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Cbt -Ocd


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Cbt -Ocd

  1. 1. 1 CBT FOR OCD Dr V.Sabitha Associate Professor Institute of Mental Health Chennai
  2. 2. 2 WHY CBT FOR OCD?  All thought processes arise from activity in appropriate neural circuits.  OCD phenomena arise from aberrant thought processes, likely due to disturbances in the cortico- thalamo-striatal circuitry.  Neural circuits can be strengthened or weakened.  Drugs modulate neural circuit activity through receptor effects and later neuroplasticity changes.  CBT triggers learning which is hardwired into the brain, and may be more enduring in its effects.
  3. 3. 3 BIOLOGICAL EFFECTS OF CBT IN OCD  Decreased metabolic activity in the right caudate nucleus (reviewed by Linden, Molecular Psychiatry 2006).  Decreased right frontal anterior cingulate cortex and bilateral thalamic activity (Saxena et al, Molecular Psychiatry 2009).  Etc.
  4. 4. 4 TREATMENT OF OCD  SRI drugs and CBT  Meta-analysis 1:  Effect size for drugs was 0.48 (13 trials)  Effect size for CBT was 1.45 (5 trials)  (Watson and Rees, J Child Psychol Psychiatry 2008)  Meta-analysis 2 (13 trials):  Effect size for group CBT pre vs post: 1.18  Effect size for group CBT vs wait list controls: >1.12  (Jonsson and Hougaard, Acta Psychiatrica Scand 2009)
  5. 5. 5 ADVANTAGES OF CBT  Effective as monotherapy.  Large effect size [caveat: biases could arise from sample selection and consenting processes].  Improves long-term outcomes with drugs.  Treating with drugs+CBT may offer the best outcomes.
  6. 6. 6 TREATMENT OF OCD  The proper treatment of OCD with CBT requires a complete understanding of the spectrum of symptoms that the patient displays.
  7. 7. 7 OCD  Prevalence, 2-5% (severe in 0.5%)  The only DSM-IV anxiety disorder in which anxiety is not the main symptom.  Primary symptoms: obsessions and/or compulsions.  Secondary symptoms include depression.  Underlying OCPD in 50% of patients.  Comorbidities include tic disorder.  OCD may be secondary to other conditions; e.g. schizophrenia, atypical antipsychotic therapy.
  8. 8. 8 NOTE  By definition, mental preoccupations or repetitive behaviors are not considered under OCD if they occur in the context of another DSM-IV Axis I disorder (e.g. hypochondriasis; eating disorders; trichotillomania)
  9. 9. 9 OBSESSIONS AND COMPULSIONS  Obsessions are repeated thoughts.  E.g. “My son is going to die.”  E.g. “I will get AIDS.”  Compulsions are repeated actions.  E.g. Handwashing.  Every time a patient sees a picture of a deity, he feels compelled to say a short, mental prayer to the deity. Is this an obsession or a compulsion.  [In CBT, the approach to treatment differs between obsessions and compulsions.]
  10. 10. 10 COMPULSIONS  Thoughts which are deliberately repeated to relieve anxiety are compulsions, not obsessions.  E.g. Compulsively repeating a prayer a certain number of times to ward off evil after a trigger event.  E.g. Repeating a prayer over and over again just in case it was not properly said previously (scrupulosity).  Important to differentiate obsession from compulsion because the treatment approach is different.
  11. 11. PSYCHOPATHOLOGY OF OCD  Fear acquired through classical conditioning and maintained by operant conditioning  Eg. Checker associates electrical appliance(conditioned stimulus) with death(unconditional stimulus;danger of fire) and thus feels anxiety (unconditional response and conditioned response) in the presence of a stove  Checking behaviour:Negative Reinforcer as it removes anxiety 11
  12. 12. OCD COGNITIONS  Inflated sense of Personal Responsibility  Undue Importance to Thoughts  A need to control thoughts  Overestimation of threat  Intolerance of Uncertainity  Perfectionism 12
  13. 13. 13 TYPES OF OBSESSIONS [obsessions provoke anxiety]  Obsessive thoughts  Obsessive ruminations  Obsessive doubts  Obsessive vacillations  Obsessive phobias  Obsessive impulses  Obsessive images
  14. 14. 14 TYPES OF COMPULSIONS [compulsions relieve anxiety]  Almost always secondary to obsessions  May be behavioral or mental  Yielding:  Counting  Checking  Ordering  Cleaning/washing  Resisting:  Repeating thoughts or actions to prevent or undo a feared event  (Overlap may be present)
  15. 15. 15 ASSESSMENT (2-4 h)  It is important to comprehensively document all aspects of the phenomenology present.  List all obsessions.  List all compulsions.  Understand the contexts which generate each.  Arrange in a hierarchy of severity.  Assess insight into the irrationality of each.  Assess motivation to change each.
  16. 16. 16 ASSESSMENT (contd.)  Make a chart with each symptom rated:  Frequency (occasions per day)  Time spent (minutes or hours)  Distress (0-10)  Impairment (0-10, with examples of impairment)  Overall severity  This chart can be used to monitor progress.  Use the Y-BOCS or LOI or other scales.
  17. 17. 17 YALE-BROWN OBSESSIVE- COMPULSIVE SCALE  10 items (5 for obsessions, 5 for compulsions)  Semi-structured interview based on an explanation to the patient about what obsessions and compulsions are.  Rated 0-4; range of possible scores, 0-40  For obsessions: Time occupied by obsessive thoughts, obsession-free interval, interference, distress, resistance, control.  Ditto for compulsions.
  18. 18. 18 LEYTON OBSESSIONAL INVENTORY  69 items  Identification of OCD s/s  Assessment of resistance  Assessment of interference  Plus: Common OCD s/s listed individually  Minus: Rare s/s are omitted.
  19. 19. 19 CORNERSTONES OF CBT  Common to both obsessions and compulsions:  Psychoeducation  Challenging assumptions  [Family support, if indicated]  Obsessions:  Thought-stopping  Distraction  Compulsions:  Exposure  Response prevention
  20. 20. 20 CBT FOR OBSESSIONS  Psychoeducation  Challenging assumptions  Family support  Thought stopping  Distraction
  21. 21. 21 PSYCHOEDUCATION FOR OBSESSIONS  Explain about OCD  Destigmatize the illness  Explain the principles of drug therapy  Explain the principles of CBT  Discuss plan of management  Review patient understanding  Time: 1-2 hours
  22. 22. 22 CHALLENGING ASSUMPTIONS  Obsessions are, by definition, irrational thoughts.  Patients don’t always recognize their irrationality.  Taking each obsession by turn, challenge the flawed logic that underlies it.  Goal: To reduce anxiety through the realization that the thought is irrational and can be ignored.  E.g. Obsessive fears: “What if that man [on the bus] is carrying a bomb?”  E.g. “What if I get AIDS?” [by using public cutlery]
  23. 23. 23 CHALLENGING ASSUMPTIONS  Generalization: The patient must learn how to reduce anxiety by arguing against his own beliefs when the obsessions arise outside the clinic.  Challenging assumptions should result in full insight. So, take as much time as the patient requires to fully grasp, appreciate, accept, and articulate the arguments.
  24. 24. 24 THOUGHT-STOPPING  Terminates the obsession  Slapping the table or pinching one’s thigh  Shouting stop  Snapping a rubber band on the wrist  Doing these physically or imaginally
  25. 25. 25 OTHER DISTRACTOR TECHNIQUES  Taking up a chore that demands attention  Phoning a friend  Speaking to a family member  Examining details in the environment  Etc. [plan these out]
  26. 26. 26 STRATEGY FOR TACKLING OBSESSIONS  Take one obsession at a time.  Go from education to challenging assumptions to thought stopping and distraction.  Preferably move to the next obsession only after the previous obsession has been satisfactorily overcome.
  27. 27. 27 CBT FOR COMPULSIONS  Psychoeducation  Challenging assumptions  Recruit family support  Exposure  Response prevention
  28. 28. 28 CHALLENGING ASSUMPTIONS: CHECKING COMPLSIONS  Did I lock the door?  Strategy  Be aware that this is a problem.  When locking, say “I have done it” [lays memory trace].  When the doubt arises, recall the memory.  Learn to trust the memory [if you cannot trust yourself, whom will you trust?]  Recall past experience [has there been any occasion that you checked and repeatedly checked and found that the door was unlocked?]
  29. 29. 29 CHALLENGING ASSUMPTIONS: WASHING COMPLSIONS  What is dirt?  Why is dirt dirty?  When is dirt dirty?  Can dirt be good (prevents allergy, builds immunity)  Why is water clean?  Note that, after the first wash, washing/soaping removes layers of skin, not dirt.
  30. 30. 30 MORE ABOUT DIRT  Why are bodily secretions dirty the moment they leave the body?  Smelling a fart and airborne particles  Do not tell the patient this!
  31. 31. 31 CHALLENGING ASSUMPTIONS  [Same as with obsessions]  E.g. for checking whether a door was locked  E.g. for removing dirt from the hand  E.g. for repeated rituals lest a deity be offended  E.g. for repeated rituals after stepping on paper  E.g. for rituals that seek to ward off harm.
  32. 32. 32 CHALLENGING ASSUMPTIONS  Challenging assumptions should result in full insight. So, take as much time as the patient requires to fully grasp, appreciate, accept, and articulate the arguments.  This is necessary to ensure motivation in exposure and response prevention exercises.
  33. 33. 33 EXPOSURE AND RESPONSE PREVENTION  Systematic desensitization  Flooding  Imaginal (as part of the desensitization hierarchy, or if in vivo exposure is not feasible)  Voluntary response prevention (should not be forced by family, hospital staff e.g. as in turning off the water supply in a patient with washing compulsions)  Goal: Anxiety reduction through habituation  Time: At least 30-120 min per exposure session; anxiety reduction must be substantial.
  34. 34. 34 EXPOSURE AND RESPONSE PREVENTION  E.g. stepping on paper  E.g. touching footwear  E.g. handling currency notes  E.g. checking a locked door  Therapist-assisted exposure (provides support)  Self-driven exposure (provides confidence, improves generalization)
  35. 35. 35 DEALING WITH BATHING RITUALS  Identify and tackle underlying obsessions.  Break up the rituals into their component parts [wetting, soaping, rinsing, wiping].  Define what is the purpose of each, and what is the normal limit of behavior for each.  Practice behavior within these set limits while simultaneously challenging the assumptions which were responsible for the obsessions.
  36. 36. 36 DEALING WITH RELIGIOUS OBSESSIONS AND RITUALS  Understand the cultural context.  Tread carefully, respect beliefs, challenge assumptions only with informed consent.  Discuss source of beliefs and practices; consider the ‘tying the dog story’.  Probe inconsistencies between obsessions and beliefs about the nature of God.  Remind patient that idols and pictures are representations, not personifications, of God.
  37. 37. 37 DEALING WITH OBSESSIVE SLOWNESS  Suggestions:  Challenge assumptions.  Set timetable with attention to problem specifics.  Enlist family supervision.
  38. 38. 38 COMMENTS  Patients sometimes develop substitute rituals after their primary symptoms are addressed.  E.g. rubbing hands to replace washing.  Not all patients are suited for CBT; not all patients will respond; however, some improvement is better than no improvement.
  39. 39. 39 SESSIONS  3-5 sessions a week for 3-5 weeks.  Each session up to 2 hours.  15 min for review of previous session, homework.  45-90 min for exposure and response prevention.  15 min for setting homework.  Ideally, when a symptom is addressed, there should be 100% compliance with therapy directions [e.g. response prevention]; otherwise, the therapy work is undermined.  Booster sessions (maintenance therapy).
  40. 40. 40 IMPORTANT THERAPIST AND CLIENT CHARACTERISTS  Client:  Motivation and compliance  Therapist:  Effort to identify the symptoms in their entirety  Ability to successfully challenge assumptions.
  41. 41. 41 ENFIN…  That’s it, folks; thanks for listening!