Specialized Cognitive Behavior Therapy for Obsessive Compulsive Disorder

An Expert Clinician Guidebook

Debbie Sookman

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317397823
• Edition: 1
• Topic: Psicología
• Subtopic: Psicología clínica

Specialized Cognitive Behavior Therapy for Obsessive Compulsive Disorder is an expert clinician guide for administration of evidence-based specialized cognitive behavior therapy (CBT) for obsessive compulsive disorder and its subtypes. This book focuses on strategies to identify and resolve complex and varied reasons for resistance to CBT and to optimize symptom remission, generalize improvement, and forestall relapse during treatment for OCD. The interventions discussed build upon and elaborate the clinical and research work of other OCD experts, clinicians and researchers in the field of cognitive therapy, and are based on the author's own research and clinical experience as an internationally known expert treating thousands of OCD patients. Criteria are outlined for symptom recovery and for treatment resistance in the context of optimal evidence-based specialized CBT delivery. Featuring treatment models and illustrative case studies, this book is a necessary addition to the library of mental health professionals who work with patients suffering from OCD.

Chapter 1

Introduction

No issue facing the field, however, is as daunting and important as the dissemination crisis, since failure to improve access to care is a threat to the relevance of all of the psychological treatments of established efficacy for OCD.

(Franklin & Foa, 2011, p. 238)

The aim of this book is to describe and illustrate specialized evidence-based cognitive behavior therapy for obsessive-compulsive disorder (OCD). This chapter describes an overview of the phenomenology, symptoms, and specialized treatment that are elaborated in subsequent chapters. Select issues relevant to treatment decisions facing clinicians treating this disabling disorder will be addressed. Symptoms of obsessive-compulsive related disorders will be briefly mentioned but are not the focus. Importantly, no guidebook is a substitute for systematized training that comprises didactics and supervised clinical practice. Training and supervision with an OCD expert are recommended of sufficient duration and scope to achieve specialty-level knowledge and clinical competency with varied OCD presentations.

About OCD

The World Health Organization (2008) ranks OCD as a leading cause of disability worldwide. Affecting approximately 3% of the population through the life span, the risk of occurrence and long-term persistence is substantial (de Bruijn, Beun, de Graaf, Have, & Denys, 2010; Peris et al., 2010). OCD affects all cultural groups and substantially impacts youth. In approximately two-thirds of cases, onset is by age 22 (Fineberg et al., 2013a). OCD is recognized as a major mental illness in which sufferers experience impaired functioning across domains on par with major physical illnesses (Koran, Thienemann, and Davenport, 1996). The disabling effect on psychosocial functioning compares with that of schizophrenia, considered to be the most severe of mental disorders that affect youth (Bystritsky et al., 2001). Depression, anxiety, and hopelessness secondary to OCD symptoms are common and further increase the impact of symptoms. However, OCD is poorly recognized, and there are insufficient clinicians experienced with evaluation and treatment of the disorder, which leads to substantial treatment delay, progression to serious illness, and high rates of treatment resistance due to intervention inadequacies (Dell’Osso, Buoli, Hollander, & Altamura, 2010). Severity and chronicity of illness are associated with high health-care costs and hospitalizations (Drummond et al., 2008). Approximately 25% of these cases attempt suicide (Kamath, Reddy, Kandavel, 2007). Comorbid major depressive disorder (to be distinguished from secondary depression) augments the risk.

In the new fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, known as DSM-5 (American Psychiatric Association, 2013), OCD and Related Disorders are a separate classification, no longer classified with Anxiety Disorders. This development represents major progress in diagnosis, reflecting convergent research that indicates OCD is distinctive in terms of psychopathology and treatment requirements. Treatment for enduring or complex OCD constitutes a specialized field. There is considerable heterogeneity of symptom subtypes that each require specific interventions (Sookman, Abramowitz, Calamari, Wilhelm, & McKay, 2005). These will be summarized and illustrated in subsequent chapters.

OCD is associated with seriously reduced quality of life as well as high levels of psychosocial impairment (Hollander et al., 1996). Impairment occurs across many different domains of life (such as basic self-care and parenting, intra-familial and social functioning, capacity for school or work) and severely restricts functioning. Eisen et al. (2006) found that one-third of their treatment-seeking sample was unable to work due to their OCD symptoms. Degree of impairment increases dramatically for people whose symptoms are in the moderate or higher level of severity: i.e., Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score of 20+, (Goodman et al., 1989). For example, obsessions about harm can make relationships with family and friends feel dangerous, with resultant social withdrawal and isolation. Intrusions about the need to be perfect interfere with completion of school or work projects, resulting in school failure or job loss. Individuals with contamination fears may avoid doctors’ offices and hospitals because they fear exposure to germs, or they may develop dermatological problems such as bleeding and skin lesions due to bathing with bleach in order to feel “clean enough.” Children and adolescents avoid socializing with peers and may be unable to attend school, with multiple long-term impacts (Hollander, Stein, Fineberg, & Legault, 2010). Young adults struggle or fail when they try to leave home to live independently. Many individuals impose ritualistic rules and prohibitions on family members (such as repeatedly cleaning every object that enters the home, with no visitors allowed for fear of contamination), which are associated with high levels of family dysfunction. Parents and significant others report feeling burdened by accommodation to a severe mental disorder and also frequently report high levels of distress. Impoverished quality of life for many sufferers as well as their families is devastating and constitutes a significant burden for society.

There is robust evidence that early detection and prompt evidence-based treatment of OCD can improve recovery rates (e.g., Hollander et al., 2010). Among the best predictors of long-term outcome is degree of improvement at posttreatment (O’Sullivan, Noshirvani, Marks, Monteiro, & Lelliot, 1991; Leonard et al., 1993; Foa et al., 2013). Symptom alleviation is associated with an improvement in quality of life (Bystritsky et al., 1999, 2001; Cordioloi et al., 2003; Tenney, Denys, van Megen, Glas, & Westenberg, 2003; Diefenbach, Abramowitz, Norberg, & Tolin, 2007). Early establishment of accurate diagnosis before the illness becomes entrenched and effective intervention would represent a major health-care advance. The aim of evidence-based treatment for OCD, as for other disorders, is sustained symptom recovery. Suboptimally treated OCD is associated with severe functional impairment across a broad range of functional and health-related quality of life domains, and impaired professional and socioeconomic status (Hollander et al., 2010). Without timely specialized treatment, remission rates among adults are low (approximately 20%, Skoog & Skoog, 1999; Bloch et al., 2009).

Education and training of primary health-care professionals and mental-health practitioners is crucial to increase early detection and accurate diagnosis of OCD throughout the life span, and to promote early intervention and appropriate referral. However, an urgent difficulty in this field is that although evidence-based treatments have been developed, these are not accessible to many sufferers because there are insufficient clinicians and clinical sites experienced with assessment and treatment of this disorder. In many regions there are long waiting lists to access care that may not be evidence based (e.g., Illing, Davies, & Shlik, 2011; Szymanski, 2012). Lengthy delays in accurate diagnosis, misdiagnosis, and unavailability of specialty treatment is most dire in remote regions but is also widespread in urban centers with long waiting periods due to insufficient staff and resources. In a survey of use of specialist services for OCD and Body Dysmorphic Disorder (BDD) in the UK, patients wait approximately 20 years from first diagnosis to receiving highly specialized treatment, with devastating consequences in terms of progression of illness to disability (Drummond, Fineberg, Heyman, Veale, & Jessop, 2013). In a national US survey of office-based practice, only 39% of visits included psychotherapy (Patel et al., 2014).

The first-line evidence-based psychotherapeutic treatment of choice for OCD is specialized cognitive behavior therapy (CBT), including exposure and response prevention (ERP). Analyses of more than 24 randomized, controlled trials have shown that approximately 60–85% of patients report a substantial reduction in symptoms following ERP, with improvement maintained at 5-year follow-up for the majority of treatment responders (Ponniah, Magiati, & Hollon, 2013). Most experts recommend that cognitive therapy and behavioral experiments be combined with ERP in CBT evidence-based approaches for OCD (e.g., Grant, 2014). However, research indicates that the “majority” of individuals with OCD do not receive optimal specialty CBT treatment for their symptoms (Shafran et al., 2009). This clinical reality has been cogently elaborated by several authors (e.g., Franklin & Foa, 2011). Research indicates that clinicians report using CBT for OCD, and patients report receiving it, but the content of sessions often does not resemble evidence-based protocols (Stobie, Taylor, Quigley, Ewing, & Salkovskis, 2007). This may be because training in general psychiatry, psychology, and/or CBT are not necessarily sufficient to acquire the specialized clinical skills required for evidence-based best practice for treating complex OCD. Academic training programs that offer longer-term rotations in the treatment of OCD as an elective are desirable, to ensure that the next generation of clinicians is adequately equipped and that sufficient qualified supervisors are available to teach this greatly needed expertise. Improvement of existing models of continuing education and training to disseminate advanced specialty clinical skills is required to optimize illness recovery, and to ensure that clinicians are not practicing with inadequate clinical skills (Sookman & Fineberg, 2015).

Pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) is the first-line evidence-based pharmacological treatment of choice (Koran & Simpson, 2013). Treatment should be optimally delivered at maximal tolerated dose levels with assessment of adherence. Sustained treatment may protect against relapse (Fineberg, Brown, Reghunandanan, & Pampaloni, 2012, Fineberg et al., 2013b; Fineberg et al., in press). Duration of suboptimally treated illness impacts adversely on response to pharmacotherapy, also underlining the need for effective and timely intervention. The evidence on efficacy of combined treatment with CBT and medication is reviewed in this chapter. Adjunctive treatment with medication acting differently from SSRIs, such as low-dose antipsychotics, or newer pharmacological compounds, may be helpful in treatment-resistant cases.

It has been emphasized by experts that the OCD patient have access to care at a level appropriate to his/her treatment needs. The application of optimal treatment, in terms of intensity and specificity, is recommended to avert unnecessary deterioration to chronicity, disability, intransigence of symptoms, ineffective health-care utilization, and erroneous labeling as “treatment resistant.” Patients who show an incomplete treatment response, that is those who remain ritualistic following treatment, remain susceptible to relapse. Training of primary health-care professionals and general mental-health practitioners is crucial to increase early detection, accurate diagnosis, and appropriate referral for treatment of OCD throughout the life span. Early referral to a specialist center may represent the cost-effective option for OCD patients regardless of illness severity (i.e., for less severely ill patients as well), as specialized treatment would be expected to increase the rate of response and recovery. In response to limited resources, “stepped care” models have been proposed that would involve many patients being offered low-intensity treatment as a first step in the pathway of care. However, these pathways have not so far been sufficiently empirically validated for OCD and Related Disorders and run the serious risk of undertreating the disorder (Sookman & Fineberg, 2015).

Clinical Symptoms of OCD

Obsessions are repetitive intrusive thoughts (e.g., of contamination), images (e.g., of violent or horrific scenes), or abhorrent urges (e.g., to stab someone) experienced as involuntary and highly distressing. Sensations reported include feeling “not just right” and a sense of incompleteness (Summerfeldt, 2007) as well as sensorial experiences (Simpson & Reddy, 2014). Patients may report repeated involuntary intrusive thoughts, images, or memories about past events about which they have strong feelings (e.g., guilt or anger) that include “every detail.” Rituals are repetitive behaviors (e.g., washing, checking) or mental acts (e.g., repeating or replacing words or images) carried out in response to an obsession in order to reduce distress or to prevent a feared event (e.g., becoming ill). Rituals are not connected realistically to feared events (e.g., arranging items perfectly to prevent harm to a loved one) or are clearly excessive (e.g., showering for five hours daily with seven repetitions on every body part). In most cases insight is retained: the individual recognizes his/her beliefs and fears are unrealistic. Mild to moderate illness involves 1–3 hours per day obsessing or doing compulsions, however, many individuals experience virtually constant distressing intrusive thoughts and rituals that are incapacitating. Up to 30% of individuals with OCD have a lifetime tic disorder, most commonly in males with childhood onset of OCD (please see DSM-5, APA, 2013).

Content of intrusive thoughts differs with the developmental stage of the individual. For example, there are higher rates of sexual and religious obsessions reported by adolescents than children. Higher rates of intrusive thoughts of harm and catastrophic events, such as death or illness to self or loved ones, are reported by children and adolescents compared with adults. These themes occur across different cultures and may be associated with different neural substrates (Clark et al., 2014). Many individuals report multiple symptom subtypes. Reported distress associated with symptoms is often intense: anxiety or panic; feelings of disgust (e.g., that one’s own or others’ bodily fluids such as urine, menstrual blood, feces are dirty or disgusting and must be avoided); a sense of “incompleteness” or uneasiness until things feel “just right” (Summerfeldt, 2007). Feared situations that provoke intrusive thoughts and urges to ritualize are commonly avoided such as restaurants, public transportation, and restrooms in the case of washers or social situations related to fears about causing harm. The content of obsessions tend to be those that are against the moral values of the individual (Rachman, 2003).

OCD Related Disorders

Body Dysmorphic Disorder (BDD)

Approximately 8–37% (Phillips, 2000) of patients suffering from OCD also report BDD. Individuals suffering from BDD report highly distressing unrealistic beliefs and preoccupations that one or multiple aspects of their appearance are “ugly,” “deformed,” or “hideous.” BDD is associated with checking rituals and multiple psychosocial impairments, including refusal to attend school. Prevalence of suicidal ideation and attempts attributed to appearance beliefs is high. The mean age of onset is 16–17 years, but the most common age of onset is 12–13 years. BDD has been reported to be associated with childhood neglect or abuse in some cases. Prevalence is elevated in first-degree relatives of individuals with OCD. One’s view of appearance generally ranges from exaggerated in a negative direction to a wholly unrealistic view. As an example of the latter, a beautiful 21-year-old woman saw 10 physicians—including dermatologists and plastic surgeons—because she believed that small lines around her eyes meant she was “prematurely aging and ugly.” Some of these patients seek and receive surgeries for perceived deformities that unsurprisingly often do not meet with the patient’s satisfaction. Specialized assessment and treatment is important prior to and instead of elective surgeries for these patients (please see DSM-5, APA, 2013 for description of OCD Related Disorders).

Trichotillomania

Trichotillomania, or hair pulling, generally develops during puberty and is associated with severe distress and social and school impairment. Hair pulling can occur in single or multiple areas including the head, eyelashes, and brows, and less often other parts of the body such as arms, legs, or the abdomen. In severe cases there are obvious bald spots on the patient’s head and an absence of eyelashes. The patient may wear hair attachments or wigs and may conceal their behavior, including avoidance of intimacy. Varied stressors such as work or school and interpersonal issues may exacerbate symptoms, but symptoms may develop a “functionally autonomous” habitual pattern as well. There may be irreversible damage to hair growth and hair quality. Infrequent medical consequences include digit purpura, musculoskeletal injury (e.g., carpal tunnel syndrome; back, shoulder, and neck pain), blepharitis, and dental damage (e.g., worn or broken teeth due to hair biting). Rarely, swallowing of hair may lead to trichobezoars, with subsequent anemia, abdominal pain, hematemesis, nausea and vomiting, and bowel obstruction (APA, 2013).

Excoriation Disorder

Excoriation (skin-picking) disorder involves recurrent picking at one’s own skin for significant amounts of time, usually several hours daily. As is common for untreated obsessive-compulsive and related disorders, symptoms may endure for years. Three-quarters of sufferers are girls, with onset during adolescence at puberty. The disorder often begins with a dermatological condition such as acne. Sites of skin picking are multiple and the usual course is chronic if untreated. A significant proportion of students report missing school and difficulties studying secondary to picking. Some patients report hours of rituals and can delineate their specific picking protocols. Medical complications include tissue damage, scarring, and (rarely) infection that can be life threatening. Antibiotic treatment for infection is frequently required. Occasionally surgery is required (APA, 2013).

Hoarding Disorder

Hoarding Disorder is characterized by persistent difficulties discarding possessions, regardless of their actual value, and excessive accumulation. Items create clutter to the point where living areas are no longer usable. For example, the individual may not be able to cook in the kitchen, sleep in bed, or sit in a chair. Clutter impairs basic activities such as moving through the house, cooking, cleaning, personal hygiene, and sleeping. Appliances may be broken and utilities such as water and electricity may be disconnected, as access for repair work may be difficult. Quality of life is often seriously impaired. Unsanitary conditions and risk of fire can result. For example, papers and other objects may be piled almost to the ceiling with heating elements covered and route to windows blocked. Concealment, denial of the seriousness of the problem, and poor insight are not uncommon. Rarely, hoarding can be life threatening: two hoarding patients in Canada froze to death when their heating stopped during winter and they did not call their landlord for fear of discovery and eviction. Intervention of third parties is often required (e.g., family members, cleaners, local authorities). Other common features of hoarding disorder include indecisiveness, perfectionism, avoidance, difficulty planning and organizing tasks, excessive attachment to possessions (“they remind me of an important time in my life” or “I may need it one day and don’t care if it’s on the Internet”), and social isolation. Hoarding symptoms first emerge around ages 11–15 years and start interfering with the individual’s daily functioning by the mid-20s. Untreated hoarding shows a progressively worsening course. When parents are seriously afflicted Youth Protection Services are often involved to remove the child from an unlivable environment. Specialized treatment approaches for hoarding have been developed and examined in numerous publications (e.g., Tolin, Frost, & Steketee, 2007; Steketee & Frost, 2014).

Summary of Central Theoretical and Treatment Issues in Assessment, Treatment, and Research of OCD

This section summarizes several key issues relevant to evidence-based clinical practice and controlled research...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Chapter 1 Introduction
• Chapter 2 OCD Subtypes and Comorbidity
• Chapter 3 Theoretical and Treatment Literature
• Chapter 4 “Resistance” to Specialized Cognitive Behavior Therapy for OCD
• Chapter 5 The Scientist–Practitioner Model
• Chapter 6 Treatment of Obsessions
• Chapter 7 Treatment of Contamination
• Chapter 8 Treatment of Checking
• Chapter 9 Treatment of Symmetry, Ordering, Arranging
• Chapter 10 A Schema-based Model
• Chapter 11 Intervention Criteria for an Optimal Trial of Specialized CBT for OCD, Criteria for Recovery, Criteria for CBT Resistance
• Chapter 12 Summary
• Notes
• References
• Index