Today’s topic: “Checking “ our tool box: Working with Youth and children with OCD

Speaker: Dr. Mariève Hurtubise, C.Psych. Psychologist Youth Psychiatry Program

child & youth

Mental Health Series

June 14th 2018

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Declaration of conflict

Speaker has nothing to disclose with regard to commercial support.

Speaker does not plan to discuss unlabeled/ investigational uses of commercial product.

Presentation overview

• OCD (What it is and what it isn’t)

• The main ingredients of CBT

• Exposure and response prevention*

• Practical tools

• Helpful resources for clinicians

OBSESSIONS Unwanted thoughts, urges or images.

Intrusive, recurring and persistent!

More than “excessive worry”

Try hard to get rid of the obsession (sometimes with another thought or behavior).

A person knows the obsession comes from his/her own mind

“STUCK or STICKY” THOUGHTS

Most common obsessions

• Aggressive 68.7%

• Contamination 57.7%

• Symmetry/exactness 53.2%

• Somatic 34.1 %

• Hoarding/saving 30.2%

• Religious 24.2 %

• Sexual 19.8 %

• Miscellaneous 55. 5 %

(Anthony et al., 1998)

What aren’t obsessions

Infatuation

Fantasies

Over-thinking

Upsetting memories

Worrying

Intrusive thoughts*

Intrusive thoughts are NORMAL

90% of people report experiencing intrusive thoughts (Salkovskis, 1998)

It is not the intrusion that makes an obsession or OCD; it is our anxiety, distress, and reaction to it…

Examples of common intrusive thoughts

“Have I locked the door?”

“What if I’ve contracted a disease?”

“What if I drive off the road?”

“Impulse to drive into oncoming traffic?”

“Urge to say something nasty”

“Unacceptable sexual thoughts or images”

“Urge to shout or disturb a peaceful gathering”

(Rachman, 2007; Jacobs, 2017)

Try not to think of....

COMPULSIONS

ACTIONS (THINGS WE DO)

Ritualized, overt, or covert.

Person feels compelled to perform in response to his/her obsessions.

Reduce distress and/or to prevent a feared event.

Often does not make sense…

Most common compulsions Checking 80.7%

Washing 63.7%

Repeating 55.5%

Ordering/arranging 40.1 %

Counting 35.2%

Hoarding 28 %

Miscellaneous 59 %

(Anthony et al., 1998)

What aren’t compulsions

Tidiness / orderliness

Habits

Impulses

Addictions

Superstitious behaviours (usually)

Compulsions can be very subtle and can include mental compulsions (counting, reciting words or sentences such as prayer).

OCD: How common is it ?

In Youth : 1-4 % prevalence rate More than half of adults with OCD had

OCD in childhood… 65% of people with OCD develop it before

25 In childhood (more common in boys); no

differences are noted in adult population Initial peak of incidence: puberty and

young adulthood (sometimes even before)

(Hyman & Pedrick, 2010)

Brief word on assessment: C-Y BOCS (Children’s Yale-Brown Obsessive

Compulsive Scale)

Family Accommodation Scale

Children’s Obsessive-Compulsive Impact Scale (COIS)

Impact

How much do they try to resist ??

Onset

Family stressors

Motivation

Associated conditions

Associated Conditions

ADHD (25%)

Tourette Syndrome (50%, Tourettic OCD-TOCD)

OCD+TS+ADHD=Tourette’s Syndrome Triad

Mood and anxiety disorders (50%)

Autism Spectrum disorders (37%)

Eating Disorders (11-69%)

Substance Use Disorders (25%)

Trichotillomania, body dysmorphic disorder, habit disorders

Misophonia, emetophobia (Abramovitch & Mittelman, 2013; Conroy, 2015;Mansueto & Keuler, 2005; Neziroglu &

Sandler, 2009;Woods et al., 2008)

Empirical evidence for CBT 12-15 sessions (60-90 minutes)

Meta-Analysis (Abramowitz, Whiteside, Deacon 2005; McGuire et al., 2015)

E/RP predicts treatment outcome (Kircanski & Peris, 2015)

Family-Based Treatment and Internet-delivered (Comer & al., 2014)

Effective for 2/3 of children and youth

When effective, enduring treatment effects

(Barrett, Farrell, Pina, Peris, & Piacentini, 2008)

Main ingredients of CBT:

1) Psychoeducation OCD and rationale for intervention

2) Cognitive techniques

3) Preparation for exposure and response prevention

4) Exposure E/RP

5) Relapse prevention

6) Involving family members

Neuro behavioural Model Neurological= leaky brakes, genes, temperament

Behavioural (thoughts, emotions, behaviours)

Trigger or intrusive thought

Ritual Relief

Negative reinforcement

ABC A=fear/trigger B=Ritual C=Relief/ Reassurance/Avoidance

Trigger Intrusive thought

Avoidance or Neutralization

Appraisal

Different parts of the brain involved:

• Thalamus= makes you hyperaware of everything going on around you.

• Basal Ganglia=opens the gate and lets in unwanted intrusive thoughts

• Orbital Cortex= mixes thoughts with emotions and tells you “Something is wrong here! Take over!”

• Cingulate gyrus=tells you to perform compulsions to relieve the anxiety.

(Hyman & Pedrick, 2010-The OCD Workbook)

Leaky Brakes B.G. (Basal Ganglia)

Controls and coordinates different body movements and routine habits.

Takes in lots of information from many different parts of the brain.

I pick which information is important and which information is not !

© 2015, CPRI Brake Shop

Basal ganglia: acts as a filter What do we know ?

WHAT CAN WE DO??

START BOSSING BACK OCD !!!

Naming OCD Some favourites:

“OCD mind”, “Bob the Bossy Brain”, “Mr. OCD”, “Mr. Clean Freak”, “Micromoron” “Pest Machine”, “The Fun vaccum”, “ “OCD”, etc.

“there goes Bob again”; “There goes OCD”

© 2015, CPRI Brake Shop

Situation

Thoughts/Obsessions (itch)

Compulsion (scratch)

Fearmometer (intensity)1-100

Tracking OCD

Things OCD Doesn’t Want You To Know…

The only thing OCD can do is raise your anxiety:

OCD can’t make all those thoughts come true!

OCD can only raise your anxiety to a certain point:

OCD just wants you to feel like it will keep going up forever!

OCD can’t keep your anxiety high for long

Whether you listen or not!

© 2015, CPRI Brake Shop

© 2015, CPRI Brake Shop

Bossing back our obsessions Constructive SELF-TALK

Identifying negative self-statements

Can’t catch me this time, OCD

I’m the boss !! Take the door this time OCD!

This task is difficult, but I can handle this much anxiety (this one time), I’ll use my tool kit.

Cognitive restructuring

Map the obsession (probabilities and alternatives)

Over responsibility

Survey: Mixture of adults and youth

Good enough sample

Present it as a mini research project

Do you think that if someone has a thought it means that they will act on it ?

What’s the evidence that this might actually happen (get contaminated if I touch other people who use drugs)?

If I think of hurting my mother with a knife, I will act on this thought. I expect that it will actually happen. I will know that this has come true if I actually grab a knife and try to act on this thought.

I will purposely think of causing harm to my mother (specific thought) while I am putting my homework away in my room. I will think of this thought two times (approximately 2 minutes each time). I expect that I will act on this thought. I will know that this happened if I am down in the kitchen looking for a knife. I will know that the meaning of this thought is off if I can stay in my room, put away my homework without picking up a knife from the kitchen.

Behavioural experiment I will act on the thought of hurting my mother with a

knife. Prediction What is your prediction (write down your thought)? What do you expect will happen? How would you know if it came true?

90%

Experiment What experiment could test this prediction? (where & when). Be specific as possible. How would you know your prediction had come true?

Bossing back the meaning This thought, impulse or image means that…

My reasons for believing this are:

The evidence for this meaning is:

What do other people think my thought could mean?

How many times have I acted on these thoughts?

Other meaning?

Is there evidence missing?

How can we collect it? (Surveys, behavioural experiment, exposure)

(Rachman, 2008)

Detachment from our thoughts Mindfulness

Cognitive defusion

Integrating ACT Acceptance and commitment therapy (Dr. Steven Hayes)

Consistent with CBT underlying exposure and response prevention but DIFFERS…

No focus on getting rid of the thoughts, feelings and experiences or symptom reduction.

Live more in the present (mindfulness).

Focus on goals and values.

Different relationship with thoughts (cognitive defusion).

Self-compassion and flexibility.

( Armstrong, et al., 2013; Twohig, Hayes & Masuda, 2006; Twohig et al., 2010)

Cognitive Defusion “thinking has as much power as real events in our

lives”

Thought-action fusion

Defusion=Distancing from our thoughts

Cognitive defusion Write down the disturbing thought over and over,

hundreds of times, until it becomes a jumble of words.

Say the thought out loud over and over, make an audio recording or video.

Sing the horrific thought in a happy, sing-song manner.

Say your thoughts in other voices.

Say horrific thoughts over and over, extremely slowly.

(Hayes & Smith, 2005; Hyman & Pedrick 2010)

Cognitive Defusion Treat the mind as an EXTERNAL event or separate

person “There goes my mind having one of those losing control thoughts”.

Thought LABELING “I am having the thought that I want to hurt this person”.

Cognitive Defusion

Imagine that thoughts are like:

Internet pop-up ads

Clouds floating across the sky

Guests entering a hotel (you can be the doorman and greet them but not follow them to their room)

Suitcases dropping onto a conveyor belt at the airport.

Leaves floating down a stream

A waterfall (you are standing behind it, not underneath it)

Integrating values and goals How does OCD interfere with your life ? Why is OCD

so annoying ?

What does OCD get in the way of ? What are the costs?

If OCD wasn’t around, what would you be doing more?

What are things that OCD is getting in the way of ? (that are REALLY important to you)

What would be easier if OCD wasn’t hanging around?

Integrating Values and goals… Personal Values Card Sort (W.R. Miller, J.Cde Baca, D.B., Matthews, P.L., Wilbourne; University of New Mexico 2001)

http://www.motivationalinterviewing.org/sites/default/files/valuescardsort_0.pdf

10 or 20 years from now…

What stories would you like to tell your friends

around the camp fire ?

Validate and normalize Bossing back our OCD (fears and rituals) is like being asked to do a swan dive off a five story building into a bucket of water…

Temporary anxiety-distress (short-term)

TEAM EFFORT= ALLIES !!!

Sometimes more difficult to resist… THAT’S OK !!!

Identifying fears of changing If I don’t do my rituals, what will I do instead to feel

safe?

How can I be guaranteed that the catastrophe I fear won’t happen.

I’d rather take medication. This is too hard.

I’ve already tried CBT, and it didn’t work for me.

My rituals are necessary to ward off dangers I fear.

I am afraid I’ll go crazy if I’m prevented from doing my rituals

(Hyman & Pedrick, 2010-The OCD Workbook)

Preparing for E/RP

MOTIVATION: Traffic light activity

Do you consider X a problem ?

Are you bothered by X?

Are you interested in change?

Are you ready to change now ?

© Based on the Motivation Group: Building motivation, SUCD (The Royal)

Importance Ruler

0 1 2 3 4 5 6 7 8 9 10

Confidence Ruler

0 1 2 3 4 5 6 7 8 9 10

Readiness Ruler

0 1 2 3 4 5 6 7 8 9 10

© Based on the Motivation Group: Building motivation, SUCD (The Royal)

Decisional balance???

Avoidance trap-the scratch trap

A

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x

i

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t

y

l

e

v

e

l

Time

Avoidance or

ritual…

Length of time

Leve

l of

dis

tres

s

Leve

l of

dis

tres

s

Exposure 1 Exposure 2 3 4

5

© Based on the Anxiety Group: Exposure SUCD (The Royal)

Exposure and response prevention

EXPOSURE=confront triggers for OCD (e.g. door knob)

PREVENTION=blocking rituals and or minimizing avoidance behaviour (extinction procedure)

*REMOVE parental positive reinforcement

(extinction occurs when parents ignore seeking or reassurance (refuse to open door for client)

E/RP Successful exposure:

SPECIFIC, MESURABLE, ACHIEVABLE, REALISTIC and TIMELY.

Planned and deliberate (not accidental !)

Child and youth decides on steps

Imaginal exposure first then in-vivo exposure (if appropriate)

Gradual, starting with 40%-50% level of anxiety

Many levels (More than 10 tasks !!)

Each step is celebrated-reinforced.

Practiced often !! (Krebs et al., 2014)

E/RP Successful exposure:

careful pre-session planning

acquiring specific materials

often leaving the clinic room with the patient to carry out experiments in the relevant anxiety-triggering environment

(Krebs et al., 2014)

E/RP

DELAYING RITUAL

SHORTENING RITUAL

DOING IT DIFFERENTLY

PERFORMING IT SLOWLY

Example (fear of contamination-drugs) SSUSUDS

Touch all objects in drug kit 98%

Touch 2 objects from drug kit-take out from container 95%

Touch 1 object from drug kit (in a container) 90%

Eat snack in hallway of SUCD program 85%

Walk by the SUCD program, touch door knobs 80%

Touch door knob used by youth without washing hands 75%

Touch chair used by youth without washing hands or purell

70%

Eat snack from hospital without a wrapper on table without washing hands or purell

67%

Eat snack from hospital in a wrapper touching the table and half of the napkin that other youth have used

60%

Eat a snack from the hospital in a wrapper on a table (on a napkin) that other youth (who use drugs) may have used

50%

Listen to music or video about street drugs, talk about various ways to use street drugs, harm reduction techniques for cannabis

40 %

Fear of acting on thought of hurting mother with knife SSUSUDS

Holding sharp knife while having conversation with mother 95%

Holding sharp knife for half of the session 95%

Holding sharp knife for 15 minutes of the session 92%

Cutting a snack with mother in room 90%

Having a conversation with mother in therapy with a sharp knife on table

85%

Cutting a snack with sharp knife 70%

Having a conversation with therapist with a sharp knife in view

65%

Having a conversation with mom in therapy with butter knife on table

60%

Having butter knife close on table during therapy and mother in waiting room

55%

Therapy with butter knife in view 53%

Coming to therapy and staying for the whole session knowing there is a knife hidden in therapist office

50%

Changing ritual of mental counting to 4, right foot SSUSUDS

Put all of clothes without counting 90%

Put all of clothes, delay counting to 4 (1 time) by 15 minutes 85%

Put pants without counting or counting to 4, 1 time 80%

Put pants on counting to 4 backwards, 2 times 70%

Walk up stairs with left foot without counting 78%

Walk up stairs with right foot (counting up to 4, 1 time) 70%

Walk up stairs with right foot (counting up to 4, 2 times) forward 68%

Walk up stairs with left foot (counting up to 4, 2 times) forward 65%

Walk up stairs with left foot (counting up to 4, 4 time)-forward 62%

Walk up stairs with right foot (counting up to 4, 4 times) backwards

60%

Walk up stairs with right foot (counting up to 4, 4 times) while listening to a funny song on cell phone (Royal)

40%

Factors associated with poor response (barriers) Insufficient focus on E/RP in sessions***

Poor insight and motivation

Family Accommodation/stressors

Co-morbidity, severity

PANDAS

Cognitive and developmental issues

Cognitive and developmental issues: 37% of youth with austim reported having OCD

ASD= less of a cognitive emphasis, more behaviourally focused, incentives for participation

Behavioural Intervention for Anxiety in Children with Autism (BIACA-Woods et al., 2009)

Boderline intellectual functioning=differential reinforcement, overcorrection and in vivo exposure)

Down Syndrome=shaping and pacing

Cognitive and developmental issues: 1) Added parental involvement

2) Simplified language

3) Decrease reliance on cognitive procedures

4) Contingency management and parental therapist role model

E/RP Something to keep in mind...

Valderhang et al., (2004) found that less than 1/3 of clinicians working with OCD use exposure techniques regularly, despite reporting CBT to be their preferred treatment approach.

Assigning exposure homework=insufficient.

(Krebs et al., 2014)

Special thanks to… Dr. Andy Jacobs, Dr. Margaret DeCorte,

Dr. Judy Makinen, Dr. Meagan Gallagher and Dr. Kim Corace, psychologists

Helpful resources for clinicians

For youth….

Primary Obsessional OCD

https://www.anxietybc.com/sites/default/files/Managing_Obsessions.pdf

Helpful resources Exposure and Response Prevention Toolbox (CPRI :

The Virtual Brake Shop Clinic) http://www.cpri.ca/families/programs-services/brake-shop/brake-shop-virtual-clinic/exposure-response-prevention-toolbox/

International OCD Foundation

https://iocdf.org/

OCD Peer Support Groups in Ottawa

https://www.ocdottawa.com/

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