Posts tagged ‘Cognitive Behavioral Therapy’
For those of you not familiar with the concept of mindfulness, it is the act of focusing on the present moment in a nonjudgmental way. Just noticing and accepting what is.
Anything strike you about this definition? To me, it seems as if mindfulness is the exact opposite of obsessive-compulsive disorder:
Focusing on the present moment? Those with OCD rarely do that. Instead they either find themselves immersed in the world of “what ifs,” worrying about everything that might go wrong, or agonizing over things they think might have already gone wrong. Lots of thinking about the future and the past. Not so much about the present.
And in a nonjudgmental way? If you have OCD, you’re probably laughing right now, because chances are you judge yourself all of the time. Whether it’s blaming yourself for bad things that might happen in the future or that possibly happened in the past, or thinking of what you did wrong or will do wrong or should have done differently, those with OCD are continually assessing their thoughts and actions. And because they often deal with cognitive distortions, these assessments are typically incorrect. One type of cognitive distortion is thought-action fusion, where people believe that thinking bad thoughts is akin to performing the action associated with the thought, or the belief that thinking these same thoughts can somehow make them come true. For example, new moms sometimes have thoughts of hurting their babies. Most will acknowledge the thoughts as having no meaning and let them go. But moms dealing with thought-action fusion might be horrified and immediately consider themselves terrible people, unfit parents, and a danger to their children, because what kind of mother thinks that way? Judgment judgment judgment.
My friend Bellsie over at Obsessively Compulsively Yours has some interesting thoughts on how mindfulness might help those with OCD, in relation to both cognitive decentering and Cognitive Behavioral Therapy.
Over the past year or so, I’ve tried to become more mindful in my own life. While I don’t have OCD, I am quite prone to “what ifs” and when I find myself heading down that road, I now easily (usually) stop myself and focus on the present moment. An act so simple, yet so powerful. And while I welcome the calm that mindfulness brings me, I am even more thankful for an additional unexpected benefit: gratitude. Focusing on the present allows me to stop and catch my breath, and when I do that I somehow become keenly aware of all the good in my life. Not in the past, and not in the future, but right now. Because right now is what really matters.
In a recent post, I talked about two of the more common roadblocks for those seeking treatment for OCD: a shortage of qualified OCD treatment providers and adequate healthcare coverage.
If you are fortunate to live near a large research university, you might be lucky enough to circumvent these two obstacles, as there just might be studies taking place that could provide treatment for obsessive-compulsive disorder at little to no cost. One such research study is now ongoing at the Pediatric Anxiety and Mood Research Clinic at Columbia University/New York State Psychiatric Institute.This is a clinical trial assessing the efficacy of an FDA-approved antibiotic (minocycline) for OCD sufferers between the ages of eight and twenty. It is an exciting study as preliminary results appear promising. Minocycline has fewer side effects than SSRI’s, is lower in cost, and has been used safely for years, mainly for the treatment of acne. Those participating in this study also receive free Cognitive Behavioral Therapy and are offered three months of follow-up care at no cost. Some participants might also be eligible for CBT and/or medication management outside of the study. For all eligibility and contact information, and to learn more about the study, click here.
Again, there are those who are working tirelessly to make life better for OCD sufferers and their families. As we enter this week of Thanksgiving, I am indeed thankful for all the professionals who have dedicated their lives to helping those with OCD. I am thankful to all of you who share your stories in the hopes of educating others and raising awareness of the disorder. I am thankful that my son Dan continues to do well. And I am thankful for my whole family, who have never once complained about the hours I spend at the computer advocating for those with OCD. I am indeed blessed.
Wishing you and your loved ones a happy Thanksgiving surrounded by those you love.
Presenting………ocdtalk’s first guest post of 2013. Dr. Marla Deibler writes about hoarding and its connection to OCD:
Hoarding is an often misunderstood problem, which has, in recent years, garnered quite a bit of media attention. In fact, some of the facts may be surprising.
Technically, hoarding is not currently a psychiatric diagnosis. In fact, hoarding is only mentioned in our current diagnostic manual (DSM-IV-TR) as a possible symptom of obsessive-compulsive personality disorder. Hoarding disorder, however, will be included in the new diagnostic manual (DSM-V) as a distinct disorder unto itself, which is slated for 2013 publication. This is an exciting development, as it will help to legitimize the struggles of those who suffer from hoarding difficulties as well as help to educate others regarding its distinction from obsessive compulsive disorder (OCD).
Hoarding disorder involves the accumulation of belongings to such an extent that the resulting clutter renders parts of the living space unusable. It involves the acquisition and failure to discard a large number of items/possession that are considered by most to be of little or no value. These possessions clutter the living space, rendering the space unable to be used in the manner in which it was intended. The hoarding behavior causes marked distress or interferes with one’s daily functioning.
So why do hoarders hoard? What drives and maintains this behavior?
1. Emotional Attachment – Individuals with compulsive hoarding tend to have strong emotional attachment to objects, finding each unique or meaningful to them and thus have difficulty parting with the items. They often prefer to have control of the items, including who is permitted to touch or sort through them.
2. Information Processing – Individuals with compulsive hoarding tend to report difficulties in remembering the location of items and like to have items visible or have visual reminders. They often worry that they might forget something and thus hold on to items as reminders. They have difficulty in utilizing broad categorization skills and find it difficult to make decisions regarding the disposition of possessions.
3. Erroneous Beliefs – Individual with compulsive hoarding tend to have erroneous beliefs regarding their possessions related to perfectionism, control, responsibility, value of individual items, and potential utility of items.
4. Distress Regarding Discarding/Acquiring – Individuals with compulsive hoarding experience significant distress and anxiety when faced with having to decide whether to discard a possession. They may also experience anxiety when they feel a need to acquire an object they desire and believe that this feeling can only be relieved through acquisition of the item.
5. Negative Reinforcement – Compulsive hoarding behavior is maintained through negative reinforcement; in other words, individuals are able to relieve their distress by putting off making decisions about disposition or discarding items, which leads to increased clutter and continued avoidance of sorting and/or discarding.
Essentially, it’s not about the clutter. It’s about the stuff. Hoarders form very powerful attachments to objects. The thought of parting with them may lead them to feel as though they are losing part of their lives.
Is it related to obsessive compulsive disorder?
Hoarding is considered to be related to obsessive-compulsive disorder (OCD), an anxiety disorder characterized by recurrent unwanted thoughts (obsessions) and repetitive behaviors (compulsions) enacted to reduce the distress associated with obsessions; however it is most recently considered to be a distinct disorder in and of itself, as a growing body of research has differentiated the two.
Compulsive hoarding is a complex disorder and may involve co-occurring disorders, trauma history, genetic factors, and/or learned behavior (modeling). Hoarding behavior typically begins in late childhood/early adolescence and progresses throughout the lifespan. Although its exact prevalence is unknown, it is believed that approximately 1% – 5% of the population exhibits compulsive hoarding. Studies suggest that 20% – 30% of individuals with OCD exhibit compulsive hoarding behavior, but only 5% – 15% of hoarding behavior can be attributed to OCD. Insight into the seriousness of the problem may be limited and relatives may be most concerned about the behavior.
What can be done to help individuals who struggle with hoarding?
Although some individuals with compulsive hoarding respond to antidepressant medication, many individuals do not. Cognitive-behavioral therapy has been demonstrated to be effective in the treatment of compulsive hoarding which involves helping individuals to change the way they think about and make decisions about their possessions in order to control their behavior and their emotional attachment to possessions. This process involves a thorough behavior assessment (to learn each individual’s contributing factors), psychoeducation (to improve insight and knowledge of the disorder), exposure/response prevention (E/RP) (for those who actively acquire, this involves exposing them to situations in which they have the opportunity to acquire, while having them refrain from acquiring – – this may be difficult for them initially, but with repeated E/RP, they habituate, or get used to, the situation and their distress decreases), cognitive restructuring (helping them to identify the flaws/distortions in their thought processes and change them to more adaptive/accurate/positive thoughts), and excavation exposure (exposing them to having to engage in the process of de-cluttering by sorting through their items while utilizing and practicing improved decision-making skills).
Thank you Dr. Deibler for this informative post. I certainly learned a lot!
Dr. Marla Deibler is a clinical psychologist and the Founder and Executive Director of The Center for Emotional Health of Greater Philadelphia in Cherry Hill and Princeton, New Jersey, specializing in the evidence-based treatment of obsessive compulsive spectrum disorders. She serves on the Board of Directors of OCDNJ, the NJ affiliate of the International OCD Foundation (IOCDF) and serves as a consultant to media outlets regarding OCD and related disorders. Dr. Deibler also contributes to PsychCentral in her blog, “Therapy That Works.”
I’ve been meaning to write a post about PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcus) for a while, but I think this recent article in The Boston Globe by Neil Swidey does a much better job of describing it than I could. PANDAS, which is characterized by a sudden onset of OCD-like symptoms, is also characterized by a good deal of controversy within the medical community. Because PANDAS is believed to be caused by a strep infection, the treatment is not Cognitive Behavioral Therapy; it’s antibiotics.
What I find most interesting about the article is not only the string of misdiagnoses, but how the correct diagnosis was finally made. The sick child’s mother was thumbing through a magazine and came across an article about PANDAS. She knew then and there that her son was suffering from this disorder. The health professionals that had treated her son had missed the mark. One had never heard of PANDAS, another diagnosed him with obsessive-compulsive disorder, and yet another suggested anorexia nervosa. Neither of these diagnoses really made sense to the mom, and then luckily, she read about PANDAS.
This story illustrates how important it is for parents to trust their instincts when it comes to their children. Nobody knows your child as well as you do, and nobody cares about him or her as much as you. If a diagnosis doesn’t seem right to you, there’s probably a good chance it isn’t. To me this article is also a great reminder of why we must spread the word about PANDAS, OCD, or other illnesses that are uncommon, misunderstood, or difficult to talk about. In some way, shape or form, we just might connect with people who will recognize themselves (or their child) and then go on to get the appropriate help.
I’m excited to introduce ocdtalk’s first guest blogger! Seth J. Gillihan, PhD, is a licensed clinical psychologist with a practice in Haverford, Pennsylvania. He completed his doctoral training at the University of Pennsylvania and specializes in cognitive-behavioral treatments for anxiety and depression. Dr. Gillihan is also a visiting assistant professor of psychology at Haverford College and a Clinical Associate at the University of Pennsylvania, Department of Psychiatry.
Let’s give him a warm welcome (I can hear you all clapping)……….
Some of my colleagues and I recently wrote an article about common therapist mistakes in exposure and response prevention (ERP) therapy for OCD. I wanted to highlight one of the sections of that paper that may be helpful to individuals whose compulsions are primarily mental. Mental compulsions typically involve words, phrases, prayers, and so forth that the person says silently in order to prevent a feared outcome, or to reduce the anxiety that the obsession causes (see full article for a list of common mental compulsions). For example, a person might have religious obsessions and may fear that her children will become sick if she has blasphemous thoughts. In response to any blasphemous thoughts or images that come to mind she will repeat to herself a memorized prayer about the greatness of God with requests for protection for her children.
The first step in treating OCD that involves primarily mental rituals is to recognize the familiar cycle of obsessions and compulsions. Just like with observable rituals, mental rituals maintain OCD by providing temporary relief from the OCD-related distress. Some clinicians may fail to identify covert/mental rituals, and people with OCD similarly may have a hard time distinguishing between an obsession and a mental compulsion. When thoughts are coming quickly one after another, some causing distress and some intended to relieve that distress, it can feel like a jumbled mess and the compulsions can be hard to identify. For this reason OCD with mostly or only mental rituals is often mistakenly labeled “Pure Obsessional” (or “Pure-O”) OCD.
The way to tell a mental compulsion from an obsessive thought is to ask what the function of the mental act is: Obsessions increase anxiety whereas mental compulsions are intended to decrease anxiety.
Once a person knows what his or her mental rituals are, it is crucial that the person eliminate them in order to recover from OCD. During ERP the individual must avoid doing mental rituals during exposure—for example, saying ritualized mental prayers to neutralize the fear of harm that comes from doing the exposures. These kinds of private rituals undermine the exposures and can prevent the person from getting better.
As discussed on an earlier post, ERP for mental rituals requires one to do the opposite of the rituals and allow oneself to have the distressing thoughts like “I’m a devil worshiper,” without any mental rituals to counteract these thoughts. Easier said than done! A lot of the difficulty, of course, comes from the almost automatic nature of the mental rituals; people with OCD often say they do a mental ritual even when they’re trying not to. For this reason the ERP therapist and person with OCD will need to work closely and creatively together to find ways to block the mental rituals. One solution is for the person with OCD to read out loud material that provokes obsessions (either in vivo or imaginal exposure—see sections 3 and 6 of the article for descriptions of these two techniques) so that the mind is not free to perform mental compulsions. It can also be helpful to say exposure statements to prevent mental compulsions, such as saying “I’m friends with the devil” instead of engaging in a ritualized prayer. Exposure statements should also be used if the person realizes he or she performed a mental ritual—what is often called “spoiling” the ritual.
A final point that we highlight in the article is that it’s usually counterproductive to tell oneself “that’s just my OCD” and similar statements when experiencing an obsession. These kinds of statements play OCD’s game of looking for certainty and trying to find a short-term fix to make obsessions less upsetting. As such, these responses to obsessions often become a ritual, another way to neutralize the anxiety and uncertainty that the obsessions cause. A more effective long-term solution is to answer obsessions with exposure statements that recognize uncertainty: “Maybe I did sell my soul to the devil”; “God might punish me for having that thought.” While I’ve focused here on religious obsessions as an example, these principles apply to any obsessional content.
The bottom line of this discussion is that, contrary to what some people with OCD believe or have heard, ERP can successfully address mental rituals. Armed with knowledge about how to recognize mental compulsions, determination to conquer them, and often with the help of a skilled therapist, individuals with mental compulsions can live more enjoyable and fulfilling lives.
Questions or comments? Please post them here or contact me by email.
Thank you, Dr. Gillihan!
As I’ve mentioned before, and most of us already know, our minds have minds of their own. All kinds of thoughts run through them on a daily basis: some happy, some distressing, some weird, some comical. So many thoughts over which we have no control. Some hang around longer than we’d like, while others are fleeting. Most of us filter out the thoughts that are necessary and important at any given time, and pay little to no attention to the rest. But for those with obsessive-compulsive disorder, it is rarely this simple.
OCD is complicated, and many different elements may contribute to the development of the disorder. One of these factors is a process known as thought-action fusion. This is when a person believes that thinking bad or distressing thoughts is just as terrible as performing the action associated with the thought. So say a thought pops into your head that involves physically hurting somebody you care about. Those who deal with thought-action fusion believe that thinking this thought is just as horrible as following through with it. Imagine how terrifying this can be (not to mention what it does to the sufferer’s self-esteem).
Additionally, thought-action fusion can also include the belief that thinking these terrible thoughts can somehow make them come true. So if you believe that thinking about harming a loved one can actually cause this harm to happen, what would you do? Most of us would try as hard as we could not to think this awful thought. And, given that our minds have minds of their own, the more we try not to think of something, the more we can’t stop thinking about it. It’s not hard to see how this process is conducive to the development of obsessions.
Even though I don’t have OCD, I can sometimes personally relate to different aspects of the disorder, to a point. In terms of thought-action fusion, I realize that I have, on occasion, been superstitious about thinking certain negative thoughts. Stop thinking that; it might come true. I don’t really believe my thoughts can control what happens, yet I find myself trying to stop these thoughts anyway. It’s no different from feeling you might “jinx” something by thinking or talking about it.
Once again we see that the thoughts and behaviors of those with OCD are often no different from those who do not have the disorder. It is the severity that sets them apart. For those who suffer from thought-action fusion that feeds their obsessive-compulsive disorder, cognitive behavioral therapy with a competent therapist can help. And once this cognitive distortion is conquered, there will be a little less fuel to feed the fire of OCD.