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Cognitive Behavioral Treatment of Obsessive-Compulsive Disorder

(5-28-19) (based on C.A. Pollard, Cognitive Behavioral Treatment of Obsessive-Compulsive Disorder, 4-21-15)

Conceptual Issues

  • Obsessions increase anxiety/distress
  • Compulsions decrease anxiety/distress
  1. Obsessions
    • Triggers (real stimuli)
    • Core Fear (imaginary consequences)
      • need to be “just right”, “just right” OCD: core fear is that feeling will never go away
  2. Compulsions
    • Behavioral (washing, checking, reassurance-seeking, straightening)
    • Cognitive (counting, mental checking, figuring it out)
      • existential fears may have a “figuring it out” compulsion
  3. Fundamental core of ODC is negative reinforcement: there’s no fun in ODC
  4. Safety learning vs. danger learning
    • Pollard suggests that danger and safety learning are associated with different areas of the amygdala, that ERP strengthens safety learning without necessary reducing perception of danger (uses committee metaphor)
    • Danger Associations
      • generalize rapidly across contexts
      • persist even without reinforcement
      • will dominate if safety learning weak
      • all that is needed for fear to persist is the absence of a corrective emotional experience
    • Safety Associations
      • generalize slowly, contextually bound
      • weaken over time if not reinforced
      • must be strong to inhibit danger learning
    • Pollard believe that human clinical research suggests:
      • anxiety does not have to decline during exposure (for clinical benefit to occur)
      • exposure does not need to be sequential
      • exposure does not have to be graduated
      • learning does not seem to have to occur in big chunks (90 consecutive minutes of exposure not necessary)
  5. related problems (functional analysis critical to establish conceptual clarity)
    • compulsive worrying: avoidance strategy; Pollard believes “first cousin of “figuring it out compulsion”
      • worry usually everyday; figuring it out out of ordinary
      • disrupt both
    • rumination: just stuck on things, not avoidant, not anxiety driven
    • addictions: start with the high, negative reinforcement secondary
    • Hoarding /Disorder: hold on to, but also going and getting
    • Impulse Disorders
      • sexual compulsions
      • Trichotillomania
      • Pathological Gambling
    • preoccupation with bodily sensations or appearance
      • Body Dysmorphic Disorder
      • Anorexia Nervosa
      • Illness Anxiety Disorder (Hypochondriasis)
    • neurologic disorders
      • Tourette’s syndrome
      • Sydenham’s chorea
      • autism spectrum disorder

Treatment

  1. Treatment sequencing
    • OCD & depression: Pollard will usually treat OCD first, if depression severe will use behavioral activation first
    • OCD & personality disorder: Pollard would usually treat personality disorder first (to increase treatment adherence)
    • GAD & OCD: which is most impairing?, would generally treat OCD first
    • PTSD & OCD: Polard was not clear to me (I would treat PTSD first)
    • substance abuse and OCD: if substance abuse primary, treat this first
  2. Psychoeducation is cognitive therapy
    • teach children that “OCD is the Lier”:
      • “What do you do with a lier?”: “ignore”
      • “Don’t do as the say”, “because they’re a lier”
    • Commitment is primary: “What are you going to give up to do your ERP?”
      • “How much should I do?”: “How fast do you want to get better?”
  3. Exposure and Response Prevention is the necessary and sufficient treatment for OCD
    • constructs and uses hierarchy
    • in session practice
    • practice outside of session
      • Gaining a healthy perspective
        • two kinds of ritual behavior
          • abnormal/unnecessary (e.g., tapping)
          • excesses of normal behavior (e.g., washing)
      • Acquiring non-avoidant coping skills
        • non-avoidance is key
          • diaphragmatic breathing
          • coping statements
          • coping scripts
          • promoting active motivation
          • mindfulness
        • distraction: interferes with safety learning but does not facilitate danger learning: does’t help get better but doesn’t make worse
      • Modifying the environment to support
      • Exposing to fear stimuli
        • constructs and uses hierarchies
          • Level of challenge
          • Low (1-3)
          • Medium (4-6)
          • High (7-10)
        • in session practice: “Exposure is about learning, not about relaxing”
        • practice outside of session
      • Maintaining the progress
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