Let s Talk About Treatment

What Doesn t Work Let s Talk About Treatment Lisa R. Terry, LPC What we ve tried Talk therapy- You can t talk you way out of a medical disorder Play Therapy Family Therapy Psychoanalysis While these are great forms of therapy in their own right, they have not been proven effective in TREATING OCD Are we Coping or Treating? More Coping Getting through it versus fixing it Making a payment on your credit card vs. paying it in full Coping Skills are helpful in REDUCING ANXIETY Relaxation reduces the body s metabolism, heart and breathing rate, blood pressure, muscle tension, and calms brain activity. Relaxation can be achieved through Meditation to spend time in quiet thought for religious purposes or relaxation Deep Breathing Progressive Muscle Relaxation a successive process whereby each large muscle group is tightened for approx 5 seconds then released Distraction divert your thinking onto something else Thought Stopping - issue the command, Stop! when you experience repeated negative, unnecessary or distorted thoughts. You then replace the negative thought with something more positive and realistic. So What Does Work? Evidence Based Treatment MEDICATION (typically your SSRIs) works!! But is Medication Right for Everyone? Not all cases are clear cut. In some cases you may need to manage co-morbid conditions before starting behavioral therapy Gather input from as many as sources as you are comfortable with as to the level of distress or impaired functioning Look at level of interference or distress with daily functioning (socially, home, school or work, relationships with others, hygiene) Consult with your doctor. Medication The following information refers to ADULTS. Medicine is an effective treatment for OCD. Most drugs that help OCD are known as antidepressants. Depression often results from OCD. Doctors can treat both the OCD and depression with the same medicine. About 7 out of 10 people with OCD will benefit from either medicine or CBT/ERP. For the people who benefit from medicine, they usually see their OCD symptoms reduced by 40-60%. This tells us there is no magic pill. For medicines to work, they must be taken regularly and as directed by their doctor. About half of OCD patients stop taking their medicine due to side effects or for other reasons. Not taking medications as prescribed may make things worse. Taken from www.iocdf.com Adapted by Lisa Terry, LPC 1

Medication Most drugs that help OCD are known as antidepressants. Eight of these drugs worked well in studies: fluvoxamine (Luvox ) fluoxetine (Prozac ) sertraline (Zoloft ) paroxetine (Paxil ) citalopram (Celexa )* clomipramine (Anafranil ) escitalopram (Lexapro ) venlafaxine (Effexor ) Taken from www.iocdf.com What Else Works? CBT / ERP Works!! Interestingly enough, ERP is the most effective form of treatment, followed by ERP and medication then medication alone. Cognitive Behavioral Therapy (CBT) helps you become aware of inaccurate or negative thinking, so you can view challenging situations more clearly and respond to them in a more effective way. (mayoclinic.org) Wikipedia describes CBT as Problem Focused and Action Oriented What is Exposure and Response Prevention (ERP) ERP is about LEARNING and developing new behaviors and thoughts instead of avoiding or repeating the ineffective compulsions over and over If you do what you have always done, you get what you have always gotten. By exposing yourself to the feared thought or situation, and not engaging in the compulsion you LEARN a new and effective way to manage the discomfort Why do we Want to Resist the Compulsions? Because they do not work! Compulsions are ineffective. If they worked, the obsessions would no longer be an issue. Compulsions provide only temporary relief Early experimental studies established that compulsions, especially cleaning, are reinforcing because they seem to reduce discomfort temporarily. Furthermore they strengthen the belief that, had the compulsion not been carried out, discomfort would have increased and harm may have occurred (or not have been prevented). This increases the urge to perform the compulsion again, and a vicious circle is thus maintained. Various avoidance behaviors and compulsions prevent the extinction of this anxiety However, compulsions do not always work by reducing anxiety and are often intermittently reinforcing. Compulsions may function as a means of avoiding discomfort, as in examples of obsessional slowness (Veale, 1993) Veale, D. (1993) Classification and treatment of obsessional slowness. British Journal of Psychiatry, 162, 198 203. Exposure and Response Prevention Exposure and Response Prevention is the gradual and controlled exposure to the objects or situations that cause anxiety, guilt or disgust. The person resists carrying out the rituals they would typically engage in resulting in habituation. Habituation is the reduction in response strength with repeated stimulus presentations (decreasing anxiety over time). Anxiety Graph 2

Fun Fact About 25% of patients refuse or drop out from exposure and response prevention, and of those that adhere to the therapy about 75% improve (National Collaborating Centre for Mental Health, 2005). So Let s Get Started Assessment Self-Report and Input from Parent and Child or any other significant caretakers Assessment Tools Yale-Brown Obsessive Compulsive Scale Y-BOC Assessment Criteria The context in which OCD has developed The degree of family involvement The degree of impairment or disruption in the person s occupational, social and family life Readiness to change and expectations of therapy, including previous experience of CBT for the disorder Cognitive behavioural therapy for obsessive compulsive disorder David Veale, Advances in Psychiatric Treatment Assessment Criteria The nature of the obsession(s): their content; the degree of insight; the frequency of their occurrence; the triggers; the feared consequence (What is the worst thing that can happen?); the patient s appraisal of the obsession (What did having the intrusive thought mean to you? What sense did you make of it? Could harm occur as a result of this? What would happen if you could not get rid of the intrusions?) The main emotion(s) linked with the obsession or intrusion The compulsion(s) and neutralizing: what the person does in response to the obsession; a rating of predicted distress if the compulsion is resisted; the feared consequences of resisting it; their experience of trying to stop a compulsion; the criteria used for terminating the compulsion and the assumptions held if they stopped using a compulsion. Indirect assessment might include activities such as the number of rolls of toilet paper or bars of soap used per week The avoidance behaviour: all the situations, activities or thoughts avoided are listed and rated on a scale (e.g. 0 100 in standard units of distress), according to how much distress the person anticipates if they experience the thought or situation without a safety-seeking behaviour Cognitive behavioural therapy for obsessive compulsive disorder David Veale, Advances in Psychiatric Treatment What is Just Right OCD? Just Right obsessions are thoughts and/or feelings that something is not quite right or that something is incomplete. For example, a Just Right obsession would be needing to rewrite a word or letter over and over until it feels just right. Those with Just Right symptoms are also more likely to have other ( co-morbid ) conditions like tic or mood disorders, ADHD or skin picking Hierarchy Use your assessment tools to build a hierarchy A hierarchy is a list of situations that trigger anxiety, guilt, disgust, or discomfort arranged from least to most discomfort Assign a number from 1-100 to each item on the hierarchy that represents level of guilt, disgust, anxiety or discomfort. This becomes your SUDS or Subjective Units of Discomfort 3

Example of Hierarchy 100 Turning in my homework without reviewing 90 Turning in my homework knowing there are errors 85 - Not fixing my Ds and Rs 73 - Not asking my mom to review my work 65 - Not being able to erase 50 - Turning in a math paper without fixing my numbers 35 - Reviewing my paper less than three times 20 - Turning in a bubble sheet Decide Between Two Types of Exposures Imaginal Exposure vs In Vivo or Real Life Use Imaginal over In Vivo if the exposure is unethical or too challenging Goals of an Exposure The main goal during both in vivo and imaginal exposure is for the person to stay in contact with the obsessional trigger without engaging in the compulsion. Goal is to tolerate the uncertainty of the what if, or the discomfort of the disgust or guilt An exposure is considered successful once the anxiety level is reduced by 50% and no compulsions have been performed If the anxiety/discomfort is too great and you engage in a compulsion, no worries, you can always do a re-exposure or do over. Anatomy of an Exposure Reminder: the client is in control of the exposure Rate Level of Discomfort every few minutes starting when you first begin to discuss the exposure Choose an exposure from your hierarchy together CLEARLY define and agree upon the exposure If anxiety is too high, start with an imaginal exposure Write out a script of (or record) the exposure as you go along. Continually raise anxiety if possible by rereading script and/or Awfulizing how could this be worse? What s going to happen next? Remember, goal is to sit with Discomfort/Fear/Guilt/Disgust and not engage in the compulsion Rate Level of Discomfort Continue to sit with Discomfort/Fear/Guilt/Disgust until you see about a 50% reduction in anxiety Audio/visual of an Exposure How do I Know if I have the Right Therapist? Ease and Relationship with Therapist Ask the treatment provider how they treat OCD in their practice Language the Therapist is using What you want to hear (Assessment, Hierarchy, ERP, SUDS) What you do not want to hear (only CBT or only relaxation or meditation techniques) While there are variations in approaches an exposure is an exposure 4

Parent and Family Tips Evaluate your own fears/concerns about the exposure If you can t assist in the exposure turn it over to the treatment provider or other team member Use phrases that acknowledge it is the OCD not your child I see OCD is making you ask that question again. or I see OCD is making you wash your hands again. Parent and Family Tips Define boundaries for the family, what are your limits with OCD? Be clear, be consistent, be supportive. Seek treatment for yourself if needed Great starting place is the International Obsessive Compulsive Foundation (IOCDF) 5