Powerpoint: OCD Spectrum Disorders

OCD Spectrum Disorders

OCD Spectrum Disorders – Presentation Transcript

  1. Body Dysmorphic Disorder, Hypochondriasis, Hoarding, and other OCD Spectrum Disorders; Comparing and Contrasting Treatments with OCD Fugen Neziroglu Ph.D., ABBP, ABPP Bio-Behavioral Institute Great Neck, NY www.biobehavioralinstitute.com
  2. Obsessive Compulsive Spectrum Disorders
    • We identify disorders on the OC spectrum because:
      • They all share in common obsessions and/or compulsions
      • They have similar symptomatology, treatment response, and family history
  3. Obsessive Compulsive Spectrum Disorders
  4. Obsessive-compulsive Spectrum Disorders
    • Obsessive-compulsive disorder
    • Hoarding
    • Body-dysmorphic disorder
    • Hypochondriasis
    • Eating disorders
    • Trichotillomania
    • Tourette’s syndrome
    • Self-mutilation
  5. Body Dysmorphic Disorder
    • A. Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person’s concern is markedly excessive.
    • B. The preoccupation causes clinically significant distress or impairment in functioning.
    • C.The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in anorexia nervosa).
  6. Prevalence
    • 1-2% of the general population
    • 4-5% of people seeking medical treatment
    • 8% of people with depression
    • More than 12% of people seeking mental health treatment
  7. General Demographics For BDD
    • Estimated Prevalence Rate 1.0%
    • Male-Female Ratio 1:1
    • Age Of Onset 16
    • Years Before First Consult 6
  8. Comorbidity
    • Heredity :
      • 4 X higher lifetime prevalence of BDD in 1 st degree relatives of those with OCD than control probands 2
      • 7% of BDD patients have a relative with OCD 3
    • Comorbidity: 30-40% with BDD have OCD; 12-16% with OCD have BDD 3 .

    1 Hollander 1993; 2 Bienvenu et al. 2000; 3 Phillips, 1998

  9. Adolescent Feelings Of Ugliness vs. BDD
    • Between the ages of 12-17, many adolescents
    • feel ugly.
    • Longevity and Severity distinguish normal adolescent concerns from BDD.
  10. Percentage of People with Body Image Dissatisfaction Phillips (1996)
  11. Normal Concerns vs. BDD
    • Time consumption  1 hour
    • Produces distress
    • Interferes with functioning
  12. Risk Factors for BDD
    • Abuse History
    • Teasing
    • Past History of Dermatological Problems
    • Shyness
    • Depression
    • Anxiety
    • Perfectionism
    • Stressors in General
  13. Is BDD a Problem of:
    • Perception
    • Somatosensory Disturbance
    • Global/Idealized Values
    • Faulty Beliefs
    • Information Processing Biases
    • Neurobiological Defect
    • Perception : Actually sees nose as big
    • Somatosensory : Feels nose is big
    • Global/Idealized Values : I value beauty as a goal to pursue
    • Faulty Cognitions : Because my nose is big, I will be alone and isolated all my life. Overgeneralization.
    • Information Processing Biases : Looking in the mirror and focusing immediately on the nose. Selective attention to details, rather than the whole.
    • Neurobiological Defect : Serotonin alteration; orbito-frontal cortex, temporal, occipital and parietal lobe involvement; genetically or ethologically transmitted.
  14. 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.
  15. Beliefs About Appearance
    • Identify and question the meaning of the defectiveness (not the defect), i.e., the assumptions about defectiveness and values (the importance of appearance)
      • Focus on assumptions and values
      • Collect information that is inconsistent with beliefs which patient normally ignores or distorts in an alternative data log

    Beliefs About Appearance (Cont.)

  16. 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
  17. 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.
  18. Safety or Avoidance Behaviors in BDD
    • Mirror gazing or avoiding
    • Excessive grooming
    • Ritualized or excessive makeup application
    • Excessive usage of skin or hair products
    • Hair removal
    • Hair cutting
    • Reassurance seeking
    • Camouflaging
    • Skin picking
    • Repeated checking of body part
    • Comparing self with others or old photos
    • Grooming, combing, smoothening, straightening, plucking or cutting hair
    • Skin cleaning, picking, peeling, bleaching
    • Facial exercises

    Safety or Avoidance Behaviors in BDD (Cont.)

  19. 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!
  20. 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)
  21. 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
  22. Safety Behaviors in BDD
    • Do it yourself surgery
    • Cosmetic or dermatological interventions
  23. 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.
  24. 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
  25. 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).
  26. OVI in BDD
    • High overvalued ideas need to be addressed prior to exposure.
    • The higher the OVI the poorer the prognosis.
  27. 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)
  28. 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
  29. 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)
  30. 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)
  31. 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)
  32. 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
  33. 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

  34. 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

  35. 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

  36. 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
  37. Appropriate Treatments for BDD
    • Exposure and response prevention
    • Cognitive therapy
    • Psychopharmacological treatment
    • Support groups
    • Family intervention
  38. Inappropriate Treatment for BDD
    • Dermatological procedures
    • Surgical and non-surgical procedures
    • Psychodynamic therapy
  39. CBT Working Model Operant Conditioning Biological Predisposition Operant Conditioning Social Learning + CS UCS CR UCR Information Processing Bias Classical/Evaluative Conditioning Body Dysmorphic Disorder Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920
    • Genetic factors
    • Visual processing problems
    • Somatosensory problems
    • Faulty neuroanatomical circuitry

    Biological Predisposition CBT Working Model (Cont.) Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

    • Person is positively and/or intermittently reinforced for:
      • Overall appearance ▪ Poise
      • Particular body part ▪ Weight
      • Height ▪ Body shape
      • Cuteness

    Biological Predisposition Operant Conditioning CBT Working Model (Cont.) Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

    • Social learning
      • Modeling/Media/Childhood teaching
      • Vicarious learning
    • Social learning and operant conditioning
      • Develop
        • Values and beliefs about attractiveness
        • Self-value based on body image

    + Biological Predisposition Operant Conditioning CBT Working Model (Cont.) Social Learning Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

    • Classical Conditioning: Acquisition BDD

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

    • Negative reinforcement
      • CR is removed through avoidance behaviors (e.g., camouflaging, mirror checking, excessive makeup)
    • Positive intermittent reinforcement
      • Maintains avoidance behaviors

    Operant Conditioning: Maintenance Of BDD Mood/CR Avoidance Behaviors Negative Reinforcement CBT Working Model (Cont.) Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

    • 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

  40. 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
  41. 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
  42. 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

  43. 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”
  44. 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
  45. 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
  46. 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
  47. Pie Chart of Values Artistic Achievement 30% Attractiveness 20% Family 15% Friendship 15% Money 10% Education 10% Neziroglu F, Khemlani-Patel S
  48. 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
  49. 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
  50. 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
  51. 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
  52. Hypochondria
    • Second Century A.D., Galen of Pergamon used the term HYPOCHONDRIA to describe broad range of digestive disorders and melancholia
  53. 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
  54. Phenomenology of HC
    • HC are more concerned with the authenticity, meaning or etiological significance of their symptoms than with the unpleasant sensation or pain
  55. 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
  56. 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
  57. 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
  58. Differential Diagnosis of HC
    • Somatization Disorder
    • Delusional Disorder
    • (monosymptomatic Hypochondriacal Disorder)
    • Panic Disorder
    • Generalized Anxiety Disorder
    • Depression
    • Obsessive Compulsive Disorder
    • (Somatic Obsessions)
    • Illness Phobia
  59. 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)
  60. OCD and HC Anxiety and Depression Scales
  61. OCD and HC Obsessions and Compulsions DS-Disorder Specific
  62. OCD and HC Body Sensations and Mobility p<.05;**p<.01
  63. HC Obsessions
    • Death 20.0%
    • Fatigue 13.3%
    • General illness 13.3%
    • Back Problems 13.3%
    • Insomnia 6.7%
    • Multiple Sclerosis 6.7%
  64. 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%
  65. Treatment Modalities For HC
    • 1) Psychodynamic Interventions
    • 2) Reassurance Therapy
    • 3) Cognitive-Behavior Therapy
    • 4) Pharmacotherapy
  66. Kellner’s Reassurance Intervention
    • Physical Examination
    • Client Centered Techniques
    • Explanatory Therapy (psychoeducation)
    • Use of Suggestion
    • Biofeedback
  67. Treatment Outcome Data
    • Cognitive Behavioral Therapy Improved
    • Salkovskis and Warwick (1986) 100%
    • Warwick and Marks (1988) 88%
    • Miller, Action & Hodge (1988) 100%
  68. Cognitive Behavioral Model of Hypochondriasis
    • Review Previous Experience
    • Formulation of Dysfunctional Assumptions
    • A Critical Incident
    • Activation of Assumptions
    • Negative Thoughts and Imagery
    • Hypochondriacal Development
  69. 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.
  70. 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
  71. COGNITIVE RESTRUCTURING
    • A.= ANTECEDENT EVENT
    • B. = BELIEFS
    • C. = CONSEQUENCES
    • 1. EMOTIONAL
    • 2. BEHAVIORAL
    • D. =DISPUTE
    • E. = EFFECT OF DISPUTING
  72. 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
  73. 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)
  74. 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)
  75. 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.
  76. 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.
  77. 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.
  78. 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.
  79. 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?
  80. 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.
  81. General Conclusions about ERP vs. CT
    • With Cognitive Therapy
    • Attrition rate lower
    • Compliance better
    • Motivation greater
    • Acceptance of therapy better
  82. 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)
  83. Hoarding: Additional Criteria
    • Clutter prevents usage of functional space
    • Significant distress or impairment
    • Frost & Hartl (1996)
  84. Disorders with Hoarding Behavior
    • OCD
    • OCPD
    • Depression
    • Dementia
    • Psychosis (eg.SZ; delusional dis.)
    • Eating Disorders
  85. Prevalence
    • 20-30% of OCD patients
    • 26.3 per 100,000 as reported by health departments
    • Frost, Steketee, Greene (2003)
  86. 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
  87. 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)
  88. Model of Hoarding
  89. 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
  90. Obsessional Thoughts in Hoarding
        •  Emotional Comfort
    •  Loss
    •  Identity
    •  Value
    •  Responsibility/Waste
    •  Memory
    •  Control
  91. 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”
  92. 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”
  93. 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)
  94. 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
  95. 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
  96. 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
  97. 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)
  98. 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)
  99. 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
  100. Y-BOCS
    • Total Score Mean SD
    • Hoarding 12.7 10.1
    • OCD 26.9 6.1
  101. 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
  102. Beck Anxiety Inventory
    • N Mean SD
    • Hoarding 10 14.5 14.1
    • OCD 16 24.1 16.3
  103. Beck Depression Inventory
    • N Mean SD
    • Hoarding 10 24.6 13.8
    • OCD 16 27.2 9.8
  104. Overvalued Ideas Scale
    • N Mean SD
    • Hoarding 10 6.7 1.3
    • OCD 16 4.6 1.3
  105. Quality of Life Issues For Everyone
    • Lack of functional living space
    • Unhealthy living conditions
    • Unsafe living conditions
    • Additional storage is not the answer
  106. 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
  107. Unhealthy Living Conditions
    • Headaches
    • Respiratory problems
    • Allergies
    • Fatigue/lethargy
    • Insomnia or sleep problems
  108. Unsafe Living Conditions
    • Structural damage to homes
      • Weight of possessions
      • Possible water damage
    • Fire hazards
      • Highly flammable situations
      • Blocked passage ways
  109. Unsafe Conditions (Cont.)
    • Rodent infestation
    • Insect infestation
    • Stairways filled with clutter
      • Fire hazard, dangerous with children
    • Can lead to legal involvement
  110. 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
  111. 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.
  112. 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
  113. 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
  114. 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
  115. Before Intervention: The Kitchen
  116. Before Intervention: The Kitchen
  117. Before Intervention: The Kitchen
  118. After Intervention: The Kitchen
  119. Before Intervention: The Living Room
  120. Before Intervention: The Living Room
  121. After Intervention: The Living Room
  122. Before Intervention: The Guest Room
  123. Before Intervention: The Guest Room
  124. Before Intervention: The Living Room
  125. After Intervention: The Guest Room