OCD Spectrum Disorders

1. 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

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
· 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)

4. Obsessive-compulsive Spectrum Obsessive-compulsive Spectrum
DisordersDisorders
Obsessive-compulsive disorder
Hoarding
Body-dysmorphic disorder
Hypochondriasis
Eating disorders
Trichotillomania
Tourette’s syndrome
Self-mutilation

5. 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).

6. PrevalencePrevalence
1-2% of the general population1-2% of the general population
4-5% of people seeking medical treatment4-5% of people seeking medical treatment
8% of people with depression8% of people with depression
More than 12% of people seeking mental More than 12% of people seeking mental
health treatmenthealth treatment

7. 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

8. ComorbidityComorbidity
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
.
11
Hollander 1993; Hollander 1993;
22
Bienvenu et al. 2000; Bienvenu et al. 2000;
33
Phillips, 1998Phillips, 1998

9. 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.

10. Percentage of People with Percentage of People with
Body Image DissatisfactionBody Image Dissatisfaction
1972 1996
Mid-torsoOverallMid-torsoOverall
Men 36 15 63 43
Women 50 23 71 56
Phillips (1996)

11. Normal Concerns vs. BDDNormal Concerns vs. BDD
Time consumption Time consumption ³³ 1 hour 1 hour
Produces distressProduces distress
Interferes with functioningInterferes with functioning

12. Risk Factors for BDDRisk Factors for BDD
Abuse HistoryAbuse History
TeasingTeasing
Past History of Past History of
Dermatological Dermatological
ProblemsProblems
ShynessShyness
DepressionDepression
AnxietyAnxiety
PerfectionismPerfectionism
Stressors in GeneralStressors in General

13. Is BDD a Problem of:Is BDD a Problem of:
PerceptionPerception
Somatosensory DisturbanceSomatosensory Disturbance
Global/Idealized ValuesGlobal/Idealized Values
Faulty BeliefsFaulty Beliefs
Information Processing BiasesInformation Processing Biases
Neurobiological DefectNeurobiological Defect

14. PerceptionPerception: Actually sees nose as big: Actually sees nose as big
SomatosensorySomatosensory: Feels nose is big: Feels nose is big
Global/Idealized ValuesGlobal/Idealized Values: I value beauty as a : I value beauty as a
goal to pursuegoal to pursue
Faulty CognitionsFaulty Cognitions: Because my nose is big, I : Because my nose is big, I
will be alone and isolated all my life. will be alone and isolated all my life.
Overgeneralization.Overgeneralization.

15. Information Processing BiasesInformation Processing Biases: Looking in the : Looking in the
mirror and focusing immediately on the nose. mirror and focusing immediately on the nose.
Selective attention to details, rather than the Selective attention to details, rather than the
whole.whole.
Neurobiological DefectNeurobiological Defect: Serotonin alteration; : Serotonin alteration;
orbito-frontal cortex, temporal, occipital and orbito-frontal cortex, temporal, occipital and
parietal lobe involvement; genetically or parietal lobe involvement; genetically or
ethologically transmitted.ethologically transmitted.

16. 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.

17. 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)

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 Beliefs About Appearance
(Cont.)(Cont.)

19. 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 better
Happiness comes from looking goodHappiness comes from looking good

20. 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 mirror
Looking good protects you from being treated Looking good protects you from being treated
badlybadly
I cannot be comfortable unless I look goodI cannot be comfortable unless I look good
Physical perfection is a realistic and attainable Physical perfection is a realistic and attainable
goalgoal
If my appearance is defective then I am If my appearance is defective then I am
inadequate and worthless.inadequate and worthless.

21. Safety or Avoidance Safety or Avoidance
Behaviors in BDDBehaviors 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 Safety or Avoidance
Behaviors in BDD (Cont.)Behaviors in BDD (Cont.)

23. 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!

24. 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)

25. 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

26. Safety Behaviors in BDDSafety Behaviors in BDD
Do it yourself surgery
Cosmetic or dermatological
interventions

27. 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.

28. Example of Differentiating BDD From Example of Differentiating BDD From
OCDOCD
Symptom Clusters
Neuropsychological Testing
Neuroimaging
Function of Compulsions/Safety Behaviors
Presence or absence of delusions, overvalued
ideation
Perceptual/Somatosensory Components

29. 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).

30. OVI in BDDOVI 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. 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)

32. Quality of LifeQuality 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 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)

34. 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)

35. 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)

36. 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

37. 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

38. 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

39. 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

40. Frequency and Percentage of Frequency and Percentage of
Abuse in BDD and OCDAbuse in BDD and OCD
Abuse TypeBDD (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 BDDAppropriate Treatments for BDD
Exposure and response prevention
Cognitive therapy
Psychopharmacological treatment
Support groups
Family intervention

42. Inappropriate Treatment for Inappropriate Treatment for
BDDBDD
Dermatological procedures
Surgical and non-surgical procedures
Psychodynamic therapy

43. CBT Working Model
Operant Conditioning
Biological Predisposition
Operant Conditioning
Social Learning+
CSUCS CRUCR
Information
Processing Bias
Classical/Evaluative
Conditioning
Body Dysmorphic Disorder
Neziroglu et al. (2004), Psychiatr Ann 34(12):915-920

44. Biological Predisposition
CBT Working Model (Cont.)
Genetic factors
Visual processing problems
Somatosensory problems
Faulty neuroanatomical
circuitry
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. 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

49. 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

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
CSUCS CRUCR
Information
Processing Bias
Classical Conditioning

51. Cognitive Therapy: Initial Cognitive Therapy: Initial
StrategiesStrategies
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. 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

53. 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”

54. 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

55. Cognitive Therapy: Cognitive Therapy:
Targeting BDD SymptomsTargeting 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: 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

57. Pie Chart of ValuesPie 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 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

59. 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

61. 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

62. 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

63. HypochondriaHypochondria
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 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

65. 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

66. HC DemographicsHC Demographics
Male: Female Ratio 1:1
Average Age 36-57
Duration of Symptoms6 months-25 years
Symptoms occur more often in single,
women, less educated, less income, non-
whites, hispanics, older, urban residence

67. Common HC SymptomsCommon HC Symptoms
Parts 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

68. Common HC SymptomsCommon HC Symptoms
Parts 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
1) Chest Complaints:
 Heart Attacks
 Chronic Asthma

69. 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

70. 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)

71. OCD and HCOCD and HC
Anxiety and Depression ScalesAnxiety and Depression Scales
0
10
20
30
40
50
60
BDI BAI STIA-S STIA-T
OCD
HC

72. OCD and HCOCD and HC
Obsessions 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

73. OCD and HCOCD and HC
Body 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

74. HC ObsessionsHC Obsessions
Death 20.0%
Fatigue 13.3%
General illness 13.3%
Back Problems 13.3%
Insomnia 6.7%
Multiple Sclerosis 6.7%

75. HC CompulsionsHC 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 HCTreatment Modalities For HC
1) Psychodynamic Interventions
2) Reassurance Therapy
3) Cognitive-Behavior Therapy
4) Pharmacotherapy

77. Kellner’s Reassurance Kellner’s Reassurance
InterventionIntervention
Physical Examination
Client Centered Techniques
Explanatory Therapy (psychoeducation)
Use of Suggestion
Biofeedback

78. Treatment Outcome DataTreatment 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 Cognitive Behavioral Model of
HypochondriasisHypochondriasis
Review Previous Experience
Formulation of Dysfunctional Assumptions
A Critical Incident
Activation of Assumptions
Negative Thoughts and Imagery
Hypochondriacal Development

80. 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.

81. 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

82. COGNITIVE COGNITIVE
RESTRUCTURINGRESTRUCTURING
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 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

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
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)

86. 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.

87. 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.

88. 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.

89. 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.

90. 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?

91. 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.

92. 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

93. 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)

94. Hoarding: Additional CriteriaHoarding: Additional Criteria
Clutter prevents usage of
functional space
Significant distress or
impairment
Frost & Hartl (1996)

95. Disorders with Hoarding BehaviorDisorders with Hoarding Behavior
OCD
OCPD
Depression
Dementia
Psychosis (eg.SZ; delusional dis.)
Eating Disorders

96. PrevalencePrevalence
20-30% of OCD patients
26.3 per 100,000 as reported by
health departments
Frost, Steketee, Greene (2003)

97. Possible Etiology of HoardingPossible 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 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)

99. Model of Hoarding
Information
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

100. Hoarding Cognitions:
Normal Behavior vs. Disorder
·Normal pattern of use for disposable object:
oAcquire ► Use ► Consider
discarding: evaluate value ► Discard or
Save.
·The Process of Hoarding:
oAcquire ► 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: 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

106. 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

107. 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

108. 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)

109. 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)

110. DemographicsDemographics
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-BOCSY-BOCS
Total Score Mean SD
Hoarding 12.7 10.1
OCD 26.9 6.1

112. 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

113. Beck Anxiety InventoryBeck Anxiety Inventory
N Mean SD
Hoarding10 14.5 14.1
OCD 16 24.1 16.3

114. Beck Depression InventoryBeck Depression Inventory
N Mean SD
Hoarding10 24.6 13.8
OCD 16 27.2 9.8

115. Overvalued Ideas ScaleOvervalued Ideas Scale
N Mean SD
Hoarding 10 6.7 1.3
OCD 16 4.6 1.3

116. Quality of Life Issues For Quality of Life Issues For
EveryoneEveryone
Lack of functional living space
Unhealthy living conditions
Unsafe living conditions
Additional storage is not the answer

117. Lack of Functional Living SpaceLack 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 ConditionsUnhealthy Living Conditions
Headaches
Respiratory problems
Allergies
Fatigue/lethargy
Insomnia or sleep problems

119. Unsafe Living ConditionsUnsafe Living Conditions
Structural damage to homes
–Weight of possessions
–Possible water damage
Fire hazards
–Highly flammable situations
–Blocked passage ways

120. Unsafe Conditions (Cont.)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 Additional Storage Is Not the
AnswerAnswer
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 FamiliesEffects 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 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

124. Treatment Steps for Family Treatment Steps for Family
MembersMembers
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 Applying the Intervention
TechniqueTechnique
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