Obsessive Compulsive Disorder: Evidenced-Based Strategies that Work! Dr. Robin Zasio, Psy.D., LCSW The Anxiety Treatment Center of Sacramento, Roseville, and El Dorado Hills Scaredy Guy Anxiety Disorders (DSM IV)

• Obsessive Compulsive Disorder • Social Phobia • Panic Disorder with or without agoraphobia • Posttraumatic Stress Disorder • Generalized Anxiety Disorder • Specific Phobia Anxiety Related Conditions l Body Dysmorphic Disorder (Somotoform) l Hoarding (No category) l Trichotillomania (Impulse Control) l Skin Picking (No Category) DSM V

Obsessive Compulsive and Related Disorders l Obsessive Compulsive Disorder l Body Dysmorphic Disorder l Hoarding Disorder l Trichotillomania l Excoriation DSM V

Anxiety Disorders l Separation Anxiety Disorder l Selective Mutism l Specific Phobia l Social Anxiety Disorder l Panic Disorder l Agoraphobia l Generalized Anxiety Disorder DSM V

Trauma and Stress Related Disorders l Reactive Attachment Disorder l Disinhibited Social Engagement Disorder l Posttraumatic Stress Disorder l Acute Stress Disorder l Adjustment Disorders Obsessive Compulsive Disorder l Obsessions: Thoughts, images or impulses that a person experiences as unwanted, distressing, irrational and often times of a bizarre nature. They are repetitive thoughts that are difficult to stop or control. l The thoughts are not excessive worries about real-life problems. l Compulsions: Behaviors that a person develops to neutralize the unwanted thoughts in an effort to obtain relief. Can be mental or physical. l The thoughts/behaviors cause marked distress. l Take up more than one hour per day. l Interfere with some aspect of daily routine. Obsessive Compulsive Disorder Continued l With good or fair insight: Recognizes that the beliefs are definitely or probably not true. l With poor insight: The individual thinks their beliefs are probably true. l With absent insight/delusional beliefs: The individual is completely convinced the beliefs are true. Body Dysmorphic Disorder l Preoccupation with one or more perceived defects or flaws in physical appearance that are not observable or appear slight to others. l At some point in the disorder, the person has peformed repetitive behaviors. l Preoccupation causes clinically significant distress or impairment. l The appearance preoccupation is not better explained by concerns with body fat or weight whose symptoms meet diagnostic criteria for an eating disorder. Hoarding Disorder l Persistent difficulty discarding or parting with possessions, regardless of their actual value. l The difficulty is due to a perceived need to save the items and to distress associated with discarding them. l The difficulty discarding the possessions results in the accumulation of possessions that congest and clutter active living areas significantly compromising their intended purpose or use. l Causes clinically significant distress or impairment. Trichotillomania l Recurrent pulling out of one’s hair, resulting in hair loss. l Repeated attempts to decrease or stop hair pulling. l Causes significant distress or impairment. l Hair pulling or hair loss is not due to another medical condition. Excoriation Disorder l Recurrent skin picking resulting in skin lesions. l Repeated attempts to decrease or stop skin picking. l Causes clinically significant distress. l Not attributable to the physiological effects of a substance or other medical condition. l Not attributable to another mental disorder (e.g. delusions, or tactile hallucinations). What Can OCD Look Like? l Fear of harming self or others l Fear of blood/HIV/AIDS/herpes l Fear of pregnancy l Fear of not doing things perfectly l Fear of becoming a child molester/pedophile l Fear of urine/feces (contaminating self or others) l Fear of homosexuality l Fear of being punished by a religious figure (Scrupulosity) What can OCD Look Like? l Fear of illness (health related/somatic obsessions) l Fear of sexual thoughts l Reading and rewriting l Perfectionism l Counting compulsions What is the Goal in OCD? l Certainty l Relief of doubt l Confirmation l Compulsions l Loved ones/family l Anything to support the cause What is Pure Obsessions? l When one only has obsessions but no compulsions l No such thing l An obsession is a compulsion Brain Chemistry l Cycle of anxiety in general l Amygdala l Sympathetic and parasympathetic nervous system l Fight or flight response l The experience of the amygdala misfiring and a sense of real danger l Perceived threat is always greater than the actual threat Cognitive Behavior Therapy Vs. Exposure and Response Prevention Cognitive Behavioral Therapy

l Looks at how distortions in thinking, impacts/affects how one feels, and then translates into behavior. l Distortions include: All or none thinking; Catastrophizing; Mind reading; “Should” statements; Fortune Telling; All or none thinking; Catastrophizing. l Logic Based approach. l Poking holes in negative thinking patterns to disprove statements. When to Use CBT When Working with Someone with OCD l When depression is impacting patients ability to address the OCD l When negative thinking patterns are a barrier to engaging in ERP CBT Exercise l 3 X 5 notecard. l Front side: Write name of distortion l Back side: One line definition and then examples of how that distortion applies to them. l Reminder: Most people have cognitive distortions. It’s whether they get caught up and stuck in them. l Looking at how it impacts their life. Exposure and Response Prevention l Exposure to feared object, thought, scenario, without doing a compulsion to neutralize the feared outcome. l Systematic desensitization. l Process of habituation. Beginning the Exposure Process

l Decide on a theme to start with l Create a fear hierarchy l Take an inventory of situations that trigger the fear l Arrange them from low anxiety to high anxiety l Assign SUDS value to each of them l Collaboratively select first item with which to start exposure therapy How Do You Create a Hierarchy? l Words l Pictures l Sounds l Videos l Actual objects/situations l In vivo versus Imaginal exposures Starting Exposure Therapy l Expose fully and repeatedly l Clients to have as much contact with the feared item or situation as possible l Allow for at least a 50% reduction of anxiety l Allow for enough time to support the desensitization process l Ensure there are no distractions l Work toward the top of the fear hierarchy What Occurs During the Exposure Process l Acknowlege the feared outcome. l Focus on the doubt and uncertainty about what the individual fears could happen l Abstain from rituals l Develop Remain in the situation until anxiety decreases or dissipates l Exposure and response prevention schedule l Engage in multiple exposures on a daily basis Response Prevention l Refers to one’s ability to focus on the feared outcome without engaging in any compulsions or rituals. l Avoid engagement in safety behaviors l Track anxiety Imaginal Exposure l Develop scenarios l Have client verbalize mental images, thoughts, or impulses in detail l Record these scenarios l Decide whether to use the voice of the patient or the voice of the therapist l Expose in a graduated fashion l Record on 1 or 3 minute endless loop tape l Expose to content and meaning of content l Expose the person to the content of their obsessions and fears Interoceptive Exposures/Symptom Induction Exercises l Head Shaking l Head lifting l Stepping Up/Running in Place l Breath Holding l Spinning l Hyperventilating l Straw Breathing Habit Reversal Training l To address repetitive behaviors. l Channel anxiety/urges into competing response. l Awareness training. l Competing response training. l Relaxation training. Assessment Assessment Tools l Yale Brown Obsessive Compulsive Survey l Yale Brown Obsessive Compulsive Scale l Beck Depression Inventory l Beck Anxiety Inventory l Reynolds Adolescent Depression Scale l Fear Survey l Brief Symptom Inventory Goals in the Initial Session l Discuss diagnostic impressions l Explain brain chemistry and why they are struggling l Review CBT and ERP as a treatment modality and how it will help to address their needs specifically l Discuss recommended protocol for treatment based on symptom severity (Individual once per week; Intensive Outpatient; Medications; and so forth) l Group therapy is to augment the process Provide treatment overview l Some patients fear treatment will make them worse. l Some fear that what they “fear” will happen if they face their fears. l Help patients to anticipate what to feel or expect. l Teach clients self-monitoring (5 section notebook, charting). l Behavioral homework assignments. l Treatment needs to be a commitment. l Helpers Further Assessment /Tools l Family Accommodation Scale l Freedom from OCD by Jonathon Grayson l About OCD Article l Reassurance Article l Unstuck l International Obsessive Compulsive Foundation Resources Be Concrete and Assume Nothing l Get the details of the symptoms, and other relevant information to help understand the perceived threat. l Some clients are reluctant to express a number of unacceptable thoughts, images, or impulses for a number of reasons. l Do not assume they are being resistant. They may feel scared. Embarrassment and Shame Continued l There can be a lot of guilt associated with years of impact on the family. l Fear that people will think they are “crazy.” l Embarrassment over the potentially bizarre nature of their thoughts/fears. Assess Impact of Symptoms on Clients General Functioning • Explore impact on work, school, relationships, home environment, etc. • Try to get them to resume chores, activity, etc. as soon as possible. • Avoidance of these activities only gives more attention to the anxiety. • Limit the time that the anxiety is talked about in conversations outside of treatment. Evaluate How Others are Involved in Maintaining the Symptoms~ Family Accommodation

• Do family members carry out activities (chores, care of children, home schooling, etc.) so that they can avoid their anxiety? • Is the family giving reassurance? • ****Remember, simply talking about symptoms can serve as a source of reassurance! • A “no talk” rule may need to be established at some point in the therapy process. What Do Clients want or fear? l Miracle l Magic pill or medication l “Just say something to make this go away.” l Did I do something wrong? Am I being punished? l Am I a bad person? What Doesn’t Work?

• “I need to find my inner child.” • “If I just know why I’m doing what I”m doing then I can stop.” • “Hypnosis…PLEASE!” • Biofeedback • “Hold and become the rock.” • “Finding what happened in your childhood that is causing this behavior.” • “I was told Cognitive Behavior Therapy…not Exposure and Response Prevention Therapy.” What Doesn’t Work Continued l Psychotherapy l Logicalizing l Using evidence to try to convince them that they don’t need to be anxious l Asking them to do something that they cannot l Flooding l Modeling exposures Motivating Factors l By taking a fight response to your anxiety, you reduce your fear. l Change the neurochemistry in your brain l What’s predictable is what you have been doing. What’s unpredictable is to do something different l Reclaim your life and do what you want to do rather than what your OCD (anxiety) wants you to do. l You can live your Greater Good!! Important Reminders l A client will typically know if you are in tune with what they are experiencing l Validate their concerns and distress. Remember, their fear is real to them l Be open with your questions yet gentle to provide an empathic approach l Seek consultation if you are stuck l It’s okay to let a client know that you are not sure how to approach certain stages The Family l Educate, educate, educate. l Eliminate all teasing. l Eventually eliminate the compulsions which serve to have them avoid. l Do not try to talk them out of their fears (Helping them to see how silly and ridiculous they are being). l Be a part of the therapy process. More of “Back to the Family” l Recognize that doing less will actually do more! l Help the family to understand that their loved one is not being “selfish.” l Remind them this is a fear based disorder. l Telling them to “just stop it” will not work, and serves to be invalidating. l Anxiety is not about trying to control others. Motivational Interviewing l Designed to help the client identify reasons why making a change would be a benefit to them, their family, and other aspects of their life. l Helps to acknowledge that while there is a cost to change, the benefits of change will serve them and their overall happiness in the long run. What Motivates People to Change? l Identification of the importance of the problem. l Having the confidence in the ability to change. l Internal desire- It cannot be imposed by others. How to Address Ambivalence l Expect it, even if they recognize that there is a problem. l Encourage them to express their ambivalence and fears. l Facilitate resolution of ambivalence with gentle encouragement. l Remind them you are in partnership to get the problem resolved in the least distressing manner possible. Factors Influencing Motivation l Social support l Home visits l Depression l Anxiety l Ability to tolerate discomfort Talk About the Goals l Decreased anxiety and fear l Improve general functioning l Increased social contact with others l Improved relationships with family l Increased time to do other activities Dealing with Resistance l Validate their feelings and distress l Acknowledge that their struggles l Actively listen l Express your concern using non-judgmental language l Make it clear that you are there to help and offer support l Acknowledge that you are their to work collaboratively to get them through their anxiety l Anger and depression may be a component to address Other Important Aspects of treatment

Increase activity ü Regular activity in the outside world ü No avoidance of normal expectancies in the house ü Increase pleasurable/social activities Food Considerations ü Be aware of excessive amounts of sugar and carbohydrates ü Do not overeat, especially prior to bedtime ü Limit caffeine intake, especially in afternoon/evening Case Example l Sarah l 28 year old Sherriff l Married with a dog l Fear of contamination l Individual therapy l Intensive Outpatient Program Resources

ü The International Obsessive Compulsive Foundation www.iocdf.org

ü OCD Sacramento www.ocdsacramento.org Final Outcome for Your Client The Anxiety Treatment Center Sacramento, CA www.anxietytreatmentexperts.com Email: [email protected] Phone: 916.366.0647