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The paradox of thought control in OCD

The paradox of thought control in OCD. Maureen L. Whittal, Ph.D. & Adam Chodkiewicz, M.D. December 4, 2003. ASSESSMENT OF OCD. Self-report measures Padua Inventory (Burns et al., 1996 Sanavio et al., 1988) Obsessive-Compulsive Inventory Revised (Foa et al., 2002)

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The paradox of thought control in OCD

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  1. The paradox of thought control in OCD Maureen L. Whittal, Ph.D. & Adam Chodkiewicz, M.D. December 4, 2003

  2. ASSESSMENT OF OCD Self-report measures • Padua Inventory (Burns et al., 1996 Sanavio et al., 1988) • Obsessive-Compulsive Inventory Revised (Foa et al., 2002) • Obsessional Belief Questionnaire (OCCWG, 2002) • Interpretations of Intrusions Inventory (OCCWG, 2002) • Personal Significance Scale (Rachman)

  3. Obsessional Belief Questionnaire (OBQ44) • Responsibility and threat estimation (e.g., even when I’m careful, I often think that bad things will happen) • Perfectionism and certainty(e.g., it is essential for everything to be clearcut, even in minor matters) • Importance and control (e.g., having violent thoughts means I will lose control and become violent)

  4. Interpretations of Intrusions Inventory (III) • Control of thoughts(e.g., I should be able to rid my mind of this thought) • Importance of thoughts (e.g., Having this thought means I’m weird or abnormal) • Responsibility(e.g., I cannot take the risk that this thought will come true)

  5. ASSESSMENT OF OCD Interviewer measures • Yale-Brown Obsessive Compulsive Scale (YBOCS; Goodman et al., 1989)

  6. A cognitively-based alternative to ERP • Rests on the cornerstone that 90+% of people experience intrusive thoughts • Interpretation of the intrusive thought is typically threatening (“I’m mad, bad, or dangerous”) • It’s the anxiety from the appraisal that promotes compulsive behaviour

  7. CBT model for the maintenance of OCD Trigger Leaving the house Intrusive thought On, open, or unplugged? Appraisal My fault if something bad happens Distress Anxiety/fear Compulsion Checking

  8. Normalizing ITs • Foundation of treatment • Use Os reported by a non-clinical sample • Survey • Within patient example

  9. Peeling back the layers of the onion • Downward arrow • Method of successive questioning designed to uncover the central fear • Focus on the emotional and not the actual consequences

  10. Example of a downward arrow If I couldn’t fix the mistake I would be responsible If that were true, what would it mean to me? I would go to jail If that were true, what would it mean to me? My family would discover that life is better without me If that were true what would it mean to me? Family would get on with other things and leave me If that were true, what would it mean to me? I’m a bad person

  11. Cognitive concepts in OCD Overimportance of thoughts (a) having the thought means it’s important and it’s important because I think about it (b) having the thought makes the outcome more likely (c) having the thought and engaging in the action are the same morally

  12. Having the thought means it’s important • Circular reasoning (e.g., fresh fruit is in demand because it’s fresh and it’s fresh because it’s in demand) thinking a thought is important dwelling on it verifies the importance of the thought further dwelling

  13. Challenging importance of thoughts • Behavioral experiment of alternating between letting thoughts ‘come and go’ vs. ‘fighting and dwelling’ • patients record overall anxiety and frequency of ITs • patients predict results of experiment prior to beginning • treating thoughts like an out of tune radio

  14. Experiment • Imagine/think about the most important person in your life Write the following sentence:

  15. Thought action fusion (TAF) • Likelihood self - because I’ve had the thought it’s more likely to happen to me • likelihood others - because I’ve had the thought, it’s more likely to happen to others (e.g., MVA) • moral - the thought is as reprehensible as the action

  16. Challenging likelihood TAF • Thought experiments - e.g., purposely having a negative thought about something bad happening to somebody yourself or something • ongoing list of ‘premonitions’ and their outcome

  17. Challenging moral TAF • Continuum • normalization of ITs • List qualities of a good and bad person • Identification of a possible double standard

  18. Challenging the needfor thought control • Set up an alternating days experiment where half of the days are “fight and dwell” and the other half are “come and go” • have patients make predictions ahead of time

  19. The paradox of thought control • The interaction between attention to thoughts and the frequency of thoughts • attention experiments

  20. The need tocontrol thoughts • The role of thought suppression and attention Belief that I must be in control of my thoughts and emotions at all times Experiences a normal intrusive thought, but appraises it as dangerous Further attempts to control thoughts Efforts are made to fight, control, suppress, distract, or neutralize the thought Not trying hard enough to control thoughts Notices more ITs Increased vigilance or attention

  21. Perfectionism • Downward arrow may reveal compromised self-worth if less than perfect • Continuum of best/worst person and least/most perfect may help identify a double standard • List qualities of a good and bad person

  22. Inflated responsibility • The belief that one has power which is pivotal to bring about or prevent subjectively crucial negative outcomes (actual or moral) (Salkovskis, 1996)

  23. Challenging responsibility with piecharting Me 10% Wife 5% Toy makers 50% Son 20% Weather 10% Playmate 5%

  24. Other challenges to responsibility • responsibility transfers • going “off duty”

  25. Overestimations of danger • Not unique to OCD • A cognitive reasoning bias?

  26. Challenging overestimations of danger Step Chance Cumulative chance 1.Not extinguish 1/10 cigarette 2.Spark falls on 1/10 the floor 3.Carpet catches 1/10 on fire 4.Carpet starts to 1/100 burn and I don’t notice 5.Too late to help 1/100 1/10,000,000

  27. The role of behavioral experiments • Central but not sufficient • Function is to test alternate appraisals and not habituation as in ERP • Not as simple as ‘try it and see what happens’

  28. Intolerance of uncertainty • Not unique to OCD • May be a variant of perfectionism

  29. Challenging uncertainty • Surveys • Behavioral experiments

  30. Concealment • Form of avoidance and serves to reinforce the appraisals • homework assignment to reveal thoughts to others

  31. Target and content of thoughts is NOT random • Based on value system • person/situation that is the most important to the individual • intrusions become repetitive BECAUSE the person is sensitive, caring, etc.

  32. Pitfalls • Arguing with the patient and/or trying to talk them out of their intrusive thought • Patients who use cognitive challenges as compulsive reassurance • Patients who can not identify appraisals

  33. Pitfalls continued • Identifying feared consequences as appraisals • focussing on reducing threat (i.e., disconfirmation) and ignoring the perceived consequences [risk = chance X consequence]

  34. How well does it work? Pre Tx Post Tx 3 mth ES @ 3 f/u mth f/u GCBT 21.9 16.1 17.3 .70 GERP 21.8 13.2 12.8 1.29 ICBT 23.5 10.3 9.3 2.22 IERP 21.7 10.4 10.6 1.26

  35. Subtype Analyses YBOCS Score at post Washers n=41 Checkers n=27 Obsessional n=22

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