Obsessive-Compulsive Disorder: Clinical picture and cognitive-behavioral treatment implications

Obsessive-Compulsive Disorder: The basics

Generally considered a commonly occurring anxiety disorder, with estimates in the general population ranging from 0.5% to between 2% and 3% Prior to Victor Meyers (1966) pivotal discovery of the effects of exposure, it had historically been thought to be an intractable condition, an incurable ailment Following Stanley Rachmans (1971) extension of selfregulated response prevention to exposure, this insidious condition has graduated to a widely recognized and accepted common disorder with multiple, efficacious treatment options available, including both psychotherapy and pharmacotherapy

OCD: The basics continued

OCD tends to take a chronic, waxing and waning course without treatment Skoog & Skoog (1999) found 50% of untreated sample experienced clinically significant symptoms after nearly 5 decades, and 33% experienced sub-clinical symptoms

Only 20% completely recovered without help

OCD episodes are lengthy and spontaneous recovery is all but unheard of On average, OCD sufferers delay the onset of treatment by 2 to 7 years

Most sufferers do NOT seek services

High utilization of mental health services = high costs

Obsessions

Recurrent and persistent thoughts, impulses or images that are experienced, at some time during the disturbance, as intrusive and inappropriate and that cause marked anxiety or distress
Thoughts, impulses and images are not excessive worries about real-life problems; instead, they are ego-dystonic

syntonic versus dystonic

The content may be viewed as foreign or alien and outside of the persons control; in other words, these signs, symptoms, or experiences are uncomfortable or unwanted

e.g., thoughts about personal finances may be useful and be seen as adaptive and as self-generated; however, having thoughts of impulsively plunging a kitchen knife into another person would probably be unhelpful and unwanted

e.g., imaginal script of mother killing her children

Obsessions: Normal and abnormal

All people demonstrate obsessions, or intrusive

thoughts with an offensive content

Why are OCD-ers so negatively impacted by such thoughts?

See handout Obsessions reported by a non-clinical sample 90% of people asked whether they think any of those, endorse in the positive!!! Similar in form and content to OCD-ers 10% lie (i.e., we all have thoughts like this)

The Obsessive Compulsive Cognitions Working Group have provided some plausible answers with respect to OCD-ers process of thinking

Frequency, intensity, uncontrollability, associated with neutralizing responses Poor insight specifier: Recognizing unreasonable nature?

Thinking style and consequent / subsequent behavior

Challenging harming obsessions: Are you evil?

Control of thought
Control of thought: attention to thoughts serves to increase their occurrence
Uh-oh reaction to intrusion Control attempts: Suppression, distraction, ignoring, compulsion Focuses attention on thought.

Intrusive thought

Uh-Oh!

Notice thought more.

Further focuses attention on thought.

Try harder to control.

Increased frequency of intrusive thought.

Over-importance of thought
Over-importance of thought: thinking the thought (e.g., Im going to Hell) is important because it occurred, and it occurred because it is important
If thought is important Dwell on thought. Verifies importance of thought. Further dwelling on thought.

Conclusion: thought is important!

Obsessive Compulsive Cognitions Working Group (OCCWG): 6 belief domains central to OCD

The maladaptive aspects of the domains predominantly focus on (1) the importance of monitoring and vigilance for certain mental events, (2) the moral consequences of not controlling thoughts, (3) psychological / behavioral consequences of failing to control thoughts, and (4) efficiency of mental control

1. 2. 3. 4. 5.

Inflated responsibility: Personal (pivotal) power to bring about or

6.

prevent subjectively negative outcomes Overimportance of thought: Presence of thought = its important Overestimation of threat: Exaggeration of probability or severity Importance of controlling thoughts: Overvaluing exerting complete control over intrusive content, and belief it is possible and desirable Intolerance of uncertainty: Necessity of being certain, personal inability to cope with unpredictable change, difficulty in functioning in ambiguous situations Perfectionism: Belief there is a perfect solution to every problem, doing perfectly is possible and necessary; minor mistakes = serious consequences

Compulsions

repetitive behaviors or mental acts that the person feels driven to performed in response to an obsession, or according to rules that must be applied rigidly

Themes of compulsions typically match the themes of obsessions

Contamination and washing Danger and checking Blaspheme and praying

These behaviors and mental acts are designed to neutralize, prevent or reduce discomfort of some dreaded event or situation, but either the activity, whether overt or covert, is not connected in a realistic way with what it is designed to neutralize or prevent, or it is clearly excessive
may include, but are not limited to: hand washing, ordering and arranging, checking, praying, counting, or repeating words silently e.g., a person washing their hands until raw and cracking would illustrate this excessive response to distress

So, whats the big deal anyhow?

Problem: It may not be immediately clear just how serious and

incapacitating these problems can be!

e.g., persistent urges to check the security of ones home before leaving for work each day can grow to such a magnitudes that it impairs individuals entire life

e.g., being troubled by intrusive, unacceptable thoughts can reach such proportions as to imprison the person and prevent them from carrying out constructive work, or maintaining interpersonal relationships
e.g., intense fear of dirt and disease can lead to moving to a new house every six months and eventually to even avoiding whole regions of the country

OCD: Comorbid diagnoses

Depression (30%) Insomnia (40%) Other anxiety disorders

Panic d/o may be primary complaint, especially for African American clients (Friedman et al., 2003)

Eating disorders (10%) Tics (20-30%) Tourettes Syndrome (5 - 7%)

OCD: Assessment Clinical interview

Diagnosis, history, risk 4 primary problem areas w/in each of following:

Obsessions (what is feared outcome?) Cues (situations, thoughts, places that trigger anxiety)

intensity of anxiety (SUDS rating) frequency of contact what types of internal and external rituals? how long do they last? how much is anxiety reduced, for how long? what type of avoidance? how often are stimuli avoided?

Rituals (neutralizing activity)

Avoidance

OCD: Assessment (cont.)

Yale Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al, 1989) 10 items total (5 obsessions, 5 compulsions)
adequate inter-rater reliability, validity & internal consistency for interview version (Goodman et al, 1989) self-report administration shows better test-retest reliability

Steketee, G., Frost, R., & Bogart, K. (1996). The Yale-Brown obsessive compulsive scale: Interview versus self-report. Behaviour Research & Therapy, 34(8), 675-684.

Self-monitoring Baseline and ongoing

Trigger Ritual Discomfort Time spent on ritual

Exposure and response prevention: The gold standard

ERP has been well established / evaluated through careful, randomized studies as an efficacious method of treatment, producing positive results in up to 70% - 90% of patients

Learn to distinguish between responders (i.e., a 25-35% change) and clinical significance / reliable change

Not unusual to see patients treated with these behavioral techniques labeled much improved at termination

most patients treated with ERP techniques move from a clinical to a nonclinical range in their OCD symptoms

Those who improve with this mainstay treatment are typically able to maintain their gains at follow-ups of one to five years

OCD: ESTs

Meds vs. behavioral therapy

Van Balkom et al. (1994) meta-analysis w/ 86 studies

serotonergic antidepressants (1.63) EX/RP (1.47) cognitive therapy (1.04) combo EX/RP + meds (1.99) combo EX/RP + placebo (1.85)

Behavioral vs. cognitive therapy

cognitive alone similar to EX/RP alone

1991; van Oppen et al., 1995) Kozak, 1994)

(c.f. Emmelkamp & Beens, (c.f. Hiss, Foa &

cognitive interventions dont add to EX/RP

findings inconclusive b/c EX/RP comparisons were not intensive

Medication & EX/RP similar in short run Medication is worse than EX/RP in long run (89% relapse after d/c) Combined slightly better than either meds or EX/RP alone Cognitive is same as nonintensive EX/RP & adds little EX/RP is best when:

OC-D: ESTs Summary

sessions are frequent (15 sessions, over 3 weeks) sessions are long (1.5 - 2 hrs) exposures are long (45 min) home exposures are intensive (2 hrs/daily) rituals are entirely prevented intensive have 83-100% have reductions of 50% or more
1994)

intensive vs. nonintensive EX/RP

(Foa & Kozak, 1997; Hiss et al,

average of 60-70% reductions in OCD sx nonintensive have average of 30-50% reductions in OCD sx
al., 1988)

(Emmelkamp et

Naturalistic treatment w/ twice weekly 45-90min sessions was moderately and similarly effective with African American (d = 1.29) & Caucasian (d = 1.24) clients (Friedman et al., 2004)

Exposure and Learning Theory

Exposure therapy is committed to the principles of learning theory, which dictates that (all) behavior is learned and, therefore, controlled by avoidance conditioning That is, we will tend to avoid experiences that make us feel uncomfortable and other, necessarily, negative states; we are hedonists! (Think TOLERANCE = we are intolerant) The environment around us (and sometimes our internal environmental processes) will dictate whether we will feel at ease to stay relaxed, or whether we will feel unease and feel compelled to do something (e.g., escape, check, wash, count, pray, order, arrange) to feel better

Mowrers (1947) two-stage theory of fear

The basis for most anxiety disorders, and the basis for most efficacious anxiety disorder treatment approaches Definition: Classically conditioned acquisition of fear is followed by operantly conditioned avoidance of fear cues, resulting in fear maintenance due to a lack of unreinforced exposure to those conditioned stimuli In a nutshell: People develop anxiety as a response set to nonthreatening situations because we have been punished in the past in the presence of those situations

Why is negative reinforcement so strong and important? we not wish to re-experience the punishment, and this desire to E&A conditions fear

Emotional reactivity promotes conditioning

Negative reinforcement model = Bhr model for OCD

Common reaction: You want me to do what???

Many patients do react negatively towards the proposal for ERP

Must be able to sell theory of habituation and extinction Must be able to sell a lemon

20% of patients who agree to do it drop out prematurely because it is so challenging 30% of patients appear refractory to ERP, but need to look at covert avoidance and rituals Up to 50% of patients not adequately helped by ERP Offer (informed) alternatives

300.3 Obsessive-Compulsive Disorder and when

it isnt OCD

Obsessions: Recurrent thoughts, images, impulses, beliefs or ideas that dominate a persons thought content, which persist, even though the person believes they are unrealistic and may try to resist them Compulsions: Acts (either physical or mental) performed repeatedly in a way that the person realizes is neither appropriate or useful Time and interference critical to deriving true OCD diagnosis Often chronic and, untreated, extremely debilitating Coding: Poor insight Caution: BDD-appearance; ED-food; Health anxiety-health; Trich-hair; Impulse control NOS-skin/complexion; MDD-guilt; paraphilias-sexual fantasies or urges

How does ERP work?

ERP deliberately exposes the patient, gradually but systematically, to all situations that upset them until their fear subsides

Process is called (normal) habituation, which is like getting used to something over time through familiarity

Repeated habituation produces extinction

Usually last at least 45 - 90 minutes but sometimes up to several hours; this is done intentionally to ensure that the patient actually becomes accustomed to the very situations that have upset them Once habituated to these situations, and each one becomes less mentally and physically upsetting, the exposures will advance up a hierarchy of feared situations until the patient has accomplished this confrontation-task for even their worst fears Must stop themselves from doing the rituals or avoidance that they would normally be tempted to do when they experience fear because compulsions prevent normal habituation from occurring

ERP & CBT & CT controversy

Behavioral researchers have argued that behavior therapy actually changes cognitive sets, therefore reducing obsessions Others suggest that exposure therapy alone merely changes OCD patients thoughts and beliefs about dangerous situations by learning through exposure what is dangerous and not (i.e., not really changing the cognitions per se) When studied carefully, it has been illustrated that ERP produces modest change in general irrational beliefs, while cognitive interventions appear to produce significant gains

2001 findings: CBT and ERP both produced significant findings, but that ERP was marginally more effective than CBT by the end of treatment and then again at the 3-month follow-up; 16% of the CBT group and 38% of the ERP group recovered

Problems in OCD Treatment

Client wont confide obsessions

90% of population has thoughts they find upsetting reassuring that nothing bad will happen if they relay thoughts giving examples of the types of thoughts others may have high distress re: ego-dystonic thoughts less likely action Share outcome data Point out that current coping methods problem worse Reassure that anxiety is not dangerous, PNS cognitive interventions (similar efficacy to nonintensive beh tx) perform ritual very slowly perform wrong number of rituals postpone ritual --> re-evaluate further postponement

Client doesnt want to do exposure

Client is not successful at RP

Obsessive-Compulsive Disorder, the Naked Truth: A Primitive Defense.

Results 3: Overall effectiveness

mean d (all studies) = 1.71 (SD = 1.04). 95% Confidence Interval: 1.28 2.14. Fail-safe N = 189. Rosenthals recommended 5:1 ratio = 125. 189 > 125, therefore robust. Weighted d =1.44 (SD = 1.08). 95% Confidence Interval: 0.99 1.89. Fail-safe N = 155. 155 > 125, therefore robust.

Orwins fail safe N

Fail safe N (Nfs) is defined as the number of unpublished, nonsignificant trials required to reduce an obtained mean effect size to a trivial magnitude; a non-significant trial can be defined as one that obtain a miniscule effect size Orwin suggested that a small effect size of d = 0.20 would qualify as a trivial value At or below such levels, it is considered reasonable to attribute the results to chance. The larger this Nfs number is, the more confidence that can be placed in the combined results. Rosenthal established the general guideline that a 5:1 ratio of nonsignificant, unpublished studies to each published study should be obtained before the possibility of a negating file drawer effect can be safely eliminated. Results that exceed this 5:1 ratio are considered to be robust, and are an estimate of the stability of the combined results; In other words, beyond the ratio the result is considered an unbiased reflection of the phenomenon under investigation.

Results 4: ERP effectiveness

mean d (all ERP) = 1.62 (SD = 1.17). 95% Confidence Interval: 1.03 2.21. Fail-safe N = 128. Rosenthals recommended 5:1 ratio = 90. 128 > 90, therefore robust. Weighted d =1.32 (SD = 1.16). 95% Confidence Interval: 0.75 1.89. Fail-safe N = 101. 101 > 90, therefore robust.

Results 5: CT effectiveness

mean d = 2.09 (SD = 0.84). 95% Confidence Interval: 0.75 3.43. Fail-safe N = 38. Rosenthals recommended 5:1 ratio = 20. 38 > 20, therefore robust. Weighted d =1.92 (SD = 0.86). 95% Confidence Interval: 0.55 3.29. Fail-safe N = 34. 34 > 20, therefore robust.

Results 6: CBT effectiveness

mean d = 1.78 (SD = 1.01). 95% Confidence Interval: 0.72 . Fail-safe N = 24. Rosenthals recommended 5:1 ratio = 15. 24 > 15, therefore robust. Weighted d =1.58 (SD = 1.04). 95% Confidence Interval: 1.00 4.16. Fail-safe N = 21. 21 > 15, therefore robust.

Results 7: More on effectiveness at follow-up

Follow-up: mean d = 1.77 (SD = 0.95) at follow-up, overall. mean d = 1.07 (SD = 0.60) at 12 weeks. mean d = 1.77 (SD = 0.66) at 24 weeks. mean d = 1.78 (SD = 0.75) at 52 weeks. mean d = 1.22 at 76 weeks. Of the 12 studies that reported follow-up data, 9 (75%) showed effect sizes that exhibited a slight, but general regression towards the pretreatment mean.

Results 8: Effectiveness of CT vs. ERP

CT Mean d = 2.09 (SD = 0.84). 95% C.I.: 0.75 3.43. Poor ERP (< 0.80) 4 studies reported effect magnitudes where d < 0.80. Mean d = 0.60 (SD = 0.17). 95% Confidence Interval: 0.06 1.14. Inadequate ERP (< 1.62) 13 studies reported effect magnitudes where d < 1.62. Mean d = 1.00 (SD = 0.35). 95% Confidence Interval: 0.78 1.22. Gold-standard ERP (> 1.62) 5 studies reported effect magnitudes where d > 1.62. Mean d = 3.20 (SD = 0.73). 95% Confidence Interval: 2.28 4.12.

Results 9: Patient cost-effectiveness

ERP Overall: Weeks to 1 Std. Dev. D = 5.73 Weeks to d = 0.80 was 6.65 Poor: Weeks to 1 Std. Dev. D = 7.10 Weeks to d = 0.80 was 10.20 Inadequate: Weeks to 1 Std. Dev. D = 5.06 Weeks to d = 0.80 was 5.83 Gold-standard: Weeks to 1 Std. Dev. D = 1.90 Weeks to d = 0.80 was 1.63

Results 9: Patient cost-effectiveness continued

CT Weeks to 1 Std. Dev. D = 5.94. Weeks to d = 0.80 was 6.78. CBT Weeks to 1 Std. Dev. D = 8.85. Weeks to d = 0.80 was 8.57.

Results 10: Provider cost-effectiveness

ERP Overall: Hours to 1 Std. Dev. D = 8.82 Hours to d = 0.80 was 9.30 Poor: Hours to 1 Std. Dev. D = 6.10 Hours to d = 0.80 was 9.45 Inadequate: Hours to 1 Std. Dev. D = 12.99 Hours to d = 0.80 was 12.39 Gold-standard: Hours to 1 Std. Dev. D = 7.37 Hours to d = 0.80 was 6.06

Results 10: Provider cost-effectiveness continued

CT Weeks to 1 Std. Dev. D = 5.23. Weeks to d = 0.80 was 7.02. CBT Weeks to 1 Std. Dev. D = 16.31. Weeks to d = 0.80 was 16.03.

Discussion 3: So why did ERP performance vary?

Regardless of poor, inadequate, or gold-standard delivery, several qualitative aspects were consistently true for optimal performance: (1) therapist-controlled vs. self-directed (or computer) (2) exposure duration (time better) (3) frequency of treatment (frequency better) (4) individual- vs. group- format These points support the psychological theory of habituation and extinction of fear, which suggests that infrequent and short contact with anxiety-provoking stimuli inhibits degrading. Less direction from provider appear to undermine adequate frequency, duration, and, likely, full ERP. ERP has not changed since 1991.

Discussion 4: What about CT and CBT?

CT Most importantly, compared with Van Balkoms analysis (RET), the current analysis (CT according to SalkovskisBeck) suggested a 97% increase in effect magnitude. When weighted, the increase was 81%. CT vs. RET implication? Note that all CT was individually delivered. Lower CT effects associated with lower session duration. CBT All also exclusively therapist-controlled. Group format performed the least well. Longer treatment phase associated with better outcome. Fundamentally same, with slight since 1991.

Discussion 5: Implications for comparison

Not advisable to compare these 3 groups, especially ERP
and CT, unless best-practice standards are honored. Matched conditions are important to be able to make objective comparisons; however, if it is clear that nongold-standard ERP will produce a suppressed effect, why make that comparison? What outcome could be expected if patients were asked to treat themselves (e.g., challenge significance of interpretations of thoughts), and in only half of an adequate trial time? Does it make sense to compare a newly-developed treatment against such an outcome? Gold-standard (3.20) ERP still looks better than CT (2.09), so be cognizant of which comparisons are made!

Discussion 6: Cost-effectiveness
Patient perspective Gold-standard ERP favored over CT and CBT CT took 264% longer to obtain 1 Std. Dev. CT took 257% longer to reach d = 0.80. CBT took in excess of a couple of months to obtain 1 Std. Dev. and reach 0.80. Provider perspective Again, gold-standard ERP favored, requiring least time input. Questionable whether non-best-practice ERP should be applied. Teaching multiple components (CBT) is worst.

Discussion 7: ERP and CT effects on OCD

The methodologies do not differentially affect obsession and compulsion sub-scores, suggesting that their change mechanism does perhaps does not differ (as CT advocates have suggested). Alternately, OCD may instead be a constellation of symptoms that perhaps change as a whole. So, why is CT needed? ERP refractory, refusers, drop-outs. Pure obsessionals. Patient choice, capacity, and symptom clusters. Professor Gallagher approach simply is not reasonable for all patients.