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Webinar Treatment of Obsessive-Compulsive Symptoms March 12, 2013 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

Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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Erin McGinty, LPC- Therapist and Director of Anxiety Services at Castlewood Treatment Center presents on the comprehensive treatment of Anxiety and OCD spectrum disorders.

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Page 1: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

WebinarTreatment of Obsessive-Compulsive Symptoms

March 12, 2013

Erin McGinty, LPC, NCCProgram Director, Anxiety Services Coordinator, and Primary Therapist

Castlewood Treatment Center for Eating Disorders800 Holland Road

636-386-6611, ext. 103www.castlewoodtc.com

Page 2: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Normal vs. Abnormal Anxiety (Barlow, 2002)

Anxiety? Fear? Worry? Panic? Terminology…

Anxiety is a future-oriented mood state associated with preparation for possible, upcoming negative events.

Fear is an alarm response to present or imminent danger (real or perceived).

Page 3: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Normal vs. Abnormal Anxiety

The fight-or-flight response:• Physiological: Changes in heart rate and breathing,

nausea• Cognitive: Attention shifts to the perceived threat• Behavioral: Actions intended to avoid or escape the

threat (e.g., fleeing, attacking)

“In times of danger, anxiety can be a person’s best friend. (Abramowitz, 2011)”

Page 4: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Normal vs. Abnormal Anxiety

Abnormal anxiety: “When anxiety occurs in the absence of danger or when it is out of proportion relative to the actual threat. Such excessive and pathological anxiety– stemming from the misperception of a safe situation as dangerous (Abramowitz, 2011).”

This leads to the development of safety behaviors and strategies intended to detect, avoid, or escape

perceived danger… that may exacerbate symptoms.

Page 5: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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)

Page 6: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Anxiety Disorders (Abramowitz, 2011)

Anxiety Disorder Fear Cue(s) Misperception(s) Coping Responses

Obsessive-Compulsive Disorder (OCD)

Intrusive thoughts, situational cues

Thought-action fusion, inflated responsibility for preventing harm

Avoidance, compulsive rituals, reassurance seeking

Specific Phobia Snakes, heights, injections, etc.

Overestimation of the likelihood or severity of danger

Avoidance, use of drugs, distraction

Social Phobia Social situations Other people are highly judgmental; negative evaluation is intolerable

Avoidance, in-situation safety behaviors (e.g., using alcohol at a party)

Page 7: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Anxiety Disorders (Abramowitz, 2011)

Anxiety Disorder Fear Cue(s) Misperception(s) Coping Responses

Panic Disorder and Agoraphobia

Arousal-related body sensations; situational cues

Misinterpretation of arousal-related body sensations as dangerous

Agoraphobic avoidance, in-situation safety behaviors, safety signals

Posttraumatic Stress Disorder (PTSD)

Intrusive memories of traumatic events

Nowhere is safe Avoidance of reminders, distraction, safety signals

Generalized Anxiety Disorder (GAD)

Thoughts/images of low probability events

Intolerance of uncertainty; overestimation of the likelihood and severity of outcomes

Reassurance seeking, worrying as a form of problem solving

Page 8: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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).

Page 9: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Functional Assessment of AnxietyComponents of Functional Assessment of Anxiety (Abramowitz,

2011):

1. Problem list

2. Background and medical history

3. 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

4. Fear cues– External situations and stimuli– Internal cues: body signs and sensations– Intrusive thoughts, ideas, doubts, images, and memories

Page 10: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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?

Page 11: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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?

Page 12: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Functional Assessment of Anxiety

5. Feared consequences of exposure to fear cues– Overestimates of the likelihood and severity of danger– Intolerance for uncertainty– Beliefs about experiencing anxiety

Page 13: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Functional Assessment of Anxiety

Feared Consequences (Abramowitz, 2011):

What is so frightening for you about flying on a plane?

What do you tell yourself if you experience tightness in your chest?

What makes it so bad for you to give public speeches?

What are you worried might happen if you went to a party where you did not know anyone?

What is the worst-case scenario that could happen if used a public bathroom?

Page 14: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Functional Assessment of Anxiety

6. 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

Page 15: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Safety Behaviors (Abramowitz, 2011)

Type of Safety Behavior Description & Examples

Passive Avoidance The deliberate failure to engage in a low-risk activity associated with a feared cue.

Checking & Reassurance Seeking Subtle or overt behaviors aimed at confirming or verifying what is usually already known about a fear trigger or feared consequence.•Checking locks, outlets, lights•Information seeking•Mental reviewing

Compulsive Rituals Repetitive behaviors, often performed according to certain self-prescribed rules and aimed at reducing anxiety, “undoing” or removing a perceived danger, or preventing feared consequences. Behavioral and mental.

Page 16: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Safety Behaviors (Abramowitz, 2011)

Type of Safety Behaviors Description & Examples

Compulsive Rituals, cont’d. •Compulsive, rule-driven handwashing•Mental rehearsing•Repeating simple behaviors•Repetitive praying•Needing to visualize a “good” outcome in response to thoughts of a bad outcome

Brief, Covert (Mini) Rituals Nonritualistic attempts to reduce anxiety, remove or escape from feared stimuli, and prevent disasters. Behavioral or mental.•Repeatedly replacing a “bad” word or image with “good” one•Trying to suppress upsetting thoughts, images, or memories•Attempting to distract oneself from a fear trigger

Page 17: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Safety Behaviors (Abramowitz, 2011)

Type of Safety Behavior Description & Examples

Safety Signals Stimuli associated with the absence (or reduced likelihood) of feared outcomes. Even if these items are not used, the mere presence can artificially reduce anxiety and make the individual feel as if he or she is safer than he or she would be if such items were not present.•Medications•Cell phone•Keys•Safe person•Hospital•Water bottle

Page 18: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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?”

Page 19: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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?

Page 20: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Functional Assessment of Anxiety

Safety Signals (Abramowitz, 2011):

What might happen if you didn’t do _____?

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)?

Page 21: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Treatment:Exposure and Response

Prevention Therapy

Page 22: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Exposure and Response Prevention Therapy

Exposure• Prolonged, graduated, repetitive, and consistent exposure to

situations and thoughts that provoke anxiety and distress– Situational/In vivo exposure– Imaginal exposure– Interoceptive exposure (Panic Disorder)

• 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– Begin with exposures in the 3 to 4 range

Page 23: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Exposure and Response Prevention TherapyANXIETY RATING SCALE

00 11 22 33 44 55 66 77

HAVE TO RESIST

TRY AS HARD AS POSSIBLE TO RESIST

CALM NO ANXIETY

NO URGES TO RITUALIZE AT

ALL

“It bothers me”

“Don’t want to do it but know it will be easier than I

think.”

A few urges to use safety behaviors.

Anxiety is bothersome, yet

manageable.

A little bit harder to resist urges but

can still do it.

Difficult to resist

urges.

“Wish I didn’t have to do it, but can do it. Glad when it’s over!”

Come close to

safety behaviors but can still

resist.

Challenging

Unsure if able to resist ritualizing.

Very hard to

resist urges to use safety behaviors.

Challenging

Extremely hard to resist urges to

use safety behaviors.

Start feeling symptoms of

panic.

Near panic

Panicking

Fear of dying.

EXAMPLE:

GOING TO THE DENTIST

A few weeks before appointment. Think about not wanting to

go, but no worries, really.

Dreading going. Really don’t want to,

but know it will be ok if I go.

Think about ‘faking being sick.’ Trying to make excuses. Go to it, but glad when it’s

over.

Can’t imagine making it through the

appointment. Think about leaving in the

middle of the appointment. Strong relief when I make it.

Don’t know if I can make it. Feel some

panic symptoms starting.

Refuse to go. Feeling panicky.

PANIC Fear of dying if I go.

Page 24: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

  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.

INVIVO EXPOSURE HIERARCHY4

______(Anxiety Rating)

Page 25: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Exposure and Response Prevention Therapy

Response Prevention• Refraining from behaviors during exposure that are meant to

reduce anxiety– Behavioral rituals– Mental rituals– Avoidance

• Needs to be clearly defined between client and the clinician• Clients learn that feared consequences of exposure are

irrational

Page 26: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Exposure and Response Prevention Therapy

• While performing the exposure trial, the client imagines the feared consequence(s) of the exposure

• The client remains exposed to the cue until the associated anxiety decreases by 50% or more

• The client records his or her peak anxiety level, the amount of time elapsed for the anxiety to reduce by 50%, and the end anxiety level

• The client usually engages in 3-5 trials per day, every day, until habituation occurs

Page 27: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Exposure and Response Prevention Therapy

Trial # Date TimePeak Anxiety

RatingElapsed Time

Final Anxiety Rating

1  4/27/2012  15:30 4  6 minutes  2

2  4/27/2012  15:40 4 3 minutes 2 

3  4/27/2012  15:50 3   5 minutes 1

4  4/27/2012  15:59 3  3 minutes 1

5  4/27/2012  16:03 2  2 minutes 1

6          

7          

8          

9          

10          

Page 28: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Exposure and Response Prevention Therapy

Habituation: The decrease in anxiety due only to the passing of time– Within-trial habituation: The decrease in the peak

anxiety experienced in one exposure trial– Between-trial habituation: The decrease in peak anxiety

ratings as a result of repeated exposure trials

Between-trial habituation is the treatment effect!

Page 29: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Exposure and Response Prevention Therapy

Page 30: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Exposure and Response Prevention Therapy

• 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).

Page 31: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Exposure and Response Prevention Therapy

Reassurance Seeking

Submit Resist

4/29 llll llll llll llll

l

Page 32: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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).

Page 33: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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

Page 34: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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

Page 35: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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.

Page 36: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

Bibliotherapy ResourcesObsessive-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.

Page 37: Webinar- Treatment of Obsessive Compulsive Symptoms- Erin McGinty

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.