Obsessive-Compulsive Disorder MRCPsych Year II

Transcription

1 Obsessive-Compulsive Disorder MRCPsych Year II Renuka Arjundas Slides adapted (with permission) from Professor Mark Freeston Newcastle Cognitive and Behavioural Therapies Centre 2011, Mark Freeston, Newcastle University and NTW NHS Foundation Trust. May be used in routine clinical practice, for all other uses please contact the author or Northumberland, Tyne & Wear NHS Trust

2 Aims for Today To provide an overview of the phenomenology of OCD To gain an understanding of the cognitive model of OCD To be aware of current treatment options To develop relevant knowledge to understand what CBT for OCD might entail Give some case examples 2011, Mark Freeston, Newcastle University and NTW NHS Foundation Trust. May be used in routine clinical practice, for all other uses please contact the author or

3 OCD : The clinical problem Prevalence - 1-2% Often early onset Interferes with development changes trajectory Can co-opt family etc. Chronic/fluctuating course Equivalent burden of illness to schizophrenia Heavily reduced functioning in otherwise healthy individuals Most will respond to treatment, but Access to treatment (hence IAPT!) Engagement in treatment (therapist skill and patient factors) Adequacy of treatment (expertise, dose) Mark Freeston, 2011

4 OCD : 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

5 Mark Freeston, 2011 OCD : Diagnosis Obsessions Unwanted, intrusive, repetitive, thoughts that are often considered as bizarre, repugnant, or contrary to the person s personality or values Forms thoughts doubts ruminations images words flashes

6 Most common forms of OCD Contamination fears and associated cleaning rituals Something bad will happen if they do not carefully check their actions, or do something the right way. Thoughts which the person sees as strongly inappropriate or immoral often associated with the fear that these thoughts imply that they might carry out the act. (e.g. sexual, blasphemous, aggressive).

7 OCD : Diagnosis Themes in obsessions errors, accidents contamination disasters severe illness, mental illness violence, horrific thoughts sexuality religion, supernatural concerns moral dilemmas, existential concerns Mark Freeston, 2011

8 OCD : Diagnosis Compulsions Behaviour that normally has an anxiety reducing function performed in response to obsessions- reduce risk of feared event Forms checking washing, cleaning arranging, ordering, repeating, slowness reassurance seeking mental rituals hoarding Mark Freeston, 2011

9 OCD : Diagnosis Belief and conviction People often know that their fears are not true but it is stronger than I am For others, their conviction may vary depending on the situation or their anxiety level For some, they may have lost the capacity to know that their fears are not true but probably did so in the past Overvalued Ideation/ delusional Mark Freeston, 2011

10 A cognitive model of OCD From Paul Salkovskis Normal intrusion Misinterpretation (appraisal : responsibility for harm Anxiety and its appraisal Strategies (neutralization) Consequences of strategies 2011, Mark Freeston, Newcastle University and NTW NHS Foundation Trust. May be used in routine clinical practice, for all other uses please contact the author or cbttraining@ntw.nhs.uk

11 A cognitive model of OCD From Paul Salkovskis I might kill my baby Thinking something is as bad as doing it Having this thought means that I m wicked and could be a child killer Anxiety and discomfort Gives baby to others, tries not to have the thought, neutralises, seeks reassurance) 2011, Mark Freeston, Newcastle University and NTW NHS Foundation Trust. May be used in routine clinical practice, for all other uses please contact the author or cbttraining@ntw.nhs.uk Consequences of strategies

12 A cognitive model of OCD (contamination obsession) Sees toddler putting hands in mouth Remembers walking past garden shop What if I have pesticide on my shoes? Anxiety Guilt My child will get sick and it will be my fault 2011, Mark Freeston, Newcastle University and NTW NHS Foundation Trust. May be used in routine clinical practice, for all other uses please contact the author or cbttraining@ntw.nhs.uk Multiple strategies Numerous consequences Puts shoes in plastic bag in garage Remembers where she has walked Cleans the floor everywhere Chastises herself Monitors toddler Remind herself to tell/ask husband about it Rings NHS Direct/ poison line

13 OCD : Behaviour Therapy Developed in late 60s and early 70s Aims to modify behavior, is less interested in the why more interested in the how Directly targets obsessive compulsive behaviour, esp compulsions Main ingredient is Exposure and Response Prevention (ERP) NICE (2006) Well established, proven effective for OCD Can be used alone or with medication Mark Freeston, 2011

14 OCD : ERP Two components Exposure - confront situations that normally provoke obsessions or compulsions/rituals Response prevention - refrain from compulsions/rituals Simple in principle, often requires structured and progressive approach to be successful Start with least difficult, practice and then move up to next least difficult, work up gradually to most difficult Mark Freeston, 2011

15 OCD : ERP Initially based on the principle of habituation Anxiety increases, reaches plateau and then decreases all by itself With repeated exposure, anxiety and urge to ritualize does not increase to such a high level and then decreases faster The way of looking at the situation often changes as well Can also be framed in cognitive terms Disconfirmation Mark Freeston, 2011

16 OCD : ERP Requires active participation of patient Client has work to do between each sessions, normally everyday sessions is typical Once a week to start with Some programs would aim for more than 1 per week Mark Freeston, 2011

17 Mark Freeston, 2011 OCD : ERP Advantages Proven technique when applied properly Good results, gains usually last Disadvantages Requires commitment by patient Time, courage, energy Requires competence and confidence by therapist Pitfalls for therapists who do not fully understand OCD People may refuse/abandon treatment if it is presented or implemented badly

18 OCD : Cognitive-Behavior Therapy (CBT) Combines 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 behavioural experiments + consolidation of new behaviors More flexible than traditional BT without losing focus on changing behavior Mark Freeston, 2011

19 By framing OCD in a cognitive way Can probably reduce refusal/drop out compared to straight ERP Can acknowledge more fully that what people believe leads them to act the way they do Can explicitly talk about beliefs and appraisals and examine them before ERP Can frame ERP as a series of behavioural experiments About anxiety About other threat beliefs Can deal with stuck points in more flexibly

20 OCD : Neutralisation In the OCD literature you may find the term neutralisation Includes safety (seeking) behaviours Includes, but is not limited to, compulsions, rituals, etc., 2011, Mark Freeston, Newcastle University and NTW NHS Foundation Trust. May be used in routine clinical practice, for all other uses please contact the author or cbttraining@ntw.nhs.uk

21 Assessment of neutralization: When the thought/situation occurs, do you talk to yourself? try and replace it with another thought? try and push it out of your mind? try and understand, analyse or think the thought through? distract yourself with activities/ things around you? perform some special routine or action? rerun the film in your head? say "stop" or something similar? pray, use inspirational texts or meditate? Try to relax, sleep, take medication or drugs or alcohol? talk to others to reassure yourself to be comforted to distract yourself avoid objects, situations, news coverage 2011, Mark Freeston, etc? Newcastle University and NTW NHS Foundation Trust. May be used in routine clinical practice, for all

22 Beliefs highly characteristic of OCD: Thought action fusion Impulsivity Thinking means I will act on it Likelihood Self/Other Thinking it increases chance that it will happen Magical thinking can actually work across time and space Moral Thinking is as bad as doing Inflated responsibility an exaggerated belief that one has the power to produce or prevent negative outcomes Beliefs about the controllability of thoughts The belief that is possible to control ones thoughts and images and desirable or necessary to do so

23 Beliefs in OCD- important but found in other disorders too Perfectionism Overestimation of threat Intolerance of uncertainty.

24 Understanding beliefs in OCD Multiple pathways to developing beliefs Personality? Background factors Family, parenting Important contexts (school, church, jobs) Influential figures Life events Severity is not necessarily important What else was happening at the time? It is what they conclude from them One-off events that teach important lessons Cumulative experience At different ages Timing of all of these can be critical 2011, Mark Freeston, Newcastle University and NTW NHS Foundation Trust. May be used in routine clinical practice, for all other uses please contact the author or

25 OCD treatment Assessment Typical example Formulation shared understanding of intrusion (obsessive thought), appraisal, and range of compulsions/ neutralising actions Discussion of alternative explanations Behavioural experiments (often graded according to tolerability/ goals) to test the alternative account

26 Examples of behavioural experiments-i Problem: Brenda has obsessional thoughts about harm coming to her family. Cancels thoughts out by rituals Target cognition: If I think something bad, it might happen (70%). If I have not done anything to prevent it it will be my fault ( 80%) Alternative perspective: A thought is just a thought and cannot make things happen.

27 Behavioural experiment Prediction: If I think a bad thought it will happen. My anxiety will get so high, I will be unable to resist neutralizing Operationalizing the prediction: See what happens as a result of gradually increasing bad thoughts, start with therapist, then family. Do bad things happen, or just anxiety. Experiment: My therapist is going to sprain her ankle My therapist is going to have a heart attack

28 Behavioural experiment I Results: Belief ratings never higher than 70-80%. Anxiety ratings started at 90%. Both ratings steadily came down to zero. Increasing confidence as predictions failed to come true.

29 Behavioural experiment II Problem: Moyra washed her hands times a day. She was concerned about being dirty and a mess and thought that others would think badly of her if her appearance was not perfect. She only wore clothes for a day, and was overly concerned about household cleanliness Target cognition: If I don t wash, then I ll be dirty and others will reject me Alternative cognition: If I reduce my washing, others will not notice Prediction: I will feel anxious if I m dirty, and concerned that others will notice me looking/smelling dirty.

30 Behavioural experiment II Preparation for the experiment Looking at others behaviour re clothes, washing. Did she think others were dirty, did she reject them? Experiment Going to work with stained top. Look at others carefully to see their reactions. Wear the same outfit for 3 days. Results: No-one noticed. Realised many steps between her and being dirty and dishevelled

31 OCD : Summary Phenomenology highly varied between patients and within individuals Generic cognitive model of OCD Obsessions, compulsions, neutralisation, beliefs or appraisals differences between different types of OCD Cognitive and behavioural approaches implicated in treatment BT (ERP); CT; CBT

32 OCD recommended reading Bennett- Levy, J. et al. (2004) Oxford guide to behavioural experiments in cognitive therapy (chapter 5) Freeston, M. and Ladoucer,R. (1999). Exposure and response prevention for obsessive throughts. Cognitive and Behvaioural practice, 6, Salkovskis, P. (1999) Understanding and treating obsessive-compulsive disorder. Behaviour research and Therapy, 37, S29-S52 Salkovskis, P., Forrester, E., Richards, H. and Morrison, N. (1998) The devil is in the detail: conceptualising and treating obsessional problems. In: N. Tarrier (ed.), Cognitive behaviour therapy for complex cases. Wiley, Chichester.