PSYCHOTHERAPY OF OBSESSIVE-COMPULSIVE DISORDER AND HYPNOSIS Tahir Özakkaş MD.,PhD Ass. Prof. Ahmet Çorak MD. Psychotherapy Institute 2008 İstanbul/Turkey

anxiety disorder compulsions reduce anxiety ‘motor obsessions’ and ‘ideational compulsions’ are not rare. Prevalance is 2.5 % fourth most common psychiatric disorder professional and social devastations in 20 % of the patients

DSM CRITERIA A. Obsessions are (1) repetitive and persistent thoughts, images or impulses that are experienced, at some point, as intrusive and inappropriate and that cause marked anxiety or distress (2) the thoughts, images or impulses are not worries about real-life problems (3) the person tries to ignore or suppress the thoughts, images or impulses, or neutralize them with some other thought or action (4) the thoughts, images or impulses are recognized as a product of one's own mind and not imposed from without

Compulsions are (1) repetitive behaviors or mental acts that one feels driven to perform in response to an obsession or according to certain rules (2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing feared consequences; however the behaviors or mental acts are clearly excessive or are not connected in a realistic way with what they are designed to neutralize or prevent.

B. At some point during the disorder the person has recognized that the obsessions or compulsions are excessive or unreasonable. C. The obsessions or compulsions cause marked distress, are time-consuming (take more than 1 hour a day), or significantly interfere with usual daily functioning. D. The content of the obsessions or compulsions is not better accounted for by another Axis I disorder, if present. (e.g., concern with appearance in the presence of Body Dysmorphic Disorder, or preoccupation with having a serious illness in the presence of hypochondriasis). E. Symptoms are not due to the direct physiological effects of a substance or a general medical

• OCD is not unitary, but, heterogeneous • Integrative approach is necessary

Behaviorial modelling, social learning, etc, Cognitive Magical thinking Psychodynamic unresolved oedipal/electral complex undoing against an unconscious phantasy reaction-formation against unconscious chaos measure against loss of control Existential defense against feelings of emptyness nihilism meaninglessness fear of death

Hypnosis A social interaction in which the subject responds to suggestions given by the hypnotist for imaginative experiences involving alterations in perception, memory, and the voluntary control of action. Thoughts are on the border of delusion Behavior are compulsory When hypnotically induced behavior is prevented from being carried out, anxiety develops, as occurs in OCD.

Behavioral models consider OCD as conditioned fear reactions compulsions reduce anxiety, and are reinforced Thought-stopping Exposure to the obsession

Exposure therapy Remain in an anxiety-provoking situation despite great distress (habituation) Via hypnosis, ‘almost in vivo’ exposure can be possible through ‘as-if-real’ hypnotic scenes. Patients must fully experience exposure anxiety Subtle avoidance can easily be uncovered

• role playing and imagination / visualization (in vitro exposure) • only homeworks are real situations (in vivo exposure). • for a highly hypnotizable subject, in vivo exposure is possible even in-session tryouts. • using hypnodrama, social learning or modelling can be reversed

Anxiety response is counterconditioned Deep breathing : parasympathetic nervous system

Cognitive approach dysfunctional cognitions overestimation of threat contamination fears cleansing behaviors intolerance of uncertainty importance of thoughts need to control thoughts responsibility perfectionism

• negative automatic thought preceded obsessions • myths • cognitive distortions can be uncovered under hypnotic state and be changed • cognitive restructuring of cognitive distortions more effectively under hypnotic state

dissociation between coping self and anxious self Cognitive distortions attributed to anxious self Rational thoughts attributed to coping self. Meet each other Struggle to dominate the person At the end rational self wins

cognitive distortions may be destructed concretely. fear-based v.s. disgust-based access to affect is easier in hypnosis

Psychodynamic therapy Hypnodramas directed to resolve the oedipal complex to mitigate the urge of superego to uncover the transference to provide symbolism in the absence of dreams Existential therapy in searching of the patient for a meaning • furnishing occasions • provoking it

psychodynamically hypnosis is regression in the service of the ego. recover forgotten incidents promote relaxation enhance imagery loosen the flow of free associations

eclectic approach integrative wholistic