How Anxiety and Repetitive Behaviors Interact to Complicate a Child s Life. Topic Relevance. Webinar Goal: Simplification. Slide 1 Common Threads:

Transcription

1 1 Common Threads: How Anxiety and Repetitive Behaviors Interact to Complicate a Child s Life 2 Topic Relevance Clinical Disorders F42.2 Obsessive-Compulsive Disorder F95.2 Tourette s Disorder F93.0 Separation Anxiety Disorder F41.1 Generalized Anxiety Disorder Kathryn Roberts, Ph.D. Postdoctoral Fellow COTTAGe University of Pennsylvania 3 Webinar Goal: Simplification

2 4 Overview Domain of anxiety-related RBs Commonalities: Diagnostic features of anxiety & RBs Reinforcement models of anxiety & RBs Evidence-based treatment approaches Utility in treatment Direction of the field Consolidation of treatment principles Flexibility and generalization 5 Anxiety-Related RBs 6 Functional Development of RBs Repetitive behaviors are adaptive in early stages of development Decrease anxiety Learn about the environment Bear similarities to repetitions of numerous psychopathological presentations

3 7 Anxiety-Related RBs Features of maladaptive anxiety-related RBs Repetition Rigidity Invariance Inappropriateness Anxiety-related : anxiety as a trigger, commonly co-occuring with anxiety disorders 8 Diagnostic Similarities 9 Anxiety-Related RBs Tic Disorders Autism Spectrum Disorders Excoriation Disorder Pathological Gambling Obsessive-Compulsive Disorder Trichotillomania Specific Phobias Separation Anxiety Generalized Anxiety

4 10 Function of Diagnosis To determine the nature of the disease in order to administer optimal treatment Cuthbert & Insel (2013) 11 Limitations to Categorial Approach Creation and definition of disorders Excessive comorbidity Overlapping symptoms and phenomenology Similar brain areas and networks involved 12 Limitations to Categorial Approach Patient 1 Patient 2 Clinical Disorders F42.2 Obsessive-Compulsive Disorder F41.9 Unspecified Anxiety Disorder F84.0 Autism Spectrum Disorder (by history) Clinical Disorders F42.2 Obsessive-Compulsive Disorder F95.2 Tourette s Disorder F93.0 Separation Anxiety Disorder F41.1 Generalized Anxiety Disorder

5 13 Limitations to Categorial Approach Creation and definition of disorders Excessive comorbidity Overlapping symptoms and phenomenology Similar brain areas and networks involved 14 Limitations to Categorial Approach Obsessive-Compulsive Disorder Trichotillomania Specific Phobias Separation Anxiety Generalized Anxiety Anxieties vs. OCD Intrusive thoughts, overlapping content areas Differentials: Avoidance vs. compulsive behaviors Extent of repetition in the moment 15 The case of Perfectionism Discomfort associated with failing, making mistakes or things not being just so

6 16 Limitations to Categorial Approach Tic Disorders Autism Spectrum Disorders Body-focused RBs Pleasurable? (Exc, TTM) Physical nature of urges, relief Cognitive urges OCD-like Excoriation Disorder Pathological Gambling Obsessive-Compulsive Disorder Trichotillomania 17 The case of Tourettic OCD Two flavors of OCD Just Right Negative Outcomes 18 Limitations to Categorial Approach Creation and definition of disorders Excessive comorbidity Overlapping symptoms and phenomenology Similar brain areas and networks involved

7 19 Reclassification of Symptoms Research Domain Criteria (RDoC) AREA OF FUNCTIONING (e.g., responsiveness to punishment) Typical Atypical 20 Reclassification of Symptoms Research Domain Criteria (RDoC) Is atypical performance monitoring a common thread across repetitive behaviors? 21 Similarities in Reinforcement Models OCD? Tics? Areas of the brain Levels of hormones, neurotransmitters Behavioral Level Brain Level

8 22 Reclassification of Symptoms NIMH s Research Domain Criteria (RDoC) Initiative Determine underlying threads associated with RBs Informs treatment precision Shift away from categorical model Brain areas & circuits underlying RBs 23 Anxiety Reinforcement Anxious Thought Relief Distress subsides temporarily Distress Anxiety, fear, disgust, shame Avoidance Anxiety, fear, disgust, shame Negative Reinforcement 24 OCD Reinforcement Obsessions Repetitive negative images or impulses Relief Distress subsides temporarily Compulsions Repetitive thoughts, images or actions Distress Anxiety, fear, disgust, shame Negative Reinforcement

9 25 Tic/TTM/Picking Reinforcement Relief Urge subsides temporarily Triggers Behavior Tics, Pulling, Picking Urges Physical or cognitive discomfort Negative Reinforcement 26 The Vicious Cycle of Avoidance D I S C O M F O R T Avoid Avoid Avoid But level of discomfort stays high long-term Avoidance temporarily relieves discomfort TIME 27 Reinforcement: Common Threads Difficulty tolerating discomfort Pattern of Avoidance

10 28 Treatment Similarities 29 Treatment Comparison Presentation Anxiety Disorders OCD Trichotillomania/Exc oriation Tic Disorders Evidence-Based Treatment Cognitive-Behavioral Therapy (CBT) Exposure/Response Prevention (EX/RP) Habit Reversal Training (HRT) Comprehensive Behavioral intervention for Tics (CBIT) Treatment Components Awareness training Cognitive restructuring Exposure Exposure Response Prevention Awareness training Competing response training Social support HRT Function-based intervention 30 Awareness Training Triggering situations - decreasing triggers - strategies to prevent behaviors (PREVENTs) Thoughts, urges - lean into anxiety - doing another behavior to ride out urge (COMPETEs) Behaviors - gradual steps to lean into urge or discomfort

11 31 Stimulus Control In Body-Focused RBs Prevent the behavior Implemented in triggering situations, when behaviors are interfering Don t increase tolerance of urges X Stimulus Control PREVENT 32 Stimulus Control In OCD Urges to engage in interfering behavior Where possible, SC can be used to decrease interfering behavior Considerations with Anxiety Urges to avoid Would perpetuate avoidance 33 EX: Flexibility to Treatment Approach Presentation: Intrusive thoughts of social media Researching compulsions Lingering, strong urge intensity Diagnostically: OCD Reinforcement Models: Discomfort: Not just right need to know Reinforcement: researching Flexible use of treatment modules: Exposure/response prevention Stimulus control at first that is faded with exposures

12 34 Competing Responses Reallocate attention Reduce tics Implemented in the presence of urges X Stimulus Control PREVENT X Competing Responses COMPETE 35 U R G E L E V E L Competing Responses/Exposure Urge PEAK MASTERY OF TICS Begin Competing Response TIME 36 Exposures: Anxiety, OCD D I S C O M F O R T Discomfort PEAK TIME

13 37 Competing Responses Tolerating not just right feelings in OCD Functioning despite anxiety (can t guarantee habituation) Attention reallocation To something motivating To task at hand EX: Flexibility to Treatment Approach Presentation: Disgust reaction to stickers ASD Diagnostically: OCD, ASD Reinforcement Models: Discomfort: Difficulty tolerating discomfort Reinforcement: avoidance Flexible use of treatment modules: Exposure/Response Prevention Competing responses during exposures EX: Flexibility to Treatment Approach Presentation: Fears shift with environment Predominant fears: Lyme disease Robbers at nighttime Diagnostically: GAD, OCD features Reinforcement Models: Discomfort: Difficulty tolerating uncertainty, Reinforcement: reassurance-seeking, checking, avoidance Flexible use of treatment modules: awareness of anxiety for shifting fears, cognitive strategies, exposure/ response prevention for compulsive behaviors

14 40 Function-Based Analyses Managing external contingencies (CBIT) Other Applications Neutral environment Reduction of accommodations Reduction of reinforcement 41 Common Threads in Treatment Awareness Training Stimulus Control Competing Responses Exposures to Discomfort Reduction: Accomod/ Reinforc. 42 Direction of the field of psychology Diagnostically: evidence of underlying brain-based threads; informing more precise treatments Reinforcement Models: understanding of how behaviors are perpetuated, informs treatment Treatment Modules: increased options and flexibility in finding most effective treatment

15 43 Tips for Parents Comfort in that there are common threads among these presentations Guide child using simple, key principles Leaning into discomfort Functioning despite discomfort Stepping stones: What piece can you do? Fading reallocation of attention Functioning despite discomfort 44 Tips for Parents Lean into discomfort 45 Implications for Providers Assuage family s fears during diagnostic evaluations Consolidate language to increase accessibility Generalize treatment principles for a client - Lean into discomfort - Relapse prevention/generalize concepts Increase flexibility for treatment Consider use of modular components to other presentations like ASD (informed by RDoC)

16 46 Take-Aways Field shifting away from categorical thinking about presentations Common threads can be useful: Understanding links among disorders Similar key principles across treatments Flexible treatment approaches Fueling research toward increased treatment precision 47 Thank you! Child & Adolescent OCD, Tic, Trich & Anxiety Group Online: Phone: Thank you to the New Jersey Center for Tourette Syndrome and Associated Disorders (NJCTS) for providing the Wednesday Webinar series!