Too much time putting out obsessive and compulsive
Too much time putting out (obsessive and compulsive) fires: Using ART for OCD Ellen Schimmels LTC, AN, PMHNP-BC, DNP Uniformed Services University, Bethesda, MD
Disclaimer The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of the U. S. Army Medical Department, the U. S. Army Office of the Surgeon General, the Department of the Army or the Department of Defense or the U. S. Government.
Disclosure The author has no financial disclosures and no conflicts of interest to disclose.
Patient cases Patients were consented for use of information in presentation although every attempt has been made to de-identify the patients presented and all information not essential to understanding the case was removed.
Objectives • Review three OCD case studies and how ART is used to treat OCD. • Explain rationale behind utilizing ART on obsessive thinking and compulsive behaviors. • Discuss future implications for ART with the challenging and difficult to treat OCD population.
OCD • More than an anxiety disorder; impulsive-compulsive disorder • Intense urge to perform acts despite full insight into how senseless it is • Relief from anxiety reinforces the behavior • Habit becomes progressively compulsive more like a conditioned response • Many other related conditions: • • Hoarding Compulsive shopping Trichotillomania Excoriation Body dysmorphic disorder Hypochondriasis Somatization
OCD • Significant burden • • Quality of life Interpersonal relationships Work Academic activities • Untreated, remission <20% • Chronic condition, often produces lifelong morbidity • 32 -74% of adults will have clinical improvement with treatment, only 20 -30% have significant improvement • Most patients do not achieve remission • Initial response from pharmacotherapy strongly associated with positive long-term outcomes
Treatment Options • Difficult to treat • Medication • High (heroic) doses of SSRIs are off label (with problematic tolerability) (fluoxetine, paroxetine, sertraline) • Fluvoxamine (SSRI with sigma-1 receptor binding properties) • Seems to have better anxiolytic properties and for psychotic/delusional symptoms • Clomipramide (TCA—antihistamine, anticholinergic, alpha-adrenergic) • Significant side effects: weight gain, sedation, blurred vision, dry mouth, urinary retention, constipation, orthostatic hypotension, dizziness • SSRI + augmentation (SGA, BZD, Lithium, buspirone) • Exposure therapy and response prevention (ERP) CBT • Helps to break the habit pattern and maintains appropriate anxiety response • Intensive outpatient care • Deep brain stimulation • Experimental
Case #1 “I feel like I’m putting out fires all day. I get through one episode and another comes up. ”
Case #1 History • 36 year old male • Single, never married, no children, difficulty maintaining relationships • “I need medication, I’ve exhausted all my other resources. ” • 15+ year history of OCD, started with taking long showers, progressed to “morally contaminated” and “exposed” to most things. Unable to use public restrooms. Showers >4 hours/day. • Anxious, constantly checking, constantly labeling people/places/things. Gets stuck in own head most of the day and has been having problems at work for some time. • Been through three separate residential programs with little improvements
Case #1 Treatment Appt #1: Intake Started SSRI, increased Appt #2 (I +30): Med check Increased SSRI despite SE Appt #3: (I + 60): Med check, ART #1: Showering as scene Appt #4: (I+90) Med check, ART #2: Little liar/Typical day SSRI decreased Appt #5: (I +135) Med check, ART #3: Scene match/childhood anxiety SSRI decreased No symptoms Appt #6: (I +180) Med check, ART #4: Typical day (reinforcement) SSRI discontinued No symptoms Appt #7: (I + 210) No medication No symptoms Check in only. ART not done Telephone check in only: (I +390) No medication No symptoms Check in only Still “in complete awe”
Case #1 Outcomes Intake Appt #2 Appt #3 (ART Appt #4 #1) (ART #2) Appt #5 (ART #3) Appt #6 (ART #4) Appt #7 BASIS 24 2. 37 2. 23 2. 10 1. 55 0. 75 0. 2 GAD 7 21 17 15 14 5 2 1 PHQ-9 5 5 4 2 1 0 0 PCL-5 15 13 10 6 5 0 0 Time from intake I I+30 days I +60 I+90 I+135 I+180 I+210 Time from last appt 0 30 days 45 days 30 days
Case #2 “I feel like I’m always being judged and people are waiting for me to fail” http: //www. bing. com/images/search? view=detail. V 2&ccid=qr 3 f 7 Nh. Y&id=77736 AD F 240 ABFE 4 F 4243508 EB 8 EC 31 D 0 B 313 D 71&thid=OIP. qr 3 f 7 Nh. YW 2 Eu 00 w. Bl. Yxf. Ng. Es Dr&q=++fans+at+soccer+game&simid=608042902527214422&selected. Index=8&a jaxhist=0 http: //www. bing. com/images/search? view=detail. V 2&ccid=Ej 2 o. Z%2 b. E 9&id=2 E 2 D 15 B 1195057 074 E 36 D 650598974 C 2 E 9 E 9967 D&thid=OIP. Ej 2 o. ZE 9 XDSexgh. ZT 2 LZlw. Es. DI&q=+soccer+game&simid=607995413096563296&selected. Index=6&aj axhist=0
Case #2 History • 39 year old male • Single, never married, no children • Obsessive thoughts about being judged, being looked at under a microscope, and compulsive behaviors-biting and skin picking, feels ashamed about behaviors and is not able to break the cycle. • Has been progressively getting worse, flying, public speaking, and presenting at work more anxiety provoking, social issues
Case #2 Treatment Appt #1: Intake SSRI started, increased Appt #4: (I+90) Med check, ART #3: Little liar, used being judged Medication decreased Appt #2 (I +30): Med check, ART #1: Typical Day protocol with riding metro Medication decreased due to SE Appt #5: (I +135) Med check, ART #4: Meta-mo (under microscope) and scene going home for holidays Medication discontinued Appt #3: (I + 60): Med check, ART #2: Metaphorical moment (soccer game) Medication unchanged Appt #6: (I +180) Med check, No medication Telephone check in only: (I+210) No medication. “Can’t believe this”
Case #2 Outcomes Intake Appt #2 (ART #1) Appt #3 (ART #2) Appt #4 (ART #3) Appt #5 (ART #4) Appt #6 BASIS 24 1. 98 1. 3 1. 15 0. 58 0. 35 GAD 7 15 13 10 5 1 1 PHQ-9 2 2 0 0 PCL-5 5 3 1 1 1 0 Time from intake I I+30 days I+90 I+150 I+195 I+225 Time from last appt 0 30 60 60 45 30
Case #3 “It’s like stepping on a crack; if I don’t count, I’m afraid something bad will happen” http: //www. bing. com/images/search? view=detail. V 2&ccid=pwze 3 Du. C&id=7129524 D 37609 C 4 E 4 F 4 B 8482 FDC 9624 D 2 CD 7 BE 71& thid=OIP. pwze 3 Du. Cwj. Pr. Rd. Ux. Tw. NVg. Es. Dh&q=step+on+a+crack&simid=608048979921600620&selectedindex=62&mode=overlay&first=1 http: //www. bing. com/images/search? view=detail. V 2&ccid=Nps 6 Tj. BN&id=7 E 3 AB 20 CEA 424 BA 37 B 3462 ADFB 7 E 4 B 2 E 9 E 225 AC 3&thid=OIP. Nps 6 Tj. BNc. Mccmc. Nv. Bi. Z 2 qg. Es&q=step+on+a+crack&simid=607995142511526 563&selectedindex=58&mode=overlay&first=1
Case #3 History • 26 year old female • Counting and checking behaviors are “out of control” • Has been on trials of multiple medications and “none of them were that effective” and she always had too many side effects • Also diagnosed with MDD, during MDEs, has a lot of thoughts about being dead, fantasizing about suicide and not dealing with life, and has felt that those thoughts get obsessive as well
Case #3 Treatment Appt #1: Intake, SSRI increased (started by PCM) Appt #4: (I+90) Med check, ART #1: Focused on suicidal thinking Appt #2 (I +30): Med check, increase SSRI, augment for sleep/anxiety Appt #5: (I +135) Med check, ART #2. Decrease SSRI. Typical day with metaphorical moments Appt #3: (I + 60): Med check. Increased SSRI. Appt #6: (I +180) Med check, ART #3. Typical day/little liar reinforcement Telephone check in only: (I+201). SSRI low dose (ongoing for depressive sx). No suicidal thinking, no obsessive thinking. Feels functioning “normally. ”
Case #3 Outcomes Intake Appt #2 Appt #3 Appt #4 (ART #1) Appt #5 (ART #2) Appt #6 (ART #3) BASIS 24 2. 39 2. 25 2. 10 1. 75 1. 2 1. 08 GAD 7 12 10 10 9 8 8 PHQ-9 17 15 17 11 10 6 PCL-5 32 30 16 10 10 7 C-SSRS 3 2 2 2 0 0 Time from intake I I+14 days I+44 I+58 I+88 I+118 Time from last appt 0 14 days 30 14 30 30
Summary • OCD “protocol” • All used some scene (shower, riding metro, suicidality) for session #1 as part of/not part of typical day • Session #2 Typical day (with/without little liar) • Session #3 Typical day (with little liar/reinforcement) • Other ART sessions as reinforcement/with metaphorical moments • Heavily relied on metaphorical moments throughout
Recommendations • Typical day protocol lends itself well to OCD treatment • Little liar has been particularly helpful • Patients seem to respond well to target trigger times; using metaphorical moments • A lot of metaphors readily available along with the insight for OCD patients seems to help • Great amount of insight/high desire to improve obviously helpful!
Future Implications • Using OCD specific scales • OCD RCT (what treatment for comparison? ) • OCD specific referrals for ART • Streamlining ART sessions even more?
References • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5 th ed. ). Arlington, VA: American Psychiatric Publishing. • ART Basic Training Manual (2016) • ART Advanced Training Manual (2016) • ART Enhanced Training Manual (2016) • Bloch, M. H. , Green, C. , Kichuk, S. A. , Dombrowski, P. A. , Wasylink, S. , Billingslea, E. , &. . . Pittenger, C. (2013). Long-term outcome in adults with obsessive-compulsive disorder. Depression & Anxiety (1091 -4269), 30(8), 716 -722. doi: 10. 1002/da. 22103 • Chase, T. , Wetterneck, C. T. , Bartsch, R. A. , Leonard, R. C. , & Riemann, B. C. (2015). Investigating Treatment Outcomes Across OCD Symptom Dimensions in a Clinical Sample of OCD Patients. Cognitive Behaviour Therapy, 44(5), 365 -376. • Finnegan, A. , Kip, K. , Hernandez, D. , Mc. Ghee, S. , Rosenzweig, L. , Hynes, C. , & Thomas M. (2015). Accelerated resolution therapy: An innovative mental health intervention to treat post-traumatic stress disorder. Journal of the Army Medical Corps, 0, 1 -8.
References cont. • Kip, K. E. , Rosenzweig, L. , Hernandez, D. F. , Shuman, A. , Sullivan, K. L, Long, C. J. , Taylor, J. , Mc. Ghee, S. , Girling, S. A. , Wittenberg, T, Sahebzamani, F. M. , Lengacher, C. A. , Kadel, R. , Diamond, D. M. (2013). Randomized controlled trial of accelerated resolution therapy (ART) for symptoms of combat-related post-traumatic stress disorder (PTSD). Military Medicine, 178, 1298 -1309. • Sadock, B. , & Sadock, V. (2013). Synopsis of Psychiatry. (11 th ed. ). Baltimore, MD: Lippicott, Williams & Wilkins. • Stahl, S. M. (2013). Essential Psychopharmacology: Neuroscientific Basis and Practical Application 4 th ed. ). New York, NY: Cambridge University Press. • Substance Abuse and Mental Health Services Adminstration (SAMHSA). Obsessivecompulsive disorder (2017). Downloaded on 1 August 2017 from https: //www. samhsa. gov/treatment/mental-health-disorders/obsessive-compulsivedisorder. • Waits, W. , Marumoto, M. , & Weaver, J. (2017). Accelerated resolution therapy (ART): A review and research to date. Current Psychiatry, 19(18), 1 -7.
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