by Ian Osborn
Does hypochondriasis belong in the OC spectrum? It closely resembles OCD in involving insistent, irrational fears that lead to repetitive checking and reassurance seeking. On closer inspection, however, it differs from OCD in several important ways. First, the hypochondriac’s concern is for the present, whereas OCDers worry about the future. Second, the hypochondriac generally has some minor but real physical symptom, such as a skin blemish or stomach cramp. Finally, and perhaps most importantly, the patient with hypochondriasis almost always has less insight into the inappropriateness or senselessness of his concerns than an OCDer.
Despite all these differences, some cases of hypochondriasis seem almost identical to OCD. Recently a twenty-one-year-old student came to see me because of an intense fear of having AIDS. Well dressed, personable, and highly anxious, he shared with me that a month before he had noticed a “bump” on his neck. Afraid he might have cancer, he went to the student health center, where he was examined and informed that he had no serious disease. A few days later, however, when the lump seemed to change in texture, he needed to be reassured with a second opinion.
The next week, after studying in the library, he left a can of chewing tobacco behind. Returning a short time later and putting a pinch under his lip, he was immediately besieged by the fear that someone with AIDS might have “done something with it.” Again he presented to the health center. This time, however, neither a physical examination nor blood tests could put his mind at ease. He started reading everything he could find about AIDS and making calls to the Center for Disease Control in Atlanta. Then he found a lump on his lip. A dentist told him that this was merely a cold sore, but thoughts of having a malignant disease now started to torture him every minute of the day.
This student’s problem had the “feel” of genuine OCD—his obsessions being intrusive thoughts of disease, and his compulsions being repeated requests for reassurance. Further history revealed that he had a number of minor compulsions, including regularly checking appliances three or four times to make sure they were off. And just like OCDers, he was a very conscientious student, prone to anxiety and feelings of guilt when he did not perform up to expectations.
He was helped by the standard OCD treatments. Using the behavior therapy technique of exposure in the imagination, he rehearsed having various dreaded diseases and having to live or die with them. He also benefited from the SRI medication fluoxetine (Prozac) at a dose of 20 milligrams a day.
Yet, there are other cases of hypochondriasis that do not have the feel of genuine OCD. Not long ago I was asked to consult on a fifty-three-year-old woman who was in the hospital for chest pains. She had been hospitalized for these pains at least once a year for the last fifteen years. She came to the emergency room so frequently that all the staff there knew her by her first name. She had had hundreds of electrocardiograms, as well as three cardiac catheterizations. No heart disease had been found.
On interview, she described in the minutest detail the sharp pains that bored inwardly to her lungs then outwardly to encompass her ribs and arms. They would immobilize her, sometimes cause her to fall in her tracks. Usually they were accompanied by a fluttering of her heart and a feeling of faintness. She spoke in an intense and dramatic manner and talked on and on with hardly a pause. I felt smothered by her strong personality and nonstop talking.
This patient’s thoughts of illness were not intrusive, fearful, or unwanted. On the contrary, she used them to relate to people and to gain attention. She refused to consider the possibility that a nervous disorder could be playing a part in her symptoms, and she saw no reason for me to visit her a second time.
The difference between these two cases illustrates a major shortcoming in our current concept of hypochondriasis. In reality, hypochondriacal symptoms are probably related to several different syndromes, OCD being only one among them.
BODY DYSMORPHIC DISORDER
Dr. Turner’s tradesman, the one who feared having syphilis, gradually became obsessed with the condition of his nose, and finally with the unlikely idea that his nose would fall off. In hindsight, this man may have developed a second psychiatric disorder: body dysmorphic disorder (BDD).
BDD is the excessive preoccupation with a slight or imagined defect in appearance. BDD sufferers exaggerate the slightest wrinkle, scar, blemish, or vascular marking of a body part (nose, face, and skin are most common) and become terrified that this minor imperfection represents a serious abnormality.
A senior in high school with a typical case of body dysmorphic disorder was referred to me by her dermatologist. She presented as a plain and shy young woman, dressed unflatteringly in dirty jeans and a T-shirt. Self-consciously, with little eye contact, she told me her story.
I’ve been messing with my skin, and I don’t have the self-control to stop. I spend an hour in front of the mirror every night. Mainly it’s my nose. I’m always thinking that the pores are infected because they look too large. So I squeeze out all the moisture from every single pore. I’m saying to myself, “You shouldn’t do this. You really shouldn’t do this.” After I leave the bathroom, I feel all kinds of guilt. The most terrifying part of the day is when I get up in the morning and have to look at my skin. Sometimes I have some pretty bad bruises on my face, and I worry that they might turn into permanent scars.
My looks are on my mind almost all the time. My hair doesn’t look good no matter what I do, so now I keep it short. I cut every strand exactly, precisely the same length. I think about my lips a lot. They seem too big, like they are swollen, so I put a lot of cream on them, and sometimes they get cracked. Then there’s funny dots under my eyes that other people don’t have. I put a lot of cream on them, too. My cuticles around my nails don’t look right, either. I work on them a lot—often until they bleed. Then there’s a curve in my spine that really bothers me. I wonder if I can get that fixed. I look so bad. No one will ever want to marry me.
Body dysmorphic disorder, “imagined ugliness,” can lead to shame, disabling avoidance, and severe depression. In one study, fully 98 percent of BDD patients reported significant social impairment because of embarrassment over their appearance, 32 percent were housebound, 83 percent had suffered major depression, and 29 percent had made suicide attempts. One patient refused to drive a car because she feared her ugliness would be so shocking to other drivers that it would cause an accident.
A major complication of this disorder is unnecessary plastic surgery. A 1993 study of fifty BDD patients found that twenty had been operated on at least once for their “defects”; and one patient had had fifteen operations. Occasionally, BDD sufferers obsess about other people’s looks. I once treated a teenager with BDD who had managed to badger her family into getting a surgeon to operate on her sister’s nose.
Until the 1970s, this syndrome was variously considered a form of phobia (“dysmorphophobia”), hypochondriasis (“beauty hypochondriasis”), or obsessive-compulsive disorder. Pierre Janet, the great turn-of-the-century French psychiatrist, viewed BDD as closely related to OCD. Most twentieth-century psychiatrists have followed his lead.
The unwanted thoughts of BDD, after all, fit quite well the definition of obsessions. They are always intrusive, recurrent, resisted, and usually recognized as excessive. Also, more than 90 percent of BDD patients develop compulsions, most commonly mirror inspections, camouflaging perceived defects, comparisons to other people, and reassurance seeking. A 1997 study by by OCD experts Fugen Neziroglu and Jose Yaryura-Tobias compared the clinical characteristics of OCD and BDD. The conclusion was that BDD is best conceptualized as a variant of OCD.
Preliminary research supports the use of exposure and response prevention techniques in BDD and a few studies indicate that, like OCD, it also responds preferentially to SRI medications (although not as robustly as OCD). I personally have had good results using behavior therapy and SRI medications with BDD patients.
Two differences have been noted between body dysmorphic disorder and OCD. BDD patients show hig
her levels of associated depression, social withdrawal, and low self-esteem than do OCD patients. This is not surprising in view of the fact that BDD deals with physical appearance, a matter of great importance to self-esteem. More puzzling is the repeated finding that, as with hypochondriasis, BDD sufferers tend to have less insight into their disorder than OCDers. It is not clear why this is so, although it may be simply that when obsessions involve our own bodies it is especially hard to gain a distanced perspective on them.
TRICHOTILLOMANIA
Repetitive, excessive plucking or pulling out of hair was first described as a psychiatric disorder in 1889 by the French physician Hallopeau. He gave it a name that means “hair pulling insanity.” The features that he noted remain, with a few minor changes, our diagnostic criteria: noticeable hair loss, not due to a medical condition, that causes distress; an increasing sense of tension before pulling out the hair; pleasure or relief afterward.
Trichotillomania and OCD are similar in many ways. Both involve repetitive, uncontrollable behaviors that disturb people’s lives. Furthermore, both hair pulling and many of the typical rituals of OCD are related to grooming, a connection that has led OCD expert Judith Rapoport to speculate that both trichotillomania and OCD may involve an abnormal release of genetically coded grooming tendencies (see Chapter 8). Another similarity between trichotillomania and OCD is that in both disorders patients keep their problem a secret. Hair pulling, like OCD, was in the past thought to be uncommon but has now been found to be widespread. A recent survey of 2500 college students found that more than 1 in 200 had diagnosable trichotillomania.
The following excerpt from my first interview of a student with typical trichotillomania illustrates the similarities between this disorder and OCD, as well as a number of important differences. Katie, a twenty-five-year-old unmarried elementary schoolteacher, had returned to college to pursue a master’s degree. She came to our clinic early in her first semester, depressed and discouraged. I asked her to tell me about her problem.
KATIE: I pull out my hair all the time. I have no hair at all up here (pointing to the top of her head). I’ve pulled my hair back so people can’t notice. If I were to comb it forward you would see that it’s totally bald. When I was in college, it was just a little patch. Now, it’s the whole top of my head.
PSYCHIATRIST: You do a good job of camouflaging.
KATIE: I’ve had a lot of practice.
PSYCHIATRIST: What bothers you the most about the hair pulling?
KATIE: It’s just that … I don’t want to be bald. I’m always thinking people are staring at me. I can’t go swimming. I’m always wearing hats or bandanas. I hate if somebody’s standing behind me, like in an elevator. I can’t have normal relationships. The last time I had a boyfriend, he picked me up at my apartment, took one look at the floor, and said, “Boy, somebody’s going bald around here.” I just about died. Now, I’m too ashamed to have a boyfriend.
PSYCHIATRIST: For how long has hair pulling been a problem?
KATIE: I’ve done it since adolescence. It was my terrifying secret. Nobody knew but my mom, and the two of us never discussed it. I always wondered if anyone else ever had it. This is actually the first time in my life that I’ve ever told anyone about it.
PSYCHIATRIST: I notice you haven’t pulled any hair as we’ve been talking.
KATIE: No, I never do it in front of anyone, but at home it’s terrible. For hours I’m telling myself, “Quit it, quit it, quit it.” But I stop for a minute, and then I’m doing it again. I have to keep my hands busy, playing Nintendo or something, or else my hands are up there pulling. Half the time I don’t even realize I’m doing it. Sometimes I wonder if I do it in my sleep.
PSYCHIATRIST: Does it feel pleasurable to pull out a hair? Or does it hurt?
KATIE: Well, neither, really. It’s just … my scalp will itch a little bit. And it relieves the itch when I pull a hair out.
PSYCHIATRIST: Do you have any thought that comes into your mind prior to the hair pulling? Do you think the hair is dirty? Or that a hair follicle is infected, or anything like that?
KATIE: No, I just get a tingling or a feeling like a pinch or something. It happens on one certain area of my scalp. Then I pull a hair and it relieves it. Sometimes I’ll get the itch on a big area. Then I have to pull in a whole circle before I can quit.
PSYCHIATRIST: Do you feel the itch now?
KATIE: Yes, but I’m resisting pulling
PSYCHIATRIST: Is there anything else that plays a part in hair pulling?
KATIE: I like it better—this is going to sound weird—if the hair has a little tuft on the end.
PSYCHIATRIST: Why is that?
KATIE: It feels good to pick it off.
PSYCHIATRIST: Do you ever eat it?
KATIE: Oh, my God, I’ve never told that to anyone in my whole life!
PSYCHIATRIST: Don’t feel embarrassed. People with trichotillomania often do that.
KATIE: I feel like I’m gross. I don’t want to do it. I try not to do it, but I still do it
PSYCHIATRIST: Why do you do it? Does it taste good, or is there some other reason?
KATIE: No, it doesn’t taste good! I don’t know why I do it.
Katie told me that she had several minor rituals, such as repeating sentences in her head and counting syllables over and over in multiples of ten, but these never caused her any trouble. She also admitted to severe depression, with low energy, poor sleep, and occasional suicidal thoughts. Yet she insisted, “Hair pulling is the big problem. I’d be fine if it weren’t for that.”
Katie’s case is typical. Trichotillomania occurs primarily in women, by a ratio of at least three to one. It usually starts in adolescence and is kept a secret for a long time. The scalp is the most frequent site of pulling, although often other body areas, such as eyebrows and genitals, are involved. Stress often makes hair pulling worse. In Katie’s case, returning to school seemed to have brought on a crisis. And oral behaviors such as rubbing, licking, or eating hair are common; they are reported by approximately half of patients with trichotillomania.
Yet there are clear differences between the rituals of trichotillomania and those of OCD. First, hair-pulling rituals are not preceded by obsessions, or recurrent unwanted thoughts. Second, a certain amount of pleasure generally accompanies hair pulling, while OCD, in contrast, is never pleasurable in any way. Finally, the rituals of trichotillomania are often done absentmindedly, automatically, whereas OCD’s compulsions are performed with focused attention.
Thus, the symptoms of the two disorders overlap and yet are distinct. Similarly, neurophysiological studies suggest that while trichotillomania and OCD are related, they are not the same. A 1997 imaging study performed by researchers at Harvard, for instance, demonstrated that trichotillomania, like OCD, does involve a demonstrable abnormality in the brain’s basal ganglia; the specific area within the basal ganglia found to be affected, however, was different than that detected in OCD.
Effective treatments for the two disorders, likewise, differ in important ways. The SRI medications that work well in OCD are also effective for trichotillomania, but the response is less vigorous. An excellent 1989 study using clomipramine (Anafranil) in the treatment of trichotillomania showed a very positive result, but since then studies using other SRIs have been less encouraging. Katie did benefit markedly from sertraline (Zoloft) at a dose of 150 milligrams per day, but that may have been mostly due to its antidepressant effect.
Behavior therapy, too, is useful in trichotillomania. Since there are no obsessions in hair pulling, however, the exposure and response prevention techniques that are useful in OCD are ineffective. What does work is “habit reversal”: (1) closely monitoring when hair pulling occurs; (2) identifying the precursors to hair pulling, such as studying or watching TV, tingling or itching of the scalp, and touching or straightening hair; (3) increasing awareness of these precursors; (4) learning a relaxation method such as deep breathing; and (5) interrupting the respo
nse of precursor leading to hair pulling by using relaxation methods.
Studies suggest that habit reversal is effective for trichotillomania, although not as effective as exposure and response prevention for OCD. Katie carried out habit reversal for only a short time, then lost her motivation. That is the usual problem. For some reason, patients usually don’t follow through with this technique. I must admit that I have not had great success with habit reversal. My impression, however, is that clinics which specialize in this technique do an especially good job. A list of such clinics may be obtained from the OC Foundation or the Trichotillomania Learning Center.
ANOREXIA NERVOSA
There is another psychiatric syndrome involving preoccupations with appearance that bears similarities to OCD. Richard Morton, M.D., personal physician to King James II of England, is credited with first describing this disorder in 1689 in a book on diseases that cause wasting away of the body:
Mr. Duke’s daughter in the eighteenth year of her age fell into a total suppression of her monthly courses from a multitude of cares and passions of her mind. Her appetite began to abate, and her digestion to be bad; her flesh also began to be flaccid and loose, and her looks pale.… She wholly neglected the care of her self for two full years, till at last being subject to frequent fainting fits, she applied herself to me for advice.
I do not remember that I did ever in all my practice see one that was so much wasted. There was no fever, but on the contrary a coldness of the whole body; no cough, or difficulty of breathing; nor an appearance of any other distemper.… Only her appetite was diminished and her digestion uneasy, with fainting fits.…