Chapter 23. Hoarding Disorder, Trichotillomania (Hair-Pulling Disorder), and Excoriation (Skin-Picking) Disorder

Hoarding disorder, trichotillomania (hair-pulling disorder), and excoriation (skin-picking) disorder have long been recognized by clinicians as diagnostic entities. Trichotillomania was included in DSM-III-R (American Psychiatric Association 1987), and hoarding disorder and excoriation disorder are new entities in DSM-5 (DSM-5 criteria for these disorders are shown in Boxes 23- , 23- , and 23- ) (American Psychiatric Association 2013). In this chapter, we review the pharmacotherapy and psychotherapy of these disorders. DSM-5 Diagnostic Criteria for Hoarding Disorder 300.3 F42 Persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty is due to a perceived need to save the items and to distress associated with discarding them. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use. If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities). The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others). The hoarding is not attributable to another medical condition (e.g., brain injury, cerebrovascular disease, Prader-Willi syndrome). The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder , decreased energy in major depressive disorder , delusions in schizophrenia or another psychotic disorder , cognitive deficits in major neurocognitive disorder , restricted interests in autism spectrum disorder ). Specify if: With excessive acquisition: If difficulty discarding possessions is accompanied by excessive acquisition of items that are not needed or for which there is no available space. Specify if: With good or fair insight: The individual recognizes that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are problematic. With poor insight : The individual is mostly convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. With absent insight/delusional beliefs: The individual is completely convinced that hoarding-related beliefs and behaviors (pertaining to difficulty discarding items, clutter, or excessive acquisition) are not problematic despite evidence to the contrary. DSM-5 Diagnostic Criteria for Trichotillomania (Hair-Pulling Disorder) 312.39 F63.3 Recurrent pulling out of one’s hair, resulting in hair loss. Repeated attempts to decrease or stop hair pulling. The hair pulling causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The hair pulling or hair loss is not attributable to another medical condition (e.g., a dermatological condition). The hair pulling is not better explained by the symptoms of another mental disorder (e.g., attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder). DSM-5 Diagnostic Criteria for Excoriation (Skin-Picking) Disorder 698.4 L98.1 Recurrent skin picking resulting in skin lesions. Repeated attempts to decrease or stop skin picking. The skin picking causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. The skin picking is not attributable to the physiological effects of a substance (e.g., cocaine) or another medical condition (e.g., scabies). The skin picking is not better explained by symptoms of another mental disorder (e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to improve a perceived defect or flaw in appearance in body dysmorphic disorder, stereotypies in stereotypic movement disorder, or intention to harm oneself in nonsuicidal self-injury).