Treatment of Anxiety and OCD- Robert Bond, Ph.D & Erin McGinty, LPC

Preferred Provider ConferenceTreatment of Obsessive-Compulsive Symptoms

April 28. 2012

Robert W. Bond, Jr., Ph.D.,Anxiety Therapist

& Erin McGinty, LPC, NCC

Program Director, Anxiety Services Coordinator, and Primary TherapistCastlewood Treatment Center for Eating Disorders

800 Holland Road636-386-6611, ext. 103www.castlewoodtc.com

Prevalence of Co-Occurring Anxiety Disorders with Eating Disorders

Kaye et al. (2004) studied the co-morbidity of anxiety disorders in an eating disorder sample, and found the following:

• Two-thirds of the subjects had one or more lifetime anxiety disorder

• A majority of the subjects reported that their anxiety disorders preceded the onset of the eating disorder

• The most common anxiety diagnoses were obsessive-compulsive disorder (OCD; 41%) and social phobia (20%)

Effects of a Co-Morbid Anxiety Disorder on Eating Disorder Symptomology

Clients with co-morbidity experience both a longer length of stay and an exacerbation of eating disorder symptoms such as:

• Baseline anxiety higher

• Perfectionism

• Obsessionality

• Harm avoidance, including:

– Higher degrees of worry, or anticipatory anxiety

– Higher degrees of intolerance of uncertainty

– Higher degrees of fatigue

– Higher degrees of pessimism

• Body image dissatisfaction

• Higher scores on depression inventories

The Importance of Treating Co-Morbid Anxiety Disorders (Steinglass et al., 2010)

• “Studies report that individuals with anorexia nervosa endorse significantly higher levels of anxiety than healthy controls both while underweight and after weight restoration”

• Trait anxiety has been identified as a differentiating factor between patients who remitted from anorexia nervosa– Trait anxiety as measured by the State-Trait Anxiety Inventory (STAI;

Speilberger)

• Symptom substitution

Elements of Clinical Anxiety

Fear Cues: Stimuli and situations that elicit anxiety

Maladaptive Beliefs: Exaggerated estimates of threat• Catastrophizing

• Probability Overestimation

Safety Behaviors: “Actions intended to detect, avoid, or escape a negative or feared outcome” (Abramowitz, 2011)


Safety Behaviors (continued; Abramowitz, 2011)

• Passive avoidance

• Checking and reassurance seeking• Checking locks, doors, outlets

• Information seeking

• Reassurance seeking

• Visual checking

• Compulsive rituals• Handwashing

• Repetition of standing up, sitting down

• Praying


Safety Behaviors (continued; Abramowitz, 2011)

• Brief, covert (mini) rituals

• Safety signals• Cell phone when leaving house

• Anti-anxiety medication

• Keys

• “Safe” person

Eating Disorders as Obsessive-Compulsive Spectrum Disorders

Fear Cue:“Fear of fat” (Steinglass et al., 2010)

Maladaptive Beliefs: Irrational thoughts regarding food, weight, and shape; overestimation of the likelihood and consequences associated with the threat

Safety Behaviors: Passive avoidance, body checking, restriction, purging, compulsive exercise, calorie counting, food rituals

The Application of Anxiety Treatments to Eating Disorders

Outcome studies suggest that Exposure and Response Prevention Therapy (ERP) is an effective form of treatment for co-morbid eating and anxiety disorders:

“Results indicate that CBT with a primary focus on ERP is a successful treatment approach for treating persons with both obsessive-compulsive disorder and an eating disorder. Significant changes in the severity of obsessive-compulsive symptoms, depressive symptoms, and eating disorder symptoms were noted (Adams, Riemann, Weltzin, & McGinty, 2007).”

Anxiety Services at Castlewood

• Anxiety Consults

• Individual Therapy

– Exposure and Response Prevention Therapy (ERP)

– Functional assessment

• Group Therapy

– Social Anxiety Group

– Improvisation Group

– Anxiety Management Group

– Awareness Cultivation Group

• Public Exposure

– Meal, snack, body image, and other exposures

Development of Exposure and Response Prevention

• Mowrer’s (1960) Two-Factor Model– Sign and Solution learning.

• Stage 1: Fear becomes a conditioned response to neutral stimulus

• Stage 2: Behavioral solutions sought to reduce the fear.– By removing the anxiety, the safety behavior becomes negatively

reinforced.

– Probability that the safety behavior will be used again increases.

– Fear is maintained by safety behaviors that prevent the natural extinction of the fear.

– ERP seeks to break the conditioned fear response and extinguish the reinforcing safety behaviors.

Exposure and Response Prevention Therapy

• Exposure Therapy– Deliberately evokes anxiety by bringing

individuals into direct contact with feared stimuli – including thoughts.

• Response Prevention– Purports to eliminate safety behaviors by

purposely prolonging exposure and anxiety while requiring individuals to refrain from using safety behaviors.

Exposure and Response Prevention TherapyExposure• Graduated, repetitive, and consistent exposure to situations and thoughts

that provoke anxiety and distress– Situational/In vivo exposure

– Imaginal exposure

– Or combination

• While performing the exposure, the client imagines the feared consequence(s) of the exposure

• The client remains exposed to the cue until the associated anxiety decreases

• Goal is to achieve habituation, or the decrease in anxiety due only to the passing of time– Within-trial habituation

– Between-trial habituation



Response Prevention

• Refraining from behaviors that are meant to reduce anxiety– Behavioral rituals

– Mental rituals

– Avoidance

• Clients learn that feared consequences of exposure are irrational

Example: Eat a feared food such as potato chips (exposuree), no purging/binging/exercise/restriction (response prevention).

Effectiveness of Exposure and Response Prevention Therapy

• Randomized control trials– (see De Haan, Hoogduin, Buitelaar, & Keijsers, 1998; Fisher

& Wells, 2005; Hodgson, Rachman, & Marks, 1972; Kozak, Liebowitz, & Foa, 2000; Marks, Hodgson, & Rachman, 1975; Rachman et al., 1979; Rachman, Hodgson, & Marks, 1971).

• Meta-analytic techniques– (see Abromowitz, 1996; Kobak, Greist, Jefferson, Katzelnick,

& Henk, 1998).• Nonrandomized samples

– (see Franklin, Abramowitz, Kozak, Levitt, & Foa, 2000; Rothbaum & Shahar, 2000).

Functional Assessment of Anxiety

“Because exposure therapy targets the patient’s specific fears, it is not enough to know that the individual has a diagnosis of (an anxiety disorder). Developing an effective exposure treatment plan requires the therapist to be cognizant of the particular situations and stimuli that trigger fears, the feared consequences of facing these fears, and the specific maladaptive strategies the individual uses to manage these fears” (Abramowitz, 2011).

Functional Assessment of AnxietyComponents of Functional Assessment of Anxiety (Abramowitz,

2011):

1. Problem list

2. Background and medical history

3. Historical course of the problem and significant events or circumstances– Personal and family history of anxiety

– Other events (e.g., media reports, illness outbreaks) that stand out as possible triggers of the current problem

4. Fear cues– External situations and stimuli

– Internal cues: body signs and sensations

– Intrusive thoughts, ideas, doubts, images, and memories


5. Feared consequences of exposure to fear cues– Overestimates of the likelihood and severity of danger

– Intolerance for uncertainty

– Beliefs about experiencing anxiety

6. Safety-seeking behaviors– Passive avoidance

– Checking and reassurance seeking

– Compulsive rituals and covert, mini- (or mental) rituals

– Safety signals

– Beliefs about the power of safety behaviors to prevent feared consequences


Feared Cues (Abramowitz, 2011):

What specific things are you afraid of? What situations do you avoid?

In what situations do you start to feel anxious or afraid? What are your triggers?

In what situations do you have to use safety behaviors, such as _____?

What bodily symptoms are you concerned with?

What happens to your body that makes you feel afraid?

What symptoms set off concerns about your health?


Feared Cues (Abramowitz, 2011):

What upsetting thoughts or memories do you have that trigger anxiety?

What thoughts do you try to avoid, resist, or dismiss?

What is it that triggers these thoughts (or memories)?

Tell me about the form of these thoughts. Are they images? Are they impulses to do something terrible?

What about these thoughts is scary for you?

What makes you feel that it is bad to have them?

What else can you tell me about the thoughts?


Feared Consequences (Abramowitz, 2011):

What is so frightening for you about wearing shorts?

What do you tell yourself if you experience the feeling of fullness?

What makes it so bad for you to gain weight?

What are you worried might happen if you allowed yourself to enjoy the taste of food?

What is the worst-case scenario that could happen if you reached your barrier weight?


Safety Behaviors (Abramowitz, 2011):

“When assessing safety behaviors it is important to understand not just the form or topography of the action, but the function or purpose of the behavior– that is, why the individual performs such behavior and in what situations it occurs.

In other words, what feared consequences does it prevent and how does the patient believe the safety behavior works?”



How do you avoid _____?

What do you avoid because of your fears of _____?

Do you check that (a feared consequence) will not happen or has not happened?

Do you ask other people for assurances that something bad will not happen?

Can you tell me exactly what you do when you do _____?

What gives you the feeling that you need to do _____? How do you know when to stop?

What might happen if you didn’t do _____?



How do you feel after you’ve done _____? What makes you feel that way?

How does _____ prevent your feared consequences from coming true?

What are you afraid will happen if you don’t do _____?

What makes you want to do _____? Why do you feel like it is necessary?

Do you perform any types of brief or subtle mental or observable actions to keep yourself safe?

Do you do anything else that has not been covered?

How well do these strategies work for you?


Safety Signals (Abramowitz, 2011):

Are there other things you do to protect yourself from (feared consequence)?

Are there any objects or people that make you feel comfortable or reduce your anxiety?

Do you carry anything with you to help you feel safe?

What precautions do you take so that you are prepared in case something terrible happens such as (specify the feared consequence)?

Implementing ERP at Castlewood

• The A to Z rule.

• Exposures are considered challenges by choice.

• Hierarchies are developed with clients using a 7-point Likert scale rating subjective units of distress.

Implementing ERP at CastlewoodANXIETY RATING SCALE

00 11 22 33 44 55 66 77

HAVE TO RESIST

TRY AS HARD AS POSSIBLE TO RESIST

CALM NO ANXIETY

NO URGES TO RITUALIZE AT

ALL

“It bothers me”

“Don’t want to do it but know it will be easier than I

think.”

A few urges to use safety behaviors.

Anxiety is bothersome, yet

manageable.

A little bit harder to resist urges but

can still do it.

Difficult to resist

urges.

“Wish I didn’t have to do it, but can do it. Glad when it’s over!”

Come close to

safety behaviors but can still

resist.

Challenging

Unsure if able to resist ritualizing.

Very hard to

resist urges to use safety behaviors.

Challenging

Extremely hard to resist urges to

use safety behaviors.

Start feeling symptoms of

panic.

Near panic

Panicking

Fear of dying.

EXAMPLE:

GOING TO THE DENTIST

A few weeks before appointment. Think about not wanting to

go, but no worries, really.

Dreading going. Really don’t want to,

but know it will be ok if I go.

Think about ‘faking being sick.’ Trying to make excuses. Go to it, but glad when it’s

over.

Can’t imagine making it through the

appointment. Think about leaving in the

middle of the appointment. Strong relief when I make it.

Don’t know if I can make it. Feel some

panic symptoms starting.

Refuse to go. Feeling panicky.

PANIC Fear of dying if I go.


• Hierarchies are not exhaustive but often contain 70 or more items.

• Hierarchies are always considered works in progress.

Exercise

1. Use public lotion.

2. Lay on bed wearing “contaminated” clothes.

3. Do not cover up body when sitting in community space.

4. Use toilet without barriers.

5. Cut meat into uneven pieces of varying sizes.

6. Do not make the bed.

7. Greet people and make eye contact.

8. Touch community keyboard.

9. Sit where “contaminated” peer sat.

10. Use colloquial expressions.

11. Go to group late.

12. Sit at the table in the “wrong” way.

13. Hold plastic bag that contains a “contaminated” bandage.

14. Walk flat footed in bathroom.

15. Hold sink faucet.

16. Put moisturizer on face with “contaminated” hands.

17. Put socks in shirt drawer with shirts.

18. Tell staff that you don’t like something they like.

19. Say 5 words in every single group.

20. Put butter on fingers without washing.

21. Shake the hands of staff.

INVIVO EXPOSURE HIERARCHY4

______(Anxiety Rating)


• Typically exposures are done incrementally by way of systematic desensitization.

• Ideally, clients work on exposures that have been rated a 3 or 4.

• Progression through the hierarchy depends largely upon habituation.

• In some cases, flooding is necessary.• However, a flooding hierarchy is typically

used to help with compliance.


• As often as possible, exposures are designed to fit into a client’s day.

• However, when this is not possible, clients are expected to complete the exposures during programming hours.

• As often as possible, exposures are assigned so that clients are frequently encountering the feared stimuli daily.

• Clients are asked to continue exposure until anxiety decreases by 50% or more.

• Clients are asked to record their work.

Implementing ERP at CastlewoodTrial # Date Time

Peak Anxiety Rating

Elapsed TimeFinal Anxiety

Rating

1 4/27/2012 15:30 4 6 minutes 2

2 4/27/2012 15:40 4 3 minutes 2

3 4/27/2012 15:50 3 5 minutes 1

4 4/27/2012 15:59 3 3 minutes 1

5 4/27/2012 16:03 2 2 minutes 1

6

7

8

9

10


• Banning safety behaviors– Bans represent the “response prevention” portion of ERP

and target the behaviors carried out to reduce anxiety.

• Why Ban behaviors?– May likely result in greater impairment and reinforce

symptoms (Calvocoressi et al., 1999; de Abreu Ramos-Cerqueira et al., 2008; Merlo et al., 2009; Peris et al., 2008; Steketee & Van Noppen, 2003; Stewart et al., 2008; Storch et al., 2007b; Storch et al., 2010a).

– May likely hinder treatment effectiveness (Amir et al., 2000).


• In order for the exposure exercises to be completely effective, it is important to reduce and eventually eliminate the safety behaviors.

• Ideally, the goal is to reduce these behaviors to 0 as soon as possible!

• “Re-contaminations”

• Ban Books– Submits and Resists

Ban Books

Treatment Resources

Anxiety Disorders Association of America

- www.adaa.org

International Obsessive Compulsive Disorders Foundation

- www.ocfoundation.org

Association for Behavioral and Cognitive Therapies

- www.abct.org

http://www.adaa.org/

http://www.ocfoundation.org/

http://www.abct.org/

Bibliotherapy Resources

Exposure and Response Prevention Therapy:

Abramowitz, J. S. (2011). Exposure therapy for anxiety: Principles and practice. New York, NY: Guilford Publications, Inc.

Abramowitz, J. S. (2006). Obsessive-compulsive disorder: Advances in psychotherapy- evidence based treatment. Cambridge, MA: Hogrefe Publishing.

Bibliotherapy ResourcesObsessive-Compulsive Disorder:

Abramowitz, J. S. (2009). Getting over OCD: A 10-step workbook for taking back your life. New York, NY: Guilford Publications, Inc.

Baer, L. (2001). The imp of the mind: Exploring the silent epidemic of obsessive bad thoughts. New York, NY: Penguin Putnam, Inc.

Gross, J. J. (2007). Handbook of Emotion Regulation. New York, NY: The Guilford Press.

Bibliotherapy Resources

Emotion Regulation:

Leahy, R. L. (2011). Emotion regulation in psychotherapy: A practitioner’s guide. New York, NY: The Guilford Press.

Rapoport, J. L. (1989). The boy who couldn’t stop washing: The experience and treatment of obsessive-compulsive disorder. New York, NY: Penguin Putnam, Inc.

Weg, A. H. (2011). OCD treatment through storytelling: A strategy for successful therapy. New York, NY: Oxford University Press.

Health & Medicine

Treatment of Anxiety and OCD- Robert Bond, Ph.D & Erin McGinty, LPC