ocd spectrum disorders
TRANSCRIPT
Body Dysmorphic Disorder, Body Dysmorphic Disorder, Hypochondriasis, Hoarding, and other Hypochondriasis, Hoarding, and other OCD Spectrum Disorders; Comparing OCD Spectrum Disorders; Comparing and Contrasting Treatments with OCDand Contrasting Treatments with OCD
Fugen Neziroglu Ph.D., ABBP, ABPP
Bio-Behavioral Institute
Great Neck, NY
www.biobehavioralinstitute.com
Obsessive Compulsive Spectrum Disorders
We identify disorders on the OC spectrum because:– They all share in common obsessions and/or
compulsions– They have similar symptomatology, treatment
response, and family history
Obsessive Compulsive Spectrum Disorders
Obsessive Compulsive Spectrum Disorders are conceptualized along a compulsivity-impulsivity continuum.
│ │ COMPULSIVE IMPULSIVE Risk Aversive/Harm Avoidant Disorders Risk Taking Disorders (e.g. Obsessive Compulsive Disorder, (e.g. Pathological Gambling, Body Dysmorphic Disorder) Sexual Compulsions)
Obsessive-compulsive Spectrum Obsessive-compulsive Spectrum DisordersDisorders
Obsessive-compulsive disorder Hoarding Body-dysmorphic disorder Hypochondriasis Eating disorders Trichotillomania Tourette’s syndrome Self-mutilation
Body Dysmorphic DisorderBody Dysmorphic Disorder
A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
B.The preoccupation causes clinically significant distress or impairment in functioning.
C.The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).
PrevalencePrevalence
1-2% of the general population1-2% of the general population4-5% of people seeking medical treatment4-5% of people seeking medical treatment8% of people with depression8% of people with depressionMore than 12% of people seeking mental More than 12% of people seeking mental
health treatmenthealth treatment
General Demographics For General Demographics For BDDBDD
Estimated Prevalence RateEstimated Prevalence Rate 1.0%1.0%
Male-Female RatioMale-Female Ratio 1:11:1
Age Of OnsetAge Of Onset 1616
Years Before First ConsultYears Before First Consult 6 6
ComorbidityComorbidity
Heredity:– 4 X higher lifetime prevalence of BDD in 1st degree relatives of those
with OCD than control probands 2
– 7% of BDD patients have a relative with OCD3
Comorbidity: 30-40% with BDD have OCD; 12-16% with OCD have BDD3.
11Hollander 1993; Hollander 1993; 22Bienvenu et al. 2000; Bienvenu et al. 2000; 33Phillips, 1998Phillips, 1998
Adolescent Feelings Of Adolescent Feelings Of Ugliness vs. BDDUgliness vs. BDD
Between the ages of 12-17, many Between the ages of 12-17, many adolescents adolescents feel ugly.feel ugly.
LongevityLongevity and and SeveritySeverity distinguish normal distinguish normal adolescent concerns from BDD.adolescent concerns from BDD.
Percentage of People with Percentage of People with Body Image DissatisfactionBody Image Dissatisfaction
1972 1996Mid-torso Overall Mid-torso Overall
Men 36 15 63 43
Women 50 23 71 56
Phillips (1996)
Normal Concerns vs. BDDNormal Concerns vs. BDD
Time consumption Time consumption 1 hour 1 hour
Produces distressProduces distress
Interferes with functioningInterferes with functioning
Risk Factors for BDDRisk Factors for BDD
Abuse HistoryAbuse HistoryTeasingTeasingPast History of Past History of
Dermatological Dermatological ProblemsProblems
ShynessShynessDepressionDepressionAnxietyAnxietyPerfectionismPerfectionismStressors in GeneralStressors in General
Is BDD a Problem of:Is BDD a Problem of:PerceptionPerceptionSomatosensory DisturbanceSomatosensory DisturbanceGlobal/Idealized ValuesGlobal/Idealized ValuesFaulty BeliefsFaulty BeliefsInformation Processing BiasesInformation Processing BiasesNeurobiological DefectNeurobiological Defect
PerceptionPerception: Actually sees nose as big: Actually sees nose as bigSomatosensorySomatosensory: Feels nose is big: Feels nose is bigGlobal/Idealized ValuesGlobal/Idealized Values: I value beauty as a goal : I value beauty as a goal
to pursueto pursueFaulty CognitionsFaulty Cognitions: Because my nose is big, I will : Because my nose is big, I will
be alone and isolated all my life. be alone and isolated all my life. Overgeneralization.Overgeneralization.
Information Processing BiasesInformation Processing Biases: Looking in the mirror : Looking in the mirror and focusing immediately on the nose. Selective and focusing immediately on the nose. Selective attention to details, rather than the whole.attention to details, rather than the whole.
Neurobiological DefectNeurobiological Defect: Serotonin alteration; orbito-: Serotonin alteration; orbito-frontal cortex, temporal, occipital and parietal lobe frontal cortex, temporal, occipital and parietal lobe involvement; genetically or ethologically transmitted.involvement; genetically or ethologically transmitted.
How Do All These How Do All These Aspects Interrelate?Aspects Interrelate?
Based on genetically and/or ethologically transmitted need Based on genetically and/or ethologically transmitted need for symmetry or aestheticism, maladaptive beliefs and for symmetry or aestheticism, maladaptive beliefs and values are learned which influences information values are learned which influences information processing and perception.processing and perception.
Beliefs About AppearanceBeliefs About Appearance
Identify and question the meaning of the defectiveness (not the defect), i.e., the assumptions about defectiveness and values (the importance of appearance)
• Focus on assumptions and values
• Collect information that is inconsistent with beliefs which patient normally ignores or distorts in an alternative data log
Beliefs About Appearance Beliefs About Appearance (Cont.)(Cont.)
Faulty Beliefs - Cognitive Faulty Beliefs - Cognitive DistortionDistortion
I need to be perfectI need to be perfect I need to be noticedI need to be noticed If I If I feelfeel that my body part is unattractive, it that my body part is unattractive, it
means that it means that it lookslooks unattractive unattractive If my body part is not beautiful, then it must be If my body part is not beautiful, then it must be
uglyugly If I looked better, my whole life would be betterIf I looked better, my whole life would be betterHappiness comes from looking goodHappiness comes from looking good
Faulty Beliefs - Cognitive Faulty Beliefs - Cognitive DistortionDistortion
The only way to The only way to feelfeel better is to better is to looklook better better I must be happy with what I see in the mirrorI must be happy with what I see in the mirrorLooking good protects you from being treated badlyLooking good protects you from being treated badly I cannot be comfortable unless I look goodI cannot be comfortable unless I look goodPhysical perfection is a realistic and attainable goalPhysical perfection is a realistic and attainable goal If my appearance is defective then I am inadequate If my appearance is defective then I am inadequate
and worthless.and worthless.
Safety or Avoidance Safety or Avoidance Behaviors in BDDBehaviors in BDD
Mirror gazing or avoiding
Excessive groomingRitualized or excessive
makeup applicationExcessive usage of
skin or hair products
Hair removalHair cuttingReassurance seekingCamouflagingSkin pickingRepeated checking of
body part
Comparing self with others or old photosGrooming, combing, smoothening,
straightening, plucking or cutting hairSkin cleaning, picking, peeling,
bleachingFacial exercises
Safety or Avoidance Safety or Avoidance Behaviors in BDD (Cont.)Behaviors in BDD (Cont.)
Avoidance Behaviors in BDDAvoidance Behaviors in BDD
Social and public situations with varying degrees of safety behaviors– Clothes or hair to hide “defect”– Certain posture– Padding– Cold Coke cans!
Skin Picking and Hair CuttingSkin Picking and Hair Cutting Self-monitoring (frequency chart)
Self-monitoring of triggers
Habit reversal
Challenge irrational beliefs regarding effectiveness and necessity of behavior
Delay response and alternative activities (e.g., not alone)
Difficult to treat due to short-term satisfaction
Identify secondary functions of behavior (stress reducer, escape, emotion regulation)
Compulsive Skin PickingCompulsive Skin Picking
Repetitive skin picking and cleaning, especially face
Aim to remove moles, freckles, blemish, scabs
Fingernails, tweezers, pins, sharp implements
Lead to bleeding, bruises, infections and/or permanent disfigurement
Short-term tension reduction and satisfaction
Followed by disgust, anger, depression
OC spectrum—BDD, OCD, trichotillomania
Safety Behaviors in BDDSafety Behaviors in BDD
Do it yourself surgery Cosmetic or dermatological
interventions
BDD vs. OCDBDD vs. OCD
Similarities – Symptoms– Response to Cognitive Behavioral Therapy– Response to Pharmacotherapy
Dissimilarities– BDD has higher OVI, more depressed, less
anxious, total self identification, more personality disorders.
Example of Differentiating BDD From Example of Differentiating BDD From OCDOCD
Symptom ClustersNeuropsychological TestingNeuroimaging Function of Compulsions/Safety BehaviorsPresence or absence of delusions, overvalued
ideationPerceptual/Somatosensory Components
OVI in OCDOVI in OCD
Examined whether OVI predicts medication treatment response
Results illustrated that OVI predicted the outcome for obsessions, but not compulsions. As patients scored higher on OVIS there was less improvement following treatment.
Neziroglu, F., Yaryura-Tobias, J., Pinto, A., & McKay, D. (2004). Psychiatry Research, 125 (1).
OVI in BDDOVI in BDD
High overvalued ideas need to be addressed prior to exposure.
The higher the OVI the poorer the prognosis.
OVI in BDD vs. OCDOVI in BDD vs. OCD
Subjects with BDD had significantly lower levels of insight than subjects with OCD
Suggests differences in insight is not attributable to symptom severity
Eisen, Phillips, Coles, & Rasmussen (2003) Phillips, Pinto, Menard, Eisen, Mancebo, Rasmussen (2007)
Quality of LifeQuality of LifeQuality of life measures impact of a disorder across area of everyday functioning
• Self esteem• Goals• Play• Love • Friendship• Community• Health• Money
Learning Helping Children Relatives Home Neighborhood Creativity Work
Quality of Life in OCDQuality of Life in OCD
Lower overall Quality of Life than general population
Mental health and psychological well being most impaired in subjects with OCD
Lower Quality of Life than Schizophrenia patients
Koran, Thienemann, & Davenport (1996) Stengler-Wenzke , Kroll, Matschinger , & Angermeyer (2006)
Quality of Life in BDDQuality of Life in BDD
BDD patients have poor Quality of Life across all psychosocial functioning and mental health domains.
BDD Patients demonstrate poorer quality of mental health life as compared to:– US general population– Patients with Major Depression or Dysthymia– Patients with chronic medical conditions.
Functioning and quality of life for BDD patients are low regardless of treatment
• Phillips , Menard, Fay, & Paagano (2005)
Quality of Life BDD vs. OCD Quality of Life BDD vs. OCD (cont)(cont)
OCD & BDD had very poor psychosocial functioning and Quality of Life
Comorbid OCD/BDD patients showed greater impairment than OCD patients but not BDD patients.
BDD severity may account for lower quality of life in the comorbid group.
Didie, Mancebo, Rasmussen, Phillips, Walters, Menard, & Eisen (2004)
Symptom Severity in Symptom Severity in OCD & BDDOCD & BDD
Y-BOCS obsessions
Y-BOCS compulsions
OCD (n=61)
M = 12.9
Severe
BDD (n=53)
M = 12.8
Severe
OCD (n=61)
M = 11.2
Severe
BDD (n=53)
M = 12.0
Severe
Overvalued Ideation Levels Overvalued Ideation Levels in BDD & OCDin BDD & OCD
OCD (n=62)
M = 4.8
Middle Range
BDD (n= 53)
M = 6.1
Upper Range
OVIS *
* = p < .001
Quality of Life in BDD & Quality of Life in BDD & OCDOCD
OCD (n=32)
M = 35.7
Low Level
BDD (n= 23)
M = 24.1
Very Low Level
QOLI *
* = p < .05
BDD: Severity of DisorderBDD: Severity of Disorder
Suicide attempt rate: 29%Suicide ideation rate: 80%Hospitalization: 36-58%Homebound: 32-40%Full-time employment/student:
42%
Phillips KA et al. (2006), Compr Psychiatry 47(2):77-87
Frequency and Percentage of Frequency and Percentage of Abuse in BDD and OCDAbuse in BDD and OCD
Abuse Type BDD (N=50) OCD (N=50)
Any Abuse 19 (38%) 7 (14%)
Sexual 11 (22%) 3 (6%)
Physical 7 (14%) 4 (8%)
Emotional 14 (28%) 1 (2%)
Neziroglu F, Khemlani-Patel, S & Yaryura-Tobias. (2006). Body Image 3: 189-193
Appropriate Treatments for BDDAppropriate Treatments for BDD
Exposure and response preventionCognitive therapyPsychopharmacological treatmentSupport groupsFamily intervention
Inappropriate Treatment for Inappropriate Treatment for BDDBDD
Dermatological proceduresSurgical and non-surgical proceduresPsychodynamic therapy
CBT Working Model
Operant Conditioning
Biological Predisposition
Operant Conditioning
Social Learning+
CS UCS CRUCR
Information Processing Bias
Classical/Evaluative Conditioning
Body Dysmorphic Disorder
Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
Biological Predisposition
CBT Working Model (Cont.)
Genetic factorsVisual processing problemsSomatosensory problemsFaulty neuroanatomical
circuitry
Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
Person is positively and/or intermittently reinforced for:– Overall appearance ▪ Poise– Particular body part ▪ Weight– Height ▪ Body shape– Cuteness
Biological Predisposition
Operant Conditioning
CBT Working Model (Cont.)
Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
Social learning– Modeling/Media/Childhood teaching – Vicarious learning
Social learning and operant conditioning– Develop
Values and beliefs about attractiveness Self-value based on body image
+
Biological Predisposition
Operant Conditioning
CBT Working Model (Cont.)
Social Learning
Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
Classical Conditioning: Acquisition BDD
CSBody part
Words: (blemish, red)
+
Biological Predisposition
Operant Conditioning
CBT Working Model (Cont.)
Social Learning
UCSAbuseTeasingAcnePuberty
UCRDisgustAnxietyShame Depression
CRMood
Biased Information Processing/ Relational Framing
Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
Operant Conditioning: Maintenance Of BDD
Negative reinforcement– CR is removed through avoidance behaviors (e.g.,
camouflaging, mirror checking, excessive makeup)
Positive intermittent reinforcement– Maintains avoidance behaviors
Mood/CR Avoidance Behaviors
Negative Reinforcement
CBT Working Model (Cont.)
Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
Operant Conditioning: Maintenance Of BDD
Negative reinforcement– CR is removed through avoidance behaviors (e.g.,
camouflaging, mirror checking, excessive makeup)
Positive intermittent reinforcement– Maintains avoidance behaviors
Mood/CR Avoidance Behaviors
Negative Reinforcement
CBT Working Model (Cont.)
Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
CBT Working Model (Cont.)
Operant Conditioning
Biological Predisposition
Operant Conditioning
Social Learning+
Body Dysmorphic Disorder
Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
CS UCS CRUCR
Information Processing Bias
Classical Conditioning
Cognitive Therapy: Initial Cognitive Therapy: Initial StrategiesStrategies
Address readiness for changeMotivational interviewing to engage patients
reluctant to continue treatment– Stress the degree of dysfunction and suffering
Target depression and/or suicidal ideation
EngagementEngagement Explaining diagnosis—emphasize “preoccupation
with the way you feel about appearance” Similar problems in disorders with OVI where
goals not shared by clinician Motivational interviewing (focus on handicap
linked to the demand about how their appearance must be or their idealized value about appearance)
OVI = overvalued ideation
Engagement (Cont.)Engagement (Cont.)
Avoid giving reassurance about appearance as patient often told “look alright”
Validate experience and help understand what the problem is
Two hypotheses either “problem unattractive” or you have a “problem with the way you feel about your appearance”
Early GoalsEarly Goals
Functioning—activity scheduling and social withdrawal/avoidance which maintains depressed mood
Decrease compulsive behaviors, such as mirror gazing and checking with hands
Skin picking
Cognitive Therapy: Cognitive Therapy: Targeting BDD SymptomsTargeting BDD Symptoms
Target cognitive distortionsBeck or Ellis modalities work wellHypothesis testing/collaborative empiricism
– Take patient’s photograph and collect ratings of attractiveness
– Interview strangers regarding relevant distorted beliefs of patient
Cognitive Therapy: Cognitive Therapy: Targeting Targeting
Values on AppearanceValues on Appearance
Targeting value of appearance may be an important treatment component in relapse prevention
Methods to target values and attitudes– Psychoeducation– Pie chart of important values
Pie Chart of ValuesPie Chart of Values
Artistic Achievement
30%
Attractiveness 20%
Family 15%
Friendship15%
Money 10%
Education 10%
Neziroglu F, Khemlani-Patel S
CBT for BDD in Social SituationsCBT for BDD in Social Situations
Exposure/behavioral experiments – Minimal or no makeup or exaggerate “defect”– No changes in posture– Not using hand or hair– Not stand by window– Refocus attention away from self
4 Ways To Challenge Beliefs 4 Ways To Challenge Beliefs for BDDfor BDD
What is the evidence that supports or contradicts this belief?
Are there any other ways to interpret this situation? Realistically, what is the worst thing that could happen
in this situation and how would it honestly affect my life?
Even if the negative belief is warranted, what can I realistically do to help remedy the situation?
Geremia, G & Neziroglu F (2001), Clinical Psych and Psychotherapy 8: 243-251
HYPOCHONDRIASISHYPOCHONDRIASIS
PREOCCUPATION WITH FEARS OF HAVING, OR THE IDEA THAT ONE HAS, A SERIOUS DISEASE BASED ON MISINTERPRETATION OF BODILY SYMPTOMS
THE PREOCCUPATION PERSISTS DESPITE APPROPRIATE MEDICAL EVALUATION AND REASSURANCE.
THEIR BELIEF IS NOT OF DELUSIONAL INTENSITY NOR DUE TO CONCERN ABOUT APPEARANCE.
SPECIFY IF:
WITH POOR INSIGHT
Historical Conceptualization Of Historical Conceptualization Of HypochondriaHypochondria
In 1621, Robert Burton wrote
“The Anatomy of Melancholy”.
He described “hypochondriacal melancholy” as including physical ailments (e.g. ears ringing, belching, vertigo.) and fear of disease
HypochondriaHypochondria
Second Century A.D., Galen of Pergamon used the term HYPOCHONDRIA to describe broad range of digestive disorders and melancholia
Cost of HC Per YearCost of HC Per Year
At least 20 billion dollars per year is spent on hypochondriacal patients, and may be as much as 100 billion dollars
Phenomenology of HCPhenomenology of HC
HC are more concerned with the authenticity, meaning or etiological significance of their symptoms than with the unpleasant sensation or pain
HC DemographicsHC DemographicsMale: Female Ratio 1:1
Average Age 36-57
Duration of Symptoms 6 months-25 years
Symptoms occur more often in single, women, less educated, less income, non-whites, hispanics, older, urban residence
Common HC SymptomsCommon HC SymptomsParts of the Body AffectedParts of the Body Affected
1) Head and Neck Complaints:
Tumors
Aneurysms
Strokes
Burning Sensation
Chronic Headaches
Muscle Spasms
Numbness in Face
Common HC SymptomsCommon HC SymptomsParts of the Body Affected (con’t)Parts of the Body Affected (con’t)
2) Abdomen Complaints: Prostate Cancer
Hernias
Irritable Bowel Syndrome
Liver Cancer
Ulcers
3) Chest Complaints: Heart Attacks
Chronic Asthma
Differential Diagnosis of HCDifferential Diagnosis of HC Somatization Disorder Delusional Disorder
(monosymptomatic Hypochondriacal Disorder)
Panic Disorder Generalized Anxiety Disorder Depression Obsessive Compulsive Disorder
(Somatic Obsessions)
Illness Phobia
Reported Dissimilarities Between OCD & Reported Dissimilarities Between OCD & HCHC
Patient with Hypochondriasis:¤ See their fears as realistic¤ Possess pervasive ideas of illness as part of their
personality¤ Are public about their concerns¤ Experience genuine somatic discomfort
Barsky (1992)
OCD and HCOCD and HCAnxiety and Depression ScalesAnxiety and Depression Scales
0
10
20
30
40
50
60
BDI BAI STIA-S STIA-T
OCD
HC
OCD and HCOCD and HCObsessions and CompulsionsObsessions and Compulsions
0
2
4
6
8
10
12
14
16
DSO* DSC* Y-BOC_O* Y-BOC_C*
OCD
HC
DS-Disorder Specific
OCD and HCOCD and HCBody Sensations and MobilityBody Sensations and Mobility
0
10
20
30
40
50
60
70
BSQ* MI,alone** MI,accompanied*
OCD
HC
p<.05;**p<.01
HC ObsessionsHC Obsessions
Death 20.0%
Fatigue 13.3%
General illness 13.3%
Back Problems 13.3%
Insomnia 6.7%
Multiple Sclerosis 6.7%
HC CompulsionsHC CompulsionsCheck Body 81.8%
Seek Reassurance 81.8%
Visit Doctors 81.8%
Washing (not Contamination) 63.7%
Read Health Literature 54.5%
Take Vitamins 54.5%
Avoid Certain Places 45.5%
Avoid Certain Foods 36.4%
Visit Emergency Room 18.2%
Avoid Doctors 9.1%
Treatment Modalities For HCTreatment Modalities For HC
1) Psychodynamic Interventions
2) Reassurance Therapy
3) Cognitive-Behavior Therapy
4) Pharmacotherapy
Kellner’s Reassurance Kellner’s Reassurance InterventionIntervention
Physical Examination Client Centered Techniques Explanatory Therapy (psychoeducation) Use of Suggestion Biofeedback
Treatment Outcome DataTreatment Outcome Data
Cognitive Behavioral Therapy Improved
Salkovskis and Warwick (1986) 100%
Warwick and Marks (1988) 88%
Miller, Action & Hodge (1988) 100%
Cognitive Behavioral Model of Cognitive Behavioral Model of HypochondriasisHypochondriasis
Review Previous Experience Formulation of Dysfunctional Assumptions A Critical Incident Activation of Assumptions Negative Thoughts and Imagery Hypochondriacal Development
General Cognitive Therapy for General Cognitive Therapy for HypochondriasisHypochondriasis
Hypochondriacs overestimate the probability of a symptom indicating the existence of an illness and underestimate their ability to cope with it.
COGNITIVE THERAPY COGNITIVE THERAPY FOCUSFOCUS
PREVENT NEUTRALIZATION
INCREASE EXPOSURE TO OBSESSIONS
MODIFY “RESPONSIBILITY” ATTITUDE
MODIFY APPRAISAL OF OBSESSIONS
INCREASE EXPOSURE TO RESPONSIBILTY BY EXPOSURE IN VIVO AND STOP REASSURANCE SEEKING
COGNITIVE COGNITIVE RESTRUCTURINGRESTRUCTURING
A.= ANTECEDENT EVENTB. = BELIEFSC. = CONSEQUENCES
1. EMOTIONAL
2. BEHAVIORAL
D. =DISPUTE
E. = EFFECT OF DISPUTING
Ellis’ ABC Paradigm in the Treatment of Ellis’ ABC Paradigm in the Treatment of OCD Applied to HCOCD Applied to HC
A = Obsession itself or any activating event
B = 1. If I do not call the doctor about my headache I have behaved irresponsibly
2. It is awful to feel anxious. 3. I must have guarantees.
C = Anxiety Active Avoidance
Cognitive Theories
Under high cost conditions obsessives make the same threat appraisal as normals.
Under low cost conditions obsessionals overestimate the probability of the occurance of the disastrous consequence.
Carr (1974)
Cognitive Theories
1. Primary Appraisal Process whereby the individual overestimates probability and the cost of the occurrence of unfavorable events.
2. Secondary Appraisal Process whereby individual underestimates his/her abilities to cope with the threat.
MC Fall and Wollersheim (1979)
Common HC Belief DistortionsCommon HC Belief Distortions
If I have something wrong with me, I will not be a desirable person.
Bodily symptoms are a sign of serious illness because every symptom has an identifiable physical cause.
I am irresponsible if I don’t go to the doctor immediately.
Common HC Belief Distortions Common HC Belief Distortions (Cont.)(Cont.)
I can’t stand the pain I can’t stand being ill. Any symptom means that I’m ill, or am going to be ill. If I’m ill, I will definitely suffer greatly (and I can not
stand the suffering). If I’m ill, I will die. I have an incurable illness. If I’m ill, I can’t be happy. Symptoms are indicative of severe illnesses.
Common HC Belief Distortions Common HC Belief Distortions (Cont.)(Cont.)
If I’m ill, there’s no need to fight because my life is over.
I want certainty that I am not ill. Every physical symptom is indicative of a serious
medical condition. I have a disease, but the doctors have not been able
to diagnose it yet. If I pay close attention to my bodily symptoms I
can prevent being sick.
Common HC Belief Distortions Common HC Belief Distortions (Cont.)(Cont.)
All symptoms are a sign of danger. I will not be able to cope with a major illness. I must know immediately if there is
something wrong with me. I can not tolerate anxiety. I must be hypervigilant to all bodily
symptoms, in order to prevent an illness.
Four Ways To Challenge Four Ways To Challenge BeliefsBeliefs
(Hypochondriasis)(Hypochondriasis)1) What is the evidence that supports or contradicts this
belief?
2) Are there any other ways to interpret the physical symptoms or my belief?
3) Ultimately if I am correct in my interpretation, realistically to what extent can I control the outcome?
4) Why is it that others don’t preoccupy themselves with the same physical symptoms, and what enables them to cope with negative outcomes?
Conclusions Conclusions (CT for HC)(CT for HC)
Cognitive Therapy is effective for HC. Cognitive Therapy decreases overvalued ideas, depression,
anxiety, frequency and severity of obsessive thoughts. Exposure and Responsive Prevention (ERP) reduces
compulsions. ERP does not decrease overvalued ideas, obsessions, nor
depression. Best to combine cognitive therapy with ERP. Cognitive Therapy effective even for severe cases.
General Conclusions about General Conclusions about ERP vs. CTERP vs. CT
With Cognitive Therapy
Attrition rate lower Compliance better Motivation greater Acceptance of therapy better
HoardingHoarding
Hoarding is the acquisition of, and failure to discard, large numbers of items that appear to have little or no value
(Frost & Gross, 1993)
Hoarding: Additional CriteriaHoarding: Additional Criteria
Clutter prevents usage of functional space
Significant distress or impairment
Frost & Hartl (1996)
Disorders with Hoarding BehaviorDisorders with Hoarding Behavior
OCDOCPDDepressionDementiaPsychosis (eg.SZ; delusional dis.)Eating Disorders
PrevalencePrevalence20-30% of OCD patients26.3 per 100,000 as reported by
health departments
Frost, Steketee, Greene (2003)
Possible Etiology of HoardingPossible Etiology of Hoarding
Informational-Processing Deficits: i.e. decision making, organizing, memory
Emotional attachment to possessionsCognitive distortions; ie. I will never
be able to get the info anywhere elseNeurobiological
Co-morbidity in Compulsive Co-morbidity in Compulsive HoardingHoarding
Social Phobia: generalized and specific – (Samuels et al, 2002; Steketee et al., 2000)
Major Depression – (Frost et al., 2000; Lochner et al., 2005; Samuels et al, 2002; Seedat & Stein, 2002)
OC spectrum conditions: trichotillomania, Tourette’s
syndrome, nail biting, skin picking– (Samuels et al, 2002; Seedat & Stein, 2002)
GAD (Lochner et al, 2005)
ADHD (Hartl et al., 2003)
Dementia (Hwang et al., 1998)
Model of HoardingInformation Processing
Beliefs Emotional Attachment
↓ ↓ ↓ → Disorganization
↑ ↓
↑ Attempts to
↑ categorize, or
↑ make decisions
↑ ↓
↑ Frustration &
↑ Anxiety
↑ ↓
←Avoidance
→→ Acquiring ↑ ↓ ↑ Emotions ↑ ↙↘ ↑ ←Positive Negative ↑ ↓ ↑ Attempts to stop ↑ ↓ ↑ Loss/Discomfort ↑ ↓ ←← Avoidance
→→Saving/Discarding
↑ ↓ ↑Attempts to Discard ↑ ↓ ↑ Anxiety/Guilt ↑ ↓ ←← Avoidance
Hoarding Cognitions:Normal Behavior vs. Disorder
Normal pattern of use for disposable object:o Acquire ► Use ► Consider discarding: evaluate value ► Discard or Save.
The Process of Hoarding:o Acquire ► Use ► Consider discarding: evaluate use ► Obsessional Thoughts ► Anxiety ► Save ► Anxiety Relief ► Obsessional Thoughts ► Anxiety ► Don’t Think About it ► Anxiety Relief ► Obsessional Thoughts
Obsessional Thoughts in Hoarding
Emotional ComfortLossIdentityValueResponsibility/WasteMemoryControl
Obsessional Thoughts in Hoarding
Emotional attachment (comfort, distress, loss, identity)o “Without this possession, I will be
vulnerable”o “If I didn’t know where this was, I would feel anxious”o “Throwing this away means losing a part of my
life”o “I might never be able to find this again”
Responsibilityo “I am responsible for finding a use
for this possession”o I am responsible for saving this for someone who might need it”o I am ashamed when I don’t have something when I need it”
Obsessional Thoughts in Hoarding
Memoryo“Saving this means I don’t have to
rely on my memoryo “If I don’t leave this in sight, I’ll
forget it”o “I must remember something about this”
·Controlo “No one has the right to touch
my possessions”o “I like to maintain sole control over my things”
Differences between Hoarding and OCD
Hoarders report less distress Hoarders are less depressed Hoarders usually have less insight: higher OVI They are harder to engage in treatment Hoarding more likely to cause family friction Hoarding more harmful to self
Neziroglu, Peterson & Weissman (2006)
Hoarding vs. OCD: Hoarding vs. OCD: ObsessionsObsessions
Thoughts triggered by objects and efforts to discard
(e.g., “I might need this; I don’t want to lose an
opportunity; I can’t waste this.”)
Not always distressing (e.g., “This is beautiful/
sentimental. I’ll keep it.”)
Impulses to acquire
Images of using item in future, but rarely distressing
Hoarding vs. OCD: Hoarding vs. OCD: Rituals and avoidance Rituals and avoidance
behaviorsbehaviors Doubting, checking, reassurance seeking are common
before discarding and reflect negative emotions like
anxiety and guilt
Efforts to control distress result in avoidance of discarding
(saving) objects
Acquiring behaviors appear to be motivated by impulsive
urges and are commonly accompanied by positive feelings
Hoarding vs. OCD: Hoarding vs. OCD: Insight, distress & interferenceInsight, distress & interference
Insight can be very poor, ambivalence about
treatment is common
Distress not always present, even in severe cases
Interference with functioning is typical
Hoarding vs. OCDHoarding vs. OCD
Individuals with compulsive hoarding are more likely to display:– Symmetry Obsessions– Counting, ordering, and repeating compulsions– Greater illness severity– Difficulty completing tasks– Problems with decision making(Sameuls, Bienvenu et. al, 2007)
Hoarding vs. OCD:Hoarding vs. OCD:NeuroanatmonyNeuroanatmony
OCD:
– Deficits in the pre-frontal cortex and basal ganglia
(Stein, 2000)
Hoarding:
- Low activity along the cingulate cortex, which is involved
in decision making and motivation.
- Implications: The low activity may account for the
disorganization and lack of motivation often seen in the
difficulty of treating hoarders.
(Saxena, 2007)
DemographicsDemographicsOCD N Mean
Female 10 33Male 6 29.8Total 16 31.8
HoardingFemale 7 54.7Male 3 51.3Total 10 53.7
Y-BOCSY-BOCS
Total Score Mean SD
Hoarding 12.7 10.1
OCD 26.9 6.1
Y-BOCSY-BOCS
Hoarding Mean SD
Obsessions 5.0 6.1
Compulsions 7.7 5.0
OCD Mean SD
Obsessions 13.9 3.2
Compulsions 13.0 3.4
Beck Anxiety InventoryBeck Anxiety Inventory
N Mean SD
Hoarding 10 14.5 14.1
OCD 16 24.1 16.3
Beck Depression InventoryBeck Depression Inventory
N Mean SD
Hoarding 10 24.6 13.8
OCD 16 27.2 9.8
Overvalued Ideas ScaleOvervalued Ideas Scale
N Mean SD
Hoarding 10 6.7 1.3
OCD 16 4.6 1.3
Quality of Life Issues For Quality of Life Issues For EveryoneEveryone
Lack of functional living spaceUnhealthy living conditionsUnsafe living conditionsAdditional storage is not the answer
Lack of Functional Living SpaceLack of Functional Living Space
Furniture not being used as furnitureLittle, if any place to gather as a familyFinancial strain from ordering meals outSocial isolation
Unhealthy Living ConditionsUnhealthy Living Conditions
HeadachesRespiratory problemsAllergiesFatigue/lethargyInsomnia or sleep problems
Unsafe Living ConditionsUnsafe Living Conditions
Structural damage to homes– Weight of possessions– Possible water damage
Fire hazards– Highly flammable situations– Blocked passage ways
Unsafe Conditions (Cont.)Unsafe Conditions (Cont.)
Rodent infestationInsect infestationStairways filled with clutter
– Fire hazard, dangerous with children
Can lead to legal involvement
Additional Storage Is Not the Additional Storage Is Not the AnswerAnswer
Does not fix the problemLeads to increased financial pressureLeads to increased family tensionEventually ends up as more cluttered,
nonfunctional space
Effects of Hoarding on FamiliesEffects of Hoarding on Families
Living in clutter is living in chaosFinancial problemsHigh levels of resentment and anger toward
hoarder– Separation, divorce, kids moving out, etc.
Getting HelpGetting Help
Family members have the right to live without clutter
Families may seek treatment first– Hoarders can be resistant to treatment on their
own– May not think it is such a big deal
Treatment Steps for Family Treatment Steps for Family MembersMembers
Psycho-education on hoardingLearn how to communicate more
effectively with hoarder– Validate, validate, validate
Learn about the intervention technique– Goal is to bring the hoarder in for treatment
Applying the Intervention Applying the Intervention TechniqueTechnique
Family members bring hoarder into a sessionOne by one, each member talks about how
the hoarding has affected themIssues are brought out in loving and
supportive tones with validationHoarder then agrees to give treatment a
chance for a specific time period
Before Intervention: The Kitchen
Before Intervention: The Kitchen
Before Intervention: The Kitchen
After Intervention: The Kitchen
Before Intervention: The Living Room
Before Intervention: The Living Room
After Intervention: The Living Room
Before Intervention: The Guest Room
Before Intervention: The Guest Room
Before Intervention: The Living Room
After Intervention: The Guest Room