OCD.ppt
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Obsessive-Compulsive Disorder
Lecture Overview
? Nature and epidemiology
? Etiology
? Empirically-supported treatments
? Efficacy data
? Moderator variables
? Class discussion
Epidemiology of OCD
? Defining features
? Prevalence
? Onset and course
? Associated features/comorbidity
Associated Disorders
? Depression
? Other anxiety disorders
? Sleep disturbance
? Eating disorders
? Tourette's disorder and motor tics
Classification of Obsessions
(Jenike et al. 1986)
? Contamination (55%)
? Concerns of harming self or others (50%)
? Sexual concerns (32%)
? Somatic concerns (35%)
? Symmetry concerns (37%)
Classification of Compulsions
? Cleaning or washing
? Checking
? Counting
? Repeating
? Neutralizing thoughts
? Obsessional Slowness*
? Touching*
? Phobic avoidance*
Functional Classification
(Foa et al, 1985)
? Internal fear cues
? External fear cues
? Fears of harm or disastrous consequences
Pharmacological Treatments
for OCD
? Clomipramine*
? SSRIs
? Fluoxetine
? Fluvoxamine*
? Sertraline
Multicenter Trial of Fluoxetine
Multicenter Trial of Fluoxetine
Empirically-Supported Psychosocial Treatments
? Psychosocial Treatments
- Exposure and Response Prevention (ERP)
- Cognitive Therapy
? Combined Medications + ERP
Rationale for Investigating Non-Drug Alternatives
? Limited proportion of patients who show clinical benefit
? Level of residual symptoms among treatment responders
? Troublesome side effects
? Extremely high relapse rates
? Role of psychological factors in OCD
Psychological Factors Implicated in OCD
? Cognitive appraisal of intrusive thoughts (Salkovskis, 1985; Rachman, 1997)
- Overestimation of danger
- Inflated personal responsibility
- Thought-action fusion
? Thought-suppression (Wegner et al, 1987)
? Cognitive deficits in selective attention
Deficits in inhibiting irrelevant stimuli (particularly internal ones such as intrusive thoughts) (Clayton et al, 1999)
Procedural Overview of Foa ERP Treatment Protocol
? Information Gathering Phase (2 sessions)
- Session 1 (2 hrs.)
? Obtaining info on OCD symptoms
? History of the problem
? Defining the disorder
? Rationale for treatment
? Overview of treatment Program
? Teaching patients to Monitor symptoms
? Taking a general history
Procedural Overview of Foa ERP Treatment Protocol Cont.
? Information Gathering Phase (2 sessions)
- Session 2 (2 hrs.)
? Inspection of patient's self-monitoring
? Collecting information about obsessions and compulsions
? Generating the treatment plan
? Rules for selection of exposure situations
? Develop clear contract between therapist and patient
? Teaching patients to Monitor symptoms
? Homework assignment
Important Areas of OC Assessment
? Obsessions
- external fear cues
- internal cues
- consequences of external and internal cues
? Avoidance Patterns
- Passive avoidance
- Rituals
- Relationship between avoidance patterns and fear cues
Procedural Overview of Foa ERP Treatment Protocol Cont.
? Treatment Phase (15 daily sessions, 120 min. each)
- Format of exposure session
- Implementation of exposure
- Homework assignments
- Comments during exposure sessions
- Response prevention
? Rules
? Return to normal behavior
- Common difficulties during sessions
Examples of In Vivo Exposure Component
? For Washer
- Session 1: walk with therapist through the building touching doorknobs, holding each for several minutes
- Session 2: Repeat above and add contact with sweat by having patient touch armpit and inside of shoe
- Session 3: Repeat above but introduce having patient touch toilet seats
- Session 4: Repeat above but introduce urine by having patient hold a paper towel dampened in his own urine
- Session 5: Repeat above but introduce fecal material by having patient hold toilet paper lightly soiled with his own fecal material
- Sessions 6-15 Daily exposure to the three most fear-provoking activities are repeated.
Examples of In Vivo Exposure Component
? For Checker
- Session 1: turn the lights on and off once, turn stove on and off once, open and close doors once (leave room immediately without checking)
- Session 2: Repeat above and add flushing of toilet without looking in the bowl
- Session 3: Repeat above but introduce opening gate to the basement and allowing daughter to play near the gate
- Session 4: Repeat above but introduce carrying daughter on concrete floor
- Session 5: Repeat above but introduce driving on highway without retracing route
- Sessions 6-15 Daily exposure to the three most fear-provoking activities are repeated.
Rules for Response Prevention
Washer
? Patients not permitted to use water on their body
? Bath powder and deodorants are permitted unless they reduce contamination concerns
? Shaving is done by electric shaver
? Supervised showers occur every 3 days for 10-min.
? Ritualistic washing of certain areas of the body is prohibited
? Family members supervise adherence to rules while patient is home
? Violations are reported to therapist
? In the last few sessions, response prevention requirements are relaxed to permit normal washing
Rules for Response Prevention
Checker
? No ritualistic checking is permitted
? One check (normal checking) is permitted
? Designated relative or friend supervises response prevention adherence at home
? Therapist/supervisor is to stay with patient until urge to check diminishes......（后略) ......
Obsessive-Compulsive Disorder
Lecture Overview
? Nature and epidemiology
? Etiology
? Empirically-supported treatments
? Efficacy data
? Moderator variables
? Class discussion
Epidemiology of OCD
? Defining features
? Prevalence
? Onset and course
? Associated features/comorbidity
Associated Disorders
? Depression
? Other anxiety disorders
? Sleep disturbance
? Eating disorders
? Tourette's disorder and motor tics
Classification of Obsessions
(Jenike et al. 1986)
? Contamination (55%)
? Concerns of harming self or others (50%)
? Sexual concerns (32%)
? Somatic concerns (35%)
? Symmetry concerns (37%)
Classification of Compulsions
? Cleaning or washing
? Checking
? Counting
? Repeating
? Neutralizing thoughts
? Obsessional Slowness*
? Touching*
? Phobic avoidance*
Functional Classification
(Foa et al, 1985)
? Internal fear cues
? External fear cues
? Fears of harm or disastrous consequences
Pharmacological Treatments
for OCD
? Clomipramine*
? SSRIs
? Fluoxetine
? Fluvoxamine*
? Sertraline
Multicenter Trial of Fluoxetine
Multicenter Trial of Fluoxetine
Empirically-Supported Psychosocial Treatments
? Psychosocial Treatments
- Exposure and Response Prevention (ERP)
- Cognitive Therapy
? Combined Medications + ERP
Rationale for Investigating Non-Drug Alternatives
? Limited proportion of patients who show clinical benefit
? Level of residual symptoms among treatment responders
? Troublesome side effects
? Extremely high relapse rates
? Role of psychological factors in OCD
Psychological Factors Implicated in OCD
? Cognitive appraisal of intrusive thoughts (Salkovskis, 1985; Rachman, 1997)
- Overestimation of danger
- Inflated personal responsibility
- Thought-action fusion
? Thought-suppression (Wegner et al, 1987)
? Cognitive deficits in selective attention
Deficits in inhibiting irrelevant stimuli (particularly internal ones such as intrusive thoughts) (Clayton et al, 1999)
Procedural Overview of Foa ERP Treatment Protocol
? Information Gathering Phase (2 sessions)
- Session 1 (2 hrs.)
? Obtaining info on OCD symptoms
? History of the problem
? Defining the disorder
? Rationale for treatment
? Overview of treatment Program
? Teaching patients to Monitor symptoms
? Taking a general history
Procedural Overview of Foa ERP Treatment Protocol Cont.
? Information Gathering Phase (2 sessions)
- Session 2 (2 hrs.)
? Inspection of patient's self-monitoring
? Collecting information about obsessions and compulsions
? Generating the treatment plan
? Rules for selection of exposure situations
? Develop clear contract between therapist and patient
? Teaching patients to Monitor symptoms
? Homework assignment
Important Areas of OC Assessment
? Obsessions
- external fear cues
- internal cues
- consequences of external and internal cues
? Avoidance Patterns
- Passive avoidance
- Rituals
- Relationship between avoidance patterns and fear cues
Procedural Overview of Foa ERP Treatment Protocol Cont.
? Treatment Phase (15 daily sessions, 120 min. each)
- Format of exposure session
- Implementation of exposure
- Homework assignments
- Comments during exposure sessions
- Response prevention
? Rules
? Return to normal behavior
- Common difficulties during sessions
Examples of In Vivo Exposure Component
? For Washer
- Session 1: walk with therapist through the building touching doorknobs, holding each for several minutes
- Session 2: Repeat above and add contact with sweat by having patient touch armpit and inside of shoe
- Session 3: Repeat above but introduce having patient touch toilet seats
- Session 4: Repeat above but introduce urine by having patient hold a paper towel dampened in his own urine
- Session 5: Repeat above but introduce fecal material by having patient hold toilet paper lightly soiled with his own fecal material
- Sessions 6-15 Daily exposure to the three most fear-provoking activities are repeated.
Examples of In Vivo Exposure Component
? For Checker
- Session 1: turn the lights on and off once, turn stove on and off once, open and close doors once (leave room immediately without checking)
- Session 2: Repeat above and add flushing of toilet without looking in the bowl
- Session 3: Repeat above but introduce opening gate to the basement and allowing daughter to play near the gate
- Session 4: Repeat above but introduce carrying daughter on concrete floor
- Session 5: Repeat above but introduce driving on highway without retracing route
- Sessions 6-15 Daily exposure to the three most fear-provoking activities are repeated.
Rules for Response Prevention
Washer
? Patients not permitted to use water on their body
? Bath powder and deodorants are permitted unless they reduce contamination concerns
? Shaving is done by electric shaver
? Supervised showers occur every 3 days for 10-min.
? Ritualistic washing of certain areas of the body is prohibited
? Family members supervise adherence to rules while patient is home
? Violations are reported to therapist
? In the last few sessions, response prevention requirements are relaxed to permit normal washing
Rules for Response Prevention
Checker
? No ritualistic checking is permitted
? One check (normal checking) is permitted
? Designated relative or friend supervises response prevention adherence at home
? Therapist/supervisor is to stay with patient until urge to check diminishes......（后略) ......
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