OCD without Compulsive Behaviors: What it is and how to treat it

Transcription

1 OCD without Compulsive Behaviors: What it is and how to treat it Charles Brady, Ph.D, ABPP Director, LCOH OCD and Anxiety Treatment Program Vice President, OCD Midwest

2 CBT Model of OCD Intrusive Thought Negative Appraisal of Intrusive thought Emotional distress Neutralizing response Short term decrease of emotional distress

3 The Nature of Thoughts

4 Klinger (1996) The Nature of Thoughts 4000 Thoughts per 16 hours 13 percent are spontaneous Therefore: An average of 520 spontaneous thoughts per day

5 The Blue Bunny Bet

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7 According to the old criteria of DSM IV, one could logically have OCD without compulsions. This is what some refer to as Pure-O

8 Diagnosis of Obsessive-Compulsive Disorder: DSM V Criteria A. Obsessions are unwanted and uninvited thoughts, urges, impulses, that cause marked anxiety and distress. and The individual tries to ignore, suppress or neutralize them. Compulsions are repetitive behavioral or mental acts aimed at preventing or reducing anxiety or distress associated with obsessions.

9 Are compulsions REALLY absent? Cognitive Compulsions MENTAL REVIEW MENTAL CHECKING feeling, sensation, intention etc THOUGHT NEUTRALIZATION SELF-REASSURANCE COUNTING COMPULSIVE FLOODING SELF-PUNISHMENT MEMORY HOARDING COMPULSIVE PRAYER MENTAL TYPING

10 E/RP for Cognitive Compulsions 1. Identify the underlying fears (This is essential as the fear drives the compulsions!!) 2. Challenge underlying assumptions with Cognitive Therapy 3. Establish hierarchy 4. Review motivational strategies and beliefs 5. Begin Exposure and Response Prevention

11 E/RP for Cognitive Compulsions Ritual Weakening: purposeful slowing/racing, postponing, desequencing, or weaning. Loop Recordings of the fear emphasis on there is no full proof insurance Sustained E/RP Trigger cards to allow continued exposure.

12 Loop Recordings A Loop Recording helps reduce avoidance of fearful thoughts and images and helps habituate these fears. 1. The patient and their therapist records a CD, mp3 recording, or loop audiocassette that contains a script of their fears that contains no reassurances or happy endings. 2. The patient listens to the loop recording, for a specific amount of time per day, or they may be requested to listen a prescribed number of times per day until SUDS < 50% is achieved Violence uncertainty Pedophile uncertainty

13 But Dr Brady, you nit-wit, haven t you been listening!? I m don t have cognitive compulsions I just obsess.

14 The difference between ruminative anxious thoughts and obsessions Obsessions Ruminative anxious thoughts 1. Hit like lightening bolts 2. Ego dystonic 3. Followed by neutralizing behaviors or thoughts. 4. Demand immediate relief 1. rumbling thunder 2. Frequently ego-syntonic 3. Not followed by rituals 4. Content to fester 5. Common in GAD 5. Defining symptom of OCD

15 Faux -Obsessions 1. I can t stop obsessing about possibly losing my job 2. I can t stop obsessing about having to go visit my step-mom in the nursing home 3. I can t get the thought of not getting into med school out of my mind 4. I constantly obsess about getting off work and going to the Horsehoe Casino 5. I obsess about my weight

16 Faux-obsessions are ruminative anxious thoughts (worries) that are usually linked with non OCD diagnoses. (e.g., GAD, social phobia, addictions, eating disorders, health anxiety)

17 What is the role of anxiety? protects us from harm improves performance Moral compass Enhances experiences of excitement and joy

18 Clinical Considerations 1. Are the thoughts ego syntonic? Do they evoke a pleasure response? (eg., gambling, drinking, pornography) Is embracing these thoughts positively reinforced? (e.g, I feel GREAT when the scale reads my happy number! I feel really connected to my kid when I am worried about her being safe at college )

19 Clinical Considerations 2. Are they focused on current problems of future (potential) problems? Current problem I can t stop obsessing about having to volunteer at the homeless shelter every day after work Potential problem I can t stop obsessing about possibly losing my job

20 Treatment of Gerbil Wheel Worries The Goal is not to stop the thought, but to change our fundamental relationship to the thought.

21 Corral the Thought Set up appointment times and places to focus thoroughly on the thought.

22 Pack a Parachute Make a detailed plan of what you will do to cope optimally if the fear comes true.

23 Awkward-ize the Thought a) Slow it down or speed it up b) Sing the worry c) Change the language

24 Mindfully Experience the Thought This is a core component in DBT and ACT approaches to managing distress inducing thoughts. The client learns to observe and make room for the thought rather than trying to banish it. E.g., The Thought Library