Week 10: Obsessive Compulsive Disorder

obsessive-compulsive disorder (OCD)

(F42) A. Presence of obsessions, compulsions, or both: Obsessions are defined by (1) and (2): 1. Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress. 2. The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion). Compulsions are defined by (1) and (2): 1. Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive. Note: Young children may not be able to articulate the aims of these behaviors or mental acts. B. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. C. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition. D. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder). Specify if: With good or fair insiglit: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true. With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true. With absent insight/deiusionai beiiefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true. Specify if: Tic-reiated: The individual has a current or past history of a tic disorder.

Inhibitory learning Outcome: Variety

-Conducting exposure in a variety of different contexts: locations, interpersonal (with and without the therapist), and different emotional conditions (fear, versus calm). -Learning occurs best when it is does in a variety of different contexts.

Habituation

-Decreasing the PHYSIOLOGICAL and Fearful Emotion Response to frequently repeated stimuli. (Use a fear ladder) -Shifting the belief system, and reducing the link between the belief and threat appraisal. -Changes Behavior First. Cognitions are changed due to the behavioral proof. Emotions change last in response to the changed cognition. -Over time as the fear decreases, the belief that the threat is high also decreases. Exposure to Distressing Stimuli (Bathroom: Floor, Door Handles, Toilet Seats, etc.) During Exposure, the Body eventually begins to decrease anxiety response Prevention Response (Cannot wash hands, must eat lunch). -Over time, client's begin to learn that the threat of the stimulus is irrational. -This is done many times, until the client states that they are no longer in distress. -This is done with the therapist present.

Inhibitory Learning Model

-Helps people learn safety behaviors that are strong enough to INHIBIT (extinction) the original fear. -We are working on ways to inhibit(extinction) the fear from returning. Goal: Clients learn that sometimes the feared outcome occurs in the presence of their obsessions, and other times their feared outcomes do not occur, and therefore there is more emotion and cognitive flexibility regarding what the outcome will be. -Starts with emotions, then cognitions, finally behavioral changes. -This is done through the following steps: Tolerating the Anxiety, Disconfirming Expectations, "Surprise", Combining Fear Cues, and Variety.

Inhibitory learning Model: Tolerating the Anxiety

-Providing clients with the knowledge that: --Obsessional Fears are less probable than predicted. --Obsessional thoughts are safe and tolerable (they are just thoughts). --Compulsions are not needed to maintain safety, nor are they needed to tolerate anxiety. -All of that to say, teaching clients to keep an open mind that fear and anxiety are an inevitable experience. -The feared stimuli is safe, and so is the emotional response. -What does this sound like? :)

Fears that cannot be tested

-Religious, and Sexual Obsessions: Are not obsessions that can necessarily be tested. Example: A person may have an obsession with prayer, otherwise they will go to hell. There isn't a way to test that. In other words there is no way to do exposure. -ERP works with clients to learn how to tolerate the uncertainty of feared outcome. No longer carry a fear association because the connections is no longer enforced through rituals or avoidance.

Disconfirming Expectations

-Teaching people to disconfirm feared outcomes. -An intervention is used to directly disconfirm the anxious prediction. -Fear of being around a knife because you are sure you are going to hurt someone. Disconfirming expectations: having someone hold a knife, and see how many people they hurt. -Each exposure is used to determine if the expected negative outcome occurred. "What ended up happening?"

Inhibitory learning Model: Surprise

-When we are surprised by the outcome, it tends to stick in our minds. -Feared expectation does not match the actual outcome.

OCD Facts

Average age of onset is approximately 19.5 years old. Rare for new incidents to occur after age 30 years old. Males have an earlier onset of the disorder than females (approximately age 10). However, females are more likely than males to develop OCD, usually beginning in adolescence. OCD is thought to come from the relationship among neurobiology, genetics and environment. Significant improvement or remission(yes this is possible) when evidenced based practices such as... you guessed it... CBT are used. * Fenske J.N., and Petersen, K. (2015) Obsessive- Compulsive Disorder: Diagnosis and Management. University of Michigan Medical School, Ann Arbor, Michigan.

Treatment

CBT to the rescue! Exposure and Response Prevention (ERP) Therapy. This is the GOLD STANDARD for treating OCD. Exposure to the source of the fear over and over again WITHOUT acting out any compulsions. See pages 118-119 in CBT For Beginners. ERP has been shown to have better effects on patients than medications alone.

Type of OCD Cognitive Distortions

Catastrophizing Emotional Reasoning: The danger is there because you think it to be so. All of Nothing Personalizing What If Fortune Telling

Inhibitory learning Theory- Combining Fear Cues

Combining multiple fear cues, and identifying that the feared outcomes did not occur.

Exposure and Response Prevention

ERP works in two ways: First, known as the Habituation. Exposure over time, teaches client's that the threat of the stimulus is unlikely. Second, Inhibitory Learning Model. Exposure brings new safety based associations to the feared stimuli. Exposure is the key underlying both parts of the model. *Abramowitz, J. (2018) The Inhibitory Learning Approach to Exposure and Response Prevention. The OCD Newsletter. Bostan,S.N., (2018) Exposure and Response Prevention for OCD: What underlying processes my cause behavior change in Treatment? Psychology Today.

Common Symptoms in Patients with OCD

Obsession: Aggressive: -Fear of harming others, recurrent violent images --Monitoring the news reports of violent crimes, asking for reassurance about being a good person Contamination: -Fear of being contaminated or contaminating others; fear of being contaminated by germs, infections or environmental factors; fear of being contaminated by bad or immoral persons --Washing or cleaning rituals Pathologic doubt about completeness: -Recurrent worries about doing things incorrectly or incompletely, thereby negatively affecting the patients or others. --Checking excessively, performing actions in a particular model Religious: -Thoughts about being immoral and eternal damnation --Asking forgiveness, praying, reassurance seeking Self-Control: -Fear of making inappropriate comments in public --Avoiding being around others Sexual: -Recurrent thoughts about being a pedophile or sexually deviant, recurrent thoughts about acting sexually inappropriate toward others. --avoiding situations that trigger the thoughts, performing mental rituals to counteract the thoughts Superstition: Fears of certain "bad" numbers or colors --Counting excessively Symmetry and Exactness: Recurrent thoughts of needing to do things in a balanced or exact fashion --Ordering and arranging

Assessment Tools

Yale-Brown Obsessive Compulsive Scale -Assess the severity of the symptoms, and the degree to which those symptoms impair the client in their areas of functioning.

ErP at Work

https://www.youtube.com/watch?v=1ISWXhNnx1o&feature=youtu.be