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9 Strategies for Success Exposures must be voluntary and only something the therapist would also be willing to do Challenge any response of I ll try Can start with a delay in the compulsion Must do purposeful, planned exposure daily - be specific Note the expectancy violation The learning is in the doing I don t want to tell you about this because then I ll have to do it Go beyond what normal people would do Find a behavioral exposure for obsessions such as an avoidance of trigger pexels Eliminate safety behaviors

10 Exposure Examples Hold a knife Look at photos Write an imaginal script Evoke feeling on purpose and don t correct it Drive around in an area with triggers Say a prayer or compulsion incorrectly Touch or ingest something contaminated Change the ritual or undo it

11 Tolerating Distress In Exposure Anxiety may get worse before it gets better Mindfulness and expansion (ACT) - The Happiness Trap by Russ Harris (2007) Headspace app Diaphragmatic breathing Coping statements i.e. I don t like feeling this way, but I can handle it. Recognizing fear of fear and anticipatory anxiety Benzodiazepine??? vimeo Use interoceptive exposures first

12 Cognitive Therapy

13 Cognitive Therapy Inflated sense of responsibility Over-estimation of the importance or power of thoughts Importance of controlling thoughts Overestimation of danger or threat Intolerance of uncertainty PublicDomainPictures.net

14 Information-seeking vs. Reassurance Seeking An information-seeker Asks a question once Asks questions to be informed Accepts the answer provided Asks people who are qualified to answer the question Asks questions that are answerable Seeks the truth Accepts relative, qualified or uncertain answers when appropriate Pursues only the necessary information to form a conclusion or make a decision A reassurance seeker Repeatedly asks the same question Asks questions to be less anxious Responds to an answer by challenging the answer, arguing, or insisting the answer be repeated or rephrased Often asks people who are unqualified Often asks questions that are unanswerable Seeks a desired answer Insists on absolute, definitive answers Indefinitely pursues information without every forming a conclusion or making a decision. Anxiety Disorders Center, St. Louis Behaviors Medicine Institute

15 How you can support Please do not Try to help figure it out. OCD cannot be figured out. It is not rational. Help the patient determine what caused the OCD. Help the patient strategize how to avoid her anxiety. Try to convince the patient his obsession is unreasonable or incorrect. Give reassurance. Answer the question once - Dr. Hancey s 4A pixabay

16 Indications the patient is not ready Drug use to manage anxiety Self-harm during distress/poor distress tolerance Always having an excuse for not doing the homework Primary fear of panic or somatic sensations -> use interoceptive exposure first

17 Obsessive Compulsive Disorders Clinic James Hancey, M.D.,Clinic Director Call for intake Location: Sam Jackson Hall, 6th Floor via Elevator C Parking: Physicians' Pavilion Clinic Hours: Monday through Friday, 8:30 am. to 5 p.m. Fax: The Obsessive Compulsive Disorders Clinic provides evaluation and treatment for patients with Obsessive Compulsive Disorder and Obsessive Compulsive Spectrum disorders such as tricho that meets on the 1st and 3rd Thursdays of the month.

18 Check out our website at ocdoregon.org us at

19 References 1. Abramowitz, J.S. (1997). Effectiveness of psychological and pharmacological treatments for obsessive-compulsive disorder: A quantitative review. Journal of Consulting & Clinical Psychology, 65(1), American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington DC: American Psychiatric Publishing. 3. American Psychiatric Association (APA). (2007). Practice guideline for the treatment of patients with obsessive-compulsive disorder. Arlington, VA: American Psychiatric Association. 4. Blanco, C., Olfson, M., Stein, D. J., Simpson, H. B., Gameroff, M. J., & Narrow, W. H. (2006). Treatment of obsessive compulsive disorder by U.S. psychiatrists. Journal of Clinical Psychiatry, 67, Eddy, K. T., Dutra, L., Bradley, R., & Westen, D. (2004). A multidimensional meta-analysis of psychotherapy and pharmacotherapy for obsessive-compulsive disorder. Clinical Psychology Review, 24(8), doi: 6. El-Sayegh, S., Bea, S., Agelopoulos, A. (2003). Obsessive-compulsive disorder: Unearthing a hidden problem. Cleveland Clinic Journal of Medicine, 70(10), Fisher, P. L., & Wells, A. (2005). How effective are cognitive and behavioral treatments for obsessive compulsive disorder? A clinical significance analysis. Behaviour Research and Therapy, 43(12), doi:

20 References cont 8. Foa, E.B., Kozak, MJ. (1986). Emotional processing of fear: exposure to corrective information. Psychol Bull, 99(1): Foa, E.B., Yadin, E., & Lichner, T.K. (2012). Exposure and Response Prevention for Obsessive-Compulsive Disorder. New York, New York: Oxford University Press. 10. Gava, I., Barbui, C., Aguglia, E., Carlino, D., Churchill, R., De Vanna, M., & McGuire, H. F. (2007). Psychological treatments versus treatment as usual for obsessive compulsive disorder (OCD). Cochrane Database of Systematic Reviews, (2), CD Gillan, C.M., Robbins, T.W. (2014). Goal-directed learning and obsessive compulsive disorder. Phials Trans R Soc Lond B Biological Sci. 369 (1655). 12. Griest, J. & Ambramowitz, J. (2016) A Brief History of Psychotherapy for OCD: ). IOCDF newsletter. 30(2): Hollander, E., Kwon, J. H., Stein, D. J., Broatch, J., Rowland, C. T., & Himelein, C. A. (1996). Obsessive-compulsive and spectrum disorders: overview and quality of life issues. The Journal of Clinical Psychiatry, 57, Suppl 8(8), International OCD Foundation (IOCDF). (2015). What causes OCD? Retrieved from: International OCD Foundation (IOCDF). (2015). Find Help. Retrieved from: Jonsson, H., & Hougaard, E. (2009). Group cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 119(2), Kobak, K. A., Greist, J. H., Jefferson, J. W., Katzelnick, D. J., & Henk, H. J. (1998). Behavioral versus pharmacological treatments of obsessive compulsive disorder: A meta-analysis. Psychopharmacology, 136(3), National Institute for Health and Care Excellence (NICE). (2005). Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. Manchester, UK: National Institute for Health and Clinical Excellence.

21 References cont 19. Romanelli, R. J., Wu, F. M., Gamba, R., Mojtabai, R., & Segal, J. B. (Aug 2014). Behavioral therapy and serotonin reuptake inhibitor pharmacotherapy in the treatment of obsessive-compulsive disorder: A systematic review and meta-analysis of head-to-head randomized controlled trials. Depression and Anxiety, 31(8), Rosa-Alcazar, A. I., Sanchez-Meca, J., Gomez-Conesa, A., & Marin-Martinez, F. (2008). Psychological treatment of obsessive-compulsive disorder: A meta-analysis. Clinical Psychology Review, 28(8), Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C. (2008). The epidemiology of obsessive-compulsive disorder in the national comorbidity survey replication. Mol Psychiatry, 15(1), Seibell, P.J., Hamblin, R. J., & Hollander, E. (2015) Obsessive-Compulsive Disorder: Overview and standard treatment strategies. Psychiatry Annals. 45(6): Simpson, HB, Huppert, JD, Petkova, E, Foa, EB, Leibowitz, MR. (2006). Response versus remission in obsessive compulsive disorder. Journal of Clinical Psychiatry. 67(2): Singer, J. (Jan 30, 2013). Obsessive compulsive disorder and uncertainty. PsychCentral. Retrieved from: lib/obsessive-compulsive-disorder-and-uncertainty/ 25. Skapinakis, P., Caldwell, D.M., Hollingworth, W Lewis, G. et. al (2016). Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis. Lancet Psychiatry. 3: Wheaton, M.G, Schwartz, M.R., Pascucci, O. & Simpson, H.B. (2015). Cognitive-Behavior Therapy Outcomes for Obsessive-Compulsive Disorder: Exposure and Response Prevention. Psychiatry Annals. 45(6);

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