(C)BT of OCD

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(C)BT of OCD

• Adam C. Chodkiewicz MD FRCP(C)
• Maureen L. Whittal, Ph.D
• UBC Hospital
• November, 2006

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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

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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

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Comorbidity

• 1/3 comorbid with depression
• 24 with another anxiety disorder
• 8 with an eating disorder
• 5 with tourettes

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Assessment of OCD

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

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YBOCS

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

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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

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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., ones elderly
  grandparents having sex)
• Impulses
• Unwanted urges or notions to behave in
  inappropriate ways (e.g., to yell obscenities)

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Typical Content of Obsessions

• Violence
• Impulse to attack a helpless person
• Image loves ones being dismembered
• Impulse to reach for a police officers gun
• Sex
• Impulse to stare at peoples genitals
• Thought what its like to be homosexual
• Blasphemy and sacrilege
• Image Jesus with an erection on the cross
• Thought God is dead

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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.

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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

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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.

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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

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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.

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Criteria for Fear Reduction During Exposure
Therapy

• Elicit fear
• Allow habituation to occur
• Provide corrective information

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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

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The Treatment of Fear

• Exposure to fear-eliciting stimuli or situations
• Abstinence from escape/avoidance behaviors
• Anxiety increases initially, followed by
  habituation

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What Happens During Exposure Therapy?
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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

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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

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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

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Cognitively focused treatment of OCD

• Based on knowledge that unwanted intrusive
  thoughts are normal
• Its 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

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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
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Overimportance of thoughts

• Having a thoughts means its 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)

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Thought Action Fusion (TAF)

• Likelihood self - because Ive had the thought
  its more likely to happen to me
• likelihood others - because Ive had the thought,
  its more likely to happen to others (e.g., MVA)
• moral - the thought is as reprehensible as the
  action

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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

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Challenging moral TAF

• Continuum
• normalization of ITs
• List qualities of a good and bad person
• Identification of a possible double standard

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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
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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

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The paradox of thought control

• The interaction between attention to thoughts and
  the frequency of thoughts
• attention experiments

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Challenging responsibility with piecharting
Me 10
Wife 5
Toy makers 50
Son 20
Weather 10
Playmate 5
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Challenging overestimations of danger