Obsessive-Compulsive and Related
Disorders Latest Updated Exam
A 19-year-old woman is referred to a psychiatrist by her internist after she admits to him
that she recurrently pulls hair from her eyebrows to the point that she has scarring and
there is little or no eyebrow hair left. She states that her natural eyebrows are "bushy"
and "repulsive" and that she "looks like a caveman." A photograph of the woman before
she began pulling her eyebrow hair shows a normal-looking teenager. What is the most
appropriate diagnosis?
A. Trichotillomania (hair-pulling disorder).
B. Body dysmorphic disorder.
C. Delusional disorder, somatic type.
D. Normal age-appropriate appearance concerns.
E. Obsessive-compulsive disorder. - ANSWER-Body dysmorphic disorder.
Explanation: There can be a variety of causes for hair pulling. Individuals with
trichotillomania pull hair out of anxiety or boredom; the behavior provides distraction,
pleasure, or a relief from anxiety. When hair pulling is purely for the purpose of
improving a perceived defect in appearance, the behavior is better conceptualized as
symptomatic of body dysmorphic disorder (BDD). As with other presentations of BDD,
insight into the behavior can be poor, and the belief can reach delusional levels. If the
delusions are limited to the appearance concerns, an additional diagnosis is not
necessary. The behavior is similar to obsessive-compulsive disorder; however, the
focus on appearance is diagnostic for BDD. It may be normal for teenagers to be
concerned about their appearance; however, the fact that this patient has pulled her hair
to the point of causing scarring makes this a pathological behavior.
A 25-year-old man is concerned that he looks "weak" and "puny" despite the fact that to
neutral observers he appears very muscular. When confronted about his belief he
believes he is being humored and that people are in fact making fun of his small size
behind his back. He has tried a number of strategies to increase muscle mass, including
exercising excessively and using anabolic steroids; however, he remains dissatisfied
with his appearance. What is the most likely diagnosis?
A. Delusional disorder, somatic type.
B. Narcissistic personality disorder.
C. Body identity integrity disorder.
D. Body dysmorphic disorder, with muscle dysmorphia.
E. Koro. - ANSWER-Body dysmorphic disorder, with muscle dysmorphia.
Explanation: Muscle dysmorphia is a form of body dysmorphic disorder (BDD) in which
an individual—usually a male—is preoccupied with the idea that his body build is too
small or insufficiently muscular. Although insight may be so poor as to be considered
, delusional, the focus on body appearance alone warrants the BDD diagnosis, and the
sole focus on perceived appearance differentiates this disorder from personality
disorders. Body identity integrity disorder (apotemnophilia) (which is not a DSM-5
disorder) involves a desire to have a limb amputated to correct an experience of
mismatch between a person's sense of body identity and his or her actual anatomy.
However, the concern does not focus on the limb's appearance, as it would in BDD.
Koro, a culturally related disorder that usually occurs in epidemics in Southeastern Asia,
consists of a fear that the penis (labia, nipples, or breasts in females) is shrinking or
retracting and will disappear into the abdomen, often accompanied by a belief that
death will result. Koro differs from BDD in several ways, including a focus on death
rather than preoccupation with perceived ugliness.
A 25-year-old man is referred to a psychiatrist by his primary care doctor after
mentioning to the doctor that he routinely spends a lot of time pulling out facial hair with
tweezers, even after carefully shaving. On evaluation, he admits to frequent pulling of
his facial hair, consuming significant amount of time; he explains that he becomes
anxious when looking at himself because his moustache, hairline, and sideburns are
asymmetrical. He pulls out hairs in an effort to make them more symmetrical, but is
rarely satisfied with the results. He finds this very upsetting but cannot resist the urge to
try and "fix" his facial hair. What is the most appropriate diagnosis?
A. Trichotillomania (hair-pulling disorder).
B. Body dysmorphic disorder (BDD).
C. Delusional disorder, somatic type.
D. Normal age-appropriate appearance concerns.
E. Obsessive-compulsive disorder(OCD). - ANSWER-Obsessive-compulsive disorder
(OCD).
Explanation: In the case of repetitive hair pulling, distinguishing among trichotillomania,
BDD, and OCD can sometimes be difficult. The differential diagnosis rests on the
reasons for the pulling. Trichotillomania generally stems from boredom or anxiety,
whereas BDD-related hair pulling is generally associated with perceived ugliness of the
hair. When the pulling is in the service of symmetry, OCD is the more appropriate
diagnosis. Further examination of the individual would likely reveal additional examples
of his preoccupation with symmetry. Although some amount of hair pulling may be
normal, the degree and the distress caused make normal age-appropriate appearance
concerns an unlikely explanation in this case. Psychotic disorders should be ruled out—
in this vignette, the patient's symptoms appear to be more a preoccupation than a
delusion.
A 48-year-old man presents to a psychiatrist, stating that he was pressured by his wife
to seek help. He explains that he likes to collect wine, and he does not see a problem
with this; he claims that many of the wines are quite valuable and a potential
investment. On further questioning, he admits that he rarely drinks the wines, because it
"never seems the right time." He has never sold or given away any wine because he
finds it hard to part with the bottles. He has had to use increasing portions of his house
Disorders Latest Updated Exam
A 19-year-old woman is referred to a psychiatrist by her internist after she admits to him
that she recurrently pulls hair from her eyebrows to the point that she has scarring and
there is little or no eyebrow hair left. She states that her natural eyebrows are "bushy"
and "repulsive" and that she "looks like a caveman." A photograph of the woman before
she began pulling her eyebrow hair shows a normal-looking teenager. What is the most
appropriate diagnosis?
A. Trichotillomania (hair-pulling disorder).
B. Body dysmorphic disorder.
C. Delusional disorder, somatic type.
D. Normal age-appropriate appearance concerns.
E. Obsessive-compulsive disorder. - ANSWER-Body dysmorphic disorder.
Explanation: There can be a variety of causes for hair pulling. Individuals with
trichotillomania pull hair out of anxiety or boredom; the behavior provides distraction,
pleasure, or a relief from anxiety. When hair pulling is purely for the purpose of
improving a perceived defect in appearance, the behavior is better conceptualized as
symptomatic of body dysmorphic disorder (BDD). As with other presentations of BDD,
insight into the behavior can be poor, and the belief can reach delusional levels. If the
delusions are limited to the appearance concerns, an additional diagnosis is not
necessary. The behavior is similar to obsessive-compulsive disorder; however, the
focus on appearance is diagnostic for BDD. It may be normal for teenagers to be
concerned about their appearance; however, the fact that this patient has pulled her hair
to the point of causing scarring makes this a pathological behavior.
A 25-year-old man is concerned that he looks "weak" and "puny" despite the fact that to
neutral observers he appears very muscular. When confronted about his belief he
believes he is being humored and that people are in fact making fun of his small size
behind his back. He has tried a number of strategies to increase muscle mass, including
exercising excessively and using anabolic steroids; however, he remains dissatisfied
with his appearance. What is the most likely diagnosis?
A. Delusional disorder, somatic type.
B. Narcissistic personality disorder.
C. Body identity integrity disorder.
D. Body dysmorphic disorder, with muscle dysmorphia.
E. Koro. - ANSWER-Body dysmorphic disorder, with muscle dysmorphia.
Explanation: Muscle dysmorphia is a form of body dysmorphic disorder (BDD) in which
an individual—usually a male—is preoccupied with the idea that his body build is too
small or insufficiently muscular. Although insight may be so poor as to be considered
, delusional, the focus on body appearance alone warrants the BDD diagnosis, and the
sole focus on perceived appearance differentiates this disorder from personality
disorders. Body identity integrity disorder (apotemnophilia) (which is not a DSM-5
disorder) involves a desire to have a limb amputated to correct an experience of
mismatch between a person's sense of body identity and his or her actual anatomy.
However, the concern does not focus on the limb's appearance, as it would in BDD.
Koro, a culturally related disorder that usually occurs in epidemics in Southeastern Asia,
consists of a fear that the penis (labia, nipples, or breasts in females) is shrinking or
retracting and will disappear into the abdomen, often accompanied by a belief that
death will result. Koro differs from BDD in several ways, including a focus on death
rather than preoccupation with perceived ugliness.
A 25-year-old man is referred to a psychiatrist by his primary care doctor after
mentioning to the doctor that he routinely spends a lot of time pulling out facial hair with
tweezers, even after carefully shaving. On evaluation, he admits to frequent pulling of
his facial hair, consuming significant amount of time; he explains that he becomes
anxious when looking at himself because his moustache, hairline, and sideburns are
asymmetrical. He pulls out hairs in an effort to make them more symmetrical, but is
rarely satisfied with the results. He finds this very upsetting but cannot resist the urge to
try and "fix" his facial hair. What is the most appropriate diagnosis?
A. Trichotillomania (hair-pulling disorder).
B. Body dysmorphic disorder (BDD).
C. Delusional disorder, somatic type.
D. Normal age-appropriate appearance concerns.
E. Obsessive-compulsive disorder(OCD). - ANSWER-Obsessive-compulsive disorder
(OCD).
Explanation: In the case of repetitive hair pulling, distinguishing among trichotillomania,
BDD, and OCD can sometimes be difficult. The differential diagnosis rests on the
reasons for the pulling. Trichotillomania generally stems from boredom or anxiety,
whereas BDD-related hair pulling is generally associated with perceived ugliness of the
hair. When the pulling is in the service of symmetry, OCD is the more appropriate
diagnosis. Further examination of the individual would likely reveal additional examples
of his preoccupation with symmetry. Although some amount of hair pulling may be
normal, the degree and the distress caused make normal age-appropriate appearance
concerns an unlikely explanation in this case. Psychotic disorders should be ruled out—
in this vignette, the patient's symptoms appear to be more a preoccupation than a
delusion.
A 48-year-old man presents to a psychiatrist, stating that he was pressured by his wife
to seek help. He explains that he likes to collect wine, and he does not see a problem
with this; he claims that many of the wines are quite valuable and a potential
investment. On further questioning, he admits that he rarely drinks the wines, because it
"never seems the right time." He has never sold or given away any wine because he
finds it hard to part with the bottles. He has had to use increasing portions of his house
