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

2. 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

3. 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

4. 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.

5. 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

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

7. 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

8. 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.

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

10. 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

11. • 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

12. Anxiety response is counterconditioned
Deep breathing : parasympathetic nervous system

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

14. • 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

15. 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

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

17. 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

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

19. eclectic approach
integrative
wholistic