Cognitive Behavioural Therapy for Obsessive Compulsive Disorder and Body Dysmorphic Disorder

Transcription

1 Cognitive Behavioural Therapy for Obsessive Compulsive Disorder and Body Dysmorphic Disorder Dr R Arjundas Consultant in Medical Psychotherapy NTW NHS Trust Newcastle upon Tyne, UK

2 Aims Overview of OCD phenomenology Introduce Cognitive Models of OCD Assess OCD Treat OCD using Cognitive and Behavioural Approaches

3 OCD Prevalence 1-2% Early onset years Course chronic and fluctuating Significant reduction in functioning Burden of illness equivalent to Schizophrenia Respond to treatment Access to treatment Availability Engagement factors (therapist and patient factors) Adequacy of treatment

4 Definition of OCD (DSM V) Essential features of OCD are presence of obsessions, compulsions or both They are time consuming (take more that one hour a day) or cause clinically significant distress or impairment in functioning. Not attributable to medical condition or to a substance Not better explained by symptoms of another mental disorder Specify With good insight Poor insight Absent/delusional beliefs 08/10/2018 4

5 Phenomenology Ever had the impulse to: Jump off or push someone off a high bridge Swear or shout in a quiet public place Double check that you have locked the door, turned off the stove Wipe the toilet seat before you ve used it, avoid touching a door handle as you leave

6 Obsessions Recurrent and persistent thoughts, impulses or urges Intrusive or unwanted Cause marked distress or anxiety Sense of diminished control over obsession Individual attempts to ignore or supress thoughts or Neutralise them with other thoughts or action (by performing a compulsion)

7 Content of Obsessions Dirt/Contamination Doubts Harm/injury to others/self Hoarding, Saving, Collecting Religious obsessions, scrupulosity Somatic/Health Sexual Symmetry/exactness Somatic/health concerns

8 Compulsions Mental Acts Repeating words, not saying certain words, praying, counting Repetitive Behaviours Ordering, checking or hand washing Feels driven to perform in response to an obsession Function of compulsive ritual or behaviour is to prevent/reduce distress or dreaded event/situation Clearly excessive

9 Forms of Compulsions Rituals - Cleaning Urges - checking Neutralisation Reassurance seeking Avoidance

10 Nice Guidelines for OCD Mild Up to 10hrs of CBT with ERP using self- help materials, via telephone (with a healthcare professional) or Group therapy with a healthcare professional If not helpful An SSRI or More than 10 hours of CBT with ERP 08/10/

11 NICE Guidelines for OCD If symptoms more severe An SSRI or More than 10hrs of CBT with ERP If symptoms are very severe Combination of CBT with ERP together with an SSRI 08/10/

12 Cognitive Models for OCD Paul Salkovskis (1985) Inflated Responsibility Model Obsessions - normal intrusive thoughts In OCD these are misinterpreted Negative interpretation (high personal responsibility) leads to anxiety Results in Neutralising to reduce distress and perceived responsibility

13 Mood state Cognitive Model of OCD (Mark Freeston, 1997) Normal intrusions Beliefs/ Assumptions Misinterpretations (appraisal- importance/responsibility for harm Daily life events Anxiety Neutralization

14 Case Illustration Chris is a 25yr old man who experiences obsessional thoughts about hitting a child when driving his car. This concern started when he narrowly missed a young child while driving in the local area. This is particularly problematic for him when driving in built up areas where schools are located and at certain times of the day. At times Chris, believing he might have hit a child has returned to the scene resulting in him being late for work and picking his children up from school. He has also been warned about being late for work by his boss.

15 Formulation of OCD Situation Driving Intrusion: Hit the kid with the car Appraisal: What if the kid is fatally harmed I have to make sure he is ok Having the thought means it has happened Anxiety Neutralisation Go back and check Try not to have the thought

16 Cognitive Model of the Persistence of Anxiety: the vicious flower! (Paul Salkovskis) Events, stimuli and situations Anxiety negative physical interpretations reactions Safety seeking behaviour

17 Role Play

18 Obsessive Thoughts Form and Content Types of thoughts reported by most people in the population Similar Content Different reactions Less distress, shorter, less frequent in normal population In OCD more importance given to the thoughts

19 Obsessive Thoughts Coping Strategies Logical to try and do something about the thought if it is distressing Research suggests clinical and non-clinical use a similar range of techniques Rationalisation, reassurance seeking, distraction same frequency in OCD and non -clinical Thought stopping, mental checking, overt compulsions, reappraisal, worry more in OCD Do nothing more often in non clinical groups

20 Obsessional Thoughts - Coping Strategies Neutralisation/Compulsive Behaviour occurs, perhaps efficient in short term Based on the success of this technique the person may continue to utilise it and ATTACH significant importance to the technique in terms of coping with the thought

21 Cognitive Appraisal Theories of OCD Over importance of thoughts Inflated Responsibility Overestimation of threat Importance of Controllability of Thoughts Intolerance of Uncertainty Perfectionistic beliefs

22 Neutralisations Any mental or physical action, regardless of form, performed with the goal of - controlling or removing the thought - changing its meaning - preventing negative consequences - preventing future thoughts - decreasing negative thought (Freeston 2004)

23 Behaviour Therapy for OCD Developed in late 60s and early 70s Aim to modify behavior Directly targets obsessive compulsive behavior, esp compulsions Main ingredient is Exposure and Response Prevention (ERP) NICE (2005) Well established, proven effective for OCD Can be used alone or with medication

24 ERP for OCD Empirically supported treatment Effective in washing and checking compulsions Mild to moderate OCD (NICE 2005) With medication in severe OCD Shortcomings 20% to 30% refuse ERP 25% fail to improve For obsessions less than adequate Treatment factors such as low motivation, non compliance with homework reduce effectiveness

25 CBT for OCD Elements of both BT and CT Currently most popular form of therapy Strongest evidence base (NICE, 2005) Must include an active Behavioural component (ERP) This may be framed cognitively as behavioral experiments + consolidation of new behaviors More flexible than traditional BT without losing focus on changing behavior From Mark Freeston 2011

26 CBT of OCD In-depth assessment Socialisation to OCD model Focus on appraisal of intrusive thoughts and thinking styles Identify neutralisation strategies Exposure and Response Prevention (ERP) Relapse Prevention

27 Assessment Patient history Assessment of OCD Symptoms Obsessions and Compulsions Establish Disruption Rating Avoidance and Safety Behaviours Establish Frequency of Use Target OCD Symptoms and Avoidant Safety Behaviours Rating Scales Provide Information on OCD

28 Assessment - OCD Identify recent episode when patient had obsession Questions to identify Intrusions appraisal emotional and behavioural reactions How did reactions affect the patient

29 Assessment - OCD To identify dysfunctional appraisal When you had the thought what did you think was the worst thing that could happen? Could anything bad happen as a result of the intrusion? Do you do anything to prevent worst from happening? What is the worst that would happen if you did not check?"

30 Socialisation to OCD Model Begins at Session One! Key Components 1) Thinking is Normal! 2) There are two parts of the model that aren t under your control occurrence of thoughts camel effect 3) There are two parts that are under your control importance that you give to the thought neutralisation strategies

31 Camel Test Camel Effect How was that Was it difficult to keep the thoughts in mind Was it difficult to keep the thoughts away

32 Camel effect KEY MESSAGES You can t influence whether you have thoughts but you can influence whether you neutralise them Each time you neutralise you reinforce the importance that you give to your thoughts

33 Appraisal of Thoughts and Thinking Styles How does the person interpret the thought? How important is the thought to the person? There may be different types of misinterpretation Thinking about this means I must want to do it Having this thought means I m bad Thinking this thought can make it happen I should be able to control my thoughts

34 Questions To Identify Neutralising Behaviour Do you seek reassurance from others? Do you try and reassure yourself by saying certain things? Do you seek/refer back to information to try and convince yourself nothing bad will happen? Do you pray or use religious or spiritual things to cancel thoughts out? Do you distract yourself away from thoughts? Do you perform actions (mental or concrete/observable) to control your thoughts, cancel them out or control the emotions associated with the thoughts (anxiety or guilt)? Do you plan to avoid people, places, objects, types of information etc that might trigger the thoughts off?

35 Principles of CBT for OCD Normalisation of intrusions Role of dysfunctional appraisals Differentiating intrusive thought from the appraisal Neutralisation strategies Excessive mental control

36 Interventions Cognitive Restructuring Behavioural Experiments Doubt Reduction Rituals and Emotional Avoidance

37 Cognitive Restructuring Education about occurrence of obsessions Dysfunctional Thought Records Worry about intrusions (appraisals) Thought - action defusion Thought - event defusion Detached Mindfulness

38 Behavioural Experiments Exposure and response prevention Overestimation of threat Intolerance of anxiety Inflated responsibility Intolerance of Uncertainty Thought Action Fusion Bias Importance of Thoughts

39 Exposure and Response Prevention (ERP) Preparing the patient psycho-education In order to break the vicious circle the patient must tolerate the thought Deliberately thinking the thought (exposure) without neutralising (response prevention) Use examples to illustrate, How would you help a child overcome their fears Progressive Exposure

40 ERP (continued) Setting specific goals break into bite size pieces How to test it tapes, physical environment, accompanied, alone Setting the scene Therapist ensures that sequence of events is not contaminated by neutralisation Do it! Utilise exposure self-monitoring forms Repetition

41 Common Pitfalls Patients discovering new thoughts Avoidance Reassurance seeking behaviour (therapist or relatives, friends) Therapy induced neutralisations Making distinctions between believing something is so and fearing something is so Focus on modification of obsessional content

42 Relapse Prevention A clear understanding of the model is essential Possibility of setbacks What to do if setbacks occur The importance of managing the day to day stresses of life Lifestyle balance

43 Further Reading Clark, D.A (2004). Cognitive Behavioural Therapy for OCD. Guilford Press. Freeston, M.H & Ladouceur, R.(1997). The Cognitive Behavioural Treatment of Obsessions: A Treatment Manual Salkovskis, P.M. (1985). Obsessionalcompulsive problems: A cognitive behavioural analysis. Behaviour Research and Therapy 23(5):

44 Body Dysmorphic Disorder Mirror Mirror on the wall, how ugly am I... Is BDD common? 08/10/

45 Definition of Body Dysmorphic Disorder Preoccupation with an imagined defect in appearance or Markedly excessive concern with a slight physical anomaly Causes significant distress or impairment in functioning 08/10/

46 Clinical Features Preoccupations are obsessional in nature Concerns focus on any body part (several frequent) Most common - nose skin hair mouth lips jaw 08/10/

47 Clinical Features (continued) Behaviours - Mirror checking Skin picking Camouflaging Reassurance seeking Co morbidity - Depression OCD Social phobia Substance abuse Suicide risk high 08/10/

48 Assessment (NICE Guidance) Questions to ask Do you worry a lot about the way you look? What specific concerns do you have about your appearance? How many hours a day is your appearance on your mind? What effect does it have on your life? Does it affect your work or social life? 08/10/

49 Cognitive Behavioural Assessment Beliefs Checklist of different parts of body What is defective and associated distress Personal meaning/assumptions held about perceived defect 08/10/

50 Beliefs (continued) Self as aesthetic object Perfectionistic beliefs Social acceptance 08/10/

51 Common Beliefs in BDD I am worthless because of the way I look My worth depends on how I look I must look perfect I ll end up alone if I don t look good 08/10/

52 Cognitive Behavioural Assessment (Behaviours/Rituals) Mirror gazing - Desire to know exactly how they look Hope they will look different If camouflage has worked Feel worse if they do not gaze (Veale & Riley, 2001) Gazing at other reflective surfaces Comparing with others appearance Reassurance seeking Camouflaging Cosmetic surgery 08/10/

53 Social Anxiety and Avoidance Fear of negative evaluation by others Use of safety behaviours Avoidance of range of situations Rate degree of distress without use of safety behaviours 08/10/

54 Engagement Present patient with 2 hypotheses a) He / she is defective; Tries to change appearance b) Excessive worry about appearance. - Appearance the most important aspect of identity. To prove the second hypothesis: a) Give examples of selective attention b) Recommend reading about BDD. 08/10/

55 A Cognitive Behavioural Model of BDD ( David Veale) Trigger (external representation of appearance), e.g. reflection in mirror selective attention Mirror-checking Negative appraisal of internal body image Processing of self as an aesthetic object Avoidance and safety behaviours to change or camouflage appearance Mood (depression and disgust) 08/10/ Rumination on ugliness or defectiveness and comparison to ideal

56 Formulation of BDD Reflection in mirror Over focus on nose Mirror checking It looks like a man s nose I am ugly Nobody will like me I will end up alone Put make up on to make Shame it less prominent Distress Cover sides of face with hair 08/10/

57 Similarities between OCD and BDD Permanent persistent thoughts Compulsive behaviours (mirror checking) Avoidance Perfectionistic beliefs 08/10/

58 Differences between OCD and BDD Thoughts not experienced as intrusive Limited to imagined flaws Not resisted More suicidal ideas/attempts in BDD 08/10/

59 BDD - Treatment Response Prevention Exposure to social situations Cognitive restructuring Behavioural Experiment Mirror Retraining Refocusing Habit reversal 08/10/

60 Cognitive Restructuring Target assumptions/meaning about being defective Behavioural experiments to evaluate assumptions Target beliefs about self as aesthetic object Reverse role play 08/10/

61 Response Prevention Mirror Retraining Interrupts Selective Attention Look at entire face/body Full length mirror Objectively describe body from head to toe Do not check parts that are disliked Use mirror only for agreed purpose 08/10/

62 Suggested Reading 1. Veale D & Wilson R (2005) Overcoming Obsessive Compulsive Disorder 2. Veale D. (2010) Body Dysmorphic Disorder: A Treatment Manual. Wiley, Chichester 3. Katharine A Phillips (2005) The Broken Mirror, Oxford Press 08/10/