"Just Right" OCD Formulation

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Gilly
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"Just Right" OCD Formulation

Post by Gilly » Wed Feb 13, 2013 2:24 pm

Hey all

So i've picked up a case of a young girl presenting with OCD type symptoms, am preparing her case for something but thought I would call on you guys for something :)

she falls into the 'just right' type of OCD, so she will put an object down, but it wont feel right, causing tension/discomfort, so will have to keep repeating the action untill it feels 'right'. Ive mapped out the traditional OCD maintanence cycle of Obsession > anxiety > compulsion > temporary relief, but when im trying to build my wider formulation, none of the OCD ones are a good fit because of the lack of assumption of danger/responsibility or dysfunctional thoughts typically found in those cases.

Im currently sitting on a generic CBT set for the top half of my formulation (predisposing, critical incidents, beliefs/assumptions etc) , which is fine, but was wondering if anyone knew of anything else that may fit this in a more specific way for me to take inspiration from?

hope that made sense!

Gilly
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Re: "Just Right" OCD Formulation

Post by Borrowed Cone » Wed Feb 13, 2013 3:02 pm

I suppose it would be inappropriate of me to interpret the "just right" feeling as an unconscious drive to undo a traumatic exit from the womb. Thus, her efforts to get things "just right" are in fact manifestations of an unconscious desire to re-enter the womb and be re-born in a pleasurable manner?*







*may be tongue in cheek.
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Re: "Just Right" OCD Formulation

Post by Dr.Dot » Wed Feb 13, 2013 3:22 pm

Transference much...you wanting to get it 'just right' Gilly.

Anyway, if she thinks its all her reponsibility to get it 'just right' then look up that Salkovkis, if not The Wells model maybe better. But the Sketty model has a lot of evidence for it. It might be an idea to do some reading around mental contamination.

If you want an intergrative formulation, you could formulate how the system is also maintaing her OCD behaviours?

It's all about ERP thoguh....just with the cognitions tested out too.
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Re: "Just Right" OCD Formulation

Post by Gilly » Wed Feb 13, 2013 3:41 pm

ARGH, DYNAMIC'D!!! :shock:

Already started ERP - although there are no cognitions per se' to actually challenge, the cogntive side of it is coming from trying to get a sense of what 'just right' is..

The thing is though that she doesnt seem to have that "responsibility" part thats evident in those models, nothing untoward will happen if she doesnt do the compulsion, she just doesnt like the feeling associated with it - will look up Sketty though (do you have a link/reference?).

i've got some hypothesis re: the system too :)
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Re: "Just Right" OCD Formulation

Post by Gilly » Wed Feb 13, 2013 3:46 pm

You're not calling for help, are you?! ;)

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Re: "Just Right" OCD Formulation

Post by Dr.Dot » Wed Feb 13, 2013 3:52 pm

Wells is all about sitting with the anxiety....

Haven't used the Sketty, don't have any refrences, Salkovskis is the IoP preferred model, obvs. Even though his trail results have never been published, so don't make it onto the Roth and Pilling competencies.

The consequences of not 'getting it right' are how she will feel if she doesn't get it right, and she doesn't want to feel it? - out of control, or summting? She has to be compelled to do for some reason/emotion - you may not get that out til she is disallowed from doing it.
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Re: "Just Right" OCD Formulation

Post by Borrowed Cone » Wed Feb 13, 2013 3:58 pm

You might try an ACT approach if that is possible, which is the alternative to ERP. Or maybe externalising the OCD monster that is telling her to get it "just right". Thoughts as thoughts etc. all that jazz?
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Re: "Just Right" OCD Formulation

Post by baa » Wed Feb 13, 2013 4:26 pm

The Salkovskis one would be a goer if you replace the responsibility stuff with the cognitions about the cognition of "it's not just right" i.e. if things aren't just right, then I'll feel awful forever, this feeling is important somehow, it means I'm not in control - or whatever it might actually be!

though I'd also be tempted to stick with the maintenance cycle, as that's the building block of all my formulations :D you don't necessarily need a bells and whistles one if the MC outlines the maintenance of the anxiety and highlights what the intervention should be and how to apply that intervention. Unless you have to write it up for a case study ;)
At least I'm not as mad as that one!

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Re: "Just Right" OCD Formulation

Post by Gilly » Wed Feb 13, 2013 4:38 pm

baa wrote:Unless you have to write it up for a case study ;)
bingo ;) well - oral case presentation, and whilst im primarily working at MC level with her (and its working well) I want to be able to present a decent, coherant formulation.

She hasnt been able to express any thoughts currently, its essentially "this feels horrible, ill do it to make it go away". but her homework is to try ERP a few times and report back, so will see whether this pushed her to come up with any thoughts/interpretations.

thanks everyone :D
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Re: "Just Right" OCD Formulation

Post by katz » Wed Feb 13, 2013 4:57 pm

with baa on this one

when i have had clients like this i too have used the metacognitive model where thoughts about the thoughts are the centre of the model i.e. 'if i dont do x i wont be able to cope with the anxiety' 'if the anxiety doesnt go away i will loose control' 'i must be in control of my thoughts' etc etc.

the intervention thus focused on for example the belief that if i dont respond the anxiety will never go away

nothing like a case study to get you analysing your formulations!

good luck

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Re: "Just Right" OCD Formulation

Post by Ruthie » Wed Feb 13, 2013 5:19 pm

I liked ACT under these circumstances very much - in my own mind ACT is like metacognitive therapy with values and more heart!

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Re: "Just Right" OCD Formulation

Post by Dr.Dot » Wed Feb 13, 2013 5:24 pm

The third wave...not sure there is any evidence for that for OCD. :twisted:
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Re: "Just Right" OCD Formulation

Post by Borrowed Cone » Wed Feb 13, 2013 5:44 pm

Dr.Dot wrote:The third wave...not sure there is any evidence for that for OCD. :twisted:
There is if you don't call it "OCD" :P

Oh and as Ruthie said the ACT approach is basically the same as working with metacognitions, although you might do less "challenging" with an ACT approach, opting for mindfulness instead when appropriate. But if it is for a piece of coursework then you're best bet will be to make it fit to model when you present it :D
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Re: "Just Right" OCD Formulation

Post by baa » Wed Feb 13, 2013 6:02 pm

Dr.Dot wrote:The third wave...not sure there is any evidence for that for OCD. :twisted:
There's no evidence for Salkovskis either, because the damn man must be sitting on a pile of half written papers :evil:
At least I'm not as mad as that one!

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Re: "Just Right" OCD Formulation

Post by eponymous85 » Wed Feb 13, 2013 6:11 pm

I want to hear Gilly's "what ifs" for if he doesn't get the formulation "just right" :D
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