Checking in OCD

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Checking in OCD

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To understand why checking becomes a problem in OCD ... Johnny Depp - Oprah Winfrey - and lots more!!! What does this tell us? Some myths about anxiety ... – PowerPoint PPT presentation

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Title: Checking in OCD


1
Checking in OCD
  • Dr Alice Hooper
  • Chartered Clinical Psychologist
  • South London Maudsley NHS Trust
  • 22nd November 2008

2
Aims of Today
  • To understand why checking becomes a problem in
    OCD
  • To understand cognitive behavioural therapy
    techniques useful for checking
  • Audience participation!!!

3
  • What would you like to get out of this workshop?

4
Suggested Plan
  • Introduction / recap of OCD
  • Cognitive behavioural models of OCD
  • What keeps obsessive checking going
  • Recent developments elevated evidence
    requirements
  • Cognitive behavioural techniques useful for
    checking

5
What is OCD?
  • Obsessive-compulsive disorder is a psychological
    disorder that consists of obsessions and/or
    compulsions
  • For a diagnosis the obsessions and/or compulsions
    must take up over one hour per day and cause
    marked distress and/or cause significant
    interference with daily life

6
Obsessions
  • Persistent, unwanted and recurrent intrusive
    thoughts, images, urges or doubts that cause
    anxiety and distress.
  • 90 of people in the general population have
    intrusive thoughts and images
  • Difference in people with OCD is levels of
    intensity, frequency, duration and anxiety these
    instrusions cause.
  • Common themes of obsessions contamination,
    doubt, ordering, aggression, sexual imagery and
    religion.

7
Compulsions
  • Repetitive overt or covert actions that
    individuals feel compelled to do following an
    obsession
  • May be overt behaviours that other people can
    see, e.g. checking appliances, washing hands, or
    covert (people cant see), e.g. thinking positive
    thoughts or repeating phrases in ones mind

8
How Common is OCD?
  • About 1-2 of general population some studies
    estimate 2-3
  • 60 million people in the UK this could mean
    that at least 600,000 people with OCD in the UK
    alone
  • May be more some people sadly do not seek help
    partly due to stigma although this is decreasing
    as awareness and detection improves
  • Compulsive checking is the most common of all
    compulsions, closely followed by washing

9
Small Group Discussion
  • What do you check?
  • How often do you check?
  • How does checking help?
  • How does it affect your life?

10
CBT of OCD model
  • Paul Salkovskis (1985 1999) introduced a CBT
    model of OCD
  • People with OCD feel overly responsible for
    preventing harm
  • They also tend to overestimate the risk of harm
  • Therefore when they have intrusive thoughts, they
    feel compelled to act against them in order to
    prevent something bad from happening

11
CBT of OCD model
  • As 90 population also have intrusions, it is not
    the intrusion itself that is the problem
  • It is the interpretation of what the intrusion
    means that causes the problem

12
CBT of OCD model
  • In OCD, people use strategies to try and prevent
    something they fear from happening and so reduce
    their anxiety.
  • These strategies might include things like asking
    for reassurance, repeatedly checking the oven is
    off, trying to distract yourself by thinking
    about something else.

13
Safety nets
  • We call these strategies safety nets as they
    are designed to help individuals feel safe and to
    prevent perceived danger
  • Using safety nets is understandable and is often
    instinctive in certain situations

14
Small Group Discussion
  • What safety nets do you use?
  • How do they help what are the advantages?
  • Are there any disadvantages?

15
CBT Model What Causes OCD?
PREVIOUS EXPERIENCES (actual or
perceived) Problems caused by not taking enough
care Taught rules about responsibility
UNHELPFUL BELIEFS e.g. not preventing disaster
is as bad as making it happen Better safe than
sorry
16
Trigger
Activates Beliefs
Normal obsessions become focus of responsibility
Worrying thoughts about what obsessions mean
Compulsions to put things right
OCD
17
What if I dont have any obsessions?
  • Sometimes people find it difficult to identify
    their obsessions and it may feel as though they
    only have compulsions (checking).
  • Remember that obsessions can also be urges and
    not just thoughts.
  • It could also be that people have been checking
    for so long it becomes a habit and the original
    obsession is not clear.

18
Checking
  • Compulsive checking occurs when people who
    believe that they have a special, elevated
    responsibility for preventing harm feel unsure
    that a perceived threat has been adequately
    reduced or removed.
  • In their attempts to achieve certainty about the
    absence or the unlikelihood of harm occurring,
    people repeatedly check for safety.
  • Paradoxically, these attempts to check for safety
    can produce adverse effects that turn the
    checking behaviour into a self-perpetuating
    mechanism.
  • Jack Rachman (2002)

19
Examples of safety nets in checking
  • Overt repeatedly checking something is
    off/closed, staring at it to make sure, staying
    in the room for a long time to make sure there is
    no fire, asking people for reassurance, avoiding
    using the oven/taps
  • Covert mentally retracing your steps, repeating
    to yourself that is done it is off, trying to
    stop thinking about the oven
  • By proxy getting someone else to check it or do
    it for you

20
Checking as a safety net
  • People often think that all safety nets help
    reduce anxiety in the situation
  • However studies have found that checking actually
    INCREASES the level of anxiety that people feel
  • The more we check, the more anxious we feel, the
    more we doubt whether we checked properly, so the
    more we check

21
Who Wants to be a Millionaire?
  • Chris Tarrant often asks people in the hot
    seat Are you sure about your answer?
  • How do people usually react to this? Do they
    feel reassured and confident? Or do they tend to
    feel some doubt creeping in?
  • What does this tell us about doubt and the urge
    to keep checking?

22
Safety nets continued..
  • The other thing about safety nets is that they
    stop you from finding out what would actually
    happen and in this way can keep you believing
    something terrible will happen
  • E.g. if I spend an hour checking my cooker is off
    and I go out, when I come back in and theres
    been no fire I might think phew, thank goodness
    I checked the cooker so carefully otherwise
    there would have been a fire

23
Elevated Evidence Requirements (EER)
  • Its normal to check things in many situations
  • e.g. on way to the airport most of us check we
    have our passports several times as the
    consequence of forgetting it would be missing the
    plane
  • So the importance of the situation dictates how
    much effort it takes us to make a decision

24
  • E.g. When looking for a new home (an important
    decision!) we might have the following criteria
  • - 2 bedrooms
  • - A big bathroom
  • Estate agents might show us lots of places that
    meet these objective criteria
  • But they might not feel right

25
Elevated Evidence Requirements
  • When making an important decision we tend to
    weigh up a lot more options than for a small
    decision
  • We use a greater quantity of criteria to consider
  • And a greater quality we study each option much
    more carefully because the consequences of our
    decision are so important to us
  • We rely more than usual on our feelings to make
    the decision

26
EER
  • It is has been found that people with OCD tend to
    use more criteria overall than other people to
    decide when to stop checking
  • People with OCD have also been found to rely more
    on their feelings when deciding to stop
    compared with other people
  • So they tend to rely more on a subjective
    emotional feeling such as feeling just right or
    certain or comfortable rather than what they
    can see, hear, touch or taste (i.e. their
    objective senses)

27
EER
  • The difficulty in OCD is that importance of many
    decisions is overestimated because the sense of
    danger is much higher due to elevated sense of
    responsibility
  • So people try too hard to be sure of decisions by
    relying on their feelings in many decisions in OCD

28
  • Compulsive checking is an exaggeration of a
    normal action
  • E.G. It is normal to switch off the tap after you
    have used it and many people check it
  • Factors understood for reasons why people start
    to check but not as much on how they decide to
    stop checking
  • Therefore researchers are looking at what keeps
    people with OCD checking such actions repeatedly
    in order to help them in treatment

29
Exercise
  • 1) how do you decide to stop checking?
  • 2) when do you know that you have checked enough?
  • 3) how much do you tend to rely on your senses
    (what you see, hear, touch, taste, smell) between
    0-100?
  • 4) how much do you tend to rely on how you feel
    (whether you feel just right/comfortable/satisfied
    ) between 0-100?

30
Vicious Cycle
Ambiguous information
Use more effort to make decision
Check again
Increased doubt did I check it properly?
Demands more attention
Decreased confidence in memory
Uses more memory
Less space in memory left for recalling action
31
Memory Confidence
  • When checking is repeated it can become confusing
    to differentiate between mental rehearsal of
    check with the actual completion
  • People doubt whether or not they have checked
    properly so keep checking (Cougle, Salkovskis
    Wahl, in press)
  • Research shows it is not a problem of memory
    accuracy people with OCD actually have better
    memory accuracy than those without OCD but
    lowered confidence

32
Psychological therapy
  • CBT is recommended for OCD by National Institute
    of Clinical Excellence (NICE) guidelines
  • Most widely psychological therapy for OCD in
    adults
  • Strong evidence-base in literature
  • Looks at links between what we think
    (cognitions), how we feel, our body sensations
    and what we do (behaviours).

33
Cognitive Behavioural Therapy (CBT)
  • Short-term, structured psychotherapy
  • Main focus on the here and now what keeps the
    problem going
  • Less focus on childhood
  • Aims to help challenge our negative thinking
    patterns and finding alternative, less
    threatening ways of looking at a situation and
    new ways of behaving as a result

34
What Does CBT Involve for Checking?
  • Assessment what drives your checking behaviour
  • Challenging the meaning of intrusive thoughts and
    urges (i.e. that they are part of normal, human
    experience) and help you see that OCD is a bully
  • Exposure response prevention
  • Behavioural experiments
  • Challenging beliefs about responsibility

35
Exposure response prevention
  • Effective form of treatment
  • Common part of CBT
  • Involves exposing yourself to things that make
    you feel anxious and NOT doing any rituals or
    checking (i.e. not using your safety nets)
  • Find out that anxiety decreases over time

36
A bit about anxiety
  • Anxiety is a very normal human emotion
  • We all get anxious in various situations
  • Fight or flight response our bodies produce
    adrenalin when we detect a threat and need to
    respond immediately

37
Fight or Flight Response
  • Evolutionarily very helpful!
  • Causes many body sensations
  • - Heart races
  • - Hot and sweating
  • - Dizzy or light-headed
  • - Vision can become distorted
  • - Thoughts race and focus on
  • Anxious thoughts
  • - Tingling in hands and feet
  • These signs can be interpreted if we dont know
    what is causing them

38
Who suffers from anxiety?
  • Everyone to different degrees
  • Some examples of famous people who have reported
    suffering from anxiety difficulties at some point
    in their lives
  • - Sir Isaac Newton
  • - Sigmund Freud
  • - Naomi Campbell
  • - David Bowie
  • - Johnny Depp
  • - Oprah Winfrey
  • - and lots more!!!
  • What does this tell us?

39
Some myths about anxiety
  • Its a sign of madness
  • Its a sign of weakness
  • It means I cant cope with anything in life
  • What about the list of famous people we just
    looked at do you think any of them are mad or
    weak? Why not?

40
Testing the OCD bully
  • CBT also involves behavioural experiments
  • These involve testing out the beliefs that you
    are responsible for harm by seeing what actually
    happens if you dont check
  • We cannot guarantee that bad things wont happen
    (none of us can in life)
  • We can guarantee however that if you keep on
    checking, OCD will continue to be a problem

41
Challenging Beliefs about Responsibility
  • Probability how many times have you worried
    about something bad happening if you dont check?
    How many times has something bad actually
    happened as a result?
  • Link with childhood and old messages
    developing new belief systems that are more
    balanced as adults
  • Responsibility pie charts how much are you
    responsible for things in reality what other
    factors are involved?

42
Responsibility beliefs
  • Thinking errors e.g. black and white thinking,
    discounting the positives, minimising,
    catastrophising (we all do these things when we
    feel anxious or upset)
  • Taking risks moving into a more balanced place
  • Thinking of advantages and disadvantages of
    taking responsibility for everything

43
Common Fears of Therapy
  • I dont know who I am without OCD
  • How would I fill it my time without it?
  • I will go to the other extreme and never check
    anything again and this is dangerous
  • In therapy we guarantee that if your worst fears
    happen (e.g. you become a danger to others) we
    will help you to reinstate all safety nets!

44
Taking Risks
  • None of us can ever be certain of what is going
    to happen
  • We cannot control much of what happens in life
    although the OCD might try and convince us that
    we can
  • Imagine life without OCD
  • If you had the choice of being free from OCD and
    losing your possessions which would you choose?
  • Treatment doesnt ask you to lose all your
    possessions, just to risk it
  • Is it worth it?

45
Small Group Discussion
  • What are the key points you have taken from this
    workshop?
  • What could you try doing differently with your
    checking?
  • How could other people help you?
  • What might be your next steps?

46
Summary
  • OCD is characterised by obsessions (instrusive
    thoughts, images, urges, doubts) and compulsions
    (actions both overt and covert designed to
    prevent feared conquences and reduce anxiety)
  • Checking is the most common compulsion
  • People often check in response to obsessions but
    they are not always obvious

47
Summary
  • In the CBT model we call compulsions safety nets
  • Checking is a safety net
  • Some safety nets can reduce anxiety in the
    short-term but they keep the OCD beliefs going as
    they stop us from finding out what would actually
    happen if we didnt check
  • Checking actually increases anxiety and thus
    leads to repeated checking

48
Summary
  • People with OCD tend to use their feelings more
    than those without to make the decision to stop
    checking
  • It is much harder to evaluate feelings as they
    are ambiguous, need more effort, use up more
    attention and memory
  • This increases doubt and so increases checking
    leading to a vicious cycle of repeated checking

49
Changing stopping Criteria
  • Research has found that if people with OCD use
    more objective criteria they spend less time
    checking
  • Therefore better to try and focus more on the
    objectives (what you can see, hear, touch and
    smell) than how you feel when checking
  • Even when urge to check will still be there, try
    and ride it through research shows it decreases
    over time, along with the anxiety

50
Possible next steps
  • Talk to your GP about a referral for CBT
  • If you are having therapy, make sure it is CBT
  • Self-help reading (reading list available on
    request)
  • Computerised CBT (there is a growing
    evidence-base to support this form of therapy)

51
My Research
  • I asked people with OCD to check things in their
    homes using different instructions one set was
    to focus on objective (sensory) facts in the
    check and the other was on how they felt about it
  • I timed how long they took to check and how they
    felt about it before, during and afterwards
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