Adolescence: A Visual Summary

Transcription

1 1 OCD and Teens/Young Adults: How to Keep Them Engaged in Their Own Treatment, Symptoms, and Lives Martin E. Franklin, Ph.D. Associate Professor of Clinical Psychology in Psychiatry University of Pennsylvania School of Medicine & Director, COTTAGe 2 Adolescence: A Visual Summary 3

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3 7 8 Developmental Considerations in CBT Younger children More directive approach Use age-appropriate language and metaphors Greater use of goalsetting and reinforcement Greater family involvement Adolescents More collaboration in exposure selection More realistic discussion of risk More identification of feared consequence, and greater use of disconfirmatory evidence 9 Meta-Analysis: A Forest Level View Type: JPG

4 10 CBT Age Effects: Individual Patient Meta-analysis (Bennett et al., 2013) Examined whether age moderated CBT response in anxiety disorder RCTs (excluding OCD & PTSD) 1,171 cases from 17 studies No age effects adolescents do just fine! Why not? CBT modifications carried out by expert therapists and supervisors in clinical trials (flexibility within fidelity) Might see effects in effectiveness context 11 CBT for Pediatric OCD: Summary CBT is efficacious relative to various comparison conditions Symptom reduction typically robust (40% - 65% in RCTs) Studies that have included follow-up (e.g., Barrett et al., 2005; Franklin et al., 2011; Piacentini et al., 2010; Storch et al., 2007) attest to durability of TX gains Lack of availability in community settings is at issue RCTs recruited across a broad age range (6 17), which presents challenge to delivery of developmentally sensitive TX 12 But What About Age Effects in OCD?

5 13 OCD Treatment Outcome x Age POTS I: Age was neither a predictor or a moderator of outcome POTS II: A hint at an age effect: Kids < 13 tended to do better NORDLOTS: Older kids didn t do as well Literature more broadly speaking: Inconsistent some studies have found age associated with outcome and others have not, so we must form an educated guess based on what is known So what do we make of it? We should be mindful of the possibility that age could affect outcome, and we have to be thoughtful about how those effects could be realized Developmental sensitivity is the key! 14 Adolescents: What Do They Bring to the CBT Context? Strong desire to develop their independence Increased importance of peer group Ability and desire to think for themselves Risk assessments sometimes inaccurate, though OCD could mitigate against this to an extent Mistrust of adults, especially those who try to make them do things that they don t want to do 15 LEAP: Launching Emerging Adults Program (Albano, Columbia U) Expected developmental milestones for end of adolescence: Emotional independence from parents Develop self-identity Behavioral independence from parents Manage money properly & develop Make & keep long-term relationships Take control of personal care

6 16 Adolescents: Potential Risk Factors for Suboptimal Response Every moderator of outcome reflects a mediator you haven t discovered yet. Steve Hollon, Vanderbilt University Longer duration of symptoms development of overlearned habits, pessimism about treatment outcome? Psychiatric comorbidity? Motivational issues/readiness for change? Parent-teen conflict about symptoms (or other stuff)? 17 CBT Interventions for OCD Typically Include: sessions delivered by trained/supervised therapists Psychoeducation re: nature of anxiety/ocd Identifying & dealing with anxiety-relevant cognitions Hierarchy development & selection of treatment targets Some form of behavioral exposure to feared thoughts/situations Relapse prevention 18 Goals of Individual Tx Components Cognitive interventions: Exposure in vivo: Imaginal exposure: Ritual prevention: Correcting erroneous cognitions (e.g., anxiety won t w/o ritualizing; externalize OCD) Prolonged confrontation with anxiety-evoking stimuli (e.g., contact with contaminants) Prolonged imaginal confrontation with feared disasters (e.g., hitting a pedestrian while driving) Blocking of compulsions (e.g., leaving the kitchen w/o checking the stove); eliminating neutralizing function of compulsions

7 19 A Simplified Theoretical Approach Blah, blah, blah, do the thing you re afraid of, Blah, blah, blah, the more you do it, the easier it gets. Gwen Franklin, age 6, to her father, Lessons To Be Learned Anxiety is transient Avoidance strengthens fear; exposure weakens it Exposure is necessary for extinction Anxiety in anticipation of exposure may be higher than anxiety during actual exposure Feared consequences do not materialize Ceiling Fan Analogy letting your anxiety make noise while you go about your business 21 PRINCIPLES OF TREATMENT Voluntary Collaborative Hierarchy-driven Focus on accomplishments, not failures Promotes mastery of anxiety Manage and face fears/urges rather than running away or giving into them Based on assessment of behaviors Parents may need to learn to accept a less active role

8 22 Setting Up Treatment: CBT for Pediatric OCD 23 Dynamic Process of CBT Mapping OCD Includes the identification of areas of life, activities, thoughts, etc. that the OCD influences Over time, the goal is to decrease the influence of OCD in as many areas as possible (similar to gaining control of territory in battle) Acknowledge current position Maintain focus on the treatment goals Always attempt a new step toward that goal 24 Flexibility within Fidelity Phil Kendall s CBT Motto

9 25 OCD is Like Hawaii 26 OCD Is Like My Dog 27 OCD Treatment is Like Learning to Play the Violin

10 28 OCD Treatment is Like Peyton Manning at the Line of Scrimmage 29 OCD is Like Whatever It Is That You Like to Think & Talk About 30 The Heart of the Matter: Conducting ERP in CBT for OCD

11 31 Climbing the Exposure Hierarchy 32 Two Kinds of Exposures In vivo exposures (during sessions and for homework) Homework assignments are logically connected to in-session work Imaginal exposures Exposures are done in a graded manner Therapists models exposures for patients Exposures should occur where the OCD lives (e.g., home, school, etc.) 33 Imaginal Exposure Courtesy of John S. March, M.D.

12 34 Exposure in Vivo Courtesy of John S. March, M.D. 35 Response Prevention Nope, I'm not going to wash Courtesy of John S. March, M.D. 36 Extinction Will I get sick? Honey, we agreed I wouldn't answer that question Courtesy of John S. March, M.D.

13 37 Early CBT Treatment Sessions Begin with only moderately distressing stimuli and intrusions Coach and encourage the child to abstain from rituals Trouble-shoot and plan for future exposure exercises together 38 Moving Up the Hierarchy Build on past successes from earlier sessions Encourage the child to choose from among equivalent stimuli for exposures Manage negative family affect Note changes in impairment and decreased symptoms to highlight improvement 39 Confronting the Greatest Fears Encouragement and praise for efforts Modeling Discussion of acceptable vs. unacceptable risk Repeated and prolonged exposure Confront fears in multiple contexts

14 40 Adolescents: Potential Risk Factors for Suboptimal Response Longer duration of symptoms development of overlearned habits, pessimism about treatment outcome? Psychiatric comorbidity? Motivational issues/readiness for change? Parent-teen conflict about symptoms (or other stuff)? 41 Adolescents: Potential Risk Factors for Suboptimal Response Longer duration of symptoms development of overlearned habits, pessimism about treatment outcome? Psychiatric comorbidity? Motivational issues/readiness for change? Parent-teen conflict about symptoms (or other stuff)? 42 Adolescents: Potential Risk Factors for Suboptimal Response Longer duration of symptoms development of overlearned habits, pessimism about treatment outcome? Psychiatric comorbidity? Motivational issues/readiness for change? Parent-teen conflict about symptoms (or other stuff)?

15 43 Adolescents: Potential Risk Factors for Suboptimal Response Longer duration of symptoms development of overlearned habits, pessimism about treatment outcome? Psychiatric comorbidity? Motivational issues/readiness for change? Parent-teen conflict about symptoms (or other stuff)? 44 LEAP Treatment Goals (Albano, Columbia U) Goals of family intervention: Reduce level of conflict & feelings of anger, blame Enhance family problem solving Facilitate disengagement from child s OCD symptoms Rebuild OCD free family interaction patters Foster an environment conductive to maintenance of gains 45

16 46 Working within School Settings Some anxiety problems can be managed successfully in the school environment without referral for specific outpatient treatment Other anxiety problems require referral but the school staff can still play an important role In either case, the goals in school are to reduce avoidance and facilitate use of more adaptive coping strategies 47 Treating Adolescents: What Can You Bring to the CBT Context? Respect their independence & work within that frame Reinforce their ability and desire to think for themselves Stay positive, even when it s difficult to do so Make effort to get their world but fess up when you don t Ignore tone, but call them out when they cross the line Don t be one of those adults they mistrust My only job here is to make you aware of the consequences of your choices, not to make those choices for you