obsessive compulsive disorder - SEED

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(Neziroglu, F. The Relationship Between Eating Disorders and OCD: Part of the ... Individuals who suffer from AN commonly diet and exercise excessively,.

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Obsessive  Compulsive  Disorder   and  Eating  Disorders   Who s  Driving  the  Bus?     By  Guy  Oberwise,  LCSW   Directory  of  Primary  Therapy  and  Mood  Disorders   Coordinator   Timberline  Knolls  Residential  Treatment  Center   Lemont,  Ill.  

Welcome  and  Background   •  Timberline  Knolls  almost  seven   years   •  25+  years  as  clinician/therapist  -­‐-­‐   down  in  the  trenches   •  Last  two  years,  more  expertise  in   Mood  and  Anxiety  Disorders   •  CertiRied  in  ERP  

Table  of  Contents   •  Relationship  between  ED  and  OCD   •  OCD  Spectrum  Disorders   •  ED  Behavior  and  OCD  Thought  Process   •  Crash  Course  in  OCD   •  Who  is  Driving  the  Bus?   •  Assessment  and  Treatment  Approaches   •  Exposure  and  Response  Prevention   •  Treatment  Approaches  for  both  ED  and   OCD  

Relationship  Between  ED  and  OCD   •  Common  views  about  eating  disorder  behaviors:   –  –  –  – 

performing  rituals  around  food   obsessing  about  what  to  eat  or  weight   whether  food  will  sit  in  their  stomachs  and  make  them  feel  ugly   preoccupation  with  body  image  

•  Most  people  do  not  think  of  ED  as  being  part  of  the  OCD  spectrum.   •  In  an  effort  to  alleviate  their  patients  suffering,  sometimes   professionals  mistake  one  for  the  other.   •  Since  behaviors  that  result  from  both  OCD  and  EDs  appear  similar,   it  might  be  difRicult  to  determine  which  of  the  two  disorders  the   patient  actually  has  if  both  are  simultaneously  present.   •  Which  disorder  is  mainly  responsible  for  bringing  about  the  other?                            (Neziroglu,  F.  The  Relationship  Between  Eating  Disorders  and  OCD:  Part  of  the  Spectrum)              

Relationship  Between  ED  and  OCD   •  Since  1939,  researchers  have  speculated  on  the   parallels  between  OCD  and  ED.   •  Numerous  studies  now  show  that  those  with  eating   disorders  have  statistically  higher  rates  of  OCD  (11%  -­‐   69%)  and  vice  versa  (10%  -­‐  17%).   •  As  recently  as  2004,  Kaye  et  al.  reported  that  64%  of   individuals  with  eating  disorders  also  possess  at  least   one  anxiety  disorder,  and  41%  of  these  individuals   have  OCD  in  particular.          

 (Neziroglu,  F.  Relationship  between  Eating  Disorders  and  OCD:  Part  of  the  Spectrum)  

Relationship  Between  ED  and  OCD   •  In  1983,  Yaryura-­‐Tobias  and  Neziroglu  proposed  that   ED  may  be  considered  part  of  the  OCD  spectrum;   currently,  boundaries  among  AN,  BN  and  OCD   remained  blurred.   •  Challenge  for  clinicians:  recognizing  whether  the   condition  is  a  particular  form  of  OCD  or  an  entirely   separate,  but  related,  disorder  with  symptoms  that   merely  have  an  obsessive-­‐compulsive  quality  to  them.   –  Individuals  who  suffer  from  AN  commonly  diet  and  exercise  excessively,   those  with  bulimia  usually  develop  a  vicious  cycle  of  binging  and  purging.   –  In  both  instances,  extreme  and  often  life-­‐threatening  behaviors  that   consist  of  either  consuming  too  little  or  too  much  food  typically  stem  from   intrusive,  obsessive  thoughts.        

 (Neziroglu,  F.  Relationship  between  Eating  Disorders  and  OCD:  Part  of  the  Spectrum)  

OCD  Spectrum  Disorders  

OCD  Spectrum  Disorders   Dysphoria

Euphoria Hoarding

Somatization Body Dysmorphic Disorder

Substance Abuse Paraphilia

OCD Hypochondriasis

Gambling

Eating Disorders

Kleptomania

Trichotillomania Nail Biting Harm

Habits

Impulse Control

(Steketee, Gail, Ph.D, Overcoming Obsessive-Compulsive Disorder, Best Practices for Therapy, 1999)

OCD  Spectrum  Disorders   •  A  variety  of  conditions  have  been  classiRied  as   OCD   Spectrum  disorders,  but  there  is  some  doubt  about   their  linkage  to  OCD  and  appropriateness  of  ERP  for   these  conditions.   •  These  disorders  vary  with  OCD  along  two  dimensions:   impulsive/compulsive  behavior  and  dysphoric/ euphoric  mood.   •  OCD  falls  into  the  moderately  dysphoric  mood  range;   the  feeling  of  being  compelled  to  engage  in  rituals   because  of  discomfort  is  the  hallmark  of  this  disorder.                                                                                                                                                      (Steketee,Gail,  Overcoming  Obsessive  Compulsive  Disorder,  Best  Practices  for  Therapy,  1999)  

OCD  and  Bulimia   •  Most  clearly  related  is  bulimia,  which  is  characterized  by   ingesting  excessive  amounts  of  food,  an  anxious  and  dysphoric   state,  followed  by  purging  and/or  use  of  laxatives  to  relieve   discomfort   •  Bulimia  has  responded  well  to  treatments  similar  to  those  used   in  OCD,  but  according  to  diagnostic  criteria  for  OCD,  when   obsessive  thoughts  are  focused  on  food  and  weight  gain,  the   condition  would  be  considered  an  eating  disorder.   •  An  exception  to  this  rule  can  be  seen  in  the  case  of  a  young   woman:   –  Obsessed  about  contamination  from  food,  poisoning  from  chemicals  or  medications   in  her  food.   –  Ate  little  and  occasionally  forced  herself  to  vomit  because  of  fears.    Although  she   was  very  thin  and  possibly  malnourished,  because  of  their  function,  her  symptoms   were  better  classed  as  OCD  than  an  eating  disorder.                                                                                                  

 (  Steketee,  Gail,  Overcoming  Obsessive  Compulsive  Disorder,  Best  Practices  for  Therapy,  1999)  

BDD  and  OCD   •  Body  Dysmorphic  Disorder  is  close  to  the   compulsive  and  dysphoric  end  of  spectrum.   •  The   disorder  of  imagined  ugliness   –  individuals  believe  that  one  or  more  parts  of  their  bodies(e.g.,   nose,  thinning  hair)  are  defective  and  provoke  ridicule  or   rejection  from  others.   –  often  seek  reassurance  and  medical  intervention  to  correct  the   presumed  defects.                      (Steketee, Gail, PhD., Overcoming Obsessive Disorder, best practices for therapy, 1999)

Hypochondriasis  and  OCD   •  Hypochondriasis  overlaps  somewhat  with  OCD,  differing  mainly  in   the  greater  generality  of  fears  of  illness  in  hypochondriacal  clients  who   are  typically    concerned  about  a  range  of  potential  diseases.       •  By  Contrast,  OCD  sufferers  report  a  focused  obsession  in  one  main   area,  as  in  the  case  of  one  woman  who  sought  medical  testing  and   checked  her  breast  repeatedly  for  cancer  (a  condition  from  which  her   mother  died)  to  the  point  of  physical  damage   •  Anorexia  resembles  BDD  and  hypochondriasis,  but  the  focus  of  anxiety   is  on  body  weight.    Distinctive  to  all  three  conditions  is  marked  lack  of   insight  into  the  presumed  physical  Rlaw,  illness,  or  underweight,   whereas  most  OCD  sufferers  express  clear  awareness  of  the   excessiveness  of  their  fears  ( I  know  this  sounds  ridiculous,  but… ),   and  only  a  minority  lack  insight.          (Steketee, Gail, PhD., Overcoming Obsessive Disorder, best practices for therapy, 1999)

Anxiety  and  Eating  Disorders   •  Anxiety  disorders  are  common  in  eating   disordered  individuals  and  often  declare   themselves  prior  to  the  onset  of  the  ED  (Kaye,   Bulik,  Thorton,  Barbarich,  &  Masters,  2004)   •  Although  rates  of  individual  AD  diagnoses  differ   among  ED  subtypes,  higher-­‐than-­‐expected  rates  of   social  phobia,  obsessive  compulsive  disorder,   panic  disorder,  agoraphobia,  and  GAD  have  been   reported  in  all  subtypes  (Hudson  etal.2007;Kaye   et  al.,2004).  

In  Summary   •  EDs  generally  implicate  phobic  elements  (e.g.,  the   fear  of  weight  gain),  obsessive  preoccupations   (e.g.,  over  attention  to  body  shape),  and   compulsive  reactions  (e.g.,  the  need  to  purge  after   eating).   •  Feasible  to  frame  and  work  with  eating  symptoms   as  variants  of  anxiety-­‐driven  behaviors,  applying   the  concepts  of   phobia, obsessions,  and   compulsions  to  weight  gain  fears,  bodily   preoccupations,  and  driven  weight  loss  strategies          

 (see  Barlow,  Allen,  &  Choate,  2004)

ED  Behavior    and   OCD  Thought  Process  

Anorexia  Nervosa   Diagnostic  Criteria   •  Refusal  (or  obsession  and  compulsion)  to  maintain   body  weight  at  or  above  a  minimally  normal  weight   for  age  and  height  (e.g.,  weight  loss  leading  to   maintenance  of  body  weight  less  than  85%  of  that   expected;  or  failure  to  make  expected  weight  gain   during  period  of  growth,  leading  to  body  weight  less   than  85%  of  that  expected).   •  Intense  fear  of  gaining  weight  or  becoming  fat,   even  though  underweight.               (Keel and Mccormick2010)

Anorexia  Nervosa   Diagnostic  Criteria   •  Disturbance  in  the  way  in  which  one s  body   weight  or  shape  is  experienced,  undue  inRluence  of   body  weight  or  shape  on  self-­‐evaluation,  or  denial  of   the  seriousness  of  the  current  low  body  weight.   •  In  postmenarcheal  females,  amenorrhea,  i.e.,  the   absence  of  at  least  three  consecutive  menstrual  cycles.  

(Keel and Mccormick2010)

Eating  Disorders   •  Sufferers  rely  on  symptoms  to  control   overwhelming  internal  feelings,  fears,   intense  pain  or  other  troubling  emotions.   •  High  co-­‐occurrence  with  substance  abuse   •  High  rates  of  trauma  

Roots  of  EDs   EDs  develop  in  the  context  of:   –  Genetic  predispositions   –  Environmental  factors   –  Medical  history   –  Life  experiences   –  The  presence  of  co-­‐occurring  psychiatric  and   addictive  disorders  

ED  Clinical  Phenomenology   •  •  •  •  •  •  •  •  •  • 

Loss  of  control   Unsuccessful  attempts  to  stop  the  ED  behaviors   Great  deal  of  time  spent  thinking  about  or  engaging  in  the  behaviors   Continuing  despite  negative  consequences   Withdrawal  symptoms  including  irritability,  restlessness,  insomnia,   depressed  mood,  self-­‐injury   Tolerance   Negative  impact  on  social,  occupational  or  recreational  activities   (disease  of  isolation)   Limited  emotion  regulation  skill   Denial/secrecy/shame   Body  image  distortions/dissatisfaction  

Food/Weight  Related  Symptoms   •  Behaviors  associated  with  ED  may  include:   –  Consistent  adherence  to  increasingly  strict  diets,  regardless   of  weight   –  Habitual  trips  to  the  bathroom  immediately  after  eating   –  Secretly  bingeing  on  large  amounts  of  food   –  Stealing  food   –  Hoarding  food   –  Exercising  compulsively  often  several  hours  per  day   –  Compulsive  weighing/body  checking  

 

Social,  Cognitive  and  Spiritual  Signs   •  Withdrawal  from  friends/family   •  Avoidance  of  meals  or  situations  where  food  may  be   present   •  Preoccupation  with  weight,  body  size  and  shape   •  Obsessing  over  calorie  intake  or  expenditure   •  Memory  and  planning  difRiculties   •  Rigid,  black  and  white  thought  patterns   •  Disconnection  from  value  system  and  self  

Crash  Course  in  OCD  

Diagnostic  Criteria  For  OCD   A.    Either  obsessions  or  compulsions.   –  Obsessions  are  deRined  by:   • 

•  • 

• 

   

Repetitive  and  persistent  thoughts,  images,  or  impulses  that   are  experienced  at  some  point,  as  intrusive  and  inappropriate   and  that  cause  marked  anxiety  or  distress.   Thoughts,  images  or  impulses  are  not  worries  about  real-­‐life   problems   Person  tries  to  ignore  or  suppress  the  thoughts,  images,  or   impulses,  or  neutralize  them  with  some  other  thought  or   action   Thoughts,  images  or  impulses  are  recognized  as  a  product  of   one s  own  mind  and  not  imposed  from  without.    

 

 (Jonathon  Abramowitz,  Obsessive-­‐Compulsive  Disorder2006)

Diagnostic  Criteria  for  OCD   –  Compulsions  are  deRined  by:   •  Repetitive  behaviors  or  mental  acts  that   one  feels  driven  to  perform  in  response   to  an  obsession  or  according  to  a  certain   rule   •  the  behaviors  or  mental  acts  are  aimed  at   preventing  or  reducing  distress  or   preventing  feared  consequences;   however  the  behaviors  or  mental  acts  are   clearly  excessive  or  are  not  connected  in   a  realistic  way  with  what  they  are   designed  to    neutralize  or  prevent   (Jonathon Abramowitz, Obsessive Compulsive Disorder2006)

Diagnostic  Criteria  for  OCD   B.  At  some  point  during  the  disorder,  the  person  has  recognized   that  the  obsessions  or  compulsions  are  excessive  and   unreasonable.   C.  The  obsessions  or  compulsions  cause  marked  distress,  are   time-­‐consuming  (take  more  than  1  hour  a  day),  or  signi=icantly   interfere  with  usual  daily  functioning.   D.  The  content  or  the  obsessions  or  compulsions  is  not  better   accounted  for  by  another  Axis  I  disorder  (e.g.  concern  with   appearance  in  the  presence  of  body  dysmorphic  disorder,  or   preoccupation  with  having  a  serious  illness  in  the  presence  of   hypochondriasis).   E.  Symptoms  are  not  due  to  the  direct  physiological  effects  of  a   substance  or  a  general  medical  condition.   ( Jonathan Abramowitz, Obsessive Compulsive Disorder2006)

Obsessions  Reported  by  a  Non-­‐ Clinical  Sample   Several  studies  have  clariRied  that  85-­‐90%  of  ordinary  people   experience  intrusive  thoughts  or  mental  rituals  that  are  quite   similar  in  nature  to  and  content  to  those  of  OCD  suffers.    Such  as:   –  –  –  –  –  –  –  –  – 

Impulse  to  hurt  or  harm  someone.   Thought  of  intense  anger  toward  someone,  related  to  a  past  experience.   Impulse  to  say  something  nasty  and  damning  to  someone.   Thought  of  harm  to,  or  death  of,  close  friend  or  family  member.   Thought  that  something  is  wrong  with  your  health.   Thought  whether  an  accident  had  occurred  to  a  loved  one.   Impulse  to  crash  car  while  driving.   Thoughts  about  accidents  or  mishaps,  usually  when  about  to  travel.   Thought  of  harm  befalling  her  children,  especially  an  accident.  

 

Thus,  it  is  not  the  intrusive  quality  of  obsessions  that  is  atypical,   but  rather  their  frequency,  intensity,  and  capacity  to  disturb  the   person  who  experiences  them,  as  well  as  the    difRiculty  in  getting   rid  of  them.          

Common  Observed  OCD   symptoms     •  Contamination  –  Obsessions  concerning  contamination  from   dirt,  germs,  body  secretions,  household  items,  poisonous   materials;  washing  and  cleaning  rituals,  avoidance   •  Harming  –  Obsessions  concerning  responsibility  for  injury  or   harm  to  others;  compulsive  checking,  seeking  assurance,   repeating  activities    to  prevent  disasters   •  Incompleteness  –  Obsessions  concerning  order,  asymmetry,   imbalance  (perhaps  the  fear  that  discomfort  will  persist   indeRinitely);  compulsive  arranging,  ordering,  repeating   •  Unacceptable  thoughts  –  Obsessional  thoughts,  impulsive   images  of  sex,  sacrilege  and  violence;  mental  rituals,   neutralizing,  seeking  assurance  

Common  Obsessions   •  Thoughts  of  contamination  from  germs,  dirt,  fungus,   animals,  body  waste,  or  household  chemicals.   •  Persistent  fears  and  doubts  that  one  is  (or  may   become)  responsible  for  harm  or  misfortunes  such   as  Rires,  burglaries,  awful  mistakes,  injuries   •  Unacceptable  sexual  ideas  (e.g.  molestation)   •  Unwanted  sacrilegious  thoughts  (e.g.  desecrating  a   synagogue)   •  Need  for  order,  symmetry,  completeness   •  Fear  of  certain  numbers  (e.g.  13,  666),  colors  or   words  (e.g.  murder)  

Common  Rituals   •  Washing  one s  hands  50  times  per  day  or  taking   multiple  (lengthy)  showers   •  Repeatedly  cleaning  objects  or  vacuuming  the  Rloor   •  Returning  several  times  to  check  that  the  door  is  locked   •  Placing  items  in  the   correct  order  to  achieve   balance   •  Re-­‐tracing  one s  steps   •  Re-­‐reading  or  re-­‐writing  things  to  prevent  mistakes   •  Calling  relative  or  experts  to  ask  for  reassurance   •  Thinking  the  word   life  to  counteract  hearing  the  word   death   •  Repeated  and  excessive  confessing  of  one s   sins   •  Repeating  a  prayer  until  it  is  said  perfectly  

Safety  Behaviors  in  OCD   •  Passive  avoidance  –  Avoidance  of  situations  and   stimuli  (e.g.,  driving,  being  the  last  one  to  leave  the   house,  toilets,   666 )   •  Compulsive  rituals  – Hand  washing,  checking,   seeking  assurances,  repeating  routine  activities   •  Covert  neutralizing  –  Mental  rituals  (e.g.,  repeating   prayers,   good  words,  or   safe  phrase),  brief   mental  acts  (e.g.,  canceling  out  a   bad  thought  with   a   good  thought)   •  Brief  or  subtle   mini  rituals  -­‐  Use  of  wipes  or   paper  towels,  quick  checks  of  appliances,   scrutinizing  others  behavior  or  facial  expressions.  

Prevalence  and  Course   •  OCD  is  quite  common,  occurring  in  2.5   percent  of  the  population  (one  in  forty   people)  at  some  point  during  their  lives.   •  Fourth  most  common  psychiatric  disorder   •  Men  and  women  affected  almost  equally   •  Age  of  onset  is  a  few  years  younger  for   males  then  for  females              (Gail  Steketee,  Ph.D.,  Overcoming  Obsessive  Compulsive  Disorder,  Best  Practices  for  Therapy1999)    

Similarities   OBSESSIVE  COMPULSIVE  DISORDER

   

  •  Individual  counts  the  number  of                                                                                                                                   mouthfuls  chewed  or  pieces  of  food     in  a  meal,  according  to  some  Rixed  or     magical  number  that  is  “correct”  or   EATING  DISORDERS   “just  right.”       •  Individual  repeatedly  washes  hands,   due  to  a  fear  of  germs,  contact  with   •  Individual  counts  mouthfuls  or  pieces   waste  products,  or  a  number  of  other   of  food  as  a  means  of  limiting   portions  and  thus  effectively  losing   sources  of  possible  contamination   more  weight.   that  exist.   •  Individual  throws  out  food  in  a  can   •  Individual  excessively  washes  hands   that  has  been  slightly  dented,  for  fear   to  remove  trace  amounts  of  oil  that   might  cause  weight  gain  if  ingested.   that  it  might  contain  food  poisoning   and  later  cause  serious  illness  to   •  Individual  throws  out  food  in  a  can   someone.   because  it  was  discovered  to  contain   too  many  calories  after  reading  the   label.                             (Neziroglu.F. The Relationship Between Eating Disorder and OCD:       Part of the Spectrum)

Similarities   OBSESSIVE  COMPULSIVE  DISORDER  

•  Individual  repeatedly  asks  a  waiter  in   a  restaurant  about  different  dishes  on   menu,  doubtful  that  he  or  she  has   •  enough  knowledge  to  make  the   perfect  meal  decision.   •  Individual  refuses  to  enter  the   kitchen  in  order  to  eat,  due  to  fear  of   accidentally  mixing  the  cleaning   •  items  with  the  food.   •  Individual  repeatedly  checks   refrigerator,  shelves  or  other  parts  of   house,  in  order  to  make  sure  that   every  piece  of  food  bought  is  in  its   •  proper,  designated  place.    

EATING DISORDERS

Individual  constantly  asks  same   waiter  about  contents  of  dishes,  so  as   to  stay  away  from  having  any  butter,   oil,  or  fat.   Individual  refuses  to  enter  the  same   room,  for  it  will  only  lead  to  the   temptation  to  eat  and  thus  get  fat.   Individual  constantly  checks  same   locations,  in  search  of  food  to  eat  in   an  extensive  bulimic  binge  period.  

(Neziroglu.F. The Relationship Between Eating Disorder and OCD: Part of the Spectrum)

So  Who  is  Driving  the  Bus?   •  In  the  case  of  both  anorexia  and   bulimia,  obsessions  lead  to  levels   of  anxiety  that  can  only  be   reduced  by  ritualistic   compulsions.   •  The  compulsive  behaviors  of   anorexics  can  often  be  seen  in   their  careful  procedures  of   selecting,  buying,  preparing,   cooking,  ornamenting,  and   eventually  consuming  food.  

(Neziroglu,F. Eating disorder and OCD:Part of the Spectrum)

So  Who  is  Driving  the  Bus?   •  Just  as  with  OCD,  compulsions  are   commonly  strengthened  by  many   other  personality  traits  such  as   uncertainty,  meticulousness,  rigidity,   perfectionism  (Yaryura-­‐Tobias  et  al.,   2001)   •  The  common  thread  linking  both   anorexia  and  bulimia  to  OCD  is  the   overwhelming  presence  of  obsessions   and  compulsions  that  eventually   affects  the  individual s  daily   functioning  even  to  the  extent  of   becoming  incapacitated.     (Neziroglu,F. Eating disorder and OCD:Part of the Spectrum)

So  Who  is  Driving  the  bus?   •  As  with  an  OCD  sufferer  who  can  never  achieve  that   just  right   feeling  on  a  speciRic  task,  so  is  a  bulimic  prevented  from  ever   reaching  his  or  her  goals  of  fullness  and  emptiness  in  an  endless   binge-­‐purge  cycle.   •  Lastly,  the  OCD  sufferer  who  may  loose  weight  excessively  and   appear  anorexic,  yet  is  doing  so  merely  as  the  result  of   contamination  concerns  or  time  consuming  rituals  that  prevent   him  or  her  from  eating  on  a  regular  basis.   •  The  potential  for  one  disorder  to  appear  as  the  other  is   virtually  endless….  

So  Who  is  Driving  the  Bus?   •  When  food  or  eating  is  the  object  of  fear  and  worry,  anxiety   symptoms  must  be  differentiated  from  an  eating  disorder.   –  For  instance,  patients  with  a  phobia  of  certain  foods  (due  to  a  fear   of  choking  or  vomiting)  may  restrict  their  eating,  lose  weight,  and   be  difRicult  to  distinguish  form  those  with  anorexia  nervosa.  

•  In  addition,  eating  and  anxiety  disorders  can  co-­‐occur,  as   with  a  woman  with  anorexia  who  has  also  had  obsessions   that  she  would  absorb  calories  (and  gain  weight)  by   merely  touching  or  looking  at  food.  (John  Abramowitz,   Exposure  Therapy  for  Anxiety2011)  

Considerations  for  Therapy  and   Approach   •  If  a  patient  is  underweight,  careful  consideration   should  be  given  to  health  implications,  as  well  as  the   potential  for  cognitive  impairment  which  could   prevent  learning  during  exposure.    Exposure  therapy   might  be  delayed  until  a  healthy  weight  can  be   maintained.   •  In  instances  where  a  speciRic  phobia  (choking  on  food)   has  resulted  in  a  signiRicant  weight  loss  that  threatens   the  patient s  health,  a  combined  exposure  and  weight   restoration  approach  may  be  required.  

Assessment  and  Treatment   Approaches  

Assessment  Tools   •  Yale-­‐Brown  Obsessive  Compulsive  Scale   •  A  symptom  checklist  and  a  severity  rating   scale   •  Symptom  checklist    provides  deRinitions  and   examples  of  obsessions  and  compulsions    

Treatment  Approaches   Currently,  two  empirically  supported   treatments  exist  for  OCD:   1.  Cognitive-­‐Behavioral  Therapy   2.  Pharmacotherapy  involving  serotonin   reuptake  inhibitors(SRI)  medication  

Medication  for  OCD   •  Anafranil            Clomipramine        Up  to  250mg/day   •  Zoloft                        Sertraline                      Up  to  200  mg/day   •  Prozac                      Fluoxetine                    Up  to  40  to  80mg   •  Luvox                        Fluvoxamine          Up  to  300  mg/day   •  Paxil                            Paroxetine                  40  to  60  mg/day   •  Celexa                      Citalopram                  up  to  60mg/day                                                (Johathan  Abramowitz,  Obsessive  Compulsive  Disroder2006)  

Medication  for  OCD   •  These  agents  are  thought  to  reduce  OCD  by   increasing  the  concentration  of  serotonin     •  On  average,  20%  to  40%  improvement  in   OCD  symptoms  over  a  12  week  period  

Advantages/Disadvantages   Advantages:   •  Safe  and  easy  to  use   •  Clinically  effective:  20  to  40  percent  of  time  

Disadvantages:   •  •  •  • 

Limited  improvement  rates   About  50%  of  people  do  not  improve   Possible  side  effects   Must  be  used  continuously  for  improvements  

Cognitive  Behavioral  Therapy   (CBT)   •  Based  on  understanding  of  the  symptoms   •  Vital  components  of  CBT  include:   –  Education   –  Cognitive  therapy  techniques   –  Exposure  Therapy   –  Response  Prevention  

CBT   •  Entails  socializing  the  patient  to  the  cognitive-­‐ behavioral  conceptual  model  and  providing   rationale  for  how  the  treatment  techniques  are   designed  to  weaken  obsessions  and   compulsions.   •  CBT  techniques  for  OCD  involve  rational   discussion  to  help  the  patient  identify  and   correct  mistaken  beliefs  that  underlie   obsessional  fears,  avoidance,  and  safety-­‐ seeking  behaviors.  

Exposure  and  Response   Prevention   •  Centerpiece  of  the  treatment  program   •  Exposure  entails  gradually  confronting  situations  and  thoughts   that  evoke  obsessive  fears   •  Accompanied  by  imagining  the  feared  consequences  of  exposure   •  Patient  remains  exposed  until  the  associated  distress  decreases   on  its  own,  without  attempting  to  reduce  the  distress  by   withdrawing  form  the  situation  or  by  performing  compulsive   rituals   •  Response  prevention  component  of  CBT  entails  refraining   from  any  behaviors  that  serve  to  reduce  obsessional  anxiety  or   terminate  exposure  

Advantages/Disadvantages  of   CBT/ERP  

Advantages:   •  Clinically  effective:  60  to  70%  symptom  reduction   on  average   •  Treatment  is  fairly  brief  (usually  15  to  20  sessions)   •  Long  term  maintenance  of  treatment  gains   Disadvantages:   •  Patient  must  work  hard  to  achieve  improvements   •  Involves  purposely  evoking  anxiety  during  exposure   •   Trained  ERP  Therapist  not  widely  available  

Developing  the  Hierarchy   •  At  TK,  therapist  Rirst  interviews  the  resident  carefully   to  obtain  a  detailed  list  of  situations  that  provoke   obsessional  fears.   •  Fears  are  arranged  in  a  hierarchy  from  least  to  most   difRicult  according  to  the  level  of  discomfort  provoked   •  Discomfort  to  each  situation  is  rated  on  a  0  (none)  to   100  (maximum)  Subjective  Units  of  Discomfort  Scale   (SUDS)   •  Based  on  SUDS  rating,  each  exposure  is  assigned  each   week  of    therapy  grouping  together  those  with  similar   themes,  contexts,  and  associated  discomfort  level  

Direct  Exposure   •  During  therapy  sessions  at  TK,    the  therapist   describes  and  often  demonstrates  how  the  resident   should  engage  in  the  exposure  to  ensure  that  she  is   not  avoiding  obsessive  cues   •  Therapist  inquires  about  the  resident s  thoughts   and  demotions,  asking  for  ratings  of  discomfort   every  Rive  to  ten  minutes  to  ensure  that  the  resident   is  fully  exposed  to  all  aspects  of  cues  for  discomfort   •  If  anxiety  is  relatively  low  or  declines  rapidly,  the   resident  will  be  asked  to  confront  the  next  item  on   her  hierarchy  

Imagined  Exposure   •  Residents  can  experience  catastrophic  obsessive   thoughts  and  images  that  occur  spontaneously  in   their  everyday  lives;  thoughts  and  images  are   difRicult  to  provoke  fully  during  direct  exposure.   •  Therapist  constructs  imaginary  scenes  in  which   these  feared  obsessions  and  their  catastrophic   outcomes  (Rire,  burglary,  running  over  a  pedestrian)   occur   •  Scenes  are  ordered  from  least  to  most  discomforting   •  During  sessions,  therapist  inquires  about  sensory   perceptions,  thoughts,  and  emotional  and   physiological  feelings    

Effective  Treatment  Approaches  for  Both   ED  and  OCD  Symptomology   •  •  •  •  •  •  •  •  •  • 

DBT   CBT   ACT   Exposure  Therapy   Medication   Expressive  Therapies   Group  Therapy   Experiential  Therapy   Family  Systems   12-­‐Steps  

Summary   •  Diagnosing  clients  with  both  ED  and  OCD   symptoms  is  not  easy!   •  Use  the  YBOC s  to  help  diagnose  OCD  symptoms   •  Weight  restoration  takes  precedence  over  OCD   symptoms   •  Exposure  Therapy  should  be  done  with  a  trained   therapist   •  Use  multiple  treatment  options  and  approaches  

Hierarchy  Examples   Contamination  fears:    SUDS  1  to  7     7    Taking  shower   6    Touching  shower  curtain  with  hand   5    Touching  shower  curtain  with  paper  towel   4    Stepping  into  shower  stall   3    Looking  at  shower,  imagine  getting  in  and   starting  to  shower   2    Looking  at  the  shower   1    Thinking  about  taking  a  shower  

Hierarchy  Example   •  •  •  •  •  •  •   

Need  to  know  or  remember       Fear  of  losing  things  –  checking  binder,  organ.   Checking  that  did  not  make  a  mistake   Checking  that  didn t  forget  something   Counting  up  to  4  and  back  down   Rewriting/rereading  homework  assignments   Fear  of  not  saying  just  the   right  thing  

Thank  you!    

Guy  Oberwise   [email protected]   630.343.2324  

A  residential  treatment  center   located  on  43  beautiful  acres   just  outside  Chicago,  offering  a   nurturing  environment  of   recovery  for  women  ages  12   and  older  struggling  to   overcome  eating  disorders,   substance  abuse,  mood   disorders,  trauma  and  co-­‐ occurring  disorders.     www.timberlineknolls.com    |    1.877.257.9611  

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