214 Chapter 6 NEUROBIOLOGICAL DIFFERENCES BETWEEN ANXIETY AND PANIC As we noted at the beginning of this chapter, contemporary theorists are drawing several fundamental distinctions between fear, panic, and anxiety, including their neurobiological bases. Fear and panic involve activation of the fight-or-flight response, and the brain areas and neurotransmitters that seem most strongly implicated in these emotional responses are the amygdala (and locus coeruleus) and the neurotransmitters norepinephrine and serotonin. Generalized anxiety (or anxious apprehension) is a more diffuse emotional state than acute fear or phobia that involves arousal and a preparation for possible impending threat; and the brain area, neurotransmitters, and hormones that seem most strongly implicated are the limbic system (especially the bed nucleus of the stria terminalis, an extension of the amygdala), GABA, and CRH (Davis, 2006; Lang et al., 2000). Although serotonin may play a role in both anxiety and panic, it probably does so in somewhat different ways. Recently, people with GAD have been found to have a smaller left hippocampal region similar to what is seen with major depression (Hettema et al., 2012); this may represent a common risk factor for the two disorders. Treatments As noted earlier, most treatment for GAD involves cognitive-behavioral or medicinal approaches. COGNITIVE-BEHAVIORAL TREATMENT CBT for gener- alized anxiety disorder has become increasingly effective as clinical researchers have refined the techniques used. It usually involves a combination of behavioral techniques, such as training in applied muscle relaxation, and cognitive restructuring techniques aimed at reducing distorted cognitions and information-processing biases associated with GAD as well as reducing catastrophizing about minor events (Barlow et al., 2007; Borkovec, 2006). GAD initially appeared to be among the most difficult of the anxiety disorders to treat, and to some extent this is still true. However, advances have been made, and a quantitative review of many controlled studies showed that CBT approaches resulted in large changes on most symptoms measured (Mitte, 2005). The magnitude of the changes seen with cognitive-behavioral treatment was at least as large as those seen with benzodiazepines, and it led to fewer dropouts (i.e., it was better tolerated). Finally, CBT has also been found to be useful in helping people who have used benzodiazepines for over a year to successfully taper their medications (Gosselin et al., 2006). CBT for Rodney’s GAD The case of Rodney, the graduate student with GAD discussed earlier, serves as an example of the success of cognitive-behavioral therapy with this condition. Before receiving CBT, Rodney had seen someone at a student counseling center for several months, but he hadn’t found the “talk therapy” very useful. He had heard that CBT might be useful and had sought such treatment. He was in treatment for about 6 months, during which time he found training in deep muscle relaxation helpful in reducing his overall level of tension. Cognitive restructuring helped reduce his worry levels about all spheres of his life. He still had problems with procrastinating when he had deadlines, but this too was improving. He also began socializing more frequently and had tentatively begun dating when treatment ended for financial reasons. He could now see that if a woman didn’t want to go out with him again, this did not mean that he was boring but simply that they might not be a good match. MEDICATIONS Many clients with generalized anxiety disorder consult family physicians, seeking relief from their “nerves” or anxieties or their various functional (psychogenic) physical problems. Most often in such cases, medications from the benzodiazepine (anxiolytic) category such as Xanax or Klonopin are used—and misused—for tension relief, reduction of other somatic symptoms, and relaxation. Their effects on worry and other psychological symptoms are not as great. Moreover, they can create physiological and psychological dependence and withdrawal and are therefore difficult to taper. A newer medication called buspirone (from a different medication category) is also effective, and it is neither sedating nor does it lead to physiological dependence. It also has greater effects on psychic anxiety than do the benzodiazepines. However, it may take 2 to 4 weeks to show results (Roy-Byrne & Cowley, 2002, 2007). Several categories of antidepressant medications like those used in the treatment of panic disorder are also useful in the treatment of GAD, and they also seem to have a greater effect on the psychological symptoms of GAD than do the benzodiazepines (Goodman, 2004; Roy-Byrne & Cowley, 2002, 2007). However, they take several weeks before their effects are apparent. Obsessive-Compulsive and Related Disorders 6.7 Describe the clinical features of obsessivecompulsive disorder and how it is treated. Obsessive-compulsive and related disorders used to be classified in the DSM as anxiety disorders; however, as of DSM-5 they have been classified separately as their own type of disorder (see the Thinking Critically about DSM-5 box). This new category includes not only OCD but also body dysmorphic disorder, hoarding disorder, excoriation (skin-picking) disorder, and trichotillomania (compulsive hair pulling). Obsessive-Compulsive Disorder Obsessive-compulsive disorder is defined by the occurrence of both obsessive thoughts and compulsive behaviors performed in an attempt to neutralize such thoughts (see the DSM-5 box for diagnostic criteria). Panic, Anxiety, Obsessions, and Their Disorders DSM-5 215 Thinking Critically about DSM-5 Why Is OCD No Longer Considered to Be an Anxiety Disorder? In DSM-5, obsessive-compulsive disorder was removed from the Yet another reason is that the neurobiological underpinnings anxiety disorders category and placed into a new category called of OCD appear to be rather different from those of other anxiety “obsessive-compulsive and related disorders.” (As you already disorders, focusing on frontal-striatal neural circuitry including the know from Chapter 5, PTSD was also removed and put into a orbitofrontal cortex, anterior cingulate cortex, and striatum (espe- new category called “trauma and stressor-related disorders.”) cially the caudate nucleus). Studies examining the “OCD-related One reason for moving OCD into the new category was that disorders” such as body dysmorphic disorder (obsessing about anxiety is not generally used as an indicator of OCD severity. perceived or imagined flaws in physical appearance) and trichotil- Indeed, for people with certain forms of OCD such as symmetry- lomania (chronic hair pulling) also suggest shared involvement of related obsessions and compulsions, anxiety is not even a prom- frontal-striatal neural circuitry. Finally, other anxiety disorders inent symptom. It was also noted that anxiety occurs in a wide respond to a wider range of medication treatments than does range of disorders, so the presence of some anxiety is not a valid OCD, which seems to respond selectively to SSRIs. reason to regard OCD as an anxiety disorder. Indeed D. J. Stein How compelling do these reasons sound to you? What kinds et al. (2010) wrote that “the highly stereotyped, driven, repetitive, of research findings might further support the grouping of OCD and nonfunctional quality of compulsive behaviors differentiate with related disorders such as hoarding or trichotillomania? On the OCD from normal acts and from the types of avoidance that contrary, what research findings might incline you to think that it occur in other anxiety disorders” (p. 497). was wrong to remove OCD from the anxiety disorders category? Obsessions are persistent and recurrent intrusive thoughts, images, or impulses that are experienced as disturbing, inappropriate, and uncontrollable. People who DSM-5 have such obsessions actively try to resist or suppress them or to neutralize them with some other thought or action. Compulsions involve overt repetitive behaviors Criteria for. . . Obsessive-Compulsive Disorder A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by (1) and (2): 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts. B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder). Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. 216 Chapter 6 Werner Muenzker/Shutterstock that are performed as lengthy rituals (such as hand washing, checking, putting things in order over and over again). Compulsions may also involve more covert mental rituals (such as counting, praying, or saying certain words silently over and over again). A person with OCD usually feels driven to perform this compulsive, ritualistic behavior in response to an obsession, and there are often very rigid rules regarding exactly how the compulsive behavior should be performed. The compulsive behaviors are performed with the goal of preventing or reducing distress or preventing some dreaded event or situation. OCD is often one of the most disabling mental disorders in that it leads to a lower quality of life and a great deal of functional impairment (Stein et al., 2009). In addition, the person must recognize that the obsession is the product of his or her own mind rather than being imposed from without (as might occur in schizophrenia). However, there is a continuum of “insight” among persons with OCD about exactly how senseless and excessive their obsessions and compulsions are (Ruscio et al., 2010). In a minority of cases, this insight is absent most of the time. Most of us have experienced minor obsessive thoughts, such as whether we remembered to lock the door or turn the stove off. In addition, most of us occasionally engage in repetitive or stereotyped behavior, such as checking the stove or the lock on the door or stepping over cracks on a sidewalk. One recent study found that more than 25 percent of people in the United States report experiencing obsessions or compulsions at some time in their lives (Ruscio et al., 2010). With OCD, however, the thoughts are excessive and much more persistent and distressing, and the associated compulsive acts interfere with everyday activities. Diagnosis requires that obsessions and compulsions take at least 1 hour per day, and in severe cases they may take most of the person’s waking hours. It is important to note that normal and abnormal obsessions and compulsive behaviors exist on a continuum, differing in the frequency and intensity of the obsessions and in the degrees to which the obsessions and compulsions are resisted and are troubling (Steketee & Barlow, 2002). The common themes of OCD typically involve cleaning, symmetry, taboo thoughts, and harm. Many obsessive thoughts involve contamination fears, fears of harming oneself or others, and pathological doubt. Other fairly common themes are concerns about or need for symmetry (e.g., having magazines on a table arranged in a way that is “exactly right”), sexual obsessions, and obsessions concerning religion or aggression. These themes are quite consistent cross-culturally and across the life span (Steketee & Barlow, 2002). Obsessive thoughts involving themes of violence or aggression might include a wife being obsessed with the idea that she might poison her husband or child, or a daughter constantly imagining pushing her mother down a flight of stairs. Even though such obsessive thoughts are very rarely acted on, they remain a source of often excruciating torment to a person plagued with them. The following case of Mark is fairly typical of severe OCD. Obsessions about Confessing and Compulsive Checking Mark was a 28-year-old single male who, at the time he entered treatment, suffered from severe obsessive thoughts and images about causing harm to others such as running over pedestrians while he was driving. He also had severe obsessions that he would commit a crime such as robbing a store of a large amount of money or poisoning family members or friends. These obsessions were accompanied by lengthy and excessive checking rituals. For example, one day when he drove, he began obsessing that he had caused an accident and hit a pedestrian at an intersection, and he felt compelled to spend several hours driving and walking around all parts of that intersection to find evidence of the accident. At the time Mark went to an anxiety disorder clinic, he was no longer able to live by himself after having lived alone for several years since college. He was a very bright young man with considerable artistic talent. He had finished college at a prestigious school for the arts and had launched a successful career as a young artist when the obsessions began in his early 20s. At first, they were focused on the possibility that he would be implicated in some crime that he had not committed; later, they evolved to the point where he was afraid that he might actually commit a crime and confess to it. The checking rituals and avoidance of all places where such confessions might occur eventually led to his having to give up his career and his own apartment and move back in with his family. At the time he presented for treatment, Mark’s obsessions about harming others and confessing to crimes (whether or not he had committed them) were so severe that he had virtually confined himself to his room at his parents’ house. Indeed, he could leave his room only if he had a tape recorder with him so that he would have a record of any crimes he confessed to out loud because he did not trust his own memory. The clinic was several hours’ drive from his home; his mother usually had to drive because of his obsessions about causing accidents with pedestrians or moving vehicles and because the associated checking rituals could punctuate any trip with several very long stops. He also could not speak at all on the phone for fear of confessing some crime that he had (or had not) Panic, Anxiety, Obsessions, and Their Disorders committed, and he could not mail a letter for the same reason. He also could not go into a store alone or into public bathrooms, where he feared he might write a confession on the wall and be caught and punished. performance of the compulsive act or the ritualized series of acts usually brings a feeling of reduced tension and satisfaction, as well as a sense of control, although this anxiety relief is typically fleeting. This is why the same rituals need to be repeated over and over (Purdon, 2009; Steketee & Barlow, 2002). As we have noted, people with OCD feel compelled to perform acts repeatedly that often seem pointless and absurd even to them and that they in some sense do not want to perform. There are five primary types of compulsive rituals: cleaning (hand washing and showering), checking, repeating, ordering or arranging, and counting (Antony et al., 1998; Mathews, 2009), and many people exhibit multiple kinds of rituals. For a smaller number of people, the compulsions are to perform various everyday acts (such as eating or dressing) extremely slowly (primary obsessional slowness), and for others the compulsions are to have things exactly symmetrical or “evened up” (Mathews, 2009; Steketee & Barlow, 2002). Prevalence, Age of Onset, and Gender Differences Washing or cleaning rituals vary from relatively mild ritual-like behavior such as spending 15 to 20 minutes washing one’s hands after going to the bathroom, to more extreme behavior such as washing one’s hands with disinfectants for hours every day to the point where the hands bleed. Checking rituals also vary in severity from relatively mild (such as checking all the lights, appliances, and locks two or three times before leaving the house) to very extreme (such as going back to an intersection where one thinks one may have run over a pedestrian and spending hours checking for any sign of the imagined accident, much as Mark does in the case study). Both cleaning and checking rituals are often performed a specific number of times and thus also involve repetitive counting. The Desiree Navarro/Everett Collection/Alamy Approximately 2 to 3 percent of people meet criteria for OCD at some point in their lifetime, and approximately 1 percent meet criteria in a given year (Ruscio et al., 2010). Over 90 percent of treatment-seeking people with OCD experience both obsessions and compulsions (Foa & Kozak, 1995; Franklin & Foa, 2007). When mental rituals and compulsions such as counting are included as compulsive behaviors, this figure jumps to 98 percent. Voronin76/Shutterstock Many of us show some compulsive behavior, but people with OCD feel compelled to perform repeatedly some action in response to an obsession, in order to reduce the anxiety or discomfort created by the obsession. Although the person may realize that the behavior is excessive or unreasonable, he or she does not feel able to control the urge. Obsessive-compulsive hand washers may spend hours a day washing and may even use abrasive cleansers to the point that their hands bleed. 217 Howard Stern, a famous radio personality and author, as with other people who have suffered from OCD, found relief in a compulsive act or ritualized series of acts to bring about a feeling of reduced tension and a sense of control. In his book Miss America, Stern describes behaviors such as turning pages in magazines only with his pinky finger, walking through doors with the right side of his body leading, and flipping through television stations in a particular order before turning the set off. Divorced (or separated) and unemployed people are somewhat overrepresented among people with OCD (Torres et al., 2006), which is not surprising given the great difficulties this disorder creates for interpersonal and occupational functioning. Some studies showed little or no gender difference in adults, which would make OCD quite different from most of the rest of the anxiety disorders. However, one British epidemiological study found a gender ratio of 1.4 to 1 (women to men; Torres et al., 2006). OCD typically begins in late adolescence or early 218 Chapter 6 adulthood, but also can occur in children, where its symptoms are strikingly similar to those of adults (Poulton et al., 2009; Torres et al., 2006). Childhood or early adolescent onset is more common in boys than in girls and is often associated with greater severity (Lomax et al., 2009) and greater heritability (Grisham et al., 2008). In most cases the disorder has a gradual onset, and once it becomes a serious condition, it tends to be chronic, although the severity of symptoms sometimes waxes and wanes over time (Mataix-Cols et al., 2002). Comorbidity with Other Disorders OCD frequently co-occurs with other anxiety disorders, most commonly social anxiety, panic disorder, GAD, and PTSD (Kessler, Chiu, Demler, et al., 2005; Mathews, 2009). Moreover, approximately 25 to 50 percent of people with OCD experience major depression at some time in their lives and as many as 80 percent experience significant depressive symptoms (Steketee & Barlow, 2002; Torres et al., 2006), often at least partly in response to having OCD. Psychological Causal Factors The following psychological factors may cause obsessivecompulsive disorder. The dominant behavioral or learning view of obsessive-compulsive disorder is derived from Mowrer’s two-process theory of avoidance learning (1947). According to this theory, neutral stimuli become associated with frightening thoughts or experiences through classical conditioning and come to elicit anxiety. For example, touching a doorknob or shaking hands might become associated with the “scary” idea of contamination. Once having made this association, the person may discover that the anxiety produced by shaking hands or touching a doorknob can be reduced by hand washing. Washing his or her hands extensively reduces the anxiety, and so the washing response is reinforced, which makes it more likely to occur again in the future when other situations evoke anxiety about contamination (Rachman & Shafran, 1998). Once learned, such avoidance responses are extremely resistant to extinction (Mineka & Zinbarg, 2006). Moreover, any stressors that raise anxiety levels can lead to a heightened frequency of avoidance responses in animals or compulsive rituals in humans (Cromer et al., 2007). Several classic experiments conducted by Rachman and Hodgson (1980) supported this theory. They found that for most people with OCD, exposure to a situation that provoked their obsession (e.g., a doorknob or toilet seat for someone with obsessions about contamination) did indeed produce distress, which would continue for a moderate amount of time and then gradually dissipate. If the person OCD AS LEARNED BEHAVIOR was allowed to engage in the compulsive ritual immediately after the provocation, however, her or his anxiety would generally decrease rapidly (although only temporarily) and therefore reinforce the compulsive ritual. This model predicts, then, that exposure to feared objects or situations should be useful in treating OCD if the exposure is followed by prevention of the ritual, enabling the person to see that the anxiety will subside naturally in time without the ritual (see also Rachman & Shafran, 1998). This is indeed the core of the most effective form of behavior therapy for OCD, as discussed later. Thus, the early behavioral model has been very useful in helping us understand what factors maintain obsessive-compulsive behavior, and it has also generated an effective form of treatment. However, it has not been so helpful in explaining why people with OCD develop obsessions in the first place and why some people never develop compulsive behaviors. OCD AND PREPAREDNESS The preparedness concept described earlier that considers the evolutionarily adaptive nature of fear and anxiety for our early ancestors also can help us to understand the occurrence and persistence of OCD (De Silva, Rachman, & Seligman, 1977; Rapoport, 1989). The fact that many people with OCD have obsessions and compulsions focused on dirt, contamination, and other potentially dangerous situations has led many researchers to conclude that these features of the disorder likely have deep evolutionary roots (Mineka & Zinbarg, 1996, 2006). In addition, some theorists have argued that the displacement activities that many species of animals engage in under situations of conflict or high arousal resemble the compulsive rituals seen in obsessivecompulsive disorder (Craske, 1999; Mineka & Zinbarg, 1996; Rapoport, 1989; Winslow & Insel, 1991). Displacement activities often involve grooming (such as a bird preening its feathers) or nesting under conditions of high conflict or frustration. They may therefore be related to the distress-induced grooming (such as washing) or tidying rituals seen in people with OCD, which are often provoked by obsessive thoughts that elicit anxiety. THE EFFECTS OF ATTEMPTING TO SUPPRESS OBSESSIVE THOUGHTS Quick, don’t think about a white bear! Gotcha. When most people attempt to suppress unwanted thoughts they sometimes experience a paradoxical increase in those thoughts later (Wegner, 1994). As already noted, people with normal and abnormal obsessions differ primarily in the degree to which they resist their own thoughts and find them unacceptable. Thus, one factor contributing to the frequency of obsessive thoughts, and the negative moods with which they are often associated, may be these attempts to suppress them (similar to what was discussed earlier about the effects of attempts to control worry in people with GAD). For Panic, Anxiety, Obsessions, and Their Disorders example, when people with OCD are asked to record intrusive thoughts in a diary, both on days when they were told to try to suppress those thoughts and on days without instructions to suppress, they reported approximately twice as many intrusive thoughts on the days when they were attempting to suppress them (Salkovskis & Kirk, 1997). In addition, thought suppression leads to a more general increase in obsessive-compulsive symptoms beyond just the frequency of obsessions (Purdon, 2004). Finally, naturalistic diary studies of people with OCD reveal that they engage in frequent, strenuous, and timeconsuming attempts to control the intrusive thoughts, although they are generally not effective in doing so (Purdon et al., 2007). 219 normal people who have obsessions and can ordinarily dismiss them from people with OCD is this sense of responsibility that makes the thought so concerning to them. Cognitive factors have also been implicated in OCD. More specifically, people with OCD have an attentional bias toward disturbing material relevant to their obsessive concerns, much as occurs in the other anxiety disorders (McNally, 2000; Mineka et al., 2003). They also have difficulty blocking out negative, irrelevant input or distracting information, so they may attempt to suppress negative thoughts stimulated by this information (McNally, 2000). As we have noted, trying to suppress negative thoughts may paradoxically increase their frequency. Moreover, those with OCD have low confidence in their memory ability (especially for situations they feel responsible for), which may contribute to their repeating their ritualistic behaviors over and over again (Cougle et al., 2007; Dar et al., 2000). An additional factor contributing to their repetitive behavior is that people with OCD have deficits in their ability to inhibit both motor responses (Morein-Zamir et al., 2010) and irrelevant information (Bannon et al., 2008). COGNITIVE BIASES AND DISTORTIONS Iakov Filimonov/Shutterstok Biological Causal Factors Quick, don’t think about a white bear! In recent years there has been an increase in research on the possible biological basis for OCD, ranging from studies about its genetic basis to studies of abnormalities in brain function and neurotransmitter abnormalities. The evidence accumulating from all three kinds of studies suggests that biological causal factors may play a stronger causal role for OCD relative to the other disorders discussed in this chapter. GENETIC FACTORS Evidence from twin studies reveals a APPRAISALS OF RESPONSIBILITY FOR INTRUSIVE THOUGHTS Salkovskis (e.g., 1989), Rachman (1997), and other cognitive theorists have distinguished between obsessive or intrusive thoughts per se and the negative automatic thoughts and catastrophic appraisals that people have about experiencing such thoughts. For example, people with OCD often seem to have an inflated sense of responsibility. In turn, in some vulnerable people, this inflated sense of responsibility can be associated with beliefs that simply having a thought about doing something (e.g., a mother’s thought about harming her infant) is morally equivalent to actually having done it, or that thinking about the behavior increases the chances of actually doing so. This is known as thought–action fusion (Berle & Starcevic, 2005; Rachman et al., 2006). This inflated sense of responsibility for the harm they may cause can motivate compulsive behaviors to try to reduce the likelihood of anything harmful happening (Rachman et al., 2006). Thus, part of what differentiates moderately high concordance rate for OCD for monozygotic twins and a lower rate for dizygotic twins. One review of 14 published studies included 80 monozygotic pairs of twins, of whom 54 were concordant for the diagnosis of OCD, and 29 pairs of dizygotic twins, of whom 9 were concordant. This is consistent with a moderate genetic heritability, although it may be at least partially a nonspecific “neurotic” predisposition (Hanna, 2000; van Grootheest et al., 2007). Consistent with twin studies, most family studies have found 3 to 12 times higher rates of OCD in first-degree relatives of OCD clients than would be expected from current estimates of the prevalence of OCD (Grabe et al., 2006; Hettema, Prescott, & Kendler, 2001). Finally, evidence also shows that early-onset OCD has a higher genetic loading than later-onset OCD (Grisham et al., 2008; Mundo et al., 2006). Further compelling evidence of a genetic contribution to some forms of OCD concerns a type of OCD that often starts in childhood and is characterized by chronic motor tics (Lochner & Stein, 2003). This form of tic-related OCD is 220 Chapter 6 linked to Tourette’s syndrome, a disorder characterized by severe chronic motor and vocal tics that is known to have a substantial genetic basis (see Chapter 15). For example, one study found that 23 percent of first-degree relatives of people with Tourette’s syndrome had diagnosable OCD even though Tourette’s syndrome itself is very rare (Pauls et al., 1986, 1991, 1995). Finally, in recent years a number of molecular genetic studies have begun to examine the association of OCD with specific genetic polymorphisms (naturally occurring variations of genes; Grisham et al., 2008; Mundo et al., 2006; Stewart et al., 2007). Preliminary findings indicate that different genetic polymorphisms are implicated in OCD with Tourette’s syndrome and in OCD without Tourette’s syndrome, suggesting that these two forms of OCD are at least partially distinguishable at a genetic level (Stewart et al., 2007). OCD AND THE BRAIN The search for brain abnormalities in OCD has been intense in the past 30 years as advances have been made in brain-imaging techniques. This research has revealed that abnormalities occur primarily in certain cortical and subcortical structures such as the basal ganglia. The basal ganglia are in turn linked at the amygdala to the limbic system, which controls emotional behaviors. Findings from a good number of studies using PET scans have shown that people with OCD have abnormally high levels of activity in two parts of the frontal cortex (the orbital frontal cortex and the cingulate cortex/gyrus), which are also linked to the limbic area. People with OCD also have abnormally high levels of activity in the subcortical caudate nucleus, which is part of the basal ganglia (see the depiction of the relevant brain parts in Figure 6.3). The orbital frontal cortex seems to be where primitive urges regarding sex, aggression, hygiene, and danger come from (the “stuff of obsessions”; Baxter et al., 1991, p. 116). These urges are ordinarily filtered by the caudate nucleus as they travel through the cortico–basal–ganglionic–thalamic circuit, allowing only the strongest to pass on to the thalamus. The caudate nucleus or corpus striatum (part of the set of structures called the basal ganglia, which are involved in the execution of voluntary, goal-directed movements) is part of an important neural circuit linking the orbital frontal cortex to the thalamus. The basal ganglia also include two other structures—the globus pallidus and the substantia nigra—that are involved in this cortico–basal–ganglionic– thalamic circuit as well. The thalamus is an important relay station that receives nearly all sensory input and passes it back to the cerebral cortex. This cortico–basal–ganglionic–thalamic circuit is normally involved in the preparation of complex sets of Figure 6.3 Neurophysiological Mechanisms for Obsessive-Compulsive Disorder This view illustrates parts of the brain implicated in OCD. The overlying cerebral cortex has been made transparent so that the underlying areas can be seen. The orbital frontal cortex, cingulate gyrus/cortex, and basal ganglia (especially the caudate nucleus) are the brain structures most often implicated in OCD. Increased metabolic activity has been found in each of these three areas in people with OCD. Basal ganglia Putamen and Globus pallidus Cerebellum Thalamus Caudate nucleus Cerebral cortex Orbital frontal cortex Cingulate gyrus/cortex Corpus callosum Frontal cortex Panic, Anxiety, Obsessions, and Their Disorders interrelated behavioral responses used in specific situations such as those involved in territorial or social concerns. Several theories have been proposed regarding what the sources of dysfunction in this circuit are. For example, Baxter and colleagues (1991, 2000) cited evidence that when this circuit is not functioning properly, inappropriate behavioral responses may occur, including repeated sets of behaviors stemming from territorial and social concerns (e.g., checking and aggressive behavior) and from hygiene concerns (e.g., cleaning). Thus, the overactivation of the orbital frontal cortex, which stimulates the “stuff of obsessions,” combined with a dysfunctional interaction among the orbital frontal cortex, the corpus striatum or caudate nucleus, and the thalamus (which is downstream from the corpus striatum) may be the central component of the brain dysfunction in OCD. According to Baxter’s theory, the dysfunctions in this circuit in turn prevent people with OCD from showing the normal inhibition of sensations, thoughts, and behaviors that would occur if the circuit were functioning properly. In this case, impulses toward aggression, sex, hygiene, and danger that most people keep under control with relative ease “leak through” as obsessions and distract people with OCD from ordinary goal-directed behavior. Evidence suggests that at least part of the reason that this circuit does not function properly may be due to abnormalities in white matter in some of these brain areas; white matter is involved in connectivity among various brain structures (Szeszko et al., 2004; Yoo et al., 2007). Considering these problems, Baxter and colleagues proposed that we can begin to understand how the prolonged and repeated bouts of obsessive-compulsive behavior in people with OCD may occur (Baxter et al., 1991, 1992, 2000). Several other slightly different theories have also been proposed as to the exact nature or source of the dysfunctions, but there seems to be general agreement about most of the brain areas involved (Friedlander & Desrocher, 2006; Harrison et al., 2009; Saxena & Rauch, 2000). NEUROTRANSMITTER ABNORMALITIES Pharmacological studies of causal factors in OCD intensified with the discovery in the 1970s that a tricyclic drug called clomipramine (Anafranil) is often effective in the treatment of OCD even though other tricyclic antidepressants are generally not very effective (Dougherty et al., 2007). Research shows that this is because clomipramine has greater effects on the neurotransmitter serotonin, which is now strongly implicated in OCD (Pogarell et al., 2003; Stewart et al., 2009). Moreover, several other antidepressant drugs from the SSRI category that also have relatively selective effects on serotonin, such as fluoxetine (Prozac), have also been shown to be about equally effective in the treatment of OCD (Dougherty, Rauch, et al., 2002, 2007). 221 The exact nature of the dysfunction in serotonergic systems in OCD is unclear. Current evidence suggests that increased serotonin activity and increased sensitivity of some brain structures to serotonin are involved in OCD symptoms. Indeed, drugs that stimulate serotonergic systems lead to a worsening of symptoms. In this view, longterm administration of clomipramine (or fluoxetine) causes a downregulation of certain serotonin receptors, further causing a functional decrease in the availability of serotonin (Dolberg, Iancu, et al., 1996; Dolberg, Sasson, et al., 1996). That is, although the immediate short-term effects of clomipramine or fluoxetine may be to increase serotonin levels (and exacerbate OCD symptoms too), the long-term effects are quite different. This is consistent with the finding that these drugs must be taken for at least 6 to 12 weeks before significant improvement in OCD symptoms occurs (Baxter et al., 2000; Dougherty, Rauch, et al., 2002, 2007). However, it is also becoming clear that dysfunction in serotonergic systems cannot by itself fully explain this complex disorder. Other neurotransmitter systems (such as the dopaminergic, GABA, and glutamate systems) also seem to be involved, although their role is not yet well understood (Dougherty et al., 2007; Stewart et al., 2009). In summary, a substantial body of evidence now implicates biological causal factors in OCD. This evidence comes from genetic studies, from studies of abnormalities in brain function, and from studies of neurotransmitter abnormalities. Although the exact nature of these factors and how they are interrelated is not yet fully understood, major research efforts that are currently under way are sure to enhance our understanding of this disorder, which is often very serious and disabling. Treatments Treatment for OCD includes behavioral and cognitivebehavioral approaches as well as medication. BEHAVIORAL AND COGNITIVE-BEHAVIORAL TREATMENTS The most effective treatment for OCD is a behav- ioral treatment called exposure and response prevention (Franklin & Foa, 2007; Stein et al., 2009). The exposure component involves having individuals with OCD repeatedly expose themselves (either in guided fantasy or directly) to stimuli that provoke their obsessions (e.g., for someone with contamination fears this may involve touching a toilet seat in a public bathroom). The response prevention component requires that they then refrain from engaging in the rituals that they ordinarily would perform to reduce their anxiety or distress. Preventing the rituals is essential so that they can see that if they allow enough time to pass, the anxiety created by the obsession will dissipate naturally down to at least 40 to 50 on a 100-point scale, even if this takes several hours. This 222 Chapter 6 Patrikslezak/Fotolia is often as distressing as it sounds, and so the treatment typically starts out with manageable first steps in the person’s fear hierarchy (e.g., touching the bottom of their shoe) and only over time, gradually works up to more intense exposures (e.g., sitting on the floor of a dirty public restroom). Exposure and response prevention treatment for OCD involves having the patient encounter the source of their obsessions, such as the germs imagined to lurk in a dirty bathroom, and preventing them from engaging in compulsive behaviors, such as repetitive cleaning. The treatment is often not fun for the patient, but can be very effective in decreasing OCD symptoms. In intensive versions of this treatment, clients who, for example, are used to spending 2 to 3 hours a day showering and hand washing may be asked to not shower at all for 3 days at a time (and when they finally do, to spend no more than 10 minutes in the shower). Later in treatment they are encouraged to shower for only 10 minutes a day, with no more than five 30-second hand washings at mealtimes, after bathroom use, and after touching clearly soiled objects. In addition to the exposures conducted during therapy sessions, “homework” is liberally assigned. For example, on one occasion well into treatment, a therapist drove a patient who was terrified of being contaminated by “dog dirt,” bathroom germs, garbage, and dead animals in the road to a place where she had observed a dead cat on the roadside. The therapist insisted that the patient approach the “smelly” corpse, touch it with the sole of her shoe, and then touch her shoe. A pebble lying close by and a stick with which she had touched the cat were presented to the patient with the instruction that she keep them in her pocket and touch them frequently throughout the day (Franklin & Foa, 2008, pp. 192–205). Although some people refuse such treatment or drop out early, most who stick with it show a 50 to 70 percent reduction in symptoms (Abramowitz et al., 2009; Steketee, 1993), as well as improvement in quality of life (Diefenbach et al., 2007). Approximately 50 percent are much improved or very much improved, and another 25 percent are moderately improved; about 76 percent maintain their gains at several-year follow-ups. These results are superior to those obtained with medication (Abramowitz et al., 2009; Franklin & Foa, 2008). There is also evidence that D-cycloserine (the drug known to facilitate extinction of fear) enhances the effectiveness of behavioral treatments like this one; however, this enhancement is blocked if the person is taking an antidepressant as well (Andersson et al., 2015). Finally, during the past 20 years a form of cognitive-behavioral therapy has also been developed by Salkovskis and colleagues (Salkovskis & Wahl, 2003). Some of the goals were to determine whether adding a cognitive component to therapy might help a higher percentage of people with OCD, or help increase the degree of symptom improvement, or decrease dropout rates. Current evidence suggests that this form of treatment can be quite effective, but unfortunately it has not been shown to be superior to more behavioral approaches like exposure and response prevention therapy in any of the predicted ways (Abramowitz et al., 2009; D. A. Clark, 2005). Moreover, some researchers have concluded that exposure and response prevention treatment might be enhanced by the addition of cognitive therapy (Abramowitz et al., 2009). Given that OCD rarely remits completely, leaving the client with some residual obsessional problems or rituals (Abramowitz et al., 2009; Franklin & Foa, 2007), there is clearly a need to improve further the efficacy of these treatments. The successful use of this exposure and response prevention treatment in the case of Mark, the young artist with severe OCD, is described here briefly. Mark’s Treatment Mark was initially treated with medication and with exposure and response prevention. He found the side effects of the medication (clomipramine) intolerable and gave it up within a few weeks. For the behavioral treatment, he was directed to get rid of the tape recorder and was given a series of exercises in which he exposed himself to feared situations where he might confess to a crime or cause harm to others, including making phone calls, mailing letters, and entering stores and public bathrooms (all things he had been unable to do). Checking rituals (including the tape recorder) were prevented. Although the initial round of treatment was not especially helpful, in part because of difficulty in getting to treatment, he did eventually make a commitment to more intensive treatment by moving to a small apartment closer to the clinic. Thereafter, he did quite well. Panic, Anxiety, Obsessions, and Their Disorders Whereas the other anxiety disorders respond to a range of drugs, OCD seems to respond best to medications that affect the serotonin system. These medications, such as clomipramine (Anafranil) and fluoxetine (Prozac) reduce the intensity of OCD symptoms, with approximately 40 to 60 percent of people showing at least a 25 to 35 percent reduction in symptoms (relative to 4 to 5 percent on placebo; Dougherty et al., 2007; Iancu et al., 2000). Some clients show greater improvement than this, but about 30 to 50 percent do not show any clinically significant improvement (Mancebo et al., 2006). In approximately one-third of people who fail to respond to these serotonergic medications, small doses of certain antipsychotic medications may produce significantly greater improvement (Bloch et al., 2006). A major disadvantage of medication treatment for OCD, as for other anxiety disorders, is that when the medication is discontinued relapse rates are generally very high (as high as 50 to 90 percent; Dougherty et al., 2007; Simpson & Liebowitz, 2006). Thus, many people who do not seek alternative forms of behavior therapy that have more long-lasting benefits may have to stay on these medications indefinitely. Studies in adults have generally not found that combining medication with exposure and response prevention is much more effective than behavior therapy alone (Foa et al., 2005; Franklin & Foa, 2002, 2007), although one large study showed that a combination treatment was superior in the treatment of children and adolescents with OCD (March & Franklin, 2006; Pediatric OCD Treatment Study, 2004). Finally, because OCD in its most severe form is such a crippling and disabling disorder, psychiatrists have begun to examine the usefulness of certain neurosurgical techniques for the treatment of severe, intractable OCD (which may afflict as many as 10 percent of people diagnosed with OCD; Mindus et al., 1994). Given the invasiveness of this intervention, before such surgery is even contemplated, the person must have had severe OCD for at least 5 years and must not have responded to any of the known treatments discussed so far (medication or behavior therapy). Several studies have shown that approximately 35 to 45 percent of these intractable cases respond quite well (at least a one-third reduction in symptoms) to neurosurgery designed to destroy brain tissue in one of the areas implicated in this condition (Dougherty, Baer, et al., 2002; Jenike, 2000; Rück et al., 2008). However, a significant number of these have adverse side effects. The results of these techniques are discussed in greater detail in Chapter 16. MEDICATIONS Body Dysmorphic Disorder Body dysmorphic disorder (BDD) was classified as a somatoform disorder in DSM-IV-TR because it involves preoccupation with certain aspects of the body. However, 223 because of its very strong similarities with OCD, it was moved out of the somatoform category and into the OCD and related disorders category in DSM-5. People with BDD are obsessed with some perceived or imagined flaw or flaws in their appearance to the point they firmly believe they are disfigured or ugly (see the DSM-5 criteria). This preoccupation is so intense that it causes clinically significant distress and impairment in social or occupational functioning. Although it is not considered necessary for the diagnosis, most people with BDD have compulsive checking behaviors (such as checking their appearance in the mirror excessively or hiding or repairing a perceived flaw). Another very common symptom is avoidance of usual activities because of fear that other people will see the imaginary defect and be repulsed. In severe cases, they may become so isolated that they lock themselves up in their houses and never go out, even to work, with the average employment rate estimated at only about 50 percent (Neziroglu et al., 2004). Not surprisingly, their average quality of life is quite poor (IsHak et al., 2012). Table 6.4 illustrates the range of activities with which BDD interferes. People with BDD may focus on almost any body part: Their skin has blemishes, their breasts are too small, their face is too thin (or too fat) or disfigured by visible blood vessels that others find repulsive, and so on. Some of the more common locations for perceived defects include skin (73 percent), hair (56 percent), nose (37 percent), eyes (20 percent), breasts/chest/nipples (21 percent), stomach (22 percent), and face size/shape (12 percent) DSM-5 Criteria for. . . Body Dysmorphic Disorder A. Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. B. At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking, reassurance seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns. C. The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The appearance preoccupation is not better explained by concerns with body fat or weight in an individual whose symptoms meet diagnostic criteria for an eating disorder. Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. 224 Chapter 6 Table 6.4 BDD Interference in Functioning Percentage of People with BDD Who Experienced the Problem Interference with social functioning (e.g., with friends, family, or intimate relationships) due to BDD 99 Periods of avoidance of nearly all social interactions because of BDD 95 Ever felt depressed because of BDD 94 Interference with work or academic functioning because of BDD 90 Ever thought about suicide because of BDD* 63 Completely housebound for at least 1 week because of BDD 29 Psychiatrically hospitalized at least once because of BDD 26 Ever attempted suicide 25 Ever attempted suicide because of BDD 14 Average Number of Days Missed Days of work missed because of BDD* 52 days Days of school missed because of BDD* 49 days Diana Eller/123RF Problem People with body dysmorphic disorder are preoccupied with perceived defects in certain aspects of their body and frequently spend an inordinate amount of time obsessively checking their appearance in the mirror. The following case illustrates the primary features of this disorder. *Since BDD began. SOURCE: Based on Katherine A. Phillips (2005). The Broken Mirror: Understanding and Treating Dysmorphic Disorder. Oxford University Press. (Phillips, 2005). Many sufferers have perceived defects in more than one body part. It is very important to remember that these are not the ordinary concerns that most of us have about our appearance; they are far more extreme, leading in many cases to complete preoccupation and significant emotional pain. Some researchers estimate that about half the people with BDD have concerns about their appearance that are of delusional intensity (Allen & Hollander, 2004). Keep in mind that others do not even see the defects that the person with BDD believes she or he has, or if they do, they see only a very minor defect within the normal range. Another common feature of BDD is that people with this condition frequently seek reassurance from friends and family about their defects, but the reassurances almost never provide more than very temporary relief. They also frequently seek reassurance for themselves by checking their appearance in the mirror countless times in a day (although some avoid mirrors completely). They are usually driven by the hope that they will look different, and sometimes they may think their perceived defect does not look as bad as it has at other times. However, much more commonly they feel worse after mirror gazing (Veale & Riley, 2001). They frequently engage in excessive grooming behavior, often trying to camouflage their perceived defect through their hairstyle, clothing, or makeup (Sarwer et al., 2004). Seeing Spots Steve is a 24-year-old engineer who presented for treatment at the request of his wife. He was recently fired from his job after refusing to go into work for a 2-week period because of his extreme concerns about his appearance. He explains that he could no longer tolerate the enormous birth marks that cover his face, and so he has begun trying to pluck them off his face with nail clippers. This led to noticeable cuts and scabs on his face, which embarrassed him further and prevented him from going to work. Steve’s wife reports that although he does have a few very small and hardly noticeable freckles on his face, Steve has never had any significant birth marks or detectable skin discoloration. Steve explained that ever since he can remember he has “not been thrilled” with the beauty marks on his face, but in the past year they have really bothered him to the point of thinking about them constantly and wishing they were gone. His wife said that Steve spends at least an hour in the mirror each morning and evening looking at the marks, asking her if she really loves him despite their presence, and researching ways to eliminate them via facial plastic surgery, bleaching, or some other cosmetic procedure. His job loss and facial lacerations were enough to push Steve’s wife to insist that he see a psychologist for treatment, and Steve has agreed to do so. PREVALENCE, AGE OF ONSET, AND GENDER DIFFERENCES Approximately 2 percent of people in the com- munity meet diagnostic criteria for BDD, as do approximately 20 percent of people seeking rhinoplasty (i.e., a “nose job”; Veale et al., 2016). The prevalence seems to be approximately equal in men and women, although the primary body parts that are focused on tend to differ in Panic, Anxiety, Obsessions, and Their Disorders men and women (Phillips, 2005; Phillips & Diaz, 1997). Men are more likely to obsess about their genitals, body build, and balding, whereas women tend to obsess more about their skin, stomach, breasts, buttocks, hips, and legs (Phillips, Menard, & Fay, 2006). The age of onset is usually in adolescence, when many people start to become preoccupied with their appearance. People with BDD very commonly also have a depressive diagnosis (with most estimates being over 50 percent; Allen & Hollander, 2004), and it can even lead to suicide attempts or death (Neziroglu et al., 2004; Phillips & Menard, 2006). Indeed, of nearly 200 patients with BDD, Phillips and Menard (2006) found that 80 percent reported a history of suicidal ideation, and 28 percent had a history of a suicide attempt. Rates of comorbid social anxiety and obsessive-compulsive disorder are also quite substantial, although not as high as for depression (Allen & Hollander, 2004; Coles et al., 2006). Not surprisingly, BDD, like OCD, is often associated with a poor quality of life (IsHak et al., 2012). Sufferers of BDD commonly make their way into the office of a dermatologist or plastic surgeon, with one estimate being that over 75 percent seek nonpsychiatric treatment (Phillips et al., 2001). An astute doctor will not do the requested procedures and may instead make a referral to a psychologist or psychiatrist. All too often, though, the patient does get what he or she requests—and unfortunately is almost never satisfied with the outcome. Even if they are satisfied with the outcome, such patients still tend to retain their diagnosis of BDD (Tignol et al., 2007). 225 anorexia are emaciated and generally satisfied with this aspect of their appearance (Phillips, 2005). BDD has existed for centuries and seems to be a universal disorder, occurring in all European countries, the Middle East, China, Japan, and Africa (Phillips, 2005). Why, then, did its examination in the literature begin only recently? One possible reason is that its prevalence may actually have increased in recent years as contemporary Western culture has become increasingly focused on “looks as everything,” with billions of dollars spent each year on enhancing appearance through makeup, clothes, plastic surgery, and other means (Fawcett, 2004). A second reason BDD has been understudied is that most people with this condition never seek psychological or psychiatric treatment. Rather, they suffer silently or go to dermatologists or plastic surgeons (Crerand et al., 2004; Phillips, 2001; Tignol et al., 2007). Factors for this secrecy and shame include worries that others will think they are superficial, silly, or vain and that if they mention their perceived defect, others will notice it and focus more on it. Part of the reason why more people are now seeking treatment is that starting in the past 15 years the disorder has received a good deal of media attention. It has even been discussed on some daily talk shows, where it is sometimes called “imaginary defect disorder.” As increasing attention is focused on this disorder, the secrecy and shame often surrounding it should decrease, and more people will seek treatment. WHY NOW? RELATIONSHIP TO OCD AND EATING DISORDERS CAUSAL FACTORS: A BIOPSYCHOSOCIAL APPROACH TO BDD Our understanding of what causes BDD is still People with BDD, like those with OCD, have prominent obsessions, and they engage in a variety of ritualistic behaviors such as reassurance seeking, mirror checking, comparing themselves to others, and camouflage. Moreover, they are even more convinced that their obsessive beliefs are accurate than are people with OCD (Eisen et al., 2003). In addition to these similarities in symptoms, there is overlap in the potential causes. For example, the same neurotransmitter (serotonin) and the same sets of brain structures are implicated in the two disorders (Rauch et al., 2003; Saxena & Feusner, 2006), and the same kinds of treatments that work for OCD are also the treatments of choice for BDD (Phillips, 2005). Some researchers have noted similarities between BDD and eating disorders, especially anorexia nervosa. Perhaps the most striking similarities between these disorders are the excessive concern and preoccupation about physical appearance, dissatisfaction with one’s body, and a distorted image of certain features of one’s body (Allen & Hollander, 2004; Cororve & Gleaves, 2001). It is important to remember, however, that people with BDD look normal and yet are terribly obsessed and distressed about some aspect of their appearance. By contrast, people with at a preliminary stage, but recent research seems to suggest that a biopsychosocial approach offers some reasonable hypotheses. First, one recent twin study found that overconcern with a perceived or slight defect in physical appearance is a moderately heritable trait (Monzani et al., 2012). Second, BDD seems to be occurring, at least today, in a sociocultural context that places great value on attractiveness and beauty, and people who develop BDD often hold attractiveness as their primary value. This means that their self-schemas are heavily focused around such ideas as “If my appearance is defective, then I am worthless” (endorsed by 60 percent in one study) (Buhlmann & Wilhelm, 2004, p. 924). One possibility why this occurs is that, in many cases, people with BDD were reinforced as children for their overall appearance more than for their behavior (Neziroglu et al., 2004). Another possibility is that they were teased or criticized for their appearance, which caused conditioning of disgust, shame, or anxiety to their own image of some part of their body. For example, one study of individuals with BDD found that 56 to 68 percent reported a history of emotional neglect or emotional abuse, and approximately 30 percent reported a history of physical or sexual abuse or physical neglect (Didie et al., 2006). 226 Chapter 6 In addition, substantial empirical evidence now demonstrates that people with BDD show biased attention and interpretation of information relating to attractiveness (Buhlmann & Wilhelm, 2004). They selectively attend to positive or negative words such as ugly or beautiful more than to other emotional words not related to appearance, and they tend to interpret ambiguous facial expressions as contemptuous or angry more than do controls. When they are shown pictures of their own face that have been manipulated to be more or less symmetrical than in reality, they show a greater discrepancy than controls between judgments of their “actual” face and their “ideal” face. Asked to choose the pictures that best matched their faces, controls’ choices were more symmetrical than their real faces, while patients with BDD lacked this bias (Lambrou et al., 2011). Moreover, several fMRI studies have found that patients with BDD showed fundamental differences in visually processing other people’s faces relative to controls. Specifically, they showed a bias for extracting local, detailed features rather than the more global or holistic processing of faces seen in controls (Feusner et al., 2007). A second study showed that when patients with BDD are shown a picture of their own face, they demonstrate greater activation than do healthy controls in brain regions associated with inhibitory processes and the rigidity of behavior and thinking (the orbitofrontal cortex and the caudate) (Feusner et al., 2010). Similarly, compared to controls, patients with BDD demonstrate performance deficits on tasks that measure executive functioning (e.g., manipulating information, planning, and organization), which is thought to be guided by prefrontal brain regions (Dunai et al., 2010). Whether or not these factors play a causal role is not yet known, but certainly having such biases and deficits in processing information would, at a minimum, serve to perpetuate the disorder once it has developed. The treatments that are effective for BDD are closely related to those used in the effective treatment of OCD. Some evidence indicates that antidepressant medications from the SSRI category often produce moderate improvement in patients with BDD, but many are not helped or show only a modest improvement (Phillips, 2004, 2005; Phillips, Pagano, & Menard, 2006). However, in some cases showing only limited improvement, it is possible that inadequate doses of the medication were used, thus leading to an underestimation of their true potential effects. In general, it seems that higher doses of these medications are needed to effectively treat BDD relative to OCD (Hadley et al., 2006). In addition, a form of cognitive-behavioral treatment emphasizing exposure and response prevention has been shown to produce marked improvement in 50 to 80 percent of treated patients (Sarwer et al., 2004; Simon, 2002). These treatment approaches focus on getting the patient to identify and change distorted perceptions of his or her body during exposure to anxiety-provoking situations (e.g., when wearing something that highlights rather than disguises the “defect”) and on prevention of checking responses (e.g., mirror checking, reassurance seeking, and repeated examination of the imaginary defect). The treatment gains are generally well maintained at follow-up (Looper & Kirmayer, 2002; Sarwer et al., 2004). Hoarding Disorder Hoarding is a condition that had received very little research attention until the past 15 to 20 years. It has been brought into public awareness recently through several TV series such as A&E’s Hoarders or TLC’s Hoarding: Buried Alive. Traditionally, hoarding was thought of as one particular symptom of OCD, but this categorization was increasingly questioned (Mataix-Cols et al., 2010) and hoarding disorder was added as a new disorder in DSM-5. Compulsive hoarding (as a symptom) occurs in approximately 3 to 5 percent of the adult population, and in 10 to 40 percent of Matthew Nock TREATMENT OF BODY DYSMORPHIC DISORDER Most people are able to maintain a balance of possessions, keeping things they perceive to be of value and discarding those that they do not. People with hoarding disorder have an extremely difficult time parting with possessions that most people would not perceive to be of value, such as clothing, empty bags or boxes, food containers, and so on. This condition often leads to enormous amounts of clutter to the point where all or parts of the person’s home become unusable.