

disorders for maximal anti-impulsive effects (Figure 3). There is some evidence that different symptom dimensions within the impulse control disorders are particularly responsive to different medication classes. 11,12 It is therefore important to individualize treatment decisions based on the limited evidence base and the patient’s presenting problems, history, and comorbid conditions.

For example, a patient with borderline personality disorder with prominent cognitive/perceptual distortion may respond to neuroleptics, while a patient with depressed mood may respond best to antidepressants. Some symptom dimensions (eg, antisocial traits) may be less responsive to medication, and some classes of medication, including the benzodiazepines, do not appear particularly effective for the treatment of impulse control disorders and should generally be avoided. 13

There may be several unique developmental trajectories to impulsivity and compulsivity (eg, ADHD, bipolar spectrum, trait impulsivity, obsessive-compulsive personality disorder) and various routes to altering motivational circuitry, such as modulators of cortico-striatal-limbic circuits. We suggest that core symptoms within disorders should be treated and appropriate

outcome measures should be used to determine targeted treatment response. Interventions should be directed at the brain circuitry that modulates core symptoms, which may be shared across disorders rather than DSM diagnoses. 14

Although the neurobiological basis of OCD (symptoms and related cognitive impairments) is unclear, lesion, functional neuroimaging, and neuropsychological studies have suggested that structural and functional dysfunction of limbic or affective cortico-striato-thalamocortical circuitry, which includes the orbitofrontal cortex, plays a key role. 15-18 These circuits, first identified in nonhuman primates, have also been identified in human lesion and imaging studies of patients who have OCD. 19-23

Treatment approaches

Intervention can occur at the symptom, syndrome, or behavioral level. Effective treatment of impulsivity and compulsivity depends on determining the cause(s) of these behaviors and selecting treatments accordingly. Pharmacological and nonpharmacological treatment, such as behavioral strategies aimed at reducing impulsive and compulsive behavior, may be most effective for the long-term treatment of the underlying chronic or recurrent illness.

There is no standardized treatment for complex disorders involving impulsivity, although a range of different medication classes have been investigated. 13 Pharmacological treatments may reduce impulsivity and normalize arousal by decreasing dopaminergic activity, enhancing serotonergic activity, shifting the balance of amino acid neurotransmitter from excitatory (glutamatergic) toward inhibitory (GABAergic) transmission, lowering glutamatergic conduction, and/or reducing or stabilizing nonadrenergic effects. Medications used to treat disorders involving impulsivity, including impulse control disorders and cluster B personality disorders, which have been shown to be effective in some clinical trials, include SSRIs, lithium, and anticonvulsants. 14,24-31 Cognitive-behavioral therapy (CBT) and psychodynamically informed psychotherapy have a useful role in the management of a number of impulse control disorders. More specific details of the pharmacotherapeutic and psychotherapeutic approaches to each of the individual impulse control disorders can be found elsewhere. 32

With regard to compulsive behavior, the most common treatment approaches for OCD are pharmacological and psychological. CBT was the first psychological treatment for which empirical support was obtained. A recent review compared psychological treatments with treatment as usual and found that psychological treatments derived from cognitive-behavioral models are effective for adults with OCD. 33

On the basis of the hypothesized underlying neurobiology of OCD and observed treatment effects, SSRIs are considered first-line treatment for OCD. However, SSRIs are often associated with delayed onset of therapeutic effect (8 to 12 weeks), only partial symptom reduction, and response failure or intolerability in 40% to 60% of patients. Pharmacological options for SSRI-
refractory cases include increasing drug dosage, changing to another SSRI or clomipramine, combining SSRIs, or changing the mode of drug delivery. Augmentation with second-generation
antipsychotics appears promising, as well as augmentation or monotherapy with some of the anticonvulsants. 34-36

Alternative interventions

Some patients with OCD remain refractory to all standard pharmacological and psychological treatments. Several alternative medical interventions have been considered for these severe cases, including ablative neurosurgery and brain stimulation techniques such as electroconvulsive therapy, transcranial magnetic stimulation (TMS), and deep brain stimulation (DBS-the nonablative neurosurgical procedure). Studies that explore these techniques for OCD treatment are limited by small sample sizes and scarcity of double-blind trials, and none of these alternative interventions are FDA-approved for treatment of OCD. However, given the promising efficacy findings thus far, reversibility, noninvasiveness or minimal invasiveness, tolerability, and possibility of double-blind trials, additional research should be conducted with TMS and DBS to refine these techniques, better establish their efficacy, and offer more options to patients who have exhausted all other available treatments. 37

Patients with comorbid disorders

Clinicians should also identify comorbid conditions and associated symptoms related to brain systems, because these can also influence treatment choice and response. For example, mood stabilizers, traditionally used to treat bipolar disorder, can be effective for other disorders, including impulse control disorders.

When treating patients at risk for bipolar disorder, SSRI-induced manic behaviors could emerge in pathological gamblers who have a history of, or are at risk for, mania or hypomania. 24 Thus, mood stabilizers such as lithium or valproate may be better treatment options for patients with comorbid impulse control disorder and bipolar disorder. Personality disorders with aggressive behavior and emotionally unstable character disorder with a disturbance of mood swings respond to lithium. A variety of personality factors and comorbid conditions such as premenstrual syndrome, bulimia, agoraphobia, major affective disorder (eg, bipolar II), and hypersomnia, which are overrepresented in patients with borderline personality disorder, often complicate the clinical picture. Depending on a mix of these factors, certain drugs may need to be avoided, nonstandard drug combinations may be needed, or safer but less effective drugs may need to replace more effective drugs whose abuse by suicidal patients may have more dangerous consequences. 38

OCD is heterogeneous in terms of types of obsessions and compulsions, heritability, and comorbid conditions, which probably reflect heterogeneity in the underlying pathology. 18 Accordingly, there are many disorders known as obsessive-compulsive spectrum disorders that share features with OCD, including trichotillomania and body dysmorphic disorder. 39,40

The apparent association between altered serotonergic function and OCD has guided attention toward the possible role of serotonergic function in the underlying cause of trichotillomania. 41 Some investigators have postulated that patients with trichotillomania who engage primarily in hair pulling, where their attention is focused on the hair pulling, are more phenomenologically similar to individuals with compulsions in OCD than those with automatic hair pulling that occurs outside conscious awareness, and thus they may be more responsive to pharmacological interventions found to be effective for OCD. 42-43 A number of investigations of the use of antidepressants with specific inhibition of serotonin reuptake (ie, fluoxetine and clomipramine) have yielded mixed results. 44-48 Naltrexone, an opioid antagonist, has been found to be superior to placebo in reducing trichotillomania symptoms. 49 Also, augmentation of SSRIs with atypical neuroleptics may be beneficial, and olanzapine may be effective as a mono-therapy for trichotillomania, as well as CBT. 50-55

Body dysmorphic disorder is a relatively common and often disabling somatoform disorder that may be an obsessive-compulsive spectrum disorder because of its similarity to OCD. 40 There is some evidence for familial aggregation and genetic links with OCD. 56 Although body dysmorphic disorder is still difficult to treat, success has been demonstrated for serotonin reuptake inhibitors and CBT. 57 A clear role for the serotonin system is evidenced by the specificity of therapeutic response to serotonergic antidepressants. 58 Higher doses of SSRIs and longer treatment trials than those used for many other psychiatric disorders, including depression, may be needed to effectively treat body dysmorphic disorder. CBT, using techniques such as cognitive restructuring, behavioral experiments, response (ritual) prevention, and exposure, also appears beneficial and is currently considered the psychotherapy of choice for body dysmorphic disorder. 59

In general, evidence suggests that mood stabilizers appear to be effective for treating the symptom domains of impulsivity and compulsivity across a wide range of psychiatric disorders and for impulse control and cluster B personality disorders in particular. We suggest that clinicians target and treat core symptoms of impulsivity and compulsivity based on the underlying neurobiology of these behaviors instead of the overall diagnosis, while taking into account comorbid disorders, associated symptoms, developmental trajectory, and family history.


How Hypochondriasis and OCD Are Similar

Though the differences between OCD and hypochondriasis exceed the similarities, there are some characteristics that remain similar between the two. Important similarities are listed below.

Ways of Reducing Anxiety

Just as people with OCD often use compulsions or rituals, such as counting, checking, ordering or washing, to reduce anxiety related to obsessions, people with hypochondriasis will often try to reduce anxiety about their health by taking their pulse or checking their blood pressure. People with hypochondriasis may also frequently seek reassurance from doctors, family or friends to reduce anxiety about their health.

Impact on Life, Relationships, and Work

For both those who are living with OCD and those with hypochondriasis, the distress and worry are often so intense that there is a severe impact on interpersonal relationships and/or performance at school or work.

Safety Behaviors

Whether a person has OCD or hypochondriasis, safety behaviors, such as checking or seeking reassurance, are used to prevent a feared outcome, or to reduce distress and anxiety. The safety behaviors feel good and are therefore used again and again.

Safety behaviors actually maintain the fear and anxiety they are supposed to prevent because they keep the person from having new experiences that could help disprove their worries. For example, constantly running to the doctor for reassurance at the first sign of a stomachache does not allow a person with hypochondriasis to learn that dangerous symptoms often go away on their own.

For someone with OCD, constantly ordering shirts in the closet to prevent the death of a loved one will never allow them to learn that their loved one will be OK despite having not performed the ritual. For this reason, psychological therapies for both OCD and hypochondriasis specifically target these kinds of rituals and compulsions.

A Word From Verywell

Only a qualified mental health professional should diagnose a complex illness, such as OCD or hypochondriasis. Extensive assessment is often required to arrive at the correct diagnosis. The treatment you receive is very much tied to your diagnosis, so it is essential that you are diagnosed correctly.

If you feel that you are experiencing symptoms of either OCD or hypochondriasis, speak with your family doctor or a mental health professional.


What is Somatization Disorder?

Somatization disorder is defined as the presence of physical complaints over a period longer than 6 months that cannot be explained by a particular disease. Patients with somatic disorders have actual complaints, the brain perceives them as real, but they do not respond to organ pathology.

Somatization disorder occurs more common in women, in elderly people, and in individuals with low socio-economic status. About 50% of the individuals with this disorder suffer from other disorders such as anxiety, depression, etc.

Symptoms of somatization disorder are diverse and vary from patient to patient. Some of the most commonly reported symptoms are pain, fatigue, loss of appetite, and other gastrointestinal problems. Complaints usually remain for a long time, with one patient being able to alternate several different complaints over time. Regardless of the type and severity of the symptoms, no specific medical reason for their occurrence can be identified.

It is assumed that chronic stress is the main triggering factor of the somatization disorder.

The diagnosis of the somatization disorder is performed with the involvement of various medical specialists. In some individuals, multiple examinations and tests are needed in order to explain the symptoms and exclude other diseases.

The treatment of somatization disorder is done with medications and/or psychotherapy. The treatment is based on the severity and type of the symptoms and the age of the patient. The best therapeutic effect is achieved with the simultaneous use of pharmacotherapy and psychotherapy.



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