Download Obsessive Compulsive Disorder

Obsessive Compulsive Disorder
Ashwini Sabnis, M.D
DSM -5 OCD Criteria
Obsessions
• Recurrent & persistent thought, impulses, or images
that are experienced, at some time during the
disturbance, as intrusive and inappropriate & that
cause marked anxiety or distress.
• The thoughts, impulses, or images aren’t simply
excessive worries about life problems.
• The person attempts to ignore or suppress such
thoughts, impulses, or images, or to neutralize them
with some other thought or action.
• The person recognizes that the obsessional thoughts,
impulses, or images are a product of his/her own mind
(not imposed from without as in thought insertion).
Compulsions
• Repetitive behaviors (e.g., hand washing,
ordering, checking) or mental acts (e.g., praying,
counting, repeating words silently) that the
person feels driven to perform in response to an
obsession, or according to rules that must be
applied rigidly.
• The behaviors or mental acts are aimed at
preventing or reducing distress or preventing
some dreaded event or situation; however, these
behaviors or mental acts either are not
connected in a realistic way with what they are
designed to neutralize or prevent or are clearly
excessive.
Epidemiology of OCD
• 2.5% lifetime prevalence
• Prevalence is similar for men and women
• Onset occurs typically occurs during adolescence
or early adulthood
• Onset is earlier for males than females
• Tends to be chronic without treatment with
periods of waxing and waning of symptoms
• Onset after age 35 in females is unusual but is
possible
Associated Disorders
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Depression
Body Dysmorphic Disorder
ADHD
Eating disorders
Tourette’s disorder and motor tics
Generalized Anxiety Disorder
Behavior theory
• Mowrer’s 2-Factor Theory
– Obsessions come to evoke anxiety through
classical conditioning
– Anxiety is reduced through compulsion, which are,
therefore, reinforced (operant conditioning)
• Evidence:
– Animals learn to avoid aversive stimuli in an
“obsessive” way
• But:
– Aren’t intrusive thoughts aversive to being with?
– Why doesn’t everyone develop OCD?
Causes of OCD
• Elevated activity in the
Frontal Lobe and Basal
Ganglia
• Activity is not typical in
people without mental
illness
• PET (Positron emission
Tomography) scan used
in brain imaging
Brain Activity
Functional Classification
(Foa et al, 1985)
• Internal fear cues
• External fear cues
• Fears of harm or disastrous consequences
Obsessions
Fear/Anxiety
Reduction in
Distress
Compulsions
Piacentini et al, 2006)
OCD cycle
SUD's
The OCD Trap
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Time
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Common Themes
• Contamination and cleaning (hand washing)
• Self doubt and checking, re-writing, repeating,
hoarding
• Organizing / need for symmetry
• Scrupulosity (religious obsessions)
• Aggressive obsessions (fear of harming others)
Treatment
• COGNITIVE BEHAVIORAL THERAPY
• Highlight the role of dysfunctional beliefs and
interpretations that sustain rituals
– More appropriate and applicable to treating
adults
• Cognitive therapy must be done carefully
– Can reinforce rituals or engender new ones
• Use CT to externalize OCD symptoms or
motivate children
– The OCD monster
– Let’s try an experiment
CBT
• Assessment
• Psychoeducation
• Socialization to treatment
– For child and family
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Development of an OCD symptoms hierarchy
Engage in exposures and active treatment
Conclude treatment
Offer booster sessions as needed
Assessments
• Office Visits
• The Anxiety Disorder Interview Schedule –
Revised (ADIS-R)
• The Yale-Brown Obsessive-Compulsive
Symptom Checklist (Y-BOC)
• The Leyton Obsessional Inventory (Lol)
• The State Trait Anxiety Inventory of Children
(STAIC)
• Overestimation of the importance of thoughts
– Distorted thinking
– Thought-action fusion
– Magical thinking
• Responsibility
• Perfectionism
– Need for certainty
– Need to know
– Need for control
Psychoeducation
• Emphasize that exposures will be gradual
• May need to motivate some youth
– Be dispassionate and firm
– Motivational interviewing techniques
• Exposure intensity corresponds with positive
treatment outcomes
• The therapist should establish rapport
– Convey warmth, optimism, confidence,
• Information Gathering Phase (2 sessions)
– Session 1 (2 hrs.)
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Obtaining info on OCD symptoms
History of the problem
Defining the disorder
Rationale for treatment
Overview of treatment Program
Teaching patients to Monitor symptoms
• Information Gathering Phase (2 sessions)
– Session 2 (2 hrs.)
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Inspection of patient’s self-monitoring
Collecting information about obsessions and compulsions
Generating the treatment plan
Rules for selection of exposure situations
Develop clear contract between therapist and patient
Teaching patients to Monitor symptoms
Homework assignment
• Obsessions
– external fear cues
– internal cues
– consequences of external and internal cues
• Avoidance Patterns
– Passive avoidance
– Rituals
– Relationship between avoidance patterns and fear cues
• Treatment Phase (15 daily sessions, 120 min. each)
– Format of exposure session
– Implementation of exposure
– Homework assignments
– Comments during exposure sessions
– Response prevention
• Rules
• Return to normal behavior
– Common difficulties during sessions
• For Washer
– Session 1: walk with therapist through the building touching
doorknobs, holding each for several minutes
– Session 2: Repeat above and add contact with sweat by having patient
touch armpit and inside of shoe
– Session 3: Repeat above but introduce having patient touch toilet
seats
– Session 4: Repeat above but introduce urine by having patient hold a
paper towel dampened in his own urine
– Session 5: Repeat above but introduce fecal material by having patient
hold toilet paper lightly soiled with his own fecal material
– Sessions 6-15 Daily exposure to the three most fear-provoking
activities are repeated.
• For Checker
– Session 1: turn the lights on and off once, turn stove on and off once,
open and close doors once (leave room immediately without checking)
– Session 2: Repeat above and add flushing of toilet without looking in
the bowl
– Session 3: Repeat above but introduce opening gate to the basement
and allowing daughter to play near the gate
– Session 4: Repeat above but introduce carrying daughter on concrete
floor
– Session 5: Repeat above but introduce driving on highway without
retracing route
– Sessions 6-15 Daily exposure to the three most fear-provoking
activities are repeated.
• No ritualistic checking is permitted
• One check (normal checking) is permitted
• Designated relative or friend supervises
response prevention adherence at home
• Therapist/supervisor is to stay with patient
until urge to check diminishes
• Violations of home practice are reported to
therapist
• Non-compliance with response prevention
instructions
• Continued passive avoidance
• Arguing/balking about exposure/response
prevention requirements
• Emotional overload
• Family reactions
Development of symptom hierarchy
• Day 1 or 2 (the easiest part of treatment)
• Work with child to develop a list of feared
stimuli or situations
• Write down everything and ask clarifying
questions
• Rank order items on a scale (1 – 10; 1 – 100)
• “Everything is a 10!”
• “Nothing scares me”
• Use of anchor points and contrasts
OCD Hierarchy
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SUDS Level
99 Touching an unknown sticky substance, without washing
95 Holding loose hair
90 Touching known sticky substances (e.g. egg), without
washing
85 Touching unknown trash articles
60 Using a public restroom
60 Witnessing a political argument
60 Witnessing other sensitive-subject arguments (i.e. religion)
OCD Hierarchy
• 60 Seeing parents spend a lot of money at one time
• 60 Touching loose hair with finger
• 55 Touching known sticky substance (e.g.
syrup),without washing
• 50 Touching a known sticky substance (e.g. soda),
without washing
• 30 Touching a dirty railing
• 30 Walking into a public bathroom
Exposure and Response
Prevention
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CBT with exposure and response prevention (ERP)
is the best established psychological treatment for
OCD.
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Gold standard (DeRubeis & Crits-Christoph, 1998).
63% to 83% of participants obtained some benefit, many long term
after ERP (Abramowitz, 1997; Foa & Kozak, 1996; Stanley & Turner,
1995).
ERP
•. With repeated exposure to the same cue or
trigger without using compulsions, anxiety and
distress reactions also decrease until the cue
becomes significantly less bothersome.
ERP
• Part One - Imaginal Scripting
– Using your hierarchy formed in the previous activity create an
imaginal script or exposure for a distressing item (SUDS around
7 or 8).
– Examples
– Funeral of a loved one
– Skydiving
ERP
• Part Two - En Vivo ERP
– Form into groups of three – be the
therapist / student
– Take turns leading one another through your
exposure
– Monitor SUDs level!
– Do not flood
– Do not go above a 5 or 6…
– Proceed until SUDS level drops by half
Check list
Trigger Obsession Compulsion Temp 1-10
Pharmacological Treatments
for OCD
• Clomipramine*
• SSRIs
• Fluoxetine
• Fluvoxamine*
• Sertraline
Prognosis
• OCD tends to last for years, even decades.
The symptoms may become less severe from
time to time, and there may be long intervals
where symptoms are mild
• For most, the symptoms are chronic
• With a combination of pharmacotherapy and
behavior therapy, symptoms can be controlled