imperfection (dysmorphophobia), itchy and dry skin being the result of infestation

(Ekboms syndrome), or disease in a specific organ.

Hypochondriasis is associated with compulsions such as checking body parts
for changes that might reflect disease (e.g. checking lymph nodes for swelling).
92
Patients also seek repeated reassurance from physicians and others that their fear
is unfounded.
93
Compulsive sexual behaviors
Deviant sexual behavior is reported in persons who have no recognizable illness
and in persons with neurologic and psychiatric conditions. Present classification
reflects social decisions more than science. For example, violent sexual offenses
are treated as criminal acts and there is no DSM/ICD diagnosis for these, but
many such persons have neurologic disease (often traumatic brain injury) that
may to some degree account for their actions.
94
Homosexuality and bisexuality
are also not medical diagnoses and were voted expunged from classification by
the American Psychiatric membership, but before the weight of evidence indi-
cated that they are biological variants observed in many species.
95
Sexual deviance
is also placed in several classes in the DSM, and the paraphilias are delineated
as if they represent a specific disorder with common determinants, but there is
little scientific support for such homogeneity. Compulsive sexual deviations are
considered here.
Most persons reported to exhibit sexually deviant behavior are male.
96
Compul-
sive sexual behavior is reported in about 5% of the general population.
97
Sexual
deviations that are OCD variants are characterized by co-occurring compulsive
behaviors, and deviant sexual obsessions and compulsions are both commonly
present.
98
In one study of 36 persons with compulsive sexual behaviors, 60%
also exhibited other OCD variants including kleptomania, compulsive buying,
pathological gambling, trichotillomania, pyromania and compulsive exercise.
99
In another study, in addition to other compulsive behaviors the patients had an
increased prevalence of anxiety disorder, depression (most likely non-melancholic)
and anxiousfearful personality traits.
100
Definitions of compulsive sexual behavior vary, but can be condensed to:
repetitive sexual acts and intrusive sexual thoughts that are experienced as having
a life of their own, the person feeling compelled or driven to think and perform
the act. Lack of control is more important in the definition than the presence of
distress or any reduction in anxiety when the act is performed.
101
Compulsive
sexual behavior includes: compulsive searching for multiple partners (Don Juanism,
satyriasis, and nymphomania), fixation on an unobtainable partner, compulsive
masturbation, and compulsive sexual activity with a partner. Paraphilia is diag-
nosed when the compulsive act is considered criminal (e.g. exhibitionism,
305 Chapter 12: Obsessivecompulsive behaviors
pedophilia, voyeurism [Peeping Tom], and frotteurism [rubbing against a
non-consenting person]) or elicits substantial distress in the person or the partner
(e.g. because of fetishism, transvestic fetishism [cross-dressing], voyeurism, com-
pulsive masturbation, dependence on pornography, and bestiality).
102
The sub-
jective experiences of such patients before, during and after the sexual compulsive
behavior are similar to those with more classic OCD, and also include distress at
the loss of control. The use of illicit drugs and alcohol at the time of the behavior
is common.
103
Obsessivecompulsive personality
The place for obsessivecompulsive personality in classification is uncertain.
The association with OCD is modest, while the linkage to other Axis II conditions
is weak. Overall, the evidence indicates it can be considered a mild form of OCD
and part of the OCD spectrum. Obsessivecompulsive personality traits are
reported to commonly precede OCD and OCD spectrum conditions, and these
traits are also common in the relatives of patients with OCD and OCD spectrum
conditions.
104
Much of the uncertain findings stems from the delineation of obsessive
compulsive personality by psychoanalytic rather than by empirically derived
descriptors and the application of descriptors categorically rather than as trait
dimensions.
105
Anal character type and the ICD anankastic personality disorder
are terms reflecting the theoretical pedigree of obsessivecompulsive personality.
Common descriptors of DSM and ICD (anankastic) obsessivecompulsive per-
sonality are: preoccupation with details (rules, lists, order, and schedules), excessive
conscientiousness, rigidity and stubbornness, and being overly controlling.
NOTES
1 Henry Maudsley (1874) cited by M. J. Clark in Scull (1981), page 271.
2 Yaryura-Tobias and Neziroglu (1997).
3 Tynes et al. (1990).
4 Bartz and Hollander (2006).
5 Dannon et al. (2006).
6 Dannon et al. (2004a,b).
7 Hollander et al. (2005); Lochner et al. (2005a).
8 They also propose a depersonalization disorder which does not fit the data.
9 Compulsive shopping and Internet usage are also being considered as variants of this
cluster.
10 Autism is also being considered for this category.
306 Section 3: Examination domains