Compulsive Spectrum Disorders

Understanding and Treating Obsessive-Compulsive Spectrum Disorders

Presented by

Martin M. Antony, PhD, ABPP Department of Psychology, Ryerson University Website: www.martinantony.com E-mail: [email protected]

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Institute for Brain Potential P.O. Box 2238 Los Banos, CA 93635

Disclosure Statement: Dr. Antony is the author of several leading books on the topic of anxiety and related problems. In this program, Dr. Antony will recommend a number of books related to anxiety disorders, including some of his own.

COURSE OBJECTIVES Participants completing this program should be able to: 1. List key symptoms and forms of OCD spectrum disorders. 2. Name several brain structures related to OCD. 3. Identify the classes of drugs that are used to treat OCD. 4. Describe how exposure and response (ritual) prevention are applied. 5. List several adjunctive therapies that can improve therapeutic outcome.

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. Customer Service . Obsessive-compulsive spectrum disorders - 888-202-2938 . Overview of OCD . Registration Department (e.g., payments) . Recommended books and DVDs . Etiology of OCD - 866-652-7414 . Overview of effective treatments . Biological treatments (e.g., medications) . Complementary and alternative treatments . Exposure and ritual prevention . Cognitive strategies . Mindfulness and acceptance-based strategies

Outline

. OCD and the family . Treating OCD in children OBSESSIVE . Body dysmorphic disorder . Hair pulling and skin picking . Obsessive-compulsive personality disorder COMPULSIVE . Health anxiety . Hoarding disorder SPECTRUM DISORDERS

OC and Related Disorders OC and Related Disorders

. Obsessive-compulsive disorder . Other specified obsessive-compulsive and . Body dysmorphic disorder related disorder . Hoarding disorder . Unspecified obsessive-compulsive and related . Trichotillomania (hair pulling disorder) disorder . Excoriation (skin-picking) disorder Other Disorders of Interest . Substance/medication induced obsessive . Tic disorders compulsive and related disorder . Illness anxiety disorder . Obsessive-compulsive and related disorder due to another medical condition . Obsessive compulsive personality disorder

DSM-5 (American Psychiatric Association, 2013) DSM-5 (American Psychiatric Association, 2013)

2 Problems That Are Not Classified As OCD-Related

. Binge eating . “Compulsive” self-harm (e.g., cutting) . “Compulsive” sexual behavior OVERVIEW . Gambling disorder . Internet addiction OF OCD . Substance related disorders

Obsessive Compulsive Disorder (OCD) Obsessions . Presence of obsessions, compulsions, or both . Recurrent and persistent thoughts urges, or . Obsessions or compulsions are time consuming images that are experienced at some point as (e.g., more than 1 hour per day) or cause intrusive and unwanted, and that cause significant distress or impairment market anxiety or distress. . Not due to a substance, medical illness, or better . Individual attempts to ignore or suppress the accounted for by another mental disorder thoughts, images, or urges, or to neutralize . Specify if: (1) with good or fair insight, (2) with them with some other thought or action (i.e., a poor insight, or (3) with absent insight/delusional compulsion) beliefs . Specify if: tic related

DSM-5 (American Psychiatric Association, 2013) DSM-5 (American Psychiatric Association, 2013)

Examples of Obsessions Frequency of Obsessions

. Contamination Obsessions Type of Obsession % of Sample (e.g., germs, bleach, H1N1, HIV, cancer, colors) Aggressive 68.7 . Doubting Obsessions Contamination 57.7 (e.g., appliances, locks, written work, running over pedestrians) Symmetry/Exactness 53.2 . Aggressive Obsessions (e.g., stab children, push loved ones into traffic) Somatic 34.1 . Obsessions about Accidentally Harming Others Hoarding/Saving 30.2 (e.g., contamination, poisoning, starting fires) Religious 24.2 . Religious Obsessions Sexual 19.8 (e.g., satanic thoughts, blasphemous thoughts) Miscellaneous 55.5 . Sexual Obsessions Current symptoms as reported by 182 adults with OCD on the Yale-Brown Obsessive- (e.g., thoughts of sex with children) Compulsive Scale (Y-BOCS) Symptom Checklist. From Antony, Downie, & Swinson, 1998

3 Compulsions Examples of Compulsions

. Repetitive behaviors or mental acts that a person feels driven to perform in response to an obsession . Washing and Cleaning or according to rules that must be applied rigidly . Checking . Behaviors or mental acts are aimed at preventing . Counting or reducing anxiety or distress, or preventing some dreaded event (note: children may be unable to . Repeating Actions articulate the purpose of the compulsion). . Repeating Words, Phrases, Thoughts, or . Behaviors may not necessarily be connected in a Prayers to Oneself realistic way to the event they are meant to prevent, . Repeated asking, confessing, or telling or they are clearly excessive. . Symmetry and Exactness

DSM-5 (American Psychiatric Association, 2013)

Frequency of Compulsions Other Features of OCD Type of Compulsion % of Sample Checking 80.7 . Avoidance of feared situations Washing 63.7 . Thought-action fusion Repeating 55.5 . Impaired confidence in judgments Ordering/Arranging 40.1 . Perfectionism Counting 35.2 . Magical thinking Hoarding 28.0 Miscellaneous 59.3 . Inflated responsibility

Current symptoms as reported by 182 adults with OCD on the Yale-Brown Obsessive- Compulsive Scale (Y-BOCS) Symptom Checklist. From Antony, Downie, & Swinson, 1998

Magical Thinking Inflated Responsibility . A child checks excessively when leaving a room . “My boyfriend will be in a car accident to make sure that nothing was left behind. if I don’t finish my term paper by . A man repeatedly asks for reassurance that midnight.” others aren’t offended by something he said. . “If I do everything seven times, I can . A lawyer spends hours reviewing reports and prevent bad things from happening.” letters to ensure that everything is accurate, so harm will not come to her clients. . “If I step on a sidewalk crack, I’ll . A new mother avoids spending time with her break my mother’s back.” baby for fear of acting on intrusive sexual obsessions.

4 Patterns of Comorbidity Patterns of Comorbidity . 41.4% had social anxiety disorder . 36% of patients diagnosed with OCD only . 24.1% had major depressive disorder . 28.7% had 1 additional diagnosis . 20.7% had a specific phobia . 17.2% had 2 additional diagnoses . 13.8% had dysthymic disorder . 11.5% had panic disorder . 18.4% had 3 or more diagnoses . 11.5% had generalized anxiety disorder . 8.0% had a tic disorder . 4.6% had trichotillomania

. Data from Anxiety Disorders Clinic patients with a principal diagnosis of OCD . Data from Anxiety Disorders Clinic patients with a principal diagnosis of OCD (Antony, Downie, & Swinson, 1998) (Antony, Downie, & Swinson, 1998) . Patients with a psychotic disorder, bipolar disorder, or substance . Patients with a psychotic disorder, bipolar disorder, or substance abuse/dependence, were excluded from the sample abuse/dependence, were excluded from the sample

Gender and OCD Culture and OCD

. In adults, OCD is about equally prevalent for . OCD occurs across cultures, religious men and women, or slightly more prevalent in groups, and geographic locations. women than men. . Sociocultural factors can affect the . In children, slightly more common in boys presentation of OCD. than girls (earlier age of onset in males). . Some evidence that OCD content is related . Prevalence rates for men vs. women are to degree of religiosity, with religious themes similar across cultures. dominating the OCD presentation in groups . Women more likely than men to report that tend to have a more conservative aggressive obsessions and cleaning rituals, religious upbringing. and less likely to report sexual obsessions.

Socioeconomic Status and OCD

. OCD is associated with lower income and underemployment, but probably no more than RECOMMENDED other chronic anxiety disorders. Relationships and OCD BOOKS AND DVDS

. Women with OCD are more likely to be ON OCD married than are men with OCD (may be related to earlier onset in males).

5 OCD Books for Therapists OCD Books for Therapists

. Antony, M.M., Purdon, C., & Summerfeldt, L.J. . Abramowitz, J.S. (2006): Obsessive-compulsive (Eds.) (2007). Psychological treatment of OCD: disorder. Cambridge, MA: Hogrefe. Fundamentals and beyond. Washington, DC: . Abramowitz, J.S. (2006): Understanding and American Psychological Association. treating obsessive-compulsive disorder: A . Clark, D.A. (2004). Cognitive-behavioral therapy cognitive behavioral approach. New York, NY: for OCD. New York, NY: Guilford. Routledge. . Wilhelm, S., & Steketee, G.S. (2006). Cognitive . Rachman, S. (2003). The treatment of therapy for obsessive-compulsive disorder: A obsessions. New York, NY: Oxford. guide for professionals. Oakland, CA: New Harbinger.

OCD Workbooks Other OCD Self-Help Books

.Abramowitz, J.S. (2009). Getting over OCD: A .Grayson, J. (2004). Freedom from obsessive- compulsive disorder: A personalized recovery 10-step workbook for taking back your life. New program for living with uncertainty. New York, NY: York, NY: Guilford Press. Berkley Publishing Group. .Hyman, B.M., & Pedrick, C. (2010). The OCD .Purdon, C., & Clark, D.A. (2005). Overcoming workbook: Your guide to breaking free from obsessive thoughts: How to gain control of your obsessive-compulsive disorder (3rd edition). OCD. Oakland, CA: New Harbinger. Oakland, CA: New Harbinger. .Salkovskis, P.M., Oldfield, V.B., & Challacombe, F. (2011). Break free from OCD: Overcoming obsessive compulsive disorder with CBT. London, UK: Random House.

Recommended OCD DVDs Recommended Anxiety Books

. Wilson, R. (2012). Cognitive therapy for . Antony, M.M., & Norton, P.J. (2009). The anti- obsessions. (DVD). Mill Valley, CA: anxiety workbook: Proven strategies to overcome Psychotherapy.net. worry, panic, phobias, and obsessions. New . Wilson, R.R. (2005). Obsessive-compulsive York, NY: Guilford Press. disorder (DVD). Washington, DC: American . Antony, M.M., & Stein, M.B. (Eds.) (2009). Psychological Association. Oxford handbook of anxiety and related disorders. New York, NY: Oxford University Press.

6 Learning and Anxiety/Fear

1. Reinforcement of Anxiety/Avoidance ETIOLOGY 2. Pathways to Fear (Rachman, 1976) . Direct Traumatic Learning OF OCD . Observational Learning . Informational/Instructional Learning

When is it Important to Practice Good Hand Hygiene? Germs and Office Surfaces

. After using the bathroom . Charles Gerba (microbiologist at U of Arizona) and . Before eating or drinking anything colleagues collected 7000 bacteria samples from 12 . Before and after handling raw foods, fish, poultry, or eggs different surfaces across four US cities. . After using a public phone . Phones, desks, water fountain handles, microwave . After riding public transportation door handles, and computer keyboards had the . In schools and day care centers highest levels of bacteria. . After changing diapers . Toilet seats had the lowest level levels of bacteria. . When one is sick . Office desks had 100 more bacteria than an kitchen . After shaking hands tables, and 400 times more bacteria per square inch . After sneezing or coughing than toilet seats.

. After touching an ATM, elevator buttons, escalator handrails Hewitt et al., 2012; Reynolds et al., 2005

Cognitive Model of OCD Normal Intrusive Thoughts

. Everyone experiences intrusive thoughts. . Thoughts of intentionally harming oneself . Normal intrusive thoughts and obsessions differ only . Intentionally harming others in the way they are interpreted by the individual . Thoughts of causing nonintentional harm . Individuals with OCD interpret intrusive thoughts as to oneself or others indicating that they are responsible for the occurrence or prevention of harm to self and others . Thoughts of physical harm or death to (e.g., “I will kill my baby” equals an increased risk of others doing so, unless I take steps to prevent it). . Thoughts of physical harm or death to self . Thought suppression and compulsive rituals help to . Thoughts of being contaminated maintain the problem. . Thoughts of causing social difficulties (Salkovskis, 1998) through impulsive actions

7 Normal Intrusive Thoughts Biological Factors in OCD . Doubts about safety at home or in the car Increased Cerebral Blood Flow in Orbitofrontal . Thoughts involving deviation from one’s moral Cortex and Basal Ganglia of OCD Patients code . Based on functional brain imaging (e.g., FMRI) . Thoughts of losing control or acting out of studies; appears to be corrected by character pharmacological or cognitive behavioral treatments . Doubts about memory Genetic Factors . Impulses to leave everything (e.g., run away . Based on family, twin, and molecular genetics and live in the mountains) studies . Sexual thoughts Altered Neurotransmitter Functioning . Symmetry, exactness, or “just right” thoughts . Serotonin (Wilhelm & Steketee, 2006) . Glutamate

Neuropsychological Findings OCD and Gray Matter . Severity of aggression symptoms are positively . A recent meta-analysis (Abramovitch et al., correlated with gray matter (GM) volumes in the lateral 2013) of of 115 studies (with 3452 patients) parietal cortex (both hemispheres) and negatively found consistent evidence of deficits in: correlated with GM volumes in the bilateral insula, left - Executive function (e.g., cognitive flexibility) putamen and left inferior orbitofrontal cortex (OFC). - Processing speed . Severity of “sexual/religious” symptoms are positively - Sustained attention correlated with GM volumes within the right middle lateral OFC and right dorsolateral prefrontal cortex - Nonverbal memory (but not verbal memory) and negatively correlated with bilateral anterior . Findings are consistent with findings cingulate cortex (ACC) suggesting that OCD is associated with . No correlations between GM volume and activation of the frontostriatal system (Saxena contamination and symmetry symptoms & Rauch, 2000) Alvarenga et al., 2012

PANDAS PANDAS

Pediatric Autoimmune Neuropsychiatric Disorders Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS) Associated with Streptococcal Infection (PANDAS) . Caused when the immune system attacks the basal . Diagnosis is controversial. Experts don’t agree ganglia (triggered by a strep infection, and often whether it even exists. associated with a genetic predisposition for OCD or . Unknown whether treatment with antibiotics is tics). useful. . Sometimes called PANS (Pediatric Acute Onset . If OCD symptoms remain after treatment with Neuropsychiatric Syndrome) to reflect the fact that it antibiotics, then treatment with medication or CBT can also be triggered by other infections. is typically recommended. . Rapid onset (usually between 3 years of age and . Preliminary data from 7 children with related OCD puberty); often with involuntary movements of legs, suggest that CBT may be effective (Storch et al., face, arms. 2006)

8 Treatment Strategies Medications . SSRIs, clomipramine, augmentation strategies (e.g., antipsychotic drugs) OVERVIEW OF Combination Treatments . CBT plus medications (e.g., SSRIs) EFFECTIVE Exposure Strategies . Exposure to feared objects, thoughts, situations TREATMENTS Ritual (Response) Prevention . Preventing compulsive rituals Cognitive Strategies . Correcting unrealistic beliefs and interpretations

Selective Serotonin Re-Uptake Inhibitors (SSRIs)

. Paroxetine (Paxil) MEDICATION . Sertraline (Zoloft) TREATMENTS . Fluvoxamine (Luvox) . Fluoxetine (Prozac; Sarafem) . Citalopram (Celexa) . Escitalopram (Lexapro; Cipralex)

Side Effects for SSRIs Selective Serotonin Re-Uptake Inhibitors (SSRIs) Gastro-Intestinal: nausea, intestinal cramping, diarrhea, vomiting, dry mouth, weight gain . Dosages Central Nervous System: nervousness, . Duration of Treatment headache, tremulousness, insomnia, hypersomnia, sedation, anxiety . Discontinuing Treatment Sexual Symptoms: delayed orgasm, difficulty becoming aroused, reduced interest Skin: allergic reactions, rashes

9 Other Antidepressants Ineffective Medications in OCD

. Clomipramine (Anafranil): Support in . Other antidepressants (e.g., numerous placebo-controlled trials. bupropion, imipramine) . Venlafaxine XR (Effexor XR): . Benzodiazepines Comparable to Paroxetine for OCD (Denys et al., 2003) . Beta-blockers . Mirtazapine (Remeron): Support in . Lithium open trials only (e.g., Koran et al., . Buspirone 2005).

Adjunctive Antipsychotics Adjunctive Antipsychotics

. Placebo controlled studies have examined . Adjunctive ziprasidone (Geodon) less effective than adjunctive use of risperidone (Risperdal), adjunctive quetiapine (Zyprexa) (Savas et al., 2008) haloperidol (Haldol), olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), and . Long Term Study: A long term trial examining 1 ziprasidone (Geodon). year of treatment with SSRI plus olanzapine, quetiapine, or risperidone in SSRI-nonresponders . Overall, findings are mixed, but a recent meta- did not support the use of these medications in analysis supports combining SRIs and OCD (Matsunaga et al., 2009) antipsychotics for treatment resistant OCD (Dold et . Fluoxetine + clomipramine more effective than al., 2011), though consistent findings were only fluoxetine + quetiapine (Diniz et al., 2011) found for risperidone (Dold et al., 2013).

Glutamatergic Agents Glutamatergic Agents

. Evidence is emerging that elevated glutamate . Memantine (Namenda): an N-methyl-D-aspartate levels may be involved in OCD and related (NMDA) antagonist (blocks NMDA glutamate problems (e.g., Chakrabarty et al., 2005). receptors), indicated for the treatment of Alzheimer’s disease. Found to be superior to placebo in a 12- . Topiramate (Topamax): An anticonvulsant that week OCD study (Haghighi et al., in press). Also augments the effects of GABA, and also inhibits found to augment the effects of fluvoxamine, relative the effects of glutamate. Support for augmenting to placebo (Gheleiha et al., 2013). the effects of SSRIs in treatment-resistant OCD . N-Acetylcysteine: A glutamate-modulating agent (Berlin et al., 2011; Mowla et al., in press). that appears to be useful for augmenting the effects of SSRIs in treatment resistant OCD (Afshar et al., 2012)

10 Pharmacotherapy Levels of Evidence Recommendations for SAD

Treatment Recommendation Summary Levels of Evidence Meta-analysis or replicated randomized controlled trial (RCT) First line Level 1 or 2 evidence + clinical support for efficacy & safety Level 1 that includes a placebo condition Second line Level 3 evidence or higher + clinical support for efficacy & safety Level 2 At least 1 RCT with placebo or active comparison condition

Level 3 Uncontrolled trial with at least 10 or more subjects Third line Level 4 evidence or higher + clinical support for efficacy & safety Level 4 Anecdotal reports or expert opinion Not Level 1 or 2 evidence for lack of efficacy recommended

From: Canadian Clinical Practice Guidelines for the Management of Anxiety, From: Canadian Clinical Practice Guidelines for the Management of Anxiety, Posttraumatic Stress, and Obsessive Compulsive Disorders (Canadian Anxiety Posttraumatic Stress, and Obsessive Compulsive Disorders (Canadian Anxiety Guidelines Initiative Group, in press) Guidelines Initiative Group, in press)

Obsessive-Compulsive Disorder: Medication Treatments for Children Recommendations for Initial Therapy . Controlled trials supporting fluvoxamine, First line Escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline sertraline, and fluoxetine for children. Second line Citalopram, clomipramine, mirtazapine, venlafaxine XR . In the USA, fluvoxamine and sertraline have IV clomipramine, duloxetine, phenelzine, tramadol, Third line tranylcypromine FDA approval for OCD, down to ages 8 and 6, First-line: aripiprazole, risperidone respectively. No SSRIs are approved in Second-line: memantine, topiramate Canada for OCD in children. Third-line: amisulpride, celecoxib, IV or oral citalopram, granisetron, haloperidol, IV ketamine, mirtazapine, N- Adjunctive acetylcysteine, olanzapine, ondansetron, pindolol, . Need to assess for suicide risk. pregabalin, quetiapine, riluzole, ziprasidone Not recommended: buspirone, clonazepam, lithium, morphine

(Canadian Anxiety Guidelines Initiative Group, in press)

Medication Treatments for Children Recommended Readings

. Medication dosages must be adjusted, depending on the . Bezchlibnyk-Butler, K.Z., Jeffries, J.J., weight of the child. Procyshyn, R.M., & Virani, A.S. (Eds.) (2014). . Children tend to have a high placebo response Clinical handbook of psychotropic drugs, 20th . Some studies suggest that it may take more than 2 edition. Boston, MA: Hogrefe. months for medication to be more effective than placebo. . Elbe, D., Bezchlibnyk-Butler, K.Z., & Virani, A.S . Suicide Risk: FDA review of about 2200 children treated (2014). Clinical handbook of psychotropic drugs with SSRIs between 1988-2006 found that 4% of children for children and adolescents, 3rd edition. Boston, reported increased rates of suicidal ideation and attempts MA: Hogrefe. (twice the rate for placebo), though there were no completed suicides. Close monitoring is important in the first 4 weeks of treatment for children, adolescents, and young adults (to age 25).

11 Complementary and Alternative Treatments

. A 2002 survey found that 62% of American adults COMPLEMENTARY had used alternative treatments in the past year for a health concern (Barnes et al., 2002). . A 2012 survey found that 50% of college students AND ALTERNATIVE had used 1 of 9 herbal products for anxiety in the past year (Birkett, 2012). TREATMENTS . According to www.holisticonline.com, the following treatments are “helpful both for relieving the anxiety of OCD and for diminishing the compulsions themselves….”

Complementary and Complementary and Alternative Treatments Alternative Treatments

. Acupressure . Homeopathy . Aromatherapy . Massage . Autosuggestion . Mind/Body Medicine . Bach Flower Remedies (White Chestnut) . Nutritional Supplements . Biofeedback . Prayer and Spirituality . Color Therapy . Reflexology . Diet Therapy . Schuessler Tissue Salts . Exercise . Yoga . Herbal Medicine

Complementary and Herbs and Supplements Alternative Treatments . Inositol: Superior to placebo (Fux et al., 1996), but Color Therapy not effective for augmenting SSRIs (Fux et al., 1999) Radiate the following colors one after the other, twice per . Silybum marianum (Marian Thistle): Equivalent to day: fluoxetine (30 mg) in an 8-week OCD study (Sayyah . Blue for 30 minutes et al., 2010) . . Green for 10 minutes . Omega-3 Fatty Acids: Not supported in a controlled . Yellow for 10 minutes study for OCD (Fux et al., 2004). Aromatherapy . Valerian root: Preliminary support in 8-week Take the following twice per day on brown sugar tablets: placebo-controlled study for OCD (Pakseresht et al., . Lavender 4% 2011) . Rosemary 4% . St. John’s Wort: Equivalent to placebo (Kobak et al., . Valerian 12% 2005) www.holisticonline.com

12 Herbs at a Glance Other Alternative Treatments

. Fact sheets published by the National . Mindfulness Meditation: Preliminary support in Center for Complementary and Alternative OCD for mindfulness training (Hanstede et al., Medicine, National Institutes of Health 2008) and kundalini yoga meditation (Shannahoff-Khalsa et al., 1999). . Provides reviews on more than 45 herbal . Aerobic Exercise: Support in two open trials for products OCD (Abrantes et al., 2009; Brown et al., 2007). . Updated regularly Controlled study now underway (Abrantes et al., 2012). . http://nccam.nih.gov/health/herbsataglance. . Meridian Tapping: Not effective for the htm treatment of OCD (Moritz et al., 2011).

Research Findings

. No OCD studies found with: other herbal remedies (e.g., kava, ginkgo OTHER biloba, SAM-e, Bach flower remedies), aromatherapy, homeopathy, massage, etc. BIOLOGICAL TREATMENTS

Psychosurgery (Cingulotomy) Deep Brain Stimulation

. Involves severing of the supracallosal . Greenberg et al. (2006) followed 8 highly treatment fibres of the cingulum bundle, which pass resistant patients for 3 years after deep brain through the anterior cingulate gyrus (in stimulation (DBS) of the ventral capsule / ventral striatum (part of the basal ganglia). 4 patients had a limbic system) >35% reduction in YBOCS scores; 2 had between 25 . At a mean of 32 months post-surgery, 45% and 35% reduction. of individuals with severe OCD who were . Depression and anxiety also improved, as did self- nonresponsive to medications and care, independent living, and work, school, and social functioning. behavior therapy obtained responded at least partially to cingulotomy, with . Adverse effects included an asymptomatic hemorrage, a single seizure, a superficial infection, transient relatively few adverse effects (Dougherty hypomanic symptoms, and worsened depression and et al., 2002). OCD when DBS was interrupted by battery problem.

13 Deep Brain Stimulation Other Biological Treatments

. In a double blind, controlled study, Mallet et al. No evidence supporting (for anxiety (2008) had 8 treatment refractory patients with OCD undergo stimulation of the subthalamic disorders): nucleus (part of the basal ganglia) for 3 months, . Electroconvulsive therapy followed by sham stimulation for 3 months. Eight other patients received sham stimulation followed . Transcranial magnetic stimulation by stimulation of the subthalamic nucleus. . Changes in OCD symptoms (but not depression or anxiety were greater during stimulation of the subthalamic nucleus than sham stimulation. . 15 serious adverse events (e.g., 1 hemorrhage, 2 infections) in 11 patients.

CBT and Clomipramine for OCD

25 COMPARING AND 20 15 COMBINING CBT 10 5

AND MEDICATION Score YBOCS Mean Total 0 CLP ERP ERP + CLP Placebo

0 Weeks 12 Weeks

Note: CLP = clomipramine Foa, Liebowitz, et al. (2005). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 162, 151-161.

CBT vs. Medications CBT vs. Medications

. Averaging across studies, CBT and . Recent findings (Simpson et al., 2008; Tundo medications tend to be equally effective in the et al., 2007) suggest that ERP may improve short term for OCD. outcomes for individuals who still have OCD . For adults, there is often not much benefit of despite taking medications, compared to stress combining CBT and medication over either management therapy. approach alone. . Following nonresponse to ERP, switching to . CBT plus fluoxetine was found to be superior to fluvoxamine appears to be more effective than fluoxetine alone for OCD (Giasuddin et al., switching to cognitive therapy (van Balcom et 2013) al., 2012)

14 CBT vs. Medications Augmenting SSRIs 30 . The average patient continues to have 25 moderate OCD symptoms following treatment, regardless of what intervention is used. 20 . There is a lack of good long term follow-up 15 data beyond 1 year. 10 . One study suggests that individuals who 5

received CBT either with fluoxetine or placebo Score YBOCS Mean Total 0 maintained treatment gains over 7 years (but Risperidone EX/RP Placebo most had additional treatment during follow-up 0 Weeks 8 Weeks Note: EX/RP = Exposure + Response Prevention period) (Rufer et al., 2005). Simpson, Foa, Liebowitz, et al. (2013). Cognitive-Behavioral Therapy vs Risperidone for augmenting serotonin reuptake inhibitors in obsessive-compulsive disorder: A randomized controlled trial. JAMA Psychiatry, Published online Sept 11, 2013.

CBT and the Brain D-Cycloserine (DCS; Seromycin)

. A study using proton magnetic resonance . Best known as a treatment for tuberculosis (500- spectroscopic imaging found that after 4 weeks of 1000 mg per day) intensive CBT, treatment response was . Side effects: mostly CNS (e.g., irritability, headache) associated with changes in glutamate metabolites (O’Neill et al., 2013). . A partial agonist at the N-methyl-D-aspartate (NMDA) glutamatergic receptor . Levels of inositol (a marker of glial activity) in the orbitofrontal cortex are predictive of CBT response . DCS is a cognitive enhancer - it improves extinction (Zurowski et al., 2012) learning (fear reduction during exposure) in rodents . NMDA antagonists seem to prevent fear learning and extinction . Question - Does DCS improve outcomes in exposure-based treatments for anxiety?

D-Cycloserine (DCS) and Anxiety D-Cycloserine (DCS) and Anxiety

. D-cycloserine enhances exposure-based . DCS (50 mg) does not appear to be effective for enhancing treatment for social phobia (Hofmann et al., VR exposure for height phobia when applied immediately after each of two sessions (Tart et al., 2013) 2006; Guastella et al., 2008) and specific . DCS (50 mg) enhances outcomes of VR exposure for phobia (Ressler et al., 2004) height phobia when provided after a successful exposures, . Seigmund et al. (2011) found the DCS speeds and appears to have detrimental effects when provided after an unsuccessful exposures (Smits et al., in press). up the effects of exposure for severe . DCS (50 mg) combined with a single session of exposure agoraphobia and panic disorder, though for snake phobia leads to long lasting changes in outcomes following treatment were equivalent. ventromedial and other prefrontal cortex responses to phobic stimuli that are not seen in exposure without DCS . D-cycloserine is supported in a meta-analytic (Nave et al., 2012). study (Norberg et al., 2008).

15 D-Cycloserine (DCS) and OCD D-Cycloserine (DCS) and OCD

. Storch et al. (2007) found no effects of DCS (250 mg), relative . Wilhelm et al. (2008) found that DCS (100 mg) was more to placebo. DCS was taken 4 hours before each of 12 weekly effective than placebo when administered 1 hr before each of sessions. Just looked at pretreatment, posttreatment, and 2- 10 behavior therapy sessions (twice per week). Differences month follow up. found for OC symptoms at midtreatment and for depression at . Preliminary evidence supporting DCS for augmenting posttreatment. No differences at 1-month follow up. exposure for children with OCD (Storch et al., 2010) . In a follow-up analysis, it was found that exposure worked 2.3 . Kushner et al. (2007 found short term benefits for DCS (125 times faster when combined with DCS, compared to when mg) for OCD at session 4, but over time the placebo condition combined with placebo (Chasson et al., 2010). caught up (no differences at posttreatment and 3-month follow up. DCS was taken 2 hrs before each of 10 sessions (conducted twice per week).

Behavioral Features of OCD . Compulsive rituals EXPOSURE . Avoidance of feared situations . Cognitive avoidance and thought AND RITUAL suppression . Compulsions and safety behaviors PREVENTION . Requests for reassurance . Alcohol or drug use

Exposure and Ritual Prevention Variations in Format

. Exposure and ritual prevention (ERP) is . Combining ERP with cognitive the “gold standard” psychological strategies treatment for OCD. . Inpatient vs. outpatient treatments . Between 63% and 83% of participants . Home-based vs. office-based who complete ERP tend to obtain some treatment benefit. . Group vs. individual therapy . Benefits are often maintained over the . Including family members long term. . Internet and self-help treatments

16 Variations in Exposure Presenting the Treatment Rationale

. In vivo vs. imaginal . Defining OCD, obsessions, . Therapist-assisted vs. self-guided compulsions exposure . Develop model of OCD . Outpatient vs. day treatment or . “Fuel for the car” metaphor inpatient . “Candy from a baby” metaphor . Discussing treatment procedures . In-person vs. telephone treatment . Making sure that supports are in place . Intensive vs. twice weekly sessions

Principles of Effective Exposure

. Predictability and perceived control . Pace of exposure (graduated) . Longer exposure practices work best . Exposures should be spaced closely . Eliminate compulsions . Vary the context of the exposure practices . Do not fight the fear

Abramowitz (2009)

Obsessive-Compulsive Disorder Practical Issues Sample Exposure Hierarchy . Role of modeling by the therapist Item Fear . Ensuring safety during exposure Visit a cancer ward in a hospital 100 . Using technology to facilitate Shake hands with a person who has cancer 90 treatment Talk to someone with cancer 75 Eat in a hospital cafeteria 70 . Including a family member in the Walk through the halls of a hospital 60 treatment Stand in front of a hospital 50 . Setting of session Read a library book about cancer 40 Talk to someone about cancer 25

17 Managing Overwhelming Urges Principles of Ritual Prevention . Engage in other activities (e.g., going for a walk) . Eliminating cognitive rituals . Seek social support (e.g., calling a friend) . Undoing the effects of rituals (e.g., with . Contact therapist additional exposure) . Distraction (e.g., watch TV) . Soliciting help from others . Breathing retraining or relaxation exercises . Complete vs. gradual ritual prevention

If Preventing Rituals is Impossible Safety Behaviors and Exposure

. Increase frequency of contact . Traditionally, it has been assumed that (therapy sessions, phone calls) eliminating safety behaviors is essential in exposure-based treatments. . Eliminate certain rituals first (based . Recent evidence from nonclinical samples on location, time of day, ritual (e.g., Rachman et al., 2011; van den Hout et content) al., 2011) suggests that exposure can be . Delay the ritual effective for reducing OCD-like symptoms even when safety behaviors are used. . Shorten the ritual . More research is needed. . Do the ritual differently

Predictors of Positive Outcome Sample Treatment Plans

. Inclusion of therapist-assisted . Contamination obsessions and washing exposure (vs. just self-exposure) . Fear of particular words or images . Stricter ritual prevention (vs. gradual or – e.g., religious symbols, colors, numbers partial ritual prevention) . Fear of running over pedestrians . Including both imaginal and situational . Fear of stabbing children exposure (vs. just situational . Need to repeat actions exposure) . Need to check one’s work (e.g., writing)

18 Exposure Trouble Shooting Exposure Trouble Shooting

. Fear doesn’t decrease during the . An unexpected negative event occurs practice (e.g., patient becomes ill during . Fear returns between practices treatment ) . Fear fluctuates during the practice . Therapist is frightened of the situation . Patient asks to end the exposure . Patient is not fearful of the practice practice due to elevated fear . Patient refuses to do a practice

Reasons for Non-Compliance Improving Compliance . Simplify the task . Patient doesn’t understand the task . Try homework task in session before leaving . Task not relevant to the patient . Schedule more frequent sessions . Task too frightening . Do homework at the therapist’s office . Interpersonal issues (e.g., rapport) . Schedule telephone contacts . Other demands (e.g., family, work) . Reinforcement for completed homework . Therapist doesn’t ask about . Deal with scheduling conflicts, other demands homework . Motivational enhancement strategies . Ambivalence about treatment

Recommended Readings

. Wilhelm, S. (2006). Feeling good about the way you look: A program for overcoming body image problems. New York, NY: Guilford Press. . Wilhelm, S., Phillips, K.A., & Steketee, G. (2013). Cognitive-behavioral therapy for body dysmorphic HAIR PULLING disorder: A treatment manual. New York, NY: Guilford Press. AND SKIN PICKING

Trichotillomania Excoriation Disorder

. Recurrent pulling of hair, resulting in hair loss . Recurrent pulling of hair, resulting in skin lesions . Repeated attempts to decrease hair pulling . Repeated attempts to decrease skin picking . Clinically significant distress or impairment . Clinically significant distress or impairment . Not due to another medical condition or mental . Not due to a substance, another medical condition, disorder or a mental disorder

32 Treatment Recommended Readings

. A small number of studies in trichotillomania support . Franklin, M.E., & Tolin, D.F. (2007). Treating the use of medication (primarily SSRIs) and trichotillomania: Cognitive-behavioral therapy for hair cognitive behavioral strategies, including: pulling and related problems. New York, NY: Springer. - Habit reversal, including awareness training . Keuthen, N.J., Stein, D.J., & Christenson, G.A. (2001). (self-monitoring), stimulus control (e.g., wearing Help for hair pullers: Understanding and coping with gloves in high risk situations), introducing a trichotillomania. Oakland, CA: New Harbinger Publications. competing response (e.g., clenching both hands) - Other strategies as needed (e.g., motivational interviewing, cognitive strategies) . Very limited research (mostly case studies) on the treatment of skin picking

DSM-5 OC Personality Disorder

A pervasive pattern of preoccupation with orderliness, OBSESSIVE- perfectionism, and mental and interpersonal control, at the expense of flexibility, openness, and efficiency, beginning by early adulthood and present in a variety of contexts, as COMPULSIVE indicated by four or more of the following: 1. Preoccupation with details, rules, lists, order, PERSONALITY organization, schedules 2. Perfectionism that interferes with task completion DISORDER 3. Excessive devotion to work and productivity 4. Overconscientious, scrupulous, and inflexible about matters of morality, ethics, or values

DSM-5 OC Personality Disorder OC Personality Disorder

Continued… Treatment 5. Inability to discard worn-out or worthless objects . There are no controlled studies on treating OCPD, but treatment typically involves cognitive 6. Reluctance to delegate tasks or to work with others strategies, exposure, and prevention of safety 7. Miserly spending style toward both self and others behaviors. 8. Rigidity and stubbornness

33 Perfectionism Self- Help Readings Professional Books and DVDs

. Antony, M.M. (2008). Cognitive behavioral therapy for . Antony, M.M., & Swinson, R.P. (2009). When perfect isn’t perfectionism over time (DVD Video). Washington, DC: good enough: Strategies for coping with perfectionism, American Psychological Association. second edition. Oakland, CA: New Harbinger . Egan, S.J., Wade, T.D., Shafran, R., & Antony, M.M. (in Publications. press, to be published in 2014). Cognitive-behavioral . Burns, E.F. (2008). Nobody’s perfect: A story for children treatment of perfectionism: A clinician’s guide. New about perfectionism. Washington, DC: magination press. York, NY: Guilford Press. . Shafran, R., Egan, S., & Wade, T. (2010). Overcoming . Flett, G.L., & Hewitt, P.L. (2002). Perfectionism: Theory, perfectionism: A self-help guide using cognitive behavioral research, and treatment. Washington, DC: American techniques. London, UK: Constable & Robinson. Psychological Association.

Treatment of Health Anxiety

Exposure Strategies . Exposure to feared situations and sensations Cognitive Strategies . Correcting anxious beliefs about illness HEALTH ANXIETY Response Prevention . Stopping excessive checking (e.g., feeling body for lumps) and reassurance seeking (e.g., doctor visits, medical texts, internet searches, etc.) Medications . SSRIs

Treatment of Realistic Health Anxiety Psychoeducation – Body Noise

. Treatment of the medical condition . What is body noise, and what causes it? . Homeostasis (e.g., sweating to cool off the body) . Changing health habits (e.g., exercise) . Shifts in daily routine (e.g., sleep, food intake) . Activity scheduling . Minor medical conditions (allergies, infections) . Problem solving . Orthostatic intolerance . Relaxation-based treatments . Health habits . Mindfulness-based interventions . Mind-body connection . Supportive psychotherapy . Attention and body focus . Medication to reduce anxiety . CBT strategies to deal with excessive anxiety Abramowitz & Braddock (2008)

34 Therapeutic Relationship Health Anxiety -Common Anxious Beliefs- . Remain open-minded about what is causing the patient’s symptoms. Meaning of Bodily Changes and Symptoms . Be aware that patients may not view their problems as psychological. . “I’m healthy only when I don’t have any bodily sensations.” . Ensure that therapy remains collaborative; avoid arguing or having the patient defend his/her views . “Bodily complaints are always a sign of disease.” . Ensure that the patient feels heard and understood. . “Red blotches are a sign of skin cancer.” . Acknowledge the stress of others not “believing” the patient and not feeling listened to. . “Both sides of my body should be symmetrical.” . Avoid explanations that are entirely psychological vs. . “Real symptoms aren’t caused by anxiety.” entirely biological. Adapted from Silver et al. (2004) Silver et al. (2004); Taylor & Asmundson (2004)

Health Anxiety Health Anxiety -Common Anxious Beliefs- -Common Anxious Beliefs-

Meaning and Consequences of Diseases View of the Self as Weak, Vulnerable, or . “If I get sick, I’ll be in great pain and Inadequate suffering.” . “My circulatory system is very sensitive.” . “People will reject or avoid me if I get ill.” . “I need to avoid exertion because I am physically . “Serious diseases are everywhere.” frail.” . “People don’t recover from serious diseases.” . “Illness is a sign of failure or inadequacy.” . “I will be a burden to my family if I become ill.” . “If I’m ill, people will abandon me.” . “If I die, my family won’t be able to cope.” . “I will die early like my father.” . “If I die, I will go to hell.” . “I am more likely to become ill than others.”

Silver et al. (2004); Taylor & Asmundson (2004) Silver et al. (2004); Taylor & Asmundson (2004)

Health Anxiety Health Anxiety -Common Anxious Beliefs- -Common Anxious Beliefs-

Physicians and Medical Tests Risks of Experiencing Anxiety . “It is possible to be absolutely certain about my health.” . “Anxiety can kill.” . “Doctors should be able to explain all my symptoms.” . “There is only so much stress my heart can take.” . “Doctors can’t be trusted because they often make . “Once anxiety starts, you can’t stop it from getting mistakes.” worse.” . “Medical tests are unreliable if you don’t have symptoms at the time of the test.” . “There is only so much stress my mind can take.” . “By going to the doctor, I will prevent any serious illnesses.” . “If I am referred for further tests, it means my doctor thinks there is something wrong with me.”

Silver et al. (2004); Taylor & Asmundson (2004) Silver et al. (2004)

35 Health Anxiety Health Anxiety -Common Anxious Beliefs- -Common Anxious Beliefs-

Benefits of Worry, Reassurance, and Vigilance Superstitious and Metacognitive Beliefs . “Worrying about my health will keep me safe.” . “If I don’t control my thoughts, I might go mad.” . “I need to check my body frequently to catch the . “Thinking I have cancer makes it more likely that I first signs of illness.” will get it.” . “I need to carefully watch my health; otherwise . “If I don’t worry about my health, something will go something terrible will happen.” wrong.” . “The internet can show me the best ways to . “If I let myself think I am well, I will tempt fate.” investigate and treat my symptoms.” . “I must check the toilet for blood every time I use . “I must check the toilet for blood every time I use it.” it.” Silver et al. (2004); Taylor & Asmundson (2004) Silver et al. (2004)

Physical Illness Health Anxiety -Common Anxious Beliefs- -Common Anxious Beliefs-

. “I might lose control of my bowels (IBS).” Death, the Afterlife, and Superstitious Beliefs . “I need to rest or I will harm myself (chronic . “I’ll be trapped and alone forever when I am fatigue).” dead.” . “Pain is a warning sign to stop. Pain is dangerous . “Death means that I will be eternally aware of (chronic pain).” what I have lost.” . “If I raise my heart rate, I will have a heart attack . “God makes bad people die early.” (heart disease).” . “If I tell myself I’m healthy, then I’ll be tempting . “My life is over. There is no point trying (cancer).” fate.” . “If I move, I’ll cause damage (post-surgery).”

Silver et al. (2004) Taylor & Asmundson (2004)

Strategies for Cyberchondria Fear of Developing Cancer (OCD) Sample Exposure Hierarchy . Keep internet-based information in perspective . Refrain from searching for symptoms online. Rather, Item Fear reserve online searches to learn more about a Visit a cancer ward in a hospital 100 diagnosis after it has been received. Shake hands with a person who has cancer 90 . Be highly selective when choosing online sites - National Cancer Institute (www.cancer.gov) Talk to someone with cancer 75 - American Heart Association (www.heart.org) Eat in a hospital cafeteria 70 - Canadian Cancer Society (www.cancer.ca) Walk through the halls of a hospital 60 - Heart and Stroke Foundation (www.heartandstroke.com) Stand in front of a hospital 50 - National Institutes of Health (www.nih.gov) - National Library of Medicine (www.medlineplus.gov) Read a library book about cancer 40 - Mayo Clinic (www.mayoclinic.org) Talk to someone about cancer 25

36 Negative Effects of How to Respond to Requests for Reassurance Frequent Treatment Seeking -Suggestions for Loved Ones (and Therapists)- . It sounds like you are looking for reassurance about that, but . Consulting with physicians may lead to increased remember we agreed that it is not helpful for me to answer anxiety (physicians may err on the side of caution those kinds of questions. and recommend unnecessary tests, or tests may . Remember that your urge to get reassurance will go down if yield false positives) you give it time. . Physicians may stop taking complaints seriously . Anxiety is temporary. It will go down in time. and miss important signs of real illness. . I know it’s hard to resist seeking reassurance. What can I do to help you get through this rough time? . Treatments for misdiagnosed illnesses may create . I’ve tried to do the right thing, but to avoid an argument, I’ll tell additional symptoms (e.g., side effects from you what you want to hear. I don’t think we’re doing the right medications) and exacerbate the problem. thing here, but I know this is hard for you. There will be other . Nocebo effect (exaggerated side effects from chances to resist seeking reassurance. medications, related to anxiety) Adapted from Abramowitz & Braddock (2008)

Fluoxetine vs. Placebo for Hypochondriasis CBT vs. Medication for Hypochondriasis Greeven et al., 2007 70

50 . 16 weeks of treatment with CBT, 40 paroxetine, or placebo Week 8 30 Week 12 . CBT = challenging hypochondriacal 20

Percent Responders thoughts, behavioral experiments, 10 exposure and response prevention, 0 Fluoxetine Placebo homework, relapse prevention Fallon et al. (2008). A double-masked, placebo-controlled study of fluoxetine for hypochondriasis. Journal of Clinical Psychopharmacology, 28, 638-645.

CBT vs. Paroxetine for Hypochondriasis Health Anxiety

60 . Abramowitz, J.S., & Braddock, A.E. (2008).

50 Psychological treatment of health anxiety and hypochondriasis: A biopsychosocial approach. 40 Cambridge, MA: Hogrefe.

rs (week 16) 30 . Furer, P., Walker, J.R., & Stein, M.B. (2007). 20 Treating health anxiety and fear of death: A 10 practitioner’s guide. New York, NY: Springer. 0 . Taylor, S., & Asmundson, G.J.G. (2004). Treating

Percent Responde CBT Paroxetine Placebo health anxiety: A cognitive-behavioral approach. Responder = having shifted from a dysfunctional range to a functional range New York, NY: Guilford Press. Overall, CBT = paroxetine, and both are better than placebo. On some analyses, CBT superior to paroxetine Greeven et al. (2007). Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: A randomized controlled trial. American Journal of Psychiatry, 164, 91-99.

37 Health Anxiety

. Asmundson, G.J.G., & Taylor, S.. (2005). It’s not all in your head: How worrying could be making you sick – and what to do about it. New York, NY: Guilford Press. TREATING . Owens, K.M.B., & Antony, M.M.(2011). Overcoming health anxiety. Oakland, CA: New HOARDING Harbinger Publications. DISORDER

Difficulty Discarding Compulsive Acquiring . Possessions may be viewed as having . Acquiring free things (e.g., extra sentimental (emotional), instrumental newspapers, magazines, coupons, (useful), or intrinsic (aesthetic) value. discarded garbage) . Clients may be able to discard some . Compulsive shopping items, but the process is difficult, and . Compulsive stealing items are often acquired faster than . Positive feelings or euphoria may be they are discarded. associated with acquiring.

Other Features of Hoarding Hoarding Disorder . Severity appears to increase with age. . Has been added in DSM-5 . Mean age for seeking treatment is 50. . Difficulty discarding or parting with personal possessions due to strong urges to save items, . Course is often chronic. distress, or indecision associated with . Appears to run in families. discarding . Often associated with a low rate of . Accumulation of clutter in living spaces marrying. . Significant distress or impairment . Not due to a general medical condition . May pose a public health risk (e.g., . Not restricted to the symptoms of another animal hoarding). disorder (e.g., due to obsessions in OCD, lack of motivation in depression, etc.).

38 Hoarding Disorder Assessment of Hoarding

. Specify if: . Home visit (with photos) . With Excessive Acquisition: If symptoms are accompanied by excessive collecting or buying or . Hoarding Interview (Steketee & Frost, 2007) stealing of items that are not needed or for which there . Saving Inventory-Revised (Frost et al., 2003) is no available space. . Children’s Saving Inventory (Storch et al., . Specify if: 2011) . Good or fair insight . Saving Cognitions Inventory (Steketee et al., . Poor insight 2003) . Absent insight . Clutter Image Rating Scale (Frost et al., 2008)

All scales are reproduced in Steketee & Frost (2007)

CBT Model of Hoarding Vulnerabilities

1. Personal and family vulnerabilities . Family history of hoarding (e.g., past experiences, parental values, . Comorbidity negative mood, information processing . Parental values toward acquiring, deficits) discarding, clutter, waste, etc. 2. Cognitive appraisals (e.g., about . Physical constraints (health, time, space) possessions, vulnerabilities, etc.) . Traumatic events (e.g., loss of parent, 3. Positive and negative emotional assault, moving, deprivation) responses 4. Hoarding behaviors (clutter, acquiring, difficulty discarding) Steketee & Frost (2007) Steketee & Frost (2007)

Information Processing Problems Cognitive Appraisals

. Difficulty maintaining attention . Finding beauty in unusual objects . Problems with organizing objects . Fear that memories will be lost if objects . Poor memory, need to rely on visual cues are discarded. . Failure to notice clutter . Seeing the usefulness of virtually anything . Tendency to generate many ideas about how . Attaching emotional significance to objects objects might be used. . Seeing objects or activities (e.g., . Focus on nonessential details shopping) as emotionally comforting . Decision-making problems (ambivalence, . Viewing objects as a source of safety fear of making mistakes, etc.)

Steketee & Frost (2007) Steketee & Frost (2007)

39 Cognitive Appraisals Treating Hoarding

. Concern about others controlling one’s . Presence of hoarding may decrease the possessions effectiveness of standard OCD treatment. . Strong beliefs about wasting possessions, . Hoarding-specific CBT is promising, based using possessions responsibly, protecting the on preliminary studies (Tolin et al., 2007; environment Steketee et al., 2010). . Concern about making mistakes . Preliminary findings for hoarding-specific . Need for completeness or feeling “just right” CBT in older adults who hoard are less . Belief that objects validate self-worth promising (Ayers et al., 2011) . Buying or collecting as a source of social . Some research supporting SSRIs as well. contact Steketee & Frost (2007)

Self-Help and Hoarding Tolin et al. (2007) study

. Bibliotherapy alone does not appear to be . Tolin et al. (2007) published an open trial of a effective for reducing hoarding (Muroff et 26-session treatment for hoarding, occurring al., 2012). over 7-12 months, with frequent home visits. . Recent study supports brief facilitated 10 out of 14 participants completed treatment. Medications were excluded. support group accompanied by the the self help book, “Buried in Treasures,” compared . Treatment targeted motivation, organization, to wait list control condition (Frost et al., acquiring, removing clutter. 2012). . 50% of completers were much improved or very much improved at posttreatment. . Compliance with homework was significantly related to outcome.

Steketee et al. (2010) study Treating Hoarding

. 26-session treatment for hoarding vs. waitlist . Steketee, G., & Frost, R.O. (2007). Compulsive hoarding and acquiring (therapist guide). New . 36 out of 46 participants completed treatment. Medications were excluded. York: Oxford. . Treatment targeted motivation, organization, . Steketee, G., & Frost, R.O. (2007). Compulsive acquiring, removing clutter. hoarding and acquiring (workbook). New York: Oxford. . 71% (based on therapist ratings) and 81% (based on client ratings) of completers were much improved or very much improved at posttreatment. . 41% of completers achieved clinically significant improvement.

40 CBT for Hoarding CBT Hoarding Treatment Goals

. Assessment (2 – 3 sessions) . Increasing understanding of compulsive . Case formulation – deriving a model (2 hoarding sessions) . Creating living space (e.g., clearing the . Skills training - organization, problem solving table) (2 sessions) . Increasing appropriate use of space (e.g., . Exposure and cognitive therapy (15 – 20 eating at the table) sessions) . Organizing possessions to make them . Motivational interviewing (to address more accessible ambivalence). Integrated into early sessions. . Relapse prevention (last 2 sessions)

CBT Hoarding Treatment Goals CBT Hoarding Treatment Rules

. Reducing compulsive acquiring (and . Therapist may not touch or remove any replacing it with other pleasurable activities) items without permission . Evaluating and changing beliefs about . Clients make all decisions about clutter possessions . Reducing clutter . Treatment proceeds systematically . Learning problem solving skills . Establish an organizing plan before sorting . Preventing future hoarding possessions.

Clutter Visualization Exercises Other Visualization Exercises

. Imagine room with all of its current clutter, . Acquiring visualization exercise and evaluate discomfort, feelings, thoughts . Ideal home visualization exercise . Visualize room with all the clutter gone . Reviewing photos of home (without thinking about where the clutter has gone). Again, evaluate level of discomfort, emotional responses, and thoughts. Also, imagine what could be done in the room now that it is not cluttered.

41 Problem Solving Steps Organizational Skills Training

1. Define problem and contributing factors . Categorizing items 2. Brainstorm solutions . Selecting locations for categorized items 3. Evaluate solutions and select one or two . Developing a plan for sorting and moving 4. Break solutions into manageable steps saved items 5. Implement the steps . Developing a plan for organizing, 6. Evaluate the outcome categorizing, and filing paper 7. Repeat the process until a good solution is . Implementing organizing plans found . Maintaining plans over time

Categorizing Unwanted Items How Long to Save Paper

. Trash . Keep for 1month (e.g., sales receipts for . Recycle minor purchases) . Donate . Keep for 1year (e.g., monthly credit card . Sell statements) . Undecided . Keep for 6 years (e.g., supporting documentation for tax returns) . Keep indefinitely (e.g., wills and trusts) . Keep in a safety deposit box (e.g., birth and death certificates)

Exposure Targets for Cognitive Strategies

. Feared tasks (e.g., sorting, discarding) . Value of objects can be treated as exposure practices, . Objects representing personal identity beginning in areas and with objects that . Objects representing safety are less frightening, and gradually moving to areas that are more frightening. . Need for objects . Eliminate rituals (e.g., checking, . Ability to tolerate discomfort reassurance seeking) . Perfectionism . Consider imaginal exposure (e.g., . Responsibility for objects imagined loss of possessions, loss of . Usefulness, avoiding waste information) . Confidence in memory . Need for control over objects

42 Reducing Acquiring Relapse Prevention

. Avoiding triggers for acquiring, at least in . Review of treatment strategies the short term (e.g., to avoid yard sales, . Strategies for dealing with setbacks don’t go out on Saturday morning) . Booster sessions as needed . Enhance motivation to reduce acquiring . Consider advantages and disadvantages . Establish rules for acquiring . Exposure to cues, without acquiring (e.g., go to mall and not buy anything) . Introduce alternative sources of enjoyment . Cognitive strategies

Accommodation and Hoarding Accommodation and Hoarding

Motivations for Accommodation Family accommodation was positively . Make the hoarder’s life easier correlated with…. . Reduce hoarder’s distress . Increased severity of hoarding . Make my life easier . Increased relationship conflict . Avoid arguments . Rejecting attitudes toward the hoarder . Reduce my own personal distress Accommodation mediated the relationship between hoarding severity and relationship problems.

Vorstenbosch, Antony, Monson, & Rowa, 2013 Vorstenbosch, Antony, Monson, & Rowa, 2013

Hoarding Self-Help Readings Hoarding DVD

. Frost, R.O., & Steketee, G. (2010). Stuff: . Antony, M.M. (2009). Behavioral therapy over Compulsive hoarding and the meaning of things. time (DVD on compulsive hoarding). New York, NY: Houghton Mifflin. Washington, DC: American Psychological . Tolin, D., & Frost, R.O., Steketee, G. (2007). Association. Buried in treasures: Help for compulsive acquiring, saving, and hoarding. New York: Oxford. . Tompkins, M.A., & Hartl, T.L. (2009). Digging out: Helping your loved one manage clutter, hoarding, and compulsive acquiring. Oakland, CA: New Harbinger.

43 after Anxiety (0–100) conclusions Evidence and realistic realistic and Evidence predictions Alternative thoughts and Alternative before Anxiety (0–100) Anxiety Workbook by Martin M. Antony and Peter Norton. J. Copyright 2009 by The Guilford Press. Anxiety Thought Record Thought Anxiety

44 Recent Books by the Presenter

1. Antony, M.M., & Roemer, L. (2011). Behavior therapy. Washington, DC: American Psychological Association. ISBN: 978-1-43380-984-2. 2. Owens, K.M.B., & Antony, M.M. (2011). Overcoming health anxiety: Letting go of your fear of illness. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-838-0. 3. Antony, M.M., & Barlow, D.H. (Eds.) (2010). Handbook of assessment and treatment planning for psychological disorders, 2nd ed. New York, NY: Guilford Press. ISBN: 978-1-60623-868-4. 4. Antony, M.M., & Norton, P.J. (2009). The anti-anxiety workbook: Proven strategies to overcome worry, phobias, panic, and obsessions. New York, NY: Guilford Press. ISBN: 978-1-59385-993-0. 5. Antony, M.M., & Stein, M.B. (2009). Oxford handbook of anxiety and related disorders. New York, NY: Oxford University Press. ISBN: 978-0-19530-703-0. 6. Antony, M.M., & Swinson, R.P. (2009). When perfect isn’t good enough: Strategies for coping with perfectionism, 2nd edition. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-559-4. 7. Antony, M.M., & Rowa, K. (2008). Social anxiety disorder: Psychological approaches to assessment and treatment. Cambridge, MA: Hogrefe. ISBN: 978-0-88937-311-2. Available as eBook only (http://www.newharbinger.com/bookstore/productdetails.cfm?PC=1693) 8. Antony, M.M., & Swinson, R.P. (2008). Shyness and social anxiety workbook: Proven, step-by-step techniques for overcoming your fear, 2nd edition. Oakland, CA: New Harbinger Publications. ISBN: 978-1- 57224-553-2. 9. Antony, M.M., Purdon, C., & Summerfeldt, L.J. (2007). Psychological treatment of OCD: Fundamentals and beyond. Washington, DC: American Psychological Association. ISBN: 978-1-59147-484-5. 10. Antony, M.M., & Rowa, K. (2007). Overcoming fear of heights: How to conquer acrophobia and live a life without limits. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-456-6. 11. Antony, M.M., Craske, M.G., & Barlow, D.H. (2006). Mastering your Fears and Phobias (client workbook), second edition. New York, NY: Oxford University Press. ISBN: 978-0-19518-918-6. 12. Antony, M.M., & Watling, M. (2006). Overcoming medical phobias: How to conquer fear of blood, needles, doctors, and dentists. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-387-3. Available for free download at http://www.martinantony.com/downloads. 13. Bieling, P.J., McCabe, R.E., & Antony, M.M. (2006). Cognitive behavioral therapy in groups. New York, NY: Guilford Press. ISBN: 978-1-60623-404-4. 14. Craske, M.G., Antony, M.M., & Barlow, D.H. (2006). Mastering your Fears and Phobias (therapist guide), second edition. New York, NY: Oxford University Press. ISBN: 978-0-19518-917-9. 15. Antony, M.M., Ledley, D.R., & Heimberg, R.G. (2005). Improving outcomes and preventing relapse in cognitive behavioral therapy. New York, NY: Guilford Press. ISBN: 978-1-59385-197-2. 16. Antony, M.M., & McCabe, R.E. (2005). Overcoming animal & insect phobias: How to conquer fear of dogs, snakes, rodents, bees, spiders & more. Oakland, CA: New Harbinger Publications. ISBN: 978-1- 57224-388-0. Available for free download at http://www.martinantony.com/downloads. 17. Antony, M.M., & McCabe, R.E. (2004). 10 simple solutions to panic: How to overcome panic attacks, calm physical symptoms, and reclaim your life. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224- 325-5. 18. Antony, M.M. (2004). 10 simple solutions to shyness: How to overcome shyness, social anxiety, and fear of public speaking. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-348-4. 19. Bieling, P.J., & Antony, M.M. (2003). Ending the depression cycle: A step-by-step guide for preventing relapse. Oakland, CA: New Harbinger Publications. ISBN: 978-1-57224-333-0. 20. Antony, M.M., Orsillo, S.M., & Roemer, L. (Eds.) (2001). Practitioner’s guide to empirically-based measures of anxiety. New York, NY: Springer. ISBN: 978-0-30646-582-6. 21. Antony, M.M., & Swinson, R.P. (2000). Phobic disorders and panic in adults: A guide to assessment and treatment. Washington, DC: American Psychological Association. ISBN: 978-1-55798-696-2.

45 Video Resources

Panic Disorder With and Without Agoraphobia AnxietyBC (2010). Effectively managing panic disorder (DVD). Vancouver, BC: Author. May be ordered from anxietybc.com. Clark, D.M. (1998). Cognitive therapy for panic disorder (DVD). Washington, DC: American Psychological Association. Dobson, K.S. (2010). Cognitive therapy over time (DVD). Washington, DC: American Psychological Association. Jongsma, A.E., & Bruce, T.J. (2010). Evidence-based treatment planning for panic disorder (DVD). Hoboken, NJ: John Wiley and Sons. Olatunji, B.O. (2011). Cognitive-behavioral therapy for clients with anxiety and panic (DVD). Washington, DC: American Psychological Association. Rapee, R.M. (1999). Fight or flight? Overcoming panic and agoraphobia (DVD). New York, NY: Guilford Press.

Social Phobia Albano, A.M. (2006). Shyness and social phobia (DVD). Washington, DC: American Psychological Association. Jongsma, A.E., & Bruce, T.J. (2010). Evidence-based treatment planning for social anxiety disorder (DVD). Hoboken, NJ: John Wiley and Sons. Rapee, R.M. (1999). I think they think…Overcoming social phobia (DVD). New York, NY: Guilford Press.

Obsessive-Compulsive Disorder and Related Problems Antony, M.M. (2009). Behavioral therapy over time (DVD on Compulsive Hoarding). Washington, DC: American Psychological Association. Jongsma, A.E., & Bruce, T.J. (2010). Evidence-based treatment planning for obsessive-compulsive disorder (DVD). Hoboken, NJ: John Wiley and Sons. Turner, S.M. (1998). Behavior therapy for OCD (DVD). Washington, DC: American Psychological Association. Wilson, R. (2012). Cognitive therapy for obsessions. (DVD). Mill Valley, CA: Psychotherapy.net. Wilson, R.R. (2005). Obsessive-compulsive disorder (DVD). Washington, DC: American Psychological Association.

Perfectionism Antony, M.M. (2008). Cognitive behavioral therapy for perfectionism over time (DVD). Washington, DC: American Psychological Association.

Anxiety Disorders and Cognitive Behavior Therapy (Miscellaneous) Dobson, K.S. (2011). Cognitive-behavioral therapy strategies (DVD). Washington, DC: American Psychological Association. Padesky, C. Guided discovery using Socratic dialog (DVD). May be ordered from www.padesky.com. Padesky, C. Testing automatic thoughts with thought records (DVD). May be ordered from www.padesky.com. Wilson, R. (2012). Exposure therapy for phobias. (DVD). Mill Valley, CA: Psychotherapy.net (exposure therapy for a client with claustrophobia).

Anxiety Disorders in Children AnxietyBC (2009). Separation anxiety: A parent’s guide to helping your child (DVD). Vancouver, BC: Author. May be ordered from anxietybc.com. AnxietyBC (2011). Obsessive compulsive disorder: A parent’s guide to helping your child (DVD). Vancouver, BC: Author. May be ordered from anxietybc.com.

46 Relevant Associations

Anxiety Disorders Association of America (ADAA) 8730 Georgia Avenue, Suite 600, Silver Spring, MD 20910, USA Tel: 240-485-1001; Fax: 240-487-1020; Web Page: www.adaa.org

Association for Behavioral and Cognitive Therapies (ABCT) 305 Seventh Avenue, 16th Floor, New York, NY 10001-6008, USA Tel: 212-647-1890 or 800-685-2228; Fax: 212-647-1865; Web Page: www.abct.org

International Obsessive-Compulsive Disorder Foundation 112 Water Street, Suite 501, Boston, MA 02119 USA Tel: 617-973-5801; Fax: 617-973-5803; Web Page: www.ocfoundation.org

Anxiety Disorders Association of Canada (ADAC) P.O. Box 117, Station Cote St. Luc, Montreal, QC H4V 2Y3 Tel: 514-484-0504 or 888-223-2252; Fax: 514-484-7892; Web Page: www.anxietycanada.ca

Canadian Association of Cognitive and Behavioural Therapies (CACBT) Department of Psychology, University of Calgary, 2500 University Drive NW, Calgary, AB, T2N 1N4 Web Page: www.cacbt.ca