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FamilyTherapyResources.net 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. References Abramowitz, J.S. (1996). Variants of exposure and response prevention in the treatment of obsessivecompulsive disorder: A meta-analysis. Behavior Therapy, 27, 583-600. American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Baer. L. (1992). Getting control. New York: Plume Beck, A.T., & Steer, R.A. (1987). Beck Depression Inventory Manual. San Antonio, TX: Psychological Corporation. Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford. Black, D.W., & Blum, N.S. (1992). Obsessive-compulsive disorder support groups: The Iowa model. Comprehensive Psychiatry, 33, 65-71. Black, D.W., Monahan, P., Gable, J., Blum, N., Clancy, G., & Baker, P. (1998). Hoarding and treatment response in 38 nondepressed subjects with obsessive-compulsive disorder. Journal of Clinical Psychiatry, 59, 420-425. Calvocoressi, L., Mazure, C., Stanislav, K., Skolnick, J., Fisk, D., Vegso, S., Van Noppen, B., & Price, L. (1999). 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Family involvement in the behavioral treatment of obsessive-compulsive disorder: A preliminary investigation. Behavior Therapy, 32, 803-820. Hibbs, E.D., Hamburger, S.D., Lenane, M., Rapoport, J.L., Kruesi, M.J.P., Keysor, C.S., & Goldstein, M.J. (1991). Determinants of expressed emotion in families of disturbed and normal children. Journal of Psychology and Psychiatry, 32, 757-770. Hiss, H., Foa, E.B., & Kozak, M.J. (1994). Relapse prevention program for treatment of obsessivecompulsive disorder. Journal of Consulting and Clinical Psychology, 62, 801-808. Kozak, M.J., Liebowitz, M., & Foa, E.B. (2000). Cognitive behavior therapy and pharmacotherapy for OCD: The NIMH-sponsored collaborative study. In W.K. Goodman, M. V. Rudorfer, & J. D. Maser (Eds.), Obsessive compulsive disorder: Contemporary issues in treatment. Mahwah, NJ: Erlbaum. Leonard, H.L., Swedo, S.E., Lenane, M.C., Rettew, D.C., Hamburger, S.D., Bartko, J.J., & Rapoport, J.L. (1993). A 2- to 7-year follow-up study of 54 obsessive-compulsive children and adolescents. Archives of General Psychiatry, 50, 429-439. Marks, I.M., Hodgson, R., & Rachman, S. (1975). Treatment of chronic obsessive-compuilsive neurosis with in vivo exposure: A 2-year follow-up and issues in treatment. British Journal of Psychiatry, 127, 349364. Marks, I.M., Stern R.S., Mawson, D., Cobb, J., & McDonald, R. (1980). Clomipramine and exposure for obsessive-compulive rituals. British Journal of Psychiatry, 136, 1-25. Marks, I.M., Lelliott, P., Basoglu, M., Noshirvani, H., Monteiro, W., Cohen, D., & Kasvikis, Y. (1988). Clomipramine, self exposure and therapist-aided exposure for obsessive compulsive rituals. British Journal of Psychiatry, 152, 522-534. Mataix-Cols, D., Marks, I.M., Greist, J.H., Kobak, K.A., & Baer, L. (2002). Obsessive-compulsive symptom dimensions as predictors of compliance with and response to behaviour therapy: Results from a controlled trial. Psychotherapy and Psychosomatics, 71, 255-262. Mataix-Cols, D., Rauch, S.L., Manzo, P.A., Jenike, M.A., & Baer, L. (1999). Use of factor-analyzed symptom dimensions to predict outcome with serotonin reuptake inhibitors and placebo in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 156, 1409-1416. McLean, P.D., Whittal, M.L., Thordarson, D.S., Taylor, S., Söchting, I., Koch, W.J., Paterson, R., & Anderson, K.W. (2001). Cognitive versus behavior therapy in the group treatment of obsessivecompulsive disorder. Journal of Clinical and Consulting Psychology, 69. 205-214. Mehta, M. (1990). A comparative study of family-based and patient-based behavioral management in obsessive-compulsive disorder. British Journal of Psychiatry, 157, 133-135. Mundo, E., Maina, G., & Uslenghi, C. (2000). Multicentre, double-blind comparison of fluvoxamine and clomipramine in the treatment of obsessive-compulsive disorder. International Clinical Psychopharmacology, 15, 69-76. Obsessive Compulsive Cognitions Working Group. (1997). Cognitive assessment of obsessivecompulsive disorder. Behaviour Research and Therapy, 35, 667-681. Obsessive Compulsive Cognitions Working Group (2001). Development and initial validation of the Obsessive Beliefs Questionnaire and the Interpretation of Intrusions Inventory. Behaviour Research and Therapy, 39, 987-1006. Osgood-Hynes, D., Riemann, B., & Björgvinsson, T. (2003). Short-term residential treatment for obsessive compulsive disorder. Brief Treatment and Crisis Intervention. Pato, M., Zohar-Kadouch, R.., Zohar, J., & Murphy, D. (1988). Return of symptoms after discontinuation of clomirparmine in patients with obsessive compulsive disorder. American Journal of Psychiatry, 145, 1521-1525. Piacentini, J., Jacobs, C., Bergman, R.L. et al. (2001). Cognitive behavior therapy for childhood obsessive-compulsive disorder: Efficacy and predictors of treatment response. Journal of the American Academy of Child and Adolescent Psychiatry. Pigott, T.A., & Seay, S.M. (1999). A review of the efficacy of selective serotonin reuptake inhibitors in obsessive-compulsive disorder. Journal of Clinical Psychiatry, 60, 101-106. Rachman, S. (1997). A cognitive theory of obsessions. Behaviour Research and Therapy, 16, 233-248. Salkovskis, P.M. (1989). Cognitive-behavioral factors and the persistence of intrusive thoughts in obsessional problems. Behaviour Research and Therapy, 27, 677-682. Steketee, G. (1993). Social support as a predictor of follow-up outcome following treatment for OCD. Journal of Behavioural Psychotherapy, 21, 81-95. Steketee, G. (1999). Overcoming compulsive disorder: Behavioral and cognitive therapy. Therapist manual and Patient manual. Oakland, CA: New Harbinger Press. Steketee, G., & Frost, R.O. (1998). Obsessive-compulsive disorder. In A.S. Bellack & M. Hersen (Eds.), Comprehensive clinical psychology, Vol 6. Adults: Clinical formulation and treatment. Oxford: Pergamon. Van Balkom, A.J.L.M., van Oppen, P., Vermeulen, A.W.A., van Dyck, R., Nauta, M.C.E., & Vorst, H.C.M. (1994). A meta-analysis on the treatment of obsessive-compulsive disorder: A comparison of antidepressants, behavior, and cognitive therapy. Clinical Psychology Review, 14, 359-381. Van Noppen, B. (2003) Functioning in adults with obsessive compulsive disorder and family responses: A transactional perspective. Unpublished dissertation. Van Noppen, B., Steketee, G., McCorkle, B.H., & Pato, M. (1997). Group and multifamily behavioral treatment for OCD: A pilot study. Journal of Anxiety Disorders, 11, 431-446. Van Oppen, P., de Haan, E., van Balkom, A., Spinhoven, P., Hoogduin, K., & van Dyck, R. (1995). Cognitive therapy and exposure in vivo in the treatment of obsessive compulsive disorder. Research and Therapy, 4, 379-390. Waters, T.L., Barrett, P.M, & March, J.S. (2001). Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: Preliminary findings. American Journal of Psychotherapy, 55, 372-387. 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. © 2002 American Association for Marriage and Family Therapy • 112 South Alfred Street, Alexandria, VA 22314-3061 Phone: (703) 838-9808 • Fax: (703) 838-9805