(C)BT of OCD

1. (C)BT of OCD Adam C. Chodkiewicz MD FRCP(C) Maureen L. Whittal, Ph.D UBC Hospital November, 2006

2. OCD Facts • 1990 WHO study - OCD listed as 5th in disease burden for women aged 15-44 • Estimated lifetime prevalence rates 2-3%, 6-month point prevalence - 1.6% • Impaired quality of life • Delay in appropriate treatment

3. Demographics • Age of onset - earlier for men (19 yoa) compared to women (22 yoa) • Gender ratio - approx equal as adults • Course - majority are episodic with incomplete remission and a small percentage progressively deteriorate

4. Comorbidity • 1/3 comorbid with depression • 24% with another anxiety disorder • 8% with an eating disorder • 5% with tourette’s

5. Assessment of OCD • YBOCS • Obsessive Compulsive Inventory • Padua Inventory (PI-WSUR) • Obsessional Belief Questionnaire • Interpretations of Intrusions Inventory • Personal Significance Scale (PSS)

6. YBOCS • Gold standard treatment outcome measure • Obsessions subscale and compulsions subscale. Scores range from 0-40. • 0-7=subclinical, 8-15=mild, 16-23=mod, 24-31=severe, and 32-40=extreme

7. OCD Subtypes • Contamination and doubting most common obsessions followed by somatic, need for symmetry, aggression, and sexual intrusions • Checking and washing most common compulsions followed by counting, the need to confess, ordering, and hoarding

8. Forms of Obsessions • Thoughts • Ideas experienced as unacceptable or unwanted (e.g., idea of stabbing my child) • Images • Mental visualizations that are experienced as troubling or distressing (e.g., one’s elderly grandparents having sex) • Impulses • Unwanted urges or notions to behave in inappropriate ways (e.g., to yell obscenities)

9. Typical Content of Obsessions • Violence • Impulse: to attack a helpless person • Image: loves one’s being dismembered • Impulse to reach for a police officer’s gun • Sex • Impulse: to stare at peoples’ genitals • Thought: what it’s like to be homosexual • Blasphemy and sacrilege • Image: Jesus with an erection on the cross • Thought: God is dead

10. What is NOT an Obsession • Worries about real-life issues (e.g., work) • Depressive ruminations • Recurrent appetitive sexual fantasies • Jealousy • Preoccupation with a new car, boyfriend, etc. • Cravings to gamble, steal, drink alcohol, etc.

11. Mental Rituals (Neutralization)vs. Obsessions • Often confused for one another • Obsessions are intrusive, unwanted thoughts that evoke anxiety or distress • Mental rituals are deliberate mental acts designed to neutralize or reduce anxiety or distress

12. Compulsions • Overt or covert responses to intrusions • Designed to counteract the obsession and to decrease the anxiety the latter produces • Sense of having ‘no choice’, is time-consuming, excessive and senseless • Egs include checking, washing, repeating, counting, ordering, silent praying etc.

13. Learning Theory View of OCD • Obsessions give rise to anxiety or distress • Compulsions reduce obsessional anxiety • The performance of compulsions prevents the extinction of obsessional anxiety • Compulsions are negatively reinforced by the brief reduction of anxiety they engender

14. Behavior Therapy Techniques • In vivo (situational) exposure • Gradual confrontation with situations that evoke obsessional thoughts • Imaginal exposure • Gradual confrontation with the unwanted thoughts (via loop tapes, etc.) • Response prevention • Refrain from neutralizing, mental rituals, reassurance-seeking, and thought control strategies, etc.

15. Criteria for Fear Reduction During Exposure Therapy • Elicit fear • Allow habituation to occur • Provide corrective information

16. Exposure and Response Prevention (ERP) • Psychosocial treatment of choice shortly after it was developed in the 1960s • Establish a fear hierarchy beginning with relatively easy items and gradually getting more difficult • Graduated exposure to triggers and habituation of fear response

17. The Treatment of Fear • Exposure to fear-eliciting stimuli or situations • Abstinence from escape/avoidance behaviors • Anxiety increases initially, followed by habituation

18. What Happens During Exposure Therapy?

19. Setting Up the Treatment Plan • Generate list of situations and thoughts that would evoke anxiety and urges to neutralize • Patient rates subjective units of discomfort (SUDS) for each situation or thought • Collaborative effort in generating exposure hierarchy • Start with situations of moderate difficulty • Highest items must be included • Situations are realistically safe, but will evoke obsessional distress

20. Treatment outcome using ERP • Approximately 80% of treatment completers report beneficial effects • Up to 6 years following treatment approximately 70% of people maintain their gains • However, ERP is not a panacea

21. Problems with ERP • “benefit” is defined as a 30% decline in YBOCS • High refusal/drop out rate • Particularly problematic for people who suffer from primary obsessions

22. Cognitively focused treatment of OCD • Based on knowledge that unwanted intrusive thoughts are normal • It’s not the intrusion that causes the anxiety and the compulsive behavior, but the appraisal of the intrusion • Goal is to cognitively challenge appraisal and identify less threatening appraisals

23. 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

24. Overimportance of thoughts • Having a thoughts means it’s important • Likelihood thought action fusion (having the thought makes the outcome seem more likely) • Moral thought action fusion (having the thought and engaging in the act are equal)

25. 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

26. 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

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

28. 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

29. 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

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

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

32. Challenging overestimations of danger