ì

EMDR17thEuropeanConference.TheHague-

Orlanda2016

TreatingObsessiveCompulsiveDisorder[OCD],usingEye

MovementDesensitisationandReprocessing[EMDR]:Acase

seriesdesign.

PaulKeenan,DrDerekFarrell,LynnKeenan&ClaireIngham

DifferentformsofOCD“Ican’tstandtheuncertainty,Ineedtheguaranteeofsafety”

SessionPlan�  WhatisOCD?

�  PsychologicalRationalforOCD

�  HasEMDRsomethingtooffer?

�  EMDROCDresearchtodate

�  Introductiontoourresearch&Results

�  Casepresentation

LearningObjectives

I.   TogainadeepercriticalunderstandingoftheutilisationofEMDRinthetreatmentofOCD.

II.   TobeabletodiscusscriticallyhowEMDRmaybeusedinreducingtheemotionalvalance,significantto“IntoleranceofUncertainty”asexperiencedinOCD.

III.   Toexaminecriticallythelimitations,ifany,intheapplicationofEMDRwithOCDwithparticularreferencetotheAdaptiveInformationProcessing(AIP)model.

TheDiagnosticPhenomenologyofOCD(DMS-IV)

•  Intrusivethoughts,ImagesandImpulses

•  ObsessionsandorCompulsions

•  Compulsionsaremeaningfullyrelatedtofears

•  Bydefinition,thepersonseekstoignoreorsupressintrusions

•  Keytodiagnosticisdistress/disability

DSM-5OCD&RelatedDisorders

ì  OCD

ì  BDD

ì  HoardingDisorder

ì  Trichotillomania

ì  ExcoriationDisorder

ì  Substance/Medication-inducedObsessiveCompulsiveandRelatedDisorders

ì  ObsessiveCompulsiveandRelatedDisordersDueToAnotherMedicalCondition

DefiningfeaturesofObsessions:

ì  Intrusivequality

ì  Unacceptability

ì  Subjectiveresistance

ì  Uncontrollability

ì  Ego-dystonicity

Compulsions

�  Compulsionsarerepetitivebehavioursthatareovertorcovert.

�  Overtcompulsionsarethosethatcanbeseenandincludehandwashing,checking,orderingandliningupobjects.

�  Covertcompulsionsarementalactsthereforecannotbeseen,suchaspraying,counting,sayingcertainphrases,orbringingimagestomind.

�  Thegoalofallcompulsionsistopreventorreducedistressandfromacognitiveperspectivetoneutraliseorpreventdanger(whichtheintrusivethoughthascreated)andtodiminishresponsibilityforitsoccurrence.

CognitiveTheoryofOCD,simplyput:

o  Unacceptableintrusionsareanormaloccurrence.

o  Whenintrusionshaveoccurred,theobsessionalpatientbelievesthattheymightberesponsibleforharm,iftheydon’treacttopreventit(TAF)

o  TheyrespondbyTRYINGTOOHARD(togetridofthethought,topreventharm,tobesure,tobeclean…andsoon)

o  Astimegoesby,THESOLUTIONBECOMESTHEPROBLEM

TheoreticalModelsofOCD

EmpiricallysupportedtreatmentsforOCD

ì  CognitiveBehaviouralPsychotherapy

ì  ExposureinVivoandResponsePrevention{Ex/RP}

ì Medication(SSRIAnti-depressants)

ì  (Veal2007;NICE2005;Salkovskisetal2000;Foaetal1997;Marks1997)

AssessmentofOCD

ì  Aspartofageneralclinicalassessment,includingrisk(notjusttothepersonbuttoothersintheirenvironment,especiallychildren).

ì  PeoplewithOCDcanalsobedepressedandmayhaveotheranxietydisorders,GAD,SocialAnxietyetc.

Assessment

ì  Engagementinassessmentinvolveshelpingthepersontofeelunderstood.

ì  Aspectsofengagementtobemindfulof:

1)Comingtoappointments45minutesearlyorarrivinglatebecauseofOCD.

2)Havingintrusivethoughtsand/orcarryingoutmentalritualsduringsessionswhichimpactsonattentionandconcentration

Assessment

3)Seekingreassurancefromyou(passingresponsibility)

4)Lingeringattheendofsessions(checkingthetherapyroomincasetheyhaveleftsomething)

5)Fearofcontamination

6)Havingdifficultycompletingquestionnaires(sometimesperfectisn'tgoodenough)

Assessment

7)Havingtodothingsacertainnumberoftimes

8)Talkingaboutobsessionscanbedeeplyembarrassing/shamefulandanxietyprovoking(talkingaboutsexualimagesorthoughtsofwantingtoharmchildren)

9)Youwillprobablyneveruncoveralltheobsessionsorcompulsions:don’tworryaboutit

Assessment

OCDmeasures:

ì  YaleBrownObsessiveCompulsiveScale(Y-BOCS)

ì  MaudsleyObsessive-CompulsiveInventory(MOCI)

ì  ResponsibilityAttitudesScale(RAS)

OCDclientswhocouldnotengageintherapy

q  AlthoughEx/RPcanbehighlyeffectiveforaround50%ofpeoplewhocompletetreatment,thereareanumberofrecogniseddrawbacks(Marr2012)

q  Ex/RPismuchlesseffectiveinclientswhoexperienceobsessiveruminationsratherthanovertcompulsions

q  Theactuallevelofimprovementisextremelyvariable(Roth2006)

q  HighDropoutrates{40%},(Rectoretal2009)

q  Highrelapserates{57.3%}(WHO2010)

Sowhataretheoptions?

§  Doaswearetold,carryonwithEx/RP

§  Medicate..(maybenecessaryanywayifco-morbiddepression)

§  EngageinExploratoryPsychotherapy?

§  EMDR?

ì  DeSilva&Marks(1999)suggestthattheremaybeacausallinkbetweentheonsetofOCDandatraumaticeventthathasadirecteffectonpathology

EMDR&OCSpectrumdisorders

ì  BodyDismorphicDisorder(Brownetal1997)

ì  OlfactoryReferenceSyndrome(McGoldric2008)

ì  Hypochondriasis(vanRood2009)

OCDRecoveryCentre:Dr.CKomor,ArizonaUSA

ì  Invitroexposure,notaseffectiveasinvivoexposure(Schwartz,1998)

ì  UseEMDRwithInVitroexposure,usingtheanxietyprovokingimage.

ì  EMDRappearstoacceleratetherateanddepthofanxietyprocessing,itseemsto“supercharge”theinvitrohabituationprocessandlessontheclientsdiscomfort.

Marr(2012)

•  Treated(14-16sessions)4subjectsusingadaptationofShapiroPhobicprotocol..

•  Marr’sworkisbasedonthetheoreticalviewthatOCDisaselfperpetuatingdisorder,withOCDcompulsionsandobsessionsandcurrenttriggersreinforcingandmaintainingthedisorder(Marr2012)

•  ClientswereassessedusingtheYale-BrownObsessiveCompulsiveInventory(Goodmanetal1989),(Y-Boc)significantimprovementwasnotedinallclientsattheendoftherapyandatfollowup.

DevelopingaComprehensive/CollaborativeEMDR-focusedCaseConceptualisation.

§  Understandtherelationshipbetweenpast,presentandfuture,consideractsof

Commission(Physical&Sexualabuse)andOmission(neglect,deprivation).

§  Evaluateself-capacity/readinessfortraumaprocessing.

§  Identify,preparation/stabilisation/resourcing:Extratime/spacemaybeneededwhereperfectionismisanissue.

§  Identifyanydevelopmental/attachmenttargetsrelatedtodisruptedpsychologicalneeds:?theonsetofresponsibility/safety/controlplateaus.

§  Identifytraumaticevents{ifpresent}relatedtocurrentsymptomsanddifficulties.§  IdentifyObsessions,Compulsions&CurrentTriggers(couldbemany)andfutureaction

goals.

CaseConceptualisation(Cont:)

§  Motivation,expectations,anysecondarygainissues?

§  Previousexperiencewithpsychotherapy

§  Activatedschemathemes(Young,1994;2003),Responsibility,Safety,Choice,Control,alsothink,Salkovskis(responsibility),Clark(control),Rachman(safety).

§  Blockingbeliefs(TAF),Fears/Phobias.

§  Unmetdevelopmentalneeds(Trustissues/attachmentissues).

§  Riskissues

§  Medication

CurrentResearchProject

ì  TreatingObsessiveCompulsiveDisorder[OCD]usingEyeMovementDesensitisationandReprocessing[EMDR]ACaseSeriesDesign

Originality

Publishedstudiestodateandindeedanecdotalexperienceshaveusuallydiscussed/usedEMDRinconjunctionwithEx/RP.ThisprojectaimsjusttouseEMDRtotargetunprocessedtraumaticmemoriesandoranxietygeneratedfromIntoleranceof

uncertainty

TheTeamPaulKeenan:EMDRConsultant&Facilitator;

CognitiveBehaviouralPsychotherapist,Trainer&Supervisor,SeniorLecturerinMentalHealth(PrincipalInvestigator).

LynnKeenan:EMDRConsultantandFacilitator;

CognitiveBehaviouralPsychotherapist.

ClaireIngham:EMDRPractitioner;CognitiveBehaviouralPsychotherapist

DrDerekFarrell:EMDRConsultant&Trainer;CognitiveBehaviouralPsychotherapist,SeniorLecturerinPsychology

ResearchMethod

o  8subjects,whohavebeendiagnosedwithOCD,havehadCBTinterventionwithinthelast5yearsbutsymptomshavenotabated.

o  Psychometrics:

o  Y-BOC(Goodmanetal1989)

o  PHQ-9(Kroenkeetal2001)

o  GAD-7(Spitzeretal2006)

o  DissociativeExperienceScale(DESII)

o  Eachsubjectreceived8sessionsofEMDR,[inanefforttomirrorIAPTservices]plus1and3monthfollow(EMDRwillnotbeadministeredatfollowup)

o  NormalEMDRprotocolusedforclientswithpastaversivelifeevents(PALE)

o  EMDRfocussingon“Intoleranceofuncertainty”willbeusedwherenoPALEwasidentified.

PsychologicalTreatmentInterventionDesignand

PsychometricMeasures

IntoleranceofUncertainty

ì  “ Intoleranceofuncertainty(IOU)canbeunderstoodasnegativeemotional,cognitiveandbehaviouralreactionstouncertainsituationsandevents.IndividualswithIOUexperienceuncertaintyasupsettingandstressful,somethingtobeavoidedandoftenhavetroublefunctioninginuncertainsituations,E.G.“haveItouchedsomeoneinappropriately?” (Buhr&Dugas2002)

8Subjects(N=4Trauma;N=4Non-Trauma

(A)  Contamination[Asbestos]IOU

(B)  Contamination/Disgust[Buttons]TraumaMemories

(C)  Hoarding[Droppedout,didnotwishtoengage...actuallywantedabiggerhouse]

(D)  Checking&Safety[Damagetoeyes]IOU

(E)  H-OCD[FearofbeingLesbianorGay]IOU

(F)  UnwantedViolentorSexualthoughts….TraumaMemories.

(G)  Scrupulosity….TraumaMemories.

(H)  Contamination[maggots]…TraumaMemories

(I)  ContaminationwithMagicalthinking.IOU

Results

o  YBOC

o  GAD-7

o  PHQ-9

Figure1:EMDRTherapywithOCDPsychometricScores(n=8)

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Figure2:PsychometricScoreswithOCDandPastTrauma(n=4)

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Figure3:YaleBrownObsessiveCompulsiveScale(YBOC)scorescomparingTraumawithNon-TraumaParticipantswithOCD

significant(.036/*p<.05)

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Trauma(N=4)

Figure4:GAD-7ScorescomparingTraumawithNon-TraumaParticipantswithOCD

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Figure5:PDQ–9ScorecomparingTraumawithNon-TraumaParticipantswithOCD

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Figure4:EMDRTherapyInterventiononCompulsions(Y-BOC)-MeanValueN=8

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NoneTrauma Trauma

TwoClients

ì  Ruth:EarlyChildhoodTrauma,IssueContamination[maggots]Method,Past,Present&Future

ì  Tom:DeniesanyChildhoodTrauma,IssueContamination[Asbestos]Method,IntoleranceofUncertainty

CasePresentation:Ruth

§  58yearoldwoman,divorced,livingalone.

§  Profession:Socialworker,nofinancialproblems

§  Gregarious,intelligentwomen,herchurchisanimportantpartofherlife.

§  Selfreferred,assheisparttheselfhelpgroupforOCD,basedinherlocalarea.

§  HashadCBTinthepast(withme)

ì  TheIssue

ì  Severeanxiety,obsessionalthoughtsandcompulsiveritualsrebecomingcontaminatedbycontactwithmaggots

ì  CriticalEvent

ì  Movedintoanewhome(toher),cleaningthekitchen,openedacupboardand“amillionmaggotsfellonme”

Ruth:thesymptoms

§  Almostcontinuousobsessionalthinkingrecontaminationtrail

§  Compulsivehandwashing:30/40timesperday[ahandwashconsistsofwashinganddryingfingersindividually,2/3minutesperwash]

§  Clotheschangingaftereverytimeshegoesout.

§  Washingcoinsbeforeputtinginpurse

§  Washesfood,vegetarian“meatcouldhavemaggotsinit”

§  Avoidsdatingmen,CSAandInterpersonalviolenceinpast

§  Avoidingfriends,asshebelievesthemcontaminated

§  Scrubshouseclean,2hourseveryday,takes3hourstodecontaminateherselfeachnightbeforeshegoestobed.

§  Alwaysfeelsdirty,cannevergetclean.

RuthPsychometricsPreEMDR

ì  Ruth:Psychometrics

§  Y-BOC=25(severeOCD)

§  GAD=15(moderate/severe)

§  PHQ-9=14(moderate/severe)

§  DES=Subclinical

Ruth:Phase1–HistoryTaking

§  4theldestchildof10siblings,eldersisterdeceased(RIP),stillfriendlywithothersiblings.

§  Parentsdeceased(RIP)

§  Motherwasveryanxious,overprotective,father,verystrict,“Iwaspetrifiedofhim”

§  Bulliedatschoolforbeing“fatandugly”Couldnottellmumasshewouldworry,couldnottelldad,ashewasnotinterested.

§  SAfromtheageof5,atSundaySchool.

§  SAat11“Iwasa36Bustat11yearsofage,toldIwasadirtylittlebitch”

§  NoticedOCDsymptomsstartingthen,ritualsinvolvingtheopeningandclosingofdoors.

§  Marriedat21,husband,critical,jealous,violent,abusive.After4yearsshelefthim.Shemovedtoarentedhouseinfestedwithmaggots….OCD+++

BackgroundInformation&Phase2:Preparation

§  IhadworkedwithRuthmanyyearsearlier,usingCBTtocombatherritualisticbehaviours

§  RuthnewaboutEMDR,assheispartofaselfhelpgroupforOCD

§  Shehadnevertriedtoaddressanyofherearlylifeexperiences,onlyrecentlytalkingaboutthemwithinherchurch.

§  Shewasabletoseethepossibleconnection,betweentheearlysexualabuseandherfeelingdirty.

ì  SpecialPlace

ì  Onholiday,inafieldwithastream,lyinginsun,readingabook.

ì  Cueword,Happy.

Phase3:AssessmentofTargetMemory

ì  Memory:SexualAbuse

ì  Image:SittingonKneeofmanatSundaySchool,hishandupmyskirt

ì  NegativeCognition:I'mDirty,itsmyfault.{Responsibility}

ì  PositiveCognition:I'mclean,itwashim.{Responsibility}

ì  StuckPoint:Itsmyfault,itsmybodyattractingthis.

ì  Interweave:Whowantedthistohappen,youorhim?

ì  Outcome:“Itsnotme,I'mbeingforced,itshim,itshim,Icanbeclean”

Ruth:PsychometricData

ì  Y-BOC=3

ì  GAD=0

ì  PHQ-9=1.

ì  Behaviours:StillhasOCD,stillengagesincleaningbehaviours,however,handwashingmuchless(5or6perday),onlycleanshousetwiceperweek,bedtimeritual,mostly10minutes,(howeverstillhasbaddays,shesaysshethinksabouttheEMDRsessionsandithelpssteadyher)

CasePresenta*on:Tom

ì  32yrs.old,whitemale,livingwithfemalepartner&twochildren

ì  Selfemployedarchitect,nofinancialproblems

ì  Widesocialnetwork,welllikedbypeers

ì  Selfreferredwhenheardabouttheprojectfromafriend.

ì  Appearedmotivatedtowork.

Tom:TheIssue

�  C/oConstantanxiety,concerningharmcomingtohiswifeandchildrenthroughcontactwithAsbestos.

�  Hebelievedhewasresponsibleforhisfamiliessafety.

�  Ifanythinghappenedtothem,itwouldbehisfault,ashehadalreadyconsideredthecatastrophicoutcomes.

Tom:TheSymptoms

ì  Myriadofcheckingbehaviours,including,children,dog,internet(lookingforlocationofoldbuildingswhichmaycontainasbestos).

ì  Handwashing,30timesperday(anormalhandwashcouldtakeupto5minutes)

ì  Washingclothes

ì  BathingChildren

ì  Questioningpartnerandchildrenretheiractivities

ì  InsistedthatnephewleavehisplaceofworkasTombelieveditnottobesafe.

ì  Avoiding:garden,shops,pubs,certainpartsofthehouse,certainbelongings(golfclubs)

ì  Alsocomplainedoflowmoodimpactingonhismotivationtogotowork

ì  Relationshipdifficulties

Tom:psychometrics

�  Y-BOC=20(ModerateOCD)

�  GAD-7=7(Mild)

�  PHQ-9=14(Moderate/Severe)

�  DES=Subclinical

NoSuicidal/selfharmissuesidentified

Tom:Phase1–HistoryTaking

•  Oldestoftwochildren,bothparentsstillalive.

•  Describedhisfamilyas“MiddleClass”,expectedtodowellatschool,butnotpressuredto??

•  DeniesanyPA,SAorEA.

•  Quietchild,reflective,“abitgeeky”

•  Neverlikedmakingmistakes,butdeniedanyobsessionalbehaviours,suchas“doover's”

•  Didwellacademically,wenttouniversity.

•  Metagirl,splitup,thenhebegantonoticeobsessionalthinking,originallycentringonmakingdecisions.

Tom

•  ThroughouthistorytakingTomdeniedanyaversiveearlylifeexperiences.

•  OCDcouldbeconceptualisedasdysfunctionallystoredinformationthatleadstoapresentlevelofdisturbancewhichisreinforcedviaovertandcovertneutralisingbehaviours.

•  TomhadreadwidelyonEMDRandunderstoodthetechnicalaspectsofatreatmentsession.

•  IexplainedtheIntoleranceofUncertaintymodel(IOU)andTomagreedtocontinue.

Tom

ì  Image:Kidsinkitchenhavingbeenplayingoutinthelocalfield.Hedoesnotaskthemtochangeandbathe,hedoesnotknowiftheyarecontaminated(IOU).[CognitiveDissonance]

ì  NegativeCognition:IamIrresponsible(Choice)or“I’mbad”(responsibility/defectiveness)…

ì  PositiveCognition:Icanletitgo(Choice)or“I’mok”(R/S)

Stuckpoint:Tom“They'reindanger”

ì  CognitiveInterweaves

-  Process,Changedirectionofeyemovement

-  Content,Th.“Doyouknowthatordoyouthinkthat?“WhatwouldyoudoifyoudidnotsufferfromOCD”“WhatisIntoleranceofuncertainty”

Tom

ì  TomsawtheOCDasaBLOB,initially,IusedEMDrtokeephimfocussed,thennormalprotocolashebegantofocus.

ì  HebegantotalktotheOCD,becomingangry,heeventuallyspokeoutloud“Getout,youhavelost!”

Tom

ì  Outcomeafter8sessionswith3monthfollowup:Psychometrics

-  Y-BOC=13(MildOCD)

-  GAD-7=7

-  PHQ-9=12

Tom

ì  Behaviours

-  Generaldecreaseinallbehaviouralexcesses,mostdifficultprovedwashinghandsandissuesconcerningchildren

-  SpontaneouslybegantoimplementsomeoftheapproachbehaviourshehadlearnedinpreviousCBP.

ì  Ruth:PrimaryOCDissue(contamination)-EarlyChildhoodTraumaTarget–ConventionalEMDRTherapyProtocol

ì  Tom:DeniedanyChildhoodTraumahoweverhisprimaryclinicalissuesrelatedto‘fearofcontamination–IOUModel,InvertedProtocol(Flash-forward)

Fig6:PsychometricScoresbetweenEMDRTherapyConventionalProtocolversusInvertedProtocol(Flash-Forward)

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Conclusions-researchquestionstogeneratefournullhypotheses:

1.  TheoverallsymptomsofOCD,asmeasuredbytheYale-BrownObsessiveCompulsiveScale(Y-BOC),demonstratenodifferencebetweenthetraumaandnon-traumagroupsinresponsetoEMDRTherapy?-REJECTED

2.  Thereisnodifferencebetweenthetraumaandnon-traumagroupsinrespectofSub-CompulsionsymptomsasmeasuredbytheYale-BrownObsessiveCompulsiveScale(Y-BOC)inresponsetoEMDRTherapy?-REJECTED

3.  Thereisnodifferencebetweenthetraumaandnon-traumagroupsinrespectoflevelsofdepressionasmeasuredbytheGAD-7inresponsetoEMDRTherapy?-ACCEPTED

4.  Thereisnodifferencebetweenthetraumaandnon-traumagroupsinrespectoflevelsofanxietyasmeasuredbythePHQ-9inresponsetoEMDRTherapy?-REJECTED

Conclusions

ì  EMDRTherapyhasdemonstratedthatitisasafeandwelltoleratedtreatmentforObsessiveCompulsiveDisorder

ì  TheTheoreticalparadigmofEMDRTherapy–AdaptiveInformationProcessingisusefulpartofcaseconceptualisation

ì  EMDRTherapyismoreeffectivewithTraumaticcomponentOCDthanNon-traumaticOCD

ì  MoreresearchisneededtofurtherexploretheutilisationofEMDRTherapywithOCDpopulations

FutureProject

EMDRvsEMDRwithExp&RPvsExp&RPinthetreatmentofOCD.

Somereading&sitestovisit

ì  Bohm,K.&Vorderholzer,U.(2010).UseofEMDRinthetreatmentofObsessiveCompulsiveDisorders:Acaseseries:EnglishversionofVerhaltensterapieVol20.175-181

ì  Brown,K.W.,McGoldrick,T.,&Buchanan,R.(1997).Bodydysmorphicdisorder:Sevencasestreatedwitheyemovementdesensitizationandreprocessing.BehaviouralandCognitivePsychotherapy25,253-207

ì  Keenan,P.S.&Farrell,D.F(2000)TreatingmorbidjealousywithEMDRutilisingCognitiveInterweave.CounsellingPsychologyQuarterlyVol13.No.2.175-189

ì  McGoldrick,T.,Begum,M.&Brown,K.W.(2008).EMDRandolfactoryreferencesyndrome:Acaseseries.JournalofEMDRPracticeandResearch2,63-68.

ì  Shapiro,F.,Kaslow,F.,&Maxfield,L.(Eds.)(2007).HandbookofEMDRandFamilyTherapyProcesses.NewYork:Wiley.

www.ocdtreatmentreviews.org.uk

www.ocdaction.org.uk

www.ocdrecoverycenters.com.ocd/art_eyemovement.html

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FinalThoughts