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Obsessive-Compulsive Disorder
Lecture Overview
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Nature and epidemiology
Etiology
Empirically-supported treatments
Efficacy data
Moderator variables
Class discussion
Defining Features: Obsessions
Defining Features:Compulsions
Defining Features:Compulsions
Epidemiology of OCD
• 2.5% lifetime prevalence
• Prevalence is similar for men and women
• Onset occurs typically occurs during
adolescence or early adulthood
• Onset is earlier for males than females
• Tends to be chronic without treatment
with periods of waxing and waning of
symptoms
Associated Disorders
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Depression
Other anxiety disorders
Sleep disturbance
Eating disorders
Tourette’s disorder and motor tics
Common Obsessions in OCD
Obsession
% of Sample (N = 182)
Aggressive
Contamination
Symmetry/exactness
68.7
57.7
53.2
Somatic
Hoarding/saving
Religious
Sexual
34.1
30.2
24.2
19.8
Misc.
55.5
Data from Antony et al., (1998).
Common Compulsions in OCD
Compulsion
% of Sample (N = 182)
Checking
Washing and cleaning
Repeating
80.7
63.7
55.5
Ordering/arranging
Counting
Hoarding
40.1
35.2
28.0
Misc.
59.3
Data from Antony et al., (1998).
Functional Classification
(Foa et al, 1985)
• Internal fear cues
• External fear cues
• Fears of harm or disastrous consequences
OCD Impairment & Costs
• Social impairment
– 62% reported difficulty maintaining a relationship
(Calvocoressi, et al., 1995)
– Instrumental role performance and social functioning more
impaired in OCD than general public, depressed, or diabetics.
(Koran, et al., 1996)
• Estimated annual medical costs: 8.2
billion
– Based on detailed analysis of direct treatment expenses,
comorbidity, and mortality (DuPont,, et al., 1995)
• Occupational impairment & lost wages
– 40% unemployed due to OC symptoms (Calvocoressi, et al.,
1995)
– Lifetime wages lost: $40 billion (Stein, et al., 1996)
Health Care Utilization and
OCD
• High utilization of dermatologist visits
relative to the general public or other
anxiety disorder groups (Kennedy &
Schwab, 1997)
• 15% of African Americans seen in
dermatologist offices had undiagnosed
OCD (Friedman et al., 1993)
Pharmacological Treatments
for OCD
• Clomipramine*
• SSRIs
• Fluoxetine
• Fluvoxamine*
• Sertraline
Multicenter Trial of Fluoxetine
40
Response Rate
35
30
25
20
15
10
5
0
Placebo
Fluoxetine -20 Fluoxetine -40 Fluoxetine -60
Data taken from Tollefson et al (1994). Archives of General Psychiatry, 51, 559-567
*NOTE: Response was defined as a 35% or more reduction in Y-BOCS scores.
Multicenter Trial of Fluoxetine
0
Change in Y-BOCS
-1
-2
-3
-4
-5
-6
-7
Placebo
Fluoxetine -20 Fluoxetine -40 Fluoxetine -60
Data taken from Tollefson et al (1994). Archives of General Psychiatry, 51, 559-567.
Treatment Effect Sizes from 4
Large Multi-Center RCTs
1.6
1.4
Effect Size
1.2
1
0.8
0.6
0.4
0.2
0
Clomipramine
N=520
Fluoxetine
Fluvoxamine
Sertraline
N=355
N=320
N=325
Data taken from Greist et al (1995). Archives of General Psychiatry, 52: 53-60. Effect size calculated
from post differences between treatment and placebo
Treatment Response Rate from 4
Large Multi-Center RCTs
Treatment Response Rate
60
50
40
30
20
10
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Clomipramine
N=520
Fluoxetine
N=355
Fluvoxamine
N=320
Data taken from Greist et al (1995). Archives of General Psychiatry, 52: 53-60.
Sertraline
N=325
Relapse Rates Following
Discontinuation of Medication
% of Patients who Relapse
100
80
60
40
20
0
Clomipramine
Fluoxetine
Data taken from Ravizza et al., 1996. Psychopharmacol Bull, 32: 167-73.
Fluvoxamine
Empirically-Supported
Psychosocial Treatments
• Psychosocial Treatments
– Exposure and Response Prevention (ERP)
– Cognitive Therapy
Rationale for Investigating NonDrug Alternatives
• Limited proportion of patients who show
clinical benefit
• Level of residual symptoms among
treatment responders
• Troublesome side effects
• Extremely high relapse rates
• Role of psychological factors in OCD
Psychological Factors
Implicated in OCD
• Cognitive appraisal of intrusive thoughts
(Salkovskis, 1985; Rachman, 1997)
– Overestimation of danger
– Inflated personal responsibility
– Thought-action fusion
• Thought-suppression (Wegner et al, 1987)
• Cognitive deficits in selective attention
Deficits in inhibiting irrelevant stimuli (particularly internal ones
such as intrusive thoughts) (Clayton et al, 1999)
Procedural Overview of Foa
ERP Treatment Protocol
• Information Gathering Phase (2
sessions)
– Session 1 (2 hrs.)
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Obtaining info on OCD symptoms
History of the problem
Defining the disorder
Rationale for treatment
Overview of treatment Program
Teaching patients to Monitor symptoms
Procedural Overview of Foa
ERP Treatment Protocol Cont.
• Information Gathering Phase (2 sessions)
– Session 2 (2 hrs.)
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Inspection of patient’s self-monitoring
Collecting information about obsessions and compulsions
Generating the treatment plan
Rules for selection of exposure situations
Develop clear contract between therapist and patient
Teaching patients to Monitor symptoms
Homework assignment
Important Areas of OC
Assessment
• Obsessions
– external fear cues
– internal cues
– consequences of external and internal cues
• Avoidance Patterns
– Passive avoidance
– Rituals
– Relationship between avoidance patterns and fear
cues
Procedural Overview of Foa
ERP Treatment Protocol Cont.
• Treatment Phase (15 daily sessions, 120 min. each)
– Format of exposure session
– Implementation of exposure
– Homework assignments
– Comments during exposure sessions
– Response prevention
• Rules
• Return to normal behavior
– Common difficulties during sessions
Examples of In Vivo Exposure
Component
• For Washer
– Session 1: walk with therapist through the building touching
doorknobs, holding each for several minutes
– Session 2: Repeat above and add contact with sweat by having
patient touch armpit and inside of shoe
– Session 3: Repeat above but introduce having patient touch
toilet seats
– Session 4: Repeat above but introduce urine by having patient
hold a paper towel dampened in his own urine
– Session 5: Repeat above but introduce fecal material by having
patient hold toilet paper lightly soiled with his own fecal
material
– Sessions 6-15 Daily exposure to the three most fear-provoking
activities are repeated.
Examples of In Vivo Exposure
Component
• For Checker
– Session 1: turn the lights on and off once, turn stove on and off
once, open and close doors once (leave room immediately
without checking)
– Session 2: Repeat above and add flushing of toilet without
looking in the bowl
– Session 3: Repeat above but introduce opening gate to the
basement and allowing daughter to play near the gate
– Session 4: Repeat above but introduce carrying daughter on
concrete floor
– Session 5: Repeat above but introduce driving on highway
without retracing route
– Sessions 6-15 Daily exposure to the three most fear-provoking
activities are repeated.
Rules for Response Prevention
Washer
• Patients not permitted to use water on their body
• Bath powder and deodorants are permitted unless they
reduce contamination concerns
• Shaving is done by electric shaver
• Supervised showers occur every 3 days for 10-min.
• Ritualistic washing of certain areas of the body is prohibited
• Family members supervise adherence to rules while patient
is home
• Violations are reported to therapist
• In the last few sessions, response prevention requirements
are relaxed to permit normal washing
Rules for Response Prevention
Checker
• No ritualistic checking is permitted
• One check (normal checking) is permitted
• Designated relative or friend supervises response
prevention adherence at home
• Therapist/supervisor is to stay with patient until urge
to check diminishes
• Violations of home practice are reported to therapist
Guidelines for Constructing
Imaginal Exposure Scenes
• Imaginal sessions should be approximately
45 min. in duration;
• Present approximately six scenes of
gradually increasing anxiety evoking
potential;
• Include external stimuli and
internal/cognitive or physiological responses
in the feared scene.
Common Difficulties During
ERP
• Non-compliance with response prevention instructions
• Continued passive avoidance
• Arguing/balking about exposure/response prevention
requirements
• Emotional overload
• Family reactions
Summary of Outcome for ERP
(Foa et al, in press)
• Reviewed 18 studies of ERP
• 83% response rate at posttreatment
• 76% response rate at follow-up (Mean 9
months)
• Mean symptom reduction was 46% at
posttreatment
Limitations of ExposureResponse Prevention for OCD
• Substantial treatment refusal rate
• Difficulty in transporting ERP to centers
that do not specialize in OCD (low
generalizability);
• Low credibility of ERP among
psychiatrists
Limitations of Combined
Treatment Studies for OCD
• Fails to provide a conclusive comparison of
the relative short and long-term effects of
the individual monotherapies;
• Fail to adequately examine whether
combined treatment is superior to either
drug or ERP administered alone
• Fail to adequately examine relapse and the
potential for ERP to reduce relapse
NIMH Multicenter Study
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Sites
Design
Strengths
Results
NIMH Multicenter Study
Results
Outcome
PBO
CMI
BT
CMI+BT
YBOCS
(Comp)
YBOCS
(ITT)
Response
Rate
(Comp)
Response
Rate
(ITT)
23.1
18.19
12.68
11.68
23.22
19.11
15.29
13.30
6.3
50.0
84.6
71.4
5.0
39.1
61.1
45.5
Multi-Site OCD
Acute Treatment Response
100
% of patients
80
60
40
20
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Intent-to-Treat
Completers
Placebo
CMI
ERP
CMI + ERP
5
6.3
39.1
50
61.1
84.6
45.5
71.4
Data taken from Kozak, Liebowitz, & Foa (2000). “Cognitive Behavior Therapy and Pharmacotherapy
for Obsessive-Compulsive Disorder: The NIMH-Sponsored Collaborative Study. In OsessiveCompulsive Disorder: Contemporary Issues in Treatment; ed by Irving Weiner.
Multi-Site OCD
Relapse at Follow-up
100
% of Patients
80
60
40
20
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Relapse %
CMI
ERP
CMI + ERP
87.5
0
10
Data taken from Kozak, Liebowitz, & Foa (2000). “Cognitive Behavior Therapy and Pharmacotherapy
for Obsessive-Compulsive Disorder: The NIMH-Sponsored Collaborative Study. In OsessiveCompulsive Disorder: Contemporary Issues in Treatment; ed by Irving Weiner.
Moderators of Treatment
Outcome
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Personality disorders
Pretreatment OCD severity
Pretreatment depression
Outcome expectancies
Compliance with treatment
Strength of belief in harm
Comorbid tic disorders*
Do the Effects of ERP
Generalize to the Real World?
Sample
Y-BOCS
(pre-post
effect size)
CTSA Outpatients
3.26
Kozak et al. (2000)
2.31
Lindsay et al. (1997)
3.88
Data taken from Franklin, et al. (2000). Journal of Consulting and Clinical Psychology, 68 (4), 594-602
Cognitive Therapy of OCD
Cognitive Factors in OCD
• Overestimation of the importance of
thoughts
– Distorted thinking
– Thought-action fusion
– Magical thinking
Cognitive Factors in OCD
• Responsibility
• Perfectionism
– Need for certainty
– Need to know
– Need for control
Cognitive Factors in OCD
• Overinterpretation of threat
• Consequences of anxiety
– Anxiety is dangerous
– Anxiety will prevent me from functioning
Empirical Support for Cognitive
Interventions
• LaDouceur et al (1996)
• Van Oppen et al (1995)
Comparison Trial of ERP and
Cognitive Therapy
80
60
40
ERP
CT
20
0
ERP
CT
Responder
Recovered
66
75
28
50
Data taken from Van Oppen et al (1995) Behaviour Research and Therapy, 33, 379-390.