Understanding Body Dysmorphic Disorder: Symptoms, Types, and Treatment
Psychiatry • Liaison Medicine • Primary Care
Other Specified Obsessive‑Compulsive and Related Disorder
This category is used for clinically significant obsessive‑compulsive spectrum presentations that cause distress or impairment but do not meet full criteria for a specific OCRD subtype (for example, atypical hoarding, subthreshold body‑focused repetitive behaviour, or obsessional slowness). It allows clinicians to begin treatment while clarifying diagnosis.
Typical presentations
- Atypical hoarding behaviours causing functional problems but not meeting full hoarding disorder criteria.
- Subthreshold trichotillomania (hair‑pulling) or excoriation (skin‑picking) with distress but short duration or partial features.
- Obsessional slowness or predominant mental rituals that impair functioning but lack overt compulsions.
- Mixed or overlapping OCRD symptoms that are clinically significant but diagnostically ambiguous.
Assessment checklist
- Clarify phenomenology: content of obsessions, type of compulsions (overt vs mental), triggers and patterns of avoidance.
- Timeline and severity: onset, course, time spent on rituals, impact on work/home and prior treatments.
- Use validated scales where useful (Y‑BOCS, DOCS, MGH scales) and obtain collateral history from family/carers when possible.
- Screen for comorbidities: depression, anxiety, tic disorders, neurodevelopmental issues and substance use; consider medical/neurological causes for abrupt/atypical onset.
Management principles
- Immediate pragmatic care: validate distress, provide psychoeducation and start low‑intensity behavioural strategies (graded behavioural experiments, stimulus control, habit reversal for body‑focused behaviours).
- First‑line psychological treatment: CBT with ERP adapted to presentation—focus on reducing avoidance and safety behaviours even in atypical cases.
- Pharmacotherapy: SSRIs at OCD‑effective doses for persistent or severe symptoms; consider specialist augmentation strategies for treatment‑resistant cases.
- Coordinate care and set a time‑limited plan (4–8 weeks) for low‑intensity treatment with clear criteria for specialist referral if insufficient improvement.
Practical techniques
- Exposure and Response Prevention (ERP): tailor exposures to the individual’s rituals and avoidance; use imaginal ERP for mental rituals or where in vivo exposure is impractical.
- Habit Reversal Training (HRT): for hair‑pulling and skin‑picking—awareness training, competing response and stimulus control.
- Behavioural experiments and activity scheduling to restore function and reduce checking/neutralising behaviours.
When to escalate / red flags
- Severe functional impairment (e.g., rituals >2 hours/day), medical complications from behaviours (skin infection, self‑harm), suicidal ideation, or rapid deterioration—urgent specialist referral required.
- Abrupt onset, late age at onset, neurological signs, or poor response to initial treatment—consider medical/neurology evaluation for secondary causes.
Case vignette
Patient: L., 35, presents with 10 weeks of obsessional slowness while performing daily tasks leading to 90 minutes of delays getting ready and missing work. No prior history. Management: provide psychoeducation, start graded behavioural experiments (time‑limited tasks with timer), set measurable goals, schedule weekly review and plan referral to specialist CBT‑ERP clinic if limited improvement after 6–8 weeks; consider SSRI if distress remains high.
தமிழில் — சுருக்கம்
Other Specified OCRD என்பது OCD‑போன்ற அறிகுறிகள் ஆனால் குறிப்பிட்ட வகையாக வராத இடைநிலையை குறிக்கிறது. ஆரம்ப நிலை CBT, habit reversal மற்றும் ஒருங்கிணைந்த பராமரிப்பு பயன்படும்.
Key takeaways
- Use this diagnosis pragmatically to start timely, evidence‑based care when OCRD symptoms are impairing but diagnostic clarity is lacking.
- Prioritise CBT‑ERP and habit reversal techniques, set measurable short‑term goals and coordinate care with clear follow‑up and escalation criteria.
- Investigate for secondary medical causes in atypical or sudden onset cases and refer to specialist OCD services for treatment‑resistant presentations.