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OCD Spectrum Disorders

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  • Hollander D (1993): Introduction. In: Hollander E, editor. Obsessive-Compulsive Related Disorders . Washington, DC: American Psychiatric Press, 1-16 Hollander E, Neville D, Frenkel M, et al: Body dysmorphic disorder: diagnostic issues and related disorders. Psychosomatics 33: 156-165, 1992 Bienvenu OJ, Samuels JF, Riddle MA , et al. The relationship of obsessive-compulsive disorder to possible spectrum disorders: results from a family study. Biol Psychiatry. 2000 Aug 15;48(4):287-93 Implications: many of same strategies, both for primary treatments and augmentation
  • Classical Conditioning:Acquisition of BDD CS UCS UCR Body part abuse disgust teasing anxiety acne shame puberty depression
  • Be aware of the agenda / goals of patient have they been sent by cosmetic surgeon or relative shut them up. Make the diagnosis - don’t say imagined defect- we try to give an alternative explanation for their symptoms with the CBT model. We emphasise the the role of selective attention and impossible ideals If depressed start on SSRI??
  • Transcript

    • 1. 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
    • 2. 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
    • 3. Obsessive Compulsive Spectrum Disorders
    • 4. Obsessive-compulsive Spectrum Disorders
      • Obsessive-compulsive disorder
      • Hoarding
      • Body-dysmorphic disorder
      • Hypochondriasis
      • Eating disorders
      • Trichotillomania
      • Tourette’s syndrome
      • Self-mutilation
    • 5. 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).
    • 6. 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
    • 7. General Demographics For BDD
      • Estimated Prevalence Rate 1.0%
      • Male-Female Ratio 1:1
      • Age Of Onset 16
      • Years Before First Consult 6
    • 8. 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
    • 9. 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.
    • 10. Percentage of People with Body Image Dissatisfaction Phillips (1996)
    • 11. Normal Concerns vs. BDD
      • Time consumption  1 hour
      • Produces distress
      • Interferes with functioning
    • 12. Risk Factors for BDD
      • Abuse History
      • Teasing
      • Past History of Dermatological Problems
      • Shyness
      • Depression
      • Anxiety
      • Perfectionism
      • Stressors in General
    • 13. Is BDD a Problem of:
      • Perception
      • Somatosensory Disturbance
      • Global/Idealized Values
      • Faulty Beliefs
      • Information Processing Biases
      • Neurobiological Defect
    • 14.
      • 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.
    • 15.
      • 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.
    • 16. 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.
    • 17. 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)
    • 18.
        • 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.)
    • 19. 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
    • 20. 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.
    • 21. 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
    • 22.
      • 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.)
    • 23. 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!
    • 24. 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)
    • 25. 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
    • 26. Safety Behaviors in BDD
      • Do it yourself surgery
      • Cosmetic or dermatological interventions
    • 27. 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.
    • 28. 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
    • 29. 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).
    • 30. OVI in BDD
      • High overvalued ideas need to be addressed prior to exposure.
      • The higher the OVI the poorer the prognosis.
    • 31. 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)
    • 32. 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
    • 33. 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)
    • 34. 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)
    • 35. 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)
    • 36. 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
    • 37. 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
    • 38. 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
    • 39. 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
    • 40. 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
    • 41. Appropriate Treatments for BDD
      • Exposure and response prevention
      • Cognitive therapy
      • Psychopharmacological treatment
      • Support groups
      • Family intervention
    • 42. Inappropriate Treatment for BDD
      • Dermatological procedures
      • Surgical and non-surgical procedures
      • Psychodynamic therapy
    • 43. 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
    • 44.
      • 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
    • 45.
      • 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
    • 46.
      • 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
    • 47.
      • 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
    • 48.
      • 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
    • 49.
      • 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
    • 50. 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
    • 51. 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
    • 52. 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
    • 53. 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”
    • 54. 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
    • 55. 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
    • 56. 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
    • 57. Pie Chart of Values Artistic Achievement 30% Attractiveness 20% Family 15% Friendship 15% Money 10% Education 10% Neziroglu F, Khemlani-Patel S
    • 58. 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
    • 59. 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
    • 60.  
    • 61. 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
    • 62. 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
    • 63. Hypochondria
      • Second Century A.D., Galen of Pergamon used the term HYPOCHONDRIA to describe broad range of digestive disorders and melancholia
    • 64. 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
    • 65. Phenomenology of HC
      • HC are more concerned with the authenticity, meaning or etiological significance of their symptoms than with the unpleasant sensation or pain
    • 66. 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
    • 67. 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
    • 68. 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
    • 69. Differential Diagnosis of HC
      • Somatization Disorder
      • Delusional Disorder
      • (monosymptomatic Hypochondriacal Disorder)
      • Panic Disorder
      • Generalized Anxiety Disorder
      • Depression
      • Obsessive Compulsive Disorder
      • (Somatic Obsessions)
      • Illness Phobia
    • 70. 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)
    • 71. OCD and HC Anxiety and Depression Scales
    • 72. OCD and HC Obsessions and Compulsions DS-Disorder Specific
    • 73. OCD and HC Body Sensations and Mobility p<.05;**p<.01
    • 74. HC Obsessions
      • Death 20.0%
      • Fatigue 13.3%
      • General illness 13.3%
      • Back Problems 13.3%
      • Insomnia 6.7%
      • Multiple Sclerosis 6.7%
    • 75. 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%
    • 76. Treatment Modalities For HC
      • 1) Psychodynamic Interventions
      • 2) Reassurance Therapy
      • 3) Cognitive-Behavior Therapy
      • 4) Pharmacotherapy
    • 77. Kellner’s Reassurance Intervention
      • Physical Examination
      • Client Centered Techniques
      • Explanatory Therapy (psychoeducation)
      • Use of Suggestion
      • Biofeedback
    • 78. Treatment Outcome Data
      • Cognitive Behavioral Therapy Improved
      • Salkovskis and Warwick (1986) 100%
      • Warwick and Marks (1988) 88%
      • Miller, Action & Hodge (1988) 100%
    • 79. Cognitive Behavioral Model of Hypochondriasis
      • Review Previous Experience
      • Formulation of Dysfunctional Assumptions
      • A Critical Incident
      • Activation of Assumptions
      • Negative Thoughts and Imagery
      • Hypochondriacal Development
    • 80. 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.
    • 81. 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
    • 82. COGNITIVE RESTRUCTURING
      • A.= ANTECEDENT EVENT
      • B. = BELIEFS
      • C. = CONSEQUENCES
      • 1. EMOTIONAL
      • 2. BEHAVIORAL
      • D. =DISPUTE
      • E. = EFFECT OF DISPUTING
    • 83. 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
    • 84. 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)
    • 85. 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)
    • 86. 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.
    • 87. 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.
    • 88. Common HC Belief Distortions (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.
    • 89. Common HC Belief Distortions (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.
    • 90. 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?
    • 91. 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.
    • 92. General Conclusions about ERP vs. CT
      • With Cognitive Therapy
      • Attrition rate lower
      • Compliance better
      • Motivation greater
      • Acceptance of therapy better
    • 93. 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)
    • 94. Hoarding: Additional Criteria
      • Clutter prevents usage of functional space
      • Significant distress or impairment
      • Frost & Hartl (1996)
    • 95. Disorders with Hoarding Behavior
      • OCD
      • OCPD
      • Depression
      • Dementia
      • Psychosis (eg.SZ; delusional dis.)
      • Eating Disorders
    • 96. Prevalence
      • 20-30% of OCD patients
      • 26.3 per 100,000 as reported by health departments
      • Frost, Steketee, Greene (2003)
    • 97. 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
    • 98. 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)
    • 99. Model of Hoarding
    • 100. 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
    • 101. Obsessional Thoughts in Hoarding
          •  Emotional Comfort
      •  Loss
      •  Identity
      •  Value
      •  Responsibility/Waste
      •  Memory
      •  Control
    • 102. 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”
          •  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”
    • 103. Obsessional Thoughts in Hoarding
          •  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”
    • 104. 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)
    • 105. 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
    • 106. 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
    • 107. 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
    • 108. 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)
    • 109. 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)
    • 110. 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
    • 111. Y-BOCS
      • Total Score Mean SD
      • Hoarding 12.7 10.1
      • OCD 26.9 6.1
    • 112. 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
    • 113. Beck Anxiety Inventory
      • N Mean SD
      • Hoarding 10 14.5 14.1
      • OCD 16 24.1 16.3
    • 114. Beck Depression Inventory
      • N Mean SD
      • Hoarding 10 24.6 13.8
      • OCD 16 27.2 9.8
    • 115. Overvalued Ideas Scale
      • N Mean SD
      • Hoarding 10 6.7 1.3
      • OCD 16 4.6 1.3
    • 116. Quality of Life Issues For Everyone
      • Lack of functional living space
      • Unhealthy living conditions
      • Unsafe living conditions
      • Additional storage is not the answer
    • 117. 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
    • 118. Unhealthy Living Conditions
      • Headaches
      • Respiratory problems
      • Allergies
      • Fatigue/lethargy
      • Insomnia or sleep problems
    • 119. Unsafe Living Conditions
      • Structural damage to homes
        • Weight of possessions
        • Possible water damage
      • Fire hazards
        • Highly flammable situations
        • Blocked passage ways
    • 120. Unsafe Conditions (Cont.)
      • Rodent infestation
      • Insect infestation
      • Stairways filled with clutter
        • Fire hazard, dangerous with children
      • Can lead to legal involvement
    • 121. 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
    • 122. 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.
    • 123. 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
    • 124. 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
    • 125. 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
    • 126. Before Intervention: The Kitchen
    • 127. Before Intervention: The Kitchen
    • 128. Before Intervention: The Kitchen
    • 129. After Intervention: The Kitchen
    • 130. Before Intervention: The Living Room
    • 131. Before Intervention: The Living Room
    • 132. After Intervention: The Living Room
    • 133. Before Intervention: The Guest Room
    • 134. Before Intervention: The Guest Room
    • 135. Before Intervention: The Living Room
    • 136. After Intervention: The Guest Room