Psychological Treatment of OCD and Hoarding Mabel Yum Principal Clinical Psychologist 23 April 2016
What is OCD? Anxiety Obsession Rituals Compulsions How much can you empathize the struggles that patients with OCD have?
Let s experience OCD Instructions: As you read the paragraph on the next slide, tell yourself that you must count all the times the letter "e" occurs. You have to count and read simultaneously -- you can't just read and then go back and count, and you can't keep track on a piece of paper. You have to do the counting in your head for this exercise. To make it a bit more "realistic," accuracy will be very important to you -- if you lose track of the count or aren't 100% sure that you've counted correctly, you'll have to go back to the beginning of the paragraph and start again. Since you have OCD, you probably will doubt that you counted correctly at least once during the exercise.
OK, begin: Children who have OCD often have hidden or silent compulsive rituals. These hidden rituals often confuse teachers who may look at a child and not realize what is going on internally that may make it almost impossible for the child to function normally at times. Young children often don't realize that what they are doing is "abnormal," and older children, teens, or adults are often don't realize that what they are doing is "abnormal," and older children, teens, or adults are often embarrassed by their rituals and won't tell you about them.
True Life: I have OCD
From the video, we can tell that OCD doesn t only have a great impact an individual s life It affects their family members in many ways too 14
OCD Case Study Mdm Y, 35yo Chinese lady, married with 5yo son Referred by husband as she had delayed sending their son to K1 Reported anxious temperament since young Hx of compulsive hand washing since she was 21yo Obsession with cleanliness worsened at 33yo when son turned 3 Claims that she checks for cleanliness only but husband reported that she also checks if doors have been locked properly Denies counting, repeated images, thoughts, ideas Denies feeling depressed but had fleeting thought of suicide when she felt distressed
OCD Case Study Impact on Son Clean/bath/wash son for hours, after he returns from the playground. Son cannot step on the floor after he had been washed. Had to sit in bed. Son s meals are served in bed. Anywhere outside the bedroom was deemed dirty (lives with MIL). Checks son to ensure that he is clean Son not allowed to attend school. Too tiring to have to wash him for hours school Went to chalet for 5 days because she was tired of cleaning. Did not bathe self and son for 5 days. Allowed him to be dirty and sleep on the dirty bed in the chalet.
OCD Case Study Impact on Husband Husband made to clean/wash/change before he could enter his bedroom after work Husband not allowed to play with his son in case he is dirty. Husband has to assist in the ritual of cleaning their son s feet. Husband noticed that their bedroom is quite dusty but patient did not allow him to clean and she refused to clean as it would take her hours to clean a small area
OCD Case Study Medical social worker reported this case to MSF. The child protection order was issued. Mdm Y had to go for mandatory psychiatric treatment, and she responded quite well to it. 18
Treatment for OCD The most proven effective psychotherapy is Cognitive Behaviour Therapy (CBT). A skills-based treatment whereby patients and therapist work together to identify problematic thinking and behavioural patterns, and develop skills to change these patterns.
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Link Between Thoughts, Feelings and Actions Situation Thoughts Actions Feelings
CBT for OCD CBT for OCD comprises of 2 components: (a) Cognitive therapy. In this component, patients will be asked to identify their negative and catastrophic thoughts, replace them with rational and helpful thoughts. Without the anxiety-provoking thoughts, anxiety reduces or eliminated, they don t have to resort to the compulsions and rituals.
Link Between Thoughts, Feelings and Actions Situation Thoughts Actions Feelings
Link Between Thoughts, Feelings and Actions A compulsive hoarder s negative thought Being the living room and see the things she keeps I will have no vase to put the flowers I hardly when receive someone flowers. give me some one day. Not keeping the Keep the vase vase Anxious neutral
Link Between Thoughts, Feelings and Actions A compulsive checker s negative thought Just used the water tap the my water house will flood not be my house flooded if the because tap is the not water turned will go off through properly. the drain. Keeps Not checking Anxious neutral
Unhelpful Thinking Styles Mental Filter aka Tunnel Vision Jumping to Conclusions aka Predictive Thinking Personalisation Catastrophising Black & White Thinking Shoulding and Musting Overgeneralization Labelling Emotional Reasoning Magnification and Minimisation
Challenge the Unhelpful Thoughts 1. What is the evidence for this catastrophic thought? 2. Is there another way to look at the situation? 3. So what? What is the worst that can happen? 4. How likely is it to happen anyway? Practise Thought Recording
Positive Statements That thought is not helpful right now. This is irrational. I am going to let it go. This feels urgent and threatening, but I know that it actually is not. It doesn't have to be perfect to be ok. I already know from my past experiences that these fears are irrational.
Positive Statements I have to take risks and accept unpredictability so that I can be free from OCD. I have done my best, I am going to let go. I want to practice listening to my rational thoughts. I don't want to suffer any longer from my OCD.. The costs to my health are too high. 30
CBT for OCD (b) Exposure and Response Prevention (ERP) to repeatedly expose to the source of obsession. to tolerate the anxiety and allow it to go away on its own, and NOT to engage in the compulsive behaviour. In this way, the patients will learn that the anxiety can and will go away on its own, without having to engage in the compulsive behaviour.
the water will flood my house if the tap is not turned off properly. X Check water tap And gradually reduce the negative thought of flooding
Find the anxiety-provoking situations The Subjective Units of Distress Scale (SUDS) 0 1 2 3 4 5 6 7 8 9 10 Not distressing Somewhat distressing Most distressing
Anxiety Hierarchy E.g. fears of being contaminated by germs
In-vivo Exposure Start with situation with a 5 SUDS first. Repeatedly perform the selected situation (record form) Exposure to an item can be stopped when it results in little or no distress for a few consecutive days. Then move up the hierarchy to try exposure with a situation that has a higher SUDS Keep going until the situation that has the highest SUDS is overcome Each exposure session should be continuous and not interrupted
ERP for Hoarding 36
Managing Compulsions it is not so easy to just stop performing compulsions and rituals. 1. Gradually decrease rituals. 2. Postpone rituals. 3. Perform ritual in slow motion be mindful of what they are doing. 4. Changing the order in which they perform the ritual. 5. Reward self if no ritual is performed or do something that they dislike if they perform the ritual.
Managing Compulsions 6. Simply DO NOT perform your ritual. Reduce anxiety by doing relaxation exercise e.g. deep breathing 7. No seeking of reassurance (e.g. asking the family whether the item that he/she touched is dirty, or asking them to check for him/her). This is because reassurance will prevent him/her from facing what he/she really fears.
Relaxation Exercise Deep Breathing Method Progressive Muscle Relaxation Guided Imagery Deep Breathing Method Breathing in (inhaling) Breathing out (exhaling)
Relaxation DVD available at KTPH Able Studio, Pharmacy, Clinic C23 Monthly Relaxation Therapy Workshop (English and Chinese) on Saturday mornings Call appointment line 6555 8828 for appointment
When patients with OCD present in my clinic Do not argue with them, be supportive and non-judgmental Encourage them to seek/continue treatment Help with gentle recognition of inconsistencies (negative thoughts) and ways to manage compulsions (exposure and other methods) Advise patients to do pleasant activities and physical exercise to de-stress Teach and/or encourage patients to learn and practise relaxation exercises (Relaxation DVD & Workshop) Refer patients for further psychiatric and /or psychological treatment
Referral for psychotherapy availability of resources (time, $, mobility etc) when medication doesn t work well or patients are not keen on using medication motivation and commitment 43