Obsessive-Compulsive DisorderLecture Overview

• 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

• Depression

• Other anxiety disorders

• Sleep disturbance

• Eating disorders

• Tourette’s disorder and motor tics

Common Obsessions in OCD

Obsession % of Sample (N = 182)Aggressive 68.7

Contamination 57.7

Symmetry/exactness 53.2

Somatic 34.1

Hoarding/saving 30.2

Religious 24.2

Sexual 19.8

Misc. 55.5

Data from Antony et al., (1998).

Common Compulsions in OCD

Compulsion % of Sample (N = 182)Checking 80.7

Washing and cleaning 63.7

Repeating 55.5

Ordering/arranging 40.1

Counting 35.2

Hoarding 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 Treatmentsfor OCD

• Clomipramine*• SSRIs

• Fluoxetine

• Fluvoxamine*

• Sertraline

Multicenter Trial of Fluoxetine

0

5

10

15

20

25

30

35

40

Res

pon

se R

ate

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

-7

-6

-5

-4

-3

-2

-1

0

Ch

an

ge

in Y

-BO

CS

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

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Eff

ect

Size

Clomipramine Fluoxetine Fluvoxamine Sertraline

Data taken from Greist et al (1995). Archives of General Psychiatry, 52: 53-60. Effect size calculated from post differences between treatment and placebo

N=520 N=355 N=320 N=325

Treatment Response Rate from 4 Large Multi-Center RCTs

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40

50

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Tre

atm

ent

Res

pons

e R

ate

Clomipramine Fluoxetine Fluvoxamine Sertraline

Data taken from Greist et al (1995). Archives of General Psychiatry, 52: 53-60.

N=520 N=355 N=320 N=325

Relapse Rates Following Discontinuation of Medication

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20

40

60

80

100

% o

f P

atie

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who

Rel

apse

Clomipramine Fluoxetine FluvoxamineData taken from Ravizza et al., 1996. Psychopharmacol Bull, 32: 167-73.

Empirically-Supported Psychosocial Treatments

• Psychosocial Treatments– Exposure and Response Prevention (ERP)

– Cognitive Therapy

Rationale for Investigating Non-Drug 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

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 PreventionWasher

• 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 PreventionChecker

• 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 Exposure-Response 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 StudyResults

Outcome PBO CMI BT CMI+BT

YBOCS(Comp)

23.1 18.19 12.68 11.68

YBOCS(ITT)

23.22 19.11 15.29 13.30

ResponseRate(Comp)

6.3 50.0 84.6 71.4

ResponseRate(ITT)

5.0 39.1 61.1 45.5

Multi-Site OCDAcute Treatment Response

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80

100%

of

pati

ents

Intent-to-Treat 5 39.1 61.1 45.5

Completers 6.3 50 84.6 71.4

Placebo CMI ERP CMI + ERP

Data taken from Kozak, Liebowitz, & Foa (2000). “Cognitive Behavior Therapy and Pharmacotherapy for Obsessive-Compulsive Disorder: The NIMH-Sponsored Collaborative Study. In Osessive-Compulsive Disorder: Contemporary Issues in Treatment; ed by Irving Weiner.

Multi-Site OCDRelapse at Follow-up

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% o

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Relapse % 87.5 0 10

CMI ERP CMI + ERP

Data taken from Kozak, Liebowitz, & Foa (2000). “Cognitive Behavior Therapy and Pharmacotherapy for Obsessive-Compulsive Disorder: The NIMH-Sponsored Collaborative Study. In Osessive-Compulsive Disorder: Contemporary Issues in Treatment; ed by Irving Weiner.

Moderators of Treatment Outcome

• 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

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20

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60

80

ERPCT

ERP 66 28

CT 75 50

Responder Recovered

Data taken from Van Oppen et al (1995) Behaviour Research and Therapy, 33, 379-390.