Treating Panic: Why it all started in the 80's

The 1980’s were the beginning of the “glory years” of cognitive-behavior therapy (CBT), in my humble opinion. After slow and steady advances in conceptualizing and treating panic, in the 1980’s, our understanding of panic really came together, especially in the CBT world. To understand modern approaches to treating panic, I’m going to walk you through some of the classic CBT texts on panic to show you how CBT researchers and practitioners developed the rationales and approaches that are now so commonly used. The foundational texts were written in the 80’s and as you may or not know, I love the 80s. So I am going to pepper this text with a few non sequitur references to that great time.

But first, let’s start in antiquity. Around 2000 years ago, around the “0080’s”, Epictetus, the Greek Stoic, when faced with racing, disturbing thoughts, advised us to say to that thought: “Impression, wait for me a little. Let me see who you are and what you represent. Let me test you”*. We learn by testing things out, by investigating, by becoming familiar with that which we fear. In the 8th century the monk Shantideva wrote a crucial Buddhist text called The Guide to the Bodhisattva’s Way of Life and in it he produced a similar sentiment as Epictetus in an even more pithy form by stating “everything is made easier through acquaintance”. At the heart of treating panic, and honestly treating all anxiety struggles, is acquainting with that which is feared.

Treatment of panic involves four major parts. The first part is education about emotions, thoughts and thinking and behaviors related to panic and the panic cycle. The second part involves working on cognition - reappraising the beliefs and ways of thinking that transmute body sensation anxiety into a panic attack. The third is interoceptive exposure - engaging with body sensations that you fear may cause panic. The fourth major part is real world exposures - engaging in environments that you fear may cause panic.

Cognitive-behavior therapy (CBT) has a history of relying on clinical and cognitive neuroscience and behavioral clinical trials to develop and test treatment approaches. Early outcomes from clinical trials have indicated that the fundamental strategies to treat panic involve: teaching individuals about the cycle of anxiety and panic, breath work, cognitive reframing, and relaxation exercises. But perhaps the most important treatment strategy is directly connecting with that which you fear. In clinical terms, we call this exposure therapy (I prefer the term “engagement” rather than exposure, but I’ll save that for another post). There are two general categories of exposure therapies - in vivo and interoceptive. In vivo exposure is just another way of saying engaging “in the real world” rather than while sitting in a therapy office. If your panic attacks tend to happen when you go to shopping malls or movie theaters, then treatment involves progressively working your way up to going to shopping malls to go to the Wherehouse to buy a “compact disc” of Freddy Mercury and Queen’s new album or a movie theater to see Ferris Beuller or Pretty in Pink (sneaky 80’s references). Interoceptive exposure refers to deliberately inducing in a progressive manner, unpleasant sensations (rapid heart rate for example) that might be related to triggering panic.

Education

Education, often called psychoeducation, is a primary treatment tool in all psychotherapy, but it is particularly important in CBT. Education about panic involves learning about anxiety on multiple levels - cognitive, emotionally, behaviorally, physically/biologically and also situationally. In CBT, psychoeducation often involves some discussion of the basics of learning. How do we learn to fear things and how do we learn to not fear things?

Reworking Beliefs and ways of thinking

Clark’s cognitive model of panic (1986) introduced a central term in the conceptualization of panic that emphasized cognition, or “thinking” in the development and in the treatment of panic. Clark emphasized that an essential piece in the cycle in of panic is a misappraisal of the meaning of a body sensation as being “catastrophic”. Clark starts by saying that panic can be induced physiologically through things like infusions of lactate or isoproterenol, inhalation of carbon dioxide or through voluntary hyperventilating. Clark then notes that these things rarely produce panic in people who do not have any history of panic attacks. He then suggests that it may not be the substances or activities themselves that induce panic symptoms, but the way the person psychologically interprets the meanings and implications of the symptoms they feel when intaking these substances or engaging in these activities. Clark states that some individuals tend to interpret unpleasant body sensations (dizziness, palpitations, shortness of breath) as having considerably more ominous or dangerous meanings that they actually do. Next, these folks intentionally or unintentionally engage in behaviors that amplify anxiety. Typically these behaviors include hyperventilating, repeating overthinking and focusing on symptoms of anxiety. This then loops back to the misinterpretation of the danger of these symptoms which then circles back to the “igniting” behaviors. This looping then leads to panic. What made Clark’s model so compelling at the time was the primacy of the interpretation of these bodily sensations as being catastrophic. This gave CBT therapists an “intervention point” - to focus on helping individuals become aware of these interpretations and then helping their clients re-interpret the meanings of these symptoms. Before this, psychotherapists tended to focus exclusively on helping clients seek insight into interpersonal relationships and early childhood as a treatment approach for treating panic. It’s hard to not over emphasize how revolutionary this way of thinking was for treating panic disorder.

Interoceptive Exposure

At almost the same time, another blockbuster paper came out written by David Barlow and his team and included exposure therapy into panic treatment (Barlow et al 1989). His team’s approach integrated Beck and Emory’s approach to treating anxiety by focusing on re-evaluating on cognitive appraisals, predictions and prescriptions about self, handling anxiety and anxiety-triggering situations. They emphasized teaching clients to use tools like analyzing faulty logic, reattribution and reframing, exploring alternative beliefs, practicing decatastrophizing, and using hypothesis testing in anxiety triggering situations. All bedrock strategies in CBT.

But Barlow also speculated that panic attacks were a learned response conditioned automatically through associative or Pavlovian conditioning and operant conditioning. Simply put, in the process of living life and having distressing experiences at times, benign or mild body sensations (like dry mouth, mild dizziness, stomach tightness) and/or external stimuli like a busy crowd at a mall become paired with a danger signal + panic response. Over time, these body sensations become a conditioned trigger for panic. For example, imagine you are at Starcourt mall (or in my case, the Glendale Galleria), walking to Hot Dog on a Stick to get their giant fresh lemonade (sneaky 80’s references) and you feel flush or dizzy. Why do you feel this way? Because it happens sometimes. You get up too quick, you are little dehydrated, or maybe you are just prone to mild dizziness. But automatically, you start to feel anxious because that sensation might remind you of a panic attack you had. The anxiety builds, you might even start focusing on “what if I have a panic attack right here right now in from of all these people? This could escalate into a full blown panic attack, or you might leave the mall to prevent a panic attack. This pattern of behavior strengthens the relationship between the sensations, the mall and a panic response.

Barlow and colleagues emphasized repeated exposure to these benign physical sensations that arise early on before a full blown panic attack develops as a way to help the body “relearn” that these sensations are normal and do not need to trigger a panic attack. These techniques involved “bringing on” specific physical sensations related to panic - like hyperventilating for 30-60 seconds to bring on rapid breathing or doing jumping jacks to bring on a sensation of elevated heart rate. They coined the term interoceptive exposure as a technique in which the therapist leads the client through a set of exercises meant to stimulate these physical sensations. By repeatedly practicing engagement with these sensations, clients begin to learn to break the chain linking these sensations to the onset of panic.

There are a variety of exercises that fall under the umbrella of interoceptive exposures and cover intentionally produced body experiences such as dizziness, shortness of breath and rapid heart rate. Lee and colleagues (2006) broke down these exercises into four categories: neurological, gastrointestinal, cardiorespiratory and dissociative. In his book on panic disorder (Taylor 2000) Steven Taylor compiled a list of 17 exercises such as spinning around while standing up with arms stretched for 1min, breathing through a narrow straw without breathing through your nose for 2 min, etc. These exercises are typically of a short duration and are practiced in session 2-3x during a session and then practiced at home 3-5x a week. Before engaging in these exercises, a client is asked what their beliefs are about triggering these sensations (I will not be able to handle it, I will be anxious for a long time afterwards, etc). Then by deliberately engaging in the triggering behavior, the client gets to experience an “expectancy violation” - i.e. the bad event either didn’t happen, or was less intense than expected, or was very intense yet the client learned to manage them. This produces new associations and new ways of thinking about the triggered sensations either automatically or through debriefing conversations with the therapist.

Real world Exposure

Reintegrating into triggering situations is the last major aspect of panic treatment. Where do people experience panic? In their bedrooms? In their cars? In restaurants? How can we help people work on getting back to being in these situations?

Real world exposures are conducted via a road map - a hierarchical listing of situations ranked in increasing distress intensity, with the most triggering situations listed at the top and the least triggering situations at the bottom. Therapist and client work together and start at the middle or lower middle of the list. Either in session or as homework the client practices being in those situations. Real world exposures are challenging - there are alot of variables at play. But they can be very helpful to clients. Therapists who work within the Acceptance and Commitment Therapy (ACT) framework of CBT prefer to scrap the hierarchy of feared situations and instead develop a listing of desired behaviors (going to a movie, taking a flight somewhere) and creating a roadmap to help the client engage these behaviors in those situations and not avoid being in situations they want to be in. ACT therapists emphasize that the most important factor in real world engagement is the desirability of being in the situation (“it’s important to me”) rather than the degree of distress the situation might trigger.

There is some indication that real world exposures are useful, but are NOT as essential to successful treatment as interoceptive exposures. Craske and colleagues (2006) compared interoceptive exposure treatment versus interoceptive + real world exposure treatment and found that the reductions in panic attacks were similar for both groups. Alessandro Pompoli and Toshi Furukawa (2017) published a review of 72 studies with a total 4064 patients with panic disorder. In their statistical review of these studies, Pompoli and Furukawa found that interoceptive exposure treatment had better outcomes than real world exposure treatment.

So, if you are getting treatment for panic, one take home message is that doing interoceptive exposures is very helpful and that doing real world exposures may be helpful, but you need to do the interoceptive exposures as well.

What about breath work or muscle relaxation? It works, people like it, but it doesn’t work as well as exposure.

Remember 5-4-3-2-1 breathing? Google panic treatment and you will find lots of write ups about how to do it. It seems like a reasonable idea that teaching people to slow their breath or to relax would be a useful technique for helping people with panic. Early treatment studies done in Barlow’s lab compared relaxation training versus cognitive therapy + exposure training (Barlow 1989) and found that both were clinically helpful in reducing panic attacks. But they noticed that cognitive training + exposure therapy group had a larger number of people reporting having zero panic attacks in the period after treatment was complete. Plus, a 2 year follow up study with the same sample found that the benefits of relaxation training did not hold up well over time, but the benefits of cognitive training + exposure training held up remarkably well and actually improved over time (Craske et al, 1991). This framed relaxation techniques as helpful but limited. These studies were ground breaking at the time but had very small sample sizes. Since those studies, many, many clinical trials seem to indicate the same thing. In the review analysis done by Pompoli and Furukawa (2017) examining 72 separate studies on panic disorder treatments, they found some interesting results on breathing retraining and muscle relaxation. They concluded that education, cognitive training and exposure therapy, specifically interoceptive exposure, were the best CBT strategies to use in terms of symptom reduction and remission rates and that muscle relaxation and breath focused strategies were the “least helpful” strategies for treating panic attacks. Yet they found that study participants liked having breathing retraining exercises to practice. So breath work helps, but not as much as you’d think, but people like doing them. So about 30 years after Barlow and Craske’s initial small pilot study findings on treating panic have held strong. Sorry to sound repetitive, but it will really help to do the interoceptive exposures. Don’t skimp on them!

The take home message

The 1980’s gave us the Showtime Lakers, Prince, Madonna, and fabulous fashion (remember Kajagoogoo and Spandau Ballet?). It also gave us the foundations of CBT based panic treatment and in the ensuing years, through a number of clinical trials and basic science studies have spelled out the important components of treatment. Psychoeducation, reworking how you interpret body sensations that are unpleasant and associated with panic, and interoceptive and real world exposures. Each component involves learning - learning about how our body learns to react with panic and perpetuate avoidance behaviors that strengthen the panic cycle (Barlow 1989), learning about the roles of cognitive appraisal in the panic cycle and how to work on it in treatment (Clark, 1986) and how engaging in exercises that trigger body sensations associated with panic helps our body learn new ways to handle these sensation instead of trying to escape or avoid them.

References

Alessandro Pompoli et al 2017. Dismantling cognitive-behaviour therapy for panic disorder: a systematic review and component network meta-analysis

Barlow 1989. Behavioral treatment of panic disorder

Clark, 1986. A cognitive approach to panic

Craske, Brown & Barlow 1991. Behavioral treatment of panic disorder: A two-year follow-up -

Craske, DeCola, Sachs, Pontillo Panic control treatment for agoraphobia

Taylor 2000. Understanding and Treating Panic Disorder: Cognitive-Behavioural Approaches. Link to the Book

* I read the Epictetus quote was in an excellent book by Donald Robertson called The Philosophy of Cognitive-Behavioural Therapy.

Through a mirror, darkly. Understanding Body Dysmorphic Disorder

What does it mean to be seen? How do we perceive our own appearance? How accurate is it? When I look at myself, am I really seeing what you see when you look at me? Is a photograph or a reflection in a mirror a real depiction of someone’s face? Is beauty or attractiveness objective? Is it subjective? A combination?

Misunderstood, under diagnosed and not properly recognized, Body Dysmorphic Disorder (BDD) is a difficult diagnosis. It involves an intense, repetitive focusing on a specific part of one’s body combined with the perception that that that body area is flawed or ugly. Skin, hair and the nose are the most common areas of focus, but a person with BDD can be preoccupied with almost any body part. Over long periods of time, a person with BDD can shift their preoccupations from 6-7 different body parts (see Wilhelm, Phillips & Steketee 2013). Typically, the body part in question is not typically viewed as ugly or flawed by others, yet what can be surprising is the strength of the conviction that people have about their perceived defects. Before CBT treatment, between 27-39% of people with BDD state that they are completely convinced about their perception of is accurate and not distorted at all (Phillips & colleagues, 2008). Along with these perceptions come a time consuming or life impacting set of behaviors centering around evaluating, covering up or fixing their appearance or avoiding situations in which they will be triggered because of their appearance.

Population studies suggest a 1-2% prevalence, meaning that 1 or 2 people out of 100 currently have BDD. If you don’t think that’s a lot of people, keep in mind there are 10 million people in Los Angeles County, so that means there are probably about 200,000 Angelenos with BDD right now. Older studies done in dermatology clinics and cosmetic surgery clinics found that rates of BDD range from 9-53% of patients (Wilhelm & colleagues, 2013, pg 11) and that people with BDD can get multiple procedures done and are consistently dissatisfied with the results of those procedures.

Do we know a lot about BDD? Yes. Could we learn much more? YES! To give you a flavor for how under studied BDD is, I did a quick PubMed search on scientific papers published with a keyword of BDD and compared it with OCD and major depressive disorder.

It’s clear from the graph above there aren’t many studies BDD. From 1950-1990 there were just 39! That’s about just one published paper per year. Compare that with over 3000 published papers on OCD during the time period. That’s 10x more. And forget about the number of papers on depression; there were about 530 papers published on depression for every one paper published on BDD.

Although understudied, there are some very good studies on BDD. Modern conceptualizations of BDD probably got their start in Genoa Italy around 1891, when Enrico Morselli coined the term of “dysmorphophobia” after doing case reviews of 78 patients. He described it as a “persistent idea of deformity combined with tremendous anxiety about that awareness” (Fava, 1992). Morselli wrote extensively about dysmorphophobia but only recently has BDD been a more commonly talked about disorder. In their excellent overview, Sabine Wilhelm, Katharine Phillips and Gail Steketee write that patients with BDD “are convinced that they are physically deformed and are reluctant to initiate or stay in psychiatric treatment” and “they need more intensive engagement and ongoing motivational interventions.” (Wilhelm, Philips and Steketee, 2013).

Details vs Holistic awareness

Exactly how one comes to get stuck on a flaw in their appearance is not exactly as you would expect. The strength of the belief that one’s skin is flawed is not hallucinatory delusion, but may actually stem from a razor focused ability to notice details combined with poorer holistic visual perception. Neuroimaging studies by Jamie Feusner and his colleagues have consistently shown that people with BDD are better able to recognize facial details than comparison control participants. Early studies showed that when it came to looking at human faces, patients with BDD had left hemisphere hyperactivity in higher-order, detail specific visual processing regions compared to non-BDD control subjects and less brain activity in front-striatal visual processing areas associated with holistic, contextual visual processing of facial features. So although patients with BDD were very good at noticing facial details, they were not good at noticing “gestalt” aspects of facial expressions. Later imaging studies found that BDD patients showed the same pattern even when not looking at people but at pictures of houses. Good at noticing details, not good at noticing the big picture.

CBT for BDD

Wilhelm and colleagues outline a treatment approach for BDD that has four core interconnected parts: awareness of maladaptive beliefs, exposure and response prevention, perception retraining, and reworking problematic deeper held beliefs about the self. In our approach at Spectrum CBT we promote and prioritize an essential additional piece which is a focused examination of the behaviors and habits involved in thinking. So not just what you believe, but what and how you think about things in your daily life.

Awareness of maladaptive beliefs

Each of our minds are so active, so talkative, that what we see, hear, touch and taste is an augmented reality. Our sensory experiences of people’s smiles, the shapes of their eyes and the sounds of their voices are augmented with memories, stereotypes, reminders, agendas. Our mind refashions sensory experience through our internalized anticipations, feelings and beliefs. “People often judge appearances”, “being attractive all the time is extremely important”. These beliefs color and shape our experience. So you and I could be talking and we could perceiving our conversation in very different ways.

In CBT, we like to use jargon like “maladaptive”. What this specifically means is a fusion or a pairing of two concepts: usefulness and a better approximation of realness or truth. TRUTH! It’s hard to figure out what’s really true and I’m not a philosopher, so I’m not going to spend too much time on truth. I don’t know if the X files are right. I don’t know if truth is out there. I don’t know if truth is knowable. But a foundational piece of being scientific and employing the scientific method is that there is an order to things, that through observation we can learn and improve our understanding of how things work. In CBT we apply this mindset to ourselves. There is an order to us, and we can learn and improve our understanding of we work and how others work. But more importantly, maladaptive relates to the concept of usefulness. Is this action useful? Is this thought useful? And then useful for what? Useful for keeping me miserable? Useful for helping me navigate life’s challenges? Maladaptive then are beliefs

Exposure and Response Prevention

I don’t like the term exposure and response prevention. It’s like saying “groovy”, “tubular” or “awesome”. There was a time and place for it and now it sounds old. I prefer “behavioral engagement”. How do you engage in tricky life situations? What beliefs wake up and become prominent? What habit urges kick in when you are challenged? And how can we work on shifting and improving these habit and approach styles? Through practice; intelligent, focused practice. Not haphazard, but thoughtful; not focused on flooding and overwhelming people so that their anxiety will go away, but focused on teaching people how to approach and handle situations differently so that they can work through them fluidly and much more effortlessly. Engagement is a form of learning by doing, like bike riding. You don’t read about riding a bike and you don’t talk about riding a bike. You practice riding a bike. Sometimes learning something is really hard so it helps to have someone to help you learn it. That is exposure and response prevention.

Perception Retraining

When you look in the mirror, what do you see? It should be an easy answer. I see myself. But, that answer hides a deeper more complex answer. The real answer is, it depends.

Sometimes I see my face, sometimes I see how I have aged, sometimes I see my nose hairs, sometimes I “don’t” see my nose hairs. The act of perceiving almost seems to toggle between between a “detail” mode and a “holistic” mode. Some people may perceive faces in a more detail-focused way and others may perceive faces in a more holistic-focused way that integrates visual information and emotional expression. People with BDD seem to perceive faces in a much more visual, detailed manner (Feusner et al, 2007, JAMA Psychiatry). People with BDD also tend to view these details and then habitually compare and evaluate details of faces. You could say that having BDD involves a tendency to automatically be in detail-mode and difficulty getting into holistic mode; plus, while in detail-mode, people with BDD also view certain details (their nose, their eyes) through an evaluative good/bad filter rather than an observant, descriptive, nonjudgmental filter. A goal of perception retraining would be to help individuals practice using that non evaluative filter instead of the default judgmental filter.

Beliefs about the self

In basically any form of therapy, we bore down into the deep of who are you? Or perhaps a better way to put it is, who do you THINK you are? Often we will find that we hold some dark, problematic views of our self and BDD is an outer manifestation of that and a perpetuating cause of those dark views. So in CBT we explore what those views are. What are those core beliefs about yourself? Chances are you hold competing views of yourself (capable vs incapable; lovable vs unlovable) and sometimes the negative, nastier views of self are more dominant, more active, and are fed more “juice” than the more positive views. So can we devise mechanisms for alternative core beliefs to get some energy? To get some sunlight?

Maladaptive habit-based thinking

Thinking is complex set of mental behaviors and just like any other set of complex behaviors like walking, running, dancing, cooking, eating etc, we have the capacity (really the necessity) of chaining simple behaviors together to form a whole-integrated pattern that then becomes fluid and feels “natural”. Then this behavior set can be linked to specific cues in our environment based on location and time. As an example, at night, I develop a routine of putting on pjs, brushing teeth and reading in bed. This becomes a habit. If I deviate from the habit, I become uneasy. Habits are behaviors that stimulus triggered and produce a feeling of resolution when I complete the habit. Thinking types - reviewing, planning, comparing, explaining, problem solving can become thinking habits. Thinking habits that I do too much, do at the wrong time, or habits that I do poorly. Habits can be helpful or problematic. If someone has BDD, they probably have thinking habits that are very problematic. So part of our job is to examine what these habits are and work with a person to start deconstructing these habits and see if we can replace them with better ones.

REFERENCES

Fava, G.A. 1992. Morselli’s Legacy: Dysmorphophobia. In Psychotherapy and Psychosomatics, Vol 58.

Feusner et al., 2007. Visual information processing of faces in body dysmorphic disorder. Arch Gen Psychiatry Vol 64.

Feusner et al 2011. Abnormalities of Object Visual Processing in Body Dysmorphic Disorder. In Psychological Medicine, Vol 41.

Wilhelm, Philips and Steketee, 2013. Cognitive-behavioral treatment of BDD. Guilford Press.

Phillips, Didie, Feusner & Wilhelm, 2008. Body Dysmorphic Disorder: Treating an Underrecognized Disorder

Why Intensive Treatment for Obsessive-compulsive and Anxiety disorders works

There was a time when successful treatment of OCD was considered almost impossible. This is born out by a quote by the psychiatrist Charles Breitner (1960) who wrote “most of us are agreed that the treatment of obsessional states is one of the most difficult tasks confronting the psychiatrist and many of us consider it hopeless”.

The first published study using exposure and response prevention that I could find was a series of case studies by Victor Meyer (1966). He reported very positive results from two case studies with people who were admitted as inpatients to his psychiatric ward at Middlesex Hospital in London. Both cases involved daily treatment during their hospital stay. So it seems reasonable to say that the first successful case studies of behaviorally treating OCD were “intensive” treatments. Intensive referring to the frequency of treatment being daily or multiple times per week. The fact that Meyer was able to achieve treatment success and that these successes persisted over a year later was a remarkable achievement at the time.

Soon after Meyer, other the research labs led by Stanley Rachman, Paul Emmelkamp and Edna Foa all started publishing studies on what eventually became called exposure and response prevention (ERP). Behavioral scientists started to migrate treatment to outpatients, typically done in sessions once a week. But relatively quickly, it became clear that daily treatment for a short period of time was extremely effective and in addition, for some patients, once a week of ERP did not seem to be sufficient (Steketee, 1987).

So it’s clear that intensive treatment works and works fast. In as little as 3 weeks to as long as 8-10 weeks, patients can see reductions in symptoms of over 40-50%. Since those early days, intensive treatment has become a mainstay for treating OCD.

It seems likely that not only is it faster, but intensive treatment might be better than 1x a week outpatient therapy for OCD. A recent paper suggests that intensive treatment may produce stronger treatment effects than once a week treatment. Hjalti Jonsson and colleagues compared four studies that were head-to-head comparisons of intensive (5x a week) vs weekly treatment. Each of these studies standardized the number of treatment hours so that every patient got the same number of treatment hours. But some got them in an intensive/daily format, and some got them once or twice a week spread out over an extended number of weeks. Their findings show a significantly stronger treatment effect (also called effect size) for intensive treatment.

Why might this be? Perhaps practicing learning new skills (like how to manage overwhelming anxiety) is well suited for frequent “squeezed together” practice, rather than practicing in spread out sessions. Keep in mind that spaced, weekly sessions do help ALOT and do work. but working in a concentrated fashion might be even better.

References

Breitner, C. Drug therapy in obsessional states and other psychiatric problems. In Diseases of the Nervous System. 1960 Vol 21, pgs 31-35.

Emmelkamp P & Rabbie, DM. Psychological treatment of obsessive-compulsive disorder. Book Chapter in Biological Psychiatry. 1981

Foa, E. Steketee G., and Ozarow, BJ Behavior Therapy with Obsessive-Compulsives. In Obsessive-Compulsive Disorder. 1985, pgs 49-129.

Jónsson H. and colleagues. Intensive cognitive behavioural therapy for obsessive-compulsive disorder: A systematic review and meta-analysis. In Journla of Obsessive-Compulsive and Related Disorders. 2015 Vol 6, pgs 83-96.

Marks, IM, Hodgson, R, & Rachman, SJ. Treatment of Chronic Obsessive-Compulsive Neurosis by in-vivo Exposure A Two-Year Follow-up and Issues in Treatment. In The British Journal of Psychiatry. 1975 Volume 127, Issue 4, pgs 349-364.

Meyer V. Modification of expectations in cases with obsessional rituals. In Behaviour Research and Therapy. (also known as BRAT ;) 1966 Vol 4, 273–280.

Steketee G Behavioral Social Work with Obsessive-Compulsive Disorder. In Journal of Social Service Research. 1987 10:2-4, 53-72

Why video sessions work

A common and reasonable concern for people starting with us is whether remote, video sessions for psychotherapy and cognitive-behavioral therapy (CBT) in particular are helpful. It turns out there is a good amount of research on these specific questions that demonstrate that video sessions actually work very well.

In a comprehensive review of 103 research studies, Fernandez and colleagues report that “video” psychotherapy is as effective as in person therapy, regardless of the type of talk therapy (Fernandez, Woldgabreal et al, 2021); but even more that that, CBT based video therapy seems even more effective. In their paper, the study authors emphasize that video therapy seems to be particularly well suited to CBT.

In the past year, we have exclusively focused on video based CBT treatment for OCD, specifically exposure and response prevention (ERP). We regularly get phone calls and emails from people who think that remote therapy wouldn’t work well for OCD. In our experience this is not at all the case and this is consistent with published studies showing the effectiveness of remote therapy for treating OCD. Bethany Wootton published a meta analytic review in 2015 on exactly this topic. She looked at results from 18 studies and found that remote treatment (video or telephone) led to significant improvements in OCD symptoms that were similar to in person treatment.

Wootton describes a few advantages of video based CBT. The first is that distance from the office is no longer a factor. Pre 2019, it would not be usual for people to come to the clinic after an hour long drive. If you lived 2-3 hours from us, you were out of luck. I had one client whose commute time was 2 hours to come see me. Yikes!

Another important factor that is specific to treating OCD is that we get to see clients in their home environment. This can be helpful because we get to conduct exposures in people’s home. Although it’s not true for everyone, but typically OCD flourishes in the home environment so working on it directly in that environment is really useful.

A third important piece is that we get to use the computer. Spreadsheets, whiteboards, sharing documents to read over are all really useful. We can do that in person too, but via video it becomes much easier. This is really great for tracking homework in that we can mutually go over what’s working and what’s not working in terms of getting homework done.

There are downsides however. The most basic one is privacy. Some people live in homes or apartments where privacy can be difficult. Privacy is vitally important to therapy because we have to have a talking area where you feel comfortable airing things out. And some of the things you air out may not be flattering to yourself or to others. But to get some honest work done, we need to put this stuff on the table. Feeling like you don’t have a private area can pose significant problems with that. These issues often have work arounds. People can use headphones, or can ask family members to not be in the house for the hour.

Some people can get distracted doing video therapy. They get text messages, email notifications, they get tempted to surf the web. The good news is that this is workable and an assertive therapist can point out that they notice the client seems distracted. Usually calling this out a couple times does the trick.

Lastly, some folks are just not tech savvy and are not interested in becoming more video or tech savvy. Ultimately, this is understandable. It is your choice.

The COVID-19 boom in video meetings, overall in my opinion, for therapy, has forced us to invest and really try out doing video therapy and to take advantage of its unique positives it offers while also making us aware of its problems. But even before COVID-19, a number of research studies clearly have shown that video CBT works very well; in fact so well, that it should not be considered a second tier alternative to in person therapy but on par with in person therapy.

REFERENCES

Ephrem Fernandez et al. Live psychotherapy by video versus in‐person: A meta‐analysis of efficacy and its relationship to types and targets of treatment In Clinical Psychology & Psychotherapy. 2021 Apr 7. doi: 10.1002/cpp.2594.Online ahead of print.

Bethany Wootton. Remote cognitive–behavior therapy for obsessive–compulsive symptoms: A meta-analysis. In Clinical Psychology Review. Volume 43, February 2016, Pages 103-113

Listening better

I have a habit of looking at my dog and talking in a “dog” voice. “Yum that chimkin sure lookin good”. It really gives me a lot of enjoyment. I don’t really know why. It’s a bad habit that would probably weird out any house guests that we have.

Then I discovered that there are scores of people that do the same thing and post videos on instagram about it. And, I can scroll through instagram enjoying doge memes. It’s not healthy. And lastly, I hate to admit it, but I understand why Christophe talks to his reindeer. We all are doing that stuff. There’s something completely, uniquely human about talking. I even talk to myself!

But sometimes all that talking is just too much. We are just TOO GOOD at talking. Let’s get better at listening. We could all hone our listening skills a fair bit. When people are struggling with OCD, anxiety, depression, or other mental health issues, they need to be heard. That comes first. That’s hard to do. Before advice or opinions, listening comes first. So let’s agree to prize listening; to restore its place at the center of connecting and talking to each other.

Listening well involves something obvious - hearing what people say. And something not so obvious - telling and showing the person that you hear them. Giving your attention is a precious gift! Give it generously. Some problems are not fixable, or aren’t fixable right now. That is exactly the time that we need to know we aren’t alone. We need to know that someone sees and hears us. Sees what we are going through. We aren’t struggling and suffering alone. When someone listens - I don’t feel as alone. It may not get rid of my ache, but yes, something does feel different, perhaps my ache feels more bearable.

Listening isn’t passive. It’s work! Im not analyzing or evaluating or interpreting when I am listening. I am focused, attentive. I am communicating I am listening by saying things like “Sounds like you are saying....” or “I hear you”. When we listen actively, we encourage conversation with open questions - we inquire. The vibe is gentle, and we don’t press or push. I know it sounds cliche, but I like to listen with some open questions like “when that happened, how did that feel?” Also, asking with a “how” is ALOT better than a “why”. Most of us don’t like “why did you do that?” We like “Oh no! how did that happen?” a little more. It’s hard to feel heard if I am spending time trying to defend myself.

Problem solving, blaming - do you know who did this? Sometimes we just want to figure out who screwed up. We want someone to take responsibility or the blame. That’s fine - but it isn’t good listening. If you want to getter better at listening, put the blaming hat away for a while and put on the “I hear ya” hat. Sometimes it’s a relief to just not have to talk as much. We can listen too.

Dark Thoughts

To understand dark thoughts we need to wipe away our existing notions of the words and approach things with a fresh set of eyes. Let’s examine things with an open, inquisitive mind. 

 Mental experiences 

Obsessions exist in the realm of mental experiences. They are subjective. I can’t tell what’s going on in your head - but you can.  Similarly, you can’t tell what is going on in my head. But we can agree that there are types of mental experiences. Here’s something I’d like for you to play with: the user interface of the mind is built to simulate social interaction between two people. For example, I can talk to myself. Talking to myself involves speaking, internally to myself. My self or mind can talk back to me. It can communicate with me verbally (eg “Remember to mail that letter”) .  

In addition to verbal interactions, my mind can communicate to me in other ways - with emotions. So what exactly is an emotion? We can slide down a slippery slope easily on this one. I will take a stab at a generic description for now (for more on this, Paul Ekman and Richard Davidson have a thoughtful book called The Nature of Emotions). Let’s say emotions are subjective, perceptual “states” of being that feel pleasant or unpleasant, with varying intensity. They can be brief or longer lasting, they have a “motivational” quality - in that they propel us to certain actions. They also have a social, communicative quality in that I might feel the urge to share or “let out” something or often others can guess or relate to what I am feeling. 

Emotions are like colors - there are some primary ones and then there are an incredible assortment of blends.  In OCD, the dominant emotions are anxiety, fear, panic, shame and disgust. Back when I was in academia, I had a conversation with a friend of mine who was trying to do a research study on emotions and the kinds of thinking that arises with specific emotions. One day I ran into him in our office hallway and he looked really frustrated. I asked him what was going on. He told me he was having trouble with his study because it was extremely difficult to devise aa procedure that cleanly and consistently produced a single emotion. “There’s always other stuff going on!” He told me that people might be anxious but also irritated; or a little sad. My take home message from this is that emotional experience can be simple at times, but a considerable amount of times it is complex. Sorry to make things even more complicated, but in OCD, people can feel considerable anxiety, panic, or fear about experiencing anxiety, panic, or fear. These “meta” emotions are emotions about an emotion. “I’m angry that I feel scared” or “I’m ashamed that I feel so panicked”. or “I’m nervous that I might get scared”. So besides verbal interchanges, our mind can communicate with us with emotions, and with emotions about emotions. 

Our mind also communicates with us via intuitions and urges. An intuition can be thought of as emotion-laden sense of “knowing”.  Here are some examples of types of intuitions: “I just know that this is the right thing for me to do”; “I have a feeling that something bad is going to happen”. Closely aligned with intuitions is another type of mental experience: urges. When partnered with emotions, urges are strong propellers of action. “I need to get out of here”. An urge is almost like an unpleasant feeling about being inactive coupled with a “promise” that some goodness will arrive if I engage in a specific action. Let’s look at thirst. I once was hiking on a trial in the Grand Canyon and ran out of water. My mouth was parched and I felt this uneasy dry mouth feeling - I’d also get images of being at the Canyon lodge cafeteria drinking a tall tumbler of water filled with ice. I could visualize it and it looked so gorgeous and I could feel that cold rush that would happen as I tipped the glass and felt the water gloriously run through my body. Do you know that feeling? So urges have this dual action of uneasiness with the present combined with a sense of fulfillment when the desired action is taken. 

 So let’s summarize. We talk to ourselves. We talk to our mind and our mind talks back. Our mind is not a unitary virtual person, but instead a variety of characters. Our mind communicates with us conversationally with words, with images, with emotions, with urges, with intuitions. See where I’m going with this? So far so good. But we haven’t addressed obsessions, compulsions, and all that good stuff. But before I do, first let’s characterize a few more players. 

 The negative propaganda machine

I’d like to propose to you that  our minds have certain pumps; these pumps pour specific kinds of thoughts into our consciousness. I had the good fortune to be listening to an interview with Bill Nighy, a British actor who has been in a number of movies that I really like. This was back when I used to listen to radio. Remember the radio? Anyway, the conversation turned to depression and he described an inner voice he struggled with - he called it the negative propaganda machine. He described how it would fill his mind with dark, critical, horrible statements about himself; about his work, relationships and about his personhood. I could relate to this. What is this thing? This soulless machine pumping negative junk into my mind space. 

Negative Automatic Thoughts

 The negative propaganda machine was a central piece to the pioneers of cognitive-behavior therapy. In the formulation of what would eventually become cognitive therapy, Aaron Beck wrote that a depressed patient he worked with “consistently embraced a negative construction of himself and his life experiences”. These negative constructions included negative judgments of the world, the future and oneself. Today, psychologists 

who specialize in CBT are interested in thoughts or thinking that have specific attributes. Early on in the development of CBT, researchers were interested in negative, automatic thoughts (NATs): automatic spontaneous thoughts about the self, self-efficacy and the future (“you are a loser”; “you will never succeed”, “you are going to become destitute and alone”). These thoughts “pop into” awareness, sometimes out of the blue, but often are triggered by situation you are in or what you are thinking about or doing. They seem to revolve around themes of loss, failure and danger. NATs are common, especially in depressive and anxiety disorders.  NATs show up verbally; to the person experiencing NATs, the NATs seem believable and the person may even agree with them at times (“I really am hopeless”). 

 So far, we’ve speculated that my mind and I communicate with each other. My mind is complex and communicates in a variety of ways (via thoughts, images, urges, intuitions) and there are “pumps” that infuse my consciousness with specific kinds of ideas, images, urges or intuitions. One such pump is the negative propaganda machine that pumps NATs - negative thoughts about myself, my world and my future into my awareness. But in this story, there is another pump and it is even weirder and freakier than the negative propaganda machine. 

The slime machine

 Slime is popular these days. Kids like to make homemade versions of it. But I think it is gross. I don’t like it and if I get some on my hands, I will try to get it off as quickly as possible. Merriam-Webster offers up two curious definitions of slime- a viscous, glutinous or gelatinous substance and a morally repulsive or odious person. One definition is a physical phenomena and the other is a mental or social phenomena. And just like the Nickelodeon channel’s tendency to drop slime on people’s heads, we have a slime pump that drops slimy thoughts into our consciousness. 

 Disturbing, unwanted thoughts. Where do they come from? What do they want? What are they?

 Thoughts like: “What if I left the door unlocked and an intruder is inside?” “What if I drove off the road right now?” “What if I had an impulse and caused a scene?”

 73 - 60 - 45.  These are the percentages of people who report that they have had the above disturbing thoughts frequently (if you have access to it, the research study was reported in a paper by Purdon and Clark in 1993 in Behavior Research & Therapy). 

 But wait there’s more.  In their study they found that 21% of a random sample of young adults reported being disturbed by thoughts like “When I see a sharp knife, I have the thought of slitting my wrist or throat”. 48% reported having unwanted thoughts about running over pedestrians or animals while driving; 19% had frequent unwanted thoughts about exposing themselves in public  and 55% reported unwanted sexual thoughts about a  boss, teacher or other authority figure.  Whoa! What’s going on here? 

 A more recent series of papers reported findings from an international multi-site study on bad slimy thoughts. Psychologists and psychiatrists call these types of thoughts intrusions. It looks like the slime machine pumps in intrusions in almost everyone. 96% of people in Turkey, 97% of people in Hong Kong and 100% of people in Iran who participated reported having these kinds of intrusive, disturbing thoughts in the past three months. Sadly, North Americans, South Americans and Europeans too had percentages ranging from 84% to 100%.  Remember these participants were drawn from the general population, not a mentally unwell subgroup. Radomsky and a large group of coauthors summarized their findings in the Journal of Obsessive-Compulsive and Related Disorders in 2014. 

 Just like the propaganda machine that pumped in scary, depressing, hopelessness generating thoughts about ourselves, our world and our future, it seems like the slime machine pumps in weird, disturbing and shocking thoughts. Although nearly everyone seems to have these thoughts there are occasional. Thankfully the slime machine doesn’t repeatedly dump their minds with sludgy, slimy thoughts. 

 But what if it did?

Obsessions

Some people get deluged with disturbing thoughts that they struggle mightily to get rid of.  We can imagine that their slime machine is big and nasty. Let’s call these kinds of thoughts obsessions. 

 In contrast to intrusions, that are experienced by virtually everyone, obsessions are different. Obsessions are more frequent, associated with stronger negative emotions, are considered more meaningful, and come with a much stronger urge to resist. 

 An unresolved puzzle is whether obsessions are intrusions that morphed into obsessions, or whether they are two separate things that have some similarities. We can explore that down the road, but for now, suffice it to say that our minds communicate with us via thoughts, images and impulses. Also, our mind has a few mental machines that squirt thoughts into our awareness. Some are like NATs, some are intrusions, and for some people, there is an obsession machine. 

 David A. Clark (in Cognitive Behavior Therapy for OCD, 2004) writes that obsessions have five attributes. They are: 1) intrusive; that is to say, the thought, image or impulse enters awareness “against one’s will”; 2) unacceptable - they are distressing in varying intensity to the person having the obsession; 3) accompanied by an urge to resist, the person feels a strong urge to resist, suppress, dismiss the obsession from conscious awareness; 4) uncontrollable , a person senses that their ability to control or suppress the obsession is i too brief or ineffective; 5) ego-dystonic meaning the obsession can (but not always) involve ideas that might be threatening to one’s sense of self or violate one’s sense of values or morality.

 There is one last quality to obsessions that make them stand out: the person experiencing them can have trouble distinguishing the obsessional mental experience from tangible reality. A thought feels like reality. If I have a thought that I might be a child molester, I may actually feel like I am a child molester. If I see an image of a spider, I actually feel like I am seeing an actual spider. This blurring of the lines between external reality and subjective experience is extremely disturbing to the experiencer. Some people have described to me that at times, when anxious, they feel like they have a split brain - one part that “sees” that what is going on and realizes it is irrational, and another part that “feels” the obsession is real. The path to getting through and managing OCD can be difficult. But starting with a willingness to learn and understand what obsessions are and how our minds tend to work can help in making the route clearer.