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??
  • OCD Spectrum Disorders

    1. 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. 2. Obsessive Compulsive Spectrum Disorders <ul><li>We identify disorders on the OC spectrum because: </li></ul><ul><ul><li>They all share in common obsessions and/or compulsions </li></ul></ul><ul><ul><li>They have similar symptomatology, treatment response, and family history </li></ul></ul>
    3. 3. Obsessive Compulsive Spectrum Disorders
    4. 4. Obsessive-compulsive Spectrum Disorders <ul><li>Obsessive-compulsive disorder </li></ul><ul><li>Hoarding </li></ul><ul><li>Body-dysmorphic disorder </li></ul><ul><li>Hypochondriasis </li></ul><ul><li>Eating disorders </li></ul><ul><li>Trichotillomania </li></ul><ul><li>Tourette’s syndrome </li></ul><ul><li>Self-mutilation </li></ul>
    5. 5. Body Dysmorphic Disorder <ul><li>A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive. </li></ul><ul><li>B. The preoccupation causes clinically significant distress or impairment in functioning. </li></ul><ul><li>C.The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa). </li></ul>
    6. 6. Prevalence <ul><li>1-2% of the general population </li></ul><ul><li>4-5% of people seeking medical treatment </li></ul><ul><li>8% of people with depression </li></ul><ul><li>More than 12% of people seeking mental health treatment </li></ul>
    7. 7. General Demographics For BDD <ul><li>Estimated Prevalence Rate 1.0% </li></ul><ul><li>Male-Female Ratio 1:1 </li></ul><ul><li>Age Of Onset 16 </li></ul><ul><li>Years Before First Consult 6 </li></ul>
    8. 8. Comorbidity <ul><li>Heredity : </li></ul><ul><ul><li>4 X higher lifetime prevalence of BDD in 1 st degree relatives of those with OCD than control probands 2 </li></ul></ul><ul><ul><li>7% of BDD patients have a relative with OCD 3 </li></ul></ul><ul><li>Comorbidity: 30-40% with BDD have OCD; 12-16% with OCD have BDD 3 . </li></ul>1 Hollander 1993; 2 Bienvenu et al. 2000; 3 Phillips, 1998
    9. 9. Adolescent Feelings Of Ugliness vs. BDD <ul><li>Between the ages of 12-17, many adolescents </li></ul><ul><li>feel ugly. </li></ul><ul><li>Longevity and Severity distinguish normal adolescent concerns from BDD. </li></ul>
    10. 10. Percentage of People with Body Image Dissatisfaction Phillips (1996)
    11. 11. Normal Concerns vs. BDD <ul><li>Time consumption  1 hour </li></ul><ul><li>Produces distress </li></ul><ul><li>Interferes with functioning </li></ul>
    12. 12. Risk Factors for BDD <ul><li>Abuse History </li></ul><ul><li>Teasing </li></ul><ul><li>Past History of Dermatological Problems </li></ul><ul><li>Shyness </li></ul><ul><li>Depression </li></ul><ul><li>Anxiety </li></ul><ul><li>Perfectionism </li></ul><ul><li>Stressors in General </li></ul>
    13. 13. Is BDD a Problem of: <ul><li>Perception </li></ul><ul><li>Somatosensory Disturbance </li></ul><ul><li>Global/Idealized Values </li></ul><ul><li>Faulty Beliefs </li></ul><ul><li>Information Processing Biases </li></ul><ul><li>Neurobiological Defect </li></ul>
    14. 14. <ul><li>Perception : Actually sees nose as big </li></ul><ul><li>Somatosensory : Feels nose is big </li></ul><ul><li>Global/Idealized Values : I value beauty as a goal to pursue </li></ul><ul><li>Faulty Cognitions : Because my nose is big, I will be alone and isolated all my life. Overgeneralization. </li></ul>
    15. 15. <ul><li>Information Processing Biases : Looking in the mirror and focusing immediately on the nose. Selective attention to details, rather than the whole. </li></ul><ul><li>Neurobiological Defect : Serotonin alteration; orbito-frontal cortex, temporal, occipital and parietal lobe involvement; genetically or ethologically transmitted. </li></ul>
    16. 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. 17. Beliefs About Appearance <ul><li>Identify and question the meaning of the defectiveness (not the defect), i.e., the assumptions about defectiveness and values (the importance of appearance) </li></ul>
    18. 18. <ul><ul><li>Focus on assumptions and values </li></ul></ul><ul><ul><li>Collect information that is inconsistent with beliefs which patient normally ignores or distorts in an alternative data log </li></ul></ul>Beliefs About Appearance (Cont.)
    19. 19. Faulty Beliefs - Cognitive Distortion <ul><li>I need to be perfect </li></ul><ul><li>I need to be noticed </li></ul><ul><li>If I feel that my body part is unattractive, it means that it looks unattractive </li></ul><ul><li>If my body part is not beautiful, then it must be ugly </li></ul><ul><li>If I looked better, my whole life would be better </li></ul><ul><li>Happiness comes from looking good </li></ul>
    20. 20. Faulty Beliefs - Cognitive Distortion <ul><li>The only way to feel better is to look better </li></ul><ul><li>I must be happy with what I see in the mirror </li></ul><ul><li>Looking good protects you from being treated badly </li></ul><ul><li>I cannot be comfortable unless I look good </li></ul><ul><li>Physical perfection is a realistic and attainable goal </li></ul><ul><li>If my appearance is defective then I am inadequate and worthless. </li></ul>
    21. 21. Safety or Avoidance Behaviors in BDD <ul><li>Mirror gazing or avoiding </li></ul><ul><li>Excessive grooming </li></ul><ul><li>Ritualized or excessive makeup application </li></ul><ul><li>Excessive usage of skin or hair products </li></ul><ul><li>Hair removal </li></ul><ul><li>Hair cutting </li></ul><ul><li>Reassurance seeking </li></ul><ul><li>Camouflaging </li></ul><ul><li>Skin picking </li></ul><ul><li>Repeated checking of body part </li></ul>
    22. 22. <ul><li>Comparing self with others or old photos </li></ul><ul><li>Grooming, combing, smoothening, straightening, plucking or cutting hair </li></ul><ul><li>Skin cleaning, picking, peeling, bleaching </li></ul><ul><li>Facial exercises </li></ul>Safety or Avoidance Behaviors in BDD (Cont.)
    23. 23. Avoidance Behaviors in BDD <ul><li>Social and public situations with varying degrees of safety behaviors </li></ul><ul><ul><li>Clothes or hair to hide “defect” </li></ul></ul><ul><ul><li>Certain posture </li></ul></ul><ul><ul><li>Padding </li></ul></ul><ul><ul><li>Cold Coke cans! </li></ul></ul>
    24. 24. Skin Picking and Hair Cutting <ul><li>Self-monitoring (frequency chart) </li></ul><ul><li>Self-monitoring of triggers </li></ul><ul><li>Habit reversal </li></ul><ul><li>Challenge irrational beliefs regarding effectiveness and necessity of behavior </li></ul><ul><li>Delay response and alternative activities (e.g., not alone) </li></ul><ul><li>Difficult to treat due to short-term satisfaction </li></ul><ul><li>Identify secondary functions of behavior (stress reducer, escape, emotion regulation) </li></ul>
    25. 25. Compulsive Skin Picking <ul><li>Repetitive skin picking and cleaning, especially face </li></ul><ul><li>Aim to remove moles, freckles, blemish, scabs </li></ul><ul><li>Fingernails, tweezers, pins, sharp implements </li></ul><ul><li>Lead to bleeding, bruises, infections and/or permanent disfigurement </li></ul><ul><li>Short-term tension reduction and satisfaction </li></ul><ul><li>Followed by disgust, anger, depression </li></ul><ul><li>OC spectrum — BDD, OCD, trichotillomania </li></ul>
    26. 26. Safety Behaviors in BDD <ul><li>Do it yourself surgery </li></ul><ul><li>Cosmetic or dermatological interventions </li></ul>
    27. 27. BDD vs. OCD <ul><li>Similarities </li></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><li>Response to Cognitive Behavioral Therapy </li></ul></ul><ul><ul><li>Response to Pharmacotherapy </li></ul></ul><ul><li>Dissimilarities </li></ul><ul><ul><li>BDD has higher OVI, more depressed, less anxious, total self identification, more personality disorders. </li></ul></ul>
    28. 28. Example of Differentiating BDD From OCD <ul><li>Symptom Clusters </li></ul><ul><li>Neuropsychological Testing </li></ul><ul><li>Neuroimaging </li></ul><ul><li>Function of Compulsions/Safety Behaviors </li></ul><ul><li>Presence or absence of delusions, overvalued ideation </li></ul><ul><li>Perceptual/Somatosensory Components </li></ul>
    29. 29. OVI in OCD <ul><li>Examined whether OVI predicts medication treatment response </li></ul><ul><li>Results illustrated that OVI predicted the outcome for obsessions, but not compulsions. As patients scored higher on OVIS there was less improvement following treatment. </li></ul><ul><li>Neziroglu, F., Yaryura-Tobias, J., Pinto, A., & McKay, D. (2004). Psychiatry Research, 125 (1). </li></ul>
    30. 30. OVI in BDD <ul><li>High overvalued ideas need to be addressed prior to exposure. </li></ul><ul><li>The higher the OVI the poorer the prognosis. </li></ul>
    31. 31. OVI in BDD vs. OCD <ul><li>Subjects with BDD had significantly lower levels of insight than subjects with OCD </li></ul><ul><li>Suggests differences in insight is not attributable to symptom severity </li></ul><ul><li>Eisen, Phillips, Coles, & Rasmussen (2003) </li></ul><ul><li>Phillips, Pinto, Menard, Eisen, Mancebo, Rasmussen (2007) </li></ul>
    32. 32. Quality of Life <ul><ul><li>Quality of life measures impact of a disorder across area of everyday functioning </li></ul></ul><ul><ul><li>Self esteem </li></ul></ul><ul><ul><li>Goals </li></ul></ul><ul><ul><li>Play </li></ul></ul><ul><ul><li>Love </li></ul></ul><ul><ul><li>Friendship </li></ul></ul><ul><ul><li>Community </li></ul></ul><ul><ul><li>Health </li></ul></ul><ul><ul><li>Money </li></ul></ul><ul><li>Learning </li></ul><ul><li>Helping </li></ul><ul><li>Children </li></ul><ul><li>Relatives </li></ul><ul><li>Home </li></ul><ul><li>Neighborhood </li></ul><ul><li>Creativity </li></ul><ul><li>Work </li></ul>
    33. 33. Quality of Life in OCD <ul><li>Lower overall Quality of Life than general population </li></ul><ul><li>Mental health and psychological well being most impaired in subjects with OCD </li></ul><ul><li>Lower Quality of Life than Schizophrenia patients </li></ul><ul><li>Koran, Thienemann, & Davenport (1996) </li></ul><ul><li>Stengler-Wenzke , Kroll, Matschinger , & Angermeyer (2006) </li></ul>
    34. 34. Quality of Life in BDD <ul><li>BDD patients have poor Quality of Life across all psychosocial functioning and mental health domains. </li></ul><ul><li>BDD Patients demonstrate poorer quality of mental health life as compared to: </li></ul><ul><ul><li>US general population </li></ul></ul><ul><ul><li>Patients with Major Depression or Dysthymia </li></ul></ul><ul><ul><li>Patients with chronic medical conditions . </li></ul></ul><ul><li>Functioning and quality of life for BDD patients are low regardless of treatment </li></ul><ul><li>Phillips , Menard, Fay, & Paagano (2005) </li></ul>
    35. 35. Quality of Life BDD vs. OCD (cont) <ul><li>OCD & BDD had very poor psychosocial functioning and Quality of Life </li></ul><ul><li>Comorbid OCD/BDD patients showed greater impairment than OCD patients but not BDD patients. </li></ul><ul><li>BDD severity may account for lower quality of life in the comorbid group. </li></ul><ul><li>Didie, Mancebo, Rasmussen, Phillips, Walters, Menard, & Eisen (2004) </li></ul>
    36. 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. 37. Overvalued Ideation Levels in BDD & OCD <ul><li>OCD (n=62) </li></ul><ul><li>M = 4.8 </li></ul><ul><li>Middle Range </li></ul><ul><li>BDD (n= 53) </li></ul><ul><li>M = 6.1 </li></ul><ul><li>Upper Range </li></ul>OVIS * * = p < .001
    38. 38. Quality of Life in BDD & OCD <ul><li>OCD (n=32) </li></ul><ul><li>M = 35.7 </li></ul><ul><li>Low Level </li></ul><ul><li>BDD (n= 23) </li></ul><ul><li>M = 24.1 </li></ul><ul><li>Very Low Level </li></ul>QOLI * * = p < .05
    39. 39. BDD: Severity of Disorder <ul><li>Suicide attempt rate: 29% </li></ul><ul><li>Suicide ideation rate: 80% </li></ul><ul><li>Hospitalization: 36-58% </li></ul><ul><li>Homebound: 32-40% </li></ul><ul><li>Full-time employment/student: 42% </li></ul>Phillips KA et al. (2006), Compr Psychiatry 47(2):77-87
    40. 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. 41. Appropriate Treatments for BDD <ul><li>Exposure and response prevention </li></ul><ul><li>Cognitive therapy </li></ul><ul><li>Psychopharmacological treatment </li></ul><ul><li>Support groups </li></ul><ul><li>Family intervention </li></ul>
    42. 42. Inappropriate Treatment for BDD <ul><li>Dermatological procedures </li></ul><ul><li>Surgical and non-surgical procedures </li></ul><ul><li>Psychodynamic therapy </li></ul>
    43. 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. 44. <ul><li>Genetic factors </li></ul><ul><li>Visual processing problems </li></ul><ul><li>Somatosensory problems </li></ul><ul><li>Faulty neuroanatomical circuitry </li></ul>Biological Predisposition CBT Working Model (Cont.) Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
    45. 45. <ul><li>Person is positively and/or intermittently reinforced for: </li></ul><ul><ul><li>Overall appearance ▪ Poise </li></ul></ul><ul><ul><li>Particular body part ▪ Weight </li></ul></ul><ul><ul><li>Height ▪ Body shape </li></ul></ul><ul><ul><li>Cuteness </li></ul></ul>Biological Predisposition Operant Conditioning CBT Working Model (Cont.) Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
    46. 46. <ul><li>Social learning </li></ul><ul><ul><li>Modeling/Media/Childhood teaching </li></ul></ul><ul><ul><li>Vicarious learning </li></ul></ul><ul><li>Social learning and operant conditioning </li></ul><ul><ul><li>Develop </li></ul></ul><ul><ul><ul><li>Values and beliefs about attractiveness </li></ul></ul></ul><ul><ul><ul><li>Self-value based on body image </li></ul></ul></ul>+ Biological Predisposition Operant Conditioning CBT Working Model (Cont.) Social Learning Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
    47. 47. <ul><li>Classical Conditioning: Acquisition BDD </li></ul>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. 48. <ul><li>Negative reinforcement </li></ul><ul><ul><li>CR is removed through avoidance behaviors (e.g., camouflaging, mirror checking, excessive makeup) </li></ul></ul><ul><li>Positive intermittent reinforcement </li></ul><ul><ul><li>Maintains avoidance behaviors </li></ul></ul>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. 49. <ul><li>Negative reinforcement </li></ul><ul><ul><li>CR is removed through avoidance behaviors (e.g., camouflaging, mirror checking, excessive makeup) </li></ul></ul><ul><li>Positive intermittent reinforcement </li></ul><ul><ul><li>Maintains avoidance behaviors </li></ul></ul>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. 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. 51. Cognitive Therapy: Initial Strategies <ul><li>Address readiness for change </li></ul><ul><li>Motivational interviewing to engage patients reluctant to continue treatment </li></ul><ul><ul><li>Stress the degree of dysfunction and suffering </li></ul></ul><ul><li>Target depression and/or suicidal ideation </li></ul>
    52. 52. Engagement <ul><li>Explaining diagnosis — emphasize “preoccupation with the way you feel about appearance” </li></ul><ul><li>Similar problems in disorders with OVI where goals not shared by clinician </li></ul><ul><li>Motivational interviewing (focus on handicap linked to the demand about how their appearance must be or their idealized value about appearance) </li></ul>OVI = overvalued ideation
    53. 53. Engagement (Cont.) <ul><li>Avoid giving reassurance about appearance as patient often told “look alright” </li></ul><ul><li>Validate experience and help understand what the problem is </li></ul><ul><li>Two hypotheses either “problem unattractive” or you have a “problem with the way you feel about your appearance” </li></ul>
    54. 54. Early Goals <ul><li>Functioning — activity scheduling and social withdrawal/avoidance which maintains depressed mood </li></ul><ul><li>Decrease compulsive behaviors, such as mirror gazing and checking with hands </li></ul><ul><li>Skin picking </li></ul>
    55. 55. Cognitive Therapy: Targeting BDD Symptoms <ul><li>Target cognitive distortions </li></ul><ul><li>Beck or Ellis modalities work well </li></ul><ul><li>Hypothesis testing/collaborative empiricism </li></ul><ul><ul><li>Take patient’s photograph and collect ratings of attractiveness </li></ul></ul><ul><ul><li>Interview strangers regarding relevant distorted beliefs of patient </li></ul></ul>
    56. 56. Cognitive Therapy: Targeting Values on Appearance <ul><li>Targeting value of appearance may be an important treatment component in relapse prevention </li></ul><ul><li>Methods to target values and attitudes </li></ul><ul><ul><li>Psychoeducation </li></ul></ul><ul><ul><li>Pie chart of important values </li></ul></ul>
    57. 57. Pie Chart of Values Artistic Achievement 30% Attractiveness 20% Family 15% Friendship 15% Money 10% Education 10% Neziroglu F, Khemlani-Patel S
    58. 58. CBT for BDD in Social Situations <ul><li>Exposure/behavioral experiments </li></ul><ul><ul><li>Minimal or no makeup or exaggerate “defect” </li></ul></ul><ul><ul><li>No changes in posture </li></ul></ul><ul><ul><li>Not using hand or hair </li></ul></ul><ul><ul><li>Not stand by window </li></ul></ul><ul><ul><li>Refocus attention away from self </li></ul></ul>
    59. 59. 4 Ways To Challenge Beliefs for BDD <ul><li>What is the evidence that supports or contradicts this belief? </li></ul><ul><li>Are there any other ways to interpret this situation? </li></ul><ul><li>Realistically, what is the worst thing that could happen in this situation and how would it honestly affect my life? </li></ul><ul><li>Even if the negative belief is warranted, what can I realistically do to help remedy the situation? </li></ul><ul><li>Geremia, G & Neziroglu F (2001), Clinical Psych and Psychotherapy 8: 243-251 </li></ul>
    61. 62. Historical Conceptualization Of Hypochondria <ul><li>In 1621, Robert Burton wrote </li></ul><ul><li>“ The Anatomy of Melancholy”. </li></ul><ul><li>He described “hypochondriacal melancholy” as including physical ailments (e.g. ears ringing, belching, vertigo.) and fear of disease </li></ul>
    62. 63. Hypochondria <ul><li>Second Century A.D., Galen of Pergamon used the term HYPOCHONDRIA to describe broad range of digestive disorders and melancholia </li></ul>
    63. 64. Cost of HC Per Year <ul><li>At least 20 billion dollars per year is spent on hypochondriacal patients, and may be as much as 100 billion dollars </li></ul>
    64. 65. Phenomenology of HC <ul><li>HC are more concerned with the authenticity, meaning or etiological significance of their symptoms than with the unpleasant sensation or pain </li></ul>
    65. 66. HC Demographics <ul><li>Male: Female Ratio 1:1 </li></ul><ul><li>Average Age 36-57 </li></ul><ul><li>Duration of Symptoms 6 months-25 years </li></ul><ul><li>Symptoms occur more often in single, women, less educated, less income, non-whites, hispanics, older, urban residence </li></ul>
    66. 67. Common HC Symptoms Parts of the Body Affected <ul><li>1) Head and Neck Complaints: </li></ul><ul><li>Tumors </li></ul><ul><li>Aneurysms </li></ul><ul><li>Strokes </li></ul><ul><li>Burning Sensation </li></ul><ul><li>Chronic Headaches </li></ul><ul><li>Muscle Spasms </li></ul><ul><li>Numbness in Face </li></ul>
    67. 68. Common HC Symptoms Parts of the Body Affected (con’t) <ul><li>2) Abdomen Complaints: </li></ul><ul><li>Prostate Cancer </li></ul><ul><li>Hernias </li></ul><ul><li>Irritable Bowel Syndrome </li></ul><ul><li>Liver Cancer </li></ul><ul><li>Ulcers </li></ul><ul><li>Chest Complaints: </li></ul><ul><li>Heart Attacks </li></ul><ul><li>Chronic Asthma </li></ul>
    68. 69. Differential Diagnosis of HC <ul><li>Somatization Disorder </li></ul><ul><li>Delusional Disorder </li></ul><ul><li>(monosymptomatic Hypochondriacal Disorder) </li></ul><ul><li>Panic Disorder </li></ul><ul><li>Generalized Anxiety Disorder </li></ul><ul><li>Depression </li></ul><ul><li>Obsessive Compulsive Disorder </li></ul><ul><li>(Somatic Obsessions) </li></ul><ul><li>Illness Phobia </li></ul>
    69. 70. Reported Dissimilarities Between OCD & HC <ul><li>Patient with Hypochondriasis: </li></ul><ul><li>See their fears as realistic </li></ul><ul><li>Possess pervasive ideas of illness as part of their personality </li></ul><ul><li>Are public about their concerns </li></ul><ul><li>Experience genuine somatic discomfort </li></ul><ul><li>Barsky (1992) </li></ul>
    70. 71. OCD and HC Anxiety and Depression Scales
    71. 72. OCD and HC Obsessions and Compulsions DS-Disorder Specific
    72. 73. OCD and HC Body Sensations and Mobility p<.05;**p<.01
    73. 74. HC Obsessions <ul><li>Death 20.0% </li></ul><ul><li>Fatigue 13.3% </li></ul><ul><li>General illness 13.3% </li></ul><ul><li>Back Problems 13.3% </li></ul><ul><li>Insomnia 6.7% </li></ul><ul><li>Multiple Sclerosis 6.7% </li></ul>
    74. 75. HC Compulsions <ul><li>Check Body 81.8% </li></ul><ul><li>Seek Reassurance 81.8% </li></ul><ul><li>Visit Doctors 81.8% </li></ul><ul><li>Washing (not Contamination) 63.7% </li></ul><ul><li>Read Health Literature 54.5% </li></ul><ul><li>Take Vitamins 54.5% </li></ul><ul><li>Avoid Certain Places 45.5% </li></ul><ul><li>Avoid Certain Foods 36.4% </li></ul><ul><li>Visit Emergency Room 18.2% </li></ul><ul><li>Avoid Doctors 9.1% </li></ul>
    75. 76. Treatment Modalities For HC <ul><li>1) Psychodynamic Interventions </li></ul><ul><li>2) Reassurance Therapy </li></ul><ul><li>3) Cognitive-Behavior Therapy </li></ul><ul><li>4) Pharmacotherapy </li></ul>
    76. 77. Kellner’s Reassurance Intervention <ul><li>Physical Examination </li></ul><ul><li>Client Centered Techniques </li></ul><ul><li>Explanatory Therapy (psychoeducation) </li></ul><ul><li>Use of Suggestion </li></ul><ul><li>Biofeedback </li></ul>
    77. 78. Treatment Outcome Data <ul><li>Cognitive Behavioral Therapy Improved </li></ul><ul><li>Salkovskis and Warwick (1986) 100% </li></ul><ul><li>Warwick and Marks (1988) 88% </li></ul><ul><li>Miller, Action & Hodge (1988) 100% </li></ul>
    78. 79. Cognitive Behavioral Model of Hypochondriasis <ul><li>Review Previous Experience </li></ul><ul><li>Formulation of Dysfunctional Assumptions </li></ul><ul><li>A Critical Incident </li></ul><ul><li>Activation of Assumptions </li></ul><ul><li>Negative Thoughts and Imagery </li></ul><ul><li>Hypochondriacal Development </li></ul>
    79. 80. General Cognitive Therapy for Hypochondriasis <ul><li>Hypochondriacs overestimate the probability of a symptom indicating the existence of an illness and underestimate their ability to cope with it. </li></ul>
    81. 82. COGNITIVE RESTRUCTURING <ul><li>A.= ANTECEDENT EVENT </li></ul><ul><li>B. = BELIEFS </li></ul><ul><li>C. = CONSEQUENCES </li></ul><ul><li>1. EMOTIONAL </li></ul><ul><li>2. BEHAVIORAL </li></ul><ul><li>D. =DISPUTE </li></ul><ul><li>E. = EFFECT OF DISPUTING </li></ul>
    82. 83. Ellis’ ABC Paradigm in the Treatment of OCD Applied to HC <ul><li>A = Obsession itself or any activating event </li></ul><ul><li>B = 1. If I do not call the doctor about my headache I have behaved irresponsibly </li></ul><ul><li>2. It is awful to feel anxious. </li></ul><ul><li>3. I must have guarantees. </li></ul><ul><li>C = Anxiety </li></ul><ul><li>Active Avoidance </li></ul>
    83. 84. Cognitive Theories <ul><li>Under high cost conditions obsessives make the same threat appraisal as normals. </li></ul><ul><li>Under low cost conditions obsessionals overestimate the probability of the occurance of the disastrous consequence. </li></ul><ul><li>Carr (1974) </li></ul>
    84. 85. Cognitive Theories <ul><li>Primary Appraisal Process whereby the individual overestimates probability and the cost of the occurrence of unfavorable events. </li></ul><ul><li>Secondary Appraisal Process whereby individual underestimates his/her abilities to cope with the threat. </li></ul><ul><li>MC Fall and Wollersheim (1979) </li></ul>
    85. 86. Common HC Belief Distortions <ul><li>If I have something wrong with me, I will not be a desirable person. </li></ul><ul><li>Bodily symptoms are a sign of serious illness because every symptom has an identifiable physical cause. </li></ul><ul><li>I am irresponsible if I don’t go to the doctor immediately. </li></ul>
    86. 87. Common HC Belief Distortions (Cont.) <ul><li>I can’t stand the pain </li></ul><ul><li>I can’t stand being ill. </li></ul><ul><li>Any symptom means that I’m ill, or am going to be ill. </li></ul><ul><li>If I’m ill, I will definitely suffer greatly (and I can not stand the suffering). </li></ul><ul><li>If I’m ill, I will die. </li></ul><ul><li>I have an incurable illness. </li></ul><ul><li>If I’m ill, I can’t be happy. </li></ul><ul><li>Symptoms are indicative of severe illnesses. </li></ul>
    87. 88. Common HC Belief Distortions (Cont.) <ul><li>If I’m ill, there’s no need to fight because my life is over. </li></ul><ul><li>I want certainty that I am not ill. </li></ul><ul><li>Every physical symptom is indicative of a serious medical condition. </li></ul><ul><li>I have a disease, but the doctors have not been able to diagnose it yet. </li></ul><ul><li>If I pay close attention to my bodily symptoms I can prevent being sick. </li></ul>
    88. 89. Common HC Belief Distortions (Cont.) <ul><li>All symptoms are a sign of danger. </li></ul><ul><li>I will not be able to cope with a major illness. </li></ul><ul><li>I must know immediately if there is something wrong with me. </li></ul><ul><li>I can not tolerate anxiety. </li></ul><ul><li>I must be hypervigilant to all bodily symptoms, in order to prevent an illness. </li></ul>
    89. 90. Four Ways To Challenge Beliefs (Hypochondriasis) <ul><li>1) What is the evidence that supports or contradicts this belief? </li></ul><ul><li>2) Are there any other ways to interpret the physical symptoms or my belief? </li></ul><ul><li>3) Ultimately if I am correct in my interpretation, realistically to what extent can I control the outcome? </li></ul><ul><li>4) Why is it that others don’t preoccupy themselves with the same physical symptoms, and what enables them to cope with negative outcomes? </li></ul>
    90. 91. Conclusions (CT for HC) <ul><li>Cognitive Therapy is effective for HC. </li></ul><ul><li>Cognitive Therapy decreases overvalued ideas, depression, anxiety, frequency and severity of obsessive thoughts. </li></ul><ul><li>Exposure and Responsive Prevention (ERP) reduces compulsions. </li></ul><ul><li>ERP does not decrease overvalued ideas, obsessions, nor depression. </li></ul><ul><li>Best to combine cognitive therapy with ERP. </li></ul><ul><li>Cognitive Therapy effective even for severe cases. </li></ul>
    91. 92. General Conclusions about ERP vs. CT <ul><li>With Cognitive Therapy </li></ul><ul><li>Attrition rate lower </li></ul><ul><li>Compliance better </li></ul><ul><li>Motivation greater </li></ul><ul><li>Acceptance of therapy better </li></ul>
    92. 93. Hoarding <ul><li>Hoarding is the acquisition of, and failure to discard, large numbers of items that appear to have little or no value </li></ul><ul><li>(Frost & Gross, 1993) </li></ul>
    93. 94. Hoarding: Additional Criteria <ul><li>Clutter prevents usage of functional space </li></ul><ul><li>Significant distress or impairment </li></ul><ul><li>Frost & Hartl (1996) </li></ul>
    94. 95. Disorders with Hoarding Behavior <ul><li>OCD </li></ul><ul><li>OCPD </li></ul><ul><li>Depression </li></ul><ul><li>Dementia </li></ul><ul><li>Psychosis (eg.SZ; delusional dis.) </li></ul><ul><li>Eating Disorders </li></ul>
    95. 96. Prevalence <ul><li>20-30% of OCD patients </li></ul><ul><li>26.3 per 100,000 as reported by health departments </li></ul><ul><li>Frost, Steketee, Greene (2003) </li></ul>
    96. 97. Possible Etiology of Hoarding <ul><li>Informational-Processing Deficits: i.e. decision making, organizing, memory </li></ul><ul><li>Emotional attachment to possessions </li></ul><ul><li>Cognitive distortions; ie. I will never be able to get the info anywhere else </li></ul><ul><li>Neurobiological </li></ul>
    97. 98. Co-morbidity in Compulsive Hoarding <ul><li>Social Phobia: generalized and specific </li></ul><ul><ul><li>(Samuels et al, 2002; Steketee et al., 2000) </li></ul></ul><ul><li>Major Depression </li></ul><ul><ul><li>(Frost et al., 2000; Lochner et al., 2005; Samuels et al, 2002; Seedat & Stein, 2002) </li></ul></ul><ul><li>OC spectrum conditions: trichotillomania, Tourette’s syndrome, nail biting, skin picking </li></ul><ul><ul><li>(Samuels et al, 2002; Seedat & Stein, 2002) </li></ul></ul><ul><li>GAD (Lochner et al, 2005) </li></ul><ul><li>ADHD (Hartl et al., 2003) </li></ul><ul><li>Dementia (Hwang et al., 1998) </li></ul>
    98. 99. Model of Hoarding
    99. 100. Hoarding Cognitions: Normal Behavior vs. Disorder <ul><ul><ul><li> Normal pattern of use for disposable object: </li></ul></ul></ul><ul><ul><ul><ul><li>o Acquire ► Use ► Consider discarding: evaluate value ► Discard or Save. </li></ul></ul></ul></ul><ul><ul><ul><li> The Process of Hoarding: </li></ul></ul></ul><ul><ul><ul><ul><li>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 </li></ul></ul></ul></ul>
    100. 101. Obsessional Thoughts in Hoarding <ul><ul><ul><li> Emotional Comfort </li></ul></ul></ul><ul><li> Loss </li></ul><ul><li> Identity </li></ul><ul><li> Value </li></ul><ul><li> Responsibility/Waste </li></ul><ul><li> Memory </li></ul><ul><li> Control </li></ul>
    101. 102. Obsessional Thoughts in Hoarding <ul><ul><ul><li> Emotional attachment (comfort, distress, loss, identity) </li></ul></ul></ul><ul><ul><ul><ul><li>o “Without this possession, I will be vulnerable” </li></ul></ul></ul></ul><ul><li>o “If I didn’t know where this was, I would feel anxious” </li></ul><ul><li>o “Throwing this away means losing a part of my life” </li></ul><ul><li>o “I might never be able to find this again” </li></ul><ul><ul><ul><li> Responsibility </li></ul></ul></ul><ul><ul><ul><ul><li>o “I am responsible for finding a use for this possession” </li></ul></ul></ul></ul><ul><li>o I am responsible for saving this for someone who might need it” </li></ul><ul><li>o I am ashamed when I don’t have something when I need it” </li></ul>
    102. 103. Obsessional Thoughts in Hoarding <ul><ul><ul><li> Memory </li></ul></ul></ul><ul><ul><ul><li>o “Saving this means I don’t have to rely on my memory </li></ul></ul></ul><ul><ul><ul><li>o “If I don’t leave this in sight, I’ll forget it” </li></ul></ul></ul><ul><li>o “I must remember something about this” </li></ul><ul><ul><ul><li>· Control </li></ul></ul></ul><ul><ul><ul><ul><li>o “No one has the right to touch my possessions” </li></ul></ul></ul></ul><ul><li>o “I like to maintain sole control over my things” </li></ul>
    103. 104. Differences between Hoarding and OCD <ul><li>Hoarders report less distress </li></ul><ul><li>Hoarders are less depressed </li></ul><ul><li>Hoarders usually have less insight: higher OVI </li></ul><ul><li>They are harder to engage in treatment </li></ul><ul><li>Hoarding more likely to cause family friction </li></ul><ul><li>Hoarding more harmful to self </li></ul><ul><li>Neziroglu, Peterson & Weissman (2006) </li></ul>
    104. 105. Hoarding vs. OCD: Obsessions <ul><li>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.”) </li></ul><ul><li>Not always distressing (e.g., “This is beautiful/ sentimental. I’ll keep it.”) </li></ul><ul><li>Impulses to acquire </li></ul><ul><li>Images of using item in future, but rarely distressing </li></ul>
    105. 106. Hoarding vs. OCD: Rituals and avoidance behaviors <ul><li>Doubting, checking, reassurance seeking are common before discarding and reflect negative emotions like anxiety and guilt </li></ul><ul><li>Efforts to control distress result in avoidance of discarding (saving) objects </li></ul><ul><li>Acquiring behaviors appear to be motivated by impulsive urges and are commonly accompanied by positive feelings </li></ul>
    106. 107. Hoarding vs. OCD: Insight, distress & interference <ul><li>Insight can be very poor, ambivalence about treatment is common </li></ul><ul><li>Distress not always present, even in severe cases </li></ul><ul><li>Interference with functioning is typical </li></ul>
    107. 108. Hoarding vs. OCD <ul><li>Individuals with compulsive hoarding are more likely to display: </li></ul><ul><ul><li>Symmetry Obsessions </li></ul></ul><ul><ul><li>Counting, ordering, and repeating compulsions </li></ul></ul><ul><ul><li>Greater illness severity </li></ul></ul><ul><ul><li>Difficulty completing tasks </li></ul></ul><ul><ul><li>Problems with decision making </li></ul></ul><ul><ul><li>(Sameuls, Bienvenu et. al, 2007) </li></ul></ul>
    108. 109. Hoarding vs. OCD: Neuroanatmony <ul><li>OCD: </li></ul><ul><ul><li>Deficits in the pre-frontal cortex and basal ganglia </li></ul></ul><ul><ul><li>(Stein, 2000) </li></ul></ul><ul><ul><li>Hoarding: </li></ul></ul><ul><ul><li>- Low activity along the cingulate cortex, which is involved in decision making and motivation. </li></ul></ul><ul><ul><li>- Implications: The low activity may account for the disorganization and lack of motivation often seen in the difficulty of treating hoarders. </li></ul></ul><ul><ul><li>(Saxena, 2007) </li></ul></ul>
    109. 110. Demographics <ul><li>OCD N Mean </li></ul><ul><li>Female 10 33 </li></ul><ul><li>Male 6 29.8 </li></ul><ul><li>Total 16 31.8 </li></ul><ul><li>Hoarding </li></ul><ul><li>Female 7 54.7 </li></ul><ul><li>Male 3 51.3 </li></ul><ul><li>Total 10 53.7 </li></ul>
    110. 111. Y-BOCS <ul><li>Total Score Mean SD </li></ul><ul><li>Hoarding 12.7 10.1 </li></ul><ul><li>OCD 26.9 6.1 </li></ul>
    111. 112. Y-BOCS <ul><li>Hoarding Mean SD </li></ul><ul><li>Obsessions 5.0 6.1 </li></ul><ul><li>Compulsions 7.7 5.0 </li></ul><ul><li>OCD Mean SD </li></ul><ul><li>Obsessions 13.9 3.2 </li></ul><ul><li>Compulsions 13.0 3.4 </li></ul>
    112. 113. Beck Anxiety Inventory <ul><li>N Mean SD </li></ul><ul><li>Hoarding 10 14.5 14.1 </li></ul><ul><li>OCD 16 24.1 16.3 </li></ul>
    113. 114. Beck Depression Inventory <ul><li>N Mean SD </li></ul><ul><li>Hoarding 10 24.6 13.8 </li></ul><ul><li>OCD 16 27.2 9.8 </li></ul>
    114. 115. Overvalued Ideas Scale <ul><li>N Mean SD </li></ul><ul><li>Hoarding 10 6.7 1.3 </li></ul><ul><li>OCD 16 4.6 1.3 </li></ul>
    115. 116. Quality of Life Issues For Everyone <ul><li>Lack of functional living space </li></ul><ul><li>Unhealthy living conditions </li></ul><ul><li>Unsafe living conditions </li></ul><ul><li>Additional storage is not the answer </li></ul>
    116. 117. Lack of Functional Living Space <ul><li>Furniture not being used as furniture </li></ul><ul><li>Little, if any place to gather as a family </li></ul><ul><li>Financial strain from ordering meals out </li></ul><ul><li>Social isolation </li></ul>
    117. 118. Unhealthy Living Conditions <ul><li>Headaches </li></ul><ul><li>Respiratory problems </li></ul><ul><li>Allergies </li></ul><ul><li>Fatigue/lethargy </li></ul><ul><li>Insomnia or sleep problems </li></ul>
    118. 119. Unsafe Living Conditions <ul><li>Structural damage to homes </li></ul><ul><ul><li>Weight of possessions </li></ul></ul><ul><ul><li>Possible water damage </li></ul></ul><ul><li>Fire hazards </li></ul><ul><ul><li>Highly flammable situations </li></ul></ul><ul><ul><li>Blocked passage ways </li></ul></ul>
    119. 120. Unsafe Conditions (Cont.) <ul><li>Rodent infestation </li></ul><ul><li>Insect infestation </li></ul><ul><li>Stairways filled with clutter </li></ul><ul><ul><li>Fire hazard, dangerous with children </li></ul></ul><ul><li>Can lead to legal involvement </li></ul>
    120. 121. Additional Storage Is Not the Answer <ul><li>Does not fix the problem </li></ul><ul><li>Leads to increased financial pressure </li></ul><ul><li>Leads to increased family tension </li></ul><ul><li>Eventually ends up as more cluttered, nonfunctional space </li></ul>
    121. 122. Effects of Hoarding on Families <ul><li>Living in clutter is living in chaos </li></ul><ul><li>Financial problems </li></ul><ul><li>High levels of resentment and anger toward hoarder </li></ul><ul><ul><li>Separation, divorce, kids moving out, etc. </li></ul></ul>
    122. 123. Getting Help <ul><li>Family members have the right to live without clutter </li></ul><ul><li>Families may seek treatment first </li></ul><ul><ul><li>Hoarders can be resistant to treatment on their own </li></ul></ul><ul><ul><li>May not think it is such a big deal </li></ul></ul>
    123. 124. Treatment Steps for Family Members <ul><li>Psycho-education on hoarding </li></ul><ul><li>Learn how to communicate more effectively with hoarder </li></ul><ul><ul><li>Validate, validate, validate </li></ul></ul><ul><li>Learn about the intervention technique </li></ul><ul><ul><li>Goal is to bring the hoarder in for treatment </li></ul></ul>
    124. 125. Applying the Intervention Technique <ul><li>Family members bring hoarder into a session </li></ul><ul><li>One by one, each member talks about how the hoarding has affected them </li></ul><ul><li>Issues are brought out in loving and supportive tones with validation </li></ul><ul><li>Hoarder then agrees to give treatment a chance for a specific time period </li></ul>
    125. 126. Before Intervention: The Kitchen
    126. 127. Before Intervention: The Kitchen
    127. 128. Before Intervention: The Kitchen
    128. 129. After Intervention: The Kitchen
    129. 130. Before Intervention: The Living Room
    130. 131. Before Intervention: The Living Room
    131. 132. After Intervention: The Living Room
    132. 133. Before Intervention: The Guest Room
    133. 134. Before Intervention: The Guest Room
    134. 135. Before Intervention: The Living Room
    135. 136. After Intervention: The Guest Room