The document discusses Body Dysmorphic Disorder (BDD) and Hypochondriasis. It compares the two disorders and outlines their key characteristics, including prevalence, demographics, comorbidities, and treatments. BDD involves a preoccupation with an imagined or slight defect in appearance. Hypochondriasis involves a preoccupation with fears of having a serious illness despite medical reassurance. Both disorders share similarities with OCD but also have distinct features and impacts on quality of life. Cognitive-behavioral therapy is an appropriate treatment approach for both.

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

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