1. A Best-Practice Approach for Clients with Obsessive-Compulsive Disorder By Emily Shields March 1, 2012 1

2. Topics for discussion: Characteristics of Obsessive-Compulsive Disorder (OCD) Best-practice methods for treatment Need for clinical flexibility 2

3. Characteristics of Obsessive- Compulsive Disorder DSM-IV identifies Obsessive-Compulsive Disorder (OCD) as an Axis I anxiety disorder distinguished by obsessions, which are “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 and distress” (DSM, American Psychiatric Association, 2000) Research has shown that OCD symptoms can be consistently categorized into four defined dimensions or types: ▫Symmetry/ordering ▫Contamination obsessions and washing compulsions ▫Compulsive hoarding ▫Obsessions/checking ▫Additionally, some suffer from aggressive, somatic, sexual, or religious obsessions 3

4. Categorization of common obsessions and compulsions (Sushevska, Olumchev, and Saveska, 2011) Obsessions Commonly associated compulsions Fear of contamination Need for symmetry, precise arranging Unwanted sexual or aggressive thoughts or images Doubts (such as gas jets turned off, doors locked) Concerns about throwing away something valuable Washing, cleaning Ordering, arranging, balancing, straightening until “just right” Checking, praying, “undoing” actions, asking for reassurance, silent repetition of words or phrases Repeated checking behaviors Hoarding 4

5. Evidence has shown that a combination of therapies are effective in treating clients with OCD, the most effective type being Cognitive-Behavioral Therapy (CBT) that includes exposure and response prevention (ERP) therapy 5 The most widely-used assessment for measuring OCD severity is the Yale-Brown Obsessive Compulsive Scale (Y- BOCS) (Goodman et al., 1989) Clinicians also evaluate the client’s level of insight which refers to the recognition that his or her thoughts are irrational, unrealistic, or exaggerated

6. A Few Statistics -OCD is equally common in men and women (APA, 2000) -The modal age of onset for men is between ages 6 and 15; while for women it is between ages 20 and 29 (Bjrögvinsson, Hart, & Heffelfinger, 2007; Thyer et al., 1985) -25 to 50% of those diagnosed with OCD are also diagnosed with a major depressive disorder and/or phobic disorder (L. Benns-Coppin, 2008; Monica Pignotti and Bruce A. Thyer, 2011) -In addition to risk of comorbidity, persons with OCD are more likely to have suicidal thoughts (~50%) and ~15% have attempted suicide (Fenske, J., & Schwenk, T. (2009) 6

7. Cognitive-Behavioral Therapy (CBT) The main goals of CBT are symptom relief and correction of cognitive processes that cause the client distress (Gerig, 2007, p. 75) Clients learn to recognize anxious thoughts, manage feelings and physical symptoms of anxiety, and develop coping thoughts 7 Some clients benefit from a more cognition-focused treatment plan ▫Obsession-rooted symptoms without clear behavioral issues, compulsions, or tics ▫Phobic-like fears

8. Exposure and Response Prevention Therapy (ERP) An empirically-proven variety of CBT for clients with OCD: ERP is a specific type of CBT that focuses on exposing the client to situations that trigger their OCD tendencies ERP involves active engagement by the client, participating in activities that OCD has limited previously Clients learn to face their fears and resist the overwhelming urges to perform compulsions through repeated exposure 8

9. ERP Treatment ERP usually consists of one- to two-hour therapy sessions for 13 to 20 weeks, and longer if needed The client’s feared situation is confronted and controlled either directly or indirectly ▫Controlled actions ▫Imagined situations 9

10. Some factors to consider… One treatment does not fit all. It has been acknowledged that due to its rigorous emotional elements, ERP is not appropriate or effective for some clients Because clients with OCD display such varying symptoms, clinicians often find a combination of treatments effective Counselors can benefit from studying the sub-types of OCD to determine a proper treatment plan for each individual client 10

11. Does ERP therapy pose any major ethical concerns? 11 What are some potential limitations to CBT with ERP therapy? What are some challenges of working with OCD clients? Clients presenting with another DSM categorized disorder?

12. References Abramowitz, J. S. (2006). The Psychological Treatment of Obsessive--Compulsive Disorder. Canadian Journal Of Psychiatry, 51(7), 407-416. Benns-Coppin, L. (2008). Understanding, respecting and integrating difference in therapeutic practice. Psychoanalytic Psychotherapy, 22(4), 262-284. Fenske, J., & Schwenk, T. (2009). Obsessive compulsive disorder: diagnosis and management. American Family Physician, 80(3), 239-245. Houghton, S., Saxon, D., Bradburn, M., Ricketts, T., & Hardy, G. (2010). The effectiveness of routinely delivered cognitive behavioural therapy for obsessive- compulsive disorder: A benchmarking study. British Journal Of Clinical Psychology, 49(4), 473-489. Kyrios, M., Moulding, R., & Jones, B. (2010). Obsessive compulsive disorder: integration of cognitive-behaviour therapy and clinical psychology care into the primary care context. Australian Journal Of Primary Health, 16(2), 167-173. Pignotti, M., & Thyer, B. A. (2011). Guidelines for the Treatment of Obsessive Compulsive Disorder. Best Practice In Mental Health, 7(2), 84-93. 12

13. References, continued… Polman, A., Bouman, T. K., van Hout, W. J., de Jong, P. J., & den Boer, J. A. (2010). Processes of change in cognitive–behavioural treatment of obsessive– compulsive disorder: Current status and some future directions. Clinical Psychology & Psychotherapy, 17(1), 1-12. Price, J. (2011). COGNITIVE BEHAVIOUR THERAPY: A REVIEW. Mental Health Practice, 14(8), 14-18. Sushevska, L., Olumchev, N., & Saveska, M. (2011). Obsessive - Compulsive Disorder and Treatment - One-Year Follow up Study. Acta Facultatis Medicae Naissensis, 28(2), 89-93. Whittal, M., Robichaud, M., Thordarson, D., & McLean, P. (2008). Group and individual treatment of obsessive-compulsive disorder using cognitive therapy and exposure plus response prevention: a 2-year follow-up of two randomized trials. Journal Of Consulting And Clinical Psychology, 76(6), 1003-1014. 13