Title: Checking in OCD
1Checking in OCD
- Dr Alice Hooper
- Chartered Clinical Psychologist
- South London Maudsley NHS Trust
- 22nd November 2008
2Aims 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?
4Suggested 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
5What 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
6Obsessions
- 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.
7Compulsions
- 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
8How 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
9Small Group Discussion
- What do you check?
- How often do you check?
- How does checking help?
- How does it affect your life?
10CBT 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
11CBT 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
12CBT 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.
13Safety 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
14Small Group Discussion
- What safety nets do you use?
- How do they help what are the advantages?
- Are there any disadvantages?
15CBT 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
16Trigger
Activates Beliefs
Normal obsessions become focus of responsibility
Worrying thoughts about what obsessions mean
Compulsions to put things right
OCD
17What 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.
18Checking
- 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)
19Examples 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
20Checking 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
21Who 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?
22Safety 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
23Elevated 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
25Elevated 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
26EER
- 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)
27EER
- 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
29Exercise
- 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?
30Vicious 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
31Memory 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
32Psychological 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).
33Cognitive 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
34What 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
35Exposure 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
36A 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
37Fight 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
38Who 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?
39Some 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?
40Testing 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
41Challenging 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?
42Responsibility 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
43Common 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!
44Taking 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?
45Small 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?
46Summary
- 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
47Summary
- 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
48Summary
- 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
49Changing 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
50Possible 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) -
51My 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