Nancy J. Keuthen

Organizational strategies mediate nonverbal memory impairment in obsessive–compulsive disorder

BACKGROUND Previous neuropsychological studies of obsessive-compulsive disorder (OCD) have indicated impaired executive functioning and nonverbal memory. The extent to which impaired executive functioning impacts nonverbal memory has not been established. The current study investigated the mediating effects of organizational strategies used when copying a figure on subsequent nonverbal memory for that figure. METHODS We examined neuropsychological performance in 20 unmedicated subjects with OCD and 20 matched normal control subjects. Subjects were administered the Rey-Osterrieth Complex Figure Test (RCFT) and neuropsychological tests assessing various aspects of executive function. RESULTS OCD subjects differed significantly from healthy control subjects in the organizational strategies used to copy the RCFT figure, and they recalled significantly less information on both immediate and delayed testing. Multiple regression analyses indicated that group differences in immediate percent recall were significantly mediated by copy organizational strategies. Further exploratory analyses indicated that organizational problems in OCD may be related to difficulties shifting mental and/or spatial set. CONCLUSIONS Immediate nonverbal memory problems in OCD subjects were mediated by impaired organizational strategies used during the initial copy of the RCFT figure. Thus, the primary deficit was one affecting executive function, which then had a secondary effect on immediate memory. These findings are consistent with current theories proposing frontal-striatal system dysfunction in OCD.

The Massachusetts General Hospital (MGH) Hairpulling Scale: 1. Development and Factor Analyses

We developed the MGH Hairpulling Scale to provide a brief, self-report instrument for assessing repetitive hairpulling. Seven individual items, rated for severity from 0 to 4, assess urges to pull, actual pulling, perceived control, and associated distress. We administered the scale to 119 consecutive patients with chronic hairpulling. Statistical analyses indicate that the seven items form a homogenous scale for the measurement of severity in this disorder.

The Massachusetts General Hospital (MGH) Hairpulling Scale: 2. Reliability and Validity

Assessment of symptom severity and change in chronic hairpulling has been limited by the absence of a psychometrically validated clinical rating scale. The Massachusetts General Hospital Hairpulling Scale demonstrated test-retest reliability, convergent and divergent validity, and sensitivity to change in hairpulling symptoms.

Reduced basal ganglia volumes in trichotillomania measured via morphometric magnetic resonance imaging

A morphometric magnetic resonance imaging (MRI) study compared volumes of brain structures in 10 female subjects with trichotillomania (repetitive hair-pulling) versus 10 normal controls matched for sex, age, handedness, and education. Three-dimensional MRI scans were blindly normalized and segmented using well-characterized semiautomated intensity and differential contour algorithms by signal intensity-frequency histograms. Consistent with one a priori hypothesis, left putamen volume was found to be significantly smaller in trichotillomania subjects as compared with normal matched controls. This is the first report of a structural brain abnormality in trichotillomania. Results are discussed in terms of putative relationships between trichotillomania, Tourettes syndrome, and obsessive-compulsive disorder.

Trichotillomania (hair pulling disorder), skin picking disorder, and stereotypic movement disorder: Toward DSM-V

In DSM‐IV‐TR, trichotillomania (TTM) is classified as an impulse control disorder (not classified elsewhere), skin picking lacks its own diagnostic category (but might be diagnosed as an impulse control disorder not otherwise specified), and stereotypic movement disorder is classified as a disorder usually first diagnosed in infancy, childhood, or adolescence. ICD‐10 classifies TTM as a habit and impulse disorder, and includes stereotyped movement disorders in a section on other behavioral and emotional disorders with onset usually occurring in childhood and adolescence. This article provides a focused review of nosological issues relevant to DSM‐V, given recent empirical findings. This review presents a number of options and preliminary recommendations to be considered for DSM‐V: (1) Although TTM fits optimally into a category of body‐focused repetitive behavioral disorders, in a nosology comprised of relatively few major categories it fits best within a category of motoric obsessive–compulsive spectrum disorders, (2) available evidence does not support continuing to include (current) diagnostic criteria B and C for TTM in DSM‐V, (3) the text for TTM should be updated to describe subtypes and forms of hair pulling, (4) there are persuasive reasons for referring to TTM as “hair pulling disorder (trichotillomania),” (5) diagnostic criteria for skin picking disorder should be included in DSM‐V or in DSM‐Vs Appendix of Criteria Sets Provided for Further Study, and (6) the diagnostic criteria for stereotypic movement disorder should be clarified and simplified, bringing them in line with those for hair pulling and skin picking disorder. Depression and Anxiety, 2010.

Prevalence of body dysmorphic disorder in a German college student sample

The prevalence of body dysmorphic disorder (BDD) was investigated in a non-clinical sample. German college students (n=133; 73.7% female) completed self-report questionnaires assessing BDD, self-esteem, symptoms of depression, obsessive-compulsive disorder and skin picking. Based on our data, seven participants (5.3%) satisfied DSM-IV BDD criteria. Significant differences were found between students with and without BDD in the number of endorsed obsessive-compulsive disorder symptoms. Poor body image was associated with poor self-esteem, symptoms of depression and obsessive-compulsive disorder. One student with BDD also reported severe skin picking. In conclusion, BDD is a common psychiatric disorder in college students.

Skin Picking in German Students Prevalence, Phenomenology, and Associated Characteristics

Severe skin picking (SP) is a repetitive, intentionally performed behavior that causes noticeable tissue damage and results in clinically significant distress or impairment. To date, SP has received little attentioninthe psychiatric literature. This study was conducted to further investigate SP and its characteristics in a German student population. The participants (N = 133) completed various self-report questionnaires. More than 90% (n = 122) reported occasional SP, with six students (4.6%) endorsing significant impairment from recurrent, self-injurious SP. SP was triggered by specific cutaneous stimuli, situations, and emotions. The students primarily squeezed (85%) and scratched (77.4%) the skin, with a primary focus on the face (94.7%) and cuticles (52.6%). About 20% (n = 26) ate the picked tissue afterward. Results suggest SP is an underrecognized problem that occurs on a continuum ranging from mild to severe with generally stable clinical characteristics across cultures.

The child and adolescent trichotillomania impact project: descriptive psychopathology, comorbidity, functional impairment, and treatment utilization.

Objective: Trichotillomania (TTM) is associated with significant morbidity, comorbidity, and functional impairment in adults. Despite the fact that TTM is typically a pediatric onset disorder, important questions remain about its phenomenology, comorbid symptoms, functional impact, and treatment utilization in youth. The current study was designed to provide an initial description of these factors using a convenience sample. Method: An internet-based survey. Results: Surveys completed by 133 youth ages 10 to 17 were analyzed. Scalp hair was the most common pulling site, followed by eyelashes and eyebrows. The majority reported tension before pulling and gratification/relief immediately after pulling. Severity of anxiety and depressive symptoms were somewhat elevated, as measured by standard instruments, and correlated positively with the severity of TTM symptoms. Moderate impairment in social and academic functioning was reported. For those who had received treatment specifically for TTM, parent ratings indicated that few (17%) children and adolescents were either very much improved or much improved after intervention. Conclusions: This study represents the largest survey of youth with TTM conducted thus far, and thus provides the most comprehensive description of TTM in youth to date. Limitations: Data was obtained from an anonymous, Internet-based sample, and thus may not be generalizable to all youth with TTM.

Skin Picking Disorder

Although skin picking has been documented in the medical literature since the 19th century, only now is it receiving serious consideration as a DSM psychiatric disorder in discussions for DSM-5. Recent community prevalence studies suggest that skin picking disorder appears to be as common as many other psychiatric disorders, with reported prevalences ranging from 1.4% to 5.4%. Clinical evaluation of patients with skin picking disorder entails a broad physical and psychiatric examination, encouraging an interdisciplinary approach to evaluation and treatment. Approaches to treatment should include cognitive-behavioral therapy (including habit reversal or acceptance-enhanced behavior therapy) and medication (serotonin reuptake inhibitors, N-acetylcysteine, or naltrexone). Based on clinical experience and research findings, the authors recommend several management approaches to skin picking disorder.

The prevalence of pathologic skin picking in US adults

OBJECTIVE Despite increasing recognition of the potentially severe medical and psychosocial costs of pathologic skin picking (PSP), no large-sample, randomized investigation of its prevalence in a national population has been conducted. METHOD Two thousand five hundred and thirteen US adults were interviewed during the spring and summer of 2004 in a random-sample, national household computer-assisted phone survey of PSP phenomenology and associated functional impairment. Respondents were classified for subsequent analysis according to proposed diagnostic criteria. RESULTS Of all respondents, 16.6% endorsed lifetime PSP with noticeable skin damage; 60.3% of these denied picking secondary to an inflammation or itch from a medical condition. One fifth to one quarter of those with lifetime PSP not related to a medical condition endorsed tension or nervousness before picking, tension or nervousness when attempting to resist picking, and pleasure or relief during or after picking. A total of 1.4% of our entire sample satisfied our criteria of picking with noticeable skin damage not attributable to another condition and with associated distress or psychosocial impairment. Pickers satisfying these latter criteria differed from other respondents in demographics (age, marital status) and both picking phenomenology and frequency.