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OCD Action - Guided Self Help – Karina Lovell

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OCD Action - Guided Self Help – Karina Lovell

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OCD Action - Guided Self Help – Karina Lovell

  1. 1. Guided self help for Obsessive Compulsive Disorder Professor Karina Lovell
  2. 2. Aims of the workshop    What is guided self help? Does guided self help work in OCD? How is guided self help applied with someone with OCD
  3. 3. Obsessive compulsive disorder     OCD is a major disorder and under recognized public health problem. Obsessive-compulsive disorder can occur at any age but most often presents for the first time in adolescence Lifetime prevalence (1.9-3.0%) There is evidence that without adequate treatment the disorder tends to have a chronic fluctuating course
  4. 4. Obsessions Obsessions are repetitive, recurring thoughts, ideas, images or impulses that are experienced as intrusive and are usually distressing or anxiety provoking. Such thoughts are often centered on dirt and contamination, accidental harm, illness, aggression, sex, orderliness and perfection.
  5. 5. Compulsions Compulsions: (rituals) are repetitive and intentional acts and serve to reduce anxiety the thoughts provoke. The person recognizes that their behavior is excessive or unreasonable.
  6. 6. Obsessions and compulsions Obsessions  Bodily fluids  Asbestos  Unspecified germs  Disease specific  Radiation  Animal specific Compulsions  Washing excessively  Avoidance  Reassurance  Magical numbers
  7. 7. What is guided self help     A self-administered intervention Involves a health technology (book, computer, audio tape) Facilitated by a health professional Role of facilitator is to guide, support, review and monitor
  8. 8. What is guided self help   GSH is one of many interventions deemed a low intensity intervention Others include, telephone, computer delivered, groups and internet delivery.
  9. 9. Rationale for alternative delivery systems      Does not meet policy recommendations Lack of therapist’s Traditional service delivery Poor access High waiting lists
  10. 10. Stepped-care model  The model provides a framework in which to organise the provision of services in order to identify and access the most effective interventions  Stepped care attempts to provide the most effective but least intrusive treatments appropriate to a person’s needs  The recommendations in the NICE guidance are structured around the stepped-care model
  11. 11. STEPPED CARE MODEL STEP 6 Inpatient care or intensive treatment programmes. CAMHS Tier 4 STEP 5 Multidisciplinary teams with specific expertise in management of OCD. CAMHS Tiers 3 and 4 STEP 4 Multidisciplinary care in primary or secondary care. CAMHS Tiers 2 and 3 STEP 3 GPs and primary care team, primary care mental health worker, family support team. CAMHS Tiers 1 and 2 STEP 2 GPs, practice nurses, school health advisors, general health settings. CAMHS Tier 1 STEP 1 Individuals, public organisations, NHS
  12. 12. Treatment options for adults with OCD Mild functional impairment Brief CBT (+ERP) < 10 therapist hours (individual or group formats) Moderate functional impairment Offer choice of: more intensive CBT (+ERP) >10 therapist hours or course of an SSRI Severe functional impairment Inadequate response at 12 weeks Multidisciplinary review Offer combined treatment of CBT (+ERP) and an SSRI Patient cannot engage in/CBT (+ERP) is inadequate
  13. 13. Low intensity interventions definition    Less than 10 hours of therapist time per patient CBT includes exposure and response prevention (ERP) The intensity of the intervention is dependent upon the degree of functional impairment and patient preference
  14. 14. Low intensity interventions  Brief individual CBT (including ERP) using structured self help  Brief individual CBT (including ERP) by telephone  Group CBT (including ERP)
  15. 15. Recommendations identified as key priorities   All people with OCD should have access to evidence-based treatments: CBT including exposure and response prevention (ERP) and/or pharmacology But, limited availability of CBT Therapists  Waiting times  Access 
  16. 16. Recommendations identified as key priorities   CBT (including ERP) should be offered in a variety of formats Treatment programmes for formats other than standard individual CBT exist but have not been widely disseminated (including guided self help, telephone and groups)
  17. 17. Small group work  In small groups discuss your views on the stepped care model recommended by the NICE guidelines and the advantages and disadvantages of guided self help.
  18. 18. Low intensity treatments – self-help materials with minimal therapist contact - The Evidence  Fritzler et al (1997) found that a third of people with OCD made clinically significant improvement with a CBT based self-help manual and minimal therapist contact  Lovell (2005) uncontrolled study found self help manuals and minimal therapist contact with people with OCD promising
  19. 19. Low intensity treatments: The Evidence     Lovell (2000) pilot study (CBT) Taylor (2003) open study ( CBT with self help book) Griest (2002) RCT ( CBT- computer accessed by telephone and work book) Lovell (2005) RCT compared CBT by telephone or face to face with adults with OCD
  20. 20. Meta-analysis of treatment intensity for CBT  Grouping Therapist hours/patient into bands Treatment intensity Study N SMD CI arms Low (<10 hrs) 11 261 .93 0.75 - 1.11 Medium (10-30) 22 461 1.44 1.29 - 1.59 High (> 30) 10 157 1.65 1.38 - 1.91   Medium, High > Low Low works, medium and high work better
  21. 21. Self help materials       Wagner A. Up and down the worry hill: a children's book about obsessive compulsive disorder and its treatment. New York: Lighthouse Press, 2002— An illustrated book designed to help parents and professionals to explain obsessive-compulsive disorder to younger children through the story of "Casey," a young boy with the disorder Wever C, Phillips N. The secret problem. Sydney: Shrink-Rap Press, 1996—A cartoon book that describes obsessive-compulsive disorder in clear and simple language to help children, teenagers, and parents to understand it and its treatment Hyman B, Pedrick C. The OCD workbook: your guide to breaking free from obsessive-compulsive disorder. Oakland, CA: New Harbinger Publications, 2005—A self help manual for adults and older adolescents, which guides the patient through exposure with response prevention; includes advice for family members Veale D, Willson R. Overcoming obsessive compulsive disorder. London: Constable & Robinson, 2005—A self help book suitable for adults and older teenagers Lovell, KOCD self help manual (available on request) Schwartz JM. Brain lock: free yourself from obsessive compulsive behaviour. New York: Harper Collins, 1997—A self treatment manual suitable for adults and older adolescents
  22. 22. Application: self-help with minimal therapist contact        Patient centred assessment Involvement of families Self help materials (which ones?) Ongoing monitoring (process and outcome measures) Collaborative working Includes exposure and response prevention 20-40 minute sessions
  23. 23. Small group work   Discuss the self help resources that you have used and would recommend? Identify a spokesperson to feed back to the larger group
  24. 24. Questions
  25. 25. Thank you for listening Karina.Lovell@manchester.ac.uk