110207 obsessive compulsive disorder

8/11/2019 110207 Obsessive Compulsive Disorder

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CNWL/RHUL IAPT

CBT PGDip.

Obsessive-Compulsive Disorder


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OBSESSIVE COMPULSIVE DISORDER

SESSION OUTLINE

DEFINITION AND DIAGNOSIS

BEHAVIOURAL AETIOLOGICAL MODELS & TREATMENT

COFFEE/TEA BREAK

CBT AETIOLOGICAL MODELS & TREATMENT

LUNCH

VIDEO & CASE DISCUSSION

SUSAN: CASE FORMULATION EXERCISE

COFFEE/TEA BREAK

ASSESSMENT MEASURES

TROUBLESHOOTING TRAINEE CONCERNS/CASES


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OCD DEFINITION AND DIAGNOSIS

NORMAL WORRIES & COMPULSIONS

DYSFUNCTIONAL/ABNORMAL

OBSESSIONS

DSM IV DIAGNOSIS

A UNITARY CONSTRUCT?

SUBCLASSES OF OCD


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OCD DIAGNOSIS

DSM IV & ICD 10A significant source of distress and/or interference

OBSESSIONS

Recurrent, persistent thoughts, images or Impulsesexperienced, at some point, as intrusive and senseless

Attempts to ignore and/or suppress and/or neutralise.

Recognition of ownership of thoughts, yet perceived as ego-

dystonic; content unrelated to another Axis 1 diagnosis.


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OCD DIAGNOSIS

COMPULSIONS

Repetitive, purposeful and intentional behaviour

Performed in response to an obsession or according to

certain rules

Designed to neutralise or prevent discomfort and/or

catastrophe.

Awareness of their unrealistic and/or excessive nature


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OCD: DIFFERENTIAL DIAGNOSIS

MAJOR DEPRESSIVE DISORDERGENERALIZED ANXIETY DISORDER

HYPOCHONDRIASIS

SPECIFIC ILLNESS PHOBIA

ANXIETY DUE TO A GENERAL MEDICAL CONDITION

APPETITIVE DISORDERS

BODY DYSMORPHIC DISORDER

DELUSIONAL DISORDER


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OCD DIFFERENTIAL DIAGNOSIS

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

ABSENCE OF OBSESSIONS AND/OR COMPULSIONS

PERVASIVE PATTERN OF:

ORDERLINESS

PERFECTIONISM

CONTROL

PREDOMINANTLY EGOSYNTONIC

ONSET BY EARLY ADULTHOOD


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OCD EPIDEMIOLOGY

INCIDENCE AND PREVALENCE

General Population: Point Prevalence


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BEHAVIOURAL MODEL OF ANXIETY

ANXIETY IS A RESULT OF MALADAPTIVE LEARNING

NAMELY, THROUGH:

A. CLASSICAL OR PAVLOVIAN CONDITIONING:

UNCONDITIONED STIMULUS (UCS)UNCOND. RESPONSE (UCR

(e.g.: shock, trauma, nausea) (i.e.: anxiety symptoms)

+

CONDITIONED STIMULUS (CS) CONDITIONED RESPONSE (C

(e.g.: dogs, crowds, dirt) (i.e. anxiety symptoms)


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B. INSTRUMENTAL OR SKINNERIAN CONDITIONS:

TWO FACTOR MODEL - 1. CLASSICAL CONDITIONING

OF ANXIETY

2. INSTRUMENTAL LEARNINGOF MALADAPTIVE RESPONSE

(e.g. Fight, Flight, Avoidance or Checking)

MALADAPTIVE RESPONSE PREVENTS EXTINCTION OF CR IN

PRESENCE OF CS

CONDITIONING OR LEARNING HISTORIES EXPLAIN ONSET AND

MAINTENANCE OF ANXIETY DISORDERS AND POINT TO

TREATMENT.


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BEHAVIOURAL TREATMENT INVOLVES EXPOSURE TO FEAREDSTIMULI/SITUATIONS (CS) WITHOUT THE UCS AND MALADAPTIVRESPONSE TO PERMIT THE EXTINCTION OF THE CONDITIONEDRESPONSE (CR)

ADVANTAGES EXPLICIT PREDICTIONS DEMONSTRABLE

PLAUSIBLE PRACTICAL/DIRECT TREATMENT

DISADVANTAGES PREPAREDNESS INDIVIDUAL DIFFERENCES DEVELOPMENTAL INFLUENCES LACK OF TRAUMATIC ONSET SOCIAL & SYMBOLIC ACQUISITION OF

ANXIETY


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OCD TREATMENTAPPROACHES

BEHAVIOUR THERAPY

Rationale & Behavioural Assessmentsee Figure 1

Exposure and Response Prevention

Maintenance and Generalizability

Relapse Prevention

T i l S i h B h i l A


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Typical Steps in the Behavioural Assessmen

of OCD

Specify the rituals and obsessions in detail

What situations evoke the rituals or obsessions (e.g., do the

rituals occur only at home)?

Are there any fluctuations in the symptoms (e.g. are they worse

the patient is alone)?

What situations does the patient avoid as a result of OCD?

Fig. 1


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Typical Steps in the Behavioural Assessment

of OCD (Contd.)

Do any thoughts, images, or impulses trigger (eg sacrilegious images,aggressive impulses) rituals or obsessions ?

Construct hierarchy of target situations based on the amount of anxiety (SUD

scale), ritualising, or obsessing they evoke.

What does the patient believe will occur if he or she does ritualise? How

strong is this belief?

Are the patients symptoms being maintained by family interactions?

Is the patient severely depressed? If so, consider trial of medication.

Fig. 1


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Typical OCD Fear Hierarchy


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OCD: Client Exposure Guidelines

ERP S i b S i H bi i


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ERP Session by Session Habituation


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OCDCBT AETIOLOGICAL MODELS

Primary Cognitions: Threat Appraisal (Figure 2)

Guilt, Responsibility and Resistance (Figure 3 & 4)

Covert Cognitive Rituals (Figure 5)

Metacognition (Figure 6)

Secondary Mood disorder

Overvalued Ideas

Stimuli and situationsFig 2


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Stimuli and situations

(Internal or external)

Including external triggers,

intrusive thoughts and information

COGNITION

DANGER, THREAT

Safety seeking

Behaviours (includingAvoidance, escape, and

neutralising)

Biological andPsychophysiological

reactions

Fig 2

CBT M d l f OCD f S lk ki (1985)


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CBT Model of OCD from Salkovskis (1985)

Potential Stimuli

Intrusion Ego Dystonic

Automatic Thoughts Ego

syntonic

Mood Disturbance,

discomfort, dysphoria,

anxiety

Neutralising ResponseEscape Behaviour

Rewarding

Non-punishment

Perception of

Responsibility

Increased Acceptance

Avoidance

Triggering Stimuli

(Internal/External)

Extrinsic Mood Disturbance

Schematic Activation:

accessibility of loss, threat or

blame ideation

Expectancy

Reduced Discomfort

Fig. 3


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A COGNITIVE THEORY OF OBSESSION

OBSESSION DESCRIPTION INTERPRETATION DISTRESS/ CONSEQUENCES

FEAR

Thought e.g.:Sinful e.g.: Revealing about me I will cause harm e.g. Intense resistance

Image Disgusting Warning signs People will reject me to obsessions

Impulse Alarming Losing control I will be locked up Attempts to block them

Going insane Neutralisations

I am dangerous Avoidance Behaviour

A postulated sequence of descriptions, interpretations and actions (from S.J. Rachma

Fig. 4


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Cognitive Obsessions and Covert Rituals

Intrusive Thought

Negative Appraisal

Increased Anxiety and Worry

Overcontrol

Vigilance (Could I really do it?) Covert Rituals Testing

Temporary Anxiety Reduction

Cycle starts all over againFig. 5

EXAMPLE OF THOUGHT/ACTION


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EXAMPLE OF THOUGHT/ACTION

FUSION AND OC METACOGNITION

Im having a bad thought that must mean Im bad.

I wouldnt be having these thoughts if I wasnt truly bad!

The more bad thoughts I have, the more proof I have that Im bad.

Because Im thinking so much about doing bad things, it must mean that Im highly likely to do someth

bad.

If I dont try hard to prevent harm from happening, it is as bad as doing something bad on purpose.

Since it is likely that Im going to do something bad, Id better watch out for it. I may even have to ma

sure that others are protected from my bad actions.

Fig. 6

OCD: COGNITIVE TREATMENT


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OCD: COGNITIVE TREATMENT

APPROACHES

Psychoeducation of CBT Model of OCD

Shared Formulation

Identification of Intrusions & Appraisals

Cognitive Restructuring of Appraisals & Beliefs Role of Compulsions, Neutralization & Avoidance: ERP

Behavioural Experiments

Modifying Metacognitive Beliefs


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OCD: Examples of Behavioural Experiments


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OCD: Relapse Prevention

OCD ADDITIONAL COGNITIVE


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OCD: ADDITIONAL COGNITIVE

TREATMENT APPROACHES

Limited Insight

Discrimination Training

Self Instructional Training

Overvalued IdeationDistress Tolerance

Reduction of Psychological Reactance

Self-Esteem Enhancement

Secondary Mood Disorder

Cognitive Restructuring of Depressive/Anxious Cognition

CNWL/RHUL IAPT


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CNWL/RHUL IAPT

CBT PGDip.


JEAN: A BATTLE WITH OBSESSION - 1


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J N: W O S SS ON

Idiosyncratic Nature: Order & Cleaning

Extreme Stimulus Generalisation, yet Stereotypy

and Restriction of Cues.

Aversion Rituals: E.g.: Guilt re. Kissing Son.

Secrecy & Family Collusion.

Catastrophic Thinking: E.g. Risk of Fits.



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Level of Over-Arousal

Cognitive Deficits: Need to Sub vocalise

Sense of Responsibility: At Home Vs. In Hospital

Daughter (Tamara: Transgenerational Mechanisms)

Secondary Depression: Attempted Suicide

Treatment: Has included Psychotherapy, ECT, Long-

term Medication and Assessment for Psychosurgery

JEAN A BATTLE WITH OBSESSION 3


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BEHAVIOUR THERAPY

Detailed Functional Analysis including the meaning ofbehaviour to the Patient

Therapeutic Relationship and Modelling.

Cognitive Factors: Behavioural Experiments.

Facilitating Anger: e.g. viz Religious Guilt

Cost of Treatment: 100K?

Systemic Changes: Family & Marital Function

Identification with Therapists Hairstyle


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OCD CBT Case Formulation

Susan is 33 year old primary school teacher, who has been married6 years. She and her husband, Steve, have a 3 year old son, Brian,

and a 3 month old infant, Jennifer.

Susans GP has referred her due to persistent washing and

checking rituals that failed to respond to SSRI medication.

Susan has had both counselling and psychotherapy that have not

been particularly helpful.

(After Abramowitz 2006)


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OCD CBT Case Formulation


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Susan Case Formulation Exercise: InstructionsForm Pairs1 as Therapist and 1 as Patient (Susan)

Role Play Part of the Assessment Interview

Therapist should question Susan about the following and fill in

details below each item on the form:

Nature & Content of Obsessional Thoughts

2. Catastrophic Thinking

3. Safety-Seeking Behaviour

When told to stop the role play please complete the attached draft

formulation:

a) With the information from 13 above in the relevant boxes

b) Any other relevant information or points in the other boxes

c) Sketch relationships between different components with

arrows

Susan: OCD Case Formulation (After Abramowitz, 2006)


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Susan: OCD Case Formulation (After Abramowitz, 2006)

External Triggers

e.g. bathrooms, dirty pupils, marking schoolwork,

sharp objects, bathing the baby

Intrusive Obsessional Thoughts

- Ideas: e.g. I am contaminated- Doubts: e.g. I might assign the wrong mark

- Images: e.g. Stabbing and drowning baby

Catastrophic Interpretations of Obsessions

- I will get ill & make my family ill

- I cant take the chance th is will happen

- The more I think it the more likely it is.

- I can & should control my thoughts or I am

fully responsible for the outcome

- These thoughts mean that Im a terrible

mother

Obsessional Anxiety/Fear

Safety-Seeking Behaviours

- Avoidance: e.g. pupils, public toilets, baby

- Rituals: e.g. washing, checking, mental

health

- Neutralising: e.g. concealment, suppression

Dysfunctional Beliefs

- Overestimates of

the probability and

severity of danger

- Inflated sense of

responsibility for

danger

- Certain thoughts

should be

controlled

Lack of Correction of Beliefs

Safety behaviours prevent

correction of catastrophic

eliefs

Thought Suppression

Leads to more unwanted

houghts

Hypervigilance

Increases

reoccupation and

salience of cues

Negative

Reinforcement

Of safety

ehaviours by

distress

eductionShort-Term Anxiety/Fear Reduction

S A E Hi h


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Susan: An Exposure Hierarchy

OCD Cli R i


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OCD: Client Ratings

Obsessive Compulsive Inventory


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Obsessive Compulsive Inventory

(OCI)

Responsibility Interpretations


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Responsibility Interpretations

Questionnaire (RIQ)

The Responsibility Attitudes


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The Responsibility Attitudes

Questionnaire (RAS)

OCD St d C M d l


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OCD Stepped Care Model


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Quick Reference Guide to OCD

http://www.nice.org.uk/nicemedia/pdf/CG031quickrefguide.pdf

OCD for CBT: Some Tips
http://www.nice.org.uk/nicemedia/pdf/CG031quickrefguide.pdfhttp://www.nice.org.uk/nicemedia/pdf/CG031quickrefguide.pdf


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OCD for CBT: Some Tips

Use Multi-faceted Assessment

Psychoeducation & Motivational InterviewingWork to an Agenda

Stay focussed and calm

Homework, homework, homework!

Recognise Roadblocks

The perfect is the enemy of the good

CNWL/RHUL IAPT


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CNWL/RHUL IAPT

CBT PGDip.


110207 obsessive compulsive disorder

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