Obsessive-Compulsive Disorder Lecture OverviewEpidemiology of OCDAssociated DisordersClassification of Obsessions (Jenike et al. 1986)Classification of CompulsionsFunctional Classification (Foa et al, 1985)Pharmacological Treatments for OCDMulticenter Trial of FluoxetineSlide 9Empirically-Supported Psychosocial TreatmentsRationale for Investigating Non-Drug AlternativesPsychological Factors Implicated in OCDProcedural Overview of Foa ERP Treatment ProtocolProcedural Overview of Foa ERP Treatment Protocol Cont.Important Areas of OC AssessmentSlide 16Examples of In Vivo Exposure ComponentSlide 18Rules for Response Prevention WasherRules for Response Prevention CheckerGuidelines for Constructing Imaginal Exposure ScenesCommon Difficulties During ERPSummary of Outcome for ERP (Foa et al, in press)Limitations of Exposure-Response Prevention for OCDLimitations of Combined Treatment Studies for OCDNIMH Multicenter StudyNIMH Multicenter Study ResultsModerators of Treatment OutcomeCognitive Therapy of OCDCognitive Factors in OCDSlide 31Slide 32Empirical Support for Cognitive InterventionsComparison Trial of ERP and Cognitive TherapyObsessive-Compulsive DisorderLecture Overview•Nature and epidemiology•Etiology•Empirically-supported treatments•Efficacy data•Moderator variables•Class discussionEpidemiology of OCD•Defining features•Prevalence•Onset and course•Associated features/comorbidityAssociated Disorders•Depression•Other anxiety disorders•Sleep disturbance•Eating disorders•Tourette’s disorder and motor ticsClassification 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 consequencesPharmacological Treatmentsfor OCD•Clomipramine*•SSRIs•Fluoxetine•Fluvoxamine*•SertralineMulticenter Trial of Fluoxetine0510152025303540Response RatePlacebo Fluoxetine -20 Fluoxetine -40 Fluoxetine -60Data taken from Tollefson et al (1994). Archives of General Psychiatry, 51, 559-567*NOTE: Response was defined as a 35% or more reduction in Y-BOCS scores.Multicenter Trial of Fluoxetine-7-6-5-4-3-2-10Change in Y-BO CSPlacebo Fluoxetine -20 Fluoxetine -40 Fluoxetine -60Data taken from Tollefson et al (1994). Archives of General Psychiatry, 51, 559-567.Empirically-Supported Psychosocial Treatments•Psychosocial Treatments–Exposure and Response Prevention (ERP)–Cognitive Therapy•Combined Medications + ERPRationale 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 OCDPsychological 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 attentionDeficits 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 historyProcedural 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 assignmentImportant 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 cuesProcedural 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 sessionsExamples 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 PreventionWasher•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
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