WHEN CLEANING GETS DIRTY: A case study of CBT

1. WHEN CLEANING GETS DIRTY:A case study of CBT /ERP intervention of OCD  Aileen Alegado Intern Psychologist Mental Health Services for Older Adults � North Shore Auckland University

2. Background Obsessive Compulsive Disorder (OCD) in the elderly occurs in as many as 1.5% (Flint, 1994) Characterised by clinically intrusive thoughts (obsessions) that increase anxiety, and ritualistic behaviours (compulsions) that serve to decrease anxiety (Stein & Hollander, 2002) Common examples of obsessions � contamination, checking, harming thoughts, fear of forgetting names Compulsions are repetitive, intentional behaviours that the person feels compelled to perform to reduce stress (Taylor, 2002)

3. Background cont. Late life onset of OCD after 65 years has been reported Possibly life-long subclinical OCD is exacerbated for some individuals following significant late life stressors (e.g. retirement, physical illness, death of spouse)

4. Efficacy of Treatments Pharmacologic interventions involving SSRIs � dosages typically higher than those used for depression Improvement at post- medication treatment in 30-40% of patients with reductions in symptoms of 40-60% (Stanley & Turner, 1995).

5. Efficacy of Treatments Behavioural approach -Exposure Response Prevention (ERP). Review by Foa et al (1985) 51% were symptom free or much improved (>70% reduction) 39% moderately improved (31-69% reduction) 10% little or no benefit (<30% reduction)

6. Efficacy of treatments cont.. Cognitive Behavioural intervention (CBT) featuring Exposure Response Prevention (ERP) has been the most effective treatment reported in OCD (Riggs &Foa, 1993; Stanley & Turner, 1995; Carmin & Wiegartz, 2000)

7. A Case Study: PAM 65 yr old Female Married, currently living with husband Has one daughter -32 years Both supportive Pre-morbidly outgoing and socially oriented Strongly identifies as a Christian

8. Presenting Problems 1 yr history of obsessive thoughts about contamination with germs and performing rituals and compulsive behaviours Decreased self confidence Increased social isolation Ceased most activities outside of the home Marital stress Self deprecating thoughts in the mornings Some depressive symptoms

9. Presenting Problems cont. Compulsive behaviours/ rituals: Using tissues to touch door handles Excessive handwashing Towels on car seat, chairs and sofa Urinating in the bath Excessive cleaning and use of disinfectant at home especially after using toilet Hanging washing indoors instead of outside in the sun Re-washing items if husband makes contact with the washing

10. Presenting Problems cont.. Wearing an apron at home Showering after bowel movement Use of anti-bacterial wipes in the car, disinfecting keys No physical contact with people Washing �outdoor clothes�

11. Psychometrics MMSE score 29/30 Some difficulty noted with executive functioning tests YBOCS score 29/40 (severe) GDS 3/15

12. Significant info Born and raised in NZ Difficult childbirth by her mother �Sickly� baby � seen as fragile Worrier by nature Sister used to put her down No prior psych history. Worrying about school cert � Thoughts about hurting her mother Mother died at 55 years of breast cancer and father died at 65 of lung cancer - guilt

13. Precipitating Factors Threat to health � melanoma diagnosed 3 yrs ago Significant changes in domestic arrangements since husband�s retirement Close friend unwell with cancer Physical deterioration (broken foot, hot flushes ? menopause) Dream � wet the bed *

14. Interventions 20 sessions of 1:1 psychological input Pharmacotherapy 10 sessions of group therapy � Anxiety Group

15. Medications Citalopram slowly titrated to 60mg

16. Anxiety Group 10 week Psychoeducational course - Anxiety (nature, causes, maintaining factors) 5 part model (CBT concepts) Management of anxiety related behaviours including avoidance Understanding the issues of Ageing Understanding and managing ongoing stressors including problem solving, assertiveness, self-esteem Stress Management and Lifestyle changes

17. Therapy Work - CBT approach Psychoeducation about anxiety Behavioural interventions aimed to improve self confidence and learn anxiety management strategies Breathing and relaxation Behavioural experiments (use of distractions, pleasurable activities Increase in involvement in community activities Increase independence and self efficacy

18. Therapy Work � CBT cont. Cognitive Approaches Learning to identify and evaluate negative thoughts to create more balanced thoughts Use of realistic thinking Use of positive coping statements Understanding of the underlying beliefs about contamination � problem as a being a �dirty person� rather than getting sick. Addressed overvalued ideas about threat of contamination Addressed underestimation of ability to cope

19. Therapy Work � ERP approach/ In vivo exposure Husband allowed to touch 1-2 items of clean clothing and Pam to resist re-washing these (Session 2-5) Graded Exposure Programme- Session 6 onwards Sofa Protectors Outdoor clothing Shopping Toilet Door handles

20. Therapy Work � ERP approach/ In vivo exposure Exposure to anxiety provoking stimuli �Spreading� the contamination Resist compulsive behaviours e.g. washing hands, cleaning Staying in the situation until anxiety reduces Repeat exercise until anxiety experienced is reduced

21. Therapy Work � ERP cont.. Cognitive strategies used during ERP Preparation phase - �I have done it before I can do it again� - �Its not REALLY contaminated� - �I have to move forward to get better� During phase �I can deal with it� �It feels uncomfortable but its only a feeling� �I can deal with feeling uncomfortable� �Its not a big deal�

22. Therapy Work � ERP cont.. After phase �I did that well� �I can deal with feeling uncomfortable�

23. Therapy Work � ERP cont.. Additional exposure exercises related to door handles

24. Therapy Work/ Useful Techniques Externalising anxiety � �contamination dragon� allowed Pam to argue/ talk back to obessional thoughts. Also empowered Pam to resist compulsions. Use of client�s language � discourse about the parallels between client�s religious faith (biblical passages/ stories) in relation to her own situation Addressing Avoidance and Safety Behaviours re: homework compliance

25. Therapy Work/ Useful Techniques Involvement of family members during assessment and treatment Rationale for ERP interventions clearly discussed, reiterated when necessary �Hand over� of responsibility for own recovery � being her own therapist

26. Outcome Measures YBOCS score 28/40 (severe) down to 19/40 (moderate) Pre and Post Anxiety Group GDS 1/15 down to 0/15 SAST 17/40 down to 13/40 Improvement as evidenced by change in behaviours related to contamination. Self report measures- 85% of old self. On YBOCS rated herself at 5/6

27. Outcome measures Sofa and couch protectors removed permanently Using toilet 75% of the time Disinfecting bathroom � twice weekly Doing washing once a week Touching door handles more frequently Shopping and socialising at least 3x weekly Spontaneous physical contact

28. Other gains Improved interpersonal relationships Lifestyle changes such as daily physical exercise, breathing and relaxation exercise, planning holidays

29. Conclusions CBT is an effective approach for late life onset OCD In vivo exposure was key to extinguishing compulsive behaviours Working with older clients involve some modifications of standard CBT/ ERP approach Tailoring the interventions for the individual

30. The end� QUESTIONS??