Sensory Over-Responsivity and OCD: How can Research Inform Practice?

Tamar Podoly, OT, Clinical PsychologistAyelet Ben-Sasson, OT, ScD

IOCDF 2016

Outline

• Concept: Sensory over-responsivity• Research: How SOR and OC interplay?• Theory: Why SOR and OC interplay?• Practice: Sensory-based intervention

Sensory Over-Responsivity• Type of sensory modulation disorder manifested by negative,

intense, rapid, prolonged responses towards daily sensations:– Auditory, tactile, vision, taste, smell, vestibular– Particularly in unstructured, unpredictable situations – Temporal and cumulative effects– Indicators: avoidance, resistance, aggression vs. distress,

distractibility, irritability• Affects 5% of pediatric population (Ahn et al., 2004)• Prevalent in many developmental disorders such as in ASD and

ADHD (Ben-Sasson et al., 2009)• SOR is an imbalance between sensitivity and habituation: high

sensitization and low habituation to stimuli

Is SOR the Sensory Phenomena in OCD?

Bodily sensations

1 .Tactile2 .Muscular/visceral

Mental sensations

1. Need for the “just right” visual, tactile, auditory sensation2. Incompleteness3. Need for energy release4. General urge

Sensory Phenomena

(Miguel et al., 2001; Rosário-Campos et al., 2005)

Inflated responsibility?Need for control?

Imperfection?

Sensory modulation disorder?

Outline

• Concept: Sensory over-responsivity• Research: How SOR and OC interplay?• Theory: Why SOR and OC interplay?• Practice: Sensory-based intervention

Research: SOR and OC interplay

1. SOR manifestation in OCD2. Types of OC symptoms associated with SOR3. OCD sub-typing and SOR

1. SOR manifestation in OCD:– Tactile, auditory, taste, smell, visual SOR (Dar et al.,

2012; Lewin et al. 2014; Taylor et al., 2014)– Clinical pediatric and adolescent samples (Hazen et

al., 2008; Reik & Anderson, 2009; Lewin et al. 2014)– SOR + poor sensory registration and less sensation

seeking (Reik & Anderson, 2009)– Bothering sensation can replace obsession in

triggering compulsion (Hazen et al., 2008)

Research: SOR and OC interplay

Sensory Profile in Adults with OCD

sensitivity avoidance low registration seeking05

1015202530354045505560

OCDADHDASDTYPICAL

(Clince et al. 2016 ; Reik & Anderson, 2009)

Rates (%) of SOR in OCD (Lewin et al., 2014)

TotalPreschoolChildAdolescent0

5

10

15

20

25

30

35

40

45

50Tactile SOR

Taste/Smell SOR

Visaul/Auditory SOR

Adults with Tourette Syndrome Report Higher Sensitivity (Belluscio et al., 2011)

• 80% report SOR across 5 modalities• Bothersome stimuli= faint, repetitive,

constant, non-salient• No dif in tactile and olfaction detection

thresholds• Higher intensity perception for faint stimuli

Research: SOR and OC interplay2. Specific types of OC symptoms implicated?

– SOR associated with greater OC severity (Lewin et al., 2014; Podoly & Ben-sasson, under review; Taylor et al., 2014)

– SOR associated only with compulsions not with obsessions? NO

– If sensitive towards a certain modality is compulsion more likely to be in that modality? NO

– SOR associated with incompleteness vs. harm avoidance? NO

• E.g.: Higher SOR in OCD associated with presence of contamination obsessions, symmetry compulsions, ritualized eating and NJRE (Lewin et al., 2014)

OCD subtyping and SOR3. OCD subtyping and SORN=272 neurotypical adults, Age =33.6 (13.2) yrs, 39.4% Males• Using K-means with SOR and OC scores results in a 4 cluster

solution: None=114; SOR=78; OCS=67, Both=15

None Both OCS SOR1

2

3

4

5

6

7

8

Clusters

Mea

n a

nxie

ty sc

ores

(Podoly & Ben-Sasson, in review)

OCD subtyping and SOR

OCD + sensory symptoms are more likely to have:• Early onset• Elevated OC severity• Have tics and co-morbid TS• Anxiety and depression • Response to pharmacological intervention• Poor response to traditional interventions

(Ferrao et al., 2012; Shavitt et al., 2006; Summerfeldt, 2004; Wang et al., 2012)

Outline

• Concept: Sensory over-responsivity• Research: How SOR and OC interplay?• Theory: Why SOR and OC interplay?• Practice: Sensory-based intervention

Theory: Why SOR and OC interplay?

• SOR creates attention bias towards stimuli which in turn leads to obsessive thoughts and compulsions.

• SOR as a vulnerability factor for psychopathology (Levit-Binnun et al., 2013)

• Anxiety mediates the relation between SOR and OCD

Model Explaining the Role of SOR in OCD

Compulsion

Obsession

Attentional bias sensory

stimuli

Dysfunc’beliefs

SOR early vulnerability

Theory: poor sensory adaptation (Guclu et al. 2015)

• Tactile sensitivity similar in OCD= detection threshold

• Worse amplitude discrimination• Reduced adaptation

Outline

• Concept: Sensory over-responsivity• Research: How SOR and OC interplay?• Theory: Why SOR and OC interplay?• Practice: Sensory-based intervention

Sensory based OCD-Identification

• Childhood and infancy history.• Parents reports. • Obsessions that involve specific body

sensations.• Compulsions that involve avoidance of specific

body sensations.

Sensory based OCD- Assessment SMD assessments available:

• Sensory Profile • Sensory Over Responsivity Scale (SensorR)• Sensory Processing Measure (SPM) • Adult Sensory Questionnaire (ASQ)• Adult Sensory Interview (ADULT-SI)• Sensory Perception Quotient (SPQ)• Sensory Habituation Questionnaire (S-HAB-Q)

Sensory based OCD- Assessment

• Family Accommodation Scale for OCD, Interviewer rated (FAS-IR)

• Cognitive Conceptualization, case formulation (Beck)

Cognitive conceptualization form (Beck, 1995)Relevant data

Core belief

Assumptions and rules

Coping Strategies

Cognitive conceptualization form (Beck, 1995)

Situation

Automatic thoughts

Meaning of AT

Emotion

Behavior

Sensory based OCD- Differential diagnosis

• ADHD• ASD• Schizophrenia• Panic disorder

The ‘Interacting Systems’ principle(Lang,1968)

Assumptions in cognitive theory (Alford & Beck,1997)

Levels of cognitionAutomatic thoughts (negative/adaptive)

"I can not deal with this thing""I can not stand it""It hurts me a lot"

Functional/Dysfunctional assumptions"Always look for danger and expect it”"If I experience discomfort I might get

hurt""I have to control the environment in

order to feel safe"

Core belief, schema"I am sensitive”

"The world is not a safe place for me”

Specificity

accessibility

flexibility

Sensory intervention• Sensory integration

• Attentional and Emotional regulation

• Focusing on the kinesthetic system

Sensory interventionself regulation

First order regulation – automatic, not controlled.

Second order regulation – controlled, Not always conscious.

Third order regulation – controlled, conscious, and requires high-functioning.

Sensory intervention

Arousal levels

Sensory system

Bottom upTop-

down

Sensory based OCDGoals

Preventing sensory overflow, yet with no avoidance behaviors.

Calming , recovery.

Optimal level of arousal, behavioral regulation and organization .

Coping with anxiety-provoking stimuli

Reducing anxiety with cognitive restructuring in relation to stimulus

Sensory based OCD Techniques

• Psycho-education • Use of sensory stimulation for regulation.• Use of cognition for regulation.• Gradual exposure (sensory based)• Classic ERP

Adjustments for OCD

• Therapeutic contract with family/parents and client.

• High family/parental involvement.

• Interesting, funny and challenging exposures.

• Flexible sensory diet to avoid ritualization.

• Do not attack all fronts at once.

• Client control and lead the exposure.

The course of treatment

Phase I – Psycho-educationPhase II - Analysis of automatic thoughtsPhase III - Planning exposure.Phase IV – Adjusting exposure to different settings.Phase V – Exposure level, practices at home and at

schoolPhase VI - When do you know that the treatment

has ended?

Psycho-education

• Sensory system

• Course of treatment

• Exposure

• Parents/children

CASE conceptualization (Beck, 1995)Relevant data

Core belief

Assumptions and rules

Coping Strategies

CASE conceptualization (Beck, 1995)

Situation

Automatic thoughts

Meaning of AT

Emotion

Behavior

Exposure

Calming techniques

Intervention program for sensory based OCD

Target population Pediatric OCDAdult OCD

Adjustments of the human environment

At the beginning, and gradually reducing

Adjustments of the non human environment

The program should take place in a variety of locations

Important elements of intervention

Psycho-educationCognitive conceptualizationExposureCalming techniques

Duration At least 6 month

Frequency At least 2 time per week with everyday practice.

Selected ReferencesBelluscio, B. A., Jin, L., Watters, V., Lee, T. H., & Hallett, M. (2011). Sensory sensitivity to external stimuli in

Tourette syndrome patients. Movement Disorders, 26(14), 2538-2543.Conelea, C. A., Carter, A. C., & Freeman, J. B. (2014). Sensory Over-Responsivity in a Sample of Children

Seeking Treatment for Anxiety. Journal of Developmental & Behavioral Pediatrics, 35(8), 510-521.Dar, R., Kahn, D.T., & Carmeli, R. (2012). The relationship between sensory processing, childhood rituals and

obsessive-compulsive symptoms. Journal of Behavior Therapy and Experimental Psychiatry, 43(1), 679-684.

Güçlü, B., Tanıdır, C., Çanayaz, E., Güner, B., İpek Toz, H., Üneri, Ö. Ş., & Tommerdahl, M. (2015). Tactile processing in children and adolescents with obsessive–compulsive disorder. Somatosensory & motor research, 32(3), 163-171.

Hazen, E.P., Reichert, E.L., Piacentini, J.C., Migule, E.C., Do Rosario, M.D., Pauls, D., & Geller, D.A. (2008). Case Series: Sensory Intolerance as a Primary Symptom of Pediatric OCD. Annual Clinical Psychiatry, 20(4), 199–203.

Lewin, A.B., Wu, S.M., Murphy, T.K., & Storch. E.A. (2014). Sensory over-responsivity in pediatric obsessive compulsive disorder. Journal of Psychopathology and Behavioral Assessment, 36, 201-211.

Podoly, T. & Ben-Sasson, A. (under review). Cluster analysis of sensory over-responsivity and obsessive compulsive symptosm.

Rieke, E.F., & Anderson, D. (2009). Adolescent/adult sensory profile and obsessive– compulsive disorder. American Journal of Occupational Therapy, 63, 138–145.

Summerfeldt, L. J. (2004). Understanding and Treating Incompleteness in Obsessive Compulsive Disorder. Journal of Clinical Psychology, 60(11), 1155-1168.

Taylor, S., Conelea, C.A., McKay, D., Crowe, K.B., & Abramowitz, J.S. (2014). Sensory intolerance: latent structure and psychopathologic correlates. Comprehensive Psychiatry, 55(5), 1279-1284.