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Transcript
Obsessive-Compulsive Disorder Lecture Overview • • • • • • Nature and epidemiology Etiology Empirically-supported treatments Efficacy data Moderator variables Class discussion Epidemiology of OCD • • • • Defining features Prevalence Onset and course Associated features/comorbidity Associated Disorders • • • • • Depression Other anxiety disorders Sleep disturbance Eating disorders Tourette’s disorder and motor tics Classification of Obsessions (Jenike et al. 1986) • • • • • Contamination (55%) Concerns of harming self or others (50%) Sexual concerns (32%) Somatic concerns (35%) Symmetry concerns (37%) Classification of Compulsions • • • • • • • • Cleaning or washing Checking Counting Repeating Neutralizing thoughts Obsessional Slowness* Touching* Phobic avoidance* Functional Classification (Foa et al, 1985) • Internal fear cues • External fear cues • Fears of harm or disastrous consequences 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. Empirically-Supported Psychosocial Treatments • Psychosocial Treatments – Exposure and Response Prevention (ERP) – Cognitive Therapy • Combined Medications + ERP 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.) • • • • • • • Obtaining info on OCD symptoms History of the problem Defining the disorder Rationale for treatment Overview of treatment Program Teaching patients to Monitor symptoms Taking a general history Procedural Overview of Foa ERP Treatment Protocol Cont. • Information Gathering Phase (2 sessions) – Session 2 (2 hrs.) • • • • • • • 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 • • • • 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 Moderators of Treatment Outcome • • • • • • • Personality disorders Pretreatment OCD severity Pretreatment depression Outcome expectancies Compliance with treatment Strength of belief in harm Comorbid tic disorders* 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.