The Use of Exposure and Ritual Prevention with OCD
←
→
Page content transcription
If your browser does not render page correctly, please read the page content below
Bradley C. Riemann, Ph.D.
Clinical Director, OCD Center and CBT Services
Rogers Memorial Hospital
The Use of Exposure and
Ritual Prevention with OCD:
Key Concepts and New Directions
OCD Center
• Rogers Memorial Hospital (Wisconsin).
– Child & Adolescent IOP.
– Adult IOP.
– Adult PHP.
– Child Residential.
– Adolescent Residential.
– Adult Residential.
– Comorbid Residential (OCD and ED).
1
Brad Riemann
• Director of OCD Center.
• Chair, Clinical Advisory Committee of the International
Obsessive Compulsive Disorder Foundation (IOCDF).
• Member, Scientific Advisory Board of IOCDF.
• Member, Clinical Advisory Board of Anxiety and
Depression Association of America.
Introduction
• Brief overview of obsessive-compulsive disorder
(OCD).
– Signs and symptoms.
– Common associated features.
– Yale-Brown Obsessive-Compulsive Scale.
• Components of exposure and ritual prevention (ERP)
for OCD.
• Keys to successful exposure therapy.
• New directions.
2
OCD
• DSM-V has reclassify under new grouping of Anxiety
and Obsessive-Compulsive Spectrum Disorders.
– Body Dysmorphic Disorder.
– Hair-pulling Disorder.
• Characterized by either obsessions or compulsions.
Obsessions
• Recurrent, and persistent thoughts, urges, or images
that are experienced as intrusive and unwanted and
cause marked anxiety or distress.
• Person attempts suppress obsessions or to neutralize
them with some other thought or action (i.e.,
compulsion).
3
Common Obsessions
• Contamination (1).
• Repeated doubt (2).
• Need for exactness or symmetry.
• Need to tell, ask or confess.
• Harming.
• Sexual imagery.
• Religious.
Compulsions
• Repetitive behaviors or mental acts that the person
feels driven to perform in response to an obsession or
according to rules that must be applied (i.e., ritual).
• Behaviors or mental acts are aimed at preventing or
reducing anxiety or distress or preventing some
dreaded event.
4
Common Compulsions
• Checking (1).
• Washing or cleaning (2).
• Counting.
• Ordering.
• Repeating.
• Praying.
• Reassurance Seeking.
Commonly Asked Questions
• How common is OCD?
– 2.5% of population life-time prevalence.
– 4th most common psychiatric condition in U.S.
• Sex differences?
– No.
– Males do seem to develop earlier however.
• Onset?
– Average age is 20.2 years.
– Roughly half by 18 years of age.
– Rarely after 50 years of age.
5
Associated Features
• Secondary depressed mood (85%).
• Low self-esteem and social withdrawal.
• Academic and occupational impairment.
• Family discord.
• Fear embarrassment (hide symptoms).
• Avoidance.
Leading Causes of Disability (WHO)
1. Major Depression.
2. Iron-deficiency anemia.
3. Falls.
4. Alcohol use.
5. Chronic obstructive pulmonary disease.
6. Bipolar disorder.
7. Congenital anomalies.
8. Osteoarthritis.
9. Schizophrenia.
10. OCD.
6
Assessment
• Yale-Brown Obsessive-Compulsive Scale (Y-BOCS;
Goodman et al., 1989).
– 60 symptom checklist (past and current).
• Self-report version.
• Childhood version (CY-BOCS).
– 10 item severity rating scale (0-4).
• 5 questions regarding obsessions.
• 5 questions regarding compulsions.
• Mean score for OCD = 24.
Y-BOCS
• 0- 7 = subclinical.
• 8-15 = mild.
• 16-23 = moderate (16 trial cut-off).
• 24-31 = severe.
• 32-40 = extreme.
7
ERP for OCD
• Key element to effective treatment for OCD.
– Meyer (1966).
– Based on the principle of habituation.
– Habituation is the decrease in anxiety experienced with
nothing but the passage of time.
Exposure and the Keys to Success
• Exposure is placing an individual in feared situations
(targets the obsessions).
– Needs to be prolonged enough to lead to within trial
habituation (at least 50% reduction in anxiety).
8
Within Trial Habituation
100
90
80
70
Fear level
60
50
40
30
20
10
0
Time
Keys to Exposure
– Needs to be repetitive enough to lead to between trial
habituation (until causes minimal to no anxiety).
– Treatment effect.
9
Between Trial Habituation
45
40
35
30 Session 1
25 Session 2
20 Session 3
15 Session 4
10
5
0
0 5 10 15 20 25
Time (mins)
Keys to Exposure
– Needs to be graduated (increases compliance).
• Compliance with doing the exposures.
• Compliance with doing the ritual prevention.
10
Ritual Prevention
• Ritual Prevention is blocking the typical response or ritual
before, during, and after exposure so habituation can take
place (targets compulsions).
– Replace the ritual with habituation as way of controlling anxiety.
Exposure Hierarchy Development
• Y-BOCS symptom checklist and severity rating scales.
• Generate specific exposure exercises.
• Patient rates each exercise on scale of 0-7 on
perceived difficulty.
• Create exposure hierarchy.
11
Sample of Exercises
• 3’S
– Touch bedroom door knob and don’t wash.
– Turn on stove and turn off and don’t check.
– Rotate couch pillow 15 degrees to left don’t fix.
– Drive past high school at 9:30 a.m. don’t drive around block
to check.
Outcomes
• American Psychiatric Association (2007) recognized
ERP, SRI, or a combination as evidenced-based
treatments for OCD.
• Foa et al. (1996) meta-analysis of 12 ERP studies with
330 patients.
– 83% much or very much improved.
12
Outcomes
• Greist et al. (1996) compared 18 studies with 294
patients.
– Average decrease in YBOCS of 11.8 with ERP (SRI’s=7.5).
• Foa et al (2005) multi-site study found:
– CMI < ERP = ERP+CMI.
• ERP also effective for pediatric OCD (e.g., POTS
Team, 2004).
Outcomes, con’t
• Low relapse rates with ERP.
– Foa (1996) 16 studies with 376 patients found 76% much or
very much improved at follow-up (average 2.5 years).
13
Advantages of ERP
• Effective and robust.
• “Only” side effect is increased anxiety during treatment
(can manage by conducting graduated exposure).
• Quick improvements (many after first week of treatment).
Disadvantages of ERP
• Hard work.
• Noncompliance.
• Absence of ERP.
• Quality of ERP when available.
14
New Directions
• Attention Retraining.
– Those with anxiety disorders have been found to exhibit an
attention bias for disorder specific threat cues.
– Computer program trains individuals to redirect their
attention away from threat onto neutral cues thus correcting
attention basis.
– Leads to significant symptom reductions.
Attention Retraining
– 6 randomized controlled trials.
– Stand-alone treatment for generalized anxiety disorder,
social anxiety disorder and chronic pain.
– CBT enhancement for OCD.
• Riemann, Kuckertz, Rozenman, Weersing & Amir (2013).
• Enhanced outcome for OCD, social anxiety, and depression vs.
placebo.
15
Summary
• OCD is a common and debilitating condition.
• Key element of effective treatment is ERP.
• Keys to effective exposure therapy include prolonged,
repetitive and graduated exposure.
• Attention retraining may also prove to be effective in
treating OCD stand-alone or as an augmentation to
ERP.
16
You can also read
