Aug
3

2014 Annual OCD Conference

OCD Foundation’s Annual Conference

I recently attended the 21st annual OCD Conference in Los Angeles put on by the International OCD Foundation. The conference was well organized and had a wide variety of session topics from highly respected speakers in the field of OCD and OCD spectrum disorders with respect to research and treatment. By OCD spectrum, I’m referring to issues such as Trichotillomania, Body Dysmorphic Disorder, Hoarding, and Tourette’s Disorder. One aspect of this conference I appreciated was that attendees were not just treatment professionals, but included children, teens and adults with OCD, parents of children with OCD looking for support, and researchers. Not surprisingly, the overwhelming majority of treatment discussions focused on Exposure and Response Prevention (ERP). ERP is the gold standard for treatment of OCD for all age groups. ERP involves identifying the underlying obsession(s), illuminating the patterns of being triggered and engaging in compulsions, developing a fear hierarchy and finally defining response prevention guidelines.

OCD Treatment with Children and Teens

Because I enjoy working with children and have a number of children with OCD on my caseload at any given time, I attended several talks geared toward OCD treatment for children and teens. A few of these were intended for children with OCD and others had content intended for treatment professionals. One of the talks I attended was about developing an effective toolbox for beating OCD, geared toward children with the disorder. One of the tools imparted on the attendees was knowledge about the adaptive nature of anxiety; for instance, when your heart races, it’s the body’s way of pumping blood to your muscles faster to help with fight or flight actions; when your body sweats, it’s so the body is slick if an attacker grabs onto you. So reduction in fear of anxiety itself can be a good first step. Another tool they wanted to arm attendees with was knowledge and experience with ERP. They helped the kids in the audience identify which type of OCD thoughts they had and as a group, we brainstormed ways to engage in exposures by figuring out how to test contamination fears, for instance, by exposure to different things in the meeting room we were in.

Using Mobile Apps for OCD

Another session I attended was geared toward mobile applications that can help kids and teens develop exposures using cell phones and tablets. One of the applications that was highlighted turns spoken fears into songs that the child or teen can listen back to as exposure homework. The goal of this application is to turn a fear into something slightly comical or entertaining through song and music. By creating a competing reaction, like laughter, the fear diminishes because it’s fairly difficult to be entertained and laughing while also being fearful or scared. A second mobile application discussed in the presentation is useful with fears of harming others. The essential feature of this application allows users to create characters based on people they fear harming, and then allows them to virtually kill these people through the application. In essence, the user is acting out the feared behavior in a virtual world while still eliciting the anxiety. Both applications are useful in situations where an in vivo exposure is either not appropriate or difficult to execute.

Insight Helps with Beating OCD

Insight is a valuable tool in therapy. Research indicates that lack of insight with OCD is associated with greater symptom severity and higher risk for co-morbidity, or an additional diagnosis or clinical issue. I attended a panel discussion that focused on the role insight in the treatment of OCD and BDD among others disorders. Insight is not fixed and can be encouraged and modeled through the therapeutic process. Overvalued ideation was another concept tossed around that looks similar to insight but refers to the strength of conviction about a belief. Without insight, it’s difficult for someone dealing with OCD to entertain the idea that the rituals aren’t accurate. Lastly, the panel mentioned that when insight is low and progress is difficult to come by, psychopharmacological options can be helpful.

Health Anxiety Sub-Types

There is a fair amount of overlap between health-related OCD and Somatic Symptom Disorder (SSD), formerly known as Hypochondriasis. Similar features include having thoughts about an illness, repeated self-checking, reassurance seeking with medical tests, doubting test results, and over-concern with the significance of bodily sensations. One of the main differences between the two is that with SSD, sufferers frequently experience visceral physical sensations, whereas OCD sufferers experience doubtful dysperceptions. It can be useful to think of health-related OCD and SSD on a continuum of doubt with OCD sufferers having considerable doubt and SSD sufferers having much less doubt. Exposure and Response Prevention can be an effective intervention with SSD as well OCD.

Another concept mentioned in the SSD vs. health-related OCD presentation was iCompulsions or CyberChondriasis, which both relate to the act of mining websites like WebMD for health and treatment information as a form of reassurance-seeking. This behavior typically results in an increase in anxiety from increased focus on the physical sensation or discomfort. This can quite easily lead to catastrophizing thoughts about what a possible diagnosis might be. Even for individuals without SSD or OCD, seeking health information online can be a confusing, scary and misleading process. So combined with a hyperfocus on physical symptoms and/or persistent doubt, it’s understandable to see how SSD and OCD can develop.

Face Your Fears!

And lastly, a quote that was provided during the conference that I think gets at the heart of ERP is as follows: “Do the thing you fear the most, and it will be the certain death of it,” attributed to Ralph Waldo Emerson.

0 Categories : Exposure and Response Prevention (ERP), OCD

Aug
2

Exposure & Response Prevention for Obsessive Compulsive Disorder (OCD)

by Laura Johnson

Exposure and Response (Ritual) Prevention for Obsessive Compulsive Disorder (OCD)

I recently attended intensive training in Exposure and Response Prevention for OCD at the Center for the Treatment and Study of Anxiety at the University of Pennsylvania in Philadelphia. In addition to terrific presentations by Dr. Elna Yadin, OCD Clinic Director, and staff members, we were honored with a Q&A session with Dr. Edna Foa. While I already considered myself a skilled therapist in treating OCD, this training helped refine my skills in systematically implementing a specialized form of OCD treatment called “Exposure and Response (Ritual) Prevention,” also know as EX/RP or ERP.

What is Obsessive Compulsive Disorder (OCD)?

Obsessive compulsive disorder (OCD) is a neurological disorder that causes severe anxiety/distress and affects your thinking and behavior. OCD tends to attack the things you value the most. When you feel anxious, it might feel like you are in danger. OCD tells you to respond, react, protect yourself, and do something to get rid of the distress. You might recognize that the fear is excessive or doesn’t make sense, yet it still feels very real, intense, and true. If you have OCD, the warning system in your brain is not working correctly. Your brain is telling you that you are in danger when you are not.

Common Types of OCD

Obsessions are unwanted, intrusive thoughts, images, or impulses that occur over and over again and feel out of your control. They are disturbing, anxiety-provoking and perhaps even disgusting to you. Common obsessions include contamination from germs, bodily fluids, diseases, or chemicals; causing or failing to prevent harm to others; fear of losing control; sexual, religious or morally offensive thoughts and images; perfectionism; and not-just-right feelings.

Compulsions are repetitive behaviors or mental rituals that you engage in to neutralize, undo or make your anxiety go away. Compulsions can also include avoiding situations that trigger obsessions. Common compulsions include checking, washing and cleaning, repeating an action, putting things in order, praying, counting, mental review, reassurance seeking, apologizing and confessing. These actions are designed to prevent or reduce emotional discomfort and avoid the occurrence of a dreaded event. Compulsions tend to provide temporary relief but the obsessions soon return.

It is important to note that OCD comes in many different forms and no two OCD sufferers are alike in their combination of obsessions and compulsions as well as the meaning they attribute to their feared catastrophe.

What is Exposure and Response (Ritual) Prevention (EX/RP)?

In a nutshell, EX/RP consists of exposing you to the triggers that cause anxiety and fear and teaching you to resist doing any compulsions or rituals to reduce the distress. The basic principles of EX/RP can be boiled down to three steps that need to be practiced consistently to overcome OCD:

Confront the things you fear as often as possible.
If you feel like you have to avoid something, don’t.
If you feel like you have to perform a ritual to feel better, don’t.

With EX/RP, your brain learns that you can tolerate anxiety and that your anxiety will eventually come down without rituals. Your brain will learn that the feared catastrophe does not happen or that you could handle it if it did. And you may start to realize just how ridiculous or unrealistic your obsessional fears are and how much OCD is taking away from your life. Basically, OCD is a bully! We will teach you how to take charge and not give OCD the attention it craves.

The main treatment components of EX/RP include:

Assessment, Education and Treatment Planning: We’ll identify all your triggers, obsessional fears and related rituals and make a plan to systematically approach your fears without engaging in rituals. We will also teach you about the sneaky ways OCD tries to trick you and lies to you. You will learn that OCD is like a “tic” in the brain that is trying to protect you but instead OCD is making you a slave and ruining your life.
In Vivo Exposure: Exposures are the heart of OCD treatment. In this step, we will expose you to real life triggers that elicit fear, anxiety and/or disgust in a gradual hierarchical manner. We will start with easy exposures and, as you gain confidence you can cope with your anxiety, we will move up the hierarchy to confront situations that are more challenging.
Imaginal Exposure: This involves prolonged exposure in your imagination to your worst fears without doing any rituals. We’ll develop a script (or series of scripts) for you to record and listen to every day until you are no longer scared of the content of your obsessions and you can visualize yourself facing your fear without any rituals.
Response (Ritual) Prevention: RP is the identification and elimination of all physical and mental compulsions so you can learn you can cope with distress without doing rituals or avoidance. You will learn that while your rituals reduce anxiety/distress in the short term, they are not building your courage that you can handle anxiety without them. Rituals are actually fuel to OCD’s fire and maintain the OCD cycle.
Cognitive Processing: The key to long term, permanent change is gaining new beliefs and increasing your self-confidence. OCD is making you believe things that aren’t true and exaggerating the danger of your fears. In order to help you overcome OCD, we won’t tell you what to think because OCD will just argue with you. Instead, we’ll discuss what you have actually learned through your EX/RP activities and reinforce your experiential learning in order to create new beliefs about the meaning of your obsessions.

Treatment Description

In EX/RP, you will purposely experience your obsessive thoughts without ritualizing so you can learn that your discomfort/anxiety will come down and your fear is eventually extinguished. With your therapist, you will develop a hierarchy of exposures that will elicit your obsessional fear and we’ll develop a plan for systematically targeting each of the items. We’ll identify both behavioral and mental rituals to eliminate. EX/RP generally takes about 20 sessions total. We recommend two 75-minute sessions per week to help you maintain continuity and motivation in doing the exposures and to progress more quickly to relieve your suffering.

Initial Evaluation Session

The goal of the initial evaluation session is to learn about your background and history as well as determine what type of anxiety you have. If the diagnosis is OCD, then we will discuss the EX/RP treatment approach and determine if it is a good fit for you. We will also begin to assess your motivation since completing daily exposures in between sessions is essential to success in this program.

Information Gathering and Education

In the next one to two sessions, we will gather a lot of information about the content of your obsessions, types of compulsions/rituals you use to reduce obsessive fears, and the feared consequences if you are unable to perform your rituals. We will use a standardized assessment tool called the YBOCS, which helps us assess all the OCD symptoms and rate the severity of your OCD from mild, moderate to severe. You will also be asked to monitor your OCD symptoms throughout the week. The goal of this phase is to develop a thorough understanding of your obsessions and compulsions and the situations likely to trigger them. We will continue to assess your motivation for treatment and how much support you will need by the therapist and family members in implementing your EX/RP plan.

Treatment Planning

Next, we will spend one to two sessions determining what the feared catastrophe is, creating the hierarchy, identifying and ranking the order of exposures, deciding whether imaginal exposure is needed, creating the plan for reducing and eliminating rituals, and deciding whether exposure requires travel outside the therapist’s office such as a home visit. The question often arises as to whether we need to create different hierarchies for each type of OCD. While this may be helpful when the OCDs seem completely unrelated to one another, it is often not needed because the ultimate fear is often the same for all the OCDs. By creating one master hierarchy and working on fears by level of discomfort/anxiety, you will learn the principles of treatment and the therapy often generalizes more effectively from one symptom to the next.

To create a hierarchy, you and your therapist will generate a list of all the situations that provoke obsessive fear and avoidance behavior. We will then ask you to rate how much distress each situation causes for you on a scale of 0 to 100 and we will place the items in order from easiest to hardest. We generally start working on exposures rated in the 40-50 range and progress to harder exposures and the easier ones are mastered.

Imaginal exposures are used when engaging in the actual situation is not possible in real life, when your feared consequences are so far into the future that they can not be disconfirmed, or when you have so much fear approaching the real life situations that we need to start with thinking about the situation before progressing to actual exposures.

Exposure and Response Prevention Treatment

EX/RP treatment begins when we start working on the first situation on your hierarchy. Generally, 15 exposure sessions are recommended but some people with mild OCD may progress more rapidly while others with more severe OCD may need extra sessions. We will start with doing exposures during the therapy session and then assign the same exposure as homework for you to practice on your own. When your distress significantly declines and you no longer fear the situation, then we will move to the next item on the hierarchy. Since we are starting with items you ranked at a moderate level and only moving up when your distress has declined, it makes working on the harder items on the hierarchy feel much easier. If you find that you are not feeling a reduction of anxiety within 45 minutes, then we have probably underestimated the difficulty of that situation and we would move to an easier item. If we are working at the right pace, you should be feeling challenged in exposure sessions but not so uneasy that you can’t do it.

While doing exposures, you will not be allowed to perform any rituals to undo the anxiety or distress. Sometimes we may allow you to modify a ritual to allow you to approach situations that are more difficult and higher on the hierarchy but our goal will be to quickly eliminate the all rituals associated with that situation. We want your brain to learn that it can face your fears and overcome obsessional fears without doing any rituals.

A key to success in EX/RP is changing how you relate to the meaning of danger created by your OCD. This is called cognitive processing, where we will discuss what you learned from the exposure without doing your normal rituals. We will stress that the content of your obsessions doesn’t matter because OCD will latch onto whatever is important to you. Most people have multiple types of OCD and notice it morphs and evolves over time into new symptoms. We want you to learn the general principles of EX/RP so you can “zap” whatever part of your life OCD wants to target in the future.

We will move up the hierarchy as quickly as you can tolerate it. When all the items on your hierarchy no longer cause distress and you are no longer performing rituals to reduce anxiety, then we can formally end the EX/RP treatment phase.

Relapse Prevention

Generally, we’ll plan on two to three relapse prevention sessions spaced out over time. OCD symptoms often wax and wane with stress and life transitions. Relapse prevention consists of reviewing your progress, identifying the tools you can use to manage any future OCD flare ups, identifying and planning how to handle potential future stressors, and knowing the warning signs of OCD and how you can treat it yourself with your tools, especially self-exposure.

0 Categories : Anxiety, Cognitive Behavior Therapy, Exposure and Response Prevention (ERP), OCD, Uncategorized

Oct
15

Pediatric OCD Treatment for Children and Teens

by Laura Johnson

OCD Treatment for Children and Teenagers

I just had the honor of attending the OCD Foundation’s first-ever Behavior Therapy Training Institute on Pediatric OCD, which was held at Rogers Memorial Hospital in Wisconsin in mid-September. The treatment for children and teens with OCD is not all that different from adults. The main components of OCD treatment include:

Education/Rapport Building (what is OCD? building the client’s trust)
Cognitive Therapy (motivation, naming and externalizing the OCD, responding to content vs themes, etc)
Exposure and Response Prevention (identifying triggers and gradually exposing the child until anxiety declines)
Family Therapy (teaching parents how to help their child)
Contingency Management (setting up a reward plan to increase motivation)
Relapse Prevention (what to do at the early signs of anxiety or stress)

While we do use cognitive strategies especially for motivation with children, we emphasize behavioral strategies even more with children. Children often aren’t able to articulate the thoughts driving their rituals. They may say “I don’t know” or “It just feels right” or “I can’t help it.” As children and teens mature, it may seem their OCD is becoming more sophisticated because they start attributing reasons to why they do things.

When we are assessing OCD in children, teens or adults, the process is the same. The therapist will be thinking about these factors:

Triggers: What stimuli trigger the obsession?
Obsession: What is the core fear?
Compulsions: How does the person attempt to neutralize the obsession?

There are four main steps in designing a personalized OCD treatment program for your child or teen.

Step 1: Define the Obsessions and Select the First Target Obsession to Work on

First, we need to determine if the thought is an obsession. If your child has a strange or irrational thought and can dismiss it, it’s not an obsession. Normal people have intrusive thoughts but the difference is that people without OCD do not attribute much meaning to them. Most people just shrug it off as a strange thought and go on with their day.

People often confuse the obsessions associated with OCD with the worries associated with Generalized Anxiety Disorder. It’s a worry if the content focuses on everyday problems that cause stress. GAD often has the same obsessional, repetitive feel to it except the theme of the worries are about real problems happening in the child’s life such as school, health, friends or family issues. An obsession, in contrast, is an intrusive, repetitive thought with senseless content. In children, common obsessions include doing things repeatedly until it feels “just right,” bad thoughts about sex or violence, superstitious thinking, and irrational concern about germs.

Step 2: Identify the Obsessions/Triggers and related Compulsions

Next, we need to identify the compulsions (rituals) that go along with the obsessive thoughts and what triggers the obsessive-compulsive cycle. External triggers are easier to work with because they are things, people, places or situations that scare people and trigger the OCD cycle. The types of OCD that usually involve external triggers include contamination, just right/not right obsessions, and doubt and uncertainty

Internal triggers, on the other hand, are the thoughts themselves, usually about sex, violence and blasphemy. For a thought to be a trigger, the thought itself must be perceived by the person as being dangerous. There are two categories of thoughts that people perceive as being toxic: the fear that having the thought can make it happen and/or the fear that having thought means something bad about the person who is experiencing the thoughts.

Step 3: Develop the Exposure Hierarchy

Exposure and Response Prevention (ERP) is the gold standard for treating OCD in all age groups. ERP is teaching you and your child an approach to life. Your child will learn that when something makes him afraid, he will face it. He will learn to approach his fears systematically through the Exposure Hierarchy. To develop a hierarchy, we will identify all the internal and external triggers for the obsessions and rank order them by level of difficulty. We will then proceed by working with you and your child in baby steps to approach their fears. We’ll use the feeling thermometer to help your child rate the difficulty of tasks. We will ask the parent to serve as the child’s ERP coach to help remind your child to practice their exposures during the week.

Step 4: Identify Response Prevention Guidelines for the Compulsions

The final step is to identify the compulsions (rituals) and to develop Response Prevention Guidelines that sound like this:
“When I get urge to (do my ritual), I will resist the urge and do this instead: XYZ.”

There are two categories of compulsions: Behavioral vs. Mental. Behavioral compulsions are things you can see your child doing such as washing, checking, reassurance seeking, straightening, etc. Mental compulsions are done in the child’s head and you may not even know they are doing them. These include counting, praying, figuring things out, replacing bad thoughts with good thoughts and mental checking.

We also need to determine if the compulsions are non-functional vs dysfunctional. Non-functional compulsions (rituals) are behaviors have no function other than to reduce anxiety related to OCD anxiety. Since these are non-sensical behaviors (like tapping three times on a door), our treatment plan will focus on eliminating these behaviors entirely because they have no function.

Dysfunctional compulsions (rituals) are excesses of normal behavior. We can’t completely eliminate these behaviors because done in moderation, they are normal behaviors like normal washing normal checking and normal prayer. For these, we help your child develop new rules for normal behavior.

During planned daily exposure time there is a schedule and specific tasks to be completed each day. Planned exposure time is generally 30 min to one hour per day. We’ll teach your child to engage in the obsessive thought while resisting the urge to ritualize. We will teach them that “When I get urge to …., I will resist the urge and do this instead …” We will also do some cognitive restructuring work where your child will learn to accept and even welcome anxiety and uncertainty by purposely choosing to expose himself to his triggers, knowing this will trigger his obsessive thoughts and urges to neutralize the anxiety with rituals.

The rest of the day, the child is taught how to deal with spontaneous exposures, or when the obsessive thoughts are triggered outside of planned exposure time. Again, we will teach your child that “When I get urge to …., I will resist the urge and do this instead …” We will help him learn to try to resist doing the compulsion and to focus on what he needs to doing instead (doing homework, watching TV, listening to music, paying attention in class, talking with friends, etc). The child will also have a list of guidelines to follow for any dysfunctional compulsions he may have an urge to do.

The key to Exposure and Response Prevention is to be ready to face your fears and to do your homework every night. You and your child will learn to ride up and down the OCD anxiety hill and beat OCD.

0 Categories : Cognitive Behavior Therapy, Exposure and Response Prevention (ERP), OCD

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