Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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Erin McGinty, LPC- Therapist and Director of Anxiety Services at Castlewood Treatment Center presents on the comprehensive treatment of Anxiety and OCD spectrum disorders.

Transcript of Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

  • 1.Webinar Treatment of Obsessive-Compulsive SymptomsMarch 12, 2013Erin McGinty, LPC, NCCProgram Director, Anxiety Services Coordinator, and Primary TherapistCastlewood Treatment Center for Eating Disorders800 Holland Road636-386-6611, ext. 103www.castlewoodtc.com

2. Normal vs. Abnormal Anxiety (Barlow, 2002)Anxiety? Fear? Worry? Panic? TerminologyAnxiety is a future-oriented mood state associated with preparation for possible, upcoming negative events.Fear is an alarm response to present or imminentdanger (real or perceived). 3. Normal vs. Abnormal AnxietyThe fight-or-flight response: Physiological: Changes in heart rate and breathing,nausea Cognitive: Attention shifts to the perceived threat Behavioral: Actions intended to avoid or escape thethreat (e.g., fleeing, attacking) In times of danger, anxiety can be a persons best friend. (Abramowitz, 2011) 4. Normal vs. Abnormal AnxietyAbnormal anxiety: When anxiety occurs in the absence of danger or when it is out of proportion relative to the actual threat. Such excessive and pathological anxiety stemming from the misperception of a safe situation as dangerous (Abramowitz, 2011). This leads to the development of safety behaviors and strategies intended to detect, avoid, or escape perceived danger that may exacerbate symptoms. 5. Elements of Clinical AnxietyFear Cues: Stimuli and situations that elicit anxietyMaladaptive Beliefs: Exaggerated estimates of threat Catastrophizing Probability OverestimationSafety Behaviors: Actions intended to detect, avoid,or escape a negative or feared outcome(Abramowitz, 2011) 6. Anxiety Disorders (Abramowitz, 2011)Anxiety Disorder Fear Cue(s) Misperception(s)Coping ResponsesObsessive- Intrusive thoughts, Thought-actionAvoidance,Compulsive situational cuesfusion, inflatedcompulsive rituals,Disorder (OCD) responsibility forreassurance seeking preventing harmSpecific PhobiaSnakes, heights,Overestimation of Avoidance, use of injections, etc.the likelihood or drugs, distraction severity of dangerSocial PhobiaSocial situations Other people areAvoidance, in- highly judgmental;situation safety negative evaluation behaviors (e.g., is intolerableusing alcohol at a party) 7. Anxiety Disorders (Abramowitz, 2011)Anxiety Disorder Fear Cue(s) Misperception(s) Coping ResponsesPanic Disorder and Arousal-related Misinterpretation of AgoraphobicAgoraphobiabody sensations;arousal-related body avoidance, in- situational cuessensations assituation safety dangerousbehaviors, safetysignalsPosttraumatic Stress Intrusive memoriesNowhere is safeAvoidance ofDisorder (PTSD)of traumatic eventsreminders,distraction, safetysignalsGeneralizedThoughts/images ofIntolerance of ReassuranceAnxiety Disorder low probability uncertainty; seeking, worrying(GAD)eventsoverestimation ofas a form of the likelihood and problem solving severity of outcomes 8. Functional Assessment of AnxietyBecause exposure therapy targets the patients specific fears, itis not enough to know that the individual has a diagnosis of(an anxiety disorder). Developing an effective exposuretreatment plan requires the therapist to be cognizant of theparticular situations and stimuli that trigger fears, the fearedconsequences of facing these fears, and the specificmaladaptive strategies the individual uses to manage thesefears (Abramowitz, 2011). 9. Functional Assessment of AnxietyComponents of Functional Assessment of Anxiety (Abramowitz, 2011):1. Problem list2. Background and medical history3. Historical course of the problem and significant events orcircumstances Personal and family history of anxiety Other events (e.g., media reports, illness outbreaks) that stand out as possible triggers of the current problem4. Fear cues External situations and stimuli Internal cues: body signs and sensations Intrusive thoughts, ideas, doubts, images, and memories 10. Functional Assessment of AnxietyFeared Cues (Abramowitz, 2011):What specific things are you afraid of? What situations do you avoid?In what situations do you start to feel anxious or afraid? What are your triggers?In what situations do you have to use safety behaviors, such as _____?What bodily symptoms are you concerned with?What happens to your body that makes you feel afraid?What symptoms set off concerns about your health? 11. Functional Assessment of AnxietyFeared Cues (Abramowitz, 2011):What upsetting thoughts or memories do you have that trigger anxiety?What thoughts do you try to avoid, resist, or dismiss?What is it that triggers these thoughts (or memories)?Tell me about the form of these thoughts. Are they images? Are they impulses to do something terrible?What about these thoughts is scary for you?What makes you feel that it is bad to have them?What else can you tell me about the thoughts? 12. Functional Assessment of Anxiety5. Feared consequences of exposure to fear cues Overestimates of the likelihood and severity of danger Intolerance for uncertainty Beliefs about experiencing anxiety 13. Functional Assessment of AnxietyFeared Consequences (Abramowitz, 2011):What is so frightening for you about flying on a plane?What do you tell yourself if you experience tightness in your chest?What makes it so bad for you to give public speeches?What are you worried might happen if you went to a party where youdid not know anyone?What is the worst-case scenario that could happen if used a publicbathroom? 14. Functional Assessment of Anxiety6. Safety-seeking behaviors Passive avoidance Checking and reassurance seeking Compulsive rituals and covert, mini- (or mental) rituals Safety signals Beliefs about the power of safety behaviors to preventfeared consequences 15. Safety Behaviors (Abramowitz, 2011)Type of Safety BehaviorDescription & ExamplesPassive AvoidanceThe deliberate failure to engage in a low-risk activity associated with a feared cue.Checking & Reassurance Seeking Subtle or overt behaviors aimed at confirming or verifying what is usually already known about a fear trigger or feared consequence. Checking locks, outlets, lights Information seeking Mental reviewingCompulsive Rituals Repetitive behaviors, often performed according to certain self-prescribed rules and aimed at reducing anxiety, undoing or removing a perceived danger, or preventing feared consequences. Behavioral and mental. 16. Safety Behaviors (Abramowitz, 2011)Type of Safety Behaviors Description & ExamplesCompulsive Rituals, contd.Compulsive, rule-driven handwashing Mental rehearsing Repeating simple behaviors Repetitive praying Needing to visualize a good outcome in response to thoughts of a bad outcomeBrief, Covert (Mini) Rituals Nonritualistic attempts to reduce anxiety, remove or escape from feared stimuli, and prevent disasters. Behavioral or mental. Repeatedly replacing a bad word or image with good one Trying to suppress upsetting thoughts, images, or memories Attempting to distract oneself from a fear trigger 17. Safety Behaviors (Abramowitz, 2011)Type of Safety BehaviorDescription & ExamplesSafety Signals Stimuli associated with the absence (or reduced likelihood) of feared outcomes. Even if these items are not used, the mere presence can artificially reduce anxiety and make the individual feel as if he or she is safer than he or she would be if such items were not present. Medications Cell phone Keys Safe person Hospital Water bottle 18. Functional Assessment of AnxietySafety Behaviors (Abramowitz, 2011):When assessing safety behaviors it is important to understandnot just the form or topography of the action, but the functionor purpose of the behavior that is, why the individualperforms such behavior and in what situations it occurs.In other words, what feared consequences does it prevent andhow does the patient believe the safety behavior works? 19. Functional Assessment of AnxietySafety Behaviors (Abramowitz, 2011):How do you avoid _____?What do you avoid because of your fears of _____?Do you check that (a feared consequence) will not happen or has nothappened?Do you ask other people for assurances that something bad will nothappen?Can you tell me exactly what you do when you do _____?What gives you the feeling that you need to do _____? How do youknow when to stop? 20. Functional Assessment of AnxietySafety Signals (Abramowitz, 2011):What might happen if you didnt do _____?Are there other things you do to protect yourself from (feared consequence)?Are there any objects or people that make you feel comfortable or reduce your anxiety?Do you carry anything with you to help you feel safe?What precautions do you take so that you are prepared in case something terrible happens such as (specify the feared consequence)? 21. Treatment:Exposure and Response Prevention Therapy 22. Exposure and Response Prevention TherapyExposure Prolonged, graduated, repetitive, and consistent exposure tosituations and thoughts that provoke anxiety and distress Situational/In vivo exposure Imaginal exposure Interoceptive exposure (Panic Disorder) The A to Z rule Exposures are considered challenges by choice Hierarchies are developed with clients using a 7-point Likertscale rating subjective units of distress Begin with exposures in the 3 to 4 range 23. Exposure and Response Prevention TherapyANXIETY RATING SCALE0123 456 7 TRY AS HARD AS POSSIBLE TO RESIST HAVE TO RESISTDifficult to resist Challenging ChallengingIt bothers me urges.Anxiety isUnsure if able toExtremely hard toCALM Dont want to do bothersome, yetWish I didntresist ritualizing. resist urges to NO ANXIETYit but know it willmanageable. have to do it, butPanickinguse safetyNear panicNO URGES TO be easier than I can do it. Glad Very hard to behaviors.RITUALIZE AT think. A little bit harder when its over!Fear of dying.resist urges to ALLto resist urges butuse safety Start feelingA few urges tocan still do it. Come close tobehaviors. symptoms ofuse safetysafety behaviorspanic.behaviors.but can still resist.Cant imagine making A few weeks before Think about fakingit through the