Cognitive Therapy for Psychiatric Problems: Hawton, Salkovskis et al

Cognitive Therapy for Psychiatric Problems: Hawton, Salkovskis et al

Contents
Chapter 5 Obsessional Disorders    1
Nature of the problem    1
Content of obsessions    2
Types of compulsive behaviour    2
The psychological model of obsessive compulsive disorder    2
Assessment    2
Factors determining suitability for treatment    2
Detailed behavioural analysis    2
Covert neutralising    3
Avoidance    3
Emotional factors    3
Behaviours    3
Other aspects of assessment    3
Difficulties in assessment    4
Chronicity    4
Treatment of obsessions with over compulsive behaviour    4

Chapter 5 Obsessional Disorders

Nature of the problem

Obsessions are the intrusive thoughts that then provoke unpleasant feelings, standardly anxiety, that are then neutralised by the compulsion. There are standardly some specific situations that trigger the thoughts, although they might be so wide spread the actual originary situation is lost, although there will definitely be modulators.  The neutralising behaviour then gives some temporary relief from the anxiety, although the obsession returns.  Patients also develop avoidant behaviour to avoid trigger situations.

Clinically OCD gets divided into obsessional rumination, which is obsession with covert compulsion and obsessions with overt compulsions (obsessional ritualizing)

Content of obsessions

Usually concerned with something personally repugnant

Types of compulsive behaviour

A theme common to OCD is future harm and a desire to prevent it. Cleaning\checking compulsions more closely resemble phobias and have more avoidant behaviour in them.  When avoidance fails then compulsion is used to neutralise.  In checking obsessions the patient strives to ensure he has not been responsible for harm coming to himself or others.  There is a functional identity between cleaning and checking, making sure I am not responsible for harm. Likewise overt compulsions can be classified into restitution, i.e. putting things right and verification i.e. checking.

The psychological model of obsessive compulsive disorder

Core features of obsessional problems are

1.       Avoidance of object which trigger obsessions

2.       Obsessions

3.       Compulsive behaviours and thought rituals

As the obsessions persist and rituals become extensive patients can present with ritualistic behaviours apparently independent of the obsession when confronted with an obsessional trigger, as the patient neutralises before the obsession occurs.

Obsessions get associated with anxiety, i.e. conditioned, the anxiety would decline naturally but is kept there by the compulsions, which reduce the anxiety temporarily but the client never sees the anxiety dropping so the conditioning remains.  Again avoidance maintains the anxiety as exposure to the thoughts occurs less often.

Assessment

A crucial aspect of assessment is the response to exposure both within session and for homework as once the link between triggers, thoughts, neutralising activities and avoidance are clear then the therapist can implement a treatment plan.

Factors determining suitability for treatment

You need to establish if the OCD is primary or as a reaction to a primary problem, if it’s the primary problem then this should be treated first. The treatment is relatively straightforward once the detailed assessment is complete and consists of exposure and response prevention.  Schizophrenic patients often show OCD symptoms

Find out how the problem has affected them over the last week, i.e. intensity and duration, then move to a specific example of the problem. Look for what triggers the behaviour and look to elucidate any thoughts that there might be, or images.

Detailed behavioural analysis

Move to a specific example, and ask about the trigger situations, go through cognitions, emotions, physiology and behaviour. Then ask about the consequences, so do an ABC analysis.

Things to look for in analysis

1.       Avoidance

2.       Reassurance

3.       Modulators

4.       Forms of obsession, thoughts, images, impulses

5.       Triggers, emotional, cognitive

6.       Emotions, how they change, pre obsession, during compulsion and post compulsion

7.       Development of problem

8.       Degree of impairment due to problem, in various domains

9.       Cost benefit analysis of change

Covert neutralising

If a client’s obsessions are obscured by compulsions, then try to get the client to provoke the obsession, or provoke it for them on an assumption of what it is. Alternatively if there is a trigger situation that forces them to compulsion then get that trigger situation done without the compulsion.

Avoidance

There can be cognitive avoidance, as the client tries not to think about something. This will prevent exposure from working.  If the client doesn’t think their behaviours are senseless or excessive then they are not obsessional, especially if they think the origin of these behaviours are external, e.g. radio waves. When a client sees their behaviour as reasonable but excessive then do a cost benefit, the amount of effort put in for a highly improbable event.

Emotional factors

Check the mood associated with the obsession, the assumption is its anxiety but many patients report it as discomfort, tension, anger or repugnance. To clarify feelings, you can ask, is it like the feeling you get before an exam, when you are fed up

Behaviours

Behavioural assessment is crucial any behaviours that trigger obsessional thoughts.  Prevent exposure to them are crucial to be understood.  Look at active and passive avoidance, so are there things that prevent you having obsessions, are there things you avoid to prevent you having obsessions.  Sometimes covert rituals are used when overt ones are not possible. The behaviours that terminate exposure are reassurance and neutralising behaviours, you should be aware of these before doing any exposure.  Neutralising behaviours can be stored up, so for eight hours you can’t neutralise, then you neutralise furiously. Modulators can be situational, emotional, cognitive or interpersonal.

Other aspects of assessment

Check family members aren’t helping to maintain their behaviours.  Do a cost benefit analysis, if you didn’t have this behaviour how would your life be different.

Behavioural tests

Get client to enter the compulsion provoking situation without doing the compulsion and to note down what they’re thinking and what they’re feeling without doing the compulsion. Often because clients have become so used to their behaviour they omit salient details, so if you can do something in session that is a trigger situation for them and then to see what they do then that would be ideal for collecting all the information.

Difficulties in assessment

Obsessional thoughts are repugnant to the client and they fear they will be rejected if people know they have them. Some patients may think talking about their obsessional fears may make them worse. There can also be shame and embarrassment about the compulsions.

Chronicity

A very chronic problem might lead to the client not wanting to talk about their thoughts, through fear they may get locked up, seen as bad etc. Here look at what the effect of having the thought is, I don’t want to be locked up, then show how because you try to stop the thought because its repugnant shows you won’t act on it, and also how thought suppression leads to the enhancement and rebound effect.

Treatment of obsessions with overt compulsive behaviour

Presenting the rational

So you can use the dogs example, i.e. little boy gets scared of dogs and as an adult crosses the road, does this help, what should we do? When clients fear that the anxiety will not decline, then to say it will be fine is counterproductive, rather use it to do another behavioural experiment.

Introduction to exposure

Clients are willing to endure high levels of distress if they think the treatment will be effective. One of the things about exposure is that it will produce anxiety but actually this is a good thing as you may well find it goes down more rapidly than you thought between 20 -60 mins.  The other thing you will find is after repeating the same exposure the anxiety will reduce more quickly

Modelling is a useful way to show the client there is no problem with doing what you are asking.  It can often help if the therapist goes beyond what they are asking the client to do. Modelling should be used only at the start of treatment but should be phased out as it can be used as a reassurance technique by the client.

If responsibility is an issue in terms of the client always seeking reassurance that they have done the task right, then get them to set their own homework, without telling the therapist, and get them to do a homework review the next week.

Reassurance

Reassurance seeking is a common aspect of obsessions. Reassurance seeking looks to ensure that harm hasn’t happened and has the effect of passing the responsibility onto someone else.  If the client does reassurance seeking in session then do an ABC on it and see how much relief it provides, then look to see what the long term picture is, does it actually maintain the anxiety.  So to get the client to think about this, then ask the client how much reassurance they would need to make the problem go away for a month, if this doesn’t work then its ineffective.  Reassurance prevents confronting and extinguishing the anxiety that’s arisen about being responsible for harm.  If relatives have problems with this then they can say hospital instructions are that I don’t answer such questions.

Difficulties encountered in the course of treatment

Habituation does not occur in session.

If you get stuck with the client, then “There are two problems we could be having, one that you are having problems with germs and need to be obsessional with it, or two you are having obsessional problems which are kept going by your compulsions, how do you think we could decide between these possibilities.

Treatment of obsessions without overt compulsive behaviour

Covert compulsive behaviours are quite difficult to gain access to and to control.  However all that needs to happen to the standard model is to recognise mental neutralising behaviour. Indeed then the exposure is the repugnant thought, and the response prevention is

Assessment

Discriminating between the obsessional thought and the compulsive thought is critical.  Intrusive involuntary thoughts need to be discriminated from neutralising thoughts which are deliberately evoked. . There also might be covert avoidance behaviour, such as thought suppression.

Treatment procedure

Habituation procedure

IN habituation training then you repeat predictably to elicit thoughts to get anxiety reduction whilst preventing any neutralising behaviours. The key here is predictable, so if there are certain triggers that get the thoughts reliably created use these. From this point then move on to unpredictable events.

Before any ERP is started though, the client must fully understand the treatment rationale, the function of their compulsions and avoidance.

To get the predictable thought then you can get the patient to say the thought to themselves or to have a tape loop with their voice on it.  Get them to listen to the tape for 10 times without any neutralising behaviours, rate anxiety and urge to neutralise. Repeat this every day for a week and see how the anxiety changes

Thought stopping

I’m not sure about this one, this seems like it could turn into a safety behaviour but still…What you do is to get the client to describe a pleasant scene or thought, then elicit a distressing thought for the client and then shout stop and  then get them to think the more pleasant thought, I guess the sense of surprise will make them change, then get them to say it to themselves. The thought stopping needs to be practised in non-stressful situations until it can be used in stressful situations.

First you direct proceedings then you get them to do it. I guess one thing with thought stopping is the novelty of it wears off after a while, so I guess some ingenuity should be used to make it still seem novel.

Alternative treatments

Behavioural treatment, is the treatment of choice.  Psychotherapy is seen to be effective for people with obsessional traits and not OCD. Learning as an in-patient can lead to difficulties in generalisation when they leave hospital.