Maladaptive Beliefs: Objectively harmful situations and stimuli are misinterpreted as highly threatening or very dangerous. Others include intolerance of uncertainty, low self-efficacy, positive expectancy of behavior to alleviate stress.
Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty
Webinar Treatment of Obsessive-Compulsive Symptoms March 12, 2013 Erin McGinty, LPC, NCCProgram Director, Anxiety Services Coordinator, and Primary Therapist Castlewood Treatment Center for Eating Disorders 800 Holland Road 636-386-6611, ext. 103 www.castlewoodtc.com
Normal vs. Abnormal Anxiety (Barlow, 2002)Anxiety? Fear? Worry? Panic? Terminology…Anxiety is a future-oriented mood state associated with preparation for possible, upcoming negative events.Fear is an alarm response to present or imminent danger (real or perceived).
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 the threat (e.g., fleeing, attacking) “In times of danger, anxiety can be a person’s best friend. (Abramowitz, 2011)”
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.
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)
Anxiety Disorders (Abramowitz, 2011)Anxiety Disorder Fear Cue(s) Misperception(s) Coping ResponsesObsessive- Intrusive thoughts, Thought-action Avoidance,Compulsive situational cues fusion, inflated compulsive rituals,Disorder (OCD) responsibility for reassurance seeking preventing harmSpecific Phobia Snakes, heights, Overestimation of Avoidance, use of injections, etc. the likelihood or drugs, distraction severity of dangerSocial Phobia Social situations Other people are Avoidance, in- highly judgmental; situation safety negative evaluation behaviors (e.g., is intolerable using alcohol at a party)
Anxiety Disorders (Abramowitz, 2011)Anxiety Disorder Fear Cue(s) Misperception(s) Coping ResponsesPanic Disorder and Arousal-related Misinterpretation of AgoraphobicAgoraphobia body sensations; arousal-related body avoidance, in- situational cues sensations as situation safety dangerous behaviors, safety signalsPosttraumatic Stress Intrusive memories Nowhere is safe Avoidance ofDisorder (PTSD) of traumatic events reminders, distraction, safety signalsGeneralized Thoughts/images of Intolerance of ReassuranceAnxiety Disorder low probability uncertainty; seeking, worrying(GAD) events overestimation of as a form of the likelihood and problem solving severity of outcomes
Functional Assessment of Anxiety“Because exposure therapy targets the patient’s specific fears, it is not enough to know that the individual has a diagnosis of (an anxiety disorder). Developing an effective exposure treatment plan requires the therapist to be cognizant of the particular situations and stimuli that trigger fears, the feared consequences of facing these fears, and the specific maladaptive strategies the individual uses to manage these fears” (Abramowitz, 2011).
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 or circumstances – 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
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?
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?
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
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 you did not know anyone?What is the worst-case scenario that could happen if used a public bathroom?
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 prevent feared consequences
Safety Behaviors (Abramowitz, 2011)Type of Safety Behavior Description & ExamplesPassive Avoidance The 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.
Safety Behaviors (Abramowitz, 2011)Type of Safety Behaviors Description & ExamplesCompulsive Rituals, cont’d. •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
Safety Behaviors (Abramowitz, 2011)Type of Safety Behavior Description & 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
Functional Assessment of AnxietySafety Behaviors (Abramowitz, 2011):“When assessing safety behaviors it is important to understand not just the form or topography of the action, but the function or purpose of the behavior– that is, why the individual performs such behavior and in what situations it occurs. In other words, what feared consequences does it prevent and how does the patient believe the safety behavior works?”
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 not happened?Do you ask other people for assurances that something bad will not happen?Can you tell me exactly what you do when you do _____?What gives you the feeling that you need to do _____? How do you know when to stop?
Functional Assessment of AnxietySafety Signals (Abramowitz, 2011):What might happen if you didn’t 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)?
Treatment:Exposure and Response Prevention Therapy
Exposure and Response Prevention TherapyExposure• Prolonged, graduated, repetitive, and consistent exposure to situations 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 Likert scale rating subjective units of distress – Begin with exposures in the 3 to 4 range
Exposure and Response Prevention Therapy ANXIETY RATING SCALE 0 1 2 3 4 5 6 7 TRY AS HARD AS POSSIBLE TO RESIST HAVE TO RESIST Difficult to resist Challenging Challenging “It bothers me” urges. Anxiety is Unsure if able to Extremely hard to CALM “Don’t want to do bothersome, yet “Wish I didn’t resist ritualizing. resist urges to NO ANXIETY it but know it will manageable. have to do it, but Panicking use safety Near panicNO URGES TO be easier than I can do it. Glad Very hard to behaviors.RITUALIZE AT think.” A little bit harder when it’s over!” Fear of dying. resist urges to ALL to resist urges but use safety Start feeling A few urges to can still do it. Come close to behaviors. symptoms of use safety safety behaviors panic. behaviors. but can still resist. Can’t imagine making A few weeks before Think about ‘faking it through the EXAMPLE: Dreading going. Don’t know if I can appointment. Think being sick.’ Trying to appointment. Think Really don’t want to, make it. Feel some Refuse to go. PANIC GOING TO about not wanting to make excuses. Go to about leaving in the but know it will panic symptoms Feeling panicky. Fear of dying if I go.THE DENTIST go, but no it, but glad when it’s middle of the be ok if I go. starting. worries, really. over. appointment. Strong relief when I make it.
INVIVO EXPOSURE HIERARCHY 4 ______ (Anxiety Rating) Exercise1. Use public lotion.2. Lay on bed wearing “contaminated” clothes.3. Do not cover up body when sitting in community space.4. Use toilet without barriers.5. Cut meat into uneven pieces of varying sizes.6. Do not make the bed.7. Greet people and make eye contact.8. Touch community keyboard.9. Sit where “contaminated” peer sat.10. Use colloquial expressions.11. Go to group late.12. Sit at the table in the “wrong” way.13. Hold plastic bag that contains a “contaminated” bandage.14. Walk flat footed in bathroom.15. Hold sink faucet.16. Put moisturizer on face with “contaminated” hands.17. Put socks in shirt drawer with shirts.18. Tell staff that you don’t like something they like.19. Say 5 words in every single group.20. Put butter on fingers without washing.21. Shake the hands of staff.
Exposure and Response Prevention TherapyResponse Prevention• Refraining from behaviors during exposure that are meant to reduce anxiety – Behavioral rituals – Mental rituals – Avoidance• Needs to be clearly defined between client and the clinician• Clients learn that feared consequences of exposure are irrational
Exposure and Response Prevention Therapy• While performing the exposure trial, the client imagines the feared consequence(s) of the exposure• The client remains exposed to the cue until the associated anxiety decreases by 50% or more• The client records his or her peak anxiety level, the amount of time elapsed for the anxiety to reduce by 50%, and the end anxiety level• The client usually engages in 3-5 trials per day, every day, until habituation occurs
Exposure and Response Prevention TherapyHabituation: The decrease in anxiety due only to the passing of time – Within-trial habituation: The decrease in the peak anxiety experienced in one exposure trial – Between-trial habituation: The decrease in peak anxiety ratings as a result of repeated exposure trialsBetween-trial habituation is the treatment effect!
Exposure and Response Prevention Therapy• Banning safety behaviors – Bans represent the “response prevention” portion of ERP and target the behaviors carried out to reduce anxiety.• Why Ban behaviors? – May likely result in greater impairment and reinforce symptoms (Calvocoressi et al., 1999; de Abreu Ramos- Cerqueira et al., 2008; Merlo et al., 2009; Peris et al., 2008; Steketee & Van Noppen, 2003; Stewart et al., 2008; Storch et al., 2007b; Storch et al., 2010a). – May likely hinder treatment effectiveness (Amir et al., 2000).
Exposure and Response Prevention Therapy Reassurance Seeking Submit Resist 4/29 llll llll llll l llll
Effectiveness of Exposure and Response Prevention Therapy• Randomized control trials – (see De Haan, Hoogduin, Buitelaar, & Keijsers, 1998; Fisher & Wells, 2005; Hodgson, Rachman, & Marks, 1972; Kozak, Liebowitz, & Foa, 2000; Marks, Hodgson, & Rachman, 1975; Rachman et al., 1979; Rachman, Hodgson, & Marks, 1971).• Meta-analytic techniques – (see Abromowitz, 1996; Kobak, Greist, Jefferson, Katzelnick, & Henk, 1998).• Nonrandomized samples – (see Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000; Rothbaum & Shahar, 2000).
Anxiety Services at Castlewood• Anxiety Consults• Individual Therapy – Exposure and Response Prevention Therapy (ERP) – Functional assessment• Group Therapy – Social Anxiety Group – Improvisation Group – Anxiety Management Group – Awareness Cultivation Group• Public Exposure – Meal, snack, body image, and other exposures
Treatment Resources Anxiety Disorders Association of America - www.adaa.org International Obsessive Compulsive Disorders Foundation - www.ocfoundation.org Association for Behavioral and Cognitive Therapies - www.abct.org
Bibliotherapy ResourcesExposure and Response Prevention Therapy:Abramowitz, J. S. (2011). Exposure therapy for anxiety: Principles and practice. New York, NY: Guilford Publications, Inc.Abramowitz, J. S. (2006). Obsessive-compulsive disorder: Advances in psychotherapy- evidence based treatment. Cambridge, MA: Hogrefe Publishing.
Bibliotherapy ResourcesObsessive-Compulsive Disorder:Abramowitz, J. S. (2009). Getting over OCD: A 10-step workbook for taking back your life. New York, NY: Guilford Publications, Inc.Baer, L. (2001). The imp of the mind: Exploring the silent epidemic of obsessive bad thoughts. New York, NY: Penguin Putnam, Inc.Gross, J. J. (2007). Handbook of Emotion Regulation. New York, NY: The Guilford Press.
Bibliotherapy ResourcesEmotion Regulation:Leahy, R. L. (2011). Emotion regulation in psychotherapy: A practitioner’s guide. New York, NY: The Guilford Press.Rapoport, J. L. (1989). The boy who couldn’t stop washing: The experience and treatment of obsessive-compulsive disorder. New York, NY: Penguin Putnam, Inc.Weg, A. H. (2011). OCD treatment through storytelling: A strategy for successful therapy. New York, NY: Oxford University Press.