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I’m Afraid I’m Really Gonna Do It!Responding to the fear of
loss of impulse control
IOCDF Annual ConferenceJuly 18-21, 2019
Allen H. Weg, Ed.Dwww.StressAndAnxiety.com
www.OCDNJ.org
Fear of loss of impulse control
n Case Presentations
n Defining characteristics for this OCD subgroup
n Review of ERP through Storytelling
n Application of treatment to case presentations
n Concluding statements/questions
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Fear of loss of impulse control
n Case Presentations
Adam is an 11 year old boy who is afraid that he will blurt out a curse word in church during the preacher’s sermon.
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Fred is a 31 year old married cable guy who finds that whenever he is installing satellite dishes on houses he becomes gripped with the fear that maybe he will impulsively throw himself off the roof.
Mat is 24 years old, single, and works as an electrician. He lives with his mother and is terrified by an intrusive thought that he might just grab a knife and stab his mother to death.
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Jessica is a 16 year old high school junior who states that she is afraid that she might kill herself.
Kelly is a 25 year old first time mom, who is terrified that she might accidentally drop her newborn baby.
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Wally is a 49 year old married businessman who finds that when he enters most stores he becomes extremely worried that maybe he will unwittingly take something and walk out of the store without paying for it, and then get caught and prosecuted.
Sandra is a 9 year old 3rd grader who is afraid she might not notice something on the sidewalk and pass it by without picking it up, and then another passerby will trip or slip on it and hurt him or herself.
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Roger is a 52 year old widowed dentist who lives with his college-aged daughter. He is terrified that he might poison her by accidentally adding household cleaning chemicals to her food when he is cooking for her.
Lauren is a 14 year old high school freshman who is afraid that she might grab at the breast area of another girl when she is near her.
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Fear of loss of impulse control
n Case Presentations
n Defining characteristics for this OCD subgroup
Defining characteristics for fear of loss of impulse control:
A: Obsessions
B: Experience- Emotional Reaction
C: Compulsions
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Fear of loss of impulse control: A: obsessions
Definition: Fear of acting on an impulse-
n to harm oneself (Fred, Jessica)n to harm others (Mat)n to act out in an embarrassing or shameful way
(Adam, Lauren)n to do something illegal (Wally)n by not being careful enough resulting in harm to others
(Roger, Sandra, Kelly).
Fear of loss of impulse control: A: obsessions, cont.
n Roger- fear of unwittingly doing something harmful to others
n Sandra- fear of unwittingly letting something happenthat is dangerous to others
n Kelly- fear of accidentally withdrawing protective behavior from others
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Fear of loss of impulse control: B: experience
n intense anxietyn shamen guiltn self-disgustn confusionn secrecyn isolationn feeling “ego dystonic”
Fear of loss of impulse control: C: compulsions
n Behavioral Avoidance:n not going into the kitchenn throwing out all the knivesn having someone else prepare meals
n Cognitive Avoidance:n distracting oneself
n Reassurance Seeking from others:n “are you sure you didn’t see me do X?”n “if you see me begin to do X will you stop me?
n Reassurance Seeking from oneselfn Mentally repeating reassuring statements
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Fear of loss of impulse control: other concepts
n When we consider the likelihood to act, typically the more a person thinks about it, the more likely they are to do it.
n For suicidality, we check for:n Ideationn Specificityn Plann Meansn Intent
n In OCD fear of loss of impulse control- THESE RULES DO NOT APPLY
Fear of loss of impulse control: other concepts, Cont.
n Differentiate from OCD with intrusive blasphemous, sexual, or violent thoughts:n Am I gay?n Am I a pedophile?n I find myself thinking bad thoughts about Godn I have intrusive thoughts of violence, and bloody corpses
n In fear of loss of impulse control, the focus is on the specific fear that I will act out on my thoughts
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Fear of loss of impulse control
n Case Presentations
n Defining characteristics for this OCD subgroup
n Review of ERP through Storytelling
Exposure and Response Prevention(ERP or ExRP)
Defining and illustrating the treatment through storytelling
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The Bee Trap(You want me to do what?)
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The Horror Movie(You want me to do that again?)
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The Swimming Pool(Can’t we find a way tomake this less painful?)
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Fear of loss of impulse control
n Case Presentations
n Defining characteristics for this OCD subgroup
n Review of ERP through Storytelling
n Application of treatment to case presentations
ERP for fear of loss of impulse control
n Exposure of your body to the environment
n Exposure of your mind to your thoughts
n Elimination of accommodations of others
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ERP for fear of loss of impulse control, cont.
n Create a hierarchy (swimming pool)n Schedule practice time (duration, frequency,
intensity)n Record practice times and Subjective Units of
Discomfort (SUDs) levelsn Use serendipitous exposure as opportunities to make
further progressn Slowly cut back on accommodations of othersn Make adjustments and change foci as neededn No one protocol is best
Adam
Schedule and practice repeatedly writing and reading the word to himself (may need to begin with just the first letter), then whispering, saying, and even shouting the curse word at home
Practice saying the word silently, repeatedly in his mind, as he spends time in more and more challenging environments, until he makes it back to church
Keep a written record of practice times and SUDs levels
Other ideas: mouthing the word, having it written in his pocket while in challenging environments
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Fred
Writes a story about how he loses control and throws himself off of the roof, out the window, or into traffic, repeatedly reading it and monitoring SUDs levels
Adds more and more detail to the story, increasingly focusing on the aspects of the story that he finds most frightening.
Brings the story with him and repeatedly reads it to himself or out loud while in increasingly challenging environments (standing progressively closer to the street corner, standing only on the center of the roof at first, progressively moving closer to windows and ledges).
MatPractices holding plastic knives, then butter knives, steak knives, and then carving knives while around more and more anxiety-producing people, ending up with his mother.
Writes out and then reads aloud stories of how he loses impulse control and stabs these people
Always scheduling practice, recording SUDs levels, reducing any accommodation and/or reassurance
Works up to holding large knives to his mother’s throat while speaking his story out loud
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Jessica:
A special issue: differentiating from true suicidality-
Is her presentation primarily anxiety or depression?
Is there a history of depression in Jessica or her family?
Is there a history of suicidal behavior in Jessica or her family?
Is there a history or a presence of other OCD symptoms?
Are there self-imposed compulsive attempts to avoid triggers or situations that might elicit self harm, including self-assurance?
Kelly
Schedules and practices holding her child for longer and longer periods of time, with a safety person, such as her husband or mother, standing further and further away from her over a period of exposures, ultimately being alone
Writes stories of how she drops the baby which she reads repeatedly, re-writing the story as she acclimates, with increasingly negative consequences
Exposes her self to increasingly greater environmental situations:holding the baby over the bedholding the baby over the carpeted floorholding the baby over the kitchen floorholding the baby over the cement sidewalkwalking with the baby in the above situationscarrying the baby down the stairs
Does the above while imagining that she drops the baby in those circumstances
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Wally
Writes stories of how he steals things, gets caught, and suffers legal consequences. Rewrites the story with increasingly negative outcomes
Practices first with discount stores, progressing to stores with more expensive portable items
Practices with safety person being further and further away in the store and then not present at all
Practices taking small items and putting them in his pocket while in the store, removing them or paying for them just before exiting
Imagines the stories while in the stores
Sandra
Practices walking with delayed checking and with longer periods of time where she only peripherally scans the ground as she walks
Practices walking more quickly, and is timed
Imagines that she walked by pebbles, then sharp stones, tabs from cans, glass
Actually places pebbles and small stones on walkway and leaves them there
Writes, reads, imagines stories of how people hurt themselves due to her “negligence”
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Roger
Writes stories of how he inadvertently puts more and more toxic items into daughter’s food
Has daughter repeatedly pull further and further back from doing cooking, and from how closely she watches him cook, ultimately leaving him alone for longer and longer periods of time
Garage closet is unlocked, chemicals are slowly brought into the house, then placed on the kitchen floor, then kitchen counter where Roger is cooking
Ultimate exposure is for Roger to pick up and put down chemical bottles in between prepping dinner, while alone, and while imagining the stories he has written
Lauren
Special case: as a minor, Lauren’s parents should be consulted about the rationale and purpose of the therapy
Writes stories of how she loses impulse control with different females in different situations and grabs at their breasts
Spends longer and longer periods of time increasingly physically closer to different females, working her way up to the ones that are most anxiety producing, such as those her own age
Lauren imagines that she loses impulse control and grabs at the females while close to them
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Fear of loss of impulse control
n Case Presentations
n Defining characteristics for this OCD subgroup
n Review of ERP through Storytelling
n Application of treatment to case presentations
n Concluding statements/questions
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Stress and Anxiety Services of New Jersey, LLCSpecializing in the Cognitive Behavioral Therapy of :
OCD (BTTI graduates)Social Anxiety DisorderPanic DisorderPhobias & other anxiety-related problemsBody Focused Repetitive Behaviors (TLC certified)PTSD (CPT certified/PE trained)
Children, Adolescents, Adults
We now offer TELEHEALTH services (TBHI certified) www.StressAndAnxiety.com
www.StressAndAnxiety.comAllen H. Weg, EdD
NJ licensed Psychologist, #2720
Stress & Anxiety Services of NJA-2 Brier Hill Ct 195 Columbia Tpk, Ste 120East Brunswick, NJ Florham Park, NJ
