Cognitive Behavioral Therapy

Cognitive Behavioral Interventions for Students with Obsessive‐ Compulsive Disorder National Association of School Psychologists Annual Conference, 2011 San Francisco, CA Douglas T. Jones, Michael L. Sulkowski, & Robert J. Wingfield

Introduction • Overview – Etiology – Associated Issues

• Cognitive Behavioral Therapy – Conceptualization – SUDs and Hierarchy

• Exposure and Response Prevention (ERP) – Treatment Practice – Treatment in schools

Overview

Obsessive Compulsive Disorder (OCD) •OCD is characterized by obsessions and/or compulsions that are significantly impairing and distressing • Functional impairment for more than 1 hr per day

American Psychiatric Association. (2000).

OCD Prevalence • 1-3% of U.S. Youth (McKay & Storch, 2009) o Child OCD – more than 1 in 100 o 4th most common psychiatric disorder in the United States (Leahy & Holland, 2000).

OCD Onset / Treatment • Usual onset in late teens or early twenties (Kessler, 2005 & Wewetzer et al., 2001). o 6-15 for males o 20-29 for females

• 80% of adults with OCD have childhood onset (Kessler, 2005). • Average total of 17 yrs

between onset of symptoms (age 14.5) and appropriate treatment (age 31.5)

OCD Etiology • Biological Model o Neurobiological abnormalities • PANDAS

• Cognitive Behavioral Model o Obsessive-Compulsive cycle • Behavioral conditioning • Cognitive distortions

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Obsessive Compulsive Disorder (OCD) • Obsessions: o Recurrent or persistent thoughts, impulses, or images seen as intrusive or inappropriate that cause marked anxiety/distress o Not simply excessive worries o Attempts are made to suppress or neutralize obsessions


Obsessive Compulsive Disorder (OCD) • Compulsions: o Repetitive behaviors or mental acts driven to perform in response to obsession, or according to rules rigidly applied o Behaviors or mental acts are aimed at preventing or reducing distress or preventing dreaded event or situation


The Obsessive-Compulsive Cycle Obsessions

Fear/Anxiety

Reduction in Distress

Compulsions Negative Reinforcement

(Piacentini et al, 2006)

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Ritual Cycle The OCD Trap 10 9 8

SUD's

7 6 5 4 3 2 1 0 1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

Time

SUDS = Subjective Units of Distress (0-10) 11

Common OCD Symptom Patterns • Contamination and cleaning (hand washing) • Self doubt and checking, re-writing, repeating, hoarding • Organizing / need for symmetry • Scrupulosity (religious obsessions) • Aggressive obsessions (fear of harming others)

Signs of OCD in Children • Contamination Behaviors o o o o

Frequent cleaning/hand washing (red, chapped hands) Long frequent trips to the bathroom. Avoidance of the playground, art supplies, sticky substances. Untied shoe laces (may be contaminated)

• Checking and redoing activities/behaviors o Compulsively going over letters and numbers with pencil. o Taking excessive time to perform tasks. o Rereading and rewriting, and frequent erasing.

Signs of OCD in Children (Cont.) • Reassurance Seeking o Am I okay, is this right?

o Asking frequent questions when the answer is already evident.

• Anxiety and Avoidance o o o o

Withdrawal from usual activities or friends. Excessive fear of bad things happening to self or others. Excessive fears of making mistakes. Persistent lateness.

• Counting and Organizing

Associated Issues o Academic Difficulties • Work completion issues o Disruptive Disorders • ADHD • ODD o Depression and Anxiety Disorders • Generalized Anxiety • Trichotillomania

Vignettes • Mary o Obsessions – Perfectionistic, Not-good-enough worries o Compulsions – Checking, Studying, Re-writing

• Joey o Obsessions – Just right feeling o Compulsions – Touching others, Pulling threads

• John o Obsessions – Contamination, sexuality o Compulsions – Cleaning, avoidance

COGNITIVE BEHAVIORAL THERAPY

Early Psychological Treatments: The “T” in CBT • OCD once was thought to be resistant to psychological treatment o Traditional treatments even could worsen symptoms (Christensen, Hadzi-Pavlovic, Andrews, & Mattick, 1987) • Can increase doubting symptoms and accommodate rituals o Traditional behavioral treatments also proved ineffective (e.g., thought stopping, relaxation training; McKay, Storch, Nelson, Morales, & Moretz, 2009).

The “B” in CBT • E/RP breaks the association between specific stimuli, situations, or anxiety-provoking thoughts and reliance on anxiety reducing rituals (Foa, Abramowitz, Franklin, & Kozak, 1999) • The therapy has a biological basis o Facilitates habituation and may affect action in basolateral amygdala, hippocampus, and the medial prefrontal cortex (Quirk & Mueller, 2007)

The “C” in CBT • Highlight the role of dysfunctional beliefs and interpretations that sustain rituals o More appropriate and applicable to treating adults

• Cognitive therapy must be done carefully o Can reinforce rituals or engender new ones

• Use CT to externalize OCD symptoms or motivate children o The OCD monster o Let’s try an experiment

Dysfunctional cognitions • Black and white/all or nothing thinking o “If it is not perfect, then it’s garbage.” • Magical thinking o “If I think a bad thought, then something bad will happen.” • Overestimation of risk o “If I even take the slightest chance, something bad will happen.” • Hypermoraity o “Ill go to hell if . . .”

Dysfunctional cognitions Thought/action fusion (similar to magical thinking) o “If I have the bad thought, it will happen.” • Overimportance of thought o “I cannot have bad thoughts—I must have a pure mind.” • “What if” thinking o “In the future, what if I . . . Make a mistake? Get AIDS? Hurt someone? • Intolerance of uncertainty o “I cannot relax unless I am 100% certain that I will be okay, safe, certain. • The martyr complex o “I choose to . . . To prevent . . . “ •

CBT For Pediatric OCD • Pioneered by Dr. John March (March & Mulle, 1998) o Must consider developmental and cognitive level o Should include family members/caregivers • Collaborative efforts between the child, caregivers, and child o Should appeal to children and be fun • Incorporate elements of play into therapy

Efficacy of CBT for Pediatric OCD • Generally large effects sizes across studies of randomized and non-randomized trials of CBT in youth (Watson & Rees, 2008) o Effect sizes range from 0.95 to 2.56

• These results are similar to those found in adult OCD treatment studies (Abramowitz, 1998)

CBT for Pediatric OCD • Assessment • Psychoeducation • Socialization to treatment o For child and family

• • • •

Development of an OCD symptoms hierarchy Engage in exposures and active treatment Conclude treatment Offer booster sessions as needed

Assessment • Omnibus behavior screeners o BASC-2, CBCL

• Single construct measures o BAI, RCMAS-2,

• Structured/semi-structured interviews • OCD specific measures o OIC-R, FOCI o CY-BOCS (the “gold standard”)

Psychoeducation • Provide information on OCD to children and caregivers o o o o

Prevalence Course of the disorder Impact on families Nature of symptoms

• Describe CBT o Treatment components o Efficacy of the treatment, especially for OCD o Typical number of sessions, length of sessions

Socialization to Treatment • Emphasize that exposures will be gradual • May need to motivate some youth o Be dispassionate and firm o Motivational interviewing techniques

• Exposure intensity corresponds with positive treatment outcomes • The therapist should establish rapport o Convey warmth, optimism, confidence, and even a playful attitude

• Get parents/caregivers on board

Development of a Symptoms Hierarchy • Day 1 or 2 (the easiest part of treatment) • Work with child to develop a list of feared stimuli or situations • Write down everything and ask clarifying questions • Rank order items on a scale (1 – 10; 1 – 100) • “Everything is a 10!” • “Nothing scares me” • Use of anchor points and contrasts

OCD Hierarchy SUDS Level 99 95 90 85 60 60 60 60 60 55 50 30 30

Touching an unknown sticky substance, without washing Holding loose hair Touching known sticky substances (e.g. egg), without washing Touching unknown trash articles Using a public restroom Witnessing a political argument Witnessing other sensitive-subject arguments (i.e. religion) Seeing parents spend a lot of money at one time Touching loose hair with finger Touching known sticky substance (e.g. syrup),without washing Touching a known sticky substance (e.g. soda), without washing Touching a dirty railing Walking into a public bathroom 30

Ranking Your Own Fears • Work with a partner to rank order your fears • List fears and corresponding thoughts o (e.g., spiders, death, heights, elevators)

• Come up with a list of ways to engender these fears (exposures) o (e.g., licking a doorknob, leaving the house unlocked when nobody is home)

Exposure and Response Prevention


CBT with exposure and response prevention (ERP) is the best established psychological treatment for OCD.

Gold standard (DeRubeis & Crits-Christoph, 1998). 63% to 83% of participants obtained some benefit, many long term after ERP (Abramowitz, 1997; Foa & Kozak, 1996; Stanley & Turner, 1995).

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How does it work?

E/RP breaks the association between specific stimuli, situations, or anxiety-provoking thoughts and reliance on anxiety reducing rituals (Foa, Abramowitz, Franklin, & Kozak, 1999) The therapy has a biological basis. Facilitates habituation and may affect action in basolateral amygdala, hippocampus, and the medial prefrontal cortex (Quirk & Mueller, 2007) 34

Informal progress monitoring strategies • Subjective units of distress (SUDs) o Thumbnail judgments of distress o Can be taken any time during therapy o Children can monitor and document their own SUDs

ERP Exposure (in vivo) Children are gradually exposed to anxiety-provoking stimuli…

Prevention While refraining (or prevented) from engaging in anxiety-reductive compulsive behaviors.

Exposure (imaginal) Children expose themselves to feared thoughts through scripting. Scripting: written in the first person containing sufficient detail to evoke an anxiety response; usually 3to5 minutes long Verbalizing: repeatedly read the script aloud until the anxiety decreases or record the scenario on an audiotape and repeatedly listen to the tape. Focus is getting used to one’s thoughts

ERP Exposure Practice Predictability and Control: combination of allowing client as much control and predictability as possible while continuing to push and challenge is the best strategy. Distraction: Encourage as much focus on the feared stimulus during exposure as possible.

Length of Exposures: Outcomes studies indicate exposure sessions generally range from 30 to 120 minutes. Longer sessions were correlated with larger effect sizes on measures of OCD symptoms Thus, 90 to 120 minute sessions may be the most useful length of session.

ERP Troubleshooting: Motivational Issues: level of readiness to change significantly predict treatment attrition (Wilson, Bell-Dolan, & Beitman, 1997) Encourage child to voice reasons for change, explore future costs and benefits of change Reassurance Seeking: Therapist and family must refrain from answering questions during exposures if the answer may provide reassurance. Reassurance seeking is another form of a compulsion.

How ERP Works 100 90 80 70 60 50 40 30

1st Trial 2nd Trial 3rd Trial 4th Trial 5th Trial

20 10 0

O ns et 5m in 10 m in 15 m in 20 m in 25 m in 30 m in 35 m in 40 m in

S U D S

Storch, 2006

School Psychologists’ Reports on OCD • Sloman et al. (2007) o 89.8% of respondents had experience with at least one OCD case. o 82.4% reported that they were “much or very much” influenced by evidence based treatments AND o 89.5% of participants adhered to a cognitive behavioral theoretical orientation AND o 81% reported that they were “much or very much” inclined to implement CBT as a choice of treatment.

• Results o Only 7.1% reported using exposure based elements “much or very much” in the treatment of OCD. o Nearly half (46%) stated that there was “minimal to no change” in outcome. (Storch , 2006)

What can school psychologists do in the school setting? • Help school personnel recognize that OCD is a neurobehavioral disorder that reflects abnormal information processing in the CNS and not “oppositional behavior.” • Help personnel view the child with OCD the same as child with diabetes or asthma • Refrain from punishing the student for situations or behaviors he or she has no control over (e.g., being tardy, absent, no attending to work) • Record changes in a child’s behavior (both negative and positive) that may be a result of medication and/or behavioral interventions.

What can school psychologists do in the school setting? • Allow breaks during testing • Extended time for homework and projects (only until child overcomes being “bossed around by OCD”) If misapplied this could reinforce OCD. • Monitor child to ensure he or she isn’t using OCD as an excuse to avoid academic demands • Students with OCD are generally eligible for 504 Plans (Marche and Mulle, 1998)

Exposure and Response Prevention Activity

• Part One - Imaginal Scripting – Using your hierarchy formed in the previous activity create an imaginal script or exposure for a distressing item (SUDS around 7 or 8). – Examples – Funeral of a loved one – Skydiving

Exposure and Response Prevention Activity • Part Two - En Vivo ERP Form into groups of three – be the therapist / student Take turns leading one another through your exposure Monitor SUDs level! Do not flood – Do not go above a 5 or 6… – Proceed until SUDS level drops by half

o – – –

Questions • Email Contacts • [email protected]

References •

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

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Abramowitz, J. S. (1998). Does cognitive-behavioral therapy cure obsessive-compulsive disorder? A meta-analytic evaluation of clinical significance. Behavior Therapy, 29, 339-335

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Abramowitz, J. S., Whiteside, S. P., & Deacon, B. J. (2005). The effectiveness of treatment for pediatric obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 36, 55-63.

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Arnold, L. M., Auchenbach, M. B., & McElroy, S. L. (2001). Psychogenic excoriation. clinical features, proposed diagnostic criteria, epidemiology and approaches to treatment. CNS Drugs, 15, 351-359.

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Barkley, R. A., & Mash, E. J. (2003). Child psychopathology (2nd ed.). New York: Gilford Press.

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Barsky, A. J., & Ahern, D. K. (2004). Cognitive behavior therapy for hypochondriasis: A randomized controlled trial. Journal of the American Medical Association, 291, 1464-1470.

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Chambless, D. L., Baker, M. J., Baucom, D. H., Beutler, L. E., Calhoun, K. S., Crits-Christoph, P., et al. (1998). Update on empirically validated therapies, II. The Clinical Psychologist, 51, 3-16.

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Christensen H., Hadzi-Pavlovic D., Andrews G., & Mattick R. (1987). Behavior therapy and tricyclic medication in the treatment of obsessive-compulsive disorder: A quantitative review. Journal of Consulting and Clinical Psychology, 55, 701-711.

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Cororve, M. B., & Gleaves, D. H. (2001). Body dysmorphic disorder: A review of conceptualizations, assessment, and treatment strategies. Clinical Psychology Review, 21, 949-970.

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Deckersbach, T., Wilhelm, S., & Keuthen, N. (2003). Self-injurious skin picking: Clinical characteristics, assessment methods, and treatment modalities. Brief Treatment and Crisis Intervention, 3, 249-260.

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DeRubeis, R. J., & Crits-Christoph, P. (1998). Empirically supported individual and group psychological treatments for adult mental disorders. Journal of Consulting and Clinical Psychology, 66, 37-52.

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Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R. Kichic, R. Hajcak, G., et al., (2002). The Obsessive–Compulsive Inventory: development and validation of a short version. Psychological Assessment, 14, 485–496. Foa, E. B., & Kozak, M. J. (1996). Psychological treatment for obsessivecompulsive disorder. In M. R. Mavissakalian & R. F. Prien (Eds.), Long-term treatments of anxiety disorders (pp. 285–309). Washington, DC: American Psychiatric Press.

References •

Hyman, B. M., & Pedrick, C. (1999). The OCD workbook: Your guide to breaking free from obsessive-compulsive disorder. Oakland, CA, US: New Harbinger Publications.

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Kessler, R. C., Berglund, P., Demler, O., Jin, R., & Walters, E. E. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62, 593-602.

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Leahy, R. L., & Holland, S. J. (2000). Treatment plans and interventions for depression and anxiety disorders. New York: Guilford.

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Foa, E. B., Abramowitz, J. S., Franklin, M. E., & Kozak, M. J. (1999). Feared consequences, fixity of belief, and treatment outcome in patients with obsessive–compulsive disorder. Behavior Therapy, 30, 717–724.

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March, J. S., & Mulle, K. (1998). OCD in Children and Adolescents. New York: Guilford.

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McKay, D. (1999). Two-year follow-up of behavioral treatment and maintenance for body dysmorphic disorder. Behavior Modification, 23, 620-632.

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McKay, D. & Storch, E.A. Eds. (2009). Cognitive-behavior therapy for children: treating complex and refractory cases. Springer, New York.

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McKay, D., Storch, E. A., Nelson, B., Morales, M., & Moretz, M. W. (2009). Obsessive-compulsive disorder in children and adolescents: Treating difficult cases. In D. McKay & E. A. Storch (Eds.), Cognitive-behavior therapy for children and adolescents: Treating difficult cases (pp. 81–114). New York: Springer.

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Pence, S. L., Jr., Sulkowski, M. L., Jordan, C., & Storch, E. A. (2010). When exposures go wrong: trouble-shooting guidelines for managing difficult scenarios that arise in exposure-based treatment for obsessive–compulsive disorder. American Journal of Psychotherapy.

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Piacentini, J., March, J., & Franklin, M. (2006). Cognitive–behavioral therapy for youth with obsessive−compulsive disorder. In P. C. Kendall (Ed.), Child and adolescent therapy: Cognitive–behavioral procedures (3rd ed., (pp. 297–321). New York: Guilford Press.

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Quirk, G. J., & Mueller, D. (2007). Neural Mechanisms of Extinction Learning and Retrieval. Neuropsychopharmacology, 33, 56-72.

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