Robert Bond, Ph.D spoke about the treatment of anxiety disorders and OCD at Castlewood Treatment Center.

1. Preferred Provider Conference
Treatment of Obsessive-Compulsive Symptoms
April 28. 2012
Robert W. Bond, Jr., Ph.D.,
Anxiety Therapist
&
Erin McGinty, LPC, NCC
Program Director, Anxiety Services Coordinator, and Primary Therapist
Castlewood Treatment Center for Eating Disorders
800 Holland Road
636-386-6611, ext. 103
www.castlewoodtc.com

2. Prevalence of Co-Occurring Anxiety Disorders
with Eating Disorders
Kaye et al. (2004) studied the co-morbidity of anxiety disorders
in an eating disorder sample, and found the following:
• Two-thirds of the subjects had one or more lifetime anxiety
disorder
• A majority of the subjects reported that their anxiety disorders
preceded the onset of the eating disorder
• The most common anxiety diagnoses were obsessive-
compulsive disorder (OCD; 41%) and social phobia (20%)

3. Effects of a Co-Morbid Anxiety Disorder on
Eating Disorder Symptomology
Clients with co-morbidity experience both a longer length of stay
and an exacerbation of eating disorder symptoms such as:
• Baseline anxiety higher
• Perfectionism
• Obsessionality
• Harm avoidance, including:
– Higher degrees of worry, or anticipatory anxiety
– Higher degrees of intolerance of uncertainty
– Higher degrees of fatigue
– Higher degrees of pessimism
• Body image dissatisfaction
• Higher scores on depression inventories

4. The Importance of Treating Co-Morbid Anxiety
Disorders (Steinglass et al., 2010)
• “Studies report that individuals with anorexia nervosa endorse
significantly higher levels of anxiety than healthy controls
both while underweight and after weight restoration”
• Trait anxiety has been identified as a differentiating factor
between patients who remitted from anorexia nervosa
– Trait anxiety as measured by the State-Trait Anxiety Inventory (STAI;
Speilberger)
• Symptom substitution

5. Elements of Clinical Anxiety
Fear Cues: Stimuli and situations that elicit anxiety
Maladaptive Beliefs: Exaggerated estimates of threat
• Catastrophizing
• Probability Overestimation
Safety Behaviors: “Actions intended to detect, avoid,
or escape a negative or feared outcome”
(Abramowitz, 2011)

6. Elements of Clinical Anxiety
Safety Behaviors (continued; Abramowitz, 2011)
• Passive avoidance
• Checking and reassurance seeking
• Checking locks, doors, outlets
• Information seeking
• Reassurance seeking
• Visual checking
• Compulsive rituals
• Handwashing
• Repetition of standing up, sitting down
• Praying

7. Elements of Clinical Anxiety
Safety Behaviors (continued; Abramowitz, 2011)
• Brief, covert (mini) rituals
• Safety signals
• Cell phone when leaving house
• Anti-anxiety medication
• Keys
• “Safe” person

8. Eating Disorders as Obsessive-Compulsive
Spectrum Disorders
Fear Cue:“Fear of fat” (Steinglass et al., 2010)
Maladaptive Beliefs: Irrational thoughts regarding
food, weight, and shape; overestimation of the
likelihood and consequences associated with the
threat
Safety Behaviors: Passive avoidance, body checking,
restriction, purging, compulsive exercise, calorie
counting, food rituals

9. The Application of Anxiety Treatments to Eating
Disorders
Outcome studies suggest that Exposure and Response Prevention
Therapy (ERP) is an effective form of treatment for co-morbid
eating and anxiety disorders:
“Results indicate that CBT with a primary focus on ERP is a
successful treatment approach for treating persons with both
obsessive-compulsive disorder and an eating disorder.
Significant changes in the severity of obsessive-compulsive
symptoms, depressive symptoms, and eating disorder
symptoms were noted (Adams, Riemann, Weltzin, & McGinty, 2007).”

10. 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

11. Development of Exposure and Response
Prevention
• Mowrer’s (1960) Two-Factor Model
– Sign and Solution learning.
• Stage 1: Fear becomes a conditioned response to neutral
stimulus
• Stage 2: Behavioral solutions sought to reduce the fear.
– By removing the anxiety, the safety behavior becomes
negatively reinforced.
– Probability that the safety behavior will be used again
increases.
– Fear is maintained by safety behaviors that prevent the natural
extinction of the fear.
– ERP seeks to break the conditioned fear response and
extinguish the reinforcing safety behaviors.

12. Exposure and Response Prevention Therapy
• Exposure Therapy
– Deliberately evokes anxiety by bringing
individuals into direct contact with feared stimuli –
including thoughts.
• Response Prevention
– Purports to eliminate safety behaviors by
purposely prolonging exposure and anxiety while
requiring individuals to refrain from using safety
behaviors.

13. Exposure and Response Prevention Therapy
Exposure
• Graduated, repetitive, and consistent exposure to situations and
thoughts that provoke anxiety and distress
– Situational/In vivo exposure
– Imaginal exposure
– Or combination
• While performing the exposure, the client imagines the feared
consequence(s) of the exposure
• The client remains exposed to the cue until the associated anxiety
decreases
• Goal is to achieve habituation, or the decrease in anxiety due only to
the passing of time
– Within-trial habituation
– Between-trial habituation

14. Exposure and Response Prevention Therapy

15. Exposure and Response Prevention Therapy
Response Prevention
• Refraining from behaviors that are meant to reduce anxiety
– Behavioral rituals
– Mental rituals
– Avoidance
• Clients learn that feared consequences of exposure are
irrational
Example: Eat a feared food such as potato chips (exposuree), no
purging/binging/exercise/restriction (response prevention).

16. 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).

17. 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).

18. Functional Assessment of Anxiety
Components of Functional Assessment of Anxiety (Abramowitz,
2011):
2. Problem list
3. Background and medical history
4. 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 problem
5. Fear cues
– External situations and stimuli
– Internal cues: body signs and sensations
– Intrusive thoughts, ideas, doubts, images, and memories

19. Functional Assessment of Anxiety
1. Feared consequences of exposure to fear cues
– Overestimates of the likelihood and severity of danger
– Intolerance for uncertainty
– Beliefs about experiencing anxiety
• 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

20. Functional Assessment of Anxiety
Feared 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?

21. Functional Assessment of Anxiety
Feared 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?

22. Functional Assessment of Anxiety
Feared Consequences (Abramowitz, 2011):
What is so frightening for you about wearing shorts?
What do you tell yourself if you experience the feeling of
fullness?
What makes it so bad for you to gain weight?
What are you worried might happen if you allowed yourself to
enjoy the taste of food?
What is the worst-case scenario that could happen if you reached
your barrier weight?

23. Functional Assessment of Anxiety
Safety 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?”

24. Functional Assessment of Anxiety
Safety 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?
What might happen if you didn’t do _____?

25. Functional Assessment of Anxiety
Safety Behaviors (Abramowitz, 2011):
How do you feel after you’ve done _____? What makes you feel
that way?
How does _____ prevent your feared consequences from coming
true?
What are you afraid will happen if you don’t do _____?
What makes you want to do _____? Why do you feel like it is
necessary?
Do you perform any types of brief or subtle mental or observable
actions to keep yourself safe?
Do you do anything else that has not been covered?
How well do these strategies work for you?

26. Functional Assessment of Anxiety
Safety Signals (Abramowitz, 2011):
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)?

27. Implementing ERP at Castlewood
• 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.

28. Implementing ERP at Castlewood
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 panic
NO 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.

29. Implementing ERP at Castlewood
• Hierarchies are not exhaustive but often
contain 70 or more items.
• Hierarchies are always considered works in
progress.

30. INVIVO EXPOSURE HIERARCHY
4
______
(Anxiety Rating)
Exercise
1. 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.

31. Implementing ERP at Castlewood
• Typically exposures are done incrementally by
way of systematic desensitization.
• Ideally, clients work on exposures that have
been rated a 3 or 4.
• Progression through the hierarchy depends
largely upon habituation.
• In some cases, flooding is necessary.
• However, a flooding hierarchy is typically
used to help with compliance.

32. Implementing ERP at Castlewood
• As often as possible, exposures are designed to fit
into a client’s day.
• However, when this is not possible, clients are
expected to complete the exposures during
programming hours.
• As often as possible, exposures are assigned so
that clients are frequently encountering the feared
stimuli daily.
• Clients are asked to continue exposure until
anxiety decreases by 50% or more.
• Clients are asked to record their work.

33. Implementing ERP at Castlewood
Peak Anxiety Final Anxiety
Trial # Date Time Elapsed Time
Rating Rating
4/27/2012 15:30 4 6 minutes 2
1
4/27/2012 15:40 4 3 minutes 2
2
4/27/2012 15:50 3 5 minutes 1
3
4/27/2012 15:59 3 3 minutes 1
4
4/27/2012 16:03 2 2 minutes 1
5
6
7
8
9
10

34. Implementing ERP at Castlewood
• 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).

35. Implementing ERP at Castlewood
• In order for the exposure exercises to be
completely effective, it is important to reduce
and eventually eliminate the safety behaviors.
• Ideally, the goal is to reduce these behaviors to
0 as soon as possible!
• “Re-contaminations”
• Ban Books
– Submits and Resists

36. Ban Books

37. 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

38. Bibliotherapy Resources
Exposure 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.

39. Bibliotherapy Resources
Obsessive-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.

40. Bibliotherapy Resources
Emotion 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.