Download Running head (Short Title): OCD and cognitive behavioural therapy

Running head (Short Title): OCD and cognitive behavioural therapy
Article Type: Extended report for Brief Clinical Reports
COGNITIVE BEHAVIOURAL THERAPY FOR OBSESSIVE COMPULSIVE SYMPTOMS
AFFECTED BY PAST PSYCHOTIC EXPERIENCE OF SCHIZOPHRENIA: A CASE REPORT.
Osamu Kobori*, Hirotoshi Sato**, Rieko Katsukura***, and Seiichi Harada***
*
Institute of Psychiatry, King’s College London
**
National Centre for Neurology and Psychiatry
***
Tokyo Institution of Cognitive Behavioural Therapy, Harada Mental Clinic
*
Correspondence concerning this article should be addressed to Osamu Kobori, Department of Psychology,
Po Box 077, Institute of Psychiatry, King’s College London, De Crespigny Park, Denmark Hill, London
SE5 8AF, UK. Email: [email protected], Tel.: 020 7848 0665; fax 020 7848 5037.
Abstract
Obsessive-compulsive symptoms (OCS) have been observed in a substantial proportion of patients with
schizophrenia. Although several studies have investigated the comorbidity associated with OCS in
schizophrenia, few case studies are available regarding cognitive behavioural therapy (CBT) for the
treatment of OCS of patients with this group. This paper describes a case report in which OCS emerged
gradually after the remission of positive symptoms. The CBT involved psycho education and case
formulation, cognitive restructuring, exposure and response prevention (EPR), and behavioural
experiments. Improvement in the compulsive behaviours led to greater insight regarding the relationship
between OCS and past experience of positive symptoms (e.g. hallucination). The cognitive characteristics
of the patient were discussed in light of current cognitive models of OCD.
Keywords: Obsessive-compulsive disorder, schizophrenia, cognitive behavioural therapy
Introduction
Obsessive-compulsive symptoms (OCS) have been observed in a substantial proportion of patients
with schizophrenia. The awareness regarding an association between OCS and schizophrenia dates back
more than a century. Cross-sectional studies have reported widely varying rates of comorbid OCS in
schizophrenia patients (see review of Byerly, Goodman, Acholonu, Bugno, & Rush, 2005; Öngür & Goff,
2005; Poyurovsky, Weizman & Weizman, 2004). Although studies have varied with regard to the
methodologies and sample selection, one-third of the patients with schizophrenia manifest OCS, and
10%–25% of patients with schizophrenia fulfil the diagnostic criteria for obsessive-compulsive disorder
(Cosoff & Hafner, 1998; Eisen, Beer, Pato, Venditto, &, Rasmussen, 1997; Krüger, Bräunig, Höffler,
Shugar, Börner, & Langkrär, 2000; Ohta, Kokai, & Morita, 2003. Tibbo, Kroetsch, Chue, & Warneke,
2000).
Initially, OCS were considered as positive prognostic indicators that protected the patients with
schizophrenia against ‘personality disintegration’ and ‘malignant schizophrenic course’ (Rosen, 1956;
Stengel, 1945). However, several studies have observed that patients with schizophrenia with OCS may
exhibit more positive and negative symptoms (e.g. Lysaker, Bryson, Marks, Greig & Bell, 2002; Nechmad,
Ratzoni, Poyurovsky, Meged, Avidan, Fuchs et al., 2003), poorer cognitive function (Lysaker, Marks,
Picone, Rollins, Fastenau, & Bond, 2000), and suicidal attempts and ideations (Sevincok, Akoglu & Kokcu,
2007) when compared with other patients with schizophrenia.
It has been suggested that these patients may have a subtype of schizophrenia with distinct
psychophysiology, treatment response, and clinical course (Berman, Chang & Klegon, 1999; Poyurovsky,
Weizman & Weizman, 2004). However, with the exception of one study (Peasley-Miklus, Massie, Baslett
and Carmin, 2005), few case reports are available regarding the use of cognitive behavioural therapy (CBT)
for the treatment of OCS in patients with schizophrenia. The present study shows a case study involving the
application of CBT for OCS which was gradually developed after the remission of positive symptoms. We
employed CBT since the patient did not improve in OCS through medication. CBT involved a 50-minute
individual therapy including the measurement. Nineteen sessions were conducted on a weekly basis and
within hospital premises (National Centre of Neurology and Psychiatry in Japan), and as standard in CBT
between-session homework was collaboratively designed.
Case Presentation
Patient Profile
The patient was a 26-year-old male who developed schizophrenia when he was 20 years old. In
the acute phase, he was not only seeing things and hearing voices but he also had insertion of thoughts. As
his positive symptoms improved through medications, checking compulsions gradually emerged. In
addition to repeated checking, he sought reassurance from his mother. He was living with his parents, and
his obsessive-compulsive problem had prevented him from holding on to a job or attending school and
community programs (e.g. day-care centre).
He was on the following medication: fluvoxamine (150mg), lorazepam (1.5mg), risperidone
(2mg), and quetiapine (100mg). The prescription was at a stable dose prior to and throughout CBT
sessions.
Psycho-education of the CBT model of OCD and formulation
The patient was first given the psycho-education as to cognitive behavioural theory and model for
OCD. He was given the following explanations: Most of us experience thoughts such as his, and such
thoughts are called intrusive thoughts. These thoughts usually fade away as time goes by. However, these
thoughts become distressing and repetitive due to the meaning people attach to them. People with OCD
engage in rituals or compulsions to reduce their negative feelings. However, such behaviours reinforce the
way people think.
Next, he was asked to make a list of things which took much of his time. He listed situations such
as:
1
Checking whether the tap is turned off properly.
2
Checking whether the door of the fridge is fully closed.
3
Checking whether the cap of the plastic bottle is fully closed.
4
Checking whether the cap of the electric shaver is on.
5
Checking whether the towel is falling off the towel bar.
6
Checking whether things are falling off the table.
7
Checking whether something has been left on the table or floor.
Finally, both the therapist and the patient collaboratively developed his case formulation based on
his experience. That is, when he experienced intrusive thoughts such as ‘I’m not sure that things were
completed or done’, his beliefs (overestimation of that and intolerance of uncertainty) were activated, and
he interpreted that it is very bad and unbearable to leave things uncertain. This interpretation led him to
discomfort, checking, and reassurance seeking. These behaviours in turn reinforced his beliefs, depriving
him of disconfirmation.
Measurement
Yale-Brown Obsessive Compulsive Scale (YBOCS; Goodman, Price, Rasmussen, & Mazure,
Fleischmann, Hill et al., 1989) was used to measure OCD symptoms. The Y-BOCS is generally
acknowledged as being the gold standard for rating obsessive–compulsive symptomatology. It is a
clinician-administered semi-structured interview that contains 16 core items scored on a five-step Likert
scale (0–4, higher scores indicate greater disturbance). The total score is computed from the first 10 items
(without items 1b and 6b). While items 1 to 5 represent obsession-related dysfunctions, items 6 to 10
measure disturbances associated with compulsions.
We did not use other OCD related scales such as Obsessive Compulsive Inventory (Foa, Kozak,
Salkovskis, Coles, & Amir, 1998), Responsibility Attitude Scale (Salkovskis, Wroe, Gledhill, Morrison,
Forrester, Richards, et al., 2000), or Beck Anxiety Inventory (Beck, 1987), because standardised versions
of these scales are not available in Japanese.
Cognitive restructuring and behavioural experiment
Cognitive restructuring and behavioural experiments were applied to situations which took much
of his time, and exposure and response prevention was collaboratively designed as homework in-between
sessions. This study presents several situations in detail.
Tap. When he felt a strong urge to check the tap repeatedly, he typically interpreted the situation in
the following way:
(1) He felt uncertain whether the tap was turned off adequately.
(2) He thought that the sink would be filled with water and that the water would overflow onto the
floor.
(3) He also thought that running water would cost a lot of money overnight.
In order to challenge his beliefs (i.e., need for certainty and overestimation of danger), we
examined the probability and awfulness of his worry through discussion and behavioural experiment.
Since he did not know how the tap closes, we first drew the picture of a tap in order to illustrate
how it turns off. He understood that the tap does not turn on by itself once it is closed, and that little water
would flow when the tap was not turned adequately. Next, we moved on to the behavioural experiment in
which we went to the sink, left the tap open, and examined if the water overflows onto the floor. Finally, he
was instructed to leave the tap slightly on as if it was left on accidentally, and the water was collected into a
vessel. We measured the total quantity of water in the vessel, and estimated the overnight cost of wasting
water. These behavioural experiments led him to alternative explanations:
(1) Water would never overflow onto the floor.
(2) It would not cost a fortune even if he accidentally left the tap slightly on.
(3) He need not check the tap repeatedly.
Door and cap. When he felt a strong urge to check the door of the fridge, he typically employed the
following interpretation and reassurance seeking behaviour:
(1) He felt uncertain whether the door was properly closed, which he considered unbearable.
(2) He thought it would be very bad to leave the door open.
(3) He repeatedly slammed the door so that he could hear the closing sound.
He generalised these neutralization strategies to other situations. For example, he repeatedly
slammed doors and windows so that he could hear the loud sound. While closing the cap of plastic bottles,
he kept turning the cap until his hand hurt. We termed this strategy as the ‘amplified sensations strategy’. In
addition to these self-reassurances, he also sought reassurance from his mother.
In order to challenge his beliefs, we examined the probability and awfulness of his worry through
discussion and behavioural experiment. Firstly, we discussed how doors and caps close. Since he did not
know how the door closes, we brought paper clips close to the door of the fridge to show that the clips stick
to the door. The patient learned that the inside of a fridge has a magnet that causes the door to close even if
it is left slightly open. He also learned that the door never opens by itself once it is closed. Next, we
demonstrated that if the cap is turned adequately, it will not unscrew because both the cap and the bottle
have spiral grooves. He also learned that when we swing the bottle, the cap would not come out even if the
cap is not turned adequately. These practical demonstrations led him to alternative explanations:
(1) Doors and caps never open once they are closed.
(2) It would not be bad even if doors and caps are slightly open.
(3) There was no need to employ the ‘amplified sensations strategy’ and seek reassurance from his
mother.
Things on the table. With regard to his worry that things might fall off the table, we gave him a
basic lecture on physics (e.g. gravity, friction) to illustrate how things remained in their original position,
and that they would not move without the application of an external power. The patient learned how
unlikely it is that things fall down and even if they do it is not disastrous. The similar discussion was applied
to his concern that the towel might fall off the towel bar.
When we asked the patient how he felt that something is left on the table, he told us that he felt as
though something like a marble could have been left on the table. Then, he remembered that he had seen
something twinkling, and he had had strange thought insertions during the acute phase of schizophrenia. He
believed that these experiences made him less confident about his perception, judgment, and memory. Then
we added the relationship between his past psychotic episode and his belief (need for certainty) to his
formulation.
In order to examine his perception, judgement, and memory, the therapists customised and
performed simple visual tests and calculations to prove that his perceptions, judgment, and memory were
not impaired. This insight led him to better understanding of his obsessive-compulsive problem, and it
seemed to the therapist that the patient’s strong desire for certainty had been modified.
Result
Over a period of 18 sessions, the patient’s Y-BOCS score decreased from 31 to 11. There was no
deterioration with regard to schizophrenia and OCD symptoms during the CBT sessions; for 2 years since
then, he has had no relapse.
Discussion
The present study showed a case study of CBT for treatment of OCS which was gradually
developed after the remission of positive symptoms of schizophrenia. We firstly discuss how his symptoms
were improved. Next, we discuss the cognitive characteristics of the patient in light of current cognitive
models of OCD. Finally, the limitations of this study are presented.
The cognitive restructuring and behavioural experiments were intended to challenge his beliefs;
intolerance of uncertainty and overestimation of threat. His beliefs were modified through examination of
how likely his worry would happen (probability) and how awful if it happens (awfulness). That is, he
learned that it would not be unbearable and very bad if things are remain uncertain. As a result, his intrusive
thoughts were no longer distressing and repetitive, and there was no need for him to check and seek
reassurance from his mother and from himself. In addition, CBT led the patient to have greater insight into
the relationship between OCS and his past experience of positive symptoms of schizophrenia. This insight
was helpful for both therapists and the patient to work on his problem more effectively.
Through cognitive restructuring and behavioural experiments, therapists provided some
information to the patient so that he knew how things close or remain closed. He was unaware of most of the
information provided to him, and he swiftly learned to use this information to examine how he interpreted
intrusive thoughts. It seemed to the therapists that most of the information was new to him possibly due to
the ‘lack of real world knowledge’ (Kingdon & Turkingdon, 1994). Some patients with schizophrenia can
be deprived of certain life knowledge or experience because of the long hospitalization and withdrawal
from daily routine. That is, they miss the chance to know something they would otherwise learn through
day–to-day living. It would be helpful for clinicians to consider the possibility that their patients may not
know something they are supposed to know, particularly when they work with patients with a long history
of hospitalization. On the other hand, careful attention needs to be given so as not to provide reassurance,
when patients become anxious and repeatedly ask the same question in order to confirm what they already
know.
Memory phenomena associated with OCD have received much attention in the recent literature.
For example, it is argued that typical OCD patients report less confidence with regard to their memory, and
they need increased information before comfortably making a decision (e.g. Foa, Mathews, Abramowitz,
Amir, Przeworski, Riggs, et al., 2003; MacDonald, Antony, MacLeod, & Richter 1997). It is also proposed
that the more they check, the less vivid and detailed the memory becomes (Radomsky, Gilchrist, &
Dussault, 2006; Van den Hout & Kindt, 2003, 2004), as quality of the memory changes from something
more episodic (i.e., ‘remembering’) to something more semantic (i.e., ‘knowing’). Consistent with these
models, it seemed to us that the patient of this study looked uncertain about his memory (e.g., things are
closed), and repeated checking decreased the vividness and detail of his memory. However, his decreased
confidence with regard to his perceptions, judgement, and memory was also caused by the experience of
positive symptoms of schizophrenia, suggesting the possibility that his memory itself might have been
impaired during the acute phase of schizophrenia. Therefore, the visual test and calculations needed to be
performed to prove his cognitive functions were recovered. Otherwise he would have been unsure of his
memory, even if he stopped checking and his memory remained vivid and detailed. It would be helpful for
clinicians to pay attention to how poor memory confidence was being caused, particularly when they work
on patients who have/had positive symptoms of schizophrenia. However, we need to be careful to perform
such visual test and calculations since it can be used as a reassurance if the memory of the patient is normal.
It would be of interest to discuss this case study with reference to the elevated evidence
requirement model (EER; Wahl & Salkovskis, 2008). According to the EER model, patients with OCD use
greater numbers of criteria in the decision to stop their actions (e.g., washing & checking). It is also
predicted that patients with OCD consider subjective criteria (e.g., feeling ‘just right’ or satisfied) as more
important than objective criteria (e.g., whether the door looks as if it was locked). The patient of this study
repeatedly slammed doors and windows so that he could hear the loud sound, and kept turning the cap of the
bottle until he his hand hurt. This can be interpreted that he tried to use a greater number of objective criteria
until his subjective criteria (e.g., ‘just right’ feeling) were met. Additionally, he was trying to make sure that
objective criteria were certainly met by amplifying his sensory perception. This was particularly important
for him because of the decreased confidence in his perceptions, judgement, and memory.
The present study has certain limitations and several important future directions. First, since we
were unable to obtain the baseline data, it was not completely clear that the improvement was due to CBT.
Second, we were unable to obtain the data other than that of Y-BOCS. The rating of anxiety, depression and
faulty beliefs would be helpful for further understanding of the case. Next, since the study was limited to the
stable schizophrenia outpatient, an understanding regarding the obsessive-compulsive problems in the
acute phase of schizophrenia remain unclear. Finally, we employed weekly, individualized therapy;
therefore, the effectiveness of other treatment options such as group therapy or intensive treatment should
be examined. In conclusion, the present study shows a case study of CBT for treatment of
obsessive-compulsive problem affected by the past experience of positive symptom of schizophrenia.
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