Recent developments in the cognitive-behavioral treatment of obsessive-compulsive disorder.

Abstract

The lifetime prevalence rate of OCD in adults is two to three percent (e.g., Karno, Golding, Sorenson, & Burnam, 1988). Symptoms typically wax and wane as a function of general life stress, and a chronic and deteriorating course is the norm if adequate treatment is not sought. In many cases, fears, avoidance, and rituals impair various areas of functioning (e.g., academic, social). Although many sufferers recognize their obsessional fears and rituals as senseless and excessive, others believe that their rituals actually serve to prevent the occurrence of disastrous consequences, i.e., they have insight (Foa et al., 1995). Depression and other anxiety disorders are often observed to co-occur with OCD. The aim of this article is to provide an up-to-date review of the latest developments in the research on cognitive-behavioral treatment of OCD. Studies on treatment effectiveness and predictors of outcome are also discussed. ********** Obsessive-compulsive disorder (OCD) is characterized by (a) recurrent, unwanted and seemingly bizarre thoughts, impulses or doubts that evoke affective distress (obsessions; e.g., that one has struck a pedestrian with their automobile); and (b) repetitive behavioral or mental rituals performed to reduce this distress (compulsions; e.g., checking the rear-view mirror). Obsessional fears tend to concern issues related to uncertainty about personal safety or the safety of others. Compulsions are performed to reduce this uncertainty. Common OCD themes are fears of contamination and washing rituals, fears of harming others and checking rituals, fears of discarding important information and saving rituals (hoarding), and blasphemous thoughts (fears of sinning) with praying rituals. Some patients also have excessive concerns about lucky/unlucky numbers, or worries about orderliness and symmetry. Development of Cognitive-Behavioral Treatment Procedures Prior to the mid 1960's, treatment for OCD consisted largely of psychodynamic psychotherapy derived from psychoanalytic ideas of unconscious motivation. Unfortunately, there are virtually no scientific studies assessing the efficacy of these treatments. However, the general consensus that OCD was considered unmanageable (Rachman & Hodgson, 1980) suggests that the effects of these therapies were neither robust nor durable. In 1966, Victor Meyer (Meyer, 1966) applied the experimentally established principles of learning theory to the treatment of OCD. He reported treating fifteen inpatients with OCD using two behavior therapy procedures that have come to be known as exposure and response (ritual) prevention (EX/RP). Meyer persuaded these patients to deliberately confront, for two hours each day, situations and stimuli they usually avoided (e.g., floors, bathrooms). The purpose of confrontation was to induce obsessional fears and urges to ritualize. The patients were also instructed to refrain from performing compulsive rituals (e.g., washing, checking) after exposure. Ten of Meyer's patients responded extremely well to this therapy and the remainder evidenced partial improvement. Follow-up studies conducted several years later found that only two of those who were successfully treated had relapsed (Meyer, Levy, & Schnurer, 1974). Foa and Kozak (1986) attempted to elucidate mechanisms involved in successful treatment of OCD (and anxiety disorders in general). They proposed that two conditions are necessary for fear reduction. First, the fear must be activated, and second, new information must be provided that is incompatible with the pathological elements of the fear. They further proposed three indicators of successful emotional processing in the context of therapy: fear activation, habituation (fear reduction) within the session, and habituation between sessions. Assessment of OCD Symptoms: The Yale-Brown Obsessive-Compulsive Scale The use of assessment instruments that are psychometrically reliable, valid, and sensitive to change is important in assuring that any improvement in symptoms is really due to the treatments, as opposed to fluctuations in a poor measuring scale. …