Manage Your Mood
in OCD & BDD
David Veale
www.veale.co.uk
Today’s objectives
•
•
•

Describe the NICE guidelines for
depression
Learn to recognize symptoms of
depression
How to use...
The size of the problem

OPCS 2000 England adults 16-64
10.8% community had mixed anxiety &
depression, 2.7% depression, 4...
Depression in OCD/ BDD
About 40% people with OCD & 60% BDD have
depression
Which comes first? In large majority OCD/ BDD c...
Recognize depression
At high risk if significant physical illness
or stress (or OCD/ BDD)
“During the past month….
Have yo...
Screening for depression
• Have you had difficulty concentrating?
• Have you lost weight or had a poor
appetite? (or comfo...
Diagnosis depression
Adolescent – especially withdrawn and
irritability
Elderly and some some cultures – more
somatic symp...
Themes in depression
Loss
Inter-personal conflict spouse/boss
Change of role in life
Deficits in life
Failure to achieve a...
Suicide
Doctors & therapists will ask about suicidal plans:
Do you sometimes feel as if you’d like to end it all?
How long...
Suicide
Risk factors:
• Significant depression or delusions; alcohol or
substance abuse;
• Hopelessness and sense that fam...
Suicide risk
Higher risk (but often cannot change) if:
• history of deliberate self-harm, suicide
attempts or violence
• m...
Generalised Anxiety
Disorder
Mental anxiety - “Do you worry a lot?” (in
different areas)
Apprehension (“Do you feel “on ed...
Background to NICE
guidelines
There are many different types of
depression
Very few trials of treating depression in
peopl...
Different types of depression Problem for controlled trials
Consider 2 young unmarried female
patients; both aged 18; both...
Patient 1: is a lone
mother
Parents divorced
Mother was depressed
Sexual abuse since age
11
Left home age 14
Casual sex si...
Patient 1: is a lone mother Patient 2: university
student
Parents divorced
Supportive parents
Mother was depressed
No FH o...
Who is responsible for
care?

What do they do?

Why do they
do it?
Acute Wards
CMHT, OPD, crisis
team, Day Hospital
PCMHW,...
Mild depression
Guided self-help CBT
[A]
Physical exercise
[B]
Problem solving
[B]
Computerised CBT
[B]
“watchful waiting”...
When “watchful wait” ?
• Less than 2 weeks
• Symptoms mild and intermittent
• Good social support
• No family history of d...
Mild depression
Guided self-help with therapist
[A]
Physical exercise
[B]
Problem solving or counselling
[B]
Computerised ...
Guided self-help based on CBT – David
Burns- Feeling Good http://www.feelinggood
.com/
Overcoming depression
Chris Williams
Guided self help CBT
Published in UK
Also CD ROM
http://http://www.fiveareas.com/
Focus on Behavioural Activation
• Psychological understanding of
depression
• Effective treatments for depression
• Sleep ...
Mild depression
Guided self-help
[A]
Computerised CBT
[B]
Physical exercise
[B]
Problem solving or counselling
[B]
“watchf...
Computerised CBT
NICE Technology appraisal, 2002
Calipso (www.fiveareas.com )

Beating the Blues (Ultrasys)
Restoring the ...
Mild depression
Guided self-help
[A]
Physical exercise
[B]
Problem solving or counselling
[B]
Computerised CBT
[B]
“watchf...
Physical exercise
Dose 45-60 minutes, 3 times a week for
12 weeks
Adherence – just telling someone to
exercise not effecti...
Mild depression
Guided self-help
[A]
Physical exercise
[B]
Problem solving or counselling
[B]
Computerised CBT
[B]
“watchf...
St John’s Wort
Hypericum perforatum
300-600mg recommended daily dose
Bought over the counter but tell GP if other drugs
Im...
Mild depression
Guided self-help
[A]
Physical exercise
[B]
Problem solving or counselling
[B]
Computerised CBT
[B]
“watchf...
Severity of depression and
placebo response in adults
Per cent response
70
60
50
40
30
20
10
15

21

27

Baseline HAM-D
An...
Anti-depressants

SSRIs for OCD/ BDD (fluoxetine,
citalopram, sertraline, paroxetine,
fluvoxamine)
• Also recommended for ...
Seasonal Affective
Disorder
Recurrent seasonal depression onset winter
Atypical symptoms
• Increased sleep
• Increased app...
Phototherapy for SAD
Phototherapy daily in Winter - starting in
autumn
Sit 2-3 feet away from light box whilst doing
other...
Mild depression
Guided self-help
[A]
Physical exercise
[B]
Problem solving or counselling
[B]
Computerised CBT
[B]
“watchf...
Counselling
For mild to moderate depression, recent
onset (not chronic depression)
Insufficient evidence for benefit at 6
...
Psychological treatments for
moderate depression
If psychological treatment for depression, CBT
and BA
Behavioural Activation
•
•
•

•
•

BA as effective as CBT, and probably easier
to apply in OCD/ BDD
Therapists not always ...
Behavioural Activation
Depression occurs when a person tries to avoid or control
unpleasant feelings and copes by becoming...
Consequences
•
•
•
•
•

Withdraw and become inactive
Lose out on events that normally bring satisfaction or
pleasure
Rumin...
Behavioural Activation
Good relationship with therapist
Therapist is a coach
Good psychological understanding of what
main...
Behavioural Activation
•
•
•

•

Define what you are avoiding
Identify what is important to you (your
valued directions in...
Functional Analysis
Learn ABC Model
A - Activating event/ trigger
B - Behaviour (what you do)
C - Consequences
- Immediate...
Behaviour in depression
Identify typical avoidance and escape
behaviours in a person with depression.
(Include behaviours ...
What do depressed people
avoid ?
Social
- withdrawn, not answer telephone,
- avoid thinking about problems in relationship...
Assess what used to
enjoy
Identify what one used to enjoy/ find
satisfying?
N.B May need a balance between
strengthen plea...
Assess Valued Directions in
Life
Valued directions are not the same as goals
(e.g. get married and have children might be
...
Activity Schedule
Baseline and to monitor subsequent
approach/avoidance activity,
One as planned timetable to guide activi...
Rumination

Trying to find reasons for bad events in the past, reasons for
feeling bad (encouraged by some therapies)
(Why...
Worry (trying to solve all
potential problems)
Worry (e.g. What if my husband dies, what if I get
cancer, what if my boss ...
Distancing self from
thoughts
Aim to reduce fusion with past memories
Thank one’s mind for it’s contribution to one’s ment...
ACTION

Use whenever not sure about function of behaviour
A ssess how this behaviour serves you. What are my
goals in this...
OCD Action - Manage your Mood in OCD & BDD - David Veale
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  • There wer a number case histories of patients treated by E & RP. Rosen published the first RCT of BDD against W-L
    Treatment consisted of 8 x 2hour sessions This was done in groups
    82% improved compared to 7% in w-l
    All women probably less severe in disability and different popualtion
  • There wer a number case histories of patients treated by E & RP. Rosen published the first RCT of BDD against W-L
    Treatment consisted of 8 x 2hour sessions This was done in groups
    82% improved compared to 7% in w-l
    All women probably less severe in disability and different popualtion
  • There wer a number case histories of patients treated by E & RP. Rosen published the first RCT of BDD against W-L
    Treatment consisted of 8 x 2hour sessions This was done in groups
    82% improved compared to 7% in w-l
    All women probably less severe in disability and different popualtion
  • There wer a number case histories of patients treated by E & RP. Rosen published the first RCT of BDD against W-L
    Treatment consisted of 8 x 2hour sessions This was done in groups
    82% improved compared to 7% in w-l
    All women probably less severe in disability and different popualtion
  • OCD Action - Manage your Mood in OCD & BDD - David Veale

    1. 1. Manage Your Mood in OCD & BDD David Veale www.veale.co.uk
    2. 2. Today’s objectives • • • Describe the NICE guidelines for depression Learn to recognize symptoms of depression How to use CBT (Behavioural activation) & SSRI anti-depressants for depression in OCD/ BDD
    3. 3. The size of the problem OPCS 2000 England adults 16-64 10.8% community had mixed anxiety & depression, 2.7% depression, 4.6% GAD More common in women (& men elderly) Unemployment, live city, homeless Separated or widowed men > separated or divorced women > married Link to alcohol & substance use
    4. 4. Depression in OCD/ BDD About 40% people with OCD & 60% BDD have depression Which comes first? In large majority OCD/ BDD come first Magic Wand? Depression not a problem In general, treat OCD/BDD and depression improves However, depression usually interferes in treatment of OCD/BDD
    5. 5. Recognize depression At high risk if significant physical illness or stress (or OCD/ BDD) “During the past month…. Have you often had low energy? Have you often felt down? Have you often had little interest or pleasure in doing things? Have you often felt hopeless?” • If yes, to any question, ask...
    6. 6. Screening for depression • Have you had difficulty concentrating? • Have you lost weight or had a poor appetite? (or comfort eating?) • Have you been waking early or sleeping long hours? • Have you felt slowed up? • Have you tended to feel worse in the mornings? Yes to 3 or more, high likelihood of depression OCD/BDD often more frustration, low self-esteem & hopelessness
    7. 7. Diagnosis depression Adolescent – especially withdrawn and irritability Elderly and some some cultures – more somatic symptoms Often part of alcohol & substance abuse
    8. 8. Themes in depression Loss Inter-personal conflict spouse/boss Change of role in life Deficits in life Failure to achieve an ideal or perfectionism and highly self-critical
    9. 9. Suicide Doctors & therapists will ask about suicidal plans: Do you sometimes feel as if you’d like to end it all? How long have you had these feelings? Do you have a specific plan for your method? Have you told anyone? What’s stopped you so far? Have you left you affairs in order? Have you prepared a note?
    10. 10. Suicide Risk factors: • Significant depression or delusions; alcohol or substance abuse; • Hopelessness and sense that family would be better off ; • an organized plan or easily available method • absence of protective factors (religion, loved ones) • regret at survival from a recent attempt • attempt to avoid discovery from recent attempt
    11. 11. Suicide risk Higher risk (but often cannot change) if: • history of deliberate self-harm, suicide attempts or violence • male (adolescent or elderly) • living alone or socially isolated • Have physical illness • Socio-economic problems
    12. 12. Generalised Anxiety Disorder Mental anxiety - “Do you worry a lot?” (in different areas) Apprehension (“Do you feel “on edge”, have difficulty concentrating, irritable?”) Tension (“Do you feel restless? Fidgety? Do you get frequent headaches? Are you unable to relax?”) Over-reactive (“Do you startle easily? Do you have difficulty getting off to sleep”) (GAD often confused with depression or is comorbid. It is different from panic attacks)
    13. 13. Background to NICE guidelines There are many different types of depression Very few trials of treating depression in people with OCD/ BDD
    14. 14. Different types of depression Problem for controlled trials Consider 2 young unmarried female patients; both aged 18; both have same depression score (e.g of 24 on standard scale)
    15. 15. Patient 1: is a lone mother Parents divorced Mother was depressed Sexual abuse since age 11 Left home age 14 Casual sex since Depressed for 2 years Recently worse since child taken into care
    16. 16. Patient 1: is a lone mother Patient 2: university student Parents divorced Supportive parents Mother was depressed No FH of depression Sexual abuse since age Many friends 11 Left home age 14 Casual sex since Depressed for 2 years Recently worse since child taken into care Affair with boyfriend last 2 years He recently left with another girl Depressed for 2 weeks since he left
    17. 17. Who is responsible for care? What do they do? Why do they do it? Acute Wards CMHT, OPD, crisis team, Day Hospital PCMHW, GP, Counsellor, social worker, psychologist GP, Practice nurse, Practice counsellor Risk to Life Treatment resistance frequent recurrences Moderate or Severe Depression Mild Depression Recognition Medication,ECT nursing care Medication, complex Psychological i.v’s Medication,Brief psych. interventions, support groups Active Review: Guided Self Help or CBT, Exercise
    18. 18. Mild depression Guided self-help CBT [A] Physical exercise [B] Problem solving [B] Computerised CBT [B] “watchful waiting” [GPP] St. John’s Wort (with reservations) [B] AD’s not recommended for initial Rx of mild depression [C]
    19. 19. When “watchful wait” ? • Less than 2 weeks • Symptoms mild and intermittent • Good social support • No family history of depression • No past history of depression (In OCD, BDD - depression is secondary and treatment is progressing to plan?)
    20. 20. Mild depression Guided self-help with therapist [A] Physical exercise [B] Problem solving or counselling [B] Computerised CBT [B] “watchful waiting” [GPP] St. John’s Wort (with reservations) [B] AD’s not recommended for initial Rx of mild depression [C]
    21. 21. Guided self-help based on CBT – David Burns- Feeling Good http://www.feelinggood .com/
    22. 22. Overcoming depression Chris Williams Guided self help CBT Published in UK Also CD ROM http://http://www.fiveareas.com/
    23. 23. Focus on Behavioural Activation • Psychological understanding of depression • Effective treatments for depression • Sleep management • Eating healthily • Problem Solving • Exercise • Alcohol, substances • St John’s Wort • Medication
    24. 24. Mild depression Guided self-help [A] Computerised CBT [B] Physical exercise [B] Problem solving or counselling [B] “watchful waiting” [GPP] St. John’s Wort (with reservations) [B] AD’s not recommended for initial Rx of mild depression [C]
    25. 25. Computerised CBT NICE Technology appraisal, 2002 Calipso (www.fiveareas.com ) Beating the Blues (Ultrasys) Restoring the Balance (Mental Health Foundation) Mood Gym http://moodgym.anu.edu.au/
    26. 26. Mild depression Guided self-help [A] Physical exercise [B] Problem solving or counselling [B] Computerised CBT [B] “watchful waiting” [GPP] St. John’s Wort (with reservations) [B] AD’s not recommended for initial Rx of mild depression [C]
    27. 27. Physical exercise Dose 45-60 minutes, 3 times a week for 12 weeks Adherence – just telling someone to exercise not effective (difficult enough when not depressed) Trials are different (bias in who is recruited, enthusiastic trainer, often group)
    28. 28. Mild depression Guided self-help [A] Physical exercise [B] Problem solving or counselling [B] Computerised CBT [B] “watchful waiting” [GPP] St. John’s Wort (with reservations) [B] AD’s not recommended for initial Rx of mild depression [C]
    29. 29. St John’s Wort Hypericum perforatum 300-600mg recommended daily dose Bought over the counter but tell GP if other drugs Improvement should occur within 3-5 weeks Continue for at least 6 months BUT interacts with some drugs (warfarin, coumadin, theophylline, digoxin, contraceptive pill) Do not combine with standard ant-dperessants No evidence for benefit in OCD/ BDD St John’s Wort Helpline 01803 528 668
    30. 30. Mild depression Guided self-help [A] Physical exercise [B] Problem solving or counselling [B] Computerised CBT [B] “watchful waiting” [GPP] St. John’s Wort (with reservations) [B] AD’s not recommended for initial Rx of mild depression [C]
    31. 31. Severity of depression and placebo response in adults Per cent response 70 60 50 40 30 20 10 15 21 27 Baseline HAM-D Angst (1993) 33 0 Placebo Antidepress
    32. 32. Anti-depressants SSRIs for OCD/ BDD (fluoxetine, citalopram, sertraline, paroxetine, fluvoxamine) • Also recommended for depression in OCD/BDD • Highest tolerated dose, daily • Side effects can usually be managed • Withdraw gradually • Duration? •
    33. 33. Seasonal Affective Disorder Recurrent seasonal depression onset winter Atypical symptoms • Increased sleep • Increased appetite/ weight gain • Lethargy Mild version very common Phototherapy
    34. 34. Phototherapy for SAD Phototherapy daily in Winter - starting in autumn Sit 2-3 feet away from light box whilst doing other activities Response often within four days 10,000 lux for half an hour morning (or if poor response morning and afternoon) Not available on the NHS but can trial Seasonal Affective Disorder Association www. sada.org.uk Outside In www.outsidein.co.uk
    35. 35. Mild depression Guided self-help [A] Physical exercise [B] Problem solving or counselling [B] Computerised CBT [B] “watchful waiting” [GPP] St. John’s Wort (with reservations!) [B] AD’s not recommended for initial Rx of mild or sub-threshold depression [C]
    36. 36. Counselling For mild to moderate depression, recent onset (not chronic depression) Insufficient evidence for benefit at 6 months 6-8 sessions over 10 weeks Counselling is a generic term and covers many different types from “support”, psychodynamic to problem solving No evidence in OCD/ BDD
    37. 37. Psychological treatments for moderate depression If psychological treatment for depression, CBT and BA
    38. 38. Behavioural Activation • • • • • BA as effective as CBT, and probably easier to apply in OCD/ BDD Therapists not always enthusiastic as it lacks complexity and no focus on reasons BA is available in NHS IAPT (Increasing Access to Psychological Therapies) www.iapt.nhs.uk Ask if therapist accredited by BABCP or receives supervision from senior therapist Ask if training in Behavioral Activation for depression
    39. 39. Behavioural Activation Depression occurs when a person tries to avoid or control unpleasant feelings and copes by becoming withdrawn and inactive and brooding about the past. Trying to escape or control the way you feel works in the short term (and therefore more likely to do it again) It is normal to want to avoid unpleasant feelings but there are number of unintended consequences • You miss out on pleasurable/satisfying events and opportunities • They make you brood and worry more (get depressed about being depressed) • They stop you doing what is important in your life • They have effect on others (e.g. people get annoyed or sarcastic or take away responsibility from you) • They prevent you from testing out some of your beliefs i.e they make you more depressed in the long term
    40. 40. Consequences • • • • • Withdraw and become inactive Lose out on events that normally bring satisfaction or pleasure Ruminate more and becoming more depressed Actions have an effect on others Goal is willingness to experience unpleasant thoughts and feelings – not to avoid, control or manage feelings but acknowledge them and to act in by still doing what is important in your life (despite how you feel)
    41. 41. Behavioural Activation Good relationship with therapist Therapist is a coach Good psychological understanding of what maintains depression If OCD/ BDD and more sever symptoms, done in parallel with treatment for OCD/ BDD
    42. 42. Behavioural Activation • • • • Define what you are avoiding Identify what is important to you (your valued directions in life) Gradually structure day/ timetable activities and act according to a plan of the acts avoided and valued directions rather than how you feel No search for internal causes or reasons from the past. No focus on content of thoughts.
    43. 43. Functional Analysis Learn ABC Model A - Activating event/ trigger B - Behaviour (what you do) C - Consequences - Immediate (reduction in negative affect) which strengthens behaviour - Unintended (long-term)
    44. 44. Behaviour in depression Identify typical avoidance and escape behaviours in a person with depression. (Include behaviours that might function as avoidance)
    45. 45. What do depressed people avoid ? Social - withdrawn, not answer telephone, - avoid thinking about problems in relationships & family issues, Non-social - challenging tasks, rather than go out watch TV - avoid thinking future, making decisions, taking opportunities, not serious about work/education or what to do in life, avoid problems of OCD/BDD Some behaviours done in excess may function as avoidance (sleep, exercise, gambling, alcohol)
    46. 46. Assess what used to enjoy Identify what one used to enjoy/ find satisfying? N.B May need a balance between strengthen pleasant activities and avoidance of thoughts and feelings (e.g. watching video, using computer game)
    47. 47. Assess Valued Directions in Life Valued directions are not the same as goals (e.g. get married and have children might be a goal but to be a good partner and parent is a valued direction all one’s life) Aim is to identify valued directions in life to incorporate in activity schedule (so not just doing something for the sake of doing it) Beware of values that are socially approved or idealised values that identify the self
    48. 48. Activity Schedule Baseline and to monitor subsequent approach/avoidance activity, One as planned timetable to guide activity and one actual activity Graded task assignments form what (a) avoid (b) enjoyable and c) valued directions Act according to plan not how one feels! Support of family member/friend to keep to timetable Imaginal and verbal rehearsal of tasks Role play of tasks avoided
    49. 49. Rumination Trying to find reasons for bad events in the past, reasons for feeling bad (encouraged by some therapies) (Why didn’t my mother love me? If only I’d done more work before the exam. Why do I feel so awful? Why was I rejected?) Also compare, self-attack Solution: 1) Identify when ruminate/ compare as automatic actvitiy 2) Identify effect on mood, energy level, activity 3) Turn “Why?”.. into action “How can I…?” do what is important to me 4) Identify motivation for ruminating .
    50. 50. Worry (trying to solve all potential problems) Worry (e.g. What if my husband dies, what if I get cancer, what if my boss doesn’t like the work, what if…) (desire certainty and control) and trying to prevent them from happening Functional analysis (Trigger, Behaviour of worry, Consequences ? Avoid) Accept what is likely or severe and prepare for them (e.g. Earthquake in LA – practise for it) (e.g. death - make a will, guardian for children, write obituary (e.g. role play what explain to boss/interview) Do not mentally prepare - only act/role play
    51. 51. Distancing self from thoughts Aim to reduce fusion with past memories Thank one’s mind for it’s contribution to one’s mental health Label thinking styles (“Oh well done an excellent example of catastrophising”) Label thoughts e.g. “I’m having a thought….” Metaphor of cars passing in road or leaves on stream Self focussed attention - focus on external world
    52. 52. ACTION Use whenever not sure about function of behaviour A ssess how this behaviour serves you. What are my goals in this situation (i.e. are you avoiding something that is waiting that you do not want to do) C hoose to avoid or activate (OK to avoid and feel worse) T ry out whatever behaviour has been chosen I ntegrate any new behaviour repeatedly into a daily routine O bserver the outcome – write down what they did and what happened (effect on mood N ever give up

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