Anxiety & Related Conditions

OCDs are often anxiety-based fear disorders and what we want to do is help patients overcome whatever fear or fears they may have. Compulsions can be anything from excessive hand washing, to needing to organize things in a certain extremely precise way, to repeatedly checking things — “is the door locked, is the stove off?” Obsessions can be worries about the compulsions, such as “I’ll get sick if I don’t wash my hands!” and also can be intrusive thoughts or images often having to do with what a person perceives as forbidden or taboo subjects, or aggressive thoughts that may involve harming themselves or someone else.

The core component of treatment is exposure with response prevention. This means exposing young people to whatever is scary to them without their reacting with their ritual or response. By learning to do that, they can teach themselves, “Oh, maybe this thing isn’t as threatening as I thought it was, or this feared outcome won’t happen.” The more you practice, the more likely it is that you extinguish the fear, or learn that you can handle the feared outcome.

So let’s take a classic example — excessive hand washing: a teenage girl is fearful of germs, unable to eat without the repetitive hand washing she believes will protect her from getting sick. First, we’ll do a complete evaluation to make sure we fully understand what she’s afraid of, what her rituals are, what she’s avoiding touching, how much she’s washing her hands, et cetera, and we’ll also do some psychoeducation. Patients need to understand what OCD is, what is anxiety is, and how cognitive behavioral therapy works. So, psychoeducation is not just a precursor to treatment but an important part of the treatment itself.

Then we move on to cognitive restructuring, in which we ask patients to re-evaluate their thoughts to try to make them more realistic, along with teaching relaxation and problem-solving techniques. But what I like to think of as the active ingredient is exposure to whatever the person is afraid of.

In the example of hand washing, we’re going to ask this patient—slowly, at a level she can handle—to touch things she thinks are dirty. We might start with asking her to touch a tabletop and then eat with her hands without first washing.

We might even proceed to more “disgusting” things like touching the floor or touching a toilet to show her that she can face her fears fully and be okay. Eventually, she will be able to do this on her own.

There has been a lot of research over the past decade that shows you get the same results whether you do treatment weekly or intensively: you can get the same outcome if you do 12 weeks of treatment, one hour a week, or do 12 hours of treatment within a single week. The idea is that condensing treatment doesn’t make it less effective.

And certain people like it better — knowing that they are likely to experience tremendous improvement in a week or two. This can be especially appealing to families and youth who are suffering greatly and are desperate for symptom relief. If a young person’s ability to function is so impeded that, for example, he can’t go to school, it’s wonderful to have this opportunity to achieve results rapidly.

We do have flexibility in the way we apply treatment strategies—and the schedules during which we apply them. None of what we do is one-size-fits-all. We offer three to ten hours of treatment sessions per week, including group, individual, and family sessions. Our child and adolescent after-school programs have groups that meet three times a week, along with individual, and family sessions that can be adapted to the participants’ schedules. Our program for young adults involves one or more clinicians from the Youth Anxiety Center.

Yes. Depending on the young person and what his or her needs are, parents and families may be present. We do want to make certain that families are actively involved in both understanding and supporting the treatment. However, we personalize our approach to each individual and his or her issues and life situation.

I’d say that families can sometimes get very wrapped up in accommodating symptoms believing they are being helpful. These attempts to alleviate distress come from a place of caring but can end up “feeding the OCD monster” by depriving a young person of the opportunity to learn how to face and manage their fears on their own.

There are scales used in research studies and for clinical purposes called the Yale-Brown Obsessive Compulsive Scale (Y-BOCS), and the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS) that look at a person’s obsessions and compulsions, how much time they take up and interfere in someone’s life, how much control a person has over them, and other areas of impairment. It’s a very reliable measure of the severity of symptoms. In the Intensive Treatment Program, we administer these scales at the beginning and end of treatment and we’ve had excellent results. Over 85 percent of patients with OCD completed a full course of treatment as recommended, with the remainder switching to a different level of care. The patients with a primary diagnosis of OCD who completed the program as recommended showed an average 46 percent reduction in their score on these scales, which is really huge—82 percent of these participants met responder or remission status.

We want the program to grow and evolve to match the needs of our patients. We also want to incorporate a training component so that other clinicians can learn our techniques and take them beyond our walls to more young people and families.

And, naturally, we want to recruit additional clinicians so that we can expand the program here. It’s wonderful to see changes in kids who have been suffering for so long — and we need to help more of them.

Read more https://www.nytimes.com/2018/08/13/health/ocd-concentrated-therapy-cbt.html