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«Innovations in CBT for Treatment Resistant OCD and BDD James M. Claiborn Ph.D. ABPP ACT Riverview Psychiatric Center Augusta Maine Characteristics of ...»

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Innovations in CBT for Treatment

Resistant OCD and BDD

James M. Claiborn Ph.D. ABPP ACT

Riverview Psychiatric Center

Augusta Maine

Characteristics of Individuals with

Treatment Resistant OCD and


Little or no response to standard treatment.

Frequently described as having over-valued

ideas or as delusional.

Likely to refuse to engage in exposure based


Their obsessions are generally seen as realistic

and compulsions seen as reasonable efforts.

Over-Valued Ideas Generally seen as poor prognostic indicators ● Assumed to be more resistant to change ● Commonly seen in BDD and in OCD with poor ● insight or in forms of OCD seen as most treatment resistant such as hoarding Definitions DSM defines an over-valued idea as ● An unreasonable and sustained belief that is maintained with less than delusional intensity The person is able to acknowledge the possibility that the belief may or may not be true The belief is not one that is ordinarily accepted by other members of the persons subculture Most sources use this as shorthand for poor insight and place it on a continuum with delusional certainty Definitions DSM defines a delusion as a false belief based ● on incorrect inference about external reality that is firmly sustained despite what almost everyone else believes and despite what constitutes incontrovertible and obvious proof or evidence to the contrary.

The difference between over-valued ideas and ● delusions is based on how firmly the belief is held Delusions?

Delusions are actually held with varying degrees ● of conviction which may fluctuate over time and are not “fixed” The definition from DSM does not accurately ● distinguish between delusions and over-valued ideas There is no qualitative distinction between ● beliefs we call delusions and other beliefs All differences are in degree ● Quality vs Quantity The standard definitions and traditional thinking ● about delusions holds that there is a qualitative difference between the thinking of people who have delusions and those who don't This distinction does not stand up to closer ● examination Normal Delusions?

A survey of 60,000 British adults found ● 50% believed in thought transference 25% believed in ghosts 25% believed in reincarnation Interview using the Peters Delusional Inventory ● 272 healthy adults 20 psychotic inpatients 10% of the healthy population scored above the mean for the deluded patients An Alternative Understanding

• The individual patient (and everyone else in the world) is attempting to make sense of their own experience. It is likely that they hear the voice and try to explain why they hear the voice. They may come up with an explanation that we think is strange but it makes sense to them.

Ideas of Reference Ideas of reference include the thought that others ● are talking about the individual and it is only a small step to the belief that they know what others are thinking about the them** Ideas of reference are typically described as a ● psychotic feature or a form of delusional belief They are extremely common in people with ●

–  –  –

Schizotypal personality disorder is a predictor of ● poor treatment response (Jenike et al) This personality disorder or trait includes ● aberrant perceptions and beliefs Schizotypal patients may simply have what we ● would otherwise describe as delusions or overvalued ideas that impact compliance with treatment or interfere with belief change as a component of therapy** Thought Action Fusion Thought action fusion can occur in moral or ●

–  –  –

Causal thought action fusion is the belief that thinking about possible events changes their probability If I think of something that can go wrong it is more likely ●

–  –  –

Delusions are present in ¾ of people diagnosed ● with schizophrenia, ½ of people with BDD and an unknown percentage of people with OCD.

They also appear in an estimated 5-10% of the ● general population.

Individuals who develop such beliefs appear to ● jump to conclusions based on minimal evidence and ignore contradictory information.

Hallucinations Hallucinations are defined as a sensory ● experience that doesn't correspond to an external environmental event Hallucinations are not listed in the diagnostic ● criteria for OCD or BDD While there is no good data, a substantial ● number of people with BDD report hearing others commenting on their appearance.

Is this a hallucinatory experience?

The Truth About Hallucinations Most people including most mental health ● professionals describe hallucinations as a sign of mental illness.

Because of this belief and the typical reaction to ● talking about hallucinations, patients often deny they experience them.

If hallucinations are acknowledged most mental ● health professionals believe discussion of them is contraindicated Hallucinations in the General Population

• The incidence of psychotic symptoms in the general population is about 100 times greater than the incidence of psychotic disorders

• The experience of hallucinations at one point in time is not a good predictor of later hallucinations

• Hanssen et al 2005 You Heard What?

• In a survey of 375 college students 71% reported some brief, occasional experiences of voices while awake.

• In another study of 586 college students 30reported hearing voices, and almost ½ reported it happened at least once a month

• Reports of hallucinations were not related to measures of psychopathology Explanation of Hallucinations Functional brain imaging data shows speech areas ● of the brain are active when people are having auditory hallucinations.

EMG data supports the conclusion that people are ● sub-vocalizing when they hear voices.

The content is essentially the same as typical ● intrusive thoughts.

Hallucinations may be explained as sub-vocalized ● intrusive thoughts which are misperceived as being from an external source.

Medical Model and Tradition The medical model and traditional way of ● understanding hallucinations and delusions


That they are the result of brain dysfunction or disease That these experiences are qualitatively different from “ normal” experience That it is futile or perhaps even harmful to engage in discussion of them That it is best to explain that they are the result of the patients illness Effects of Confrontation To some extent the caution about discussing ● delusions is supported by the fact that confronting them is most likely to lead to strengthening conviction.

Arguing with the patient that their beliefs are ● false or that what they experience is not real will not only not convince them it will probably be experienced as invalidating and damage the therapy relationship.

The European Model of OverValued Ideas Most American sources seem to use intensity of ● conviction as the defining variable.

The European model includes the idea that over ●

valued ideas are characterized by:

preoccupation, being more ego syntonic, development is comprehensible, and associated with a high degree of affect??

Application of these Distinctions If we view the distinctions suggested in the ● European model and allow for the fact that delusions are not held with absolute conviction it may suggest that we can understand beliefs as falling on several continua and that this more complex model can lead to implications for interventions.

Where do Delusions Come From?

Beliefs arise from a search for meaning.

● Delusional beliefs may arise from attempts to ● explain experiences that are anomalous and which are emotionally important.

They arise as a result of an attempt to find ● meaning and are influenced by both environment and preexisting beliefs.

Personal Importance Principle Obsessions attach to concerns that are of central ● importance to the individual. For example the patient who holds strong religious beliefs is most bothered by intrusive thoughts that conflict with religious values.

Similarly?? delusions attach to central concepts ● about beliefs about the self and the world.

Why do Delusions Persist?

Obsessions seem to persist because people avoid ● situations which could produce disconfirming information and compulsions produce negative reinforcement which strengthens the belief in the obsession.

In delusional beliefs the same mechanisms are in ● place. Compulsions and other safety behaviors prevent disconfirmation Why Treatment Resistance Over valued ideas and delusions are more ● resistant to treatment in part because they tend to be held with greater conviction but in addition they may have a stronger affective component.

This stronger affective component means that ● addressing them at all is likely to be perceived as threatening.

Due to being more ego syntonic conflicting ● arguments are more likely to be experienced as personal attacks.

Hallucinations and Treatment Resistance In effect the problem with hallucinations is not ● the presence but the reaction to them.

In BDD the reported hallucinations are often ● confirming of the beliefs about appearance and others reaction to it.

If the mental health professional is seen as not ● believing in the experience it is another event that can be interpreted as attacking or demeaning to the patient.

Discussion of Beliefs in Therapy Since most people with OCD will admit their ● beliefs or fears are exaggerated or irrational they are more likely to be willing to discuss or question them or consider a therapy task that would test them.

More centrally held beliefs are more likely to be ● “OFF LIMITS” and an attempt to question or test them is likely to be threatening to the individual.

What does Cognitive Therapy Offer?

The traditional view is that delusional patients ● need to be treated with medication.

In fact approximately 60% of patients will still ● have psychotic symptoms when fully compliant with medication.

A body of evidence has been accumulated that ● cognitive behavioral therapy produces a clinically important benefit in otherwise drug resistant psychotic patients.

Engagement in Therapy When the patient is able to question the beliefs ● or meaning of experiences it is easier to engage in a collaborative therapy approach.

Both parties can engage in an effort to reduce ● dysfunction and distress beginning with a shared conceptualization of the problem.

In working with a delusional patient this ● engagement is impeded.

Enhancing Engagement Early establishment of goals ● Sharing of the cognitive model ●

Therapist presentation:

● Knowledgeable, Trustworthy, Likable, Confident Expectations for therapy ● Therapists work hard and patients get better vs.

Patients work hard and therapists get better Patience ● Can You Tell Me About Them?

• If we inquire in an empathetic way the patient may be able to describe the experience with voices.

• This includes many characteristics – Number, Identity, Social position, Gender, Volume, Power, Knowledge, Occurrence, Content, Beliefs about origin and mechanism An Alternative Understanding

• The individual patient (and everyone else in the world) is attempting to make sense of their own experience. It is likely that they hear the voice and try to explain why they hear the voice. They may come up with an explanation that we think is strange but it makes sense to them.

What is it Like

• If given a chance and an accepting response many people with voices will describe their experience. We tend to shut this down when we respond to the presence as a symptom of an illness and an indication that more medication is all that is needed to take it away. Consider how you would feel if you reported an experience and others said that is just a sign you are sick. ??

The Message to Give Patients You are not crazy, the problems you have are ● understandable.

Either your concerns are real or you believe them ● to be real. (Both explain how you feel) How you interpret events affects how you feel.

● It is important to evaluate beliefs by testing them ● and this involves changing your behavior.

What you pay attention to and how you pay ●

–  –  –

Engaging the patient in the collaborative ● production of an explanatory normalizing rationale /model of symptom emergence is the first crucial step in developing a relationship with the patient (Kingdon and Turkington) How Can We Engage the Delusional Patient?

Empathy warmth and genuineness are central to ● building any therapeutic relationship but are especially critical with individuals with psychotic symptoms.

Word perfect accuracy contributes to avoiding ● invalidating experiences.

Instead of invalidating or denying delusional ● beliefs engage in evaluating them collaboratively by gathering evidence and developing alternative explanations.

More on Engagement Be willing to agree to disagree.

● When the patient is distressed it may be useful to ● engage in tactical withdrawal.

Allow the illogical or psychotic logic to flow ● over you. Eventually it becomes comprehensible Teach a cognitive model, emotional responses ● are the result of interpretation of events, not the events themselves. Events can include intrusive thoughts, images, obsessions or hallucinations.

Examining Antecedents It is important to look at events leading to ● development of symptoms in the context of how they could be interpreted to support the conclusions embedded in delusions or lead to experiences such as hallucinations in context so they may lead to development of alternative explanations.

Anna's Belief that She is Ugly When asked about evidence that she was ugly a ● BDD patient reported that her father had told her she was when she was a child.

This was seen as irrefutable evidence of a fact.

● A cognitive restructured alternative was that this ● was evidence only that her father said this not that it was a fact.

This alternative “clicked” and led to a dramatic ● shift in the patients self image.

What Can We Do?

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