Obsessive-Compulsive Disorder Lecture Overview Nature and epidemiology Etiology Empirically-supported treatments Efficacy data Moderator variables Class discussion

Epidemiology of OCD Defining features Prevalence Onset and course Associated features/comorbidity

Associated Disorders Depression Other anxiety disorders Sleep disturbance Eating disorders Tourette’s disorder and motor tics

Classification of Obsessions (Jenike et al. 1986) Contamination (55%) Concerns of harming self or others (50%) Sexual concerns (32%) Somatic concerns (35%) Symmetry concerns (37%)

Classification of Compulsions Cleaning or washing Checking Counting Repeating Neutralizing thoughts Obsessional Slowness* Touching* Phobic avoidance*

Functional Classification (Foa et al, 1985) Internal fear cues External fear cues Fears of harm or disastrous consequences

Pharmacological Treatments for OCD Clomipramine* SSRIs Fluoxetine Fluvoxamine* Sertraline

Multicenter Trial of Fluoxetine Data taken from Tollefson et al (1994). Archives of General Psychiatry, 51, *NOTE: Response was defined as a 35% or more reduction in Y-BOCS scores.

Multicenter Trial of Fluoxetine Data taken from Tollefson et al (1994). Archives of General Psychiatry, 51,

Empirically-Supported Psychosocial Treatments Psychosocial Treatments –Exposure and Response Prevention (ERP) –Cognitive Therapy Combined Medications + ERP

Rationale for Investigating Non- Drug Alternatives Limited proportion of patients who show clinical benefit Level of residual symptoms among treatment responders Troublesome side effects Extremely high relapse rates Role of psychological factors in OCD

Psychological Factors Implicated in OCD Cognitive appraisal of intrusive thoughts (Salkovskis, 1985; Rachman, 1997) –Overestimation of danger –Inflated personal responsibility –Thought-action fusion Thought-suppression (Wegner et al, 1987) Cognitive deficits in selective attention Deficits in inhibiting irrelevant stimuli (particularly internal ones such as intrusive thoughts) (Clayton et al, 1999)

Procedural Overview of Foa ERP Treatment Protocol Information Gathering Phase (2 sessions) –Session 1 (2 hrs.) Obtaining info on OCD symptoms History of the problem Defining the disorder Rationale for treatment Overview of treatment Program Teaching patients to Monitor symptoms Taking a general history

Procedural Overview of Foa ERP Treatment Protocol Cont. Information Gathering Phase (2 sessions) –Session 2 (2 hrs.) Inspection of patient’s self-monitoring Collecting information about obsessions and compulsions Generating the treatment plan Rules for selection of exposure situations Develop clear contract between therapist and patient Teaching patients to Monitor symptoms Homework assignment

Important Areas of OC Assessment Obsessions –external fear cues –internal cues –consequences of external and internal cues Avoidance Patterns –Passive avoidance –Rituals –Relationship between avoidance patterns and fear cues

Procedural Overview of Foa ERP Treatment Protocol Cont. Treatment Phase (15 daily sessions, 120 min. each) –Format of exposure session –Implementation of exposure –Homework assignments –Comments during exposure sessions –Response prevention Rules Return to normal behavior –Common difficulties during sessions

Examples of In Vivo Exposure Component For Washer –Session 1: walk with therapist through the building touching doorknobs, holding each for several minutes –Session 2: Repeat above and add contact with sweat by having patient touch armpit and inside of shoe –Session 3: Repeat above but introduce having patient touch toilet seats –Session 4: Repeat above but introduce urine by having patient hold a paper towel dampened in his own urine –Session 5: Repeat above but introduce fecal material by having patient hold toilet paper lightly soiled with his own fecal material –Sessions 6-15 Daily exposure to the three most fear-provoking activities are repeated.

Examples of In Vivo Exposure Component For Checker –Session 1: turn the lights on and off once, turn stove on and off once, open and close doors once (leave room immediately without checking) –Session 2: Repeat above and add flushing of toilet without looking in the bowl –Session 3: Repeat above but introduce opening gate to the basement and allowing daughter to play near the gate –Session 4: Repeat above but introduce carrying daughter on concrete floor –Session 5: Repeat above but introduce driving on highway without retracing route –Sessions 6-15 Daily exposure to the three most fear-provoking activities are repeated.

Rules for Response Prevention Washer Patients not permitted to use water on their body Bath powder and deodorants are permitted unless they reduce contamination concerns Shaving is done by electric shaver Supervised showers occur every 3 days for 10-min. Ritualistic washing of certain areas of the body is prohibited Family members supervise adherence to rules while patient is home Violations are reported to therapist In the last few sessions, response prevention requirements are relaxed to permit normal washing

Rules for Response Prevention Checker No ritualistic checking is permitted One check (normal checking) is permitted Designated relative or friend supervises response prevention adherence at home Therapist/supervisor is to stay with patient until urge to check diminishes Violations of home practice are reported to therapist

Guidelines for Constructing Imaginal Exposure Scenes Imaginal sessions should be approximately 45 min. in duration; Present approximately six scenes of gradually increasing anxiety evoking potential; Include external stimuli and internal/cognitive or physiological responses in the feared scene.

Common Difficulties During ERP Non-compliance with response prevention instructions Continued passive avoidance Arguing/balking about exposure/response prevention requirements Emotional overload Family reactions

Summary of Outcome for ERP (Foa et al, in press) Reviewed 18 studies of ERP 83% response rate at posttreatment 76% response rate at follow-up (Mean 9 months) Mean symptom reduction was 46% at posttreatment

Limitations of Exposure- Response Prevention for OCD Substantial treatment refusal rate Difficulty in transporting ERP to centers that do not specialize in OCD (low generalizability); Low credibility of ERP among psychiatrists

Limitations of Combined Treatment Studies for OCD Fails to provide a conclusive comparison of the relative short and long-term effects of the individual monotherapies; Fail to adequately examine whether combined treatment is superior to either drug or ERP administered alone Fail to adequately examine relapse and the potential for ERP to reduce relapse

NIMH Multicenter Study Sites Design Strengths Results

NIMH Multicenter Study Results

Moderators of Treatment Outcome Personality disorders Pretreatment OCD severity Pretreatment depression Outcome expectancies Compliance with treatment Strength of belief in harm Comorbid tic disorders*

Cognitive Therapy of OCD

Cognitive Factors in OCD Overestimation of the importance of thoughts –Distorted thinking –Thought-action fusion –Magical thinking

Cognitive Factors in OCD Responsibility Perfectionism –Need for certainty –Need to know –Need for control

Cognitive Factors in OCD Overinterpretation of threat Consequences of anxiety –Anxiety is dangerous –Anxiety will prevent me from functioning

Empirical Support for Cognitive Interventions LaDouceur et al (1996) Van Oppen et al (1995)

Comparison Trial of ERP and Cognitive Therapy Data taken from Van Oppen et al (1995) Behaviour Research and Therapy, 33,