Mastery of Obsessive Compulsive Disorder A Cognitive

Behavioral Approach

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OXTORD
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Copyright © 1997 by Graywind Publications Incorporated

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ISBN 978-0-19-518682-6

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in the Appendix in this publication in complete pages, with the
copyright notice, for instructional use and not for resale.

9 8
Printed in the United States of America
on acid-free paper
Contents

'Section 1: 1:
.. Section Description
Description andand
Ass meofntOCD
Assessment of OCA
Chapter 1: Symptoms of OCD 3
Introduction 3
Definition of OCD 4
Prevalence 5
Course 5
Associated Disorders 6

Chapter 2: Theories ©f OCD 7

Learning Theories 1
Cognitive Theories 8
Neurochemical Theories 10
Neuroanatomical Factors 11

Chapter 3: Assessment of OCD 13

Diagnostic Interview 13
Differential Diagnosis 15
Obsessions Versus Ruminations 15
OCD and Other Anxiety Disorders 15
Hypochondriasis 16
Body Dysmorphic Disorder 16
Tourette's Disorder and Tic Disorder 16
Delusional Disorder 17

Section 2: Available Treatement

Ter of OCD
Chapter 4: Psychosocial Therapy for OCD 21
Cognitive-Behavioral Treatment 21
Exposure Versus Response Prevention 22
Imaginal Versus Actual Exposure 22
Gradual Versus Immediate Exposure 23
Duration of Exposure 23
iii
 Frequency of Exposure 23
Therapist-Guided Exposure Versus Self-Exposure 24
Ritual Prevention 24
Requests for Assurance 25
Cognitive Therapy 26

Chapter 5: Pharmaeotherapy for OCD 29

Serotonergic Medications 29
Combined Treatment by Exposure and Medication 30

Chapter B: Choice of Treatment 33

Discussion of Treatment Options With the Client 34
Additional Considerations 38
Treatment History 38
Combined Treatments 38

-:-• Section 3l Cognitive-Behavioral Treatment

by
Exposure Ritual
prevention
and
Chapter 7: Treatment Planning: Understanding and Persuading 43
Understanding the Client 44
Identifying Obsessions 44
Identifying Avoidance Patterns 44
Identifying Rituals 45
The Nature of Obsessions 45
Avoidance and Rituals 49
General Functioning 51
History 51
Development of the Client's Symptoms 51
Previous Treatment 52
General History 53
Depression 53
Persuading the Client 53
Definition of OCD 53
Explanation of Treatment 54
Chapter 8: Treatment Planning: In Vivo Exposure 59
Creating a List of Exposure Situations 59
Guidelines for Selecting Exposure Situations 60
Lines of Inquiry 60
Sample Lists of Exposure Items 64

iv iv
 Sample Exposure Plans 66
Washer 66
Checker 69
Hoarder 70
Chapter 9: Treatment Planning; ImaginaS Exposure 75
Medium of Exposure 76
Problems With Imaginal Exposure 77
Guidelines for Imaginal Exposure 78
Model Introduction to Imaginal Exposure 78
Sample Narrative Script for Imaginal Exposure 79

Chapter 10: Treatment Planning: Ritual Prevention 81

Introducing the Concept and Persuading the Client 81
Sample Guidelines for Refraining From Rituals 83
Decontamination Rituals 83
Checking Rituals 84
Self-Monitoring of Rituals 84
Guidelines for Self-Monitoring 85
Reviewing the Self-Monitoring 86
Chapter 11: Treatment Planning: Social Support 87
Patterns of Collaboration 87
Interpersonal Conflicts 89

Chapter 12: Reviewing the Plan: Explicating the Contract 93

Chapter 13: Beginning Exposure: Revision and Consent 97

Goals of the Exposure Sessions 97
Revealing Mistaken Beliefs 97
Building Confidence in the Therapist and in the Program 98
The Importance of Consistency 98
Refining the Program 99
A Typical Exposure Session 100
Imaginal Exposure 100
In Vivo Exposure 102
Instructions for Washers 102
Exposure for Checkers 103
Homework Instructions 105

V
Chapter 14: Middle Exposure: From Bete Noir to Paper Tiger 107
Introducing the Most Difficult Exposures 108
Tactics for Helping the Clients 108
Scheduling 108
Encouragement 109
Courage 109
Risk Taking 109
The Paper Tiger Metaphor 110
Therapist Attitude Ill
Alternatives to the Planned Exposure 112
Discontinuing Therapy 112
Intermediate Exercises • • . 113
Crises Unrelated to Exposure 114
Chapter 15: End Exposure: Theme and Variations us
Repetitions and Generalizations 115
Teaching Normal Patterns of Behavior 116
Rules for "Normal" Behavior 117
Chapter 16: Relapse Prevention: Self-Exposure 119
The Process of Relapse 119
Rules for Self-Exposure 120
Stress-Management Techniques 120
Meeting With Significant Others 121
New Activities and Interests 121
Scheduling Follow-Up Contacts 122
Chapter 17: Resistance and Other Difficulties 123
Concealment of Symptoms 123
Discussing Problems With Client and Support Person 124
First Instance of Concealment 127
Second Instance of Concealment 127
Symptom (Ritual) Substitution 128
Unforbidden Avoidance 129
Incomplete Abstinence From Rituals 129
Handling Arguments 130
Emphasizing the Client's Control Over Treatment 131
Intermediate Tasks 131
Emotional Obstacles 132

vi
Chapter 18: Adjustment for Clients With Mental Retardation 133
Diagnosis of OCD 133
Behavioral Stereotypes Versus Rituals 134
Interviewing the Client 134
Other Sources of Information 134
Treatment of OCD 135
Adjustments of Exposure Treatment 135
Pessimism 136
Impaired Discrimination and Distractibility 136
Slower Learning 137
Maintenance of Gains 137
Chapter 19: Adjustment for Children 139
Comorbidity in Pediatric OCD 139
Adjustment of Exposure Treatment 140
Teaching Children and Families About OCD 141
Explanation of OCD as a Psychobiological Disease 141
Explanation of OCD as a Set of Strong Habits 142
Evaluating Parent's Observations 142
Pace of Exposure for Children 142
A Model Treatment Program 143
Assessment and Treatment Planning 144
Ritual Prevention 144
Reframing OCD as the Child's Enemy 144
Family Involvement With Treatment 145

Chapter 20: Conclusion 147

References 149
Appendix A 165

vii
Series Introduction

The psychosocial treatment program in this Therapist Guide is part of a

series of empirically supported treatment programs. The purpose of the
series is to disseminate knowledge about specific interventions for which
systematic research studies indicate effectiveness. This treatment program,
along with others in the series, has been clearly demonstrated to have
empirical support for its efficacy in treating the particular condition you
are addressing. However, clinicians operate with a wide variety of patients
with different characteristics who are treated in different settings. Thus,
the manner in which the treatment program is implemented will be the
decision of the treating clinician with his or her unparalleled knowledge
of the local clinical situation and the particular patient under care. Al-
though some data indicate that allegiance to the treatment protocol pro-
duces the best results, only the treating clinician is in a position to judge
the degree of flexibility required to achieve optimal results.

We sincerely hope that you find the psychosocial treatment program, of

which this Therapist Guide forms an integral part, useful in your clinical
practice. This Therapist Guide is meant to accompany various clinical mate-
rials that you would be prescribing for patients in the implementation
of this program. It is designed to assist clinicians in the systematic and
sequential administration of the particular treatment program being imple-
mented. As such it highlights relevant, practical information and exercises
for the sessions. It also presents typical problems that may arise during
specific therapeutic procedures and provides suggestions for solving these
problems. Thus, you may want to review the brief individual chapters corre-
sponding to each therapeutic session or intervention before conducting
sessions, perhaps while reviewing case notes.

Although the Therapist Guide is not a full description of the theoretical

approach and empirical work that supports this treatment, references for
additional information are provided. We encourage review of these readings
for a comprehensive understanding. Please let us know if you have sugges-
tions for improving our systems for helping you deliver effective psychoso-
cial treatments for clients under your care.

David H. Barlow, PhD

Distinguished Professor

viii
About the Authors

M ICHAEL]. KOZAK received his PhD in clinical psychology at the Uni-

versity of Wisconsin-Madison in 1982. Currently he is associate
professor of psychiatry at Allegheny University of the Health Sciences
and Clinical Director at the Center for the Treatment and Study of
Anxiety. He has studied the process and outcome of psychosocial treat-
ment and pharmacotherapy for anxiety disorders, including blood/injury
phobia, obsessive-compulsive disorder, posttraumatic stress disorder
(PTSD), and social anxiety. His expertise in exposure-based treatment
for obsessive-compulsive disorder (OCD) has been developed over 14
years of daily clinical practice with OCD patients. His scholarly publica-
tions include reports of individual case studies and controlled outcome
trials of cognitive-behavior therapy and pharmacotherapy for anxiety
disorders, laboratory psychophysiological studies of emotion, theoretical
and review articles, and philosophical analyses. He was a member of the
Workgroup on Obsessive-Compulsive Disorder for the Diagnostic and
Statistical Manual of Mental Disorders—Fourth Edition of the American
Psychiatric Association.

E DNA B. FOA, PhD, professor at the Allegheny University of the Health

Sciences (formerly Medical College of Pennsylvania and Hahnemann
University) and Director of the Center for the Treatment and Study of
Anxiety, is an internationally renowned authority on the psychopathol-
ogy and treatment of anxiety. Her research aiming at delineating etiologi-
cal frameworks and targeted treatment has been highly influential and
she is currently one of the leading experts on obsessive-compulsive disor-
der and phobias. The program that she has developed for rape victims is
considered to be the most effective therapy for posttrauma sequela. More
recently she has been investigating the psychopathology and treatment
of social phobia. She has published several books and over 100 articles
and book chapters, has lectured extensively around the world, and was
the chair of the OCD workgroup and cochair of the PTSD workgroup of
the DSM-IV. Dr. Foa is the recipient of numerous awards and honors,
including the Fulbright Distinguished Professor Award, the Distinguished
Scientist Award from the Scientific section of the American Psychological
Association, the First Annual Outstanding Research Contribution Award
from the Association for the Advancement of Behavior Therapy and the
American Psychological Association Award for Distinguished Scientific
Contributions to Clinical Psychology.

ix
Acknowledgments

In clinical science, we extend our scope by standing on the shoulders

of those who have preceded us. We owe much to the work of those who
pioneered the application of behavior therapy to OCD, such as Meyer,
Marks, and Rachman. Our conceptualization of emotional processing
in exposure therapy has been greatly influenced by the bio-informational
theory of Peter Lang, another trailblazer. Our many colleagues in research
and practice over the years have also contributed to the development
of our cognitive-behavioral approach. We are especially indebted to our
patients with OCD, whose courage in confronting their obsessive fears
has revealed so clearly the potency of exposure treatment, and to the
National Institute of Mental Health, which has been supporting our
research on OCD for almost 20 years.

Our appreciation is extended to various persons at The Psychological

Corporation, especially for the support we have received from John
Dilworth, President; Joanne Lenke, PhD, Executive Vice President;
and Aurelio Prifitera, PhD, Vice President and Director of the Psychologi-
cal Measurement Group. The expertise contributed by Larry Weiss,
PhD, Senior Project Director, has been invaluable in ensuring the high
quality of the Therapist Guide. Special thanks are extended to those
individuals whose meticulous and diligent efforts were essential in
preparing the Therapist Guide for publication. Among this group are
John Trent, Research Assistant; Kathy Overstreet, Senior Editor; Cynthia
Woerner, Consulting Editor; and Javier Flores, Designer.

X
Sectio n1
Description and
m

Assessment of OCD
This page intentionally left blank
CHAPTER 1
Symptoms of OCD

Introduction
This Therapist Guide is designed to help psychotherapists in assessing
and treating obsessive-compulsive disorder (OCD). It is divided into three
sections. In the first section, a summary of the symptoms of OCD and
methods for assessing the disorder are presented. In the second section,
the relative efficacy of the available treatments and how to arrive at treat-
ment recommendations for individuals with OCD who seek treatment
are discussed. In the third section, a guide to cognitive-behavioral treat-
ment by exposure and ritual prevention (i.e., refraining from performing
rituals) is provided. Also in this section, the components of the treatment
procedures whose efficacy has been experimentally documented are
described and illustrated, as well as those aspects of their practical appli-
cation that inhabit experimentally uncharted territory of clinical wisdom
and artistry.

This treatment program is referred to as cognitive-behavioral therapy

because it incorporates techniques aimed at modifying cognitive struc-
tures, including unrealistic associations and mistaken beliefs, that
underlie obsessions and compulsions. However, use of the term
"cognitive behavioral" does not imply, in the Skinnerian tradition,
that thoughts are "cognitive behaviors." Throughout the Therapist
Guide, the program is interchangeably referred to as "exposure therapy,"
"cognitive-behavioral therapy," and "exposure and ritual prevention."

3
 This Therapist Guide may be used either alone or with the accompanying
Client Workbook, available from The Psychological Corporation.

Definition of OCD
According to the Diagnostic and Statistical Manual of Mental Disor-
ders—Fourth Edition (DSM-IV; American Psychiatric Association, 1994),
the essential features of OCD are severe recurrent obsessions or compul-
sions. Obsessions are "persistent ideas, thoughts, impulses, or images
that are experienced as intrusive and inappropriate, and that cause
marked anxiety or distress" (p. 418). Compulsions are "repetitive
behaviors . . . or mental acts . . . the goal of which is to prevent or
reduce anxiety or distress" (p. 418).

The traditional (pre-DSM-/F) definition of OCD reflects three basic ideas:

(a) Obsessions are mental events, and compulsions are behavioral events;
(b) obsessions and compulsions may either be connected or occur inde-
pendently; and (c) those with OCD recognize the senselessness of their
obsessions. The DSM-IV definition, however, reflects more contemporary
views about these issues. In contrast to the traditional idea that obses-
sions are thoughts and that compulsions are actions, for the past two
decades, experts have recognized that compulsions can be either actions
or thoughts. Thus, the distinction between an obsession and a compul-
sion cannot rest solely on the modality of expression, that is, on whether
or not the manifestation is a thought or an observable behavior.

If one cannot rely on the simple notion that obsessions are thoughts
and that compulsions are actions, how can they be distinguished from
one another? A current view is that obsessions and compulsions may
be defined according to whether they produce or reduce distress (Foa &
Tillmanns, 1980). Accordingly, obsessions are thoughts, images, or
impulses that produce anxiety or distress, and compulsions are overt
(behavioral) or covert (mental) actions that reduce or prevent distress
brought on by the obsessions. Behavioral rituals are thus functionally
equivalent to mental rituals (such as silently repeating numbers) in that
both aim to reduce obsessional distress. Sometimes mental rituals are
referred to as "neutralizing thoughts" (Rachman, 1976). In summary,
both behavioral and mental rituals may be performed to prevent harm,
restore safety, or reduce distress.

4
 The second notion found in the Diagnostic and Statistical Manual of
Mental Disorders—Third Edition (DSM-III; American Psychiatric Associ-
ation, 1980) and retained in the DSM-IV is that although most obses-
sions and compulsions are functionally related in the manner just
described, some compulsions are carried out without direct relationship
to any obsession. Findings of a study that was designed to address this
issue indicate that about 90% of rituals are performed either to reduce or
undo an obsession or to reduce an unspecified distress. However, about
10% of compulsions are unrelated to obsessions in the minds of the
clients (Foa et al, 1995).

The third traditional notion about OCD, which was revised in the
DSM-IV, is that individuals with OCD recognize their obsessions and
compulsions as senseless or unreasonable. Kozak and Foa (1994) have
argued elsewhere that the clinical picture of OCD is more accurately
represented by a continuum of "insight" or "strength of belief" than by the
dichotomy of presence or absence of insight. Consensus about this issue
has grown over the last several years (Foa & Kozak, 1996; Insel & Akiskal,
1986; Lelliott, Noshirvani, Basoglu, Marks, & Monteiro, 1988), and the
DSM-IV reflects this by stipulating a subtype of OCD "with poor insight."

Prevalence
No longer thought to be a rare disorder, OCD is now estimated to occur in
about 2.5% of the population (Karno, Golding, Sorensen, & Burnam, 1988).
Slightly more than half of those with OCD are female (Rasmussen &
Tsuang, 1986). Age of onset ranges from early adolescence to young adult-
hood, with earlier onset in males (modal onset at 13-15 years old) than in
females (modal onset at 20-24 years old; Rasmussen & Eisen, 1990).

Course
Development of OCD is usually gradual, but acute onset has been
reported. Chronic waxing and waning of symptoms is typical, but
episodic and deteriorating courses have been observed in about 10%
of clients (Rasmussen & Eisen, 1989). Many individuals with OCD have
the disorder for years before seeking treatment. In one study, individuals
first presented for psychiatric treatment over seven years after the onset
of significant symptoms (Rasmussen & Tsuang, 1986). OCD is routinely
associated with impaired general functioning, such as disruption of