Heather Melena, MSN, APRN, PMHNP-BC

 

PANS stands for Pediatric Acute-onset Neuropsychiatric Syndrome and encompasses cases of strep induced neuropsychiatric presentations (PANDAS), as well as presentations brought on by other infections, toxins, or stress. To understand the mechanism in which this autoimmune response is triggered, we must understand how and what our immune system does. Our immune system (innate and adaptive) is responsible for several important roles in our bodies.  When our immune system wrongly identifies our own cells, which can resemble a pathogen’s cell, it attacks our own tissue and causes damage- otherwise known as molecular mimicry (Antoine, 2024). This is, very simply put, what evidence has shown to happen in autoimmunity. Autoimmune or autoinflammatory disease /illness (in PANS/PANDAS) is believed to be activated by exposure to several infectious pathogens that overthrow the immune system and/or generate abnormal reactions which then attacks neuronal cells, leading to inflammation and resulting symptoms (Pandas Physicians Network [PPN], 2024).

What are the hallmark signs and symptoms of PANS and PANDAS? Firstly, we see a very abrupt and severe onset of obsessive-compulsive disorder and/or severe restriction of food intake. With this initial onset, we usually see a rapid (which is unusual in most psychiatric conditions) onset of the following symptoms (PPN, 2024):

  • Severe separation and/or social anxiety (that is atypical for the person affected)
  • Severe mood lability
  • Irritability, aggression, or oppositional behaviors (that previously were not present)
  • Developmental regression
  • Significant and stark decline in school performance
  • Sensory integration dysfunction (to sounds, light, textures, smells
  • Tics or abnormal movements
  • Hypotonia, clumsiness, changes to fine motor skills
  • Enuresis (nighttime bedwetting)
  • Sleep disturbances (insomnia, night terrors)

It is important for people to understand that this is a very significant and drastic change that happens rapidly, if your child/adolescent is functioning normally, and then suddenly is struggling with these symptoms in a very severe manner that is out of character for their typical baseline, that is usually a tell-tale sign. If they have a history of psychiatric illness that ranges from mild to severe, and gets worse with an infection, that does not necessarily indicate PANS or PANDAS, though every case is unique. Approximately 88% of cases have a sudden onset, usually within 3 days (Antoine, 2024). Historically it was believed to have an onset from ages 3-11, though more recent evidence suggests that onset following puberty or even early adulthood, has been captured.

To diagnose, a very detailed and precise clinical picture must be obtained. We take a thorough history including past medical, surgical, and psychiatric history as well as understanding family history with an emphasis on autoimmune disorders. We complete a comprehensive physical exam and finally complete diagnostic studies to rule in/out other possible reasons for sudden and abrupt onset of symptoms as PANS & PANDAS is a diagnosis of exclusion. Lab studies including a complete blood count, complete metabolic panel, inflammatory markers, infectious disease, immune function, hormones, immunoglobins, nutritional deficiencies and autoantibodies are performed but is specific to the patient and their presentation.

How are PANS and PANDAS treated? Treatment is dependent on the severity of the case and at times can include a comprehensive treatment team to deliver care across several specialties including neurology, allergy/immunology, psychiatry, and more. More mild cases usually require antibiotics, steroids, anti-inflammatories, cognitive-behavioral therapy and very low doses of psychotropic medications (Neuroimmune Foundation, 2025). With more severe cases treatment can include IVIG, Plasmapheresis, longer courses of steroids, and other immunologic agents (Neuroimmune Foundation, 2025). It is important to help identify allergens, toxins, and environmental factors which could also be playing a role in the dysregulation of the immune system and continued inflammation.

References

Antoine, S. & Antoine, E. (2024). The comprehensive physicians’ guide to the management of PANS and PANDAS: An evidence-based approach to diagnosis, testing, and effective treatment. Forefront books.

Neuroimmune Foundation. (2025). What are PANS/PANDAS? https://neuroimmune.org/patient-and-family-resources/what-are-pans-pandas/

Pandas Physicians Network [PPN]. (2024). What is PANS/PANDAS? https://www.pandasppn.org/what-are-pans-pandas/

 Stanford Medicine Children’s Health. (2025). Diagnosis and Treatment for PANS and PANDAS. https://www.stanfordchildrens.org/en/services/pans-pandas/diagnosis-and-treatment.html

By Angela Couch, RN, MSN, PMHNP-BC,
Psychiatric Nurse Practitioner, Lindner Center of Hope

The goal of treatment for OCD is not to get rid of the thoughts but to learn to tolerate uncertainty. For someone who struggles with OCD, the idea of this, of tolerating uncertainty, can create a lot of discomfort.  Medications will not get rid of the thoughts, unfortunately.  This is because we cannot “control” our thoughts or prevent them.  Thoughts come into our brains, often unbidden, and sometimes contain content we didn’t ask for or want, which may be scary or upsetting.  For someone who has OCD, this occurrence creates a more intense feeling of distress, which often leads to various compulsions, in an effort to relieve the distress and the uncertainty.

Medication is recommended for the treatment of OCD any time someone has a moderate to severe case of OCD. Appropriate psychotherapy is very important; generally, this is a sub-type of CBT (Cognitive Behavioral Therapy) called ERP (Exposure and Response Prevention), or sometimes ACT (Acceptance and Commitment Therapy). The combination of medication and psychotherapy is the most powerful between medication alone, psychotherapy alone or both together. Those who have completed appropriate psychotherapy also, have a lower risk of significant relapse if medication treatment is stopped.

Medication can help make the thoughts less “sticky” in the brain. It also can slow the thoughts down and somewhat reduce the level of distress caused by the thoughts. This can make it easier for someone to participate in the appropriate psychotherapy to manage the OCD.  Medication can help someone ride the waves of OCD/uncertainty more effectively. There are many treatment options, which should be individualized to the patient.

The frontline treatments for OCD are typically the SSRI (Selective Serotonin Reuptake Inhibitors) or the TCA (Tri-cyclic antidepressant) clomipramine, or sometimes an SNRI (Serotonin Norepinephrine Reuptake Inhibitors). These medications slowly build in the patient’s system after repeated administration to a steady state at which the medications begin to assert their effects. Dose increases are common because OCD typically requires higher dosing than when treating depression or anxiety disorders such as Generalized Anxiety Disorder, Panic Disorder, etc.
Sometimes, this may include “off-label” dosing (dosing higher than the FDA label for the drug). Typically, we don’t call a drug trial a true failure until the patient has taken the highest dose for up to twelve weeks because it often takes longer for the medications to impact OCD than the other disorders listed above.

Sometimes, an augmentation strategy is used in conjunction with the primary treatment. Augmentation strategies may more commonly include SDA’s (Serotonin Dopamine Antagonists, also called second-generation antipsychotics), or drugs that may impact the neurotransmitter glutamate such as NMDA receptor antagonists, certain mood stabilizers, or acetylcysteine. SDA’s or mood stabilizers are also commonly used when a patient has a concurrent bipolar spectrum illness, because treatment with an SSRI, SNRI, or TCA alone may cause mood switching.
Sometimes, when a patient has a diagnosis of OCD alone, they may very slowly taper off the medication after having a longer period of stability on the medication and psychotherapy. Sometimes this is successful for some period of time, but sometimes an individual’s brain simply needs the support to keep symptoms manageable, and that is okay, too. Patients who also have a mood or other type of disorder may need to take the medication longer term. These treatment decisions need to be tailored to the individual’s circumstances.

In conclusion, psychotherapy is a critical piece of the treatment plan, there are many medications that may provide benefit in the treatment of OCD, and treatment decisions should be individualized.

 

Common Assessment Tools for Identifying and Treating OCD

By Whitney Peters LPCC
OCD Specialist, Lindner Center of Hope 

Beginning a successful journey in obsessive compulsive disorder (OCD) treatment starts with the right diagnosis. OCD occurs in people from any gender, age, or ethnicity, and happens to approximately 1 in 100 adults and 1 in 200 kids and teens. Many people think of OCD as being a germaphobe or preferring things to be organized, but the reality of OCD is far from the stereotype we think of.

People with OCD spend hours a day preoccupied with upsetting concerns that cause them feelings of anxiety and disgust, and in order to alleviate themselves or prevent those uncomfortable feelings, they must perform physical or mental acts. People with OCD can develop obsessions about anything they find to be important or valuable. This may include developing obsessions about things like their family, careers, spiritual beliefs, or identity, among many others.

For example, someone with Harm OCD might be bothered by an obsession around the possibility of having hit someone with their car.  This obsession takes over their thoughts so that they spend a lot of time driving around looking for evidence, repeating memories of their drive to reassure themselves, and frequently checking their rear-view mirror. This is all to make sure they didn’t hit anyone. People with OCD realize what they are afraid of is unlikely, but the distress they face with these concerns make it difficult to resist checking, ruminating, or looking for reassurance that they are safe. OCD symptoms can become so intrusive that a person may have difficulty functioning in daily life or attending work or school. OCD is considered one of the top 10 most disabling conditions, and the symptoms of OCD can look very different depending on the person. It is critical that a clinician the individual is working with knows how to spot it. OCD assessment tools can help us more effectively identify symptoms, specific subtypes, and assess for severity.

OCD Assessment Tools

The Obsessive Compulsive Inventory (OCI)
The Obsessive Compulsive Inventory (OCI) is a 42-item measure and screening tool for some OCD symptoms that a patient can complete independently or during a structured interview. The OCI measures some OCD symptoms, including Checking, Doubting, Ordering, Hoarding, and Neutralizing. This assessment offers check box examples that a patient and provider can indicate the severity of each prompt on mild to severe ranges and scores are added to determine the occurrence and severity of one’s OCD. The measure can also be given periodically during treatment to measure progress made in each area and help providers target treatment.

(Obsessive-compulsive Inventory (OCI) – Reproduced & adapted by permission of the authors: Foa, E.B., Kozak, M.J., Salkovskis, P.M., Coles, M.E., & Amir, N.)

Yale Brown Obsessive Compulsive Scale (Y-BOCS)
and Child Yale Brown Obsessive Compulsive Scale (CY-BOCS)
One of the most widely used assessments is the Yale Brown Obsessive Compulsive Scale (YBOCS) or the Child Yale Brown Obsessive Compulsive Scale (C-YBOCS) and is considered the Gold Standard of OCD assessments. These assessments identify the presence of obsessions and compulsions by offering examples that a patient can check independently or during a structured interview with a provider. The Y-BOCS helps providers and patients identify current and past obsessions and compulsions, and can provide structure in treatment.

(Adapted from Goodman, W.K., Price, L.H., Rasmussen, S.A. et al.: “The Yale-Brown Obsessive Compulsive Scale.” Arch Gen Psychiatry 46:1006-1011,1989; Scahill, L., Riddle, M.A., McSwiggin-Hardin, M., Ort, S.I., King, R.A., Goodman, W.K., Cicchetti, D. & Leckman, J.F. (1997). Children’s Yale-Brown Obsessive Compulsive Scale: reliability and validity. J Am Acad Child Adolesc Psychiatry, 36(6):844-852.)

Dimensional OCD Scale (DOCS)

The Dimensional OCD Scale is an assessment that breaks down OCD into four main categories, although there are some obsessions that may not fit neatly into these categories of Contamination and Sickness, Responsibility for Harm or Mistakes, Unacceptable or Taboo thoughts, and Incompleteness/Asymmetry. This assessment can be self-reported by the patient or given as an interview by the provider. The patient or provider will scale their symptoms in 5 domains, including estimated hours per day experiencing symptoms, degree of intensity of anxious distress, degree of avoidance behaviors, degree of impact on day-to-day functioning, and degree of difficulty in disregarding their compulsions. This assessment can be given at periodic intervals during treatment to measure improvements by comparing scores.

(Abramowitz, J. S.; Deacon, B.; Olatunji, B.; Wheaton, M. G.; Berman, N.; Losardo, D.; Timpano, K.; McGrath, P.; Riemann, B.; Adams, T.; Bjorgvinsson, T.; Storch, E. A.; Hale, L. (2010). “Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the Dimensional Obsessive-Compulsive Scale”. Psychological Assessment. 22 (1): 180–198. doi:10.1037/a0018260. PMID 20230164. S2CID 7206349.)

Family Accommodation Scale
With patients who are children or live with a family, we may often use the Family Accommodation Scale, which can identify potential accommodations performed by family members that can harm progress in treatment. A family member, spouse, or guardian may complete a Family Accommodation Scale alone or assisted by a provider. The prompts ask how many days a week a person may be performing common accommodations to help identify accommodations and to measure improvement in reduced accommodations over time. They can also help a family identify which accommodations to begin eliminating and help provide structure to treatment.

(The Family Accommodation Scale for Obsessive Compulsive Disorder – Self-Rated Version (FAS-SR) Copyright © 2012 by Anthony Pinto, Ph.D., Barbara Van Noppen, Ph.D., & Lisa Calvocoressi, Ph.D. The Family Accommodation Scale for Obsessive Compulsive Disorder – Self-Rated Version (FAS-SR) includes a modified version of the Yale Brown Obsessive Compulsive Scale (YBOCS) Checklist, copyright © 1986, 1989, with permission.)

Assessments help both professionals, patients, and their families understand the specific symptoms present in a disorder and can be used to identify areas of progress in treatment by comparing previous results with current scores.

By: Dr. Nicole Bosse, PsyD, Lindner Center of HOPE

 

OCD is a disorder that responds very well to a form of Cognitive Behavioral Therapy called Exposure and Response Prevention. Brain imaging studies found that people with OCD have excessive levels of activity in the orbital cortex, the caudate nucleus, the cingulate gyrus, and the thalamus. Differences are unrelated to intelligence and most other cognitive abilities. These studies also show that the brain changes in response to Exposure and Response Prevention. The overactive parts of the brain become less active and similar to others without OCD after engaging in Exposure and Response Prevention.

Exposure and Response Prevention consists of confronting what you are afraid and abstaining from the related compulsions. Specifically, exposures are purposeful and gradual confronting and maintaining contact with feared objects, thoughts, or images to allow the anxiety to rise, peak, and subside. Response Prevention is the halting of neutralizing actions and/or thoughts (i.e., compulsions) to allow habituation to a feared stimulus (e.g., not washing after touching a doorknob). This is done with the help of a trained therapist. It is a form of therapy that is collaborative and the individual works with the therapist to brainstorm various exposure ideas to start forming a hierarchy.

A hierarchy ranges from items that bring about low to high distress/anxiety. An example hierarchy for someone that has a fear of snakes could look like: reading about snakes, looking at pictures of snakes, watching videos of snakes, looking at snakes behind glass, being in the room with someone holding a Gardner snake, being in the room with someone holding a boa constrictor, touching a Gardner snake while someone else is holding it, touching a boa constrictor that someone else is holding, holding a Gardner snake, and being in a bathtub with boa constrictor snakes. The last item can be something that wouldn’t necessarily be done for exposures, it is just used as a something to help scale other exposures.

There are two types of exposures I usually talk about with patients, planned vs. spontaneous. Planned exposures can take various forms, from in vivo to imaginal. In vivo exposures are exposures that are completed in person, for example touching things that could be contaminated with germs or breaking down avoidance of certain people for fear of harming them. Imaginal exposures are usually implemented when it is impossible/unethical to do in person exposures. For example, the individual can be instructed to write sentences about hurting someone or write an imaginal script detailing their worst fear. These exposures can be done over and over in one sitting until it starts to get boring.

Spontaneous exposures are things that happen throughout the day that are unplanned and typically cause significant anxiety. For instance, if someone is afraid of germs and someone sneezes on food etc. With spontaneous exposures, I usually instruct individual to do one of two things, either abstain from the compulsion or do something called ritual weakening. Ritual weakening is completing the compulsion but doing it differently than the OCD desires. For example, postponing washing hands or writing down that you are giving into a compulsion in order to be able to do the compulsion. The idea is it makes it slightly less convenient to do the compulsion, which over time weakens OCD.

In sum, Exposure and Response Prevention is a very successful form of treatment for OCD. To be effective, the individual must be willing and motivated. An individual is never made to do something they are uncomfortable with. It is best to go slow in order for the individual to learn their anxiety will decrease over time.

 

 

 

By Jennifer B. Wilcox Berman, PsyD, Lindner Center of HOPE

 

OCD and OCPD are often mistaken for one another or used interchangeably. Although there is some overlap between the two disorders, it’s important to distinguish between them because they are quite different in many ways. It is important to note that although there are differences, some people may have symptoms of both OCD and OCPD. The two disorders are differentiated below.

Obsessive-Compulsive Disorder (OCD) is a debilitating psychiatric disorder that presents in many forms. OCD is comprised of obsessions, which are persistent and unwanted intrusive thoughts, images, or urges. To reduce or eliminate this distress or discomfort, OCD sufferers begin to engage in compulsive behavior, which is ritualized behavior or mental acts, that serve to reduce their discomfort and anxiety. It should be noted that not all compulsions are outwardly observable and may include avoidance of triggers or engaging in mental compulsions. Unfortunately, engaging in compulsions or avoidance of triggers reinforces obsessive thinking. Therefore, the goal of treatment is to reduce compulsions while learning how to tolerate the distress that comes from intrusive thoughts. Some subtypes of OCD include fears related to contamination, scrupulosity (religious-based fears)/morality, fear of harming others (aggressive or sexual), ordering and arranging, repeating, and checking. There are several other subtypes of OCD not noted here. In OCD, these intrusive thoughts are considered ego-dystonic, meaning they are inconsistent with someone’s self-image, beliefs, and values. Therefore, these obsessions cause significant distress, anxiety, and worry and can greatly interfere with one’s life. People with OCD tend to seek help when these thoughts and behaviors cause problems in their life.

According to the Diagnostic and Statistical Manual of Mental Disorders (5th edition), Obsessive-Compulsive Personality Disorder (OCPD) is “a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control.” Due to this, people with OCPD struggle with flexibility, openness to new ideas, and are often inefficient at completing tasks due to perfectionism. Their rigidity and inflexibility can lead to preoccupation with details, rules, lists, order, organization, and schedules. They can hold themselves to perfectionistic standards that interfere with their ability to complete tasks. They are often overly devoted to work and productivity at the expense of leisure activities and interpersonal relationships, leading to a poor work-life balance. People with OCPD can be overly conscientious, very scrupulous, and are often inflexible about matters of ethics, morality, and personal values. Some people with OCPD tend to be miserly, may hoard money for the future, and may have difficulty discarding worn-out or useless items. They may appear to be stubborn or rigid, and may struggle to delegate tasks or work with others because they don’t believe others will do things to their high standards. OCPD is considered ego-syntonic, meaning that it is consistent with someone’s self-image, beliefs, and values. People with OCPD tend to feel validated in their patterns of rigidity and perfectionistic rules and schedules. Therefore, people with OCPD are less likely to seek treatment, unless their behavior begins to negatively impact those around them.

While Exposure and Response Prevention (ERP) is considered the “gold standard” treatment for OCD, there is no such definitive standard intervention for OCD. Exposure and Response Prevention (ERP) is a type of Cognitive-Behavior Therapy (CBT). Cognitive-Behavior Therapy varies from other types of talk therapy in that it is focused on changing thinking patterns and behaviors. It tends to be directed at the present, rather than the past and is goal-oriented and solution-focused. ERP aims to change behavioral patterns, allowing someone to confront their fears and therefore, reduce their OCD symptoms. Exposure refers to the direct confrontation of one’s fear through voluntarily taking steps towards their fears and triggers. Response Prevention refers to someone voluntarily agreeing to reduce their usual rituals and compulsions. It is very important for someone who is working on doing exposures to simultaneously refrain from engaging in compulsions. Without reducing or refraining from the related compulsions, the person cannot learn that they can tolerate the exposure or that the compulsion is unnecessary.

Treatment for OCPD tends to focus on the identification of rigid rules and lifestyle and how these things may be negatively impacting one’s life. Therapeutic intervention includes working on flexibility, willingness to make changes, and focusing on one’s values as motivation for change.

For those suffering from symptoms of OCD or OCPD, therapeutic intervention can be helpful. It is important to seek a specialized provider that can accurately diagnose and treat these disorders.

 

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).

Grant, J. E., Pinto, A., & Chamberlain, S. R., (Eds.) (2020). Obsessive compulsive personality disorder.    American Psychiatric Association Publishing.

Hyman, B. M., & Pedrick, C. (2010). The OCD workbook: Your guide to breaking free from obsessive-compulsive disorder (3rd ed.). New Harbinger.

By Angela Couch, RN, MSN, PMHNP-BC, Lindner Center of HOPE, Psychiatric Nurse Practitioner

Hypochondriasis has been replaced in the DSM 5 by Somatic Symptom Disorder (SSD) or Illness Anxiety Disorder (IAD), both categorized under Somatic Symptom and Related Disorders.  Previous diagnoses classified under Somatoform Disorders were often interpreted with a negative connotation, implying that the patient’s concerns were not real or valid. However, it is not appropriate to give a person a mental diagnosis for no other reason than no medical cause can be identified, nor does the presence of a medical diagnosis exclude a co-morbid mental disorder.  About 75% of persons previously diagnosed with Hypochondriasis will fall into the category of Somatic Symptom Disorder, while the other 25% will meet criteria for Illness Anxiety Disorder.  Let’s examine the differences.

Somatic Symptom Disorder (SSD)

Somatic Symptom Disorder (SSD), requires the patient to have one or more somatic symptoms (that is to say, pertaining to the body), that are distressing or result in significant disruption of daily life. Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns are manifested by at least one of the following: disproportionate and persistent thoughts about the seriousness of one’s symptoms, persistently high level of anxiety about health or symptoms, and excessive time and energy devoted to these symptoms or health concerns.  Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent, generally more than 6 months duration. Specifiers include predominant pain (formerly pain disorder), persistent, and mild, moderate or severe. High health anxiety can be a symptom of SSD but is not necessary for a diagnosis of SSD. Patients with SSD often seek care from multiple doctors and often feel their assessments were inadequate. Reassurance given does not seem adequate nor to last for these patients. Patients with SSD may worry that excessive physical activity may damage their body and may seem more sensitive to medication side effects.  The prevalence in adults may be 5-7% of the population, likely more common in females. In comparison to Obsessive-Compulsive Disorder (OCD), the recurrent worries are less intrusive and individuals may not exhibit repetitive behaviors aimed at reducing anxiety other than seeking assessment.  Usually in OCD, the obsessions would not be confined to somatic symptoms.

Illness Anxiety Disorder (IAD)

Illness Anxiety Disorder (IAD), requires the patient to have a preoccupation with having or acquiring a serious illness. Somatic symptoms are either not present or are mild in intensity. If another medical condition is present or there is a high likelihood of developing a medical condition, the preoccupation is excessive or disproportionate. There is a high level of anxiety about health and the individual is easily alarmed about their health status. The individual performs excessive health related behaviors, such as body checking, or exhibits maladaptive avoidance, such as avoiding medical assessment.  In IAD, the distress has been present for at least 6 months, though the specific illness targeted may change during that time. The preoccupation is not better explained by another mental disorder such as SSD, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder or delusional disorder. In IAD, the distress comes from the distress about the significance, meaning or cause of the complaint, not from a specific physical symptom or sensation. Most commonly, the physical symptoms exhibited are normal type sensations or considered benign or self-limiting dysfunction. Individuals who have IAD may be easily alarmed by reading or hearing about illnesses, and often will seek reassurance about illnesses through internet research or speaking to doctors or friends and family. In a smaller number of cases, the patient may be help avoidant versus help seeking. The reassurance given by medical professionals may potentially heighten the patient’s anxiety. Those who have IAD may avoid activities in order to avoid harming themselves or catching an illness from others.  The prevalence of IAD is possibly between 1.3-10% in the general population, and in ambulatory medical populations the 6-12 month prevalence is between 3-8%, and about equal across the sexes. The prevalence in OCD is also equal across the sexes. Persons with IAD may exhibit the intrusive thoughts about having a disease and may do compulsive behaviors such as reassurance seeking, but the preoccupations are usually focused on having a disease; in OCD, the intrusive thoughts are often about potentially getting a disease in the future or wanting certainty that they do not have one right now. In OCD, the obsessions and compulsions usually extend beyond disease concerns.

One study examined 118 treatment seeking patients with health anxiety, and gave them structured diagnostic interviews to assess for Hypochondriasis, IAD and SSD, as well as co-morbid mental disorders; additionally, the study looked at self-report measures of health anxiety, co-morbid symptoms, cognitions and behaviors, as well as service utilization. 45% of patients were diagnosed with SSD, 47% with IAD, and 8% with co-morbid SSD/IAD.  SSD and IAD were seen to be more reliable diagnoses than Hypochondriasis. Half of the sample group met criteria for Hypochondriasis, and of that sample, 56% met criteria for SSD, 36% for IAD, and 8% for co-morbid SSD/IAD.  SSD was characterized by higher levels of health anxiety, depression, somatic symptoms, and health service utilization, in addition to higher rates of major depression, panic disorder and agoraphobia.

Patients with these diagnoses often present in medical settings initially, and arrive in a mental health care setting via referral from another medical provider. It is important that medical providers validate the individual’s experience of symptoms and their anxiety, but also explain the rationale of supplementing medical interventions with mental health treatment.

Summary of Differences:

IAD                                                                             SSD

Absence/minimal distressing physical                Presence of distressing physical
symptoms                                                                  symptoms

 

High health anxiety not a requirement                 High health anxiety always present

 

Reassurance seeking common, but also             Reassurance/assessment seeking
less frequently can be care avoidant related
to anxiety

Equal across sexes                                                 More common in females

 

May engage in additional compulsions                More frequently associated with co-morbid depression, panic disorder,

higher level of health anxiety, and more utilization of medical services

To learn about anxiety disorders treatment at Linder Center of HOPE, visit https://lindnercenterofhope.org/anxiety-disorders/

References:

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5th Edition.  Arlington, VA, American Psychiatric Association, 2013.

Newby, J.M., Hobbs, M.J., Mahoney, E.J., Shiu, W. and Andrews, G. DSM-5 illness anxiety disorder and somatic symptom disorder: Comorbidity, correlates, and overlap with DSM-IV hypochondriasis. Journal of Psychosomatic Research, 101, 31-37.

Obsessive-Compulsive Disorder (OCD) is a debilitating psychiatric disorder that presents in many forms. OCD is comprised of obsessions, which are persistent and unwanted intrusive thoughts, images, or urges. In OCD, these intrusive thoughts are considered ego-dystonic, meaning they are inconsistent with someone’s self-image, beliefs, and values. Therefore, these obsessions cause significant distress, anxiety, and worry and can greatly interfere with one’s life. To reduce or eliminate this distress or discomfort, OCD sufferers begin to engage in compulsions, which are ritualized behaviors or mental acts that serve to reduce their discomfort and anxiety. Unfortunately, engaging in compulsions reinforces obsessive thinking. Some subtypes of OCD include fears related to contamination, scrupulosity (religious-based fears)/morality, fear of harming others (aggressive or sexual), ordering and arranging, repeating, and checking. It should be noted that not all compulsions are outwardly observable and may include avoidance of triggers or mental compulsions.

Recommended Questions for Assessing OCD

Exposure and Response Prevention (ERP) is a type of Cognitive-Behavior Therapy (CBT). Cognitive-Behavior Therapy varies from other types of talk therapy in that it is focused on changing thinking patterns and behaviors. It tends to be directed at the present, rather than the past and is goal-oriented and solution-focused. ERP aims to change behavioral patterns, allowing someone to confront their fears and therefore, reduce their OCD symptoms. ERP is widely considered to be the “gold standard” therapy for Obsessive-Compulsive Disorder.

Exposure refers to the direct confrontation of one’s fear through voluntarily taking steps towards their fears and triggers. Response Prevention refers to someone voluntarily agreeing to reduce their usual rituals and compulsions. It is very important for someone that is working on doing exposures to simultaneously refrain from engaging in compulsions. Without reducing or refraining from the related compulsions, the person cannot learn that they can tolerate the exposure or that the compulsion is unnecessary.

How is ERP done? 

ERP is done by working with a therapist to examine the person’s specific obsessions and compulsions, generate a fear hierarchy, and begin to work on exposures while limiting engagement in compulsive rituals. A fear hierarchy is a personalized list of exposures. This list is created collaboratively by the person with OCD and their therapist. Exposures include situations, stimuli, or thoughts that evoke a strong, negative emotional response and to which the person has a fear or an aversion. Exposures on the fear hierarchy list should be very specific and can include variations of the same exposure (such as touching several different places on an object and for varying amounts of time). People with OCD often engage in avoidance of triggering stimuli to prevent unwanted distress as well. Much of the fear hierarchy can be generated by examining situations and stimuli that the person avoids. A Yale-Brown Obsessive-Compulsive Symptom (Y-BOCS) Checklist may be completed to help generate ideas. It can also be helpful to gather ideas from family members as well. The goal of exposure work is to slowly and carefully work to approach each of these triggers in a strategic manner.

In vivo exposures refer to confronting one’s fears “in life” or through direct confrontation. This type of exposure is appropriate for things that can be directly approached or confronted. Imaginal exposures refer to mentally imagining being exposed to one’s fears. This type of exposure is utilized for exposures not appropriate for direct confrontation (fear of hitting someone with one’s car). Similarly to in vivo exposures, imaginal exposures are done in a gradual manner and should always be done voluntarily. A SUDS (Subjective Units of Distress Scale) is used to communicate the person’s perceived level of distress, generated by engaging in exposures while refraining from compulsions. The fear hierarchy is arranged to allow someone to work from lower-level exposures to higher-level exposures.

The central premise of OCD is intolerance of uncertainty, with the goal of ERP being to increase the level of tolerance to uncertainty, rather than working to disprove the fear or find ways to become certain. Although it is very common for families to accommodate compulsive behavior or give reassurance when they see a loved one in distress, accommodation and reassurance exacerbate OCD by not allowing the person to learn to tolerate their discomfort. Instead, it is helpful to allow the person to gradually learn how to tolerate their distress with the help of a trained therapist.

How does ERP help with OCD symptoms? 

Exposure and Response Prevention is accomplished through gradual behavioral change, which occurs in the form of habituation and extinction. Habituation occurs with repeated exposure to a particular stimulus. This happens when we become numb or desensitized to things that we see, hear, or do on a regular basis. For example, if we live next to a noisy highway, we might initially be very aware of the noise. However, after living there for a while, we become accustomed to this constant sound, and we learn how to “drown it out.” Habituation in ERP works in a similar manner by repeatedly exposing a person to their feared triggers. Over time they habituate to those triggers and the strong emotions associated with their fears disappear. Extinction occurs when a reinforcer (something that influences behavior) is no longer effective at bringing pleasure or reducing distress. In the case of ERP, by reducing the compulsive behavior that reinforces the anxiety or distress, the obsessive thoughts decrease over time.

If you believe that you or someone you know might be suffering from OCD symptoms, it’s important to reach out to a professional with specialized training in OCD treatment. With the proper treatment, OCD can be a very manageable condition.

By: Jennifer B. Wilcox, PsyD

By: Jennifer B. Wilcox, PsyD
Staff Psychologist, OCD and Anxiety Disorders Program

 

 

 

 

What is compulsive hoarding?

Hoarding Disorder is a psychiatric illness and is considered to be a subtype of Obsessive-Compulsive and Related Disorders. The Diagnostic and Statistical Manual of Mental Disorders – 5th Edition (DSM-5) defines Hoarding Disorder (HD) as:

Persistent difficulty discarding or parting with possessions, regardless of their actual value. This difficulty is due to a perceived need to save the items and to the distress associated with discarding them.

The difficulty of discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromises their intended use.

The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).

The hoarding is not attributable to another medical condition and is not better explained by another mental disorder.

 

 

 

 

 

 

How is compulsive hoarding different from normal clutter or collections?

It is not uncommon for people to acquire a few extra possessions from time to time, resulting in occasional clutter. However, while normal clutter or collecting doesn’t usually interfere with a person’s daily functioning, compulsive hoarding often does. Compulsive hoarding also differs from normal clutter or collecting as it tends to become unmanageable, overwhelming, and causes significant distress or family discord. Though collections usually bring people joy and fill them with pride, hoarding often comes with shame and embarrassment.

Why do people hoard things?

Compulsive hoarding is thought to result from a combination of factors including genetics, environmental factors, life experiences, and learned behaviors. The reason one person hoards may not be the same as the reason someone else hoards. Some people who hoard are compulsive shoppers and acquire more things than they need or have room to accommodate. Others may have difficulty categorizing or making decisions about what to do with particular items. Sometimes they can’t remember what they own or where it is, leading to the purchase of duplicate items. Other times people hold on to possessions for emotional or sentimental reasons or get anxious when they discard things. Some people believe that the hoarded items may be useful someday and keep the items despite not needing them currently. The level of insight a person has about their struggles in these areas can vary widely from completely absent insight to good insight.

What types of things do people hoard?

The types of items a person hoards vary based on factors such as the reason they are hoarding and how severe their hoarding issues have become. Some commonly hoarded items include books, newspapers, magazines, boxes, bottles, clothes, food, items purchased in bulk, collectibles or vintage items, furniture, animals, or digital media.

How many people suffer from Hoarding Disorder and who does it affect?

While the exact prevalence of people who suffer from Hoarding Disorder is not certain, it is estimated that it affects approximately 2.5% of the general population. Studies have shown that prevalence rates in men and women are nearly equal and appear to be consistent across developed countries. Most studies report onset between 15 and 19 years of age and show a chronic course over the lifespan.

What is the treatment for Hoarding Disorder?

Hoarding Disorder is treated using Cognitive-Behavioral Therapy (CBT), a type of therapy that allows someone to work with a therapist to shift their thinking patterns and change their behavioral patterns to healthier ones. Randomized controlled trials have shown this to be an effective treatment for hoarding. While the data on the efficacy of medication for Hoarding Disorder is limited, there is some evidence to support the use of medication in the treatment of this disorder. For those hoarders who have limited insight, a Motivational Interviewing (MI) approach can help to foster their motivation and confidence. Finally, working on skills that improve the hoarder’s ability to maintain attention and focus, categorize items, and decision-making can be beneficial in treating Hoarding Disorder.

What can I do to help a loved one who seems to have issues with compulsive hoarding?

It is generally not recommended for family and friends to discard hoarded items without the hoarder’s permission. This can be extremely distressing for a compulsive hoarder and tends to make them upset, anxious, or angry. Instead, it is recommended that friends and family talk to their loved ones about their concerns and help them to seek professional treatment. Additional resources are available at the International Obsessive-Compulsive Disorder Foundation (IOCDF) and the Anxiety and Depression Association of America (ADAA).

Resources:

American Psychiatric Association, 2013. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. American Psychiatric Association Publishing, Arlington, VA.

Treatment of Hoarding Disorder

https://instituteofliving.org/programs-services/anxiety-disorders-center/what-we-treat-at-the-adc/compulsive-hoarding

https://www.psychiatry.org/patients-families/hoarding-disorder/what-is-hoarding-disorder

Postlethwaite, A., Kellett, S., Mataix-Cols, D., 2019. Prevalence of Hoarding Disorder: A systematic review and meta-analysis. Journal of Affective Disorders 256, 309-316.

OCD, or Obsessive-Compulsive Disorder, affects 1 in 40 people and is the third most common psychiatric condition. This disorder uses deceptive “OCD tricks” and lies to keep people trapped in cycles of anxiety. Here are 10 powerful tips for combatting OCD’s tricks, helping you recognize and challenge the common lies OCD tells you.

1. Spot the “This Isn’t OCD” Trick

One of OCD’s biggest tricks is convincing you, “This time, it’s not OCD.” OCD often feels like an urgent emergency, but challenging this with the “public service announcement” test can help. Imagine calling a radio station to announce your fear (e.g., “Please inform everyone they must wipe at least 20 times for safety”). This approach can reveal the irrational nature of your fear, promoting acceptance of uncertainty and helping you resist compulsions.

2. Normalize Intrusive Thoughts

OCD may make you think, “Only crazy, bad, or dangerous people have these thoughts.” In reality, everyone has intrusive thoughts. Remembering that you cannot control all thoughts helps you recognize OCD’s lies and reduces the power of its tricks. Accepting this truth can be one of the most powerful tips for OCD management.

3. Let Go of the Need to Find “Why”

OCD may convince you that finding out “why” you have certain thoughts will help you stop them. But recovery typically comes from applying evidence-based Cognitive Behavioral Therapy (CBT) skills, not from understanding “why.” Tips for combatting OCD should focus on actionable steps, not just understanding.

4. Resist the Urge to Give Up on Fighting OCD

OCD often tells you, “You’ll never beat me, so don’t bother trying.” But avoiding OCD short-term only makes it stronger. Committing to face temporary discomfort by resisting OCD’s lies will ultimately bring more freedom.

5. Accept Your Thoughts Without Trying to Control Them

Another trick OCD plays is convincing you that you must control your thoughts. The reality is that trying to control them can make them worse. Practice mindfulness techniques like “leaves on a stream,” where you observe thoughts rather than trying to control them. This OCD tip is especially effective for releasing the need for control.

6. Allow Yourself to Do Compulsions Imperfectly

OCD often insists that compulsions must be done perfectly. Combat this by intentionally performing compulsions imperfectly, such as using your non-dominant hand or changing your approach. This can break OCD’s hold and weaken its influence.

7. Embrace Uncertainty in Daily Life

OCD might convince you that rituals will bring certainty, but complete certainty doesn’t exist. Recognize areas in your life where you already tolerate uncertainty, like driving or grocery shopping. Increasing your tolerance for uncertainty is a powerful tip for combatting OCD.

8. Limit Reassurance-Seeking Behaviors

OCD often tricks you into thinking reassurance will help you feel better, but it’s a temporary fix. Track your reassurance-seeking behaviors and aim to reduce them gradually by 20% each day or week. This practice promotes resilience and helps manage OCD symptoms long-term.

9. Release the Responsibility for Others’ Safety

One OCD trick is making you believe you’re responsible for others’ safety. Try challenging this by thinking things like, “I hope you get a flat tire.” This exercise shows that your thoughts don’t control others’ outcomes, breaking the illusion of responsibility.

10. Challenge the Fear of Bad Outcomes

OCD often tells you, “If you don’t do this ritual, something bad will happen to you or your family.” Challenge this by altering the ritual or even purposefully wishing for the feared outcome. Addressing this fear directly reduces its power, making this one of the most effective OCD tips for long-term relief.

By learning to identify and challenge OCD’s tricks, you can build resilience against its lies and take steps toward managing OCD more effectively. Embrace these tips for OCD as tools to help regain control and reduce the disorder’s impact on your life. For those needing more intensive support, the Lindner Center of Hope offers residential treatment programs specifically designed to help individuals with OCD.

 

Many who struggle with OCD are probably noticing a spike in their symptoms during these unprecedented times. Stress and uncertainty can often make OCD symptoms flare. Those who struggle with specific types of OCD may be having an even harder time: specifically those with contamination concerns and those concerned with harming others. Another symptom of OCD that may be particularly hard currently are perfectionism tendencies. While it may be harder to fight back against OCD with everything going on right now, it is more important than ever to not give in to compulsions and let them take over your life. One simple step you can take is to stay connected to your therapist, likely via telehealth at the moment. Having regular sessions during this time is key, especially as symptoms flare. Staying connected to others online or through social media options is also important, as the more you are connected to others the less stress you will notice. Another key piece is to continue to do things you enjoy and that bring you pleasure, as this will help lessen stress as well. Keeping a structured routine can be helpful and can help make things to continue to feel more normal. It can be important to try to continue with whatever routine you had going before that you are still able to do, for instance still getting at the same time in the morning and getting ready for work even if you are working from home. Adding consistent exercise into that routine will also be helpful, as this helps create endorphins and naturally lessens anxiety. Lastly, avoid reading the news all day, which will only lead to more stress and anxiety. It is important to limit access to only a couple of trusted sites and not get carried away with reading up on everything all day long.

Some specific OCD related steps you can take will vary depending on the type of OCD you have. For those who struggle with contamination concerns, get familiar with the CDC guidelines for the current pandemic and do not add other steps that are not recommended. For instance, they are recommending only washing hands for 20 seconds after being outside or in public, before eating, after going to the bathroom, and after you’ve coughed/sneezed/blown your nose. If soap and water are not available, they recommend you use hand sanitizer that contains at least 60% alcohol. They also only recommend disinfecting surfaces once per day. This should only take a few minutes per day and they suggest only focusing on the surfaces in your home that are frequently touched. It is also important to think about whether this is truly needed (for example, if you stayed home all day and had no visitors, do you really need to disinfect that doorknob?). It is also important to avoid some news sources that might not offer expert recommendations but rather their own opinions.

For those who struggle with fears of harming others, these symptoms might tackle the current pandemic and cause you to obsess about whether or not you might have infected someone or whether or not you might infect someone in the future. This might be a similar theme to past fears of contamination concerns, but it will still be helpful to alert your therapist to the new content so that new exposures can developed.

For those who struggle with perfectionism tendencies, this might be an especially trying time. The perfectionism could target all of the changes going on and adaptations people are having to make to conduct
their jobs, manage their families etc. It is important to give yourself a break and realize that it is impossible to be perfect in anything we do, but especially now during all of this change and uncertainty. Practice doing one or two things imperfectly on purpose as an exposure.

One important exercise I make sure to encourage all of my patients to do is to keep track of their victories against OCD, whether the victories are big or small. Keeping track of successes and not dwelling on everything that is going wrong is a helpful way to stay on track and to realize everything that you are doing to fight OCD, which is likely a lot. It can sometimes be hard to pick out the successes and often others only notice the failures or slips, but there are victories in there as well that deserve your attention and that can help give you confidence to fight back even harder next time

Nicole Bosse, PsyD
Lindner Center of HOPE, Staff Psychologist