Download Stress and Anxiety in Obsessive

Stress and Anxiety in
Obsessive-Compulsive
Disorder
Kieron O`Connor & Frederick Aardema
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Characterized by the occurrence of persistent
thoughts, urges, or images that are
experienced as intrusive and unwanted
(obsessions), and compulsive actions that the
individual feels driven to perform in response
to an obsession aimed at preventing or
reducing anxiety or distress, or preventing
some dreaded event or situation from
occurring (American Psychiatric Association
[APA], 2013).
Obsessive Compulsive Disorder
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making mistakes / ‘rightness’
provoking accidents
contamination
severe illness and/or mental illness
violence, horrific thoughts
sexuality
religion, moral dilemmas, existential
concerns
Obsessional Themes
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checking
washing
cleaning
arranging, ordering
reassurance seeking
mental rituals
hoarding
avoidance
Types of Compulsions
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Obsessive compulsive Disorder no longer
classified as an anxiety disorder in DSM-V, so
what role does anxiety play in this disorder?

Purely behavioral models of OCD view
anxiety as a key emotion.
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Most cognitive -behavioral models, and
appraisal models of OCD in particular, view
anxiety (and compulsions) as mediated by
the appraisal of intrusive cognitions.
The Role of Anxiety in OCD
Stimulus
(stress?)
Anxiety
(stress?)
Compulsion
Obsession
Behavioral Models of OCD
Intrusive
Thought
Appraisal
of the
Thought
Obsession
Anxiety
(stress?)
Compulsion
Appraisal Model of OCD
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The distinction between stress and
anxiety not always clear in cognitivebehavioral models.
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Treating OCD with stress-management is
as effective as treating OCD though an
appraisal model of OCD (Whittal et
al,2010).
However, severity of OCD affects the
effectiveness of stress management
therapy for OCD (Maher at al, 2010).
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Stress in Models of OCD
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Is stress a trigger, or a consequence
similar to anxiety in OCD?
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The literature suggests that stress may be
more like a trigger or vulnerability factor
rather than a consequence like anxiety.
Stress: Trigger or Consequence?
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It has been proposed that people develop
compulsions to deal with control over
stress and negative life events (ReuvenMagril et al, 2008).
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However, perceived stress in obsessivecompulsive disorder is related with
obsessive but not compulsive symptoms
(Morgado et al. 2013)
Stress as a Trigger in OCD
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Low distress tolerance and life stressors
predict obsessions, but not compulsions
(Macatee, 2013).
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Intrusive and repetitive thought appears
to be a general stress-response tendency
seen in a large proportion of persons after
even mild to moderately stressful events
(Horowitz, 1975).
Stress as a Trigger in OCD
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While stress not appear to cause OCD,
stress and negative life events may
increase vulnerability to OCD.
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Psychosocial stress predicts future
symptom severities in children and
adolescents with obsessivecompulsive disorder (Haiqun et al. 2007).
Stress as a vulnerability factor
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Stressful life events often precede the
onset of OCD (60.8%) and are associated
with a rapid onset of OCD and somatic
obsessions (Gianluca, 2012).
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High thought suppression coupled with
low control over stressful life events is
associated with OCD symptoms
(MacLaren et al., 2003).
Stress as a vulnerability factor
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There is a distinction between positive
and negative stress.
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Exposure in vivo and response prevention
in the treatment of OCD triggers stress,
but has positive effects in reducing
obsessions and compulsions.
Positive and Negative Stress
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Goal directed positive stress as applied in
demanding treatments may have different
effects than negative effects.
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For example, despite considerable stress
induced in the patient during exposure in
vivo, there is no increase in cortisol levels
(Kelner et al, 2012)
Goal Directed Positive Stress
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A patient in stress often gets caught up in
meta-cognitive negative thinking about
his/her problems that are not at the core
of the problems.
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The client feels “lost” in the general
negative feeling of it all.
Stress in Clinical Practice
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Difficult to initiate regular treatment when
the client is constantly stressed, and
dealing with meta-cognitions and stress
before initiating regular treatment may be
required.
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Stress management could be considered
before commencing regular treatment to
both reduce the amount of triggers and
preoccupation with symptoms.
Stress in Clinical Practice
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Other feelings can also act as a trigger for
symptoms, and there are different forms
of negative stress, such as frustration and
boredom (Roberts & O’Connor 2013).
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For example, in a simulated provocation
task, Riskind (2007) found that when
OCD patients were frustrated in reaching
their goals, they experienced significantly
more intrusive thoughts and distress than
non-clinical controls.
Different Forms of Negative Stress
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The literature suggests that stress primarily
acts as either a vulnerability factor or trigger
in OCD.
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Stress is not related to compulsions, but it
may increase the occurrence of obsessions.
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No clear distinction in current appraisal
models of OCD, which mainly focus on
intrusive cognitions and appraisals, but not
on triggers.
Summary: Stress and Anxiety
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OCD is no longer considered an anxiety
disorder in DSM-V.
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Anxiety is a consequence, whereas stress
primarily acts as a vulnerability factor or
trigger.
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An Inference Based approach (IBA)
conceptualizes OCD rather as a belief
disorder.
OCD as a Belief Disorder
Prompt/
Trigger
A thought,
situation,
or feeling
which
draws
attention
Doubt
Imagined
Consequences
Anxiety
Compulsive
Action
Start to
doubt that
everything
is okay
If everything is not
okay,
then there
will be bad
consequences
Your level
of anxiety
goes up
even if
you try
to resist
You feel
that you
have to do
something
to make sure
everything
is okay
The IBA Model: Case
conceptualisation
Prompts/Triggers - What draws the
attention to doubt
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Internal:
◦ Can be a thought, an emotion, a physical
sensation, and feelings of stress.
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External:
◦ Can be the sight or touching of an object, a
situation or environment, and stressors in the
environment.
Case Conceptualization: Prompts
and Stress
Internal/
external
prompt
Rushing out
of the
house when
late for
work
Obsessional
doubt
Consequences
of doubt
Maybe the
door is not
shut properly
If it's not
shut, someone
will be able to
get into my
house and
steal my
belongings
Anxiety
Compulsive
action
I'll be lost
without my
belongings
I better
check the
door
Example of stress trigger
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Degree of belief in obsessional doubt
detemines other emotions and
consequences.
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Understanding the nature of pathological
doubt reduces vulnerability to stress
triggers and seems to reduces
consequences of anxiety across OCD
subtypes (Int. J. of Cognitive
therapy,7,1,2014: Special Issue).
Thank You!