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Four Steps of Cognitive Biobehavioral Therapy

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FOUR STEPS OF COGNITIVE BIOBEHAVIORAL THERAPY

BASED ON JEFFREY SCHWARTZ’S TREATMENT OF OCD

Interpreted and summarized by Barbara J Nichols, Ph.D.

“It’s not me—it’s my OCD”

“Mindful awareness and the impartial spectator will empower you”

Many people on the autism spectrum suffer with obsessive-compulsive-like symptoms.  The symptoms of OCD are wide ranging and may include frequent hand washing, checking the stove, the door locks, or the faucets repeatedly, adhering to rigid rituals and routines that have no functional benefit like dressing in a certain order, repeating words and phrases, engaging in behavioral mannerisms (nail biting, picking at the skin, or pulling the hair) and hording books, magazines, or papers. These behaviors are accompanied by thoughts that repeat themselves over and over and are annoying and stubborn. Anxiety, guilt and remorse often plague people with OCD.

People who engage in OCD-like behaviors can spend an inordinate amount of time with the non-functional behaviors that interfere with job duties, relationships, and pursuing interests and hobbies. Depression and anxiety are often associated with OCD symptoms and low self-esteem, self-recrimination and self-deprecation can be socially crippling. Thoughts of suicide, as a way to escape from the insidious thoughts and behaviors that seem to control one’s life, are prevalent.  However, there are very promising therapies for OCD and the outcomes are very hopeful.

Dr. Jeffrey Schwartz, after years of research and experience treating OCD patients, devised a treatment protocol that has been found to be highly effective in controlling OCD symptoms. The treatment grew out of Dr. Schwartz’s study of mindfulness practices and his brain scan studies. Studies of the brain before and after weeks of treatment by Dr. Schwartz showed that the brain responded as well as it would under prescription drug therapy for the same condtion. Below is a brief synopsis of the treatment .

*The four steps numbered below are Dr. Schwartz’s protocol. I have illuminated and separated out associated steps for clarity.

“The goal of the first three steps is to use your knowledge of OCD as a medical condition caused by a biochemical (and structural) imbalance in the brain to help you clarify that this feeling is not what it appears to be and to refuse to take the thoughts and urges at face value, to avoid performing compulsive rituals, and to refocus (your attention) on constructive behaviors.” (Dr. Jeffrey Schwartz)

FORCE OF WILL: Neuroplasticity is the brain’s ability to physically change in response to your efforts:

Because OCD patterns are rooted in overused neuropathways, it takes strong discipline to resist the old patterns and institute new ones.  Placing your mental health at the top of your priority list by following the below-listed steps with discipline and determination will result in the emergence of new functional and healthy neuropathways that will become, with time and effort, the path of least resistance. Dr. Schwartz performed brain scans before and after treatment. He found that before treatment, the orbitofrontal cortex and the caudate neucleus are over active. After treatment both brain structures are returned to normal function and the difference is as significant as that seen in OCD patients who are administered drug therapy.

REJUVENATE: People with OCD and autism are vulnerable when under stress. Stress management is crucial to recovery. The following list suggests life style alterations that are known to lower stress levels and increase energy:

  • Sleep – 7 to 8 hours, darkened and quiet room
  • Nutrition –regular meals, whole nourishing foods, reduce caffeine, alcohol, and sweets
  • Exercise–vigorous regular exercise 4-5 times a week for at least 20 minutes at a time
  • Recreation–spend time with friends who renew you
  • Meditation, yoga, prayer, contemplation, Tai Chi, Chi Cong at least 20 minutes per day
  • Mindfulness practices such as walking  meditation, meditation in action, watching the thoughts
  • Breathing exercises: slow, deep, smooth breathing with attention to the details of the breath
  • Energy psychology techniques such as EFT, TFT and FIT

Four Steps of Biobehavioral Therapy with Additional Mindfulness Practices 

Preliminary Step 1. REVIEW AND KNOW YOUR PATTERNS:

  • Make a complete list of your usual OCD behaviors and thoughts and display the list where you can readily access it for reference.
  • Keep a journal of the frequency and duration of OCD behaviors and thoughts.

Preliminary Step 2. RECOGNIZE OBSESSIVE THOUGHTS AND COMPULSIVE URGES WITH MINDFUL AWARENESS AS THEY ARISE:

  • Pay attention to the early signs that the pattern is about to commence: e.g., fear, anxiety, dread, rumination, guilt, remorse, an urge to find the right feeling by repeating the behavior.
  • Develop the “impartial spectator” or the “witness” that observes without judgement.
  • Mindful awareness is deep and precise, and achieved through focused effort.
  • Be mindful of the lack of sensory data that supports your fear when the obsession begins. It is a thought not an experience that is fueling the fear.

STEP ONE: PART I: RELABEL:      

  • Use the labels obsession and compulsive, e.g., “I’m having an obsessive thought to perform the compulsion of washing my hands.”
  • “This thought is an obsession; this urge is compulsive”.
  • I am not washing my hands because they are contaminated. I am washing my hands because I have OCD.

STEP ONE: PART II: REFUSE TO ENGAGE IN THE COMPULSIVE BEHAVIOR:

  • The goal is to resist the urges, not to stop the thoughts.
  • Block any temptation to engage in the OCD behavior. Total response prevention over a period of three days has been shown to powerfully reduce subsequent urges.
  • Just because the urge is there, does not mean you have to respond.
  • Only by learning to resist OCD symptoms, can you change the brain.
  • If you have rechecking behaviors, like rechecking locks, be mindful while you perform the duty the first time around. Resist all temptation to recheck.
  • Maintain the witness mode until the urge has weakened or passed (at least 15 minutes).

STEP TWO: PART I: REATTRIBUTE – CHANGE THE MEANING OF THE PATTERN:

  • “This is a biochemical imbalance in my brain”.
  • “This is not real.  It is just my OCD”.
  • “This is the result of faulty wiring in my brain. It is not my personal self. “
  • Understand and know the obitofrontal cortex (OFC) in the brain, responsible for decision making, is hyperactive. The caudate nucleus, lying close to the OFC which is the center for habit control and the traffic hub between the cerebral cortex (conscious thought) and the amygdala (center for fear), is also hyperactive.  The hyperactivity of the OFC and the CN result in the repetition found in OCD symptoms.

STEP TWO: PART II: REMEMBER NEUROPLASTICITY:

  • The brain constantly changes in response to your thoughts, actions, emotions, and attitudes.
  • Change your thoughts and automatic responses and you will rewire your brain.

STEP THREE: REFOCUS: SWITCH TO ANOTHER BEHAVIOR/THOUGHT WITH EFFORT AND MINDFULNESS:

  • Practice distracting yourself to prevent engaging in the OCD behaviors and thoughts: e.g., shift your attention to something pleasant, e.g., mindfulness exercises like deep, slow breathing, walking, exercising, playing music, singing, dancing, calling a friend, reading………….
  • Keep a journal of the thoughts, feelings, behaviors with Labels and Reattributions
  • Uncomfortable feelings will continue for a short while and then will recede. Wait it out.
  • Goal of Refocusing: never again perform a compulsive behavior in response to an OCD thought, but, if the thought persists, impose a time delay (15 minutes) before performing any compulsion. You will find that you no longer feel compelled to respond.

STEP FOUR:  REVALUE:

  • “These OCD thoughts and behaviors are not worth my time and energy. They are trash.”
  • The obsessions and compulsions are simply false messages coming from the brain and are not rooted in sensory data. They are just useless mindstuff.

REFERRENCES:

DEFINITIONS FROM WIKIPEDIA:

Caudate nucleus: innervated by dopamine neurons, highly involved in learning and memory. It has been found to be dysfunctional in persons with OCD in that it may be unable to properly regulate transmission of information regarding worrying events between the thalmus and the OFC. PET scans found that people with OCD have increased grey matter volumes extending to the caudate nuclei, versus the decreased grey matter in neighboring structures as in anxiety disorders. In OCD, smooth, efficient filtering and the shifting of thoughts and behaviors are disrupted by a glitch in the CN.

Orbitofrontal cortex (OFC) is a prefrontal cortex region in the frontal lobes in the brain which is involved in the cognitive processing of decision-making. It has been proposed that the OFC is involved in sensory integration, in representing the affective value of reinforcers, and in decision-making and expectation.  In particular, the OFC seems to be important in signaling the expected rewards/punishments of an action given the particular details of a situation. In doing this, the brain is capable of comparing the expected reward/punishment with the actual delivery of reward/punishment, thus, making the OFC critical for adaptive learning.

When OFC connections are disrupted, varying cognitive, behavioral, and emotional consequences may arise. Disorders associated with dysregulated OFC connectivity/circuitry center around decision-making, emotion regulation, and reward expectation.

Other disorders of executive functioning and impulse control may be affected by OFC circuitry dysregulation, such as attention deficit disorder, obsessive–compulsive disorder and trichotillomania.

 

Distinguishing Between Autism Spectrum Disorder and Schizoid Personality Disorder

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BARBARA J NICHOLS, Ph.D.
LICENSED CLINICAL PSYCHOLOGIST
ADULT ASPERGER’S ASSOCIATION

 

Distinguishing Between Autism Spectrum Disorder and Schizoid Personality Disorder

The two disorders of autism spectrum disorder and schizoid personality disorder had been considered two separate disorders. However, in the recent past, the two disorders have begun to be thought of as related mainly because they share many traits and characteristics. Additionally, both disorders have been found among families where bi-polar disorder, schizophrenia or attention deficit disorder had been diagnosed in first degree relatives. Some experts now believe that schizoid personality disorder belongs in the autism spectrum of disorders although this is controversial and requires further investigation before that placement is established.

A possible distinguishing feature between the two disorders lies in the age of onset. However, this distinction may be more of a problem of identification than a real difference. Schizoid personality disorder appears to begin in early adulthood while autism is seen in the infant or small child. Early adulthood is when the individual is expected to move toward establishing a career, developing romantic relationships, and engaging in a full social life with hobbies and interests and it is at this time that the traits of schizoid personality disorder become more prominent.

The person with schizoid personality disorder first becomes a concern to her parents at this point because she appears to lack motivation in developing in the expected way in the areas of relationships and career. The person with schizoid personality disorder may exhibit traits and characteristics in childhood that portend a later problem, but most often the parent does not recognize these premorbid traits until adolescence or young adulthood. Problems become much more obvious after high school graduation.

In school, there is structure in the classroom that encourages functional, focused activity. There are organized social activities and an easy access to peer groups. Additionally, the adolescent brain is wired for social interaction much more strongly than the adult brain. This fact may mask the avoidance of social interaction in adolescent schizoid personality disorder.

Autism spectrum disorder, on the other hand, is most often identified in infancy and childhood. The autistic child shows little or no interest in others, has strong preferences and interests to the exclusion of others, engages in repeated, odd, and nonfunctional behaviors that are obvious and sometimes extreme, and has sensory defensiveness for textures, lights, sounds, and spaces. The autistic individual has great difficulty with non-verbal communication and has very concrete thinking. She may not be able to understand the meaning of jokes, parables, and analogies.

The two disorders are difficult to distinguish in adulthood in some people but the primary difference is in the apathy that is seen in the schizoid personality. Because depression is often co-occurring in both disorders, apathy may be present in both. This complicates the diagnostic picture. However, if problems did not surface until after high school, if an extreme lack of interest in others and low motivation to engage in ordinary adult life activities pervades the personality and appears to be present with or without depression, the diagnosis would likely lean toward schizoid personality disorder over autism spectrum disorder. Although people with Asperger’s disorder are often anxious around other people and prefer to be alone in order to avoid anxious feelings, they desire friendship and social interaction. This is not true of the schizoid personality who has no interest in others.

Autistic individuals may appear apathetic because they lack the ability to express emotion in a recognizable way, but they do have strong feelings and often have great passion for particular topics of interest.  They are often motivated to develop a career. Dealing with the social aspects of a work environment and understanding social protocol is confusing, at best, for them, but they most often try hard to make progress in these two important aspects of adult life.  The person with schizoid personality disorder, on the other hand, not only lacks the motivation, but lacks the passion to develop an independent, functional adult life style, career, and social contacts.AUSTISM SPECTRUM  SCHIZOID SPECTRUM edited_Page_2

The Sameness of Days

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Reprinted from ipaimpress.com

Those of us with Aspergers/Autism find it difficult to navigate in an environment that is both foreign and un-inviting to us.

On one hand, you will find we like things in our environment, the same each day. We may wear the same clothes, watch the same tv program’s, eat the same food. We like things ordered, and to a degree, predictable. We want to find the keys and remote in exactly the same place each day.

We almost ritualise certain events. I myself have a tendency to eat virtually the same things everyday. Breakfast is usually hot oatmeal cooked on a stove (NOT microwaved!) It’s not that we don’t know how, it is that innately we desire a sense of control and order over our environment. This is shown in the things we say and do. For variety though, I do have polenta occasionally, Cheerios, and on Wednesdays and Sundays – an omelette which I make for myself. It’s not laziness or lack of initiative, or even lack of knowledge (I am an accomplished cook.) We have a daily schedule, to which invariably, we internally adhere.

We sit in the same place in restaurants. Why? Because we know where everything is. God help us, if the floor is wet, and we have to sit someplace strange. (The booth next door.) I am fortunate in having a friend here, that understands that I need to scope out the inside of a restaurant to make sure it is not too crowded. Autistics NEVER like to have their escape path to the outside, blocked. Perhaps unconsciously, we position ourselves so that we can always see the exit. When things get too intense for us from a sensory overload (just several people talking at the same time in a room, makes a cacophony of sound, that overwhelm many of us.) I have left meetings simply because my escape route was suddenly cut off. Sometimes we need to exit a situation, that becomes over stimulating for us.

I was in the Emergency Room of a hospital here last week. Many of us, can’t filter out the distractions: lights, sounds, colors, noises, or odors that envelop us. And so we may ask to dim the lights, close the curtain or close the door. Anything to block the over stimulation. When I informed the staff that I had Aspergers, I might as well have said I am from another planet. Most Medical Professionals I have discovered, are 129% clueless when it comes to Autism.

My Primary Care Doctor, let me explain to him, what having Aspergers is like for me. He took the time, to accommodate Autism. His welcome and inviting tone and manner greeted me when I was finally transferred to a room. I didn’t have to explain. He already knew. More people would be wise to follow in my physician’s footsteps, and take a few minutes to educate themselves, on how Autism affects our daily lives.

A good place to start:

All Cats Have Asperger Syndrome by Kathy Hoopmann

As much as we like things to stay the same, we also want to form bonds and friendships. That is an area, where we Aspies (as we call ourselves) don’t function well. We are unable to read the social cues and body language of the people around us. It is very hard for us to form relationships, simply because we don’t have the skills necessary to do so.

We isolate ourselves from a harsh and cruel world, because we are tired of the rejection and snide comments made by NT’s. (Neuro-Typicals. Our name for people that are NOT on the Autistic Spectrum.) We sit in the corner, and pretend to be a wall flower. We don’t belong. We don’t fit in. We feel like the proverbial square peg in a round hole. We go into survival mode. Magical thinking.

If we sit in a corner, we can be invisible and won’t have to talk. Gosh what do we talk about? I don’t watch sports, and the weather: Yup it’s hot out there, all right! Aspies are not interested in weather, or sports per se. But I speak for myself only. We’d rather discuss: books, movies, politics, religion, sex or music. Anything other then the dull. Mundane. Ordinary. We might discuss things which are resolutely insignificant to the world, but which makes our inner world, revolve.

Yeah we’re the kid in the corner who sits by himself, because he is so beaten up emotionally, that removing himself mentally into an imaginary world, might be the only method of coping. I am the adult, who sits in the same booth almost everyday, orders the same thing off the menu everytime, and sits alone. I talk to imaginary friends as well, because there is no one else.

Pets for many of us, are the only creatures we know on the planet, that won’t automatically judge us. They love unconditionally: just as I am. We don’t have to hide who we are. We are free to be ourselves. They give back to us, the love that the world so harshly with holds.

Many of us, are penurious. We give our time, instead of money. All we want is to be recognised for our contribution, however small it may be. We depend on others to remind us of God’s love and God’s forgiveness, by returning a simple please or thank you. Basic Human kindness. The little things.

We all need affirmation. What’s that? It’s simply saying the right thing, at the right time. Looking beyond the quirks and eccentricities, to see someone and something of value. Few people are willing to take the time to get to know us, let us stumble through friendship, and make a deep and enduring impression on our lives. Those few that do venture into the world of Aspergers, may find a deep, abiding friendship and loyalty that is unparalleled in their own world. But until that happens, everyday is like the day that came before. Nothing varies. Nothing changes.

Accommodating Autism

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Accommodating Autism and Autistic people and their families. Church, Barbershop, Restaurant, Movie Theatre. From ABC’S World News Tonight, December 18, 2009 (from Charlie Gibson’s last broadcast —

Autism and Employment

Jon Donvon’s (ABC NEWS) report on Autism and Employment:

Asperger’s and schizotypal personality disorder

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I recently attended a seminar on the topic of the personality disorders. One such personality disorder is called schizotypal personality disorder. Read the description and you will see that there is a tremendous amount of cross-over with the symptoms and traits of the autism spectrum disorders.

There is a good deal of controversy at this time as to whether or not the two diagnoses are actually separate entities or the same syndrome. One possible distinguishing characteristic may be the age of onset of symptoms. Schozotypal PD can only be diagnosed in adulthood whereas Asperger’s disorder, or autism spectrum disorders, can be diagnosed in early childhood and even as early as infancy.

There may be prodromal signs of schizotypal personality disorder in childhood but it cannot be diagnosed until after the age of 18, by definition. If a person did not have symptoms of the autism spectrum of disorders or schizotypal PD before adolescence, it is most likely that he does not have autism and has Schizotypal PD instead. Also, people with schizotypal PD have magical thinking such as grandiosity, paranoia, and delusions much like schizophrenia.

They may also have family members with diagnosed schizophrenia. Can someone have both schiotypal and autism. Possibly but not enough data are there to support it. The jury is out on this mysterious syndrome and its relationship to autism.

—- Barbara J Nichols, Ph.D., Licensed Clinical Psychologist.