Obsessive-Compulsive Disorder Lecture Overview

1. Obsessive-Compulsive DisorderLecture Overview • Nature and epidemiology • Etiology • Empirically-supported treatments • Efficacy data • Moderator variables • Class discussion

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

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

4. 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%)

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

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

7. Pharmacological Treatmentsfor OCD • Clomipramine* • SSRIs • Fluoxetine • Fluvoxamine* • Sertraline

8. Multicenter Trial of Fluoxetine Data taken from Tollefson et al (1994). Archives of General Psychiatry, 51, 559-567 *NOTE: Response was defined as a 35% or more reduction in Y-BOCS scores.

9. Multicenter Trial of Fluoxetine Data taken from Tollefson et al (1994). Archives of General Psychiatry, 51, 559-567.

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

11. 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

12. 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 attentionDeficits in inhibiting irrelevant stimuli (particularly internal ones such as intrusive thoughts) (Clayton et al, 1999)

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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.

19. Rules for Response PreventionWasher • 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

20. Rules for Response PreventionChecker • 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

21. 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.

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

23. 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

24. 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

25. 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

26. NIMH Multicenter Study • Sites • Design • Strengths • Results

27. NIMH Multicenter StudyResults

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

29. Cognitive Therapy of OCD

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

31. Cognitive Factors in OCD • Responsibility • Perfectionism • Need for certainty • Need to know • Need for control

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

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

34. Comparison Trial of ERP and Cognitive Therapy Data taken from Van Oppen et al (1995) Behaviour Research and Therapy, 33, 379-390.