OCD Spectrum Disorders

Body Dysmorphic Disorder, Hypochondriasis, Hoarding, and other OCD Spectrum Disorders; Comparing and 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
Obsessive-compulsive disorder
Hoarding
Body-dysmorphic disorder
Hypochondriasis
Eating disorders
Trichotillomania
Tourette’s syndrome
Self-mutilation

Body 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).

Prevalence
1-2% of the general population
4-5% of people seeking medical treatment
8% of people with depression
More than 12% of people seeking mental health treatment

General Demographics For BDD
Estimated Prevalence Rate 1.0%
Male-Female Ratio 1:1
Age Of Onset 16
Years Before First Consult 6

Comorbidity
Heredity :
4 X higher lifetime prevalence of BDD in 1 st degree relatives of those with OCD than control probands 2
7% of BDD patients have a relative with OCD 3
Comorbidity: 30-40% with BDD have OCD; 12-16% with OCD have BDD 3 .
1 Hollander 1993; 2 Bienvenu et al. 2000; 3 Phillips, 1998

Adolescent Feelings Of Ugliness vs. BDD
Between the ages of 12-17, many adolescents
feel ugly.
Longevity and Severity distinguish normal adolescent concerns from BDD.

Percentage of People with Body Image Dissatisfaction Phillips (1996)

Normal Concerns vs. BDD
Time consumption  1 hour
Produces distress
Interferes with functioning

Risk Factors for BDD
Abuse History
Teasing
Past History of Dermatological Problems
Shyness
Depression
Anxiety
Perfectionism
Stressors in General

Is BDD a Problem of:
Perception
Somatosensory Disturbance
Global/Idealized Values
Faulty Beliefs
Information Processing Biases
Neurobiological Defect

Perception : Actually sees nose as big
Somatosensory : Feels nose is big
Global/Idealized Values : I value beauty as a goal to pursue
Faulty Cognitions : Because my nose is big, I will be alone and isolated all my life. Overgeneralization.

Information Processing Biases : Looking in the mirror and focusing immediately on the nose. Selective attention to details, rather than the whole.
Neurobiological Defect : Serotonin alteration; orbito-frontal cortex, temporal, occipital and parietal lobe involvement; genetically or ethologically transmitted.

How Do All These Aspects Interrelate? Based on genetically and/or ethologically transmitted need for symmetry or aestheticism, maladaptive beliefs and values are learned which influences information processing and perception.

Beliefs 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 (Cont.)

Faulty Beliefs - Cognitive Distortion
I need to be perfect
I need to be noticed
If I feel that my body part is unattractive, it means that it looks unattractive
If my body part is not beautiful, then it must be ugly
If I looked better, my whole life would be better
Happiness comes from looking good

Faulty Beliefs - Cognitive Distortion
The only way to feel better is to look better
I must be happy with what I see in the mirror
Looking good protects you from being treated badly
I cannot be comfortable unless I look good
Physical perfection is a realistic and attainable goal
If my appearance is defective then I am inadequate and worthless.

Safety or Avoidance Behaviors in BDD
Mirror gazing or avoiding
Excessive grooming
Ritualized or excessive makeup application
Excessive usage of skin or hair products
Hair removal
Hair cutting
Reassurance seeking
Camouflaging
Skin picking
Repeated checking of body part

Comparing self with others or old photos
Grooming, combing, smoothening, straightening, plucking or cutting hair
Skin cleaning, picking, peeling, bleaching
Facial exercises
Safety or Avoidance Behaviors in BDD (Cont.)

Avoidance 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 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 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 BDD
Do it yourself surgery
Cosmetic or dermatological interventions

BDD 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 OCD
Symptom Clusters
Neuropsychological Testing
Neuroimaging
Function of Compulsions/Safety Behaviors
Presence or absence of delusions, overvalued ideation
Perceptual/Somatosensory Components

OVI 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 BDD
High overvalued ideas need to be addressed prior to exposure.
The higher the OVI the poorer the prognosis.

OVI 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 Life
Quality 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 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 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 (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 OCD & 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 in 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 & OCD
OCD (n=32)
M = 35.7
Low Level
BDD (n= 23)
M = 24.1
Very Low Level
QOLI * * = p < .05

BDD: 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 Abuse 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 BDD
Exposure and response prevention
Cognitive therapy
Psychopharmacological treatment
Support groups
Family intervention

Inappropriate Treatment for BDD
Dermatological procedures
Surgical and non-surgical procedures
Psychodynamic therapy

CBT Working Model Operant Conditioning Biological Predisposition Operant Conditioning Social Learning + CS UCS CR UCR Information Processing Bias Classical/Evaluative Conditioning Body Dysmorphic Disorder Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

Genetic factors
Visual processing problems
Somatosensory problems
Faulty neuroanatomical circuitry
Biological Predisposition CBT Working Model (Cont.) 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
CS Body part Words: (blemish, red) + Biological Predisposition Operant Conditioning CBT Working Model (Cont.) Social Learning UCS Abuse Teasing Acne Puberty UCR Disgust Anxiety Shame Depression CR Mood Biased Information Processing/ Relational Framing Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

Negative reinforcement
CR is removed through avoidance behaviors (e.g., camouflaging, mirror checking, excessive makeup)
Positive intermittent reinforcement
Maintains avoidance behaviors
Operant Conditioning: Maintenance Of BDD 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 CR UCR Information Processing Bias Classical Conditioning

Cognitive Therapy: Initial Strategies
Address readiness for change
Motivational interviewing to engage patients reluctant to continue treatment
Stress the degree of dysfunction and suffering
Target depression and/or suicidal ideation

Engagement
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.)
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 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: Targeting BDD Symptoms
Target cognitive distortions
Beck or Ellis modalities work well
Hypothesis testing/collaborative empiricism
Take patient’s photograph and collect ratings of attractiveness
Interview strangers regarding relevant distorted beliefs of patient

Cognitive Therapy: Targeting Values 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 Values Artistic Achievement 30% Attractiveness 20% Family 15% Friendship 15% Money 10% Education 10% Neziroglu F, Khemlani-Patel S

CBT 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 for 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

HYPOCHONDRIASIS
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 Hypochondria
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

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

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

HC Demographics
Male: 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 Symptoms Parts of the Body Affected
1) Head and Neck Complaints:
Tumors
Aneurysms
Strokes
Burning Sensation
Chronic Headaches
Muscle Spasms
Numbness in Face

Common HC Symptoms Parts of the Body Affected (con’t)
2) Abdomen Complaints:
Prostate Cancer
Hernias
Irritable Bowel Syndrome
Liver Cancer
Ulcers
Chest Complaints:
Heart Attacks
Chronic Asthma

Differential 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 & HC
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 HC Anxiety and Depression Scales

OCD and HC Obsessions and Compulsions DS-Disorder Specific

OCD and HC Body Sensations and Mobility p<.05;**p<.01

HC Obsessions
Death 20.0%
Fatigue 13.3%
General illness 13.3%
Back Problems 13.3%
Insomnia 6.7%
Multiple Sclerosis 6.7%

HC Compulsions
Check 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 HC
1) Psychodynamic Interventions
2) Reassurance Therapy
3) Cognitive-Behavior Therapy
4) Pharmacotherapy

Kellner’s Reassurance Intervention
Physical Examination
Client Centered Techniques
Explanatory Therapy (psychoeducation)
Use of Suggestion
Biofeedback

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

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

COGNITIVE THERAPY FOCUS
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 RESTRUCTURING
A.= ANTECEDENT EVENT
B. = BELIEFS
C. = CONSEQUENCES
1. EMOTIONAL
2. BEHAVIORAL
D. =DISPUTE
E. = EFFECT OF DISPUTING

Ellis’ ABC Paradigm in the Treatment of OCD 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
Primary Appraisal Process whereby the individual overestimates probability and the cost of the occurrence of unfavorable events.
Secondary Appraisal Process whereby individual underestimates his/her abilities to cope with the threat.
MC Fall and Wollersheim (1979)

Common 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 (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.

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.

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 Beliefs (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 (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 ERP vs. CT
With Cognitive Therapy
Attrition rate lower
Compliance better
Motivation greater
Acceptance of therapy better

Hoarding
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 Criteria
Clutter prevents usage of functional space
Significant distress or impairment
Frost & Hartl (1996)

Disorders with Hoarding Behavior
OCD
OCPD
Depression
Dementia
Psychosis (eg.SZ; delusional dis.)
Eating Disorders

Prevalence
20-30% of OCD patients
26.3 per 100,000 as reported by health departments
Frost, Steketee, Greene (2003)

Possible Etiology of Hoarding
Informational-Processing Deficits: i.e. decision making, organizing, memory
Emotional attachment to possessions
Cognitive distortions; ie. I will never be able to get the info anywhere else
Neurobiological

Co-morbidity in Compulsive Hoarding
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 Hoarding

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 Comfort
 Loss
 Identity
 Value
 Responsibility/Waste
 Memory
 Control

 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”
 Responsibility
o “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”

 Memory
o “Saving this means I don’t have to rely on my memory
o “If I don’t leave this in sight, I’ll forget it”
o “I must remember something about this”
· Control
o “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: Obsessions
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: Rituals and avoidance behaviors
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: Insight, 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. 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: Neuroanatmony
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)

Demographics
OCD N Mean
Female 10 33
Male 6 29.8
Total 16 31.8
Hoarding
Female 7 54.7
Male 3 51.3
Total 10 53.7

Y-BOCS
Total Score Mean SD
Hoarding 12.7 10.1
OCD 26.9 6.1

Y-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 Inventory
N Mean SD
Hoarding 10 14.5 14.1
OCD 16 24.1 16.3

Beck Depression Inventory
N Mean SD
Hoarding 10 24.6 13.8
OCD 16 27.2 9.8

Overvalued Ideas Scale
N Mean SD
Hoarding 10 6.7 1.3
OCD 16 4.6 1.3

Quality of Life Issues For Everyone
Lack of functional living space
Unhealthy living conditions
Unsafe living conditions
Additional storage is not the answer

Lack of Functional Living Space
Furniture not being used as furniture
Little, if any place to gather as a family
Financial strain from ordering meals out
Social isolation

Unhealthy Living Conditions
Headaches
Respiratory problems
Allergies
Fatigue/lethargy
Insomnia or sleep problems

Unsafe Living Conditions
Structural damage to homes
Weight of possessions
Possible water damage
Fire hazards
Highly flammable situations
Blocked passage ways

Unsafe Conditions (Cont.)
Rodent infestation
Insect infestation
Stairways filled with clutter
Fire hazard, dangerous with children
Can lead to legal involvement

Additional Storage Is Not the Answer
Does not fix the problem
Leads to increased financial pressure
Leads to increased family tension
Eventually ends up as more cluttered, nonfunctional space

Effects of Hoarding on Families
Living in clutter is living in chaos
Financial problems
High levels of resentment and anger toward hoarder
Separation, divorce, kids moving out, etc.

Getting 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 Members
Psycho-education on hoarding
Learn 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 Technique
Family members bring hoarder into a session
One by one, each member talks about how the hoarding has affected them
Issues are brought out in loving and supportive tones with validation
Hoarder then agrees to give treatment a chance for a specific time period

Before Intervention: The Kitchen

After Intervention: The Kitchen

Before Intervention: The Living Room

After Intervention: The Living Room

Before Intervention: The Guest Room

Before Intervention: The Living Room

After Intervention: The Guest Room

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OCD Spectrum Disorders

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