Checking in OCD

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Checking in OCD

• Dr Alice Hooper
• Chartered Clinical Psychologist
• South London Maudsley NHS Trust
• 22nd November 2008

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Aims of Today

• To understand why checking becomes a problem in
  OCD
• To understand cognitive behavioural therapy
  techniques useful for checking
• Audience participation!!!

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• What would you like to get out of this workshop?

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Suggested 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

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What 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

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Obsessions

• 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.

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Compulsions

• 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

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How 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

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Small Group Discussion

• What do you check?
• How often do you check?
• How does checking help?
• How does it affect your life?

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CBT 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

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CBT 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

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CBT 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.

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Safety 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

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Small Group Discussion

• What safety nets do you use?
• How do they help what are the advantages?
• Are there any disadvantages?

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CBT 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
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Trigger
Activates Beliefs
Normal obsessions become focus of responsibility
Worrying thoughts about what obsessions mean
Compulsions to put things right
OCD
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What 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.

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Checking

• 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)

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Examples 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

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Checking 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

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Who 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?

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Safety 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

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Elevated 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

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• 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

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Elevated 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

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EER

• 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)

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EER

• 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

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• 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

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Exercise

• 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?

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Vicious 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
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Memory 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

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Psychological 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).

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Cognitive 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

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What 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

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Exposure 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

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A 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

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Fight 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

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Who 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?

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Some 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?

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Testing 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

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Challenging 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?

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Responsibility 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

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Common 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!

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Taking 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?

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Small 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?

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Summary

• 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

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Summary

• 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

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Summary

• 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

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Changing 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

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Possible 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)

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My 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