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Clinical Update: Obsessive Compulsive Disorder
Gail Steketee, Ph.D.
OCD and the Family
Obsessive compulsive disorder (OCD) is a common anxiety disorder that afflicts approximately 1 to 2% of
the population. Like many mental health problems, it stems from exaggerations of normal phenomenon,
in this case mental intrusions in the form of unwanted thoughts, images or impulses that are experienced
by most people. When these intrusions acquire the capacity to provoke considerable distress, sufferers
seek a multitude of ways to avoid, dismiss or undo them. Strategies usually include elaborate avoidance
behaviors, efforts to suppress thoughts, and compulsive rituals designed to "neutralize" the thoughts or
prevent the feared harm.
For example, during ordinary driving, running over a pothole or sticks on the road can bring on a brief
horrific image of having run over a person. If this produces doubt, anxiety and/or guilt, the person might
try to dismiss the thought, review the experience mentally to make sure it did not happen, and even avoid
driving on that road or other roads where visibility might not be clear or pedestrians may be frequent. If
these actions are insufficient to reduce discomfort, gradually, the driver may begin retracing the route to
make sure no hit and run accident has occurred. Over time, these actions work less and less well and
anxiety and often depression mount in the face of increasing impairment.
Many family members have difficulty understanding the exaggerated behaviors people with OCD engage
in, and they may misinterpret these actions as willful or crazy and react with frustration and anger or
excessive efforts to help. Some of these reactions have been described as expressed emotion (EE), a
term that refers to critical comments, hostility and emotional over-involvement (intrusiveness,
overprotection). High levels of EE have predicted poor outcome for treatment of OCD in some studies
(Hibbs et al., 1991; Leonard et al., 1993). In addition, relatives' attributions that the OCD patient could just
stop his or her rituals predicted fewer gains 9 months after treatment ended (Steketee, 1993). In another
recent study, Chambless and Steketee (1999) determined that relative's hostility was especially
problematic and led to more dropout and worse outcomes after behavioral treatment. Simple criticism
without hostility assessed during a family interview was actually associated with slightly better outcome,
perhaps because family members appropriately encouraged patients to confront their fears. Emotional
over-involvement among family members was associated with dropping out of therapy.
These findings suggest that educating families about OCD and reducing any strong negative reactions to
symptoms might improve the ability to remain in treatment and also lead to better outcomes for patients
struggling with this disorder. Some strategies for family interventions that may prove fruitful for both the
patient and the family are described below.
Diagnosis and Assessment
Diagnostic criteria provided in the Diagnostic and Statistical Manual of Mental Disorders-Version IV
(DSM-IV; APA, 1994) provide a common language for mental health clinicians. Currently, OCD is
characterized by recurrent obsessions or compulsions that provoke distress and interfere with a person's
routine social and/or occupational functioning. Intrusive thoughts, images or impulses become obsessions
that the person perceives as inappropriate and markedly distressing. Compulsions or rituals are repetitive
behaviors or mental acts performed in response to an obsession and purposely aimed at preventing a
dreaded consequence or to reduce emotional discomfort. Covert mental compulsions include such
activities as praying, reviewing events, counting or repeating words or phrases to neutralize anxiety or
feared outcome. DSM-IV includes a "poor insight type" referring to a lack of recognition of the
unreasonableness or excessiveness of the obsessions and compulsions. However, a history of insight at
some point during the disorder is required to distinguish OCD from delusions. Not surprisingly, lack of
insight can be especially troubling to family members. Common manifestations of OCD are fears of
contamination and washing rituals, concerns about harm accompanied by checking or mental
compulsions, and the need for symmetry followed by ordering and arranging rituals. Many sufferers
experience more than one type of obsession or compulsion.
To complete a diagnosis of OCD, clinicians must verify the presence of obsessions and of behavioral
and/or mental compulsions. The symptoms of OCD range from no symptoms to mild subclinical problems,
and to serious diagnosable disorders. Generally, sufferers do not seek treatment until symptoms are at
least moderate in severity. Some conditions are very similar to OCD but are considered different
diagnoses because of the focalized nature of the obsessive concerns, such as bulimia which is classified
as an eating disorder, and hypochondriasis or body dysmorphic disorder which are classified as somatic
conditions. Compulsive hoarding is considered a symptom of OCD but is also classified as one of several
symptoms that constitute compulsive personality disorder. Disorders such as trichotillomania, skin
picking, Tourette's syndrome, and compulsive gambling are sometimes considered OC spectrum
conditions, but there remains much controversy about their similarity to OCD compared to impulse control
disorders where most of these are presently classified.
Formal diagnostic interview schedules are available to assist clinicians with diagnosis. Most useful are
those that include all relevant symptoms, distinguish between potentially overlapping conditions, and also
permit quantification of severity of symptoms. Among the best of the standardized interview measures for
OCD diagnosis is the Anxiety Disorders Interview Schedule (ADIS, DiNardo, Brown, & Barlow, 1994). The
section on OCD is especially useful because it permits clinicians to determine the type and severity of
presenting symptoms, including frequency, persistence, distress and resistance. This level of detail helps
determine which symptoms should be treated first. The ADIS also includes sections to identify
environmental stressors (family, work, finances, health) and insight into obsessive fears, consistent with
new DSM criteria for the insight modifier. The ADIS includes diagnostic questions for hypochondriasis but
not for other OC spectrum conditions.
To determine the type and severity of OCD symptoms, clinicians should be familiar with the widely used
Yale-Brown Obsessive Compulsive Scale (YBOCS). This scale has an interview form (Goodman et al.,
1989) that requires 30-45 minutes to administer and a self-report format (see appendix in Baer, 1992) that
takes about 20-25 minutes. Both forms include a detailed list of symptoms to identify specific obsessions
and compulsions, followed by 10 questions that inquire about the frequency, intensity and disturbance
caused by the symptoms. More recently developed and gaining in popularity is the Obsessive
Compulsive Inventory which has a long and short version (Foa et al., 1998) that include subscales
pertaining to types of symptoms. Both the YBOCS and OCI are reliable and valid and quite useful in
routine clinical practice.
Another arena that merits special assessment is the patient's beliefs that support the OCD and basic
assumptions or core beliefs about themselves. A group of international researchers, the Obsessive
Compulsive Cognitions Working Group (OCCWG, 1997), has described these beliefs and developed
instruments that measure the strength of beliefs and attitudes about several areas that appear to be
important for most OCD patients (OCCWG, 2001). These include the importance of thoughts and need to
control them, beliefs that are especially relevant to obsessions about harming others, as well as sexual
and religious obsessions. Another set of problem beliefs concerns the tendency to feel responsible for
harm and to overestimate the probability and severity of danger, for example the possible harmful effects
of germs or of making a mistake. In addition, many people with OCD suffer from excessively high
standards or perfectionistic beliefs about themselves and the need to feel absolutely certain about events
or experiences. Of course, OCD is not the only diagnosis associated with excessive concerns about
danger or perfectionistic beliefs, but these have proved to be productive areas to focus on during
treatment. In some cases, patients hold very negative core beliefs about themselves-for example, that
they are inadequate or unloveable- and these may underlie attitudes related to OCD symptoms.
Important features to assess in the family situation include the family's emotional reactions to the patient
(especially criticism, hostility, and overinvolvement or intrusiveness), accommodation to the symptoms,
and attributions or beliefs about the patient and his or her behavior. This is especially important when the
person with OCD is living with parents who are likely to have a strong influence on the outcome of the
therapy. Family assessment is also important when the relative is a spouse or partner who may need
education about the problem to reduce criticism and promote constructive communication during the
therapy. Not surprisingly, many family members become very frustrated with OCD symptoms that appear
peculiar, irrational and demanding both for the patient and for the family as a whole. Perhaps even more
remarkable than negative family responses are the many family members who, despite the problems
provoked by OCD symptoms, are simply concerned about the sufferer and tolerant of the symptoms.
Although an overall supportive attitude is certainly helpful, sometimes it can lead to too much
accommodation. Examples include doing rituals like washing or checking at the patient's request, taking
over routine chores that cause discomfort (e.g., taking out the trash) or giving reassurance about
obsessive fears. Unfortunately, these actions simply feed the fears and avoidance, making the therapist's
task that much harder. The Family Accommodation Scale (Calvocoressi et al., 1999) assesses several
areas of accommodation (see Figure 1), providing a useful guide for intervening with family members
during treatment.
Treatment Options
Four main types of treatments are effective for OCD. These are behavior therapy that includes exposure
to feared situations and blocking rituals, family interventions in conjunction with behavioral treatment,
cognitive therapy, and medications that affect the serotonin system.
Behavioral Treatment
Obsessions provoke discomfort whereas compulsions reduce it. This conceptualization of OCD led to the
development of behavioral treatment methods that included prolonged exposure to feared obsessions
and prevention of rituals, methods developed in the late 1960's and early 1970's. Exposure is designed to
reduce (habituate or extinguish) the negative emotions (anxiety and guilt) provoked by obsessions using
a graduated hierarchy of increasingly feared situations. This process is similar to helping a person
overcome his or her fear of dogs by coming closer and closer to increasingly larger and more active
animals. At the same time exposure is occurring, all behavioral and mental compulsions, as well as other
forms of neutralizing, undoing or avoiding the obsessions are prevented, again usually in a gradual
fashion. This exposure and response prevention (ERP) may also alter the person's expectations of
catastrophic outcomes. For example, after repeated exposures without rituals, a person fearful of
becoming ill from germs or of losing control and harming someone after obsessive thoughts about
harming others may become convinced that these feared outcomes will not happen.
Early clinical trials of exposure and response prevention (ERP) were very encouraging, and subsequent
controlled studies have demonstrated quite clearly that this treatment is very effective for OCD. The
majority of patients who receive ERP are rated "much improved", showing gains of 70% or more on OCD
symptoms. Relatively few are considered failures, even when assessed several years later. Since the first
report of this treatment, at least 30 open trials and controlled studies have investigated the effects of 10 to
20 sessions of ERP for OCD in more than 600 patients (for review see Steketee & Frost, 1998), and
several meta analyses have supported the efficacy of this treatment (Abramowitz, 1996; Van Balkom et
al., 1994). In recent studies, many of the patients treated with exposure no longer met criteria for the
disorder and few showed any relapse. Overall, these are impressive results for a disorder once
considered difficult to treat.
It is clear that both exposure and response prevention are necessary for good outcomes since exposure
has the greatest effect on obsessions, whereas response prevention reduces rituals (Foa, Steketee,
Grayson, Turner, & Latimer, 1984). The therapist can use the intensity of the discomfort reported at initial
exposure and the degree of reduction in discomfort as indicators of progress during therapy. Treatment
can be delivered with limited therapist involvement to advise the patient about homework, and this type of
self-directed ERP may actually protect patients from relapse (Emmelkamp, van den Heuvell, Ruphan, &
Sanderman, 1989). A boon for clinicians working in agencies or private practice, research indicates that
ERP can be delivered very effectively in routine clinical practice (Franklin, Abramowitz, Kozak, Levitt, &
Foa, 2000).
The optimum number of exposure sessions appears to be 15 to 20 scheduled to occur as often as daily
or as infrequently as once a week. Imagined exposure can be added to direct exposure, especially for
patients who worry greatly about catastrophic consequences related to their obsessions (for example,
causing a fire, dying from an illness, being punished by God). Including strategies to prevent relapse in
the future helps patients maintain their gains over the long term (Hiss, Foa & Kozak, 1994). Research has
shown that exposure can be delivered effectively in a group format (e.g., Fals-Stewart , Marks, & Schafer,
1993), although the best outcomes seem to occur following intensive individual treatment. The value of
including family members in ERP is discussed below. Inpatient therapy may be needed to assist very
severe patients with round the clock supervision during ERP treatment (Osgood-Hynes, Rieman &
Thordarson, 2003).
To relieve OCD symptoms using ERP, therapists may need to depart from usual office-based talk-therapy
methods. Especially in severe cases, treatment can be demanding for both therapist and patient as the
therapist directs the patient to persistently confront his or her worst fears. Since patients cannot use
avoidance and rituals to escape their fears, exposure is actually in effect 24 hours a day for weeks at a
time. This process has been described in detail in Steketee (1999). For example, one man who had
obsessions about blaspheming God and being punished in hell had begun to avoid a wide variety of
situations associated with his Catholic religion in which he was raised quite strictly. Thus, his hierarchy
included reading passages from the Bible without praying or undoing "blasphemous" thoughts, parking his
car facing a distant church, driving by churches, attending religious services, and other situations that
provoked anxiety and rituals. Accompanied by his therapist, he also consulted with a local priest to help
him clarify actual church teachings in relation to his obsessive fears.
Behavioral Family Treatment
Several studies have examined inclusion of family members in treatment for OCD. Family members and
patients both tend to benefit when family members participate in psychoeducational groups, especially
when patients are concurrently in behavioral treatment (e.g., Black & Blum, 1992; Marks, Hodgson, &
Rachman, 1975). Efforts to reduce family accommodation to OCD symptoms have shown promise
(Grunes, Neziroglu & McKay, 2001). Patients whose family members were involved in an 8-week group
showed more improvement in OCD and depression compared to those whose relatives did not
participate. In addition, relatives also improved on depressed mood and anxiety when they
accommodated less.
Research on the benefits of including family members as assistants in behavioral treatment for OCD
patients have produced mixed findings. Involving the spouse did not enhance outcomes in one study
(Emmelkamp et al., 1990), but in another, including spouses and parents in ERP treatment led to
significantly greater gains in OCD symptoms and functioning (Mehta, 1990). Family members who were
firm and not anxious were more successful in providing support and supervision than anxious and
inconsistent ones, and especially compared to those who engaged in argument and ridicule. It also
appears that longer treatment (e.g., 24 sessions) may be more beneficial for this purpose.
Studies of multifamily behavioral treatment have also indicated good benefits for patients (Van Noppen,
Steketee, McCorkle, & Pato, 1997). Family members and patients together received education about
OCD and worked together on exposure treatment. They were also taught to contract with each other for
behavior change and to apply exposure at home. This treatment improved OCD symptom severity and
also family functioning. As might be expected, families with worse communication skills had worse
outcome on OCD symptoms. Studies of family intervention with children who have OCD are also quite
promising (Piacentini et al., 2001; Waters, Barrett & March, 2001). Psychoeducation, disengagement from
the child's OCD symptoms, and interventions for conflict and family disruption led to improvement in
nearly 80% of patients. Other methods that may be helpful are parental participation in childhood
relaxation training, parental anxiety management, and problem solving skills training.
These findings are very promising. Given the important role family members play in the patient's life, it is
reasonable to expect that treatments that include family members will be beneficial for many OCD
patients and families. However, in some cases when relatives are especially hostile or excessively
intrusive in patients' lives, education of family members, but not involvement in behavioral treatment, may
be indicated.
Cognitive Therapy
Cognitive therapy (CT) is based on the understanding that intrusive thoughts are normal phenomena; in
fact, nearly 90% of people have intrusions that are similar in content to OCD obsessions. When these
intrusions are misinterpreted, they can develop into OCD because avoidance and rituals prevent the
testing and discarding of the mistaken appraisals (Salkovskis, 1989; Rachman, 1997). CT targets these
misinterpretations and beliefs which usually pertain to overestimating the probability and severity of harm,
excessive responsibility, overimportance of and need to control thoughts, and the need for certainty and
perfectionism. These beliefs are common among people with OCD, although several (e.g., perfectionism,
overestimation of threat) are also found in other psychiatric disorders (OCCWG, 1997).
Based on Aaron T. Beck's (1987) model, CT uses Socratic dialogue in a series of thoughtful questions to
help the patient identify and evaluate beliefs that support OCD behavior. A variety of cognitive strategies
may be used once belief domains are identified. For example, a responsibility pie might be used for
patients who overestimate their responsibility for causing events. Patients first state their own percent of
the responsibility. They then list all other sources of responsibility with help from the therapist, assigning
each an appropriate portion of the pie, their own responsibility estimated last. Comparisons of original
(exaggerated) and new estimates shape more realistic attitudes about responsibility. Another technique
challenges overestimation of danger by having the patient state the feared outcome (such as burning the
house down) and then list all the steps required for this to occur. For example, the patient smokes a
cigarette, fails to extinguish it, ash jumps from the ashtray onto the carpet, the carpet burns without
anyone noticing, no fire extinguisher is available, no one calls the fire department, and the fire burns out
of control. The patient assigns each step a probability of occurrence (for example, .01 or 1/10) and these
are multiplied to yield the actual likelihood of smoking leading to the house burning down. Metaphors may
be used for other types of interpretations. For example, over-importance of thoughts might be examined
by describing the neighbor who paints his house with purple polka dots to ward off flying elephants from
smashing in his roof. When a neighbor points out that this has never happened, he says, "See, it works!"
This can help patients identify the magical reasoning that contributes to their overestimating harm.
Several studies have tested this CT method. Twelve sessions of CT were as effective as ERP treatment
with up to 50% of patients who received CT improving so much they were considered recovered (Van
Oppen et al., 1995). In a French study, Cottraux et al. (2000) found excellent effects from a 20 session
version of CT which was also as effective as ERP treatment, although CT produced more benefit for
depression. Both treatments also significantly reduced OCD beliefs, and changes in beliefs correlated
with change in OCD symptoms for both therapies. When CT was applied in a 12 session group format, it
did not produce as much improvement as when applied in individual treatment (McLean et al., 2001).
Thus, cognitive treatment should probably be individualized for each patient and is a good alternative to
ERP, especially for patients who are unwilling to engage in the anxiety-provoking behavioral therapy.
Combining CT with ERP has proven very effective in treating OCD patients with mental rituals (also called
pure obsessionals), producing an 84% success rate that was maintained at a 1-year follow-up.
Pharmacological Treatment
So far, the most effective medications for improving OCD symptoms are the serotonergic reuptake
inhibitors (SRI) like clomipramine and the selective serotonergic reuptake inhibitors (SSRI) that work
almost exclusively on the serotonin system. These include fluoxetine, fluvoxamine, sertraline, paroxetine,
citalopram, with new drugs continuing to appear on the market. Although clomipramine has been the
most extensively studied drug for OCD, it does not appear to produce significantly stronger effects
compared to other serotonergic medications (Abramowitz, 1996; Pigott & Seay, 1999). Newer SSRIs
have now largely replaced clomipramine as first line drug treatments for OCD because they are generally
better tolerated by patients and show comparable anti-obsessional effects. To date, fluvoxamine has
probably been most studied and produces very good results (Mundo et al., 2000) with OCD symptoms
reduced by half and the majority of patients showing symptom reductions into the non-clinical. In general,
however, reviews of the comparative effectiveness of a variety of SSRIs have indicated that there is little
difference among these medications and the mechanisms of action remain unclear. Most studies continue
to indicate that medication does not eradicate obsessive compulsive disorder but reduces the force of
obsessions and urges to ritualize so the patient can exert more control. Relapse is very common among
patients whose SRI medications are withdrawn (Pato et al., 1988).
What about the combination of SSRI medications and behavioral therapy? So far these drugs have not
been studied in relation to cognitive therapy. Some studies have suggested that medications (mainly
clomipramine) do not potentiate behavioral treatment (e.g., Marks, Stern, Mawson, Cobb, & McDonald,
1980; Marks et al., 1988). Preliminary findings suggest that combined treatment performed similarly to
behavior therapy alone (responder rates were 71% and 85% respectively), and better than clomipramine
alone (50% responders) (Kozak, Liebowitz, & Foa, 2000). In addition, having had behavior therapy
protected patients from relapse when medications were withdrawn. In studying the effects of fluvoxamine
and behavioral treatment, Cottraux et al. (1989) found a slight advantage for the combined treatment over
each therapy alone. Others (e.g., Van Balkom et al., 1994) have reported that adding SSRI medication to
psychological treatment did not increase the benefit, a finding similar to that reported by Kozak et al.
(2000).
Despite the lack of definitive information regarding the value of combining treatments, many clinicians
prefer combined therapies and there may be reasons to do so for individual patients. For example, for
patients who are unwilling to engage in a treatment that is anxiety provoking, medications that reduce
discomfort from obsessions may enhance motivation for ERP. For patients who are already medicated,
the high probability of relapse on drug withdrawal is a good indicator for the use of behavior therapy.
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Steketee, G. (1993). Social support as a predictor of follow-up outcome following treatment for OCD.
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Steketee, G. (1999). Overcoming compulsive disorder: Behavioral and cognitive therapy. Therapist
manual and Patient manual. Oakland, CA: New Harbinger Press.
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Resources for Practitioners
1. Obsessive Compulsive Foundation, 203-315-2190; [email protected]; www.ocfoundation.org
This national organization provides information and referral services for those seeking help for OCD and
spectrum disorders. An annual conference on OCD and related topics is scheduled annually during the
summer and provides an excellent forum for clinical training and for sufferers to meet each other and the
experts. The OCF also has an extensive publication list of books, articles and videos available for sale.
2. Steketee, G. (1999). Overcoming compulsive disorder: Behavioral and cognitive therapy. Therapist
manual; Patient manual. Oakland, CA: New Harbinger. This pair of manuals are useful for therapists
assisting patients in exposure and response prevention treatment and the use of cognitive therapy
methods.
3. Van Noppen, B., Pato, M., & Rasmussen, S. (2003). Learning to live with OCD: Help for Families. New
Haven, CT: Obsessive Compulsive Foundation. In its 4th revision, this booklet is a mainstay for family
members trying to understand OCD and how to deal with these symptoms in the family environment.
4. Baer, L. (2000). The Imp of the Mind. New York: Little, Brown & Co. Lee Baer has written an excellent
book describing how obsessions become embedded in the psyche. This is a useful resource for patients
and therapists.
5. Swinson, R.P., Antony, M.M., Rachman, S., & Richter, M.A. (Eds.) (1998). Obsessive-compulsive
disorder: Theory research and treatment. New York: Guilford, Therapists wanting more detail on a wide
variety of topics pertinent to OCD will find the chapters of this edited volume most informative.
6. The Touching Tree: A Story of a Child with OCD. (OC Foundation, CT, 1993). Patients and families,
clinicians and classroom instructors will find this award winning video of a patient suffering from OCD
helpful in clarifying the problems patients face.
Sidebar
Compulsive Hoarding
Although compulsive hoarding is considered a symptom of OCD (and also of obsessive
compulsive personality disorder), it has several features that make this problem somewhat unique and
more resistant to usual medication and behavioral therapy for OCD. Based on descriptions and a model
developed by Frost and Hartl (1996) and elaborated by Steketee and Frost (2003), compulsive hoarding
consists of 3 key features: excessive acquisition, difficulty discarding and clutter, which is the visible
hallmark of the condition.
These problems develop because of several deficits that are manifest in many but not necessarily all
people with hoarding problems. These include information processing problems in the areas of attention,
categorization and organization, and decision making. Some compulsive hoarders appear to have
difficulty focusing their attention long enough to be able to sort belongings and reduce clutter. Many also
generate too many categories, making it difficult to file items and decide which ones to combine and
where to put them. A second problem is excessive emotional attachment to and beliefs about
possessions, especially with regard to personal identification with objects, fears about being unable to
remember or find important information if it is put away, and responsibility for protecting and controlling
possessions. Finally, distress and avoidance behavior make it difficult to reduce acquisition and increase
discarding (what if I need it someday) and learn skills for organizing the clutter.
The limited research on treatment provides evidence that current serotonergic medications for OCD are
largely ineffective for treating hoarding (see Black et al., 1998; Mataix Cols et al., 1999). Although the
effects of behavioral treatment using ERP are not entirely clear, it appears that patients with compulsive
hoarding are often among those who do not benefit adequately (Mataix-Cols et al., 2002). A cognitive
behavioral therapy that focuses on the specific deficits described above appears more promising, with
several patients showing at least moderate success (Hartl & Frost, 1999; Steketee et al., 2000).
Treatment includes motivational interviewing to improve retention in treatment, cognitive therapy directed
at faulty beliefs and attachments, and behavioral methods to help train organizing skills and practice
exposures to non-acquiring and discarding hierarchies. Further development of the therapy will be
needed to render it most useful in clinical practice.
Terminology
Compulsions: Also called rituals, these are repetitive behaviors or mental acts performed in response to
an obsession and aimed at preventing a feared consequence or at reducing emotional discomfort.
Examples are washing, cleaning, checking, putting things in order, repeating actions, making written or
mental lists, praying, and forming a corrective image.
Core beliefs: Beliefs considered central to the person's identity, usually expressed in a very brief
statement about the self, such as "I am bad" or "I'm unloveable." Core beliefs color the personality and
foster negative emotions such as anxiety, depression and guilt that may be manifest in OCD or other
psychiatric symptoms.
Expressed emotion (EE): Relatives' negative emotional responses to patient's symptoms, such as
critical comments, hostility and emotional over-involvement (intrusiveness, overprotection), as well as
positive responses such as warmth and positive comments.
Family accommodation: Relative's efforts to help patients manage their OCD symptoms, by
participating in or taking over activities to reduce discomfort, providing reassurance, and a variety of
measures to assist the patient.
Habituation: Reduction of anxiety or other emotional arousal during repeated or prolonged exposure to
the disturbing stimulus situation.
Hierarchy: A list of 10 to 20 feared situations in order of their anxiety producing potential. This list is used
to design the order of exposures during treatment of anxiety disorders, including OCD.
Impulse control disorders (ICDs): Psychological disorders in which individuals have difficulty controlling
impulses to engage in actions that may be detrimental to their functioning. Examples are gambling,
substance abuse, and some disorders considered to be part of the OC spectrum like trichotillomania, skin
picking and Tourette's Syndrome.
Intrusions: Unwanted thoughts, images or impulses that are experienced by most people but can
become obsessions if interpreted negatively and accompanied by unpleasant emotions such as anxiety,
depression and guilt.
Multifamily behavioral treatment (MFBT): A group of patients and their relatives participate together in
psychotherapy that begins with education about the problem and about the method of treatment. The
therapy includes exposure and prevention of rituals, as well as teaching family members to develop
formal contracts with each other for behavior change.
Neutralize/neutralization: Physical or mental activities designed to correct or undo the negative effects
of obsessions. For example, forming a mental image of a healthy person in response to an obsession
about someone becoming ill or having an accident. Praying can be a neutralization strategy if used to
reduce discomfort associated with blasphemous obsessions.
Serotonergic reuptake inhibitors (SRIs): psychotropic medications that block the reuptake of serotonin.
Medications such as clomipramine are SRIs that not only work on the serotonin system but also affect
other body systems. Selective serotonergic medications (SSRIs) influence the serotonin system more
specifically without other effects.
Socratic dialogue: A cognitive therapy technique in which the therapist asks a series of logical questions
designed to help the patient draw rational conclusions instead of mistaken interpretations of situations
that provoke obsessive fears. This method is described and illustrated clearly by J. Beck (1995).
Tourette's Syndrome (TS): Gilles de la Tourette's Syndrome is a psychiatric disorder related to OCD in
that the majority of patients with TS also have OCD. However, most people with OCD do not have TS.
The disorder is characterized by vocal and movement tics over which patients do not appear to have
control and is thought to have a neurological basis.
Figure 1: Family Accommodation (adapted from the Family Accommodation Scale by Calvocoressi et
al., 1995)
.Providing reassurance
.Watching rituals
.Waiting for the patient
.Refraining from saying/doing things
.Facilitating avoidance
.Facilitating rituals
.Participating in rituals
.Helping with tasks or decisions
.Tolerating disruptions
.Modifying personal and/or family routines
.Taking on patient's responsibilities
About the Author
Gail Steketee, Ph.D. is a Professor at the Boston University School of Social Work where she co-chairs
the Clinical Practice department. She has conducted a variety of research studies on the
psychopathology and treatment of obsessive compulsive disorder, focusing on familial factors such as
expressed emotion (EE) that influence treatment, cognitive therapy for OCD, and the psychopathology
and treatment of compulsive hoarding. She co-chairs the international Obsessive Compulsive Cognitions
Working Group (OCCWG) dedicated to the study of cognitive aspects of OCD. Dr. Steketee has
published well over 100 articles and chapters on OCD, other anxiety disorders, and hoarding problems
and has written and edited 4 books on OCD published by Guilford Press, New Harbinger, and Elsevier.
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