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Brief treatment 3:2Overview of Treatments for Obsessive-
Compulsive Disorder and Spectrum
Theory, and Practice
Nicholas Maltby, PhD
David F. Tolin, PhD
This paper presents an overview of obsessive-compulsive disorder (OCD) and theobsessive-compulsive spectrum disorders (OCSDs) by outlining the major arguments for and against the spectrum construct. Cognitive, behavioral, and biological models are reviewed, as are assessment strategies for adults and children. Treatment options forOCD are critically evaluated, and it is argued that exposure and ritual prevention (ERP)has the best support as the first-line psychological treatment. Suggestions forovercoming the most common obstacles faced during treatment are provided. Inaddition, strategies for dealing with partial or nonresponse or treatment refusal arediscussed. Stepped-care models are presented as a potential method of addressing theproblems caused by the expense and time commitment of existing treatments. [BriefTreatment and Crisis Intervention 3:127–144 (2003)] KEY WORDS: obsessive-compulsive disorder, obsessive-compulsive spectrum, reviews, cognitive-behavioral therapy, pharmacotherapy.
Obsessive-compulsive disorder (OCD) is a chro- sion, and alcohol abuse). OCD often severely dis- nic anxiety disorder, marked by recurrent, in- rupts social and vocational functioning (Leon, trusive, and distressing thoughts (obsessions) Portera, & Weissman, 1995), and it is associated and/or repetitive behaviors (compulsions). Epi- with a fourfold risk of unemployment (Koran, demiological data suggest a 6-month prevalence Thienemann, & Davenport, 1996). Family func- of 1–2% (Myers et al., 1984) and a lifetime tioning is usually impaired, due in part to the prevalence of 2–3% (Robins et al., 1984), mak- large burden assumed by spouses and parents ing OCD the world’s fourth most common men- (Amir, Freshman, & Foa, 2000; Calvocoressi et tal disorder (exceeded only by phobias, depres- al., 1995). Age of onset is typically early, be-tween 10 and 23 years (Rasmussen & Tsuang,1986), and the disorder is usually chronic. Be- From the Anxiety Disorders Center at The Institute of Livingin Hartford, CT.
cause of OCD’s high prevalence and because of Contact author: Nicholas Maltby, PhD, Anxiety Disorders the chronic, debilitating nature of its symptoms, Center, The Institute of Living, 200 Retreat Avenue, Hart- ford, CT 06106. Phone: (860) 545-7685. Fax: (860) 545-7156. E-mail: firstname.lastname@example.org.
among the top 10 causes of years lived with illness-related disability (Murray & Lopez, 1996).
The symptoms of OCD tend to cluster into rec- from obsessions by their function. Obsessions ognizable subtypes. Checking and washing are elicit anxiety, while compulsions either reduce the most common and together account for over anxiety or are completed to stave oﬀ a perceived 50% of OCD cases (Foa et al., 1995; Mataix-Cols, consequence. It is very rare for an OCD patient Baer, Rauch, & Jenike, 2000). Other common not to engage in ritualizing; 99.8% of OCD pa- subtypes include doubting, mental ritualizing, tients describe either mixed behavioral and ordering, hoarding, and scrupulosity (Foa, Ko- mental compulsions, or behavioral compulsions zak, Salkovskis, Coles, & Amir, 1998). A num- only (Foa et al., 1995). Thus, the presence of ber of studies have attempted to empirically de- covert rituals should be routinely assessed, es- rive OCD subtypes by applying factor analysis pecially in the absence of overt compulsions.
to the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) symptom checklist (Goodman, Price,Rasmussen, Mazure, Delgado, et al., 1989; OCD Spectrum Disorders
Goodman, Price, Rasmussen, Mazure, Fleisch-mann, et al., 1989). These studies yield from Although obsessions and compulsions are the three to five factors with a high degree of con- defining criteria for OCD, these symptoms are sensus across studies. All studies identified a also present in a number of other disorders. For contamination/cleaning factor, and all studies example, body dysmorphic disorder, Tourette’s with four or more factors identified obsessions/ syndrome, and trichotillomania all involve in- checking, symmetry/ordering, and hoarding as trusive or repetitive thoughts or behaviors. Be- factors (Leckman et al., 1997; Mataix-Cols, cause of the phenomenological overlap of these Rauch, Manzo, Jenike, & Baer, 1999; Summer- disorders with OCD, as well as their apparent pre- feldt, Richter, Antony, & Swinson, 1999).
ferential response to serotonergic medications, Mataix-Cols and colleagues (1999) added an ad- researchers have proposed grouping these disor- ditional factor, sexual/religious obsessions, in ders together into a category called obsessive- their five-factor solution, while Baer’s (1994) compulsive spectrum disorders (OCSDs). It has three-factor solution combined symmetry and been argued that the OCSDs aﬀect as many as hoarding into one factor and added another fac- 10% of the U.S. population and cause significant tor, “pure obsessions,” that may be consistent economic burden, as well as disruptions in qual- with the obsessions/checking factor in other ity of life (Hollander et al., 1996).
studies. Thus, factor-analytic studies are gener- One conceptualization places OCSDs along a ally consistent in identifying at least four core continuum from “compulsive” to “impulsive” subtypes of OCD: washing, checking, ordering, (Hollander et al., 1996). The “compulsive” end of the spectrum is characterized by harm– avoidant rituals and includes OCD, hypochon- the prevalence of patients classified as being driasis, restrictive anorexia, and body dysmor- “purely” obsessional, without any compul- phic disorder (McElroy, Phillips, & Keck, 1994).
sions. This notion may be an artifact of early def- The “impulsive” end of the spectrum is char- initions of OCD, which maintained that obses- acterized by self-damaging behaviors and in- sions were mental events and that compulsions cludes trichotillomania, compulsive gambling, were overt behaviors. However, current theories Tourette’s syndrome, bulimia nervosa, klep- recognize that compulsions can be either actions tomania, and impulsive personality disorders or thoughts. Mental compulsions (e.g., mental (McElroy et al., 1994). Another conceptualization review, counting, praying) are diﬀerentiated places disorders along a motoric/obsessional di- Brief Treatment and Crisis Intervention / 3:2 Summer 2003
mension. Motoric disorders involve repetitive orate on specific OCSDs and their relationship behaviors without obsessions (e.g., Tourette’s disorder). Obsessional disorders reflect the in-verse pattern of obsessions without repetitivebehaviors (Hollander & Wong, 2000).
Models of OCD
versy over the degree to which they reflect ei- Behavioral
ther a more unified disorder or many distinctdisorders. Patients with OCD frequently present Behavioral models of OCD (e.g., Kozak & Foa, with symptoms of more than one subtype (Ras- 1997) posit that compulsive behaviors are a form mussen & Eisen, 1988), suggesting a more uni- of avoidance that maintain obsessive fears via fied solution. However, that some subtypes of negative reinforcement (anxiety reduction) and OCD appear to respond diﬀerentially to diﬀerent by blocking opportunities for habituation to treatments (Buchanan, Meng, & Marks, 1996; feared objects and situations. Indeed, labora- Jenike, Baer, Minichiello, Rauch, & Buttolph, tory studies show that exposure to feared stim- 1997; Lelliott, Noshirvani, Basoglu, Marks, & uli increased patients’ anxiety, whereas per- Monteiro, 1988; Rachman, 1980) suggests that forming compulsions led to decreased anxiety they may be distinct disorders. Similarly, critics (Hodgson & Rachman, 1972). Some individuals argue that the concept of the OCD spectrum is with OCD, generally checkers, do report in- predicated mainly on superficial similarities in creased fear after performing compulsions surface topography, selective interpretation of (Roper, Rachman, & Hodgson, 1973); however, medication response data, and misinterpreta- mildly anxiety-evoking behaviors might be con- tion of relatively sparse and inconsistent neuro- sidered as avoidance behaviors if they serve to imaging data. Behaviors that resemble each prevent the occurrence of strong anxiety (Herrn- other, they argue, may not represent the same stein, 1969). Thus, while checking the stove may illness, and impulsive behaviors do not serve the elicit anxiety in some patients, refraining from same neutralizing function as do compulsions checking the stove is perceived as an even more (Abramowitz & Houts, in press; Tolin & Foa, anxiety-producing event because of the in- 2001). In addition, the spectrum concept could creased risk of an aversive event (e.g., the house become overinclusive. For example, the same burning down). In summary, the specific func- similarities used to relate Tourette’s syndrome to tion of compulsions may vary, but the general OCD have also been used to relate Tourette’s syn- function appears to be one of anxiety reduction drome to autistic spectrum disorders (Barnhill & Horrigan, 2002; Bejerot, Nylander, & Lind-strom, 2001). On the other hand, some of the Cognitive
spectrum disorders tend to respond to similarpharmacological and psychosocial treatments, Traditional cognitive models of psychopathol- and some demonstrate a functional relationship ogy have been “top-down”; that is, they empha- between mental and behavioral events that par- size the role of dysfunctional cognitions in the allels that of OCD; it is therefore suggested that etiology and maintenance of disorders (Beck, at least some OCSDs may be related to OCD. Ar- Emery, & Greenberg, 1985). According to such ticles by Steketee and Neziroglu, Stemberger, models, OCD is characterized by dysfunctional Stein, and Mansueto, and Deckersbach, Keu- assumptions, such as overestimation of threat, then, and Wilhelm in this special issue will elab- intolerance of uncertainty, importance of Brief Treatment and Crisis Intervention / 3:2 Summer 2003
thoughts, need to control thoughts, responsibil- serotonergic medications or a placebo. However, ity, and perfectionism (Obsessive Compulsive more direct tests of the serotonin hypothesis, Cognitions Working Group, 1997). Thus, OCD such as biological challenge studies, have been develops and is maintained as normal unpleas- inconclusive (Barr, Goodman, & Price, 1993; ant thoughts as being perceived as harmful, im- Barr, Goodman, Price, McDougle, & Charney, moral, or dangerous. Such beliefs are strength- 1992). Neuroimaging and neurosurgical evidence ened when neutralizing strategies lead to de- suggests that OCD is associated with hyper- creased anxiety, a factor that overlaps with the activity in frontal-striatal curcuits of the brain, behavioral model (Rachman, 1998; Salkovskis, which includes the orbitofrontal cortex, an- 1985). More recent models of psychopathology terior cingulate cortex (ACC), caudate nucleus, have been “bottom-up,” reflecting an emphasis and thalamus (Baxter, 1992; Breiter et al., 1996; not on beliefs but rather on the processes of Saxena & Rauch, 2000). The biological models of mental activity (Williams, Watts, MacLeod, & OCD are not wholly separate from cognitive- Mathews, 1997). Information-processing stud- behavioral models. Neurotransmitter activity, ies of OCD have shown that OCD is characterized regional metabolic actvity, behavioral reinforce- by an attentional bias toward threat cues (Foa, ment, maladaptive beliefs, and information- Ilai, McCarthy, Shoyer, & Murdock, 1993; Lavy, processing biases may be conceptualized as diﬀ- van Oppen, & van den Hout, 1994); increased erent ways of understanding OCD symptoms.
memory for, and impaired forgetting of, threat- Similarly, each of these systems might be thought related stimuli (Constans, Foa, Franklin, & to influence the others, rather than rely on a sin- Mathews, 1995; Radomsky & Rachman, 1999; gular direction of causality (e.g., biological ir- Tolin, Hamlin, & Foa, 2002; Wilhelm, McNally, regularities cause dysfunctional behaviors). As Baer, & Florin, 1996); decreased memory confi- an example of these complex interrelationships, dence (Constans et al., 1995; Tolin, Abramowitz, both SRI medications and behavior therapy ap- Brigidi, et al., 2001); and diﬃculty inhibiting pear to produce comparable changes in brain the processing of irrelevant information (En- metabolic activity (Schwartz, Stoessel, Baxter, right & Beech, 1990, 1993; Tolin, Abramowitz, Przeworski, & Foa, 2002). Bottom-up and top-down models of OCD should not be consideredmutually exclusive; indeed, we propose that an Assessment of OCD
integrated cognitive-behavioral model of OCDmust take into account both dysfunctional be- Steketee and Neziroglu in this volume discuss liefs and biases as well as deficits in information assessment strategies for OCD. In our clinic, as- sessment of OCD includes a comprehensive eval-uation of current and past OCD symptoms, asso-ciated functional impairments, the patient’s de- Biological
gree of insight into the senselessness of OCD Biological models of OCD have focused on the symptoms, and structured interviews for co- role of abnormal serotonin metabolism and hy- morbid Axis I and Axis II psychopathology. peractive frontal-striatal circuits in creating the In addition, we examine the patient’s under- symptoms of OCD. The serotonin hypothesis standing of OCD and its treatment, and weis predicated on the observation that patients provide education as needed. The Yale-Brown with OCD respond preferentially to serotonin Obsessive-Compulsive Scale (Y-BOCS) (Good- reuptake inhibitors (SRIs) as opposed to non- man, Price, Rasmussen, Mazure, Delgado, et al., Brief Treatment and Crisis Intervention / 3:2 Summer 2003
fear, for facilitating treatment planning, for Fleischmann, et al., 1989) is considered the monitoring progress, and for measuring treat- “gold standard” of OCD assessment. This semi- ment outcome (Mavissakalian & Barlow, 1981).
structured interview contains a symptom check- Behavioral-avoidance tests (BATs) represent one list and a severity scale. The symptom checklist form of behavioral assessment that can be tai- includes a list of obsessions and compulsions, lored to the patient’s symptom profile. For ex- categorized according to content. The severity ample, patients with contamination concerns scale of the Y-BOCS assesses symptom severity may be asked to touch “dirty” objects like door- using five questions for obsessions and five knobs, garbage cans, or toilets; checkers may befor compulsions. A variation of the Y-BOCS, the asked to leave doors unlocked, to drive over pot- Child Yale-Brown Obsessive-Compulsive Scale holes, or to leave objects in a manner that might (CY-BOCS; Scahill et al., 1997), is used for chil- cause someone harm (e.g., placing sticks on a pathway); hoarders can bring objects into the A number of standardized self-report mea- oﬃce to be discarded; and patients with order- sures have been developed for the assessment of ing compulsions can be asked to misarrange ob- OCD. Because of their ease of use and relatively jects in their house or car. Because of the idio- quick completion time, these measures may syncratic nature of many compulsions, behav- provide greater utility in monitoring treatment ioral assessment often requires creativity and progress than do structured interviews. A num- the willingness to travel with the patient. As ber of sources (e.g., Antony, Orsillo, & Roemer, will be discussed later, such BATs tie in nicely 2001) provide detailed examination of individ- with exposure and ritual-prevention exercises ual measures, but a brief listing of the most com- that are used to reduce the patient’s fear of these monly used inventories includes a self-report version of the Y-BOCS (Warren, Zgourides, &Monto, 1993); the Obsessive Compulsive In-ventory (Foa et al., 1998; a recently published, Treatment of OCD
abbreviated version of which appears in Foa etal., in press); the Maudsley Obsessional Com- Exposure and Ritual Prevention
pulsive Inventory (Hodgson & Rachman, 1977);and the Padua Inventory (Sanavio, 1988). In ad- Exposure and ritual prevention (ERP), also dition to these diagnostic measures, several called exposure and response prevention, con- other measures have been published that assess sists of gradual, prolonged exposure to fear- cognitive features thought to underlie OCD; we eliciting stimuli or situations, combined with routinely include these measures as part of a strict abstinence from compulsive behavior. In practice, this treatment would mean that a pa- sures include the Obsessive Beliefs Question- tient with contamination concerns, for example, naire (Obsessive Compulsive Cognitions Work- would be encouraged to touch progressively ing Group, 2001), the Thought-Action Fusion “germier” objects while simultaneously refrain- Scale (Shafran, Thordarson, & Rachman, 1996), ing from washing or cleaning. Similarly, a patient and the Thought Control Questionnaire (Wells with obsessive concerns about harming other people while driving might be encouraged to drive in increasingly congested areas without not commonly reported in the literature, but it looking in the rearview mirror. The purpose of can be very useful for evaluating the severity of these exercises is to allow patients to experience Brief Treatment and Crisis Intervention / 3:2 Summer 2003
a reduction of their fear response, to recognize symptoms, and they must be willing to leave the that these situations are not excessively danger- oﬃce because many exposures can only be done ous, and to accept their fear will not last forever.
in the patient’s home or at another fear-relevant Thus, although ERP is a “behavioral” interven- tion, its mechanism of action may well be cogni- Numerous studies attest to the eﬃcacy of ERP in adult outpatients with OCD (e.g., Cottraux, One of the more diﬃcult aspects of ERP is that Mollard, Bouvard, & Marks, 1993; Fals-Stewart, patients must eventually be willing to perform Marks, & Schafer, 1993; Kozak, Liebowitz, & exposures to their highest fears—and these ex- Foa, 2000; Lindsay, Crino, & Andrews, 1997; posures often feel very risky to the patient. For van Balkom et al., 1998). Approximately 75% of instance, the highest exposure for the contami- patients treated with ERP improve significantly, nation patient just mentioned might be touch- usually defined as 30 to 50% improvement, and ing a toilet in a public restroom. To help patients they remain so at follow-up (Franklin & Foa, make judgments about the appropriateness of an 1998). Despite this fact, ERP is not widely used exposure, we often use the principle of accept- by mental health practitioners, as shown by a re- able risk in defining the range of possible expo- cent survey of nine Boston-area hospitals and sures with the patient. No exposure is risk free; clinics, many of which are known for their ex- however, the risk of the exposure may be simi- pertise in treating anxiety disorders (Goisman et lar to risks commonly taken every day and thus al., 1993). One possible explanation for this dis- be acceptable. For instance, the patient who crepancy is that while ERP is eﬃcacious, it may balks at touching a toilet without hand washing not be cost eﬀective. ERP is time consuming and may be asked to compare the risk of this expo- expensive; thus, many patients and third-party sure to that of a camping trip where cleanliness payers are unable or unwilling to pay for treat- is often delayed for days or weeks. We also find it helpful to encourage patients to assume that a also refuse ERP (Franklin & Foa, 1998), presum- situation is safe unless there is clear evidence to ably because of apprehension about the diﬃ- the contrary; typically, OCD patients tend to as- culty and intensity of the treatment. To address sume a situation is dangerous unless they can this obstacle, we (Maltby, Tolin, & Diefenbach, find clear evidence of safety (which is often dif- 2002) have developed a brief, four-session readi- ficult to obtain). Therapists can influence the ness intervention consisting of psychoeduca- patient’s willingness to engage in more diﬃcult tion, a videotape example of an ERP session, mo- exposures by preparing the patient for these at tivational interviewing techniques, and a phone an early stage, by maintaining an expectation conversation with a former ERP patient. Initial that they will be doing so, and by collabora- results are encouraging: to date, 60% of patients tively engaging in exposures along with the pa- receiving the readiness intervention chose to tient. With this in mind, it is also important to begin ERP, whereas only 20% of patients in a pace the level of anxiety elicited during expo- sures. Exposures should elicit anxiety, but notso much that the patient feels overwhelmed.
Regular subjective units of distress (SUDS) rat-ings can help gauge levels of anxiety. As can be We believe that the distinction between “be- seen, ERP demands flexibility of the patient and havioral” and “cognitive” therapy is somewhat clinician. Therapists must be able to design cre- arbitrary. During ERP, we routinely assist pa- ative exposures that address the patient’s OCD tients in changing inaccurate beliefs about Brief Treatment and Crisis Intervention / 3:2 Summer 2003
feared situations, such as pointing out that The specific eﬃcacy of CT for OCD has not feared consequences did not occur or that the been firmly established. In two studies, RET was patient’s fear did not remain forever. Similarly, found to yield results that did not diﬀer from cognitive therapy (CT) often involves direct be- those of ERP (Emmelkamp, Visser, & Hoekstra, havioral suggestions to reduce avoidant behav- 1988), and the addition of RET to ERP did not ior. In OCD, the specific goal of CT is to teach pa- appear to enhance treatment results (Emmel- tients to identify and correct their dysfunc- kamp & Beens, 1991). In comparative eﬃcacy tional beliefs about feared situations (e.g., studies of adults with OCD, Beck-style CT pro- Freeston et al., 1997). Wilhelm (this issue) elab- duced moderately strong results that did not orates on the use of CT, so we will describe it diﬀer significantly from those of ERP (Cottraux here only briefly. To date, CT strategies have em- et al., 2001; van Balkom et al., 1998; van Oppen phasized the top-down (beliefs and appraisals), et al., 1995); in a comparison study of group treat- rather than the bottom-up (information pro- ment, CT yielded moderate results that were not cessing), cognitive models of OCD. In most as strong as those obtained using group ERP cases, this strategy has involved either rational- (McLean et al., 2001). It should be noted, how- emotive therapy (RET), in which irrational ever, that in each of these CT comparison stud- thoughts are identified and targeted via rational ies, ERP sessions were briefer and more widely debate, or CT along the lines of Beck and col- spaced than were those used in ERP studies leagues (1985), in which Socratic questioning (Kozak et al., 2000), and they did not emphasize and behavioral experiments are used to chal- intense, therapist-assisted exposures. Our pref- lenge the validity of distorted thoughts. In ei- erence, based on these data, is to use ERP when- ther case, the patients are asked to elaborate ever possible. However, cognitive therapy mayon their “automatic” appraisals of feared situa- play a useful, adjunctive role when ERP has not tions, and they are then taught to identify the produced optimal results. In an open trial with inaccuracies or logical inconsistencies in those five adult OCD patients who had failed to re- thoughts. For example, a patient with contami- spond to pharmacotherapy and ERP, an inten- nation concerns may identify the belief that all sive CT program was associated with decreases germs are dangerous. The therapist helps the pa- in self-reported OCD symptoms (Krochmalik, tient to identify and label the irrational features of this belief (e.g., “overgeneralization”). Thepatients are then instructed to monitor the oc- Anxiety Management Training
currence of this thought in their daily life, andthey are given specific instructions for challeng- Some clinicians have argued for the use of anxi- ing the thought. In this case, the patient might ety management training (AMT) in the treat- be instructed either to recall that many germs ment of patients with OCD, particularly with are benign or even beneficial or to acknowledge children (March & Mulle, 1998). AMT strategies that deaths from germs are more rare than would include training in slow, diaphragmatic breath- be expected if this thought were true. The pa- ing; progressive muscle relaxation; and coping tient may be encouraged to conduct behavioral imagery. AMT strategies such as relaxation have experiments, in which they come into contact not been shown to be an eﬀective component of with certain germs in order to see that they are treatment for OCD (Marks, 1987). Because AMT not harmed. The overlap of these strategies with strategies are designed to reduce exposure to ERP should be clear; we suggest that the diﬀer- anxiety, they may interfere with the core pro- cess of ERP—that is, evoking anxiety to allow Brief Treatment and Crisis Intervention / 3:2 Summer 2003
for habituation and cognitive change to occur.
do SSRIs but that no SSRI is superior to any In general, patients are able to tolerate the dis- other (Greist, Jeﬀerson, Kobak, Katzelnick, & tress of ERP, and they therefore do not require Serlin, 1995; Stein, Spadaccini, & Hollander, AMT (Franklin, Tolin, March, & Foa, 2001).
1995). However, clomipramine’s side-eﬀect pro- However, some patients may be so anxious at file prevents it from being widely accepted as a baseline that they are unable to tolerate even first-line intervention; prescribers typically pre- mild exposure; thus, AMT may be a useful ad- fer to begin pharmacotherapy with the more easily tolerated SSRIs. In a large randomizedcontrolled trial, clomipramine was superior toplacebo. However, ERP was superior to clom- Pharmacotherapy
ipramine (85% responder rate vs. 50%, respec- Serotonin reuptake inhibitors (SRIs) are the tively). Interestingly, and contrary to common first-line pharmacological treatment of choice clinical practice, the combination of clomipra- for OCD (Rasmussen & Eisen, 1997). These are mine and ERP yielded a 71% responder rate, also reviewed by Pato and colleagues in this is- which was superior to clomipramine alone but sue. SRIs commonly used in OCD treatment in- not to ERP alone (Kozak et al., 2000). Another clude the selective SRIs (SSRIs) fluoxetine, ser- randomized controlled trial found that fluvox- traline, fluvoxamine, paroxetine, and citalopram; amine yielded similar treatment outcomes as the serotonin-norepinephrine reuptake inhib- ERP and CT did, and all were superior to pla- itor (SNRI) venlafaxine; and the tricyclic anti- depressant clomipramine. Although 30–60% ofpatients respond to treatment utilizing SRIs,relapse rates are high (65–90%) when acute treat- Predictors of Treatment Response
ment is discontinued. Longer-term pharmaco-therapy may therefore be required. Most re- No reliable markers of treatment response have searchers recommend at least one year of con- been identified for cognitive-behavioral or phar- tinued treatment following successful treatment macological treatments. Some studies have (March, Frances, Carpenter, & Kahn, 1997); how- found that higher initial severity of OCD symp- ever, few studies of maintenance treatment have toms was associated with poorer outcomes (de been conducted. In one discontinuation study Haan et al., 1997; Keijsers, Hoogduin, & Schaap, (Koran, Hackett, Rubin, Wolkow, & Robinson, 1994) while others have not (Cottraux, Messy, 2002), patients randomly assigned to receive pla- Marks, Mollard, & Bouvard, 1993; Steketee & cebo following one year of sertraline were more Shapiro, 1995). Research on the eﬀects of co- likely to experience an acute exacerbation in morbid personality disorders is similarly mixed, their OCD symptoms as measured by the Y-BOCS with some studies that found attenuated treat- and CGI than were patients who continued to re- ment response and with other studies that did ceive sertraline. In a discontinuation study of not (Fals-Stewart & Lucente, 1993; Fals-Stewart CBT versus clomipramine (O’Sullivan, Noshir- & Schafer, 1993; Mavissakalian, Hamann, & vani, Marks, Monteiro, & Lelliott, 1991), patients Jones, 1990; Steketee, 1990). Type of OCD may who received CBT fared better at 6-year follow- also be related to outcome. Hoarding in particu- up than did clomipramine patients, who did not lar has been associated with poor response to diﬀer from patients who had received placebo.
ERP (Abramowitz, Franklin, Schwartz, & Furr, Meta-analytic studies suggest that clomipra- 2002; Black et al., 1998; Mataix-Cols, Marks, mine yields higher rates of responding than Greist, Kobak, & Baer, 2002), SRI medications Brief Treatment and Crisis Intervention / 3:2 Summer 2003
(Black et al., 1998; Mataix-Cols et al., 1999) or interventions tailored to the idiosyncratic na- their combination (Saxena et al., 2002). Like- ture of hoarding-related symptoms (Hartl & wise, sexual and religious concerns have also been associated with poor response to ERP(Mataix-Cols et al., 2002); this factor may be due to poorer insight among patients in these Treatment Augmentations
subgroups (Tolin, Abramowitz, Kozak, & Foa,2001). Duration of OCD was unrelated to out- Partial or nonresponse is common among cogni- come in two studies of CBT (Cottraux, Messy, et tive-behavioral and pharmacological interven- al., 1993; Steketee & Shapiro, 1995), but later tions for OCD. In general, the recommendation is age of onset was associated with positive out- to augment or change to an alternative treat- come in one study of clomipramine (Ackerman, ment when a patient reports an insuﬃcient re- Greenland, Bystritsky, Morgenstern, & Katz, sponse to a treatment of adequate dose and du- 1994). Early reports suggested that pretreatment ration (March et al., 1997; McDonough & Ken- depression predicted poorer outcome of ERP nedy, 2002). Thus, an inadequate response to (Foa, 1979); however, later research indicated an SRI could be followed by CBT with a diﬀer- that highly and mildly depressed patients re- ent SRI, or it could be augmented with a diﬀer- sponded similarly to treatment (Foa, Kozak, Ste- ent class of medications. Inadequate responses ketee, & McCarthy, 1992). In a large sample of to CBT may be addressed by using an alternate OCD patients, only severe depression was asso- form of CBT or by adding SRI augmentation.
ciated with attenuated outcome of ERP, al- Medications typically used to augment SRI though even those patients showed significant treatment include clonazepam, buspirone, l-tryp- clinical improvement (Abramowitz, Franklin, tophan, lithium, olanzapine, and risperidone Street, Kozak, & Foa, 2000). Lower initial moti- (McDonough & Kennedy, 2002). Empirical stud- vation appears to be associated with poorer out- ies of these recommendations, however, have come of cognitive-behavioral therapy (de Haan been lacking. A recent study indicated that seven et al., 1997; Keijsers et al., 1994); this result may of nine patients who had failed to respond to flu- be mediated by reduced follow-through with oxetine showed at least a 25% Y-BOCS reduc- exposure exercises (Araujo, Ito, & Marks, 1996; tion when treated with weekly ERP. We are cur- O’Sullivan et al., 1991). Insight into the irra- rently examining the eﬃcacy of ERP for pa- tionality of obsessive fears has been associated tients who have failed to respond to multiple with poorer outcome in some studies of pharma- SRI trials; preliminary results suggest that OCD cotherapy and CBT (Catapano, Sperandeo, Per- symptoms decrease with ERP augmentation, but ris, Lanzaro, & Maj, 2001; Erzegovesi et al., to a lesser extent than has been found with treat- 2001; Foa, 1979; Neziroglu, Stevens, & Yaryura- ment-naïve patients (Tolin, Diefenbach, Maltby, Tobias, 1999), but not in others (Eisen et al., Woodhams, & Worhunsky, 2002). Similarly, a 2001; Foa et al., 1983; Hoogduin & Duivenvoor- highly focused cognitive therapy has been asso- den, 1988). Ideally, further research on predic- ciated with significant improvements for some tors of outcome will lead to the development of patients who had previously failed ERP or mul- treatment algorithms in which patients can be tiple trials of SRI medications (Jones & Menzies, matched a priori to specific treatments; how- ever, the available body of research does not yet Because of OCD’s substantial impact on family support such decisions with the possible ex- functioning as well as the risk of family mem- ception of hoarding, which may require specific bers’ accommodating (and inadvertently rein- Brief Treatment and Crisis Intervention / 3:2 Summer 2003
forcing) patients’ compulsions (Amir et al., Future Directions
2000; Calvocoressi et al., 1995), family interven-tion may also be indicated as a supplement to Given that OCD is heterogeneous and that many traditional CBT and pharmacological interven- OCD subtypes and OCSDs may respond diﬀer- tions. In individual and group settings, inclu- entially to existing behavioral and pharmaco- sion of family members resulted in superior out- logical treatments, one potential goal of future comes than did CBT alone (Grunes, Neziroglu, & research is to construct treatment algorithms McKay, 2001; Van Noppen, Steketee, McCorkle, based on predictors of outcome. As described & Pato, 1997). Family intervention is particu- previously, this line of research is in its infancy.
larly helpful in the treatment of children with However, early research has indicated that OCD, by training parents to utilize ERP methods unique variations of CBT can be developed for (Knox, Albano, & Barlow, 1996). In some cases, family intervention alone may be suﬃcient to (Hartl & Frost, 1999), contamination fears (Kroch- elicit reductions in compulsive behaviors, such malik et al., 2001), trichotillomania (Lerner, as instructing parents not to respond to exces- Franklin, Meadows, Hembree, & Foa, 1998; Ni- sive reassurance-seeking (Francis, 1988; Tolin, nan, Rothbaum, Marsteller, Knight, & Eccard, 2000; Tolin, Franklin, Diefenbach, & Gross, For patients with severe, intractable, and de- 2002), hypochondriasis (Clark et al., 1998; Vis- bilitating OCD that has failed to respond to ser & Bouman, 2001; Warwick, Clark, Cobb, &CBT and pharmacological interventions, neuro- Salkovskis, 1996), and body dysmorphic disor- surgery may be an option. Current neurosurgi- der (McKay et al., 1997; Wilhelm, Otto, Lohr, & cal approaches include subcaudate tractomy (Bridges et al., 1994), anterior cingulotomy (Baer Nonetheless, the lack of a comprehensive bio- et al., 1995; Dougherty et al., 2002), anterior psychosocial model of OCD and OCSDs likely capsulotomy (Mindus & Nyman, 1991), and impedes progress in understanding and treat- combined orbitomedial/cingulate lesions (Hay ing these conditions. In other disorders (such et al., 1993). To date, no controlled studies of as panic disorder), the development of such these procedures have been conducted; how- models has led to significant advances in con- ever, the available evidence suggest that 20– ceptualization and treatment (e.g., Clark, 1986).
40% of patients receive significant benefits from Indeed, Foa and Kozak (1997) suggest that be- these procedures, though many patients require havior therapy in general may have reached an more than one operation (Baer et al., 1995; “eﬃcacy ceiling” that will only be broken by Bridges et al., 1994; Dougherty et al., 2002; Hay et al., 1993; Rauch et al., 2001). Newer tech- research. In addition to potentially advancing niques that minimize or avoid destruction of the treatment of OCD, biopsychosocial models brain tissue such as transcranial magnetic stim- may provide testable hypotheses that help re- ulation and deep brain stimulation are being de- solve the current controversies in OCD re- veloped but their eﬃcacy has yet to be estab- search, such as the heterogeneity problem and lished (Greenberg et al., 2000; Malhi & Sachdev, the relative placement of spectrum disorders.
2002; Nuttin, Cosyns, Demeulemeester, Gybels, We suggest that a comprehensive biopsycho- & Meyerson, 1999; Sachdev et al., 2001).
social model must explain and predict not onlyobsessions and compulsions, but also the at-tributional and information-processing biases Brief Treatment and Crisis Intervention / 3:2 Summer 2003
noted in OCD, findings from neuroimaging stud- Abramowitz, J. S., Franklin, M. E., Street, G. P., ies, and genetic and familial factors.
Kozak, M. J., & Foa, E. B. (2000). Eﬀects of co- morbid depression on response to treatment for ment of CBT have been identified as barriers to obsessive-compulsive disorder. Behavior Therapy, treatment, there is a need to develop alter- Abramowitz, J. S., & Houts, A. C. (in press). What native treatment algorithms that are acceptable is OCD and what is not: Problems with the OCD to patients, that contain costs, and that deliver spectrum concept. Scientific Review of Mental the most eﬀective treatment components. Group therapy represents one promising area of treat- Ackerman, D. L., Greenland, S., Bystritsky, A., ment development; preliminary results indi- Morgenstern, H., & Katz, R. J. (1994). Predictors cate that CBT can be delivered eﬀectively in a of treatment response in obsessive-compulsive brief group format, with good results (Himle disorder: Multivariate analyses from a multi- et al., 2001; McLean et al., 2001; Van Noppen, center trial of clomipramine. Journal of Clinical Pato, Marsland, & Rasmussen, 1998). Other re- Psychopharmacology, 14, 247–254.
searchers have explored the use of self-help Amir, N., Freshman, M., & Foa, E. B. (2000). Family manuals (Fritzler, Hecker, & Losee, 1997) and distress and involvement in relatives of obsessive- computer-assisted therapy (Baer & Greist, 1997; compulsive disorder patients. Journal of Anxiety Baer, Minichiello, Jenike, & Holland, 1988; Antony, M. M., Orsillo, S. M., & Roemer, L. (Eds.).
Nakagawa et al., 2000) as ways of reducing (2001). Practitioner’s guide to empirically based health care costs. The utility of these approaches, measures of anxiety. New York: Kluwer Academic/ however, is limited by the inability to self- correct by providing patients with their opti- Araujo, L. A., Ito, L. M., & Marks, I. (1996). Early mal level of treatment and no more. A prefer- compliance and other factors predicting outcome able approach might be the use of stepped-care of exposure for obsessive-compulsive disorder.
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the least expensive, intrusive, and diﬃcult treat- Baer, L. (1994). Factor analysis of symptom sub- ment (e.g., self-help) and then step up through types of obsessive compulsive disorder and their more intensive treatment modalities if previ- relation to personality and tic disorders. Journal ous steps fail or yield only a partial response. We of Clinical Psychiatry, 55(Suppl.), 18–23.
have been piloting stepped-care models of de- Baer, L., & Greist, J. H. (1997). An interactive livering ERP for OCD, though it is still too early computer-administered self-assessment and self-help program for behavior therapy. Journal of to determine if this model of delivering treat- Clinical Psychiatry, 58(Suppl. 12), 23–28.
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5.6 Stability test and controller setting with the frequency response of theopen control loopAs illustrated in ﬁgure 5-23, the control loop will be opened and excitedwithas the input variable of the controller. In the settled condition the out-put variable of the controlled system will be xa(t) = Xa · cos (ωt + ϕ) . xa = −GS · GR · xe = −G 0 (jω) · xe = −|G 0 (jω)| · ejϕ 0