A cognitive approach to the treatment of OCD Beyond exposure and response prevention Adam S. Radomsky, Ph.D. Contact information Department of Psychology Concordia University 7141 Sherbrooke St. West Montréal, QC H4B 1R6 CANADA [email protected] AFTCC workshop, Paris, 15 décembre 2016. Table of Contents Page Workshop slides 1 Reading list 32 Examples of unwanted, intrusive thoughts 37 Personal Significance Scale (PSS) 38 Thought‐Action Fusion (TAF) Scale 40 Vancouver Obsessional Compulsive Inventory (VOCI) 41 VOCI‐Mental Contamination Subscale (VOCI‐MC) 44 Contamination Sensitivity Scale (CSS) 45 Contamination Thought‐Action Fusion Scale (C‐TAF) 46 Behavioural Experiment Form 47 31 11/30/2016 A COGNITIVE APPROACH TO THE TREATMENT OF OCD BEYOND EXPOSURE AND RESPONSE PREVENTION Adam S. Radomsky, Ph.D. Concordia University AFTCC, Paris, 15 décembre 2016. Acknowledgements • I am grateful to Jack Rachman, Roz Shafran, Michelle Lee, Allison Ouimet and Sarah Holling for their contributions to the development of these materials • I also wish to acknowledge the Canadian Institutes of Health Research for their support of my work Outline • History of OCD treatment • Exposure and Response Prevention (ERP) • Development of theory • A cognitive approach • Outcome research based on these models • A few cases • Phenomenology and treatment of OCD • Contamination, Checking, Obsessions • Hoarding will not be a focus • Videos • Q & A 1 11/30/2016 Obsessive‐compulsive disorder (OCD) • Obsessions: Recurrent, unwanted, intrusive, thoughts, images, impulses or doubts that cause distress/interference (e.g., blasphemous, aggressive or sexually repugnant thoughts, images, impulses or doubts) • Compulsions: Repetitive behaviour that an individual feels driven to perform to reduce distress or to prevent some dreaded event from happening (e.g., washing, checking, counting, praying) OCD • Prevalence estimates between 1.5 and 3.5% • In adults, sex distribution is even • In children, there appear to be more boys with OCD than girls • Boys have an earlier onset • OCD is known to have particularly high comorbidities with depression and most, if not all of the anxiety disorders • Comorbidities with impulse control disorders, Tourette’s syndrome are elevated, but controversial The experience of treating OCD • “OCD is a ‘weird’ problem” • “People with OCD are fundamentally different from other people” • “It’s a kind of psychosis” • “If you treat OCD all day, you’ll go mad” 2 11/30/2016 Standard Treatment • In 1966, Victor Meyer treated two people with contamination‐based OCD • Today, we would call his approach flooding, but it lay the foundation for Exposure and Response Prevention (ERP) • This intervention is grounded in a habituation‐based model • In this context, people with OCD must habituate to their anxiety, obsessions and/or urges to engage in compulsive behaviour Video of Patient –ERP Approach ERP • After collaboratively constructing an exposure hierarchy, clients/patients are asked to expose themselves (gradually) to feared stimuli, and importantly, to refrain from engaging in compulsive (neutralising) behaviours • Jam 3 11/30/2016 Problems with ERP/Exposure • Foa et al. (2005 example) • Intent‐to‐treat analysis, responders • 62% ERP, 42% Clomipramine, 70% Combo, 8% Placebo • 37 enrolled • 8 dropped out when assigned to ERP condition & 8 dropped out during ERP • So, 16/37 (43%) did not complete ERP treatment • Dropouts from a generalist CBT service = 43.8% of clientele • Bados, Balaguer & Saldaña (2007) • Supported by a recent systematic review (Öst, 2015) • Many therapists prefer not to use it • (Addis & Krasnow, 2000; Addis, Wade & Hatgis, 1999) • We are not effectively delivering effective treatment Treatment Advances: The Cognitive Revolution • In the 1970’s, psychologists started investigating various aspects of cognition • Attention, memory, information processing • This coincided with the work of Ellis, Beck • Construed psychopathology as being based in not only behaviour, but also the ways that people think (attention, memory, etc.) • In general, the evidence shows that CT, BT and CBT are equivalent in terms of outcome • Cottraux et al. (2001); Van Oppen et al. (1995); Whittal, Thordarson & McLean (2005) Treatment acceptability • Cognitively‐based treatments are significantly more acceptable to student and clinical samples than behavioural approaches • Levy, Senn & Radomsky (2014); Milosevic & Radomsky (2013a); Öst (2015) • When safety behaviour is judiciously incorporated into CBT, it enhances the acceptability of and engagement with treatment • Parrish, Radomsky & Dugas (2008); Rachman, Radomsky & Shafran (2008); Levy & Radomsky (2014, 2016a,b); Milosevic & Radomsky (2008, 2013b) 4 11/30/2016 Video of Patient –Cognitive Behavioural Approach Salkovskis (1985), a simple version • Inflated responsibility • Intuitive: Why would people check, wash things if they didn’t feel responsible to protect themselves/others from bad events? • Has received much empirical support • OCCWG, 2001, 2005 • Lopatka & Rachman (1996); Shafran (1997); Radomsky, Rachman & Hammond (2001); plus many others Volunteer? • During the next break, I’ll need to step out for a short while and would like someone to look after my laptop • Would anyone be willing to help me? • I would very much appreciate it 5 11/30/2016 Framework for cognitive case formulation Trigger Intrusive thought (or feeling) Interpretation Appraisal Beliefs Avoidance Emotion Neutralisation Schoolyard Spontaneous image of naked child This thought means that I am dangerous Avoid parks, Anxiety Thought replacement Children. Guilt Reassurance Escape Terror Concealment Nature of interpretations • In OCD, appraisals/misinterpretations appear to revolve around three main themes • I am mad, bad or dangerous (Rachman, 1997, 1998) • Beliefs related to responsibility, threat, perfectionism, intolerance of uncertainty, importance of thoughts, control of thoughts may also be relevant (OCCWG, 1997, 2005) • Beliefs about memory too (Alcolado & Radomsky; 2011, in press) 6 11/30/2016 Assessment • It is critical to conduct a good assessment • Obsessions about being a serial killer vs. wanting to kill someone • A combination of interview, self‐report and behavioural measures is recommended • Newer scales (e.g., OCI, VOCI) are preferred • Y‐BOCS or your own, semi‐structured interview • Ask about triggers, appraisals and neutralization • BAT’s, family input, etc. • Finally, assessment is ONGOING • Measures administered in EACH SESSION, if possible The importance of a good history • A good history is essential • CBT therapists ARE interested in people’s early experiences as they can help shed light on appraisals and beliefs about particular thoughts and situations • “My parents used to tell me that sex was bad” • “My aunt was killed in a fire and nobody ever knew the cause; we thought it was her smoking” • “My father used to sexually abuse my mother; when they fought, she would always call him a ‘dirty old man’” • “My alcoholic father would hit me if my room wasn’t tidy” CBT Outcome • Abramowitz review (2006) • No difference between ERP and CT response rates • Replicated in Öst, 2015 review and meta‐analysis • ERP likely to incorporate cognitive elements • CT does not add to ERP (1 study) • CT has lower drop out rates (1 study) • Replicated in Öst, 2015 review and meta‐analysis • ERP not suitable for ‘pure obsessions’ • But CBT is both suitable and effective – Whittal, Woody, McLean, Rachman & Robichaud (2010) 7 11/30/2016 Brief, general treatment description • The treatment always begins with psychoeducation and collaborative development of the model • Case conceptualization • Treatment is heavily based on behavioural experiments –more on this later • Treatment techniques are NOT necessarily symptom specific CONTAMINATION 8 11/30/2016 Case Conceptualisation Video Trigger Intrusive thought (or feeling) Interpretation Appraisal Beliefs Avoidance Emotion Neutralisation Understanding the experience of contamination • There are two kinds of contamination Rachman (2004) • Contact (germs, dirt, harmful substances) • This one is familiar to all of us • Have you ever touched something dirty, dangerous, contaminated and felt like washing? • Mental (pollution, morphing, etc.) • This concept is newer and more complicated • You can feel dirty, even if you haven’t touched anything • Thoughts, memories, appraisals/interpretations 9 11/30/2016 Contact vs. Mental Contamination Contact Contamination Mental Contamination • Always related to dirt, • ‘Pollution of the mind’ germs, harmful • Often related to other substances people • Contact based • Source is difficult to • Identifiable source identify • Washing helpful • Washing not helpful • Contaminant can be • Contaminant difficult to removed remove Illustration of mental contamination • The “dirty kiss” paradigm • Listen to this recording • Variants have been used in a number of “dirty kiss” experiments in Vancouver, Montreal and Reading • Elliott & Radomsky (2009, 2012, 2013); Fairbrother, Newth & Rachman (2005); Herba & Rachman (2007); Radomsky & Elliott (2009) • We’ve also used a similar recording to examine mental contamination among male ‘perpetrators’ • Rachman, Radomsky, Elliott & Zysk (2012) What is a behavioural experiment? • A carefully planned experiment designed to test out specific beliefs, biases, appraisals and/or interpretations through behavioural exercises • Form in your handouts • Sometimes, these can be repeated • Often, the patient will want to repeat them •