OCD Service: Back to Clinical Practice. August 7, 2015
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1 OCD Service: Back to Clinical Practice August 7, 2015
2
3 Pichaya Kusalaruk, Ratana Saipanish, Thanita Hiranyatheb
4 First line treatment t t for OCD Selective serotonin reuptake inhibitors (SSRIs) Cognitive behavior therapy (CBT) Exposure and response / ritual prevention (EX/RP or ERP)
5 Insert a VDO of OCD Case
6 Cognitive Behavioral Therapy for OCD
7 Outline Concept of CBT Assessment for OCD Case conceptualization How does CBT tackle OCD? Let s bring it to our practice!!
8 Concept of CBT
9 Event Appraisal Emotional Bh Behavioral response response
10 Assessment for OCD
11 Assessment for OCD Fear profiles Avoidance profiles Ritual profiles Reassurance seeking behaviors Involving others Stressors Past treatment
12 Measures Yale Brown Obsessive Compulsive Scale (Y BOCS) Yale Brown Obsessive Compulsive Scale Second Edition (Y BOCS II) Florida Obsessive Compulsive Inventory (FOCI)
13 Thai version of the Yale Brown Obsessive Compulsive Scale Second Edition (Y BOCS II T) Thai self report version of the Yale Brown Obsessive Compulsive Scale Second Edition (Y BOCS II SR T) Thai version of the Florida Obsessive Compulsive Inventory (FOCI T) severity scale symptom checklist
14 Case conceptualization
15 Emotional response Intrusions Appraisals Selective attention Rituals and Avoidance neutralising
16 How does CBT tackle OCD?
17
18 Exposure and response prevention (ERP)
19 Anxiety Time
20
21 Anxiety Habituation Time
22 Ltt Let try some experiments!!
23 Cognitive restructuring
24 Dysfunctional beliefs promote problematic behaviors Inflated responsibility Thought action fusion Overestimate of threat Intolerance of uncertainty
25 Responsibility Pie chart
26 Socratic questioning Evidences support/against your beliefs? Another explanations of the situation? Effect of thinking or believing this? Effect of thinking differently? Third person perspective?
27 Metaphor
28
29 Let s bring it to our practice!!
30 1. Finding information & Get in Rx Assessment Case conceptualization Empathy, validation Psychoeducation & Socializing CBT
31 2.Exposure/Behavioral experiment Tackle OCD behaviors
32 In session exposure
33 Events Subjectiveunitof unit distress (SUDs) Touching public bin 100 Using public toilet 80 Touching car 60 Cleaning table 40
34 Rating scale of anxiety (0 10) Listing avoidance situation Stop avoidance Rate your anxiety level again!! Reflection
35 3. Cognitive restructuring Tackle OCD thoughts Externalizing OCD : Naming OCD Pie chart, socratic questions, metaphor
36 Exposure/ Cognitive Behavioral restructuring experiment
37 4. Feedback and Homework What you have learnt? What are useful/useless things? Homework
38 Conclusion Assessment ERP Cognitive restructuring Feedback& homework
39
40
41 How to choose treatment modality Combined treatment Unsatisfied response to monotherapy Severely ill Co-morbid conditions for which SRIs are effective Pts wish to limit the duration of SRIs APA. Practice Guideline for the Treatment of patients with OCD, 2007
42 Which SSRI do you usually prescribe for your OCD patients? Fluoxetine Fluvoxamine Paroxetine Sertraline Escitalopram
43 Pharmacotherapy Drugs Starting Usual target Usual Occasionally dose dose maximum maximum Dose dose Clomipramine Escitalopram Fluoxetine Fluvoxamine Paroxetine Sertraline
44 After starting medication, most OCD patients will experience improvement around. 4-6 weeks 6-10 weeks weeks >12 weeks
45 How many of OCD patients do not response satisfactorily to SRIs monotherapy? 20% 20-40% 40-60% *** >60% *** Pallanti and Qurecioli Prog Neuropsychopharmacol Bio Psychiatry 2006: 30;
46 Which drug do you use for augmentaion? Haloperidol Risperidoneid Olanzapine Quetiapine Aripipazole
47 Augmentation: ti Augmentation: Antipsychotics Antipsychotics i Risperidone appears to have the strongest effects. Dold M et al. Int J Neuropsychopharmacol. 2013; 16(3): Aripiprazole, i haloperidol, l risperidone id significantly outperformed placebo. Dold M et al. Int J Neuropsychopharmacol. 2015; 18(9): 1-11
48 Successful medication should be continue for..? 6 months 1 year 2 years 5 years Successful medication treatment should be continued for 1 2 years before considering a gradual taper by decrements of 10% 25% % every 1 2 months while observing for symptom return or exacerbation
49 How to choose treatment modality ERP alone Not too depressed, anxious, severely ill to cooperate Prefer not to take medication Willing to do the work in ERP SRI alone Not able to cooperate with ERP Has previously responded to drugs Prefer SRIs alone APA. Practice Guideline for the Treatment of patients with OCD, 2007
50 Outcome of SRIs Fontenelle et al. Expert Opin. Pharmacother. 2007;8 (5):
51 Outcome of SRIs Response ~ 30% responded to first drug trial Minimal symptoms (Remission)???
52 What to do next? Response Continue for 1-2 yr, then consider gradual taper off Partial response Augment with SGA Add ERP Little or no response Switch to different SSRI (may try more than one) Clomipramine Venlafaxine Mirtazapine Augment with SGA APA. Practice Guideline for the Treatment of patients with OCD, 2007
53 What to do next? Consider Switch to different SRI, different augmenting g with SGA Augment with Clomipramine, Buspirone, Pindolol, Morphine, Inositol, Glutamate antagonist, MAOI CBT (ERP) if not already provided. TMS, DBS, ablative neurosurgery APA. Practice Guideline for the Treatment of patients with OCD, 2007
54 Outcome of ERP in OCD Khodarahimi S. J Contemp Psychother 2009; 39: 203-7
55 Outcome of ERP in OCD ERP > Waiting list Fritzler, Hecker, & Losee, 1997 van Balkom et al, 1998 McLean et al, 2001 Vogel, Stiles, & Gotestam, 2004 Khodarahimi, 2009 ERP > anxiety management Lindsay et al., 1997 > Progressive Muscle Relaxation Fals-Stewart et al., 1993 Marks et al., 2000 Greist et al., 2002 > Stress Management Simpson et al., 2008b
56 Outcome of ERP in OCD Half of all treated patients show clinically significant change with ERP Fewer still show full remission Ponniah et al. JOCRD (2013)
57 Comparing SRI VS ERP Foa, et al. Am J Psychiatry 2005;162:151-61
58 Comparing SRI VS ERP Romanelli et al. Depression & Anxiety 2014;1-12
59 Augmentation
60 Augmentation: ti Augmentation: Antipsychotics Antipsychotics Bloch et al. Mol Psychiatry. 2006;11(7):
61 Augmentation: ERP Tenneij et al. J Clin Psychiatry 2005; 66:
62 Augmentation ti to SRIs ERP VS antipsychotic
63 Augmenting SRIs:ERP vs Risperidone 100 OCD patients on SRIs > 12 wks Moderate severity (YBOCS 16) RCT ERP=40,Risperidone=40,placebo=40 Simpson, Foa et al. JAMA 2013;70(11):1190-8
64 Augmenting SRIs:ERP vs Risperidone Simpson, Foa et al. JAMA 2013;70(11):1190-8
65 ERP has superior efficacy and less negative adverse effect profile than negative adverse effect profile than antipsychotics
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