Volume 3 – June 2011 IN THIS ISSUE Welcome to Ben Groot Attorneys’ e-mail newsletter · Welcome We are halfway into the year, and well into winter! Luckily, most of the holidays · What we offer? have also passed, and we can now (hopefully) all focus on business again. · Labour Law Economically, retail seems to be doing better, with the news indicated that ·
Brief treatment 3:2Overview of Treatments for Obsessive-
Compulsive Disorder and Spectrum
Theory, and Practice
Nicholas Maltby, PhD
David F. Tolin, PhD
This paper presents an overview of obsessive-compulsive disorder (OCD) and theobsessive-compulsive spectrum disorders (OCSDs) by outlining the major arguments for and against the spectrum construct. Cognitive, behavioral, and biological models are reviewed, as are assessment strategies for adults and children. Treatment options forOCD are critically evaluated, and it is argued that exposure and ritual prevention (ERP)has the best support as the first-line psychological treatment. Suggestions forovercoming the most common obstacles faced during treatment are provided. Inaddition, strategies for dealing with partial or nonresponse or treatment refusal arediscussed. Stepped-care models are presented as a potential method of addressing theproblems caused by the expense and time commitment of existing treatments. [BriefTreatment and Crisis Intervention 3:127–144 (2003)] KEY WORDS: obsessive-compulsive disorder, obsessive-compulsive spectrum, reviews, cognitive-behavioral therapy, pharmacotherapy.
Obsessive-compulsive disorder (OCD) is a chro- sion, and alcohol abuse). OCD often severely dis- nic anxiety disorder, marked by recurrent, in- rupts social and vocational functioning (Leon, trusive, and distressing thoughts (obsessions) Portera, & Weissman, 1995), and it is associated and/or repetitive behaviors (compulsions). Epi- with a fourfold risk of unemployment (Koran, demiological data suggest a 6-month prevalence Thienemann, & Davenport, 1996). Family func- of 1–2% (Myers et al., 1984) and a lifetime tioning is usually impaired, due in part to the prevalence of 2–3% (Robins et al., 1984), mak- large burden assumed by spouses and parents ing OCD the world’s fourth most common men- (Amir, Freshman, & Foa, 2000; Calvocoressi et tal disorder (exceeded only by phobias, depres- al., 1995). Age of onset is typically early, be-tween 10 and 23 years (Rasmussen & Tsuang,1986), and the disorder is usually chronic. Be- From the Anxiety Disorders Center at The Institute of Livingin Hartford, CT.
cause of OCD’s high prevalence and because of Contact author: Nicholas Maltby, PhD, Anxiety Disorders the chronic, debilitating nature of its symptoms, Center, The Institute of Living, 200 Retreat Avenue, Hart- ford, CT 06106. Phone: (860) 545-7685. Fax: (860) 545-7156. E-mail: firstname.lastname@example.org.
among the top 10 causes of years lived with illness-related disability (Murray & Lopez, 1996).
The symptoms of OCD tend to cluster into rec- from obsessions by their function. Obsessions ognizable subtypes. Checking and washing are elicit anxiety, while compulsions either reduce the most common and together account for over anxiety or are completed to stave oﬀ a perceived 50% of OCD cases (Foa et al., 1995; Mataix-Cols, consequence. It is very rare for an OCD patient Baer, Rauch, & Jenike, 2000). Other common not to engage in ritualizing; 99.8% of OCD pa- subtypes include doubting, mental ritualizing, tients describe either mixed behavioral and ordering, hoarding, and scrupulosity (Foa, Ko- mental compulsions, or behavioral compulsions zak, Salkovskis, Coles, & Amir, 1998). A num- only (Foa et al., 1995). Thus, the presence of ber of studies have attempted to empirically de- covert rituals should be routinely assessed, es- rive OCD subtypes by applying factor analysis pecially in the absence of overt compulsions.
to the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) symptom checklist (Goodman, Price,Rasmussen, Mazure, Delgado, et al., 1989; OCD Spectrum Disorders
Goodman, Price, Rasmussen, Mazure, Fleisch-mann, et al., 1989). These studies yield from Although obsessions and compulsions are the three to five factors with a high degree of con- defining criteria for OCD, these symptoms are sensus across studies. All studies identified a also present in a number of other disorders. For contamination/cleaning factor, and all studies example, body dysmorphic disorder, Tourette’s with four or more factors identified obsessions/ syndrome, and trichotillomania all involve in- checking, symmetry/ordering, and hoarding as trusive or repetitive thoughts or behaviors. Be- factors (Leckman et al., 1997; Mataix-Cols, cause of the phenomenological overlap of these Rauch, Manzo, Jenike, & Baer, 1999; Summer- disorders with OCD, as well as their apparent pre- feldt, Richter, Antony, & Swinson, 1999).
ferential response to serotonergic medications, Mataix-Cols and colleagues (1999) added an ad- researchers have proposed grouping these disor- ditional factor, sexual/religious obsessions, in ders together into a category called obsessive- their five-factor solution, while Baer’s (1994) compulsive spectrum disorders (OCSDs). It has three-factor solution combined symmetry and been argued that the OCSDs aﬀect as many as hoarding into one factor and added another fac- 10% of the U.S. population and cause significant tor, “pure obsessions,” that may be consistent economic burden, as well as disruptions in qual- with the obsessions/checking factor in other ity of life (Hollander et al., 1996).
studies. Thus, factor-analytic studies are gener- One conceptualization places OCSDs along a ally consistent in identifying at least four core continuum from “compulsive” to “impulsive” subtypes of OCD: washing, checking, ordering, (Hollander et al., 1996). The “compulsive” end of the spectrum is characterized by harm– avoidant rituals and includes OCD, hypochon- the prevalence of patients classified as being driasis, restrictive anorexia, and body dysmor- “purely” obsessional, without any compul- phic disorder (McElroy, Phillips, & Keck, 1994).
sions. This notion may be an artifact of early def- The “impulsive” end of the spectrum is char- initions of OCD, which maintained that obses- acterized by self-damaging behaviors and in- sions were mental events and that compulsions cludes trichotillomania, compulsive gambling, were overt behaviors. However, current theories Tourette’s syndrome, bulimia nervosa, klep- recognize that compulsions can be either actions tomania, and impulsive personality disorders or thoughts. Mental compulsions (e.g., mental (McElroy et al., 1994). Another conceptualization review, counting, praying) are diﬀerentiated places disorders along a motoric/obsessional di- Brief Treatment and Crisis Intervention / 3:2 Summer 2003
mension. Motoric disorders involve repetitive orate on specific OCSDs and their relationship behaviors without obsessions (e.g., Tourette’s disorder). Obsessional disorders reflect the in-verse pattern of obsessions without repetitivebehaviors (Hollander & Wong, 2000).
Models of OCD
versy over the degree to which they reflect ei- Behavioral
ther a more unified disorder or many distinctdisorders. Patients with OCD frequently present Behavioral models of OCD (e.g., Kozak & Foa, with symptoms of more than one subtype (Ras- 1997) posit that compulsive behaviors are a form mussen & Eisen, 1988), suggesting a more uni- of avoidance that maintain obsessive fears via fied solution. However, that some subtypes of negative reinforcement (anxiety reduction) and OCD appear to respond diﬀerentially to diﬀerent by blocking opportunities for habituation to treatments (Buchanan, Meng, & Marks, 1996; feared objects and situations. Indeed, labora- Jenike, Baer, Minichiello, Rauch, & Buttolph, tory studies show that exposure to feared stim- 1997; Lelliott, Noshirvani, Basoglu, Marks, & uli increased patients’ anxiety, whereas per- Monteiro, 1988; Rachman, 1980) suggests that forming compulsions led to decreased anxiety they may be distinct disorders. Similarly, critics (Hodgson & Rachman, 1972). Some individuals argue that the concept of the OCD spectrum is with OCD, generally checkers, do report in- predicated mainly on superficial similarities in creased fear after performing compulsions surface topography, selective interpretation of (Roper, Rachman, & Hodgson, 1973); however, medication response data, and misinterpreta- mildly anxiety-evoking behaviors might be con- tion of relatively sparse and inconsistent neuro- sidered as avoidance behaviors if they serve to imaging data. Behaviors that resemble each prevent the occurrence of strong anxiety (Herrn- other, they argue, may not represent the same stein, 1969). Thus, while checking the stove may illness, and impulsive behaviors do not serve the elicit anxiety in some patients, refraining from same neutralizing function as do compulsions checking the stove is perceived as an even more (Abramowitz & Houts, in press; Tolin & Foa, anxiety-producing event because of the in- 2001). In addition, the spectrum concept could creased risk of an aversive event (e.g., the house become overinclusive. For example, the same burning down). In summary, the specific func- similarities used to relate Tourette’s syndrome to tion of compulsions may vary, but the general OCD have also been used to relate Tourette’s syn- function appears to be one of anxiety reduction drome to autistic spectrum disorders (Barnhill & Horrigan, 2002; Bejerot, Nylander, & Lind-strom, 2001). On the other hand, some of the Cognitive
spectrum disorders tend to respond to similarpharmacological and psychosocial treatments, Traditional cognitive models of psychopathol- and some demonstrate a functional relationship ogy have been “top-down”; that is, they empha- between mental and behavioral events that par- size the role of dysfunctional cognitions in the allels that of OCD; it is therefore suggested that etiology and maintenance of disorders (Beck, at least some OCSDs may be related to OCD. Ar- Emery, & Greenberg, 1985). According to such ticles by Steketee and Neziroglu, Stemberger, models, OCD is characterized by dysfunctional Stein, and Mansueto, and Deckersbach, Keu- assumptions, such as overestimation of threat, then, and Wilhelm in this special issue will elab- intolerance of uncertainty, importance of Brief Treatment and Crisis Intervention / 3:2 Summer 2003
thoughts, need to control thoughts, responsibil- serotonergic medications or a placebo. However, ity, and perfectionism (Obsessive Compulsive more direct tests of the serotonin hypothesis, Cognitions Working Group, 1997). Thus, OCD such as biological challenge studies, have been develops and is maintained as normal unpleas- inconclusive (Barr, Goodman, & Price, 1993; ant thoughts as being perceived as harmful, im- Barr, Goodman, Price, McDougle, & Charney, moral, or dangerous. Such beliefs are strength- 1992). Neuroimaging and neurosurgical evidence ened when neutralizing strategies lead to de- suggests that OCD is associated with hyper- creased anxiety, a factor that overlaps with the activity in frontal-striatal curcuits of the brain, behavioral model (Rachman, 1998; Salkovskis, which includes the orbitofrontal cortex, an- 1985). More recent models of psychopathology terior cingulate cortex (ACC), caudate nucleus, have been “bottom-up,” reflecting an emphasis and thalamus (Baxter, 1992; Breiter et al., 1996; not on beliefs but rather on the processes of Saxena & Rauch, 2000). The biological models of mental activity (Williams, Watts, MacLeod, & OCD are not wholly separate from cognitive- Mathews, 1997). Information-processing stud- behavioral models. Neurotransmitter activity, ies of OCD have shown that OCD is characterized regional metabolic actvity, behavioral reinforce- by an attentional bias toward threat cues (Foa, ment, maladaptive beliefs, and information- Ilai, McCarthy, Shoyer, & Murdock, 1993; Lavy, processing biases may be conceptualized as diﬀ- van Oppen, & van den Hout, 1994); increased erent ways of understanding OCD symptoms.
memory for, and impaired forgetting of, threat- Similarly, each of these systems might be thought related stimuli (Constans, Foa, Franklin, & to influence the others, rather than rely on a sin- Mathews, 1995; Radomsky & Rachman, 1999; gular direction of causality (e.g., biological ir- Tolin, Hamlin, & Foa, 2002; Wilhelm, McNally, regularities cause dysfunctional behaviors). As Baer, & Florin, 1996); decreased memory confi- an example of these complex interrelationships, dence (Constans et al., 1995; Tolin, Abramowitz, both SRI medications and behavior therapy ap- Brigidi, et al., 2001); and diﬃculty inhibiting pear to produce comparable changes in brain the processing of irrelevant information (En- metabolic activity (Schwartz, Stoessel, Baxter, right & Beech, 1990, 1993; Tolin, Abramowitz, Przeworski, & Foa, 2002). Bottom-up and top-down models of OCD should not be consideredmutually exclusive; indeed, we propose that an Assessment of OCD
integrated cognitive-behavioral model of OCDmust take into account both dysfunctional be- Steketee and Neziroglu in this volume discuss liefs and biases as well as deficits in information assessment strategies for OCD. In our clinic, as- sessment of OCD includes a comprehensive eval-uation of current and past OCD symptoms, asso-ciated functional impairments, the patient’s de- Biological
gree of insight into the senselessness of OCD Biological models of OCD have focused on the symptoms, and structured interviews for co- role of abnormal serotonin metabolism and hy- morbid Axis I and Axis II psychopathology. peractive frontal-striatal circuits in creating the In addition, we examine the patient’s under- symptoms of OCD. The serotonin hypothesis standing of OCD and its treatment, and weis predicated on the observation that patients provide education as needed. The Yale-Brown with OCD respond preferentially to serotonin Obsessive-Compulsive Scale (Y-BOCS) (Good- reuptake inhibitors (SRIs) as opposed to non- man, Price, Rasmussen, Mazure, Delgado, et al., Brief Treatment and Crisis Intervention / 3:2 Summer 2003
fear, for facilitating treatment planning, for Fleischmann, et al., 1989) is considered the monitoring progress, and for measuring treat- “gold standard” of OCD assessment. This semi- ment outcome (Mavissakalian & Barlow, 1981).
structured interview contains a symptom check- Behavioral-avoidance tests (BATs) represent one list and a severity scale. The symptom checklist form of behavioral assessment that can be tai- includes a list of obsessions and compulsions, lored to the patient’s symptom profile. For ex- categorized according to content. The severity ample, patients with contamination concerns scale of the Y-BOCS assesses symptom severity may be asked to touch “dirty” objects like door- using five questions for obsessions and five knobs, garbage cans, or toilets; checkers may befor compulsions. A variation of the Y-BOCS, the asked to leave doors unlocked, to drive over pot- Child Yale-Brown Obsessive-Compulsive Scale holes, or to leave objects in a manner that might (CY-BOCS; Scahill et al., 1997), is used for chil- cause someone harm (e.g., placing sticks on a pathway); hoarders can bring objects into the A number of standardized self-report mea- oﬃce to be discarded; and patients with order- sures have been developed for the assessment of ing compulsions can be asked to misarrange ob- OCD. Because of their ease of use and relatively jects in their house or car. Because of the idio- quick completion time, these measures may syncratic nature of many compulsions, behav- provide greater utility in monitoring treatment ioral assessment often requires creativity and progress than do structured interviews. A num- the willingness to travel with the patient. As ber of sources (e.g., Antony, Orsillo, & Roemer, will be discussed later, such BATs tie in nicely 2001) provide detailed examination of individ- with exposure and ritual-prevention exercises ual measures, but a brief listing of the most com- that are used to reduce the patient’s fear of these monly used inventories includes a self-report version of the Y-BOCS (Warren, Zgourides, &Monto, 1993); the Obsessive Compulsive In-ventory (Foa et al., 1998; a recently published, Treatment of OCD
abbreviated version of which appears in Foa etal., in press); the Maudsley Obsessional Com- Exposure and Ritual Prevention
pulsive Inventory (Hodgson & Rachman, 1977);and the Padua Inventory (Sanavio, 1988). In ad- Exposure and ritual prevention (ERP), also dition to these diagnostic measures, several called exposure and response prevention, con- other measures have been published that assess sists of gradual, prolonged exposure to fear- cognitive features thought to underlie OCD; we eliciting stimuli or situations, combined with routinely include these measures as part of a strict abstinence from compulsive behavior. In practice, this treatment would mean that a pa- sures include the Obsessive Beliefs Question- tient with contamination concerns, for example, naire (Obsessive Compulsive Cognitions Work- would be encouraged to touch progressively ing Group, 2001), the Thought-Action Fusion “germier” objects while simultaneously refrain- Scale (Shafran, Thordarson, & Rachman, 1996), ing from washing or cleaning. Similarly, a patient and the Thought Control Questionnaire (Wells with obsessive concerns about harming other people while driving might be encouraged to drive in increasingly congested areas without not commonly reported in the literature, but it looking in the rearview mirror. The purpose of can be very useful for evaluating the severity of these exercises is to allow patients to experience Brief Treatment and Crisis Intervention / 3:2 Summer 2003
a reduction of their fear response, to recognize symptoms, and they must be willing to leave the that these situations are not excessively danger- oﬃce because many exposures can only be done ous, and to accept their fear will not last forever.
in the patient’s home or at another fear-relevant Thus, although ERP is a “behavioral” interven- tion, its mechanism of action may well be cogni- Numerous studies attest to the eﬃcacy of ERP in adult outpatients with OCD (e.g., Cottraux, One of the more diﬃcult aspects of ERP is that Mollard, Bouvard, & Marks, 1993; Fals-Stewart, patients must eventually be willing to perform Marks, & Schafer, 1993; Kozak, Liebowitz, & exposures to their highest fears—and these ex- Foa, 2000; Lindsay, Crino, & Andrews, 1997; posures often feel very risky to the patient. For van Balkom et al., 1998). Approximately 75% of instance, the highest exposure for the contami- patients treated with ERP improve significantly, nation patient just mentioned might be touch- usually defined as 30 to 50% improvement, and ing a toilet in a public restroom. To help patients they remain so at follow-up (Franklin & Foa, make judgments about the appropriateness of an 1998). Despite this fact, ERP is not widely used exposure, we often use the principle of accept- by mental health practitioners, as shown by a re- able risk in defining the range of possible expo- cent survey of nine Boston-area hospitals and sures with the patient. No exposure is risk free; clinics, many of which are known for their ex- however, the risk of the exposure may be simi- pertise in treating anxiety disorders (Goisman et lar to risks commonly taken every day and thus al., 1993). One possible explanation for this dis- be acceptable. For instance, the patient who crepancy is that while ERP is eﬃcacious, it may balks at touching a toilet without hand washing not be cost eﬀective. ERP is time consuming and may be asked to compare the risk of this expo- expensive; thus, many patients and third-party sure to that of a camping trip where cleanliness payers are unable or unwilling to pay for treat- is often delayed for days or weeks. We also find it helpful to encourage patients to assume that a also refuse ERP (Franklin & Foa, 1998), presum- situation is safe unless there is clear evidence to ably because of apprehension about the diﬃ- the contrary; typically, OCD patients tend to as- culty and intensity of the treatment. To address sume a situation is dangerous unless they can this obstacle, we (Maltby, Tolin, & Diefenbach, find clear evidence of safety (which is often dif- 2002) have developed a brief, four-session readi- ficult to obtain). Therapists can influence the ness intervention consisting of psychoeduca- patient’s willingness to engage in more diﬃcult tion, a videotape example of an ERP session, mo- exposures by preparing the patient for these at tivational interviewing techniques, and a phone an early stage, by maintaining an expectation conversation with a former ERP patient. Initial that they will be doing so, and by collabora- results are encouraging: to date, 60% of patients tively engaging in exposures along with the pa- receiving the readiness intervention chose to tient. With this in mind, it is also important to begin ERP, whereas only 20% of patients in a pace the level of anxiety elicited during expo- sures. Exposures should elicit anxiety, but notso much that the patient feels overwhelmed.
Regular subjective units of distress (SUDS) rat-ings can help gauge levels of anxiety. As can be We believe that the distinction between “be- seen, ERP demands flexibility of the patient and havioral” and “cognitive” therapy is somewhat clinician. Therapists must be able to design cre- arbitrary. During ERP, we routinely assist pa- ative exposures that address the patient’s OCD tients in changing inaccurate beliefs about Brief Treatment and Crisis Intervention / 3:2 Summer 2003
feared situations, such as pointing out that The specific eﬃcacy of CT for OCD has not feared consequences did not occur or that the been firmly established. In two studies, RET was patient’s fear did not remain forever. Similarly, found to yield results that did not diﬀer from cognitive therapy (CT) often involves direct be- those of ERP (Emmelkamp, Visser, & Hoekstra, havioral suggestions to reduce avoidant behav- 1988), and the addition of RET to ERP did not ior. In OCD, the specific goal of CT is to teach pa- appear to enhance treatment results (Emmel- tients to identify and correct their dysfunc- kamp & Beens, 1991). In comparative eﬃcacy tional beliefs about feared situations (e.g., studies of adults with OCD, Beck-style CT pro- Freeston et al., 1997). Wilhelm (this issue) elab- duced moderately strong results that did not orates on the use of CT, so we will describe it diﬀer significantly from those of ERP (Cottraux here only briefly. To date, CT strategies have em- et al., 2001; van Balkom et al., 1998; van Oppen phasized the top-down (beliefs and appraisals), et al., 1995); in a comparison study of group treat- rather than the bottom-up (information pro- ment, CT yielded moderate results that were not cessing), cognitive models of OCD. In most as strong as those obtained using group ERP cases, this strategy has involved either rational- (McLean et al., 2001). It should be noted, how- emotive therapy (RET), in which irrational ever, that in each of these CT comparison stud- thoughts are identified and targeted via rational ies, ERP sessions were briefer and more widely debate, or CT along the lines of Beck and col- spaced than were those used in ERP studies leagues (1985), in which Socratic questioning (Kozak et al., 2000), and they did not emphasize and behavioral experiments are used to chal- intense, therapist-assisted exposures. Our pref- lenge the validity of distorted thoughts. In ei- erence, based on these data, is to use ERP when- ther case, the patients are asked to elaborate ever possible. However, cognitive therapy mayon their “automatic” appraisals of feared situa- play a useful, adjunctive role when ERP has not tions, and they are then taught to identify the produced optimal results. In an open trial with inaccuracies or logical inconsistencies in those five adult OCD patients who had failed to re- thoughts. For example, a patient with contami- spond to pharmacotherapy and ERP, an inten- nation concerns may identify the belief that all sive CT program was associated with decreases germs are dangerous. The therapist helps the pa- in self-reported OCD symptoms (Krochmalik, tient to identify and label the irrational features of this belief (e.g., “overgeneralization”). Thepatients are then instructed to monitor the oc- Anxiety Management Training
currence of this thought in their daily life, andthey are given specific instructions for challeng- Some clinicians have argued for the use of anxi- ing the thought. In this case, the patient might ety management training (AMT) in the treat- be instructed either to recall that many germs ment of patients with OCD, particularly with are benign or even beneficial or to acknowledge children (March & Mulle, 1998). AMT strategies that deaths from germs are more rare than would include training in slow, diaphragmatic breath- be expected if this thought were true. The pa- ing; progressive muscle relaxation; and coping tient may be encouraged to conduct behavioral imagery. AMT strategies such as relaxation have experiments, in which they come into contact not been shown to be an eﬀective component of with certain germs in order to see that they are treatment for OCD (Marks, 1987). Because AMT not harmed. The overlap of these strategies with strategies are designed to reduce exposure to ERP should be clear; we suggest that the diﬀer- anxiety, they may interfere with the core pro- cess of ERP—that is, evoking anxiety to allow Brief Treatment and Crisis Intervention / 3:2 Summer 2003
for habituation and cognitive change to occur.
do SSRIs but that no SSRI is superior to any In general, patients are able to tolerate the dis- other (Greist, Jeﬀerson, Kobak, Katzelnick, & tress of ERP, and they therefore do not require Serlin, 1995; Stein, Spadaccini, & Hollander, AMT (Franklin, Tolin, March, & Foa, 2001).
1995). However, clomipramine’s side-eﬀect pro- However, some patients may be so anxious at file prevents it from being widely accepted as a baseline that they are unable to tolerate even first-line intervention; prescribers typically pre- mild exposure; thus, AMT may be a useful ad- fer to begin pharmacotherapy with the more easily tolerated SSRIs. In a large randomizedcontrolled trial, clomipramine was superior toplacebo. However, ERP was superior to clom- Pharmacotherapy
ipramine (85% responder rate vs. 50%, respec- Serotonin reuptake inhibitors (SRIs) are the tively). Interestingly, and contrary to common first-line pharmacological treatment of choice clinical practice, the combination of clomipra- for OCD (Rasmussen & Eisen, 1997). These are mine and ERP yielded a 71% responder rate, also reviewed by Pato and colleagues in this is- which was superior to clomipramine alone but sue. SRIs commonly used in OCD treatment in- not to ERP alone (Kozak et al., 2000). Another clude the selective SRIs (SSRIs) fluoxetine, ser- randomized controlled trial found that fluvox- traline, fluvoxamine, paroxetine, and citalopram; amine yielded similar treatment outcomes as the serotonin-norepinephrine reuptake inhib- ERP and CT did, and all were superior to pla- itor (SNRI) venlafaxine; and the tricyclic anti- depressant clomipramine. Although 30–60% ofpatients respond to treatment utilizing SRIs,relapse rates are high (65–90%) when acute treat- Predictors of Treatment Response
ment is discontinued. Longer-term pharmaco-therapy may therefore be required. Most re- No reliable markers of treatment response have searchers recommend at least one year of con- been identified for cognitive-behavioral or phar- tinued treatment following successful treatment macological treatments. Some studies have (March, Frances, Carpenter, & Kahn, 1997); how- found that higher initial severity of OCD symp- ever, few studies of maintenance treatment have toms was associated with poorer outcomes (de been conducted. In one discontinuation study Haan et al., 1997; Keijsers, Hoogduin, & Schaap, (Koran, Hackett, Rubin, Wolkow, & Robinson, 1994) while others have not (Cottraux, Messy, 2002), patients randomly assigned to receive pla- Marks, Mollard, & Bouvard, 1993; Steketee & cebo following one year of sertraline were more Shapiro, 1995). Research on the eﬀects of co- likely to experience an acute exacerbation in morbid personality disorders is similarly mixed, their OCD symptoms as measured by the Y-BOCS with some studies that found attenuated treat- and CGI than were patients who continued to re- ment response and with other studies that did ceive sertraline. In a discontinuation study of not (Fals-Stewart & Lucente, 1993; Fals-Stewart CBT versus clomipramine (O’Sullivan, Noshir- & Schafer, 1993; Mavissakalian, Hamann, & vani, Marks, Monteiro, & Lelliott, 1991), patients Jones, 1990; Steketee, 1990). Type of OCD may who received CBT fared better at 6-year follow- also be related to outcome. Hoarding in particu- up than did clomipramine patients, who did not lar has been associated with poor response to diﬀer from patients who had received placebo.
ERP (Abramowitz, Franklin, Schwartz, & Furr, Meta-analytic studies suggest that clomipra- 2002; Black et al., 1998; Mataix-Cols, Marks, mine yields higher rates of responding than Greist, Kobak, & Baer, 2002), SRI medications Brief Treatment and Crisis Intervention / 3:2 Summer 2003
(Black et al., 1998; Mataix-Cols et al., 1999) or interventions tailored to the idiosyncratic na- their combination (Saxena et al., 2002). Like- ture of hoarding-related symptoms (Hartl & wise, sexual and religious concerns have also been associated with poor response to ERP(Mataix-Cols et al., 2002); this factor may be due to poorer insight among patients in these Treatment Augmentations
subgroups (Tolin, Abramowitz, Kozak, & Foa,2001). Duration of OCD was unrelated to out- Partial or nonresponse is common among cogni- come in two studies of CBT (Cottraux, Messy, et tive-behavioral and pharmacological interven- al., 1993; Steketee & Shapiro, 1995), but later tions for OCD. In general, the recommendation is age of onset was associated with positive out- to augment or change to an alternative treat- come in one study of clomipramine (Ackerman, ment when a patient reports an insuﬃcient re- Greenland, Bystritsky, Morgenstern, & Katz, sponse to a treatment of adequate dose and du- 1994). Early reports suggested that pretreatment ration (March et al., 1997; McDonough & Ken- depression predicted poorer outcome of ERP nedy, 2002). Thus, an inadequate response to (Foa, 1979); however, later research indicated an SRI could be followed by CBT with a diﬀer- that highly and mildly depressed patients re- ent SRI, or it could be augmented with a diﬀer- sponded similarly to treatment (Foa, Kozak, Ste- ent class of medications. Inadequate responses ketee, & McCarthy, 1992). In a large sample of to CBT may be addressed by using an alternate OCD patients, only severe depression was asso- form of CBT or by adding SRI augmentation.
ciated with attenuated outcome of ERP, al- Medications typically used to augment SRI though even those patients showed significant treatment include clonazepam, buspirone, l-tryp- clinical improvement (Abramowitz, Franklin, tophan, lithium, olanzapine, and risperidone Street, Kozak, & Foa, 2000). Lower initial moti- (McDonough & Kennedy, 2002). Empirical stud- vation appears to be associated with poorer out- ies of these recommendations, however, have come of cognitive-behavioral therapy (de Haan been lacking. A recent study indicated that seven et al., 1997; Keijsers et al., 1994); this result may of nine patients who had failed to respond to flu- be mediated by reduced follow-through with oxetine showed at least a 25% Y-BOCS reduc- exposure exercises (Araujo, Ito, & Marks, 1996; tion when treated with weekly ERP. We are cur- O’Sullivan et al., 1991). Insight into the irra- rently examining the eﬃcacy of ERP for pa- tionality of obsessive fears has been associated tients who have failed to respond to multiple with poorer outcome in some studies of pharma- SRI trials; preliminary results suggest that OCD cotherapy and CBT (Catapano, Sperandeo, Per- symptoms decrease with ERP augmentation, but ris, Lanzaro, & Maj, 2001; Erzegovesi et al., to a lesser extent than has been found with treat- 2001; Foa, 1979; Neziroglu, Stevens, & Yaryura- ment-naïve patients (Tolin, Diefenbach, Maltby, Tobias, 1999), but not in others (Eisen et al., Woodhams, & Worhunsky, 2002). Similarly, a 2001; Foa et al., 1983; Hoogduin & Duivenvoor- highly focused cognitive therapy has been asso- den, 1988). Ideally, further research on predic- ciated with significant improvements for some tors of outcome will lead to the development of patients who had previously failed ERP or mul- treatment algorithms in which patients can be tiple trials of SRI medications (Jones & Menzies, matched a priori to specific treatments; how- ever, the available body of research does not yet Because of OCD’s substantial impact on family support such decisions with the possible ex- functioning as well as the risk of family mem- ception of hoarding, which may require specific bers’ accommodating (and inadvertently rein- Brief Treatment and Crisis Intervention / 3:2 Summer 2003
forcing) patients’ compulsions (Amir et al., Future Directions
2000; Calvocoressi et al., 1995), family interven-tion may also be indicated as a supplement to Given that OCD is heterogeneous and that many traditional CBT and pharmacological interven- OCD subtypes and OCSDs may respond diﬀer- tions. In individual and group settings, inclu- entially to existing behavioral and pharmaco- sion of family members resulted in superior out- logical treatments, one potential goal of future comes than did CBT alone (Grunes, Neziroglu, & research is to construct treatment algorithms McKay, 2001; Van Noppen, Steketee, McCorkle, based on predictors of outcome. As described & Pato, 1997). Family intervention is particu- previously, this line of research is in its infancy.
larly helpful in the treatment of children with However, early research has indicated that OCD, by training parents to utilize ERP methods unique variations of CBT can be developed for (Knox, Albano, & Barlow, 1996). In some cases, family intervention alone may be suﬃcient to (Hartl & Frost, 1999), contamination fears (Kroch- elicit reductions in compulsive behaviors, such malik et al., 2001), trichotillomania (Lerner, as instructing parents not to respond to exces- Franklin, Meadows, Hembree, & Foa, 1998; Ni- sive reassurance-seeking (Francis, 1988; Tolin, nan, Rothbaum, Marsteller, Knight, & Eccard, 2000; Tolin, Franklin, Diefenbach, & Gross, For patients with severe, intractable, and de- 2002), hypochondriasis (Clark et al., 1998; Vis- bilitating OCD that has failed to respond to ser & Bouman, 2001; Warwick, Clark, Cobb, &CBT and pharmacological interventions, neuro- Salkovskis, 1996), and body dysmorphic disor- surgery may be an option. Current neurosurgi- der (McKay et al., 1997; Wilhelm, Otto, Lohr, & cal approaches include subcaudate tractomy (Bridges et al., 1994), anterior cingulotomy (Baer Nonetheless, the lack of a comprehensive bio- et al., 1995; Dougherty et al., 2002), anterior psychosocial model of OCD and OCSDs likely capsulotomy (Mindus & Nyman, 1991), and impedes progress in understanding and treat- combined orbitomedial/cingulate lesions (Hay ing these conditions. In other disorders (such et al., 1993). To date, no controlled studies of as panic disorder), the development of such these procedures have been conducted; how- models has led to significant advances in con- ever, the available evidence suggest that 20– ceptualization and treatment (e.g., Clark, 1986).
40% of patients receive significant benefits from Indeed, Foa and Kozak (1997) suggest that be- these procedures, though many patients require havior therapy in general may have reached an more than one operation (Baer et al., 1995; “eﬃcacy ceiling” that will only be broken by Bridges et al., 1994; Dougherty et al., 2002; Hay et al., 1993; Rauch et al., 2001). Newer tech- research. In addition to potentially advancing niques that minimize or avoid destruction of the treatment of OCD, biopsychosocial models brain tissue such as transcranial magnetic stim- may provide testable hypotheses that help re- ulation and deep brain stimulation are being de- solve the current controversies in OCD re- veloped but their eﬃcacy has yet to be estab- search, such as the heterogeneity problem and lished (Greenberg et al., 2000; Malhi & Sachdev, the relative placement of spectrum disorders.
2002; Nuttin, Cosyns, Demeulemeester, Gybels, We suggest that a comprehensive biopsycho- & Meyerson, 1999; Sachdev et al., 2001).
social model must explain and predict not onlyobsessions and compulsions, but also the at-tributional and information-processing biases Brief Treatment and Crisis Intervention / 3:2 Summer 2003
noted in OCD, findings from neuroimaging stud- Abramowitz, J. S., Franklin, M. E., Street, G. P., ies, and genetic and familial factors.
Kozak, M. J., & Foa, E. B. (2000). Eﬀects of co- morbid depression on response to treatment for ment of CBT have been identified as barriers to obsessive-compulsive disorder. Behavior Therapy, treatment, there is a need to develop alter- Abramowitz, J. S., & Houts, A. C. (in press). What native treatment algorithms that are acceptable is OCD and what is not: Problems with the OCD to patients, that contain costs, and that deliver spectrum concept. Scientific Review of Mental the most eﬀective treatment components. Group therapy represents one promising area of treat- Ackerman, D. L., Greenland, S., Bystritsky, A., ment development; preliminary results indi- Morgenstern, H., & Katz, R. J. (1994). Predictors cate that CBT can be delivered eﬀectively in a of treatment response in obsessive-compulsive brief group format, with good results (Himle disorder: Multivariate analyses from a multi- et al., 2001; McLean et al., 2001; Van Noppen, center trial of clomipramine. Journal of Clinical Pato, Marsland, & Rasmussen, 1998). Other re- Psychopharmacology, 14, 247–254.
searchers have explored the use of self-help Amir, N., Freshman, M., & Foa, E. B. (2000). Family manuals (Fritzler, Hecker, & Losee, 1997) and distress and involvement in relatives of obsessive- computer-assisted therapy (Baer & Greist, 1997; compulsive disorder patients. Journal of Anxiety Baer, Minichiello, Jenike, & Holland, 1988; Antony, M. M., Orsillo, S. M., & Roemer, L. (Eds.).
Nakagawa et al., 2000) as ways of reducing (2001). Practitioner’s guide to empirically based health care costs. The utility of these approaches, measures of anxiety. New York: Kluwer Academic/ however, is limited by the inability to self- correct by providing patients with their opti- Araujo, L. A., Ito, L. M., & Marks, I. (1996). Early mal level of treatment and no more. A prefer- compliance and other factors predicting outcome able approach might be the use of stepped-care of exposure for obsessive-compulsive disorder.
algorithms, in which patients initially receive British Journal of Psychiatry, 169, 747–752.
the least expensive, intrusive, and diﬃcult treat- Baer, L. (1994). Factor analysis of symptom sub- ment (e.g., self-help) and then step up through types of obsessive compulsive disorder and their more intensive treatment modalities if previ- relation to personality and tic disorders. Journal ous steps fail or yield only a partial response. We of Clinical Psychiatry, 55(Suppl.), 18–23.
have been piloting stepped-care models of de- Baer, L., & Greist, J. H. (1997). An interactive livering ERP for OCD, though it is still too early computer-administered self-assessment and self-help program for behavior therapy. Journal of to determine if this model of delivering treat- Clinical Psychiatry, 58(Suppl. 12), 23–28.
ment adequately addresses the cost, eﬀective- Baer, L., Minichiello, W. E., Jenike, M. A., & Hol- ness, and patient acceptance concerns for which land, A. (1988). Use of a portable computer program to assist behavioral treatment in a case of obsessive compulsive disorder. Journal of Behavior Therapy and Experimental Psychiatry, References
Baer, L., Rauch, S. L., Ballantine, H. T., Jr., Martuza, Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., R., Cosgrove, R., Cassem, E., et al. (1995). Cin- & Furr, J. (2002). Symptom presentation and out- gulotomy for intractable obsessive-compulsive come of cognitive-behavior therapy for obsessive- disorder. Prospective long-term follow-up of 18 compulsive disorder. Manuscript submitted for patients. Archives of General Psychiatry, 52, Brief Treatment and Crisis Intervention / 3:2 Summer 2003
Barnhill, J., & Horrigan, J. P. (2002). Tourette’s syn- Catapano, F., Sperandeo, R., Perris, F., Lanzaro, M., drome and autism: A search for common ground.
& Maj, M. (2001). Insight and resistance in Mental Health Aspects of Developmental Dis- patients with obsessive-compulsive disorder.
Psychopathology, 34, 62–68.
Barr, L. C., Goodman, W. K., & Price, L. H. (1993).
Clark, D. M. (1986). A cognitive approach to panic.
The serotonin hypothesis of obsessive compulsive Behaviour Research and Therapy, 24, 461–470.
disorder. International Journal of Clinical Psycho- Clark, D. M., Salkovskis, P. M., Hackmann, A., pharmacology, 8 (Suppl. 2), 79–82.
Wells, A., Fennell, M., Ludgate, J., et al. (1998).
Barr, L. C., Goodman, W. K., Price, L. H., Two psychological treatments for hypochond- McDougle, C. J., & Charney, D. S. (1992). The riasis. A randomised controlled trial. British serotonin hypothesis of obsessive compulsive Journal of Psychiatry, 173, 218–225.
disorder: implications of pharmacologic challenge Constans, J. I., Foa, E. B., Franklin, M. E., & Math- studies. Journal of Clinical Psychiatry, 53 (Suppl), ews, A. (1995). Memory for actual and imagined events in OC checkers. Behaviour Research and Baxter, L. R., Jr. (1992). Neuroimaging studies of obsessive compulsive disorder. Psychiatric Clinics Cottraux, J., Messy, P., Marks, I. M., Mollard, E., of North America, 15, 871–884.
& Bouvard, M. (1993). Predictive factors in the Beck, A. T., Emery, G., & Greenberg, R. L. (1985).
treatment of obsessive-compulsive disorders with Anxiety disorders and phobias: A cognitive perspec- fluvoxamine and/or behavior therapy. Behav- ioural Psychotherapy, 21, 45–50.
Bejerot, S., Nylander, L., & Lindstrom, E. (2001).
Cottraux, J., Mollard, E., Bouvard, M., & Marks, I.
Autistic traits in obsessive-compulsive disorder.
(1993). Exposure therapy, fluvoxamine, or com- Nordic Journal of Psychiatry, 55, 169–176.
bination treatment in obsessive-compulsive dis- Black, D. W., Monahan, P., Gable, J., Blum, N., order: One-year followup. Psychiatry Research, Clancy, G., & Baker, P. (1998). Hoarding and treat- ment response in 38 nondepressed subjects with Cottraux, J., Note, I., Yao, S. N., Lafont, S., Note, B., obsessive-compulsive disorder. Journal of Clinical Mollard, E., et al. (2001). A randomized con- trolled trial of cognitive therapy versus intensive Breiter, H. C., Rauch, S. L., Kwong, K. K., Baker, J. R., behavior therapy in obsessive compulsive dis- Weisskoﬀ, R. M., Kennedy, D. N., et al. (1996).
order. Psychotherapy and Psychosomatics, 70, Functional magnetic resonance imaging of symp- tom provocation in obsessive-compulsive disor- de Haan, E., van Oppen, P., van Balkom, A. J., der. Archives of General Psychiatry, 53, 595–606.
Spinhoven, P., Hoogduin, K. A., & Van Dyck, R.
Bridges, P. K., Bartlett, J R., Hale, A. S., Poynton, (1997). Prediction of outcome and early vs. A. M., Malizia, A. L., & Hodgkiss, A. D. (1994).
late improvement in OCD patients treated with Psychosurgery: Stereotactic subcaudate tractomy.
cognitive behaviour therapy and pharmaco- An indispensable treatment. British Journal of therapy. Acta Psychiatrica Scandinavica, 96, Psychiatry, 165, 599–611; discussion, 612–593.
Buchanan, A. W., Meng, K. S., & Marks, I. M.
Dougherty, D. D., Baer, L., Cosgrove, G. R., Cassem, (1996). What predicts improvement and com- E. H., Price, B. H., Nierenberg, A. A., et al.
pliance during the behavioral treatment of obses- (2002). Prospective long-term follow-up of 44 sive compulsive disorder? Anxiety, 2, 22–27.
patients who received cingulotomy for treatment- Calvocoressi, L., Lewis, B., Harris, M., Trufan, S. J., refractory obsessive-compulsive disorder. Ameri- Goodman, W. K., McDougle, C. J., et al. (1995).
can Journal of Psychiatry, 159, 269–275.
Family accommodation in obsessive-compulsive Eisen, J. L., Rasmussen, S. A., Phillips, K. A., Price, disorder. American Journal of Psychiatry, 152, L. H., Davidson, J., Lydiard, R. B., et al. (2001).
Insight and treatment outcome in obsessive- Brief Treatment and Crisis Intervention / 3:2 Summer 2003
compulsive disorder. Comprehensive Psychiatry, obsessive-compulsive Inventory: Development and validation of a short version. Psychological Emmelkamp, P. M., & Beens, H. (1991). Cognitive therapy with obsessive-compulsive disorder: A Foa, E. B., Ilai, D., McCarthy, P. R., Shoyer, B., & comparative evaluation. Behaviour Research and Murdock, T. (1993). Information processing in obsessive-compulsive disorder. Cognitive Therapy Emmelkamp, P. M., Visser, S., & Hoekstra, R. J.
(1988). Cognitive therapy vs exposure in vivo in Foa, E. B., & Kozak, M. J. (1986). Emotional pro- the treatment of obsessive-compulsives. Cognitive cessing of fear: Exposure to corrective informa- Therapy and Research, 12, 103–144.
tion. Psychological Bulletin, 99, 20–35.
Enright, S. J., & Beech, A. R. (1990). Obsessional Foa, E. B., & Kozak, M. J. (1997). Beyond the eﬃ- states: Anxiety disorders or schizotypes? An in- cacy ceiling? Cognitive behavior therapy in formation processing and personality assessment.
search of theory. Behavior Therapy, 28, 601–611.
Psychological Medicine, 20, 621–627.
Foa, E. B., Kozak, M. J., Goodman, W. K., Hollander, Enright, S. J., & Beech, A. R. (1993). Reduced E., Jenike, M. A., & Rasmussen, S. A. (1995).
cognitive inhibition in obsessive-compulsive DSM-IV field trial: Obsessive-compulsive disor- disorder. British Journal of Clinical Psychology, der. American Journal of Psychiatry, 152, 90–96.
Foa, E. B., Kozak, M. J., Salkovskis, P. M., Coles, Erzegovesi, S., Cavallini, M. C., Cavedini, P., M. E., & Amir, N. (1998). The validation of a new Diaferia, G., Locatelli, M., & Bellodi, L. (2001).
obsessive compulsive disorder scale: The obses- Clinical predictors of drug response in obsessive- sive compulsive inventory. Psychological Assess- compulsive disorder. Journal of Clinical Psycho- Foa, E. B., Kozak, M. J., Steketee, G. S., & Fals-Stewart, W., & Lucente, S. (1993). An MCMI McCarthy, P. R. (1992). Treatment of depressive cluster typology of obsessive-compulsives: A and obsessive-compulsive symptoms in OCD measure of personality characteristics and its rela- by imipramine and behaviour therapy. British tionship to treatment participation, compliance Journal of Clinical Psychology, 31, 279–292.
and outcome in behavior therapy. Journal of Francis, G. (1988). Childhood obsessive-compulsive Psychiatric Research, 27, 139–154.
disorder: Extinction of compulsive reassurance- Fals-Stewart, W., Marks, A. P., & Schafer, J. (1993).
seeking. Journal of Anxiety Disorders, 2, 361–368.
A comparison of behavioral group therapy and in- Franklin, M. E., & Foa, E. B. (1998). Cognitive- dividual behavior therapy in treating obsessive- behavioral treatments for obsessive-compulsive compulsive disorder. Journal of Nervous and disorder. In J. M. Gorman (Ed.), A guide to treat- Mental Disease, 181, 189–193.
ments that work (pp. 339–357). New York: Fals-Stewart, W., & Schafer, J. (1993). MMPI cor- relates of psychotherapy compliance among ob- Franklin, M. E., Tolin, D. F., March, J. S., & Foa, sessive-compulsives. Psychopathology, 26, 1–5.
E. B. (2001). Treatment of pediatric obsessive- Foa, E. B. (1979). Failure in treating obsessive- compulsive disorder: A case example of intensive compulsives. Behaviour Research and Therapy, cognitive-behavioral therapy incorporating ex- posure and ritual prevention. Cognitive and Foa, E. B., Grayson, J. B., Steketee, G. S., Doppelt, Behavioral Practice, 8, 297–304.
H. G., Turner, R. M., & Latimer, P. R. (1983).
Freeston, M. H., Ladouceur, R., Gagnon, F., Thi- Success and failure in the behavioral treatment of bodeau, N., Rheaume, J., Letarte, H., et al. (1997).
obsessive-compulsives. Journal of Consulting and Cognitive-behavioral treatment of obsessive Clinical Psychology, 51, 287–297.
thoughts: A controlled study. Journal of Consult- Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., ing and Clinical Psychology, 65, 405–413.
Kichic, R., Hajcak, G., et al. (in press). The Fritzler, B. K., Hecker, J. E., & Losee, M. C. (1997).
Brief Treatment and Crisis Intervention / 3:2 Summer 2003
Self-directed treatment with minimal therapist order: Seven vs. twelve-week outcomes. Depres- contact: Preliminary findings for obsessive- sion and Anxiety, 13, 161–165.
compulsive disorder. Behaviour Research and Hodgson, R. J., & Rachman, S. (1972). The eﬀects of contamination and washing in obsessional Goisman, R. M., Rogers, M. P., Steketee, G. S., patients. Behaviour Research and Therapy, 10, Warshaw, M. G., Cuneo, P., & Keller, M. B. (1993).
Utilization of behavioral methods in a multicenter Hodgson, R. J., & Rachman, S. (1977). Obsessional- anxiety disorders study. Journal of Clinical compulsive complaints. Behaviour Research and Goodman, W. K., Price, L. H., Rasmussen, S. A., Hollander, E., Kwon, J. H., Stein, D. J., Mazure, C., Delgado, P., Heninger, G. R., et al.
Broatch, J., Rowland, C. T., & Himelein, C. A.
(1989). The Yale-Brown Obsessive Compulsive (1996). Obsessive-compulsive and spectrum dis- Scale. II. Validity. Archives of General Psychiatry, orders: overview and quality of life issues. Jour- nal of Clinical Psychiatry, 57(Suppl. 8), 3–6.
Goodman, W. K., Price, L. H., Rasmussen, S. A., Hollander, E., & Wong, C. M. (2000). Spectrum, Mazure, C., Fleischmann, R. L., Hill, C. L., et al.
boundary, and subtyping issues: Implications for (1989). The Yale-Brown Obsessive Compulsive treatment-refractory obsessive-compulsive dis- Scale. I. Development, use, and reliability.
order. In J. D. Maser (Ed.), Obsessive-compulsive Archives of General Psychiatry, 46, 1006–1011.
disorder (pp. 3–22). Mahwa, NJ: Earlbaum.
Greenberg, B. D., Ziemann, U., Cora-Locatelli, G., Hoogduin, C. A., & Duivenvoorden, H. J. (1988). Harmon, A., Murphy, D. L., Keel, J. C., et al.
A decision model in the treatment of obsessive- (2000). Altered cortical excitability in obsessive- compulsive neuroses. British Journal of Psych- compulsive disorder. Neurology, 54, 142–147.
Greist, J. H., Jeﬀerson, J. W., Kobak, K. A., Katzel- Jenike, M. A., Baer, L., Minichiello, W. E., nick, D. J., & Serlin, R. C. (1995). Eﬃcacy and Rauch, S. L., & Buttolph, M. L. (1997). Placebo- tolerability of serotonin transport inhibitors in controlled trial of fluoxetine and phenelzine for obsessive-compulsive disorder. A meta-analysis.
obsessive-compulsive disorder. American Journal Archives of General Psychiatry, 52, 53–60.
of Psychiatry, 154, 1261–1264.
Grunes, M. S., Neziroglu, F., & McKay, D. (2001).
Jones, M. K., & Menzies, R. G. (1997). Danger Family involvement in the behavioral treatment ideation reduction therapy (DIRT): Preliminary of obsessive-compulsive disorder: A preliminary investigation. Behavior Therapy, 32, 803–820.
washers. Behaviour Research and Therapy, 35, Hartl, T. L., & Frost, R. O. (1999). Cognitive- behavioral treatment of compulsive hoarding: Keijsers, G. P., Hoogduin, C. A., & Schaap, C. P.
A multiple baseline experimental case study.
(1994). Predictors of treatment outcome in the Behaviour Research and Therapy, 37, 451–461.
behavioural treatment of obsessive-compulsive Hay, P., Sachdev, P., Cumming, S., Smith, J. S., disorder. British Journal of Psychiatry, 165, Lee, T., Kitchener, P., et al. (1993). Treatment of obsessive-compulsive disorder by psychosurgery.
Knox, L. S., Albano, A. M., & Barlow, D. H. (1996).
Acta Psychiatrica Scandinavica, 87, 197–207.
Parental involvement in the treatment of child- Herrnstein, R. J. (1969). Method and theory in hood obsessive-compulsive disorder: A multiple- the study of avoidance. Psychological Review, 76, baseline examination incorporating parents. Be- havior Therapy, 27, 93–115.
Himle, J. A., Rassi, S., Haghighatgou, H., Krone, Koran, L. M., Hackett, E., Rubin, A., Wolkow, R., K. P., Nesse, R. M., & Abelson, J. (2001). Group & Robinson, D. (2002). Eﬃcacy of sertraline in behavioral therapy of obsessive-compulsive dis- the long-term treatment of obsessive-compulsive Brief Treatment and Crisis Intervention / 3:2 Summer 2003
disorder. American Journal of Psychiatry, 159, treatments for the management of neuropsychi- atric disorders. Journal of Psychosomatic Research, Koran, L. M., Thienemann, M. L., & Davenport, R.
(1996). Quality of life for patients with obsessive- Maltby, N., Tolin, D. F., & Diefenbach, G. J. (2002, compulsive disorder. American Journal of Psychi- November). A brief readiness intervention for treatment-ambivalent patients with obsessive- Kozak, M. J., & Foa, E. B. (1997). Mastery of compulsive disorder. Presented at the Association obsessive-compulsive disorder: A cognitive- for Advancement of Behavior Therapy, Reno, NV.
behavioral approach. San Antonio, TX: The March, J. S., Frances, A., Carpenter, D., & Kahn, D. A. (1997). The expert consensus guideline ser- Kozak, M. J., Liebowitz, M. R., & Foa, E. B. (2000).
ies: Treatment of obsessive-compulsive disorder.
Cognitive behavior therapy and pharmacotherapy Journal of Clinical Psychiatry, 58 (Suppl. 4), for obsessive-compulsive disorder: The NIMH- sponsored collaborative study. In J. D. Maser March, J. S., & Mulle, K. (1998). OCD in children (Ed.), Obsessive-compulsive disorder: Contempo- and adolescents: A cognitive-behavioral treatment rary issues in treatment (pp. 501–530). Mahwah, manual. New York: Guilford Press.
Marks, I. (1987). Fears, phobias, and rituals. New Krochmalik, A., Jones, M. K., & Menzies, R. G.
(2001). Danger Ideation Reduction Therapy (DIRT) Mataix-Cols, D., Baer, L., Rauch, S. L., & Jenike, for treatment-resistant compulsive washing. Be- M. A. (2000). Relation of factor-analyzed symp- haviour Research and Therapy, 39, 897–912.
tom dimensions of obsessive-compulsive disorder Lavy, E., van Oppen, P., & van den Hout, M. (1994).
to personality disorders. Acta Psychiatrica Scan- Selective processing of emotional information in obsessive compulsive disorder. Behaviour Re- Mataix-Cols, D., Marks, I. M., Greist, J. H., Kobak, search and Therapy, 32, 243–246.
K. A., & Baer, L. (2002). Obsessive-compulsive Leckman, J. F., Grice, D. E., Boardman, J., Zhang, symptom dimensions as predictors of compliance H., Vitale, A., Bondi, C., et al. (1997). Symptoms with and response to behaviour therapy: Results of obsessive-compulsive disorder. American Jour- from a controlled trial. Psychotherapy and Psycho- nal of Psychiatry, 154, 911–917.
Lelliott, P. T., Noshirvani, H. F., Basoglu, M., Marks, Mataix-Cols, D., Rauch, S. L., Manzo, P. A., Jenike, I. M., & Monteiro, W. O. (1988). Obsessive- M. A., & Baer, L. (1999). Use of factor-analyzed compulsive beliefs and treatment outcome.
symptom dimensions to predict outcome with Psychological Medicine, 18, 697–702.
serotonin reuptake inhibitors and placebo in the Leon, A. C., Portera, L., & Weissman, M. M. (1995).
treatment of obsessive-compulsive disorder.
The social costs of anxiety disorders. British Jour- American Journal of Psychiatry, 156, 1409–1416.
nal of Psychiatry, 166 (Suppl. 27), 19–22.
Mavissakalian, M., & Barlow, D. H. (1981). Assess- Lerner, J., Franklin, M. E., Meadows, E. A., ment of obsessive-compulsive disorder. In D. H.
Hembree, E., & Foa, E. B. (1998). Eﬀectiveness Barlow (Ed.), Behavioral assessment of adult dis- of a cognitive-behavioral treatment program for orders. New York: Guilford Press.
trichotillomania: An uncontrolled evaluation.
Mavissakalian, M., Hamann, M. S., & Jones, B.
Behavior Therapy, 29, 157–171.
Lindsay, M., Crino, R., & Andrews, G. (1997). Con- obsessive-compulsive disorder: Changes with trolled trial of exposure and response prevention treatment. Comprehensive Psychiatry, 31, in obsessive-compulsive disorder. British Journal of Psychiatry, 171, 135–139.
McDonough, M., & Kennedy, N. (2002). Pharma- Malhi, G., & Sachdev, P. (2002). Novel physical cological management of obsessive-compulsive Brief Treatment and Crisis Intervention / 3:2 Summer 2003
disorder: a review for clinicians. Harvard Review Nuttin, B., Cosyns, P., Demeulemeester, H., Gybels, J., of Psychiatry, 10, 127–137.
& Meyerson, B. (1999). Electrical stimulation in McElroy, S. L., Phillips, K. A., & Keck, P. E., Jr.
anterior limbs of internal capsules in patients (1994). Obsessive compulsive spectrum disorder.
with obsessive-compulsive disorder. Lancet, 354, Journal of Clinical Psychiatry, 55(Suppl), 33–51; McKay, D., Todaro, J., Neziroglu, F., Campisi, T., Group. (1997). Cognitive assessment of obsessive- Moritz, E. K., & Yaryura-Tobias, J. A. (1997).
compulsive disorder. Behaviour Research and evaluation of treatment and maintenance using Obsessive Compulsive Cognitions Working Group.
exposure with response prevention. Behaviour (2001). Development and initial validation of the Research and Therapy, 35, 67–70.
obsessive beliefs questionnaire and the interpre- McLean, P. D., Whittal, M. L., Thordarson, D. S., tation of intrusions inventory. Behaviour Research Taylor, S., Sochting, I., Koch, W. J., et al. (2001).
Cognitive versus behavior therapy in the group O’Sullivan, G., Noshirvani, H., Marks, I., Mon- treatment of obsessive-compulsive disorder.
teiro, W., & Lelliott, P. (1991). Six-year follow-up Journal of Consulting and Clinical Psychology, 69, after exposure and clomipramine therapy for obsessive compulsive disorder. Journal of Clinical Mindus, P., & Nyman, H. (1991). Normalization of personality characteristics in patients with inca- Rachman, S. (1980). Obsessions and compulsions. pacitating anxiety disorders after capsulotomy.
Acta Psychiatrica Scandinavica, 83, 283–291.
Rachman, S. (1998). A cognitive theory of ob- Murray, C. J., & Lopez, A. D. (Eds.). (1996). The sessions: elaborations. Behaviour Research and global burden of disease: A comprehensive assess- ment of mortality and disability from diseases, in- Radomsky, A. S., & Rachman, S. (1999). Memory juries, and risk factors in 1990 and projected to bias in obsessive-compulsive disorder (OCD).
2020. Cambridge, MA: Harvard University Press.
Behaviour Research and Therapy, 37, 605–618.
Myers, J. K., Weissman, M. M., Tischler, G. L., Rasmussen, S. A., & Eisen, J. L. (1988). Clinical and Holzer, C. E., III, Leaf, P. J., Orvaschel, H., et al.
epidemiologic findings of significance to neuro- (1984). Six-month prevalence of psychiatric dis- pharmacologic trials in OCD. Psychopharmacology orders in three communities 1980 to 1982.
Archives of General Psychiatry, 41, 959–967.
Rasmussen, S. A., & Eisen, J. L. (1997). Treatment Nakagawa, A., Marks, I. M., Park, J. M., Bacho- strategies for chronic and refractory obsessive- fen, M., Baer, L., Dottl, S. L., et al. (2000). Self- compulsive disorder. Journal of Clinical Psy- treatment of obsessive-compulsive disorder guided chiatry, 58(Suppl. 13), 9–13.
by manual and computer-conducted telephone Rasmussen, S. A., & Tsuang, M. T. (1986). Clinical interview. Journal of Telemedicine and Telecare, 6, characteristics and family history in DSM-III obsessive-compulsive disorder. American Journal Neziroglu, F., Stevens, K., & Yaryura-Tobias, J. A.
of Psychiatry, 143, 317–322.
(1999). Overvalued ideas and their impact on treat- Rauch, S. L., Dougherty, D. D., Cosgrove, G. R., ment outcome. Revista Brasileira de Psiquiatria, Cassem, E. H., Alpert, N. M., Price, B. H., et al.
(2001). Cerebral metabolic correlates as potential Ninan, P. T., Rothbaum, B. O., Marsteller, F. A., predictors of response to anterior cingulotomy for Knight, B. T., & Eccard, M. B. (2000). A placebo- obsessive compulsive disorder. Biological Psy- controlled trial of cognitive-behavioral therapy and clomipramine in trichotillomania. Journal of Robins, L. N., Helzer, J. E., Weissman, M. M., Orva- Clinical Psychiatry, 61, 47–50.
schel, H., Gruenberg, E., Burke, J. D., Jr., et al.
Brief Treatment and Crisis Intervention / 3:2 Summer 2003
(1984). Lifetime prevalence of specific psychiatric Steketee, G. (1990). Personality traits and disorders disorders in three sites. Archives of General Psy- in obsessive-compulsive disorder. Journal of Anx- iety Disorders, 4, 351–364.
Roper, G., Rachman, S., & Hodgson, R. (1973). An Steketee, G., & Shapiro, L. J. (1995). Predicting be- experiment on obsessional checking. Behaviour havioral treatment outcome for agoraphobia and Research and Therapy, 11, 271–277.
obsessive-compulsive disorder. Clinical Psych- Sachdev, P. S., McBride, R., Loo, C. K., Mitchell, P. B., Malhi, G. S., & Croker, V. M. (2001). Right versus Summerfeldt, L. J., Richter, M. A., Antony, M. M., left prefrontal transcranial magnetic stimulation & Swinson, R. P. (1999). Symptom structure in for obsessive-compulsive disorder: A preliminary obsessive-compulsive disorder: A confirmatory investigation. Journal of Clinical Psychiatry, 62, factor-analytic study. Behaviour Research and Salkovskis, P. M. (1985). Obsessional-compulsive Tolin, D. F. (2001). Bibliotherapy and extinction problems: A cognitive-behavioural analysis. Be- treatment of obsessive-compulsive disorder in a haviour Research and Therapy, 23, 571–583.
five-year-old boy. Journal of the American Acad- Sanavio, E. (1988). Obsessions and compulsions: emy of Child and Adolescent Psychiatry, 40, The Padua Inventory. Behaviour Research and Tolin, D. F., Abramowitz, J. S., Brigidi, B. D., Saxena, S., Maidment, K. M., Vapnik, T., Golden, Amir, N., Street, G. P., & Foa, E. B. (2001). Mem- G., Rishwain, T., Rosen, R. M., et al. (2002).
Obsessive-compulsive hoarding: Symptom sever- compulsive disorder. Behaviour Research and ity and response to multimodal treatment. Journal of Clinical Psychiatry, 63, 21–27.
Tolin, D. F., Abramowitz, J. S., Kozak, M. J., & Saxena, S., & Rauch, S. L. (2000). Functional neuro- Foa, E. B. (2001). Fixity of belief, perceptual imaging and the neuroanatomy of obsessive- aberration, and magical ideation in obsessive- compulsive disorder. Psychiatric Clinics of North compulsive disorder patients. Journal of Anxiety Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Tolin, D. F., Abramowitz, J. S., Przeworski, A., Ort, S. I., King, R. A., Goodman, W. K., et al.
& Foa, E. B. (2002). Thought suppression in (1997). Children’s Yale-Brown Obsessive Compul- obsessive-compulsive disorder. Behaviour Re- sive Scale: Reliability and validity. Journal of search and Therapy, 40, 1255–1274.
the American Academy of Child and Adolescent Tolin, D. F., Diefenbach, G. J., Maltby, N., Wood- hams, E., & Worhunsky, P. (2002, November).
Schwartz, J. M., Stoessel, P. W., Baxter, L. R., Jr., Behavior therapy for medication nonresponders Martin, K. M., & Phelps, M. E. (1996). Systematic with obsessive-compulsive disorder. In D. F. Tolin changes in cerebral glucose metabolic rate after (Chair), Cognitive-behavioral therapy for medica- successful behavior modification treatment of tion nonresponders with anxiety disorders. Sympo- obsessive-compulsive disorder. Archives of Gen- sium presented at the Association for Advance- eral Psychiatry, 53, 109–113.
Shafran, R., Thordarson, D. S., & Rachman, S.
Tolin, D. F., & Foa, E. B. (2001). Compulsions. In (1996). Thought-action fusion in obsessive com- C. B. Nemeroﬀ (Ed.), The Corsini encyclopedia pulsive disorder. Journal of Anxiety Disorders, 10, of psychology and behavioral science (3rd ed., pp. 338–339). New York: John Wiley & Sons.
Stein, D. J., Spadaccini, E., & Hollander, E. (1995).
Tolin, D. F., Franklin, M. E., Diefenbach, G. J., Meta-analysis of pharmacotherapy trials for & Gross, A. (2002, November). Cognitive- obsessive-compulsive disorder. International behavioral therapy for pediatric trichotillomania: Clinical Psychopharmacology, 10, 11–18.
An open trial. In N. Keuthen (Chair), Symposium Brief Treatment and Crisis Intervention / 3:2 Summer 2003
presented at the Association for Advancement hypochondriasis: Exposure plus response preven- tion vs cognitive therapy. Behaviour Research and Tolin, D. F., Hamlin, C., & Foa, E. B. (2002). Directed forgetting in obsessive-compulsive disorder: Warren, R., Zgourides, G., & Monto, M. (1993). Replication and extension. Behaviour Research Self-report versions of the Yale-Brown Obsessive- Compulsive Scale: An assessment of a sample of van Balkom, A. J., de Haan, E., van Oppen, P., normals. Psychological Reports, 73, 574.
Spinhoven, P., Hoogduin, K. A., & van Dyck, R.
Warwick, H. M., Clark, D. M., Cobb, A. M., (1998). Cognitive and behavioral therapies alone & Salkovskis, P. M. (1996). A controlled trial versus in combination with fluvoxamine in the of cognitive-behavioural treatment of hypo- treatment of obsessive compulsive disorder. Jour- chondriasis. British Journal of Psychiatry, 169, nal of Nervous and Mental Disease, 186, 492–499.
Van Noppen, B. L., Pato, M. T., Marsland, R., & Wells, A., & Davies, M. I. (1994). The Thought Rasmussen, S. A. (1998). A time-limited behav- Control Questionnaire: A measure of individual ioral group for treatment of obsessive-compulsive diﬀerences in the control of unwanted thoughts.
disorder. Journal of Psychotherapy Practice and Behaviour Research and Therapy, 32, 871–878.
Wilhelm, S., McNally, R. J., Baer, L., & Florin, I.
Van Noppen, B. L., Steketee, G., McCorkle, B. H., (1996). Directed forgetting in obsessive- & Pato, M. (1997). Group and multifamily behav- compulsive disorder. Behaviour Research and ioral treatment for obsessive compulsive disorder: A pilot study. Journal of Anxiety Disorders, 11, Wilhelm, S., Otto, M. W., Lohr, B., & Deckersbach, T. (1999). Cognitive behavior group therapy for van Oppen, P., de Haan, E., van Balkom, A. J., body dysmorphic disorder: A case series. Behav- Spinhoven, P., Hoogduin, K., & van Dyck, R.
iour Research and Therapy, 37, 71–75.
(1995). Cognitive therapy and exposure in vivo in Williams, J. M. G., Watts, F. N., MacLeod, C., & the treatment of obsessive compulsive disorder.
Mathews, A. (1997). Cognitive psychology and Behaviour Research and Therapy, 33, 379–390.
emotional disorders (2nd ed.). New York: John Visser, S., & Bouman, T. K. (2001). The treatment of Brief Treatment and Crisis Intervention / 3:2 Summer 2003
Chapter 17 Review 17.1 : Psychoanalysis At his friends’ urging, Barney has decided to seek help for the depression he has been struggling with ever since moving away from home and starting college two months ago. He’s heard a lot about Sigmund (1) Freud’s therapy, called (2) psychoanalysis , in which patients use (3) free association to express whatever comes to mind in order to un