Menu Icon Search
Close Search

About the ads

  1. If you prefer the SDN Blue style, go to the bottom left of the page and select "SDN Blue"

Exposure Ideas for this OCD case

Discussion in 'Psychology [Psy.D. / Ph.D.]' started by cbrons, 02.21.12.

  1. cbrons

    cbrons love machine

    Joined:
    07.29.07
    Messages:
    4,788
    Location:
    The dog LB
    Status:
    Medical Student
    SDN 7+ Year Member

    SDN Members don't see this ad. (About Ads)
    A few weeks ago I posted about a patient with a pulse checking compulsion.

    I need to come up with some exposures to get him used to constatly feeling his heart beat, no matter what the rate or how "hard" or "soft" it is. He does not have resting tachycardia and his electrophysiologist cannot detect any abnormalities whatsoever. So this is now a psych issue officially.

    See the thing with OCD is that when he first focused on his HR, it was fine as long as it wasn't over a 100. Then he would check hiss pulse and would see its under 100 and then ignore it for some time. Then one day he started checking more often, getting nervous if it was over 80. Then even more often, getting nervous if it was over 70. Now even regular heart rate in the 60s is a "noxious/annoying/dangerous" feeling. At this point even ritualistic checking behavior offers no relief and he has palpitations (feels/notices his heart beat even without checking his pulse most of the day at a normal rate, rhythm, and blood pressure).

    ^ as a side note this is a fascinating (albeit devastating disorder). This is an individual of above-average intelligence, who realizes his fears of sudden cardiac death, tachyarrythmia, etc. are completely irrational yet now even his regular, normal, and (comparably) slow heart rate is noxious. Just another example of how giving into rituals to ease anxiety really just makes the problems all the more worse in the long-run.

    Anyone have any exposure ideas? The goal is to get this kid focused on things other than his heart, so that it gradually fades into the background like everyone else. I'm sure at this point there are medication option but I think the less invasive desensitation protocols (if any of you have any ideas) could be even more effective.
    Last edited: 02.21.12
  2. Huxwell

    Huxwell Ph.D. Student

    Joined:
    05.14.11
    Messages:
    52
    Status:
    Psychology Student
    One question first- a physical abnormality has been ruled out, but does he believe it? If there are features of hypochondriasis, this case is going to be a whole lot tougher.

    I would create a hierarchy of feared situations with him and work your way up it. I assume that situations where his heart rate are elevated will be worse for him (i.e. running), so you would want to start lower, like walking down the hallway and back. The key is then not allowing him to check his pulse. He'll hate it, but not doing the behavior is ultimately what will help. Read up on Exposure and Response Prevention for more detail.
  3. cbrons

    cbrons love machine

    Joined:
    07.29.07
    Messages:
    4,788
    Location:
    The dog LB
    Status:
    Medical Student
    SDN 7+ Year Member

    Yes, he has been under the care of an electrophysiologist. All cardiac workups (and they have been extensive to the point of unreasonable) have come back normal. He has also seen an endocrinologist who ruled other issues as well. The patient does not believe he has a heart problem (so he says he knows it is totally irrational).

    Additionally, this patient USED to suffer from daily panic attacks. A psychologist working with him helped him get to the point where he could sit and float through them, and he hasn't had any panic attacks at all for nearly 2 months... which is very interesting IMO. Now he just seems like an overly anxious person keyed up all day because of his focus on his heart beat.
  4. Ollie123

    Ollie123

    Joined:
    02.19.07
    Messages:
    3,851
    Status:
    Psychology Student
    SDN 7+ Year Member
    Strenuous exercise. Have him run a 5k in blistering heat in a straight jacket. I say that only half-kidding - that obviously isn't a goal for tomorrow, but I agree with Huxwell that this could absolutely call for ERP if you can get him on board. Develop the hierarchy and I imagine something like that would be wayyyyyy at the top of the ladder, but based solely off the information that you presented that's probably the direction I'd go. You don't want to go too far too fast, but its also important to recognize that these treatments ARE invasive and that the client SHOULD experience discomfort as part of this process. If he's not willing to engage or tolerate the discomfort enough to do the exposures, I'd view that through a motivational lens and focus on what he needs TO be ready to do those things, rather than forgoing the exposures or doing it half-arsed. Anxious clients will want to avoid discomfort. Its what they know, its what they do. Your job is to get him willing to accept and tolerate discomfort, and then guide him through those uncomfortable experiences. As one of our faculty says "If you are going to do exposures, its important not to be a wuss about it".

    This is of course assuming he has been really, truly 100% medically cleared (or you may have a gigantic lawsuit on your hands), recognizes this is psychological, is willing to do so, etc.
  5. nitemagi

    nitemagi Senior Member

    Joined:
    10.15.01
    Messages:
    2,284
    Location:
    Los Angeles, CA
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    Exposure can be as simple as extending the amount of time, progressively, between checking his pulse. Basically exposing him to the anxiety of not knowing, which is a large part of his fear. That of not knowing.

    Aside from teaching relaxation exercises, I've also found it useful to lead them through bringing on the anxiety deliberately, then practicing reducing it via relaxation exercises. It demonstrates a level of mastery, rather than perpetuating the sensation that their body is out of their control.
  6. futureapppsy2

    futureapppsy2 Ed Psych PhD student Moderator Gold Donor

    Joined:
    12.25.08
    Messages:
    4,261
    Status:
    Psychology Student
    SDN 5+ Year Member
    Actually, a lot of EXRP therapists argue against using relaxation with EXRP, as it doesn't reinforce the natural peaking and decline of anxiety and can, essentially, build new compulsions.
  7. nitemagi

    nitemagi Senior Member

    Joined:
    10.15.01
    Messages:
    2,284
    Location:
    Los Angeles, CA
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    I know. And I see the point in certain circumstances, but in the same model as building skills is better than just processing emotions and not giving ways to deal with them the next time they come, I think that teaching relaxation exercises as a skill set can give a sense of mastery over anxious sensations. Leslie Sokol (ACT) was a big proponent of exposure for exposure's sake, and I can see some utility to it. But one of the beter lessons I learned from her was teaching the patient to turn anxiety on and off (such as via hyperventilation) indirectly teaches that sense of mastery and that they can have some level of control over their sx's.

    It also allows for more trust in therapy that you're actually going to make them feel better, which pure exposure can be incredibly challenging and lead to a large dropout rate.
  8. nika751

    nika751

    Joined:
    02.07.12
    Messages:
    60
    Status:
    Psychology Student
    Any chance he is using the compulsion as an almost psychological substitute for his brain to release the anxiety he was releasing in the panic attacks? Just a thought....
  9. nika751

    nika751

    Joined:
    02.07.12
    Messages:
    60
    Status:
    Psychology Student
    How old is the child? I work with a lot of special needs kids and one thing we have to work with any anxious child is a weighted vest or jacket. The weight really calms some of my kids down. Would this be something he could try?

    Another possibility if the child is younger would be that there are two components to taking a pulse. You have to be able to feel your heartbeat and have a clock to see how fast it is going. If you could eliminate the clocks it would be impossible for him to get his pulse rate... Of course if this is a teenager with a cell phone that would get extremely difficult.
  10. nitemagi

    nitemagi Senior Member

    Joined:
    10.15.01
    Messages:
    2,284
    Location:
    Los Angeles, CA
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
  11. nitemagi

    nitemagi Senior Member

    Joined:
    10.15.01
    Messages:
    2,284
    Location:
    Los Angeles, CA
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    I don't think anyone ever said it was a child. Where are you getting that from?
  12. cbrons

    cbrons love machine

    Joined:
    07.29.07
    Messages:
    4,788
    Location:
    The dog LB
    Status:
    Medical Student
    SDN 7+ Year Member
    24. So not really a child

    Looking more for CBT suggestions, I don't know if this is along the lines of the psychoanalytic school here. Anyway about the pulse checking, this individual suffered a "major" panic attack and thereafter began checking his pulse constantly (also checking his BP, which we got him to give up altogether). It's a cardiac neurosis, not being able to just accept the sensation of your heart beating.

    As to the person who asked again about his medical workup, believe me this guy has been worked up and down, left and right, sideways front and back. He has seen 2 cardiologists (right now he was seeing an EP specialist who was chasing every zebra he could find just to appease the patient) and an endocrinologist.
  13. Doctor Eliza

    Doctor Eliza

    Joined:
    07.30.10
    Messages:
    797
    Status:
    Psychologist
    SDN 2+ Year Member
    To get him to buy into the CBT model, you might encourgage him to read Burns' "When Panic Attacks.". It is a good book illustrating CBT treatment and principles with a lot of examples. It covers all sorts of anxiety, not just PA's. Burns is good at selling CBT. It also is available as an audiobook.

    Best,
    Dr. E
  14. nitemagi

    nitemagi Senior Member

    Joined:
    10.15.01
    Messages:
    2,284
    Location:
    Los Angeles, CA
    Status:
    Attending Physician
    Physician Faculty SDN 10+ Year Member
    Ordering more tests does not lead to more satisfaction.
    http://www.ncbi.nlm.nih.gov/pubmed/19273865
  15. 54321

    54321

    Joined:
    01.18.07
    Messages:
    66
    SDN 7+ Year Member
    I don't usually post much on here but am now because I need to say that I think this thread is bordering on being too specific about a confidential case. I now know the age, sex, and specifics of this quite unique case just by reading a public forum. Just a reminder to exercise caution.
  16. eudaimonPsyD

    eudaimonPsyD Clinical PsyD Student

    Joined:
    09.06.11
    Messages:
    166
    Location:
    California
    Status:
    Psychology Student
    SDN 2+ Year Member
    Ah an age old dilemma in anxiety treatment. I think there was even a mini-debate about this between some of the anxiety heavy hitters at the last IOCDF conference. There are definitely arguments for both. I was trained in the former - you ride that anxiety wave and don't use distraction, relaxation, or any other type of intervention other than focusing on the physical/mental experience, being present in the moment with the anxiety, and feeling your body naturally decline in anxious feelings. I still think relaxation has solid place in anxiety treatment, but just not for very serious compulsions, IMO. (Somewhat similar to this, I knew of a client who was introduced to "scripts", a method of imaginal exposure, and actually ended up becoming obsessed with writing scripts to expose themselves to anxiety, and would compulsively write scripts for every worry that came up for them. Sometimes the tricks of the trade can turn against us!)


    As for the client at hand, I think most people have already hit the nail on the head with creating a fear hierarchy that is going to centralize around exposures to feeling his heart beat. Another exposure idea may be to have him listen to heart monitors (not necessarily connected to him at first, but could eventually be connected to him). It's going to be a delicate balance between letting the client go at their own pace and pushing them to try exposures. But I think to help him build up a tolerance to the anxiety of feeling/hearing his heart beat even w/o checking his pulse, he needs to actually focus on that feeling until the anxiety around it has dissipated. He should kind of feel bored by it, that is usually a sign that anxiety has diminished. And if he says it's not anxiety, that it's "annoyance" or "discomfort", that often translates to low levels of anxiety, and exposure could still be beneficial.

    What an interesting case. I love working with anxiety disorders!
  17. Markp

    Markp Clinical Psychologist

    Joined:
    11.19.07
    Messages:
    2,269
    Status:
    Psychologist
    SDN 5+ Year Member
    Call me paranoid, but hasn't there been a prohibition on discussing treatment on the msg board in the past?

    Did the policy change?
  18. cbrons

    cbrons love machine

    Joined:
    07.29.07
    Messages:
    4,788
    Location:
    The dog LB
    Status:
    Medical Student
    SDN 7+ Year Member
    Info has been sufficiently changed/amended.
  19. cbrons

    cbrons love machine

    Joined:
    07.29.07
    Messages:
    4,788
    Location:
    The dog LB
    Status:
    Medical Student
    SDN 7+ Year Member
    Here is just the crux of the matter, and something I would like a psychologist to answer.

    We have a person who finds a very natural, normal sensation (heart beat) noxious/annoying.

    IF we get this person to focus more on that sensation, in fact, to focus so much on it, can we really rewire his brain?

    I recently read Brain Lock by the way.

    I am only a medical student. I find OCD to be a fascinating disorder. People who know their behavior is totally irrational yet they allow it to destroy their lives. It's sad but I really have a heart for these people.
  20. eudaimonPsyD

    eudaimonPsyD Clinical PsyD Student

    Joined:
    09.06.11
    Messages:
    166
    Location:
    California
    Status:
    Psychology Student
    SDN 2+ Year Member
    I don't know if that's the policy. If it is I will gladly remove my post.
  21. cbrons

    cbrons love machine

    Joined:
    07.29.07
    Messages:
    4,788
    Location:
    The dog LB
    Status:
    Medical Student
    SDN 7+ Year Member
    Thanks, this is a GREAT idea.
  22. AcronymAllergy

    AcronymAllergy Neuropsychologist Moderator

    Joined:
    01.07.10
    Messages:
    5,426
    Status:
    Psychologist
    Psychologist SDN 2+ Year Member
    If by "rewire his brain" you mean change his habits and the chain of thoughts and behaviors associated with them, then yes, it's very possible (and is the mechanism of change of most "talk" therapies). Whether or not such change results in any concomitant neurophysiological change is still up for debate, but personally, my opinion is yes (based on a variety of factors).
  23. KillerDiller

    KillerDiller

    Joined:
    03.14.07
    Messages:
    1,557
    Status:
    Post Doc
    SDN 7+ Year Member
    Is it? I thought it was pretty much a certainty for people who don't buy into dualism. (Not trying to be flip here, just genuinely curious).
  24. cbrons

    cbrons love machine

    Joined:
    07.29.07
    Messages:
    4,788
    Location:
    The dog LB
    Status:
    Medical Student
    SDN 7+ Year Member
    I had some other ideas, including interoceptive exposures. I think the problem with cardiophobes (so-called) and others in the same category is largely somatosenstory amplication. Perhaps we can get him doing hard cardiovascular exercise, perhaps taking some stimulants, etc. to get him to gradually stop paying attention to an accelerated heart rate. It does seem pretty invasive though but I have heard of this sort of thing really working.

// Share //

Style: SDN Universal