110207 Obsessive Compulsive Disorder

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    CNWL/RHUL IAPT

    CBT PGDip.

    Obsessive-Compulsive Disorder

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    OBSESSIVE COMPULSIVE DISORDER

    SESSION OUTLINE

    DEFINITION AND DIAGNOSIS

    BEHAVIOURAL AETIOLOGICAL MODELS & TREATMENT

    COFFEE/TEA BREAK

    CBT AETIOLOGICAL MODELS & TREATMENT

    LUNCH

    VIDEO & CASE DISCUSSION

    SUSAN: CASE FORMULATION EXERCISE

    COFFEE/TEA BREAK

    ASSESSMENT MEASURES

    TROUBLESHOOTING TRAINEE CONCERNS/CASES

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    OCD DEFINITION AND DIAGNOSIS

    NORMAL WORRIES & COMPULSIONS

    DYSFUNCTIONAL/ABNORMAL

    OBSESSIONS

    DSM IV DIAGNOSIS

    A UNITARY CONSTRUCT?

    SUBCLASSES OF OCD

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    OCD DIAGNOSIS

    DSM IV & ICD 10A significant source of distress and/or interference

    OBSESSIONS

    Recurrent, persistent thoughts, images or Impulsesexperienced, at some point, as intrusive and senseless

    Attempts to ignore and/or suppress and/or neutralise.

    Recognition of ownership of thoughts, yet perceived as ego-

    dystonic; content unrelated to another Axis 1 diagnosis.

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    OCD DIAGNOSIS

    COMPULSIONS

    Repetitive, purposeful and intentional behaviour

    Performed in response to an obsession or according to

    certain rules

    Designed to neutralise or prevent discomfort and/or

    catastrophe.

    Awareness of their unrealistic and/or excessive nature

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    OCD: DIFFERENTIAL DIAGNOSIS

    MAJOR DEPRESSIVE DISORDERGENERALIZED ANXIETY DISORDER

    HYPOCHONDRIASIS

    SPECIFIC ILLNESS PHOBIA

    ANXIETY DUE TO A GENERAL MEDICAL CONDITION

    APPETITIVE DISORDERS

    BODY DYSMORPHIC DISORDER

    DELUSIONAL DISORDER

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    OCD DIFFERENTIAL DIAGNOSIS

    OBSESSIVE-COMPULSIVE PERSONALITY DISORDER

    ABSENCE OF OBSESSIONS AND/OR COMPULSIONS

    PERVASIVE PATTERN OF:

    ORDERLINESS

    PERFECTIONISM

    CONTROL

    PREDOMINANTLY EGOSYNTONIC

    ONSET BY EARLY ADULTHOOD

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    OCD EPIDEMIOLOGY

    INCIDENCE AND PREVALENCE

    General Population: Point Prevalence

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    BEHAVIOURAL MODEL OF ANXIETY

    ANXIETY IS A RESULT OF MALADAPTIVE LEARNING

    NAMELY, THROUGH:

    A. CLASSICAL OR PAVLOVIAN CONDITIONING:

    UNCONDITIONED STIMULUS (UCS)UNCOND. RESPONSE (UCR

    (e.g.: shock, trauma, nausea) (i.e.: anxiety symptoms)

    +

    CONDITIONED STIMULUS (CS) CONDITIONED RESPONSE (C

    (e.g.: dogs, crowds, dirt) (i.e. anxiety symptoms)

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    BEHAVIOURAL MODEL OF ANXIETY

    B. INSTRUMENTAL OR SKINNERIAN CONDITIONS:

    TWO FACTOR MODEL - 1. CLASSICAL CONDITIONING

    OF ANXIETY

    2. INSTRUMENTAL LEARNINGOF MALADAPTIVE RESPONSE

    (e.g. Fight, Flight, Avoidance or Checking)

    MALADAPTIVE RESPONSE PREVENTS EXTINCTION OF CR IN

    PRESENCE OF CS

    CONDITIONING OR LEARNING HISTORIES EXPLAIN ONSET AND

    MAINTENANCE OF ANXIETY DISORDERS AND POINT TO

    TREATMENT.

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    BEHAVIOURAL MODEL OF ANXIETY

    BEHAVIOURAL TREATMENT INVOLVES EXPOSURE TO FEAREDSTIMULI/SITUATIONS (CS) WITHOUT THE UCS AND MALADAPTIVRESPONSE TO PERMIT THE EXTINCTION OF THE CONDITIONEDRESPONSE (CR)

    ADVANTAGES EXPLICIT PREDICTIONS DEMONSTRABLE

    PLAUSIBLE PRACTICAL/DIRECT TREATMENT

    DISADVANTAGES PREPAREDNESS INDIVIDUAL DIFFERENCES DEVELOPMENTAL INFLUENCES LACK OF TRAUMATIC ONSET SOCIAL & SYMBOLIC ACQUISITION OF

    ANXIETY

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    OCD TREATMENTAPPROACHES

    BEHAVIOUR THERAPY

    Rationale & Behavioural Assessmentsee Figure 1

    Exposure and Response Prevention

    Maintenance and Generalizability

    Relapse Prevention

    T i l S i h B h i l A

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    Typical Steps in the Behavioural Assessmen

    of OCD

    Specify the rituals and obsessions in detail

    What situations evoke the rituals or obsessions (e.g., do the

    rituals occur only at home)?

    Are there any fluctuations in the symptoms (e.g. are they worse

    the patient is alone)?

    What situations does the patient avoid as a result of OCD?

    Fig. 1

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    Typical Steps in the Behavioural Assessment

    of OCD (Contd.)

    Do any thoughts, images, or impulses trigger (eg sacrilegious images,aggressive impulses) rituals or obsessions ?

    Construct hierarchy of target situations based on the amount of anxiety (SUD

    scale), ritualising, or obsessing they evoke.

    What does the patient believe will occur if he or she does ritualise? How

    strong is this belief?

    Are the patients symptoms being maintained by family interactions?

    Is the patient severely depressed? If so, consider trial of medication.

    Fig. 1

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    Typical OCD Fear Hierarchy

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    OCD: Client Exposure Guidelines

    ERP S i b S i H bi i

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    ERP Session by Session Habituation

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    OCDCBT AETIOLOGICAL MODELS

    Primary Cognitions: Threat Appraisal (Figure 2)

    Guilt, Responsibility and Resistance (Figure 3 & 4)

    Covert Cognitive Rituals (Figure 5)

    Metacognition (Figure 6)

    Secondary Mood disorder

    Overvalued Ideas

    Stimuli and situationsFig 2

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    Stimuli and situations

    (Internal or external)

    Including external triggers,

    intrusive thoughts and information

    COGNITION

    DANGER, THREAT

    Safety seeking

    Behaviours (includingAvoidance, escape, and

    neutralising)

    Biological andPsychophysiological

    reactions

    Fig 2

    CBT M d l f OCD f S lk ki (1985)

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    CBT Model of OCD from Salkovskis (1985)

    Potential Stimuli

    Intrusion Ego Dystonic

    Automatic Thoughts Ego

    syntonic

    Mood Disturbance,

    discomfort, dysphoria,

    anxiety

    Neutralising ResponseEscape Behaviour

    Rewarding

    Non-punishment

    Perception of

    Responsibility

    Increased Acceptance

    Avoidance

    Triggering Stimuli

    (Internal/External)

    Extrinsic Mood Disturbance

    Schematic Activation:

    accessibility of loss, threat or

    blame ideation

    Expectancy

    Reduced Discomfort

    Fig. 3

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    A COGNITIVE THEORY OF OBSESSION

    OBSESSION DESCRIPTION INTERPRETATION DISTRESS/ CONSEQUENCES

    FEAR

    Thought e.g.:Sinful e.g.: Revealing about me I will cause harm e.g. Intense resistance

    Image Disgusting Warning signs People will reject me to obsessions

    Impulse Alarming Losing control I will be locked up Attempts to block them

    Going insane Neutralisations

    I am dangerous Avoidance Behaviour

    A postulated sequence of descriptions, interpretations and actions (from S.J. Rachma

    Fig. 4

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    Cognitive Obsessions and Covert Rituals

    Intrusive Thought

    Negative Appraisal

    Increased Anxiety and Worry

    Overcontrol

    Vigilance (Could I really do it?) Covert Rituals Testing

    Temporary Anxiety Reduction

    Cycle starts all over againFig. 5

    EXAMPLE OF THOUGHT/ACTION

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    EXAMPLE OF THOUGHT/ACTION

    FUSION AND OC METACOGNITION

    Im having a bad thought that must mean Im bad.

    I wouldnt be having these thoughts if I wasnt truly bad!

    The more bad thoughts I have, the more proof I have that Im bad.

    Because Im thinking so much about doing bad things, it must mean that Im highly likely to do someth

    bad.

    If I dont try hard to prevent harm from happening, it is as bad as doing something bad on purpose.

    Since it is likely that Im going to do something bad, Id better watch out for it. I may even have to ma

    sure that others are protected from my bad actions.

    Fig. 6

    OCD: COGNITIVE TREATMENT

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    OCD: COGNITIVE TREATMENT

    APPROACHES

    Psychoeducation of CBT Model of OCD

    Shared Formulation

    Identification of Intrusions & Appraisals

    Cognitive Restructuring of Appraisals & Beliefs Role of Compulsions, Neutralization & Avoidance: ERP

    Behavioural Experiments

    Modifying Metacognitive Beliefs

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    OCD: Examples of Behavioural Experiments

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    OCD: Relapse Prevention