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17-Mar-22

Obsessive Compulsive Disorder and PTSD Considerations for Screening and Treatment

Obsessive compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) rank among the most debilitating, distressing, difficult and expensive-to-treat mental health conditions. While the two conditions were once considered to be unrelated, accumulating evidence indicates they often co-occur.   Estimated rates of PTSD and OCD co-occurrence range from 24 to 41 percent. PTSD patients with symptoms of OCD appear to exhibit more severe PTSD than those without OCD. Co-morbid OCD and PTSD is particularly challenging to treat. OCD and PTSD commonly occur in people with trauma history. Although the association between the co-occurrence of the two disorders is unclear, some researchers have speculated that obsessive-compulsive behavior may be used to cope with, reduce, and avoid trauma-related stimuli. Assessment Screening and treatment for PTSD are routine in DOD and VA health care systems, however, OCD often goes unrecognized and untreated, or is inadequately treated. A recent study showed that less than half of VA providers could identify exposure and response prevention (ERP) as the frontline treatment for OCD, and less than 25 percent had training in OCD treatment. OCD and PTSD share some symptoms: Feelings of disgust or guilt Recurrent, intrusive memories or thoughts that induce distress Behaviors and actions that reduce or neutralize distress (e.g., rituals, isolation, avoidance) Disentangling the symptoms of OCD and PTSD can be tricky. A clinician may recognize and treat PTSD symptoms but may not identify and address co-occurring OCD. It can further complicate OCD diagnosis that some patients do not exhibit behavioral compulsions such as checking but instead engage in less observable mental rituals. Use of OCD screening and assessment tools among PTSD patients, coupled with availability of training for evidence-based OCD treatment, is essential. Treatment When addressing PTSD it is important for providers to be aware of a potential co-occurrence of OCD and how it may influence treatment. If only one disorder is identified and treated, the failure to consider the other may greatly intensify patient distress. And when both disorders are co-occurring, treatments targeted separately for each can sometimes be counterproductive. ERP treatment is the psychotherapeutic treatment of choice for OCD, while cognitive behavioral therapies (CBTs) such as prolonged exposure and cognitive processing therapy are recommended by VA/DoD clinical practice guidelines for PTSD. However, ERP treatment for OCD has been shown in some cases to be adversely influenced by co-occurring PTSD. Clinicians should assess for both PTSD and OCD in trauma patients to better direct the appropriate combinations of treatments and ensure the overall quality of care. Neglecting to do so can significantly reduce treatment efficacy and contribute to patient distress.  Additional resources The International OCD Foundation is a donor-supported nonprofit organization that provides resources and training for clinicians as well as links to resources for OCD sufferers and their families, including support groups and teletherapy. Although there is no VA/DOD clinical practice guideline for the treatment of OCD or co-occurring OCD and PTSD, you can consult the VA/DOD guideline for PTSD and other relevant links for PTSD treatment. The VA’s South Central Mental Illness Research Education and Clinical Center provides a fact sheet on Examining the Differential Diagnosis Between OCD and PTSD.     Dr. Skopp is a research psychologist at the Psychological Health Center of Excellence West at Joint Base Lewis McChord in Tacoma, WA and an affiliate associate professor at the University of Washington Department of Psychiatry and Behavioral Sciences. Her expertise is in military psychological health research.

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17-Mar-22

Dialectical Behavior Therapy: An Evidence-Based Treatment for Suicide Risk

Clinicians should utilize all helpful strategies at their disposal in order to assist service members at risk for suicide. Dialectical Behavior Therapy (DBT) is one approach to help service members keep themselves safe when they experience suicidal ideation. DBT is recommended in the VA/DOD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for SuicideAssessment and Management of Patients at Risk for Suicide (2019) as an evidence-based treatment for those with suicidal thoughts, attempts, and self-harm behaviors. DBT is a multifaceted approach that includes aspects of Cognitive Behavioral Therapy and teaches skills to address emotion regulation, distress tolerance, and interpersonal effectiveness.1   Since it was first presented in 1993 by Marsha Lineham2 as a treatment for individuals with borderline personality disorder, DBT was adapted for use with additional populations, including service members who are at risk for suicide. DBT teaches effective and accessible strategies for managing emotions and reducing risky behaviors. Once learned, many strategies can be easily practiced by service members.   Providers who are interested in adding to their clinical toolbox to help address suicide risk may seek training in DBT. The training, as well as the treatment regimen, can be time-consuming. Mindfulness is one strategy taught within DBT that is widely accepted by both providers and clients, and can be easily incorporated into clinical work.1 The use of individual interventions outside of the full DBT framework is not necessarily evidence-based and may have limited effectiveness. However, mindfulness-based interventions show promise and have documented benefits to those with suicidal ideation, including veterans.3,4,5   Mindfulness Mindfulness skills are foundational within DBT and facilitate increased awareness of thoughts and emotions.4 It is a form of meditation that is taught within DBT to help service members focus on the present, avoiding rumination of the past or worrying too much about the future.   In the context of suicide risk care, mindfulness can help service members observe their present suicidal thoughts and accompanying emotions without judgment. With guilt and shame so often accompanying and worsening suicidal ideation, the skill allows them to think and feel without further burdening themselves.   Mindfulness is not a practice easily reinforced in our fast-paced, multi-tasking world, and specifically in the daily lives of service members. Many beginners report difficulty remaining focused or getting easily distracted during their meditation practice. Because it may feel foreign at first, basic mindfulness skills should be taught and practiced in session. You can teach basic skills such as the one described below, and once mastered, progress to more advanced skills. Below are some instructions for a basic mindfulness exercise.   Beginner Mindfulness Practice   Instruct the service member to assume a comfortable seated position and take some slow and deep breaths. Have them choose an item object to focus their attention on (You may choose to have some specific items in your office for this purpose. If so, offer these to the service member to choose). Instruct them that as they complete this exercise, it is likely that their attention may wander, and encourage them that, as this happens, they are simply to bring their attention back to the object they are observing.   Instruct them to observe the object and note anything they observe about the item: the color(s), shape, angles, texture, and anything else about the object that makes it unique. You should ask them prompting questions about these and other aspects as a way to guide them through this exercise at first. They should silently note these and continue to do so for a period of time agreed upon by the two of you at the beginning of the exercise (around 5 minutes at first).   When first teaching this skill, be sure to instruct in session and then send the service member home with printed instructions to practice on their own. Try practicing this skill in session until the service member feels they have learned it well enough to use on their own when experiencing suicidal thoughts or feeling overwhelmed. They can use mindfulness to observe their suicidal thoughts without judgment and without acting on them. This strategy can help them to get through moments of heightened risk and set the stage for the use of additional coping skills when in crisis.   For more information:   For additional reading on the utility of DBT for treatment of suicide risk in service members, please review the VA/DoD Clinical Practice Guideline for the Assessment and Management of Patients at Risk for SuicideAssessment and Management of Patients at Risk for Suicide (2019).   References: The Assessment and Management of Suicide Risk Work Group. (2019). VA/DoD clinical practice guideline for the assessment and management of patients at risk for suicide. Washington, DC: Department of Veterans Affairs and Department of Defense. https://www.healthquality.va.gov/guidelines/mh/srb/Assessment and Management of Patients at Risk for Suicide (2019) Lineham, M. (2015). DBT skills training manual (2nd ed.). New York, NY: The Guilford Press. Barnhofer, T., Crane, C., Brennan, K., Duggan, D. S., Crane, R. S., Eames, C., Radford, S., Silverton, S., Fennell, M. J. V., & Williams, J. M. G. (2015). Mindfulness-based cognitive therapy (MBCT) reduces the association between depressive symptoms and suicidal cognitions in patients with a history of suicidal depression. Journal of Consulting and Clinical Psychology, 83(6), 1013–1020. Interian, A., Chesin, M.S., Stanley, B., Latorre, M., St. Hill, L.M., Miller, R.B., King, A.R., Boschulte, D.R., Rodriguez, K.M., & Kline, A. (2021). Mindfulness-based cognitive therapy for preventing suicide in military veterans: A randomized clinical trial. The Journal of Consulting and Clinical Psychology, 83(6), 1939-2117. Kline, A., Chesin, M., Latorre, M., Miller, R., St. Hill, L., Shcherbakov, A., King, A., Stanley, B., Weiner, M.D., & Interian, A. (2016). Rationale and study design of a trial of mindfulness-based cognitive therapy for preventing suicidal behavior (MBCT-S) in military veterans. Contemporary Clinical Trials, 50, 245-252. Dr. Bentley is a licensed professional clinical counselor and contracted subject matter expert at the Psychological Health Center of Excellence. She has worked with individuals experiencing chronic suicidality and has facilitated dialectical behavior therapy groups for women in residential treatment.