Obsessive-Compulsive Disorder (OCD)

Obsessive‐Compulsive Disorder (OCD)

Presented by: KEPRO SW PA Health Care Quality Unit (KEPRO HCQU)

December 2016 eh

Disclaimer

Information or education provided by the HCQU is not intended to replace medical advice from the individual’s personal care physician, existing facility policy, or federal, state, and local regulations/codes within the agency jurisdiction. The information provided is not all inclusive of the topic presented.

Certificates for training hours will only be awarded to those attending the training in its entirety. Attendees are responsible for submitting paperwork to their respective agencies.

1 Objectives

• Recognize key features of Obsessive Compulsive Disorder (OCD)

• Recall how OCD affects people with intellectual and developmental disabilities (I/DD)

• Identify support techniques for managing OCD in people with I/DD

Obsessive Compulsive Disorder and Related Disorders

• Body Dysmorphic Disorder

• Hoarding Disorder

• Trichotillomanina (hair‐pulling disorder)

• Excoriation (skin picking) Disorder

2 Key Feature ‐ Obsessions

• Obsessions – Persistent thoughts, images, or impulses – Experienced as intrusive or unwanted – Cause anxiety or distress – Not worries about everyday life stressors

• Examples: – Fear of becoming contaminated – Excessive desire to have everything “just right” – Excessive doubt – Fear of harm to self or loved ones – Fear of losing control of aggressive urges – Forbidden thoughts

Key Feature ‐ Compulsions

• Compulsions: – Repeated actions, behaviors, rituals – Intended to reduce tension created by thoughts (obsessions) – Do not realistically relieve fears

• Examples: – Hand washing – Checking – Counting – Ordering/arranging – Hoarding – Repeating – Touching/smelling

3 Obsessive Compulsive Disorder (OCD)

• Obsessions /compulsions are time consuming

• Recognition that obsessions are excessive

• Causes distress or impairment in functioning

• Symptoms can be managed

OCD and I/DD: Diagnostic Issues

• Differences in how DSM diagnostic criteria is applied – Mild/moderate vs. severe/profound – need for diagnostic modifications – The higher the intellectual functioning, the more symptoms resemble clinical diagnosis • Limitations in speech / language • Abstract thinking • Physical limitations • Repetitive behaviors • Lack of observable anxiety • Sensory differences • Aggression may mask obsessions and compulsions

4 Associated Features

• Avoidance of situations

• Hypochondriacal concerns

• Intense guilt / unreasonable sense of responsibility

• Sleep disturbances

• Dry skin (from repeated hand washing)

• Stress on relationships

• Decreased productivity at work

Associated Conditions

• Depression

• Anxiety disorders

• Eating disorders

• Obsessive compulsive personality disorder (OCPD)

5 Course of OCD

• Can occur at any age – Typically adolescences or early adulthood

• Age of onset is earlier in males

• Onset is usually gradual

• Symptoms “wax and wane”

Causes of OCD

No known cause

• Brain structure

• Brain chemistry

• Genetics

• Environment

• PANDAS

6 Medication

• Medication can be helpful with treatment

Therapy

• Behavioral Techniques

– Saturation and thought stopping

– Systematic desensitization

– Cognitive Behavioral Therapy (CBT)

– Relaxation techniques

7 Activity: Relaxation

Caregiver Considerations

• Safety

• Person‐Centered Support

• Communication

• Recognize a “need” behind the behavior – Acknowledge – Validate – Feedback

• The “PROPP” support plan

8 Working With the Psychiatrist

• Psychiatrist often rely on caregiver reports

• Describe behaviors objectively – Let go of assumptions – Describe the behavior as seen or heard – Avoid using labels and words that have more than one meaning

• Provide specific documentation – Duration – Frequency – Intensity – Change

Positive Approaches Assumptions about Behavior

• All behavior has meaning

• People have valid reasons to do what they do

• People do the best they can with what they have at that point in time and within that context

9 Related Training Topics

• Bipolar Disorder

• Depression

• Post Traumatic Stress Disorder (PTSD)

References

• American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 5ifth Edition. Arlington, VA, American Psychiatric Association, 2013 • Goodman, W. (2016). Medications for Obsessive‐compulsive Disorder. Psych Central. Retrieved on December 27, 2016, from http://psychcentral.com/lib/medications‐for‐obsessive‐ compulsive‐disorder/ • International OCD Foundation. (2016). What Causes OCD? Retrieved December 27, 2016, from https://iocdf.org/about‐ ocd/what‐causes‐ocd/ • International OCD Foundation. (2016). What is PANDAS / PANS? Retrieved December 27, 2016, from https://kids.iocdf.org/what‐is‐ocd/pandas/

10 References

• Mayo Clinic. Obsessive‐compulsive disorder (OCD). (2016, September 17). Retrieved December 27, 2016, from http://www.mayoclinic.org/diseases‐conditions/obsessive‐ compulsive‐disorder/home/ovc‐20245947 • McGlone K, Tretter S, Depka L: Systemic Lupus Erythematosous (SLE) self‐help course trainer’s guide. Atlanta, GA, Arthritis Foundation, 1990. • Medina, J. (2016). Obsessive‐Compulsive Disorder (OCD) Treatment. Psych Central. Retrieved on December 15, 2016, from http://psychcentral.com/disorders/obsessive‐ compulsive‐disorder‐treatment/

References

• National Association for the Dually Diagnosed. (2007). Diagnostic Manual – Intellectual Disability: A Textbook of Diagnosis in Person’s with Intellectual Disabilities. New York. • National Alliance on Mental Illness (NAMI). (2016). Obsessive‐compulsive Disorder. Retrieved December 27, 2016, from http://www.nami.org/Learn‐More/Mental‐Health‐ Conditions/Obsessive‐compulsive‐Disorder • Vitiello, B., Spreat, S., Behar, D. (1989). Obsessive‐compulsive disorder in mentally retarded patients. The Journal of Nervous and Mental Disease.1989 Apr;177(4):232‐6. Retrieved from www.ncbi.nlm.nih.gov/pubmed/2703828

11 To register for future trainings or for more information on this or any other physical or behavioral health topic, please visit hcqu.kepro.com

Test and Evaluation

Please take a few moments to complete the test and evaluation forms for this training.

Thank you!

12 Relaxation Techniques

Visualization Relaxation

Visualization can include a variety of ways of using one’s imagination. Some forms of visualization rely heavily on the imagination, while others are guided by details provided through descriptions, audio, and/or video. Here are examples of ways to use visualization for relaxation:

1. Imagine a safe place, a calming environment, or a relaxing scene. Create all the details in your mind. Picture all the sights, sounds, and smells.

 floating on a cloud  watching a burning candle or campfire  lying on a beach  traveling in a canoe  sitting by a calm pool or pond  walking by the lake  strolling on a country road  walking in a peaceful forest  driving a fast car on a beautiful road  playing a sport and doing well  gazing at the stars  watching fish swim in a tank

2. Watch a video of a setting described above and imagine spending time there.

3. Listen to a guided visualization script and imagine the scenes described.

4. Read a book, and use your imagination to visualize the characters, places, and events.

It is possible to use creative activity to relax, even if such activities are unfamiliar. Keep the focus on the process rather than the end product. Enjoying the process of being creative can be highly therapeutic and very relaxing.

 Make something, taking the time to focus on each step and enjoy the process.  Listen to a creative expression relaxation script that guides listeners through a creative task in a way that encourages self‐expression and relaxation.  Watch an instructional video and follow along with the demonstrated task.  Other specific examples of ways to relax with creativity include:

 drawing  painting  pastels  dance  playing a musical instrument  writing a song  writing a letter  scribbling or doodling  singing  moving rhythmically  drama and acting  carpentry or woodwork  mechanics  building something  taking an object apart and putting it back together  calligraphy  digital illustration  photography  making videos  stamping  card‐making  knitting  sewing

The senses ‐ vision, hearing, touch, taste, smell can be powerful tools for relaxation. For those with sensory sensitivity, control the levels of exposure to particular sensations. Find ways to experience a variety of calming sensations. Some examples of how to use sensory techniques for relaxation include:

 Determine which senses are the most calming for you, and which kind of sensations may provoke stress. For example, is background music relaxing or distracting?  Use the senses to promote relaxation in daily life. Focus on activities that use vision, hearing, sense of touch, smell, or taste.  Some specific ways to use sensation to relax:

 taking a warm bath  applying a cool pack to the forehead or neck  using scented candles, air fresheners, or cooking food to provide pleasing smells  massage  manicures  brushing hair  wearing soft clothing  rolling dough  digging in the mud  walking barefoot in grass  petting a dog or cat  listening to music  watching TV  using colored lamps to light a room  putting up a string of colored lights  eating flavorful food  adding spice to food

Muscle relaxation can involve performing physical tasks to release stress or engaging in progressive relaxation exercises, where muscles are consciously relaxed, one muscle group at a time.

Examples of ways to use muscle relaxation include:

 running  walking  swimming  lifting weights  stretching  yoga  tai chi / qigong  pilates  dance  housework  playing a sport  shake out tension  yawn and stretch  massage  physical work (e.g. mowing the lawn, vacuuming, hammering)

The “PROPP” Support Plan By Bernie Maly

A. PRAISE Review Goal: Make a positive connection, build self‐esteem, promote bonding

1. Praise and thanks for effort and all good qualities 2. Positive affirmations

B. Offer help Goal: Make the challenging behavior a source of alliance with the person rather than a source of division

1. Identify the behavior and the need it might be expressing. Talk more primarily about the feeling associated with the behavior than the behavior itself. 2. Ask something like “How can I help make things go better?” 3. Talk about helping the person to change the behavior primarily for reasons that benefit him or her, rather than the other people in the person’s environment

C. Practice a Plan Goal: Create a plan together and teach a pre‐determined strategy of what to do when feelings or physical signs that precede challenging behaviors occur or when difficult environmental situations cannot be avoided.

1. Explore options (move away from the stressful situation, take deep breaths, come to caregiver for help, talk about it, use planned relaxation techniques, verbal request or sign for a break, etc…) 2. Choose option together (if possible, the focus person should create an option or choose from a list of acceptable options) 3. Review and practice. Role play if appropriate (make it fun) 4. Reaffirm the plan and your desire to help 5. Express confidence that the person will be successful

“Handbook of Mental Health Care for Persons with Developmental Disabilities”, Ruth Ryan MD, 2001

DM‐ID Adapted Criteria for People with Intellectual/Developmental Disabilities

DSM‐IV TR Criteria Adapted Criteria for Mild Adapted Criteria for Sever to Moderate I/DD to profound I/DD

A. Either Obsessions or A. Either Obsessions or A. Either Obsessions or Compulsions Compulsions Compulsions (although obsessions (although obsessions may be impossible to may be impossible to elicit due to elicit due to communication communication deficits). deficits).

Obsessions are defined by: No adaptation. No adaptation. (1), (2), (3), and (4):

(1) Recurrent and (1) Recurrent and (1) Recurrent and persistent thoughts, persistent thoughts, persistent thoughts, impulses, or images impulses, or images impulses, or images that are experienced, may not be may not be at some time during experienced, at some experienced, at some the disturbance, as time during the time during the intrusive, and disturbance, as disturbance, as inappropriate and that intrusive or intrusive or cause marked anxiety inappropriate nor inappropriate nor or distress. cause marked anxiety cause marked anxiety or distress. or distress. (2) The thoughts, (2) No adaptation. (2) No adaptation. impulses or images are not simply excessive worries about real‐life problems. (3) The person may make (3) The person attempts (3) The person’s attempts no attempt to to ignore or suppress to ignore or suppress suppress compulsions such thoughts, thoughts may not be and obsessions. They impulses, or images, or possible to determine may be unable to to neutralize the due to cognitive and report wanting to anxiety with some communicative ignore, suppress, or other thought or deficits. neutralize such action. thoughts/urges.

National Association for the Dually Diagnosed. Diagnostic Manual – Intellectual Disability: A Textbook of Diagnosis of Mental Disorders in Person’s with Intellectual Disability. (2007). New York. (4) The person recognizes (4) May not be possible (4) This does not apply to that the obsessional to determine due to children and does not thoughts, impulses, or cognitive and apply to people with images are a product communicative Severe to Profound of his or her own mind deficits. I/DD, i.e., who have (not imposed from young developmental without, as with ages. thought insertion).

Compulsions are defined by No adaptation. No adaptation. (1) and (2):

(1) Repetitive behaviors (1) Repetitive behaviors (1) The absence of (e.g., hand washing, (particularly ordering, compulsions or ordering, checking) or hoarding, telling, or obsessions that mental acts (e.g., asking, or rubbing) or require abstract praying, counting, mental acts (these thinking (compulsive repeating words may be difficult or counting, excessive silently) that a person impossible to elicit concern about germs feels driven to perform due to cognitive or safety) does not in response to an impairment or rule OCD in person’s obsessions, or communicative with Severe to according to rules that difficulties) that a profound I/DD. Look must be applied person feels driven to for compulsions rigidly. perform in response to requiring simple an obsession, or thinking such as (2) The behaviors or according to rules that insisting on fixed mental acts are aimed must be applies rigidly. sequences or at preventing or arrangements, reducing distress or (2) The function of the excessive ordering, preventing some compulsive behavior filling/emptying dreaded event or may not be compulsions. situation; however, ascertainable. these behaviors or (2) The function of the mental acts either are compulsive behavior not connected in a may not realistic way with what ascertainable. they are designed to neutralize or prevent or are clearly excessive.

National Association for the Dually Diagnosed. Diagnostic Manual – Intellectual Disability: A Textbook of Diagnosis of Mental Disorders in Person’s with Intellectual Disability. (2007). New York. B. At some point during B. Recognition of B. This criteria does not the course of the excessive or apply to children, and disorder, the person unreasonableness does not apply to has recognized that may not be present. persons with Severe the obsessions or to Profound I/DD, i.e., compulsions are who have young excessive or developmental ages. unreasonable. Note: This does not apply to children. C. The obsessions or C. Anxiety or other C. Anxiety or other compulsions cause distress may not distress may not occur marked distress, are occur. An effect of with strong urges and time consuming (take happiness or an preoccupation to more than 1 hour a intense preoccupation engage in compulsive day), or significantly or drive to perform activity. Aggression interfere with the the compulsion may may be directed to person’s normal be observed. caregivers who block routine, occupational Challenging behaviors, or impede the person functioning, or usual particularly engaging in social activities or aggression, and self‐ obsessive/compulsive relationships. injury may occur if the activities. There are person is prevented many possible from completing the underlying reasons for compulsion. self‐injurious behaviors/movement s in people with I/DD; therefore, self‐injury should not be used for making a diagnosis of OCD.

D. If another Axis I D. There is also a need to D. Stereotypic actions disorder is present, distinguish such as rocking, the content of the compulsions from banging objects, obsessions or stereotypies and an flipping or swinging compulsions is not insistence on objects, and pointing restricted to it (e.g., sameness. to body parts preoccupation with repeatedly are food in the presence statistically of an Eating Disorder; distinguishable from hair pulling in the behaviors in people presence of Body with I/DD. Other

National Association for the Dually Diagnosed. Diagnostic Manual – Intellectual Disability: A Textbook of Diagnosis of Mental Disorders in Person’s with Intellectual Disability. (2007). New York. Dysmorphic Disorder; repetitive behaviors preoccupation with such as pacing, drugs in the presence humming, stealing, of a Substance Abuse demanding attention, Disorder; masturbating, over‐ preoccupation with eating or drinking, having a serious illness smoking, and verbal in the presence of perseveration have Hypochondriasis; been excluded by preoccupation with researchers of OCD in sexual urges or people with I/DD in fantasies in the making a diagnosis of presence of a OCD in this Paraphilia; or guilty population. ruminations in the presence of Major Depressive Disorder).

E. The disturbance is not E. No adaptation E. Rule out drug‐induced due to the direct movement disorders. physiological effects of Persons in the Severe a substance (e.g., a to Profound range of drug of abuse, a I/DD cannot be medication) or a expected to report general medical distress or pain. condition.

National Association for the Dually Diagnosed. Diagnostic Manual – Intellectual Disability: A Textbook of Diagnosis of Mental Disorders in Person’s with Intellectual Disability. (2007). New York.