Understanding and Treating Obsessive-Compulsive Disorder

A Cognitive Behavioral Approach

Jonathan S. Abramowitz

• Publisher: Routledge
• Year: 2006
• ISBN:
  9781135607470
• Edition: 1
• Topic: Psychology
• Subtopic: Abnormal Psychology
• Index: Psychology

Among the most prevalent and personally devastating psychological disorders the development of a cognitive approach to obsessive compulsive disorder (OCD) has transformed our understanding and treatment of it. In this highly practical and accessible book, Jonathan Abramowitz presents a model of OCD grounded in the most up-to-date research that incorporates both cognitive and behavioral processes. He then offers a step-by-step guide to psychological treatment that integrates psychoeducation, cognitive techniques, and behavioral therapy (exposure and response prevention). Unlike other manuals for the treatment of OCD, this book teaches the reader how to tailor the choice of techniques and delivery modes for individuals presenting with a wide range of specific OCD symptoms, such as contamination fears and cleaning rituals, fears of harm and compulsive checking, symmetry and ordering, and severe obsessions with mental rituals. The techniques are illustrated with numerous case examples; clinical forms and handouts are provided for use with patients. A final chapter suggests strategies for overcoming common obstacles in treatment.

II

How to Conduct Consultation
and Treatment for OCD

6

Consultation I: Diagnosis and Assessment

Psychological consultation entails obtaining a thorough assessment of a patient's problem and providing education, information, and recommendations to that individual and his or her family or support network (Brown, Pryzwansky, & Schulte, 2001). Consultative services are based on the consultant's education, training, and experience, as well as on knowledge of the relevant scientific literature. This chapter provides a detailed description of how to conduct a diagnostic interview, assess the nature and severity of OCD symptoms, and provide feedback to the patient regarding his or her symptoms. Collection and discussion of this information constitutes one portion of the initial consultation that should precede therapy. The second portion of the consultation, described in chapter 7, involves discussing and recommending an effective treatment. The assessment procedures covered in this chapter can be conducted over a 2- to 3-hour period, and may be divided across multiple sessions if necessary. More time may be required in complex cases or for therapists new to working with individuals with OCD. The case of Susan T., described next, will be used to illustrate the consultation and treatment procedures throughout the second part of this book.

Susan T., a 33-year-old elementary school teacher, had been married for 6 years. She and her husband, Steve, have a 3-year-old son, Brian, and a 3-month-old infant, Jennifer. Susan's primary care physician has referred her to a psychologist because of persistent washing and checking rituals that were not responding to various serotonergic medications. Susan had also undergone numerous trials of talk therapy that had not been particularly helpful in alleviating her symptoms.

OVERVIEW AND PURPOSE OF ASSESSMENT

Assessment is an ongoing and conceptually driven pursuit where theories of the causes, maintenance, and treatment of OCD determine what is important to evaluate. Initial assessment begins with a clinical interview to substantiate a diagnosis of OCD, identify possible comorbid conditions, and rule out problems that are sometimes mistaken for OCD. Next, the content and severity of the individual's obsessions and safety-seeking behaviors are determined. The presentation of OCD symptoms, range of comorbid psychopathology, and impact of the disorder on the individual's functioning vary widely from patient to patient. Thus, assessment should encompass the individual's level of functioning, support network, and treatment goals. Understanding this broad context helps the clinician identify factors that might exacerbate or ameliorate OCD symptoms, or impact adherence to treatment recommendations. It also helps with recognizing additional forms of psychopathology that warrant clinical attention or that might impact treatment planning.

DEVELOPING A THERAPEUTIC RELATIONSHIP

Careful assessment provides an excellent opportunity to begin developing an alliance with the patient and engaging him or her in the process of goal setting. Many patients with OCD come to their initial consultation embarrassed about their symptoms, perhaps having hidden their obsessional thoughts and compulsive rituals from friends or relatives for many years. In such cases, the clinician can destigmatize these symptoms by recasting them as manifestations of a clinical disorder, rather than eccentric or “mad” behavior. It might help to point out that about 1 in 40 people have OCD, and to provide examples of obsessions and compulsions reported by others. In contrast to those who conceal their symptoms, other patients will have become caught up in vicious cycles of mutual irritation or coercion with family members. Here, the assessment process provides a chance to encourage collaboration and cooperation in implementing a jointly agreed on treatment program.

IMPORTANCE OF ONGOING ASSESSMENT

Continually assessing the nature and severity of OCD and related symptoms throughout the course of treatment assists the therapist in evaluating whether, and in what ways, the patient is responding. This is consistent with the emphasis on objective measurement of treatment effectiveness within evidence-based practice. It is not sufficient for the clinician simply to think, “He seems to be less obsessed,” or “It sounds like she has cut down on her compulsions”; or even for the patient (or a relative) to report that he or she “feels better.” Instead, progress should be assessed systematically by comparing current functioning against the baseline obtained at the outset of treatment. Thus, periodic assessment using the psychometrically validated instruments described later in this chapter should be conducted to clarify in what ways treatment has been helpful and what work remains to be done.

ASSESSMENT AS PSYCHOEDUCATION

Helping the patient understand why his or her seemingly bizarre and senseless thoughts and behaviors persist despite strong resistance enhances the value of assessment for the patient. For example, learning that most everyone normally experiences odd or upsetting unwanted thoughts helps normalize these experiences. Frequently, patients fail to see the connections between their obsessional fears and their avoidance or safety-seeking behaviors. Pointing out that these responses are means of coping with obsessional fear helps validate such behaviors, even if they are excessive; for example, “I know you think it's a bit strange, but if you are afraid of catching germs from dead bodies, I can see why you'd want to shower after driving past a cemetery.” Linking avoidance and safety behaviors to obsessional thoughts in this way also makes the patient increasingly aware that his or her behaviors are consistent and predictable. In turn, this awareness helps patients identify their obsessions and compulsions more accurately.

ESTABLISHING THE DIAGNOSIS OF OCD

The clinician should begin with unstructured inquiry into the present symptoms, history, family issues, and feelings about treatment. This information will guide the structured component of the assessment described later in this chapter.

Assessing the Chief Complaint and History

The assessor's initial job is to determine whether the patient's symptoms fit into the category of OCD and whether comorbid conditions are present. Chapter 2 provides useful guidelines for distinguishing between OCD and other disorders that, although just as disturbing, are not the same as OCD. It is useful to begin by asking the patient to describe his or her chief complaint and purpose for coming to the session. The patient might also be asked to describe a typical day, highlighting the frequency, intensity, and duration of OCD symptoms. The interviewer can probe for information about how the problem is managed and how symptoms interfere with functioning. Table 6.1 contains a list of additional questions for eliciting more information about the presence of obsessions, compulsions, avoidance, and other safety-seeking strategies. Information about the onset, historical course of the problem, comorbid conditions, social and developmental history, and personal and family history of psychiatric treatment should also be obtained.

Susan T. described intense fears of becoming ill from germs, particularly from bodily fluids and secretions such as urine and sweat. She awakened at 4 a.m. each morning to complete a 2-hour bathroom routine before leaving for work. Her ritualistic behavior included extensive decontamination of the toilet and shower using heavy-duty cleansers, the need for half of a roll of toilet paper to wipe herself when using the toilet, and a 45-minute shower routine that included washing her body according to specific rules she had devised. Hand washing occurred throughout the day and Susan was spending over an hour cleaning the dishes after dinner. She also described a fear of fires and break-ins, and often got “stuck” checking that doors and windows were locked, and that appliances were off and unplugged. At work she rechecked paperwork extensively, which often caused her to be late for picking up her son from day care. Soon after the birth of her daughter, Susan began having scary unwanted thoughts of hurting this child. For example, she was afraid to carry Jennifer for fear of dropping her down the stairs, and at times, asked her husband, Steve, to bathe the baby because of unwanted thoughts about drowning her in the bathtub. Although Susan was able to work, she was constantly behind in her paperwork and felt as if things were getting worse.

Insight

When assessing the patient's ability to recognize the senselessness of his or her symptoms, the clinician should keep in mind that this capability often fluctuates. Some individuals will willingly concede that their obsessional fears are irrational, yet they still cause distress and urges to perform rituals. A smaller group firmly believes that their obsessions are realistic and compulsive rituals serve to prevent feared disasters. In most patients, however, the strength of belief changes depending on the situation, making it difficult

TABLE 6.1
Examples of Open-Ended Questions to Help in Assessing the Presence of OCD Symptoms

How often do the obsessional thoughts come to mind? How long do they last? What kinds of activities or situations trigger the obsessional thoughts or urge to ritualize? What kinds of activities do you avoid to prevent yourself from worrying about accidents or mistakes? What do you do to avoid coming into contact with ______(triggers)? What do you do to prevent yourself from thinking thoughts that upset you or make you worried? When you come into contact with ______(trigger), what do you do? How many times a day do you feel the urge to ______(insert safety-seeking ritual)? How long does each ritual last? After you have completed this safety-seeking ritual how do you feel? How anxious are you? When you are worrying about accidents, mistakes, or harm, how do you assure yourself that things are OK? What precautions do you take to make sure you don't make terrible mistakes, have an accident, or hurt anyone? What do you do to keep yourself from acting on unwanted thoughts? If you were unable to ______(give examples of rituals), how would you feel? What are you afraid might happen? How much do you think these rituals are senseless or excessive? How often do you resist or delay your rituals? What happens when you try? How else are these fears and rituals interfering with your life? What are you avoiding because of your fears? How does your family react to your symptoms? What do they think of your situation? Are other people involved in your rituals? Do they help you avoid feared situations?

to pin down the precise degree to which they recognize the symptoms are irrational. For example, in the session, a patient might be able to state that the risk of acting on an intrusive impulse to stab someone is quite low. However, when the impulse occurs at home as triggered by watching a sleeping child, it might evoke intense fear that the dreaded consequences will occur. Assessment of insight is illustrated by the following exchange between Susan and her therapist:

Therapist:	Can you tell me how likely it is that a fire would start if you left the toaster plugged in while you were away from your house for a few hours?
Susan:	I wouldn't do that. I definitely think it would cause a fire.
Therapist:	So, you are saying that there is a 100% chance that leaving the toaster plugged in will cause a fire; right?
Susan:	Well … I guess so.
Therapist:	Hmmm. Most people leave appliances like toasters plugged in even when they are not using them. For example, in my house, the toaster stays plugged in all the time whether someone is home or not. In fact, it's probably been plugged into the electrical outlet continuously for several years. But what you're saying is that by now, my house should have burned down; and probably lots of others' homes too. How do you explain that house fires are less common than that, and that fire prevention guidelines don't say that you should unplug toasters every time you leave the house?
Susan:	Hmm. I hadn't thought about it that way. Maybe it's not 100% likely. Maybe it's less likely, like 10% or even less.

Because Susan was able to notice the inconsistency in her thinking and revise her probability estimate (although it remained excessively high), she was considered to have good insight into the senselessness of her symptoms.

Mood

Because most individuals with OCD also suffer from depressive symptoms it is important to assess mood state. Clinicians should inquire about the chronological history of mood complaints to establish whether such symptoms should be considered as a primary diagnosis or as secondary to OCD symptoms. Primary depression develops in parallel with OCD, and might precede OCD onset. In contrast, when depressive symptoms develop subsequent to OCD, and when the patient describes being depressed about having OCD, the depression is considered secondary to OCD.

Social Functioning

Clinicians should assess the degree of impairment in lei...

Table of contents

• Cover Page
• Half Title page
• Title Page
• Copyright Page
• Dedication
• Contents
• About the Author
• Preface
• Acknowledgments
• I What We Know About OCD
• II How to Conduct Consultation and Treatment for OCD
• Appendix A: OCD Treatment History Form for Assessing the Adequacy of Previous Cognitive-Behavioral Therapy Trials
• Appendix B: The OCD Section of the Mini International Neuropsychiatric Interview (MINI)
• Appendix C: Yale-Brown Obsessive Compulsive Scale Symptom Checklist and Severity Scale
• Appendix D: The Brown Assessment of Beliefs Scale
• Appendix E: The Obsessive-Compulsive Inventory-Revised Version (OCI-R)
• Appendix F: The Obsessive Beliefs Questionnaire and Interpretation of Intrusions Inventory
• Appendix G: Interview on Neutralization
• References
• Author Index
• Subject Index