ocd spectrum disorders

Body Dysmorphic Disorder, Body Dysmorphic Disorder, Hypochondriasis, Hoarding, and other Hypochondriasis, Hoarding, and other OCD Spectrum Disorders; Comparing OCD Spectrum Disorders; Comparing and Contrasting Treatments with OCDand Contrasting Treatments with OCD

Fugen Neziroglu Ph.D., ABBP, ABPP

Bio-Behavioral Institute

Great Neck, NY

www.biobehavioralinstitute.com

Obsessive Compulsive Spectrum Disorders

We identify disorders on the OC spectrum because:– They all share in common obsessions and/or

compulsions– They have similar symptomatology, treatment

response, and family history

Obsessive Compulsive Spectrum Disorders

Obsessive Compulsive Spectrum Disorders are conceptualized along a compulsivity-impulsivity continuum.

│ │ COMPULSIVE IMPULSIVE Risk Aversive/Harm Avoidant Disorders Risk Taking Disorders (e.g. Obsessive Compulsive Disorder, (e.g. Pathological Gambling, Body Dysmorphic Disorder) Sexual Compulsions)

Obsessive-compulsive Spectrum Obsessive-compulsive Spectrum DisordersDisorders

Obsessive-compulsive disorder Hoarding Body-dysmorphic disorder Hypochondriasis Eating disorders Trichotillomania Tourette’s syndrome Self-mutilation

Body Dysmorphic DisorderBody Dysmorphic Disorder

A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.

B.The preoccupation causes clinically significant distress or impairment in functioning.

C.The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).

PrevalencePrevalence

1-2% of the general population1-2% of the general population4-5% of people seeking medical treatment4-5% of people seeking medical treatment8% of people with depression8% of people with depressionMore than 12% of people seeking mental More than 12% of people seeking mental

health treatmenthealth treatment

General Demographics For General Demographics For BDDBDD

Estimated Prevalence RateEstimated Prevalence Rate 1.0%1.0%

Male-Female RatioMale-Female Ratio 1:11:1

Age Of OnsetAge Of Onset 1616

Years Before First ConsultYears Before First Consult 6 6

ComorbidityComorbidity

Heredity:– 4 X higher lifetime prevalence of BDD in 1st degree relatives of those

with OCD than control probands 2

– 7% of BDD patients have a relative with OCD3

Comorbidity: 30-40% with BDD have OCD; 12-16% with OCD have BDD3.

11Hollander 1993; Hollander 1993; 22Bienvenu et al. 2000; Bienvenu et al. 2000; 33Phillips, 1998Phillips, 1998

Adolescent Feelings Of Adolescent Feelings Of Ugliness vs. BDDUgliness vs. BDD

Between the ages of 12-17, many Between the ages of 12-17, many adolescents adolescents feel ugly.feel ugly.

LongevityLongevity and and SeveritySeverity distinguish normal distinguish normal adolescent concerns from BDD.adolescent concerns from BDD.

Percentage of People with Percentage of People with Body Image DissatisfactionBody Image Dissatisfaction

1972 1996Mid-torso Overall Mid-torso Overall

Men 36 15 63 43

Women 50 23 71 56

Phillips (1996)

Normal Concerns vs. BDDNormal Concerns vs. BDD

Time consumption Time consumption 1 hour 1 hour

Produces distressProduces distress

Interferes with functioningInterferes with functioning

Risk Factors for BDDRisk Factors for BDD

Abuse HistoryAbuse HistoryTeasingTeasingPast History of Past History of

Dermatological Dermatological ProblemsProblems

ShynessShynessDepressionDepressionAnxietyAnxietyPerfectionismPerfectionismStressors in GeneralStressors in General

Is BDD a Problem of:Is BDD a Problem of:PerceptionPerceptionSomatosensory DisturbanceSomatosensory DisturbanceGlobal/Idealized ValuesGlobal/Idealized ValuesFaulty BeliefsFaulty BeliefsInformation Processing BiasesInformation Processing BiasesNeurobiological DefectNeurobiological Defect

PerceptionPerception: Actually sees nose as big: Actually sees nose as bigSomatosensorySomatosensory: Feels nose is big: Feels nose is bigGlobal/Idealized ValuesGlobal/Idealized Values: I value beauty as a goal : I value beauty as a goal

to pursueto pursueFaulty CognitionsFaulty Cognitions: Because my nose is big, I will : Because my nose is big, I will

be alone and isolated all my life. be alone and isolated all my life. Overgeneralization.Overgeneralization.

Information Processing BiasesInformation Processing Biases: Looking in the mirror : Looking in the mirror and focusing immediately on the nose. Selective and focusing immediately on the nose. Selective attention to details, rather than the whole.attention to details, rather than the whole.

Neurobiological DefectNeurobiological Defect: Serotonin alteration; orbito-: Serotonin alteration; orbito-frontal cortex, temporal, occipital and parietal lobe frontal cortex, temporal, occipital and parietal lobe involvement; genetically or ethologically transmitted.involvement; genetically or ethologically transmitted.

How Do All These How Do All These Aspects Interrelate?Aspects Interrelate?

Based on genetically and/or ethologically transmitted need Based on genetically and/or ethologically transmitted need for symmetry or aestheticism, maladaptive beliefs and for symmetry or aestheticism, maladaptive beliefs and values are learned which influences information values are learned which influences information processing and perception.processing and perception.

Beliefs About AppearanceBeliefs About Appearance

Identify and question the meaning of the defectiveness (not the defect), i.e., the assumptions about defectiveness and values (the importance of appearance)

• Focus on assumptions and values

• Collect information that is inconsistent with beliefs which patient normally ignores or distorts in an alternative data log

Beliefs About Appearance Beliefs About Appearance (Cont.)(Cont.)

Faulty Beliefs - Cognitive Faulty Beliefs - Cognitive DistortionDistortion

I need to be perfectI need to be perfect I need to be noticedI need to be noticed If I If I feelfeel that my body part is unattractive, it that my body part is unattractive, it

means that it means that it lookslooks unattractive unattractive If my body part is not beautiful, then it must be If my body part is not beautiful, then it must be

uglyugly If I looked better, my whole life would be betterIf I looked better, my whole life would be betterHappiness comes from looking goodHappiness comes from looking good

Faulty Beliefs - Cognitive Faulty Beliefs - Cognitive DistortionDistortion

The only way to The only way to feelfeel better is to better is to looklook better better I must be happy with what I see in the mirrorI must be happy with what I see in the mirrorLooking good protects you from being treated badlyLooking good protects you from being treated badly I cannot be comfortable unless I look goodI cannot be comfortable unless I look goodPhysical perfection is a realistic and attainable goalPhysical perfection is a realistic and attainable goal If my appearance is defective then I am inadequate If my appearance is defective then I am inadequate

and worthless.and worthless.

Safety or Avoidance Safety or Avoidance Behaviors in BDDBehaviors in BDD

Mirror gazing or avoiding

Excessive groomingRitualized or excessive

makeup applicationExcessive usage of

skin or hair products

Hair removalHair cuttingReassurance seekingCamouflagingSkin pickingRepeated checking of

body part

Comparing self with others or old photosGrooming, combing, smoothening,

straightening, plucking or cutting hairSkin cleaning, picking, peeling,

bleachingFacial exercises

Safety or Avoidance Safety or Avoidance Behaviors in BDD (Cont.)Behaviors in BDD (Cont.)

Avoidance Behaviors in BDDAvoidance Behaviors in BDD

Social and public situations with varying degrees of safety behaviors– Clothes or hair to hide “defect”– Certain posture– Padding– Cold Coke cans!

Skin Picking and Hair CuttingSkin Picking and Hair Cutting Self-monitoring (frequency chart)

Self-monitoring of triggers

Habit reversal

Challenge irrational beliefs regarding effectiveness and necessity of behavior

Delay response and alternative activities (e.g., not alone)

Difficult to treat due to short-term satisfaction

Identify secondary functions of behavior (stress reducer, escape, emotion regulation)

Compulsive Skin PickingCompulsive Skin Picking

Repetitive skin picking and cleaning, especially face

Aim to remove moles, freckles, blemish, scabs

Fingernails, tweezers, pins, sharp implements

Lead to bleeding, bruises, infections and/or permanent disfigurement

Short-term tension reduction and satisfaction

Followed by disgust, anger, depression

OC spectrum—BDD, OCD, trichotillomania

Safety Behaviors in BDDSafety Behaviors in BDD

Do it yourself surgery Cosmetic or dermatological

interventions

BDD vs. OCDBDD vs. OCD

Similarities – Symptoms– Response to Cognitive Behavioral Therapy– Response to Pharmacotherapy

Dissimilarities– BDD has higher OVI, more depressed, less

anxious, total self identification, more personality disorders.

Example of Differentiating BDD From Example of Differentiating BDD From OCDOCD

Symptom ClustersNeuropsychological TestingNeuroimaging Function of Compulsions/Safety BehaviorsPresence or absence of delusions, overvalued

ideationPerceptual/Somatosensory Components

OVI in OCDOVI in OCD

Examined whether OVI predicts medication treatment response

Results illustrated that OVI predicted the outcome for obsessions, but not compulsions. As patients scored higher on OVIS there was less improvement following treatment.

Neziroglu, F., Yaryura-Tobias, J., Pinto, A., & McKay, D. (2004). Psychiatry Research, 125 (1).

OVI in BDDOVI in BDD

High overvalued ideas need to be addressed prior to exposure.

The higher the OVI the poorer the prognosis.

OVI in BDD vs. OCDOVI in BDD vs. OCD

Subjects with BDD had significantly lower levels of insight than subjects with OCD

Suggests differences in insight is not attributable to symptom severity

Eisen, Phillips, Coles, & Rasmussen (2003) Phillips, Pinto, Menard, Eisen, Mancebo, Rasmussen (2007)

Quality of LifeQuality of LifeQuality of life measures impact of a disorder across area of everyday functioning

• Self esteem• Goals• Play• Love • Friendship• Community• Health• Money

Learning Helping Children Relatives Home Neighborhood Creativity Work

Quality of Life in OCDQuality of Life in OCD

Lower overall Quality of Life than general population

Mental health and psychological well being most impaired in subjects with OCD

Lower Quality of Life than Schizophrenia patients

Koran, Thienemann, & Davenport (1996) Stengler-Wenzke , Kroll, Matschinger , & Angermeyer (2006)

Quality of Life in BDDQuality of Life in BDD

BDD patients have poor Quality of Life across all psychosocial functioning and mental health domains.

BDD Patients demonstrate poorer quality of mental health life as compared to:– US general population– Patients with Major Depression or Dysthymia– Patients with chronic medical conditions.

Functioning and quality of life for BDD patients are low regardless of treatment

• Phillips , Menard, Fay, & Paagano (2005)

Quality of Life BDD vs. OCD Quality of Life BDD vs. OCD (cont)(cont)

OCD & BDD had very poor psychosocial functioning and Quality of Life

Comorbid OCD/BDD patients showed greater impairment than OCD patients but not BDD patients.

BDD severity may account for lower quality of life in the comorbid group.

Didie, Mancebo, Rasmussen, Phillips, Walters, Menard, & Eisen (2004)

Symptom Severity in Symptom Severity in OCD & BDDOCD & BDD

Y-BOCS obsessions

Y-BOCS compulsions

OCD (n=61)

M = 12.9

Severe

BDD (n=53)

M = 12.8

Severe

OCD (n=61)

M = 11.2

Severe

BDD (n=53)

M = 12.0

Severe

Overvalued Ideation Levels Overvalued Ideation Levels in BDD & OCDin BDD & OCD

OCD (n=62)

M = 4.8

Middle Range

BDD (n= 53)

M = 6.1

Upper Range

OVIS *

* = p < .001

Quality of Life in BDD & Quality of Life in BDD & OCDOCD

OCD (n=32)

M = 35.7

Low Level

BDD (n= 23)

M = 24.1

Very Low Level

QOLI *

* = p < .05

BDD: Severity of DisorderBDD: Severity of Disorder

Suicide attempt rate: 29%Suicide ideation rate: 80%Hospitalization: 36-58%Homebound: 32-40%Full-time employment/student:

42%

Phillips KA et al. (2006), Compr Psychiatry 47(2):77-87

Frequency and Percentage of Frequency and Percentage of Abuse in BDD and OCDAbuse in BDD and OCD

Abuse Type BDD (N=50) OCD (N=50)

Any Abuse 19 (38%) 7 (14%)

Sexual 11 (22%) 3 (6%)

Physical 7 (14%) 4 (8%)

Emotional 14 (28%) 1 (2%)

Neziroglu F, Khemlani-Patel, S & Yaryura-Tobias. (2006). Body Image 3: 189-193

Appropriate Treatments for BDDAppropriate Treatments for BDD

Exposure and response preventionCognitive therapyPsychopharmacological treatmentSupport groupsFamily intervention

Inappropriate Treatment for Inappropriate Treatment for BDDBDD

Dermatological proceduresSurgical and non-surgical proceduresPsychodynamic therapy

CBT Working Model

Operant Conditioning

Biological Predisposition

Operant Conditioning

Social Learning+

CS UCS CRUCR

Information Processing Bias

Classical/Evaluative Conditioning

Body Dysmorphic Disorder

Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

Biological Predisposition

CBT Working Model (Cont.)

Genetic factorsVisual processing problemsSomatosensory problemsFaulty neuroanatomical

circuitry

Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

Person is positively and/or intermittently reinforced for:– Overall appearance ▪ Poise– Particular body part ▪ Weight– Height ▪ Body shape– Cuteness

Biological Predisposition

Operant Conditioning

CBT Working Model (Cont.)

Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

Social learning– Modeling/Media/Childhood teaching – Vicarious learning

Social learning and operant conditioning– Develop

Values and beliefs about attractiveness Self-value based on body image

+

Biological Predisposition

Operant Conditioning

CBT Working Model (Cont.)

Social Learning

Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

Classical Conditioning: Acquisition BDD

CSBody part

Words: (blemish, red)

+

Biological Predisposition

Operant Conditioning

CBT Working Model (Cont.)

Social Learning

UCSAbuseTeasingAcnePuberty

UCRDisgustAnxietyShame Depression

CRMood

Biased Information Processing/ Relational Framing

Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

Operant Conditioning: Maintenance Of BDD

Negative reinforcement– CR is removed through avoidance behaviors (e.g.,

camouflaging, mirror checking, excessive makeup)

Positive intermittent reinforcement– Maintains avoidance behaviors

Mood/CR Avoidance Behaviors

Negative Reinforcement

CBT Working Model (Cont.)

Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

Operant Conditioning: Maintenance Of BDD

Negative reinforcement– CR is removed through avoidance behaviors (e.g.,

camouflaging, mirror checking, excessive makeup)

Positive intermittent reinforcement– Maintains avoidance behaviors

Mood/CR Avoidance Behaviors

Negative Reinforcement

CBT Working Model (Cont.)

Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

CBT Working Model (Cont.)

Operant Conditioning

Biological Predisposition

Operant Conditioning

Social Learning+

Body Dysmorphic Disorder

Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

CS UCS CRUCR

Information Processing Bias

Classical Conditioning

Cognitive Therapy: Initial Cognitive Therapy: Initial StrategiesStrategies

Address readiness for changeMotivational interviewing to engage patients

reluctant to continue treatment– Stress the degree of dysfunction and suffering

Target depression and/or suicidal ideation

EngagementEngagement Explaining diagnosis—emphasize “preoccupation

with the way you feel about appearance” Similar problems in disorders with OVI where

goals not shared by clinician Motivational interviewing (focus on handicap

linked to the demand about how their appearance must be or their idealized value about appearance)

OVI = overvalued ideation

Engagement (Cont.)Engagement (Cont.)

Avoid giving reassurance about appearance as patient often told “look alright”

Validate experience and help understand what the problem is

Two hypotheses either “problem unattractive” or you have a “problem with the way you feel about your appearance”

Early GoalsEarly Goals

Functioning—activity scheduling and social withdrawal/avoidance which maintains depressed mood

Decrease compulsive behaviors, such as mirror gazing and checking with hands

Skin picking

Cognitive Therapy: Cognitive Therapy: Targeting BDD SymptomsTargeting BDD Symptoms

Target cognitive distortionsBeck or Ellis modalities work wellHypothesis testing/collaborative empiricism

– Take patient’s photograph and collect ratings of attractiveness

– Interview strangers regarding relevant distorted beliefs of patient

Cognitive Therapy: Cognitive Therapy: Targeting Targeting

Values on AppearanceValues on Appearance

Targeting value of appearance may be an important treatment component in relapse prevention

Methods to target values and attitudes– Psychoeducation– Pie chart of important values

Pie Chart of ValuesPie Chart of Values

Artistic Achievement

30%

Attractiveness 20%

Family 15%

Friendship15%

Money 10%

Education 10%

Neziroglu F, Khemlani-Patel S

CBT for BDD in Social SituationsCBT for BDD in Social Situations

Exposure/behavioral experiments – Minimal or no makeup or exaggerate “defect”– No changes in posture– Not using hand or hair– Not stand by window– Refocus attention away from self

4 Ways To Challenge Beliefs 4 Ways To Challenge Beliefs for BDDfor BDD

What is the evidence that supports or contradicts this belief?

Are there any other ways to interpret this situation? Realistically, what is the worst thing that could happen

in this situation and how would it honestly affect my life?

Even if the negative belief is warranted, what can I realistically do to help remedy the situation?

Geremia, G & Neziroglu F (2001), Clinical Psych and Psychotherapy 8: 243-251

HYPOCHONDRIASISHYPOCHONDRIASIS

PREOCCUPATION WITH FEARS OF HAVING, OR THE IDEA THAT ONE HAS, A SERIOUS DISEASE BASED ON MISINTERPRETATION OF BODILY SYMPTOMS

THE PREOCCUPATION PERSISTS DESPITE APPROPRIATE MEDICAL EVALUATION AND REASSURANCE.

THEIR BELIEF IS NOT OF DELUSIONAL INTENSITY NOR DUE TO CONCERN ABOUT APPEARANCE.

SPECIFY IF:

WITH POOR INSIGHT

Historical Conceptualization Of Historical Conceptualization Of HypochondriaHypochondria

In 1621, Robert Burton wrote

“The Anatomy of Melancholy”.

He described “hypochondriacal melancholy” as including physical ailments (e.g. ears ringing, belching, vertigo.) and fear of disease

HypochondriaHypochondria

Second Century A.D., Galen of Pergamon used the term HYPOCHONDRIA to describe broad range of digestive disorders and melancholia

Cost of HC Per YearCost of HC Per Year

At least 20 billion dollars per year is spent on hypochondriacal patients, and may be as much as 100 billion dollars

Phenomenology of HCPhenomenology of HC

HC are more concerned with the authenticity, meaning or etiological significance of their symptoms than with the unpleasant sensation or pain

HC DemographicsHC DemographicsMale: Female Ratio 1:1

Average Age 36-57

Duration of Symptoms 6 months-25 years

Symptoms occur more often in single, women, less educated, less income, non-whites, hispanics, older, urban residence

Common HC SymptomsCommon HC SymptomsParts of the Body AffectedParts of the Body Affected

1) Head and Neck Complaints:

Tumors

Aneurysms

Strokes

Burning Sensation

Chronic Headaches

Muscle Spasms

Numbness in Face

Common HC SymptomsCommon HC SymptomsParts of the Body Affected (con’t)Parts of the Body Affected (con’t)

2) Abdomen Complaints: Prostate Cancer

Hernias

Irritable Bowel Syndrome

Liver Cancer

Ulcers

3) Chest Complaints: Heart Attacks

Chronic Asthma

Differential Diagnosis of HCDifferential Diagnosis of HC Somatization Disorder Delusional Disorder

(monosymptomatic Hypochondriacal Disorder)

Panic Disorder Generalized Anxiety Disorder Depression Obsessive Compulsive Disorder

(Somatic Obsessions)

Illness Phobia

Reported Dissimilarities Between OCD & Reported Dissimilarities Between OCD & HCHC

Patient with Hypochondriasis:¤ See their fears as realistic¤ Possess pervasive ideas of illness as part of their

personality¤ Are public about their concerns¤ Experience genuine somatic discomfort

Barsky (1992)

OCD and HCOCD and HCAnxiety and Depression ScalesAnxiety and Depression Scales

0

10

20

30

40

50

60

BDI BAI STIA-S STIA-T

OCD

HC

OCD and HCOCD and HCObsessions and CompulsionsObsessions and Compulsions

0

2

4

6

8

10

12

14

16

DSO* DSC* Y-BOC_O* Y-BOC_C*

OCD

HC

DS-Disorder Specific

OCD and HCOCD and HCBody Sensations and MobilityBody Sensations and Mobility

0

10

20

30

40

50

60

70

BSQ* MI,alone** MI,accompanied*

OCD

HC

p<.05;**p<.01

HC ObsessionsHC Obsessions

Death 20.0%

Fatigue 13.3%

General illness 13.3%

Back Problems 13.3%

Insomnia 6.7%

Multiple Sclerosis 6.7%

HC CompulsionsHC CompulsionsCheck Body 81.8%

Seek Reassurance 81.8%

Visit Doctors 81.8%

Washing (not Contamination) 63.7%

Read Health Literature 54.5%

Take Vitamins 54.5%

Avoid Certain Places 45.5%

Avoid Certain Foods 36.4%

Visit Emergency Room 18.2%

Avoid Doctors 9.1%

Treatment Modalities For HCTreatment Modalities For HC

1) Psychodynamic Interventions

2) Reassurance Therapy

3) Cognitive-Behavior Therapy

4) Pharmacotherapy

Kellner’s Reassurance Kellner’s Reassurance InterventionIntervention

Physical Examination Client Centered Techniques Explanatory Therapy (psychoeducation) Use of Suggestion Biofeedback

Treatment Outcome DataTreatment Outcome Data

Cognitive Behavioral Therapy Improved

Salkovskis and Warwick (1986) 100%

Warwick and Marks (1988) 88%

Miller, Action & Hodge (1988) 100%

Cognitive Behavioral Model of Cognitive Behavioral Model of HypochondriasisHypochondriasis

Review Previous Experience Formulation of Dysfunctional Assumptions A Critical Incident Activation of Assumptions Negative Thoughts and Imagery Hypochondriacal Development

General Cognitive Therapy for General Cognitive Therapy for HypochondriasisHypochondriasis

Hypochondriacs overestimate the probability of a symptom indicating the existence of an illness and underestimate their ability to cope with it.

COGNITIVE THERAPY COGNITIVE THERAPY FOCUSFOCUS

PREVENT NEUTRALIZATION

INCREASE EXPOSURE TO OBSESSIONS

MODIFY “RESPONSIBILITY” ATTITUDE

MODIFY APPRAISAL OF OBSESSIONS

INCREASE EXPOSURE TO RESPONSIBILTY BY EXPOSURE IN VIVO AND STOP REASSURANCE SEEKING

COGNITIVE COGNITIVE RESTRUCTURINGRESTRUCTURING

A.= ANTECEDENT EVENTB. = BELIEFSC. = CONSEQUENCES

1. EMOTIONAL

2. BEHAVIORAL

D. =DISPUTE

E. = EFFECT OF DISPUTING

Ellis’ ABC Paradigm in the Treatment of Ellis’ ABC Paradigm in the Treatment of OCD Applied to HCOCD Applied to HC

A = Obsession itself or any activating event

B = 1. If I do not call the doctor about my headache I have behaved irresponsibly

2. It is awful to feel anxious. 3. I must have guarantees.

C = Anxiety Active Avoidance

Cognitive Theories

Under high cost conditions obsessives make the same threat appraisal as normals.

Under low cost conditions obsessionals overestimate the probability of the occurance of the disastrous consequence.

Carr (1974)

Cognitive Theories

1. Primary Appraisal Process whereby the individual overestimates probability and the cost of the occurrence of unfavorable events.

2. Secondary Appraisal Process whereby individual underestimates his/her abilities to cope with the threat.

MC Fall and Wollersheim (1979)

Common HC Belief DistortionsCommon HC Belief Distortions

If I have something wrong with me, I will not be a desirable person.

Bodily symptoms are a sign of serious illness because every symptom has an identifiable physical cause.

I am irresponsible if I don’t go to the doctor immediately.

Common HC Belief Distortions Common HC Belief Distortions (Cont.)(Cont.)

I can’t stand the pain I can’t stand being ill. Any symptom means that I’m ill, or am going to be ill. If I’m ill, I will definitely suffer greatly (and I can not

stand the suffering). If I’m ill, I will die. I have an incurable illness. If I’m ill, I can’t be happy. Symptoms are indicative of severe illnesses.

Common HC Belief Distortions Common HC Belief Distortions (Cont.)(Cont.)

If I’m ill, there’s no need to fight because my life is over.

I want certainty that I am not ill. Every physical symptom is indicative of a serious

medical condition. I have a disease, but the doctors have not been able

to diagnose it yet. If I pay close attention to my bodily symptoms I

can prevent being sick.

Common HC Belief Distortions Common HC Belief Distortions (Cont.)(Cont.)

All symptoms are a sign of danger. I will not be able to cope with a major illness. I must know immediately if there is

something wrong with me. I can not tolerate anxiety. I must be hypervigilant to all bodily

symptoms, in order to prevent an illness.

Four Ways To Challenge Four Ways To Challenge BeliefsBeliefs

(Hypochondriasis)(Hypochondriasis)1) What is the evidence that supports or contradicts this

belief?

2) Are there any other ways to interpret the physical symptoms or my belief?

3) Ultimately if I am correct in my interpretation, realistically to what extent can I control the outcome?

4) Why is it that others don’t preoccupy themselves with the same physical symptoms, and what enables them to cope with negative outcomes?

Conclusions Conclusions (CT for HC)(CT for HC)

Cognitive Therapy is effective for HC. Cognitive Therapy decreases overvalued ideas, depression,

anxiety, frequency and severity of obsessive thoughts. Exposure and Responsive Prevention (ERP) reduces

compulsions. ERP does not decrease overvalued ideas, obsessions, nor

depression. Best to combine cognitive therapy with ERP. Cognitive Therapy effective even for severe cases.

General Conclusions about General Conclusions about ERP vs. CTERP vs. CT

With Cognitive Therapy

Attrition rate lower Compliance better Motivation greater Acceptance of therapy better

HoardingHoarding

Hoarding is the acquisition of, and failure to discard, large numbers of items that appear to have little or no value

(Frost & Gross, 1993)

Hoarding: Additional CriteriaHoarding: Additional Criteria

Clutter prevents usage of functional space

Significant distress or impairment

Frost & Hartl (1996)

Disorders with Hoarding BehaviorDisorders with Hoarding Behavior

OCDOCPDDepressionDementiaPsychosis (eg.SZ; delusional dis.)Eating Disorders

PrevalencePrevalence20-30% of OCD patients26.3 per 100,000 as reported by

health departments

Frost, Steketee, Greene (2003)

Possible Etiology of HoardingPossible Etiology of Hoarding

Informational-Processing Deficits: i.e. decision making, organizing, memory

Emotional attachment to possessionsCognitive distortions; ie. I will never

be able to get the info anywhere elseNeurobiological

Co-morbidity in Compulsive Co-morbidity in Compulsive HoardingHoarding

Social Phobia: generalized and specific – (Samuels et al, 2002; Steketee et al., 2000)

Major Depression – (Frost et al., 2000; Lochner et al., 2005; Samuels et al, 2002; Seedat & Stein, 2002)

OC spectrum conditions: trichotillomania, Tourette’s

syndrome, nail biting, skin picking– (Samuels et al, 2002; Seedat & Stein, 2002)

GAD (Lochner et al, 2005)

ADHD (Hartl et al., 2003)

Dementia (Hwang et al., 1998)

Model of HoardingInformation Processing

Beliefs Emotional Attachment

↓ ↓ ↓ → Disorganization

↑ ↓

↑ Attempts to

↑ categorize, or

↑ make decisions

↑ ↓

↑ Frustration &

↑ Anxiety

↑ ↓

←Avoidance

→→ Acquiring ↑ ↓ ↑ Emotions ↑ ↙↘ ↑ ←Positive Negative ↑ ↓ ↑ Attempts to stop ↑ ↓ ↑ Loss/Discomfort ↑ ↓ ←← Avoidance

→→Saving/Discarding

↑ ↓ ↑Attempts to Discard ↑ ↓ ↑ Anxiety/Guilt ↑ ↓ ←← Avoidance

Hoarding Cognitions:Normal Behavior vs. Disorder

Normal pattern of use for disposable object:o Acquire ► Use ► Consider discarding: evaluate value ► Discard or Save.

The Process of Hoarding:o Acquire ► Use ► Consider discarding: evaluate use ► Obsessional Thoughts ► Anxiety ► Save ► Anxiety Relief ► Obsessional Thoughts ► Anxiety ► Don’t Think About it ► Anxiety Relief ► Obsessional Thoughts

Obsessional Thoughts in Hoarding

Emotional ComfortLossIdentityValueResponsibility/WasteMemoryControl

Obsessional Thoughts in Hoarding

Emotional attachment (comfort, distress, loss, identity)o “Without this possession, I will be

vulnerable”o “If I didn’t know where this was, I would feel anxious”o “Throwing this away means losing a part of my

life”o “I might never be able to find this again”

Responsibilityo “I am responsible for finding a use

for this possession”o I am responsible for saving this for someone who might need it”o I am ashamed when I don’t have something when I need it”

Obsessional Thoughts in Hoarding

Memoryo“Saving this means I don’t have to

rely on my memoryo “If I don’t leave this in sight, I’ll

forget it”o “I must remember something about this”

·Controlo “No one has the right to touch

my possessions”o “I like to maintain sole control over my things”

Differences between Hoarding and OCD

Hoarders report less distress Hoarders are less depressed Hoarders usually have less insight: higher OVI They are harder to engage in treatment Hoarding more likely to cause family friction Hoarding more harmful to self

Neziroglu, Peterson & Weissman (2006)

Hoarding vs. OCD: Hoarding vs. OCD: ObsessionsObsessions

Thoughts triggered by objects and efforts to discard

(e.g., “I might need this; I don’t want to lose an

opportunity; I can’t waste this.”)

Not always distressing (e.g., “This is beautiful/

sentimental. I’ll keep it.”)

Impulses to acquire

Images of using item in future, but rarely distressing

Hoarding vs. OCD: Hoarding vs. OCD: Rituals and avoidance Rituals and avoidance

behaviorsbehaviors Doubting, checking, reassurance seeking are common

before discarding and reflect negative emotions like

anxiety and guilt

Efforts to control distress result in avoidance of discarding

(saving) objects

Acquiring behaviors appear to be motivated by impulsive

urges and are commonly accompanied by positive feelings

Hoarding vs. OCD: Hoarding vs. OCD: Insight, distress & interferenceInsight, distress & interference

Insight can be very poor, ambivalence about

treatment is common

Distress not always present, even in severe cases

Interference with functioning is typical

Hoarding vs. OCDHoarding vs. OCD

Individuals with compulsive hoarding are more likely to display:– Symmetry Obsessions– Counting, ordering, and repeating compulsions– Greater illness severity– Difficulty completing tasks– Problems with decision making(Sameuls, Bienvenu et. al, 2007)

Hoarding vs. OCD:Hoarding vs. OCD:NeuroanatmonyNeuroanatmony

OCD:

– Deficits in the pre-frontal cortex and basal ganglia

(Stein, 2000)

Hoarding:

- Low activity along the cingulate cortex, which is involved

in decision making and motivation.

- Implications: The low activity may account for the

disorganization and lack of motivation often seen in the

difficulty of treating hoarders.

(Saxena, 2007)

DemographicsDemographicsOCD N Mean

Female 10 33Male 6 29.8Total 16 31.8

HoardingFemale 7 54.7Male 3 51.3Total 10 53.7

Y-BOCSY-BOCS

Total Score Mean SD

Hoarding 12.7 10.1

OCD 26.9 6.1

Y-BOCSY-BOCS

Hoarding Mean SD

Obsessions 5.0 6.1

Compulsions 7.7 5.0

OCD Mean SD

Obsessions 13.9 3.2

Compulsions 13.0 3.4

Beck Anxiety InventoryBeck Anxiety Inventory

N Mean SD

Hoarding 10 14.5 14.1

OCD 16 24.1 16.3

Beck Depression InventoryBeck Depression Inventory

N Mean SD

Hoarding 10 24.6 13.8

OCD 16 27.2 9.8

Overvalued Ideas ScaleOvervalued Ideas Scale

N Mean SD

Hoarding 10 6.7 1.3

OCD 16 4.6 1.3

Quality of Life Issues For Quality of Life Issues For EveryoneEveryone

Lack of functional living spaceUnhealthy living conditionsUnsafe living conditionsAdditional storage is not the answer

Lack of Functional Living SpaceLack of Functional Living Space

Furniture not being used as furnitureLittle, if any place to gather as a familyFinancial strain from ordering meals outSocial isolation

Unhealthy Living ConditionsUnhealthy Living Conditions

HeadachesRespiratory problemsAllergiesFatigue/lethargyInsomnia or sleep problems

Unsafe Living ConditionsUnsafe Living Conditions

Structural damage to homes– Weight of possessions– Possible water damage

Fire hazards– Highly flammable situations– Blocked passage ways

Unsafe Conditions (Cont.)Unsafe Conditions (Cont.)

Rodent infestationInsect infestationStairways filled with clutter

– Fire hazard, dangerous with children

Can lead to legal involvement

Additional Storage Is Not the Additional Storage Is Not the AnswerAnswer

Does not fix the problemLeads to increased financial pressureLeads to increased family tensionEventually ends up as more cluttered,

nonfunctional space

Effects of Hoarding on FamiliesEffects of Hoarding on Families

Living in clutter is living in chaosFinancial problemsHigh levels of resentment and anger toward

hoarder– Separation, divorce, kids moving out, etc.

Getting HelpGetting Help

Family members have the right to live without clutter

Families may seek treatment first– Hoarders can be resistant to treatment on their

own– May not think it is such a big deal

Treatment Steps for Family Treatment Steps for Family MembersMembers

Psycho-education on hoardingLearn how to communicate more

effectively with hoarder– Validate, validate, validate

Learn about the intervention technique– Goal is to bring the hoarder in for treatment

Applying the Intervention Applying the Intervention TechniqueTechnique

Family members bring hoarder into a sessionOne by one, each member talks about how

the hoarding has affected themIssues are brought out in loving and

supportive tones with validationHoarder then agrees to give treatment a

chance for a specific time period

Before Intervention: The Kitchen

Before Intervention: The Kitchen

Before Intervention: The Kitchen

After Intervention: The Kitchen

Before Intervention: The Living Room

Before Intervention: The Living Room

After Intervention: The Living Room

Before Intervention: The Guest Room

Before Intervention: The Guest Room

Before Intervention: The Living Room

After Intervention: The Guest Room