We’re in day two of our Mental Health Month series where we discuss different DSM-5 diagnoses and the research behind them. Today we’re talking about Obsessive Compulsive and Related Disorders, including Body Dsymorphic Disorder.
What is Obsession?
Let’s distinguish the difference between being obsessed with something and obsession ruling your life.
If you have an obsession with Michael Kors, you probably don’t have a condition.
If you have an obsession with, like, that one show that, like, you stream on Netflix, you probably don’t have a condition.
If you had to touch all of the buttons, one by one, on the television, the remotes, the kitchen appliances, the computer, before you leave the house to prevent a house fire, and this becomes so disruptive you leave the house only twice a week for essentials (even when NOT in a pandemic), then you might think about searching for some support.
But OCD (obsessive-compulsive disorder) is not the only condition that exists under this category. There is also:
1.Body Dysmorphic Disorder
3.Trichotillomania (hair pulling)
4. Excoriation (skin-picking)
5. Substance/medication-induced obsessive compulsive and related
6.Obsessive-compulsive and related disorder due to another medical condition.
7. unspecified obsessive-compulsive and related disorder (like obsessional jealousy).
Is Hoarding Like That T.V Show?
Hoarding gained a lot of popularity after A&E came out with their show HOARDERS, which follows the lives of extreme hoarders, often living in squalor beneath their belongings. The people featured are often reluctant to get rid of their material items because of an obsessive emotional attachment to them. This doesn’t just extend into beautiful or valuable items, like a porcelain doll or an antique speaker; most people will be hard-pressed to give away something that has some semblance of importance or function. For the people on hoarders, even garbage or blankets covered in rat droppings and urine are part of their livelihood, either because of memories or because of the simple fact that that item, along with all the other items in the house, fills a void.
Indeed, those with Hoarding Disorder have “persistent difficulty discarding or parting with possessions, regardless of their actual value”, per the criteria of the diagnosis. That difficulty leads to an “accumulation of possessions that congest and clutter active living areas”, much like what you see on Hoarders. This causes “distress or impairment” in all areas of functioning.
We also see a variety of personalities on Hoarders. Some people have what the DSM calls “good or fair insight”. They recognize their hoarding has been causing problems, but feel both trapped and safe among their things. Some people have “poor insight”, in that the clutter isn’t viewed as problematic. As we see in the television show, some people with this level of insight will accept help but fight against losing too much stuff. Some revert back into their old ways after the trauma of losing things all over again. Those with “absent insight/delusional beliefs”, are absolutely convinced nothing is wrong–yes, to the extent of delusion. These are the people you see who halt the process in the show, and the house or yard is cleaned only in a hundred square feet or so.
These behaviors may be related to the temperament of the person, indecisiveness being a leading trait, and also related to some traumatic or stressful event that exacerbates the behavior. Let me give a personal example.
When I was 11, we lived in a two story, two bedroom apartment next to a registered sex offender and across from a drunken, drug-addled manager. My dad, a musician, also spent most of his free time drinking or working on cars, and it was only a matter of time before him and the manager got into an irreparable fight. The problem is, she was the manager and we were the tenants; her words against ours to property management meant nothing. We were evicted.
My parents’ credit was in the tank, and we were not rich, so no other apartments in town would take us and we bounced around from hotels, to a tent, to rooms in houses of family friends—that doesn’t sound terrible, but three years of much more drugs, alcohol, and uncertainty (in every place we stayed) isn’t all that fun.
A two-story, two bedroom apartment can hold a lot of stuff. Everything in my room except important papers and one hand-me-down banana republic plastic shelf went in the dump–bed included. We didn’t have enough space for all my stuff and my parent’s stuff in the small storage locker we rented, so we sacrificed most of our belongings.
I noticed I started clinging to things later when we finally got another apartment. I picked up stuff from the street I didn’t need–like broken street signs, discarded car review mirrors, desks, and even a bent reflector. I kept that bent reflector for ten years. In fact, I kept all of it for ten years. My closet is still full of junk I picked up from the street or things I thought were valuable from the dump. My room itself is cluttered, disorganized, and it took three years of picking through invaluable things with perceived value to keep at least two feet of walk space from my bed to the door. I still haven’t learned how to organize.
This example doesn’t mean I have Hoarding Disorder. I only share this to show that obsessions with material items don’t make people vain or stupid or rude. Loss and grief of any kind can make us cling to whatever solid, certain, undying thing we can find.
I don’t know how much of A&E’s Hoarders is dramatized for television. Sometimes it seems the film is edited to make the people look disgusting and defeated, and then a sob story told to make us feel pity. At the end we’re supposed to feel amazed the house is clean or disappointed in the person if it’s not, without recognizing the uniqueness of each individual’s process. All in all, the people are real. I don’t know about the show, though.
Is Body Dysmorphic Disorder Real?
In fact, it’s the first disorder listed in the category. People struggling with this perceive a defect or flaw in their appearance that seems slight to every one else but causes severe preoccupation for the sufferer. This could cause people to go to drastic measures to fix this flaw–which may include several cosmetic plastic surgery interventions, or cause them to remain indoors, trapped behind the fear that everyone will see, ridicule, and be disgusted by their flaw. This is not the same as being preoccupied with ones weight, and it cannot be Body Dysmorphia if the symptoms of an eating disorder are present.
This is linked to people who have relatives with OCD, and has been seen correlated with high rates of childhood neglect and abuse. Females are more likely to have a co-morbid (occuring at the same time) eating disorder and males are more likely to be preoccupied with their genital region. What does all of this mean?
It means life is a living hell. Being in the view of others causes such distress there are people who hide behind their curtains, in their house, for years. And this is, again, not a vain “omg nobody look at me”. This is such a level of heightened anxiety that an entire life is disrupted. I feel that many obsessive conditions get looked at as people being selfish: the person living with OCD can’t take care of their child because the compulsions take up most of the day–that means they don’t care about their kid enough. Or the people with Trichotillomania has pulled a bald spot on their head, but then complains about being nervous of others seeing the bald spot–they need to just stop pulling their hair. And things just aren’t that simple. None of this is vanity or selfishness, it’s anxiety, it’s stress, it’s trauma response.
Here is a great Ted Talk by Meredith Leston that highlights how body image is spread in the world and how troublesome views can lead to great distress and disruptive conditions for some people. Let’s remember: our environment plays a huge role in dictating which genes turn on and off. Everyone has the potential to develop a mental condition at some pointing their life. Why it happens to some and doesn’t to others not only depends on environment, but social factors and genetic make up too. Not so much brain chemistry.
If anyone watched Barcroft on Youtube, you might like this clip on Body Dysmorphia and OCD. I tend not to watch them too often, but sometimes they have okay material. Let me know how real or not real this is.
What Kind of Treatment is Available?
For some of these conditions, like Trichotillomania, there are no drugs that reduce symptoms. Even in cases of severe OCD, psychotropic medications fail miserable. This is a testament to how much we still don’t know and why some researchers are putting more weight on alternative treatments and Cognitive Behavioral Therapy, the only psychotherapy which has been tested (with high reliability AND validity) and proven to change the course of people’s thoughts.
This Double-blind, placebo controlled, Cross-over study examined the possibility for Milk Thistle as a treatment for Trichotillomania. They concluded their sample size too small to yield any confident results, and that their evidence only weakly supported the use for Milk Thistle.
This placebo study with Trichotillomania only further showed that 1) change is possible depending on expectations of the participant and 2) easy access, simple treatments for this condition remain elusive and the condition reminds misunderstood on a clinical level.
I will say that OCD itself gets a lot of research while these other disorders fall short of people interested in finding treatments. For OCD there is a long list of possible SSRI treatment, ECT treatment (if you don’t mind losing your memory), different therapies, stimulants, and even EMDR. This is why I speak on the disorders we don’t hear much about. Because for the rest of these unknown, quiet, hidden disorders, sloppy therapy and hopeful medication are thrown at patients. Many suffer in silence.
For a condition like Body Dysmorphic Disorder, other alternatives are being studied too. This experiment examines whether an intranasal dose of Oxytocin could cue a helpful response for BDD. This too failed. It increased self-blame and “other-directed blame”, and the researchers “advise against the use of Oxytocin in BDD patients”. Glad science kept us from THAT mistake.
But, for those diagnosed with BDD and Social Anxiety disorder, this study found that Cognitive Behavioral Therapy and attention retaining significantly improved the Body Dysmorphic aspect of the participants life.
There is some progress.
What can we do?
If someone comes to you and tells you they have been struggling with one of these conditions, withhold whatever your initial reaction is. Remind yourself that many who struggle with these types of conditions blame themselves enough. Even those who don’t blame themselves may still feel guilty for the disruption it causes their lives. I feel guilty sometimes for the disruptions my anxiety and Schizoaffective-ness has caused in my life and others lives.
Remember that they are not disgusting or vain or weird. Remember that there may be a whole list of trauma you’ve never learned about. Remember that even clinicians don’t understand this, probably because they’re trying to understand it on a biological level too much–some things need a different perspective in life.
So, this Mental Health Month, let’s keep in mind that there is a lot of suffering going on right now. Let’s not compare our pain to others, but instead use that energy to remind each other we’re not as alone as we feel. If you are suffering in silence, may this space give you the extreme–almost inhumane it feels sometimes– courage it takes to send a text, or call to someone you can trust. You can comment on this blog even, or contact me on my home page; eventually the burden of silence will hurt your back. It’s damn near broke mine before.
I write these posts in this format because I’m tired of articles listing symptoms, bland, over-used, understudied treatments, and urging people to talk to their doctor. It’s a good idea sometimes to seek professional help, but to do so uneducated and so desperate for relief that you’re unable to look at things critically will only trap you in the quantum loop that is the mental health system, especially if you’re in America. Mental Health Month is about education and reducing stigma. We can’t do that if we don’t preach from the side of lived experience AND scientific research.
Tomorrow we cover: Trauma and Stressor related DIsorders.
Next week, we cover: Schizophrenia, Bipolar, and Dissociative disorders. If you’d like to submit your story for any of these, please contact me HERE, or on my social media handles below:
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