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. 4 th 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 25 20 15 10 5 0 0 5 10 15 20 25 Time (mins) Session 1 Session 2 Session 3 Session 4 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