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The paradox of thought control in OCD. Maureen L. Whittal, Ph.D. & Adam Chodkiewicz, M.D. December 4, 2003. ASSESSMENT OF OCD. Self-report measures Padua Inventory (Burns et al., 1996 Sanavio et al., 1988) Obsessive-Compulsive Inventory Revised (Foa et al., 2002)

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the paradox of thought control in ocd

The paradox of thought control in OCD

Maureen L. Whittal, Ph.D. &

Adam Chodkiewicz, M.D.

December 4, 2003

assessment of ocd
ASSESSMENT OF OCD

Self-report measures

  • Padua Inventory (Burns et al., 1996 Sanavio et al., 1988)
  • Obsessive-Compulsive Inventory Revised (Foa et al., 2002)
  • Obsessional Belief Questionnaire (OCCWG, 2002)
  • Interpretations of Intrusions Inventory (OCCWG, 2002)
  • Personal Significance Scale (Rachman)
obsessional belief questionnaire obq44
Obsessional Belief Questionnaire (OBQ44)
  • Responsibility and threat estimation (e.g., even when I’m careful, I often think that bad things will happen)
  • Perfectionism and certainty(e.g., it is essential for everything to be clearcut, even in minor matters)
  • Importance and control (e.g., having violent thoughts means I will lose control and become violent)
interpretations of intrusions inventory iii
Interpretations of Intrusions Inventory (III)
  • Control of thoughts(e.g., I should be able to rid my mind of this thought)
  • Importance of thoughts (e.g., Having this thought means I’m weird or abnormal)
  • Responsibility(e.g., I cannot take the risk that this thought will come true)
assessment of ocd5
ASSESSMENT OF OCD

Interviewer measures

  • Yale-Brown Obsessive Compulsive Scale (YBOCS; Goodman et al., 1989)
a cognitively based alternative to erp
A cognitively-based alternative to ERP
  • Rests on the cornerstone that 90+% of people experience intrusive thoughts
  • Interpretation of the intrusive thought is typically threatening (“I’m mad, bad, or dangerous”)
  • It’s the anxiety from the appraisal that promotes compulsive behaviour
cbt model for the maintenance of ocd
CBT model for the maintenance of OCD

Trigger

Leaving the house

Intrusive thought

On, open, or unplugged?

Appraisal

My fault if something

bad happens

Distress

Anxiety/fear

Compulsion

Checking

normalizing its
Normalizing ITs
  • Foundation of treatment
  • Use Os reported by a non-clinical sample
  • Survey
  • Within patient example
peeling back the layers of the onion
Peeling back the layers of the onion
  • Downward arrow
  • Method of successive questioning designed to uncover the central fear
  • Focus on the emotional and not the actual consequences
example of a downward arrow
Example of a downward arrow

If I couldn’t fix the mistake I would be responsible

If that were true, what would it mean to me?

I would go to jail

If that were true, what would it mean to me?

My family would discover that life is better without me

If that were true what would it mean to me?

Family would get on with other things and leave me

If that were true, what would it mean to me?

I’m a bad person

cognitive concepts in ocd
Cognitive concepts in OCD

Overimportance of thoughts

(a) having the thought means it’s important and it’s important because I think about it

(b) having the thought makes the outcome more likely

(c) having the thought and engaging in the action are the same morally

having the thought means it s important
Having the thought means it’s important
  • Circular reasoning (e.g., fresh fruit is in demand because it’s fresh and it’s fresh because it’s in demand)

thinking a thought is important

dwelling on it

verifies the importance

of the thought

further dwelling

challenging importance of thoughts
Challenging importance of thoughts
  • Behavioral experiment of alternating between letting thoughts ‘come and go’ vs. ‘fighting and dwelling’
  • patients record overall anxiety and frequency of ITs
  • patients predict results of experiment prior to beginning
  • treating thoughts like an out of tune radio
experiment
Experiment
  • Imagine/think about the most important person in your life

Write the following sentence:

thought action fusion taf
Thought action fusion (TAF)
  • Likelihood self - because I’ve had the thought it’s more likely to happen to me
  • likelihood others - because I’ve had the thought, it’s more likely to happen to others (e.g., MVA)
  • moral - the thought is as reprehensible as the action
challenging likelihood taf
Challenging likelihood TAF
  • Thought experiments - e.g., purposely having a negative thought about something bad happening to somebody yourself or something
  • ongoing list of ‘premonitions’ and their outcome
challenging moral taf
Challenging moral TAF
  • Continuum
  • normalization of ITs
  • List qualities of a good and bad person
  • Identification of a possible double standard
challenging the need for thought control
Challenging the needfor thought control
  • Set up an alternating days experiment where half of the days are “fight and dwell” and the other half are “come and go”
  • have patients make predictions ahead of time
the paradox of thought control
The paradox of thought control
  • The interaction between attention to thoughts and the frequency of thoughts
  • attention experiments
the need to control thoughts
The need tocontrol thoughts
  • The role of thought suppression and attention

Belief that I must be in

control of my thoughts

and emotions at all times

Experiences a normal

intrusive thought, but

appraises it as dangerous

Further attempts to

control thoughts

Efforts are made to fight,

control, suppress, distract,

or neutralize the thought

Not trying hard

enough to control

thoughts

Notices

more ITs

Increased vigilance

or attention

perfectionism
Perfectionism
  • Downward arrow may reveal compromised self-worth if less than perfect
  • Continuum of best/worst person and least/most perfect may help identify a double standard
  • List qualities of a good and bad person
inflated responsibility
Inflated responsibility
  • The belief that one has power which is pivotal to bring about or prevent subjectively crucial negative outcomes (actual or moral) (Salkovskis, 1996)
challenging responsibility with piecharting
Challenging responsibility with piecharting

Me 10%

Wife 5%

Toy makers

50%

Son 20%

Weather 10%

Playmate

5%

other challenges to responsibility
Other challenges to responsibility
  • responsibility transfers
  • going “off duty”
overestimations of danger
Overestimations of danger
  • Not unique to OCD
  • A cognitive reasoning bias?
challenging overestimations of danger
Challenging overestimations of danger

Step

Chance

Cumulative

chance

1.Not extinguish

1/10

cigarette

2.Spark falls on

1/10

the floor

3.Carpet catches

1/10

on fire

4.Carpet starts to

1/100

burn and I don’t

notice

5.Too late to help

1/100

1/10,000,000

the role of behavioral experiments
The role of behavioral experiments
  • Central but not sufficient
  • Function is to test alternate appraisals and not habituation as in ERP
  • Not as simple as ‘try it and see what happens’
intolerance of uncertainty
Intolerance of uncertainty
  • Not unique to OCD
  • May be a variant of perfectionism
challenging uncertainty
Challenging uncertainty
  • Surveys
  • Behavioral experiments
concealment
Concealment
  • Form of avoidance and serves to reinforce the appraisals
  • homework assignment to reveal thoughts to others
target and content of thoughts is not random
Target and content of thoughts is NOT random
  • Based on value system
  • person/situation that is the most important to the individual
  • intrusions become repetitive BECAUSE the person is sensitive, caring, etc.
pitfalls
Pitfalls
  • Arguing with the patient and/or trying to talk them out of their intrusive thought
  • Patients who use cognitive challenges as compulsive reassurance
  • Patients who can not identify appraisals
pitfalls continued
Pitfalls continued
  • Identifying feared consequences as appraisals
  • focussing on reducing threat (i.e., disconfirmation) and ignoring the perceived consequences

[risk = chance X consequence]

how well does it work
How well does it work?

Pre

Tx

Post

Tx

3

mth

ES @ 3

f/u

mth f/u

GCBT

21.9

16.1

17.3

.70

GERP

21.8

13.2

12.8

1.29

ICBT

23.5

10.3

9.3

2.22

IERP

21.7

10.4

10.6

1.26

subtype analyses
Subtype Analyses

YBOCS Score at post

Washers

n=41

Checkers

n=27

Obsessional

n=22