Clinical Handbook of Obsessive-Compulsive and Related Disorders

Clinical Handbook of Obsessive
Compulsive and Related Disorders
Eric A. Storch Adam B. Lewin

Editors
Clinical Handbook of
Obsessive
Compulsive and
Related Disorders
A Case-Based Approach to
Treating Pediatric and Adult
Populations
1C
Editors
Eric A. Storch
Department of Pediatrics, Health Policy
& Management, Psychiatry & Behavioral
Neurosciences, and Psychology
University of South Florida, St. Petersburg,
FL, USA
Adam B. Lewin
Departments of Pediatrics, Psychiatry and
Psychology
University of South Florida
Tampa, FL, USA
ISBN 978-3-319-17138-8ISBN 978-3-319-17139-5 (eBook)

DOI 10.1007/978-3-319-17139-5
Library of Congress Control Number: 2015937904
Springer Cham Heidelberg New York Dordrecht London
Springer International Publishing Switzerland 2016
This work is subject to copyright. All rights are reserved by the Publisher, whether the
whole or part of the material is concerned, specifically the rights of translation, reprinting,
reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other
physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter
developed.
The use of general descriptive names, registered names, trademarks, service marks, etc.
in this publication does not imply, even in the absence of a specific statement, that such
names are exempt from the relevant protective laws and regulations and therefore free
for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the
publisher nor the authors or the editors give a warranty, express or implied, with respect
to the material contained herein or for any errors or omissions that may have been made.
Printed on acid-free paper
Springer is a brand of Springer International Publishing
Springer International Publishing is part of Springer Science+Business Media
(www.springer.com)
Dedicated with much love to Jill, Maya, Noah,

and Ellie.
Eric A. Storch
To Dr. Gary R. Geffken, mentor, colleague, and friend.
Adam B. Lewin
Contents
Part I ObsessiveCompulsive Disorder Among Adults

1Introduction 3
Eric A. Storch and Adam B. Lewin
2 Treatment of Contamination Obsessive-Compulsive Disorder 5
Shannon M. Bennett
3Treatment of Sexual Obsessive-Compulsive Symptoms During
Exposure and Response Prevention 23
Adam M. Reid, Cindy Flores, Brian Olsen, Megan A. Barthle,
Mariam Rahmani, Andrew C. Rakhshani, Mathew Nguyen,
Gary R. Geffken and Joseph P. H. McNamara
4Treatment of Scrupulosity-Related Obsessive-Compulsive
Disorder 39
Jedidiah Siev and Jonathan D. Huppert
5Treatment of Aggressive Obsessions in an Adult with
Obsessive-Compulsive Disorder 55
Ashleigh Golden, William C. Haynes, Melanie M. VanDyke
and C. Alec Pollard
6 Treatment of Symmetry-Obsessive-Compulsive Disorder 69
Kiara R. Timpano, Julia Y. Carbonella, Shelby E. Zuckerman
and Demet ek
7Treatment of Perfectionism-Related Obsessive-Compulsive
Disorder 85
Heather K. Hood and Martin M. Antony
vii
viii
Part II Pediatric ObsessiveCompulsive Disorder

8Treatment of Contamination in Childhood
Amy Przeworski, Jennifer Freeman, Abbe Garcia,
Martin Franklin and Jeffrey Sapyta
9Treatment of Sexual Obsessions in Childhood
Danielle Ung, Chelsea M. Ale and Stephen P. H. Whiteside
reatment of Scrupulosity in Childhood
10 T
Tara S. Peris and Michelle Rozenman
11 Treatment of Aggressive Obsessions in Childhood
Ella L. Milliner-Oar, Jacinda H. Cadman and Lara J. Farrell
reatment of Symmetry in Childhood Obsessive-Compulsive
12 T
Disorder 171
Brittany M. Rudy and Sophia Zavrou
reatment of Perfectionism in Childhood
13 T
Dean McKay and Lauren Mancusi
reatment of Not-Just-Right Experiences in Childhood
14 T
Jessica Schubert, Ariel Ravid and Meredith E. Coles
Part III ObsessiveCompulsive Spectrum Disorders
15 Treatment of a Child with Tourette Syndrome 213
Loran P. Hayes, Michael B. Himle and John Piacentini
16 Treatment of an Adult with Trichotillomania 227
Martin E. Franklin and Madelyn J. Silber
17 Treatment of an Adult with Hoarding Disorder 241
Jordana Muroff and Patty Underwood
18 Treatment of an Adult with Body Dysmorphic Disorder 259
Angela Fang, Rachel A. Schwartz and Sabine Wilhelm
reatment of an Adult with Excoriation (Skin-Picking)
19 T
Disorder 273
Lauren S. Hallion, Jennifer M. Park and Nancy J. Keuthen
Contents
Contents
ix
Part IV Special Populations and Considerations

20 Treatment of Obsessive-Compulsive Disorder in Very Young
Children 291
Carly J. Johnco and Adam B. Lewin
21 Treatment of a Youngster with Tourettic Obsessive-Compulsive
Disorder 305
Krishnapriya Ramanujam and Michael B. Himle
22 Treatment of Extreme Family Accommodation in a Youth with
Eli R. Lebowitz
23 Treatment of Comorbid Obsessive-Compulsive Disorder
in Youth with ASD: The Case of Max 337
Lara J. Farrell, Sophie C. James, Brenna B. Maddox,
Donna Griffiths and Susan White
24 Treatment of Comorbid Disruptive Behavior in a Youth with
Chelsea M. Ale and Stephen P. H. Whiteside
25 Treatment of Comorbid Depression and Obsessive-Compulsive
Disorder 371
Ryan J. Jacoby and Jonathan S. Abramowitz
26 Treatment of an Adult with Obsessive-Compulsive Disorder
with Limited Treatment Motivation 385
Michael G. Wheaton, Anthony C. Puliafico, Allan Zuckoff
and H. Blair Simpson
27 Treatment of Individuals with Obsessive-Compulsive
Disorder Who Have Poor Insight 399
Michael J. Larson, Kaitlyn Whitcomb, Isaac J. Hunt
and Daniel Bjornn
28 Treatment of Obsessive-Compulsive Personality Disorder 415
Anthony Pinto
29 Treatment of Suicide Obsessions in Obsessive-Compulsive
Disorder with Comorbid Major Depressive Disorder 431
Chad T. Wetterneck, Monnica T. Williams, Ghazel Tellawi
and Simone Leavell Bruce
Index 447
Contributors
Jonathan S. Abramowitz Department of Psychology, UNC-Chapel Hill,

Chapel Hill, NC, USA
Chelsea M. Ale Department of Psychiatry and Psychology, Mayo Clinic,
Rochester, MN, USA
Martin M. Antony Department of Psychology, Ryerson University, Toronto,
ON, Canada
Megan A. Barthle Division of Medical Psychology, Department of Psychiatry, University of Florida, Gainesville, FL, USA
Shannon M. Bennett Weill Cornell Medical College, New York, NY, USA
Daniel BjornnDepartment of Psychology, Brigham Young University,
Provo, UT, USA
Simone Leavell BruceDepartment of Psychological & Brain Sciences,
Center for Mental Health Disparities, University of Louisville, Louisville,
KY, USA
Jacinda H. Cadman School of Applied Psychology and Menzies Health
Institute QLD, Griffith University, Gold Coast, QLD, Australia
Julia Y. Carbonella University of Miami, Coral Gables, FL, USA
Demet ek University of Miami, Coral Gables, FL, USA
Meredith E. ColesDepartment of Psychology, Binghamton University,
Binghamton, NY, USA
Angela FangMassachusetts General Hospital/Harvard Medical School,
Boston, MA, USA
Lara J. Farrell School of Applied Psychology and Behavioural Basis of
Health, Griffith University and Menzies Health Institute Queensland, Gold
Coast Campus, QLD, Australia
Cindy Flores Division of Medical Psychology, Department of Psychiatry,
University of Florida, Gainesville, FL, USA
xi
xii
Martin E. Franklin University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Jennifer FreemanWarren Alpert Medical School of Brown University,
Providence, RI, USA
Abbe Garcia Warren Alpert Medical School of Brown University, Providence, RI, USA
Gary R. Geffken Division of Medical Psychology, Department of Psychiatry, University of Florda, Gainesville, FL, USA
Department of Clinical and Health Psychology, University of Florida,
Gainesville, FL, USA
Ashleigh GoldenSaint Louis Behavioral Medicine Institute, Saint Louis
University, Saint Louis, MO, USA
Donna Griffiths School of Applied Psychology, Griffith University, Gold
Lauren S. HallionMassachusetts General Hospital/Harvard Medical
School, Boston, MA, USA
Loran P. Hayes Department of Psychology, University of Utah, Salt Lake
City, UT, USA
William C. Haynes St. Louis Clinical Trials, LC, Saint Louis, MO, USA
Michael B. Himle Department of Psychology, University of Utah, Salt Lake
City, UT, USA
Heather K. HoodDepartment of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, ON, Canada
Homewood Health Centre, Guelph, ON, Canada
Isaac J. HuntDepartment of Psychology, Brigham Young University,
Provo, UT, USA
Jonathan D. HuppertThe Hebrew University of Jerusalem, Jerusalem,
Israel
Ryan J. Jacoby Department of Psychology, UNC-Chapel Hill, Chapel Hill,
NC, USA
Sophie C. James School of Applied Psychology, Griffith University, Gold
Carly J. Johnco Department of Pediatrics, University of South Florida, St.
Petersburg, FL, USA
Nancy J. KeuthenOCD and Related Disorders Program, Massachusetts
General Hospital, Boston, MA, USA
Michael J. LarsonDepartment of Psychology and Neuroscience Center,
Brigham Young University, Provo, UT, USA
Contributors
Contributors
xiii
Eli R. Lebowitz Child Study Center, Yale University, New Haven, CT, USA
Adam B. LewinDepartments of Pediatrics, Psychiatry and Psychology,
University of South Florida, Tampa, FL, USA
Brenna B. Maddox Child Study Centre, Virginia Tech University, Blacksburg, VA, USA
Lauren Mancusi Department of Psychology, Fordham University, Bronx,
NY, USA
Dean McKay Department of Psychology, Fordham University, Bronx, NY,
USA
Joseph P. H. McNamara Division of Medical Psychology, Department of
Psychiatry, University of Florida, Gainesville, FL, USA
Ella L. Milliner-Oar School of Applied Psychology and Menzies Health
Institute QLD, Griffith University, Gold Coast, QLD, Australia
Jordana Muroff Boston University School of Social Work, Boston, MA,
USA
Mathew Nguyen Division of Medical Psychology, Department of Psychiatry, University of Florida, Gainesville, FL, USA
Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of Florida, Gainesville, FL, USA
Brian OlsenDivision of Medical Psychology, Department of Psychiatry,
Jennifer M. Park Massachusetts General Hospital/Harvard Medical School,
Boston, MA, USA
Tara S. Peris Division of Child and Adolescent Psychiatry, UCLA Semel
Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
Los Angeles, CA, USA
John PiacentiniSemel Institute for Neuroscience and Human Behavior,
University of California, Los Angeles, CA, USA
Anthony Pinto Department of Psychiatry, Hofstra North Shore-LIJ School
of Medicine, The Zucker Hillside Hospital, Ambulatory Psychiatry Center,
Glen Oaks, NY, USA
C. Alec Pollard Saint Louis Behavioral Medicine Institute, Saint Louis University, Saint Louis, MO, USA
Amy PrzeworskiDepartment of Psychological Sciences, Case Western
Reserve University, Cleveland, OH, USA
Anthony C. PuliaficoDepartment of Psychiatry, Columbia University
Medical Center, Columbia University, New York, NY, USA
Mariam RahmaniDivision of Child and Adolescent Psychiatry, Department of Psychiatry, University of Florida, Gainesville, FL, USA
xiv
Andrew C. RakhshaniDivision of Medical Psychology, Department of

Psychiatry, University of Florida, Gainesville, FL, USA
Krishnapriya Ramanujam Department of Psychology, University of Utah,
Salt Lake City, UT, USA
Ariel Ravid Department of Psychology, Binghamton University, Binghamton, NY, USA
Adam M. Reid Division of Medical Psychology, Department of Psychiatry,
Department of Clinical and Health Psychology, University of Florida,
Gainesville, FL, USA
Michelle Rozenman Division of Child and Adolescent Psychiatry, UCLA
Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA,
USA
Brittany M. Rudy Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida, St. Petersburg, FL, USA
Jeffrey Sapyta Duke University Medical Center, Durham, NC, USA
Jessica Schubert Department of Psychology, Binghamton University, Binghamton, NY, USA
Rachel A. SchwartzMassachusetts General Hospital/Harvard Medical
Jedidiah Siev Center for Psychological Studies, Nova Southeastern University, Fort Lauderdale, FL, USA
Madelyn J. Silber University of Pennsylvania School of Medicine, Philadelphia, PA, USA
H. Blair Simpson Anxiety Disorders Clinic and the Center for OCD and
Related Disorders, New York State Psychiatric Institute, New York, NY, USA
Department of Psychiatry, Columbia University Medical Center, Columbia
University, New York, NY, USA
Eric A. Storch Department of Pediatrics, Health Policy & Management,
Psychiatry & Behavioral Neurosciences, and Psychology University of South
Florida, St. Petersburg, FL, USA
Rogers Behavioral HealthTampa Bay, Tampa, FL, USA
All Childrens HospitalJohns Hopkins Medicine, St. Petersburg, FL, USA
Ghazel Tellawi Department of Psychological & Brain Sciences, Center for
Mental Health Disparities, University of Louisville, Louisville, KY, USA
Kiara R. Timpano Department of Psychology, University of Miami, Coral
Gables, FL, USA
Patty Underwood Riverside Community Care, Newton, MA, USA
Danielle UngDepartment of Psychology, University of South Florida,
Tampa, FL, USA
Contributors
Contributors
xv
Melanie M. VanDykeSaint Louis Behavioral Medicine Institute, Saint

Louis University, Saint Louis, MO, USA
St. Louis College of Pharmacy, Saint Louis, MO, USA
Chad T. Wetterneck Rogers Memorial Hospital, Oconomowoc, WI, USA
Department of Psychological & Brain Sciences, Center for Mental Health
Disparities, University of Louisville, Louisville, KY, USA
Michael G. Wheaton Anxiety Disorders Clinic and the Center for OCD and
Related Disorders, New York State Psychiatric Institute, New York, NY, USA
Kaitlyn Whitcomb Department of Psychology, Brigham Young University,
Provo, UT, USA
Susan WhiteChild Study Centre, Virginia Tech University, Blacksburg,
VA, USA
Stephen P. H. Whiteside Department of Psychiatry and Psychology, Mayo
Clinic, Rochester, MN, USA
Sabine Wilhelm Department of Psychiatry, Massachusetts General Hospital/Harvard Medical School, Simches Research Center, Boston, MA, USA
Monnica T. Williams Department of Psychological & Brain Sciences, Center for Mental Health Disparities, University of Louisville, Louisville, KY,
USA
Sophia Zavrou Department of Pediatrics, Rothman Center for Neuropsychiatry, University of South Florida, St. Petersburg, FL, USA
Shelby E. Zuckerman Nova Southeastern University, Fort Lauderdale, FL,
USA
Allan ZuckoffDepartments of Psychology and Psychiatry, University of
Pittsburgh, Pittsburgh, PA, USA
Part I
ObsessiveCompulsive Disorder
Among Adults
Introduction
Eric A. Storch and Adam B. Lewin
Obsessive-compulsive disorder (OCD) and

obsessive-compulsiverelated disorder (OCRD)
conditions ( i.e., trichotillomania, hoarding disorder, body dysmorphic disorder, excoriation disorder, Tourettes syndrome) are psychiatric conditions that are relatively common (Lewin and
Piacentini 2009), distressing to the patient and
their family (Geffken etal. 2006; Storch etal.
2014), and negatively impact the functionality
and quality of life (Lewin etal. 2009; Piacentini
etal. 2003; Storch etal. 2010). Fortunately, the
past decades have been characterized by exciting
treatment developments that have demonstrated
the efficacy of behaviorally based interventions
for OCD, trichotillomania, hoarding disorder,
body dysmorphic disorder, excoriation disorder,
and Tourettes syndrome (Foa and Kozak 1996;
Lewin etal. 2014; Murphy etal. 2013). However,
dissemination of such interventions has lagged
significantly, and many individuals are not able
E.A.Storch()
Department of Pediatrics, Health Policy & Management,
Psychiatry & Behavioral Neurosciences, and Psychology
University of South Florida, Box 7523, 880 6th Street
South, St. Petersburg, FL 33701, USA
e-mail: estorch@health.usf.edu
Rogers Behavioral HealthTampa Bay, Tampa, FL,
USA
All Childrens HospitalJohns Hopkins Medicine,
St. Petersburg, FL, USA
Adam B. Lewin
Departments of Pediatrics, Psychiatry and Psychology,
to access care (Blanco etal. 2006; U.S.D.H.H.S.

1999).
Given the poor dissemination of evidence-based
interventions for OCRDs, considerable efforts
have been made to provide training in evidencebased psychotherapy, both within the context of
clinician training programs and via continuing
education opportunities for licensed professional.
Even for clinicians who receive specialized training, it is not uncommon for there to be a sizable
gap between training and an opportunity to utilize
the relevant skills in practice. In generalized (nonspecialty OCRD) practices, it may be months, if
not longer, between relevant patients. In addition,
training often focuses on exemplar, straightforward
cases where, as in practice, comorbidity and other
complexities add to the sophistication. Regardless,
it is impossible to prepare clinicians for the full
range of patients through didactics alone. With
this in mind, we set out to create a text that provides
clear, structured, and easy-to-follow case illustrations written by leading experts for using evidencebased interventions in working with the range of
OCRDs across the developmental continuum that
may be encountered in clinical practice.
We have organized the book into four major
sections. The first and second sections detail
case presentations and treatment of adults and
children with OCD, covering common clinical
presentations (e.g., contamination, taboo obsessions, perfectionism, just right rituals, etc.).
The third section details clinical presentations
and treatment of OCRDs, including Tourettes
syndrome, trichotillomania, hoarding
disorder,

E. A. Storch, A. B. Lewin (eds.), Clinical Handbook of Obsessive-Compulsive and Related Disorders,
DOI 10.1007/978-3-319-17139-5_1
body dysmorphic disorder, and excoriation

disorder. Lastly, the fourth section focuses on
special populations and clinical characteristics in
OCRDs, such as working with young children,
common comorbidities (e.g., autism spectrum
disorders, disruptive behavior, depression), and
potentially complicating clinical constructs (e.g.,
family accommodation, limited insight and motivation, etc.).
To orient the reader, each chapter follows a
specific format in which the nature of problem
and associated research basis will be initially reviewed. Thereafter, a description of the presenting problem and case information is provided. Information on assessment and case conceptualization are reviewed next. The bulk of each chapter
is devoted to conveying an illustrative treatment
course that clearly describes the implementation
of evidence-based care into applied practice for
the respective clinical presentation. Complicating factors and how they were addressed are
discussed next, with the authors providing their
concluding thoughts about the particular case and
extant literature.
In undertaking this edited text, it was our
hope that this book would disseminate information about evidence-based treatment for OCRDs
in adults and youth, and provide clinicians who
work with those affected by OCRDs with a deeper understanding of conceptualization and treatment. Too often, we meet individuals who have
tirelessly pursued intervention only to be stymied
in their efforts for relief because they could not
access evidence-based care. With this in mind,
we hope that this book will serve to further develop our network of expert clinicians, which
will translate into improved treatment access and
outcomes of individuals with OCRDs.
References
Blanco, C., Olfson, M., Stein, D. J., Simpson, H. B., Gameroff, M. J., & Narrow, W. H. (2006). Treatment of
obsessive-compulsive disorder by U.S. psychiatrists.
The Journal of Clinical Psychiatry, 67(6), 946951.
E. A. Storch and A. B. Lewin

Foa, E. B., & Kozak, M. J. (1996). Psychological treatments for obsessive compulsive disorder. In M. R.
Mavissakalian & R. F. Prien (Eds.), Long-term treatments of anxiety disorders (pp.285309). Washington,
D.C.: American Psychiatric.
Geffken, G. R., Storch, E. A., Duke, D. C., Monaco, L.,
Lewin, A. B., & Goodman, W. K. (2006). Hope and
coping in family members of patients with obsessivecompulsive disorder. Journal of Anxiety Disorders,
20(5), 614629.
Lewin, A. B., & Piacentini, J. (2009). Obsessive-compulsive disorder in children. In B. J. Sadock, V. A.
Sadock, & P. Ruiz (Eds.), Kaplan & Sadocks comprehensive textbook of psychiatry: Vol.2. (9th ed.,
pp.36713678). Philadelphia: Lippincott, Williams &
Wilkins.
Lewin, A. B., Piacentini, J., Flessner, C. A., Woods, D. W.,
Franklin, M. E., Keuthen, N. J., etal. (2009). Depression, anxiety, and functional impairment in children
with trichotillomania. Depression and Anxiety, 26(6),
521527.
Lewin, A. B., Wu, M. S., McGuire, J. F., & Storch, E.
A. (2014). Cognitive behavior therapy for obsessive-compulsive and related disorders. The Psychiatric Clinics of North America, 37(3), 415445.
doi:10.1016/j.psc.2014.05.002.
Murphy, T. K., Lewin, A. B., Storch, E. A., Stock, S., &
American Academy of Child Adolescent Psychiatry
Committee on Quality Issues. (2013). Practice parameter for the assessment and treatment of children and
adolescents with tic disorders. Journal of the American Academy of Child and Adolescent Psychiatry,
52(12), 13411359. doi:10.1016/j.jaac.2013.09.015.
Piacentini, J., Bergman, R. L., Keller, M., & McCracken,
J. (2003). Functional impairment in children and adolescents with obsessive-compulsive disorder. Journal of Child and Adolescent Psychopharmacology,
13(Suppl 1), S61S69.
Storch, E. A., Bjorgvinsson, T., Riemann, B., Lewin, A.
B., Morales, M. J., & Murphy, T. K. (2010). Factors
associated with poor response in cognitive-behavioral
therapy for pediatric obsessive-compulsive disorder.
Bulletin of the Menninger Clinic, 74(2), 167185.
doi:10.1521/bumc.2010.74.2.167 [pii].
Storch, E. A., Wu, M. S., Small, B. J., Crawford, E. A.,
Lewin, A. B., Horng, B., & Murphy, T. K. (2014).
Mediators and moderators of functional impairment
in adults with obsessive-compulsive disorder. Comprehensive Psychiatry, 55(3), 489496. doi:10.1016/j.
comppsych.2013.10.014.
U.S.D.H.H.S. (1999). Mental health: A report of the surgeon generalexecutive summary. Rockville, MD:
U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, National
Institutes of Health, National Institute of Mental
Health.
Treatment of Contamination
Obsessive-Compulsive
Disorder
Shannon M. Bennett
Cleaning Out the Anxiety:

Phenomenology, Assessment, and
Treatment of Contamination Obsessive-Compulsive Disorder in an Adult
The contamination subtype of obsessive-compulsive disorder (OCD) is characterized by thoughts,
images, or impulses (obsessions) of dirt, germs,
and illness that are typically intrusive, repetitive,
and exaggerated beyond the actual likelihood
of contamination, the spread of germs, or contracting a disease. These contamination-related
obsessions cause fear, disgust, discomfort, and/
or distress and most often result in compensatory behaviors, habits, or rituals (compulsions)
performed to achieve temporary relief or to neutralize the concern, such as excessive washing,
cleaning, or avoidance of contamination-related
stimuli or situations (5th ed.; DSM-5; American Psychiatric Association 2013). The lifetime
prevalence of OCD is estimated to be around
23% (Kessler etal. 2005), and roughly 50% of
patients report experiencing contamination-related symptoms (Ball etal. 1996; Rasmussen and
Eisen 1988). OCD typically follows a chronic
course (Skoog and Skoog 1999) and is among the
most disabling of psychiatric and medical conditions without adequate intervention (Murray and
Lopez 1996). Several studies have described contamination OCD symptoms to be among the most
S.M.Bennett()
Weill Cornell Medical College, New York, NY, USA
e-mail: smb9017@med.cornell.edu
impairing, causing significant functional impairment and decreased quality of life (Albert etal.
2010; Fontenelle etal. 2010; Vorstenbosch etal.
2012; Jacoby etal. 2014).
Phenomenology of Contamination OCD

For an individual with contamination OCD, potential contaminants can be anywhere and everywhere, including other people, certain places,
objects, or even the air, often leaving the patient
constantly vigilant, anxious, and alert for germs,
dirt, or other impurities. Even in a seemingly
safe environment, such as ones home, one
may string together a series of connections to the
contaminated outside world that leaves the individual feeling anxious and in need to clean (e.g.,
I smelled something odorous while walking outside, it was probably animal feces, it must be on
my shoe, my shoe was in my car, my bag was
also in my car, I brought my bag inside the home,
so there is now animal feces in my home).
Some studies suggest that contamination OCD
symptoms are found to be associated with poor insight more often than other symptom types (Cherian etal. 2012). The amount of insight the patient
has into the exaggerated nature of their concerns
and unnecessary frequency of the compulsions is
an important qualifier when describing patients
with OCD. Limited or poor insight is often associated with more severe OCD and can make
treatment more challenging. In a sample of 545
patients with OCD (91% with good insight, 9%

DOI 10.1007/978-3-319-17139-5_2
with poor insight), contamination-related OCD

symptoms (contamination fears and washing
compulsions) were associated with poor insight
(X2=16.114, p<0.001) above all other symptom
clusters (N=40, 85.1% of poor insight group).
Poor insight was also associated with increased
(worse) clinical global severity rating (Guy and
Bonato 1970; clinical global impression (CGI)
severity, X2=3.273, p=0.001 in this study). This
speaks to the difficulty many patients have recognizing that their contamination-related concerns
are not rationally related to the actual risk.
Patients who recognize that their contamination-related fears and behaviors are irrational
may still hold strong beliefs about germs and
cleanliness that fall toward the extreme end of
the cleanliness spectrum when compared to
the general population. Many individuals with
contamination anxiety may have inherited and/
or learned these beliefs and behaviors from family members (Alonso etal. 2004; Monzani etal.
2014). Many studies support the heritability of
OCD and suggest that symptom dimensions, such
as contamination, may be heritable as well. In
youth, parenting practices can also contribute to
the maintenance and often exacerbation of OCD
symptoms. For example, parental accommodation
of compulsions, avoidance, and other behaviors
related to contamination fears is typically related
to greater symptom severity over time (Liebowitz etal. 2012). In addition, family factors such
as high family cohesion, low family conflict, and
low parental blame are significantly linked to better treatment outcome (Peris etal. 2012) .
Disgust has emerged as a key affective experience for many patients with contamination
OCD. Disgust sensitivity, or the degree to which
one feels disgusted by specific stimuli or situations, has been correlated with contamination
OCD above other symptom clusters (Woody and
Tolin 2002). Similar to fear, avoidance related
to a strong disgust reaction prevents the individual from learning that disgusting stimuli are
not harmful or dangerous, and that the feared
outcome is not likely to come true. With patients
for whom disgust is a significant part of the emotional distress related to contamination concerns,
exposure to and tolerance of this feeling is an
S. M. Bennett
important aspect of the treatment (Adams etal.

2010).
Washing and cleaning rituals can take up a
significant amount of time, often making these
patients late, interfering with work or school, and
detracting from interpersonal relationships and
social situations. In one study of 53 individuals
with OCD and 53 matched controls, those with
OCD reported significantly lower quality of life,
with washing compulsions predicting 31% of the
variance on the quality-of-life scale (Fontenelle
etal. 2010). Another study showed that contamination symptoms were the only symptom dimension related to functional impairment after controlling for other study variables, given the significant social, physical, and health-related consequences of excessive and compulsive washing
behaviors (Jacoby etal. 2014). Many people with
contamination OCD symptoms complain of skin
irritation as a result of excessive and repetitive
washing and sanitizing rituals. The avoidance
related to contamination fears also impacts the
quality of life for these individuals.
Treatment of Contamination OCD

Like most OCD symptoms, randomized-controlled trial research has demonstrated cognitivebehavioral therapy (CBT), specifically exposure
and response prevention (ERP) treatment, to
be efficacious in reducing contamination OCD
symptoms in adults (Foa etal. 2005; Simpson
etal. 2008) and to improve the quality of life
for these patients (Diefenbach etal. 2007). Pharmacotherapy with serotonin reuptake inhibitors
(SRIs) has also been shown to be efficacious
in the treatment of OCD (Foa etal. 2005), yet
a review of studies examining the additive effect of using these medications in combination
with ERP showed little to no advantage over ERP
alone (Foa etal. 2002). Further, ERP was found
to augment SRI treatment in adults with OCD,
with 80% of patients achieving an additional
25% score decrease on the YaleBrown Obsessive Compulsive Scale (YBOCS; Goodman
etal. 1989). Another study found that ERP, as an
augmenting agent, was superior to the atypical
2 Treatment of Contamination Obsessive-Compulsive Disorder
antipsychotic medication risperidone and to placebo in reducing OCD symptoms and improving
insight, functioning, and quality of life (Simpson
etal. 2013). However, the large majority of patients with OCD, including contamination OCD,
are treated with SRI medication (65%), according to the analysis of the 1997 and 1999 American Psychiatric Institute for Research and Education Practice Research Network (PRN) Study
of Psychiatric Patients and Treatments, while
just 7.5% of patients in this sample received
CBT (Blanco etal. 2006). The patients who did
receive CBT reported the highest scores on the
Global Access of Functioning (GAF) Scale. The
use of benzodiazepines and antipsychotic medications were also a common form of treatment in
this sample of patients, often in the absence of an
SRI medication, despite limited support for these
medications as primary interventions for OCD.
In ERP treatment, the patient is gradually put
in contact with feared stimuli, while refraining
from engaging in compensatory compulsions.
When ERP is effective, prolonged, and repeated
exposure results in habituation to or learned tolerance of the anxiety and an extinction of the fear
that previously triggered compulsive behavior
(Abramowitz 2006). ERP is a challenging treatment modality, requiring motivation, work, and
often discomfort to achieve benefit. In order to
help patients tolerate the exposure process, these
practices are typically done gradually in accordance with a predetermined list made by the patients therapist, called an exposure hierarchy.
Despite the challenge inherent in ERP treatment,
a survey of patient preferences found that patients reported preference for ERP or combination treatment (ERP+medication) over medication alone or other novel and experimental interventions (Patel and Simpson 2010).
Case Example
Presenting Problem
MR is a 24-year-old Caucasian male presenting
with intrusive, distressing thoughts about contamination and germs, particularly an exaggerated
fear of contracting the flu, and a strong disgust

reaction triggered by other peoples breath. He
also worried about being poisoned by environmental contaminants that he feared could get into
his food from cleaning supplies and other sources.
MR recalled first experiencing intrusive contamination fears in middle school, and again in his last
year of high school and first year of college. His
symptoms became interfering once again about 6
months after he graduated from college; however,
MR believed he could take care of the symptoms
by [him]self and thus did not immediately seek
treatment. Over the past year, MR found that his
contamination fears and washing compulsions became worse and worse, until they were taking up
nearly three to four hours of his time each day.
In addition to the amount of time taken up by
compulsions, the consequences of these behaviors were interfering with MRs standing at his
job, his social relationships, and were causing
physical discomfort. MRs hands were dry and
cracked from frequent washing. He had received
warnings at work because he was often late and
was not meeting deadlines or minimum work requirements due to frequent trips to the bathroom
to wash. MR reported that his compulsive and
avoidant behaviors were motivated by intrusive
thoughts and intense anxiety related to contracting a disease, such as the flu. His social relationships were suffering because he typically avoided eating anywhere outside of his home in an attempt to avoid contact with cleaning substances
that he believed to be poisonous or bad for his
health. He also had a hard time maintaining conversations with most people outside of his closest
family and friends because he was anxious about
being contaminated by other peoples breath.
He stated that while he knew this thought was
crazy, he feared that if he inhaled the breath of
other people he could take on the qualities of
their lifestyle or personality that he did not like.
MR noted that intrusive thoughts about contracting a disease, being poisoned, or taking on other
peoples negative qualities came into his mind
nearly all day long, and, though he could delay
his compulsions sometimes, his anxiety was too
overwhelming to resist engaging in compulsive
behaviors to negate these beliefs.
Background Information Having been anxious

since an early age, MR reported his earliest memories of obsessions and compulsions occurring in
middle school when he started a new school following his family moving to a neighboring town.
MR lived with his mother, father, and younger
brother in a middle-class neighborhood where
he attended a public school. MR reported that
his mother was always very conscientious about
cleanliness, often asking MR and his brother
if they had washed their hands when they got
home or before meals. He described growing up
in a very neat and clean home, and shared that
he could receive an allowance for completing
household chores, which he did diligently. MR
said that his father worked a lot, and MR could
not recall if his father exhibited any symptoms of
anxiety OR OCD. MR was a good student who
excelled in math and science, but struggled somewhat with reading when he was in grade school.
MR recalled that at the start of his seventhgrade year in a new school, he became more
anxious about getting sick and did not like when
other childrens things would touch his desk for
fear that his desk would be contaminated, particularly the students whom he believed were dirty
or did not wash their hands enough. He remembered worrying that if he were to become sick, he
would have to miss school and then would fall
behind in schoolwork and miss out on opportunities to make friends. After a classmate vomited
in the classroom, MRs anxious thoughts about
getting sick became more frequent, and he sometimes had a hard time focusing in class. When he
began leaving the classroom multiple times per
day to wash his hands, he was asked to visit with
the guidance counselor and began meeting with
her on a weekly basis. The guidance counselor
suggested that MR join the basketball team as
a way to make friends. MR remembered that at
first he was anxious about getting sweat from the
other players on his skin, but he really liked being
a part of the team and found that he was able to
concentrate better on his homework after practice
and found it easier to fall asleep. By the spring of
that year, his intrusive thoughts and compulsive
behaviors were no longer interfering in his day-
S. M. Bennett
to-day life, though he remained more attentive to

cleanliness than many of his peers.
MR reported that he remained free from major
intrusions related to OCD symptoms until he was
a senior in high school, at which point he believes
the stress of applying to college caused his intrusive thoughts to resurface. He became so worried
about the deadlines for applications, and anxious
about not getting into a school of his choosing,
that he found himself washing his hands several
times a day and taking longer and longer showers, with particular cleaning rituals he would need
to perform before he could move on with his day.
MR feared that if he did not complete these compulsions that he would get sick and would not
be able to complete his work. He also reported
an intrusive thought that if he did not complete
his cleaning rituals in just the right way, then he
would not get into college, though he knew rationally that cleaning rituals and college acceptance
were not causally related. MR recalled that these
thoughts and rituals took up time from his day,
even after he was accepted into college and into
his freshman year. He compulsively cleaned his
side of the dorm room and tried to keep his things
separate from his roommates possessions, so as
not to contaminate his belongings. When cleaning rituals began to interfere with MRs ability
to get to class on time and enjoy social activities, MR visited the student health center and was
started on fluoxetine. He found that this medicine took the edge off and helped him to feel
a little less anxious overall. MR took fluoxetine
for about a year but went off of this medication
during his second year of college because he had
a serious girlfriend and found the sexual side effects to be interfering. He found that he was able
to manage his anxiety without medication for the
most part throughout the rest of college.
When MR graduated, he moved to a large
city where he took a job at a mobile application
development company, collecting and analyzing
data on recently released apps. MR reported
that this was not his dream job but that he was
happy to have found a job after college, as many
of his friends were still struggling to do so, and
he was hoping this job would lead to another
position in which he was more interested. MR
reported that he had been nervous to move to a

big city and was finding the environment to be
anxiety provoking. He could not afford to live
alone and found a roommate through a friend, but
was currently unhappy with his living situation.
He found himself separating his things from his
roommates things, and labeling all of his food
in the kitchen, as intrusive thoughts of contamination became more frequent and distressing. He
would also throw away any cleaning products in
the apartment that were not labeled organic, for
fear that he could be poisoned or develop a brain
tumor from the chemicals. MR developed more
and more compulsions and rituals in response
to intrusive thoughts, and found that OCD was
taking up a significant portion of his day. He decided to seek treatment after he was given a second warning at work for frequent tardiness and a
decline in his job performance.
At his first appointment, MR described that he
would start his day with a showering ritual that lasted about one hour every morning. MR described
that if he did not complete this morning routine
correctly, he would have to start over for fear that
something terrible would happen at some point
during the rest of the day. MR would first rinse
off the shower with warm water to get rid of any
cleaning solution residue that could be left in the
shower, even if the shower had not been cleaned
with a cleaning solution the day before. He would
then wash his hands for about 5min to make sure
there was no cleaning solution on his hands. MR
washed himself for about 30min in the shower,
during which time he felt like he had to wash his
face several times to get rid of any remnants of
other peoples breath that may still be on him from
the previous day. Upon exiting the shower, MR
washed his hands, feet, and face again at the sink
to make sure there were no cleaning solvents on
those parts of his body, he used a clean towel to
dry off, and then could begin dressing.
Throughout the day, MR would wash his
hands and face when he feared he was contaminated by another persons breath, particularly
after conversations with strangers, acquaintances, or with people he did not particularly like.
In the evening, he repeated the morning shower
routine before he could get into bed in order to
get rid of any contaminants from his day and so

as not to contaminate his bed. He washed his
clothes and towels each day because he did not
want them to touch or contaminate anything else
in his room. He would not bring his workbag
into his room because it was contaminated by the
outside world, and would frequently wipe off his
phone and laptop with a cleaning wipe when he
got home before using these items in his apartment or bringing them into his bedroom.
MR reported that he had a group of friends
with whom he enjoyed spending time, but that he
had been more particular about where he would
go with them of late, which was limiting his social contact. He refused to eat at most restaurants
because he did not know what kind of cleaning
products they used on the dishes and silverware,
though there were a handful of places where he
felt comfortable because he had been there many
times without anything bad happening. He also
had difficulty meeting new people because of his
intrusive thoughts about being contaminated by
their breath if he had not yet had time to judge
the good and bad aspects of their personality.
MR could articulate that each of these concerns
was irrational; however, the anxiety produced by
these intrusive thoughts and fears of something
bad happening was very strong, and he was unable to resist giving in and performing the compulsions despite the multiple domains of functional impairment.
Assessment and Case Conceptualization

As part of the initial assessment, MR completed
the YBOCS (Goodman etal. 1989), a clinicianled interview tool designed to assess the type
and severity of OCD symptoms. The patient
was asked to report on the time spent on obsessions, the interference and distress experienced,
and how much resistance and control he felt he
had over these thoughts, and each item is rated
from 0 (none) to 4 (extreme). The same five domains were assessed for compulsions separately,
resulting in a total score between 0 and 40 for
the ten items. MRs total YBOCS score at intake
was 26, which put him in the lower end of the
10
S. M. Bennett
severe range on this scale. MR endorsed that the

intrusive thoughts about germs, contamination,
or something bad happening were on his mind
nearly all day, scoring a 4 on this item. However,
he described the interference and distress related
to the obsessions themselves as challenging but
manageable, scoring a 2 on those items. He reported that he made a good effort to resist the obsessions, but rarely felt like he was able to stop or
control the thoughts, which scored as a 2 and a 3
on the resistance and control items, respectively.
MR endorsed that he spent 34h per day,
on average, engaged in compulsive washing
or cleaning behaviors, scoring a 3 on this item.
Given that he had recently been reprimanded for
a second time at his job because of tardiness, MR
feared he was at risk of losing his job if he was
not able to better manage his compulsions, which
was considered to be a severe interference earning a 3 on the scale. However, MR said that, in
the moment, the anxiety associated with his rituals was somewhat manageable, and he was able
to delay engaging in compulsions at times, earning a 2 for distress. MR often made an effort to
resist his compulsions, at least temporarily, before giving in to them eventually or making up
for the delay in his morning and evening shower
ritual, which was rated as a two and a three on the
resistance and control scales, respectively.
A comprehensive list of MRs obsessions and
compulsions was compiled from the items he
endorsed on the YBOCS. MR was then asked
to rate the anxiety associated with changing or
resisting compulsions, or decreasing avoidance,
and rank these from easiest to most challenging
or anxiety provoking, creating an exposure hierarchy (see Fig.2.1).
MRs OCD symptoms were chronic, recurring, and had become functionally impairing at
various points in his development, as is typical
for OCD when it is not adequately treated. MR
had experienced some relief from supportive
counseling during his early teen years, and from
medication during college, but he had never engaged in CBT or ERP treatment. Given that MR
was motivated to change his ritual behaviors in
order to decrease impairment in his work and
social life, he expressed interest in trying ERP.
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Fig. 2.1 MRs exposure hierarchy
However, while he could articulate that he knew

his obsessive thoughts were unrealistic, he maintained a what if belief that it was still possible
he could get sick if he did not follow his rituals
correctly. Given this variation in his insight and
the relief he experienced from medication previously, combination treatment (ERP plus SSRI)
was recommended, and a referral to a psychiatrist
was made. MR was started on sertraline, given
the evidence base for efficacy in treating OCD
and to potentially avoid the negative side effects
he had previously experienced on fluoxetine.
Treatment Course
Psychoeducation (Sessions 12) Following the
initial assessment, MRs treatment began with
11
psychoeducation in session 1 about the nature

of OCD and its treatment. We discussed MRs
symptoms in the context of the three-component
model of emotions (Barlow etal. 2011), highlighting the connections between his thoughts,
feelings, and behavior (see Fig.2.2), as follows:
OCD is a characterized by fear and anxiety
which can often feel out of control. If I were to
tell you to just stop feeling anxious about contamination, it would probably not be helpful.
However, we can break your anxiety down into
three parts: the intrusive thoughts you are having, the discomfort you feel in your body when
you have those thoughts, and the compulsive behaviors you engage in to try to feel better. What
we will then do in treatment is learn and practice skills and strategies in each of these three
areas, for example: learning how to respond to
7KUHH&RPSRQHQW0RGHORI(PRWLRQV
7KRXJKWV
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Fig. 2.2 Three-component model of emotions. (Adapted from Barlow etal. 2011)
12
your intrusive thoughts in a more helpful way by

ignoring the thoughts instead of fighting them
or by challenging the validity or helpfulness of
those thoughts; learning strategies to calm your
body down or to tolerate uncomfortable feelings
in your body until they go away; and then gradually learning to resist engaging in compulsive behaviors or rituals that are taking up so much time
for you.
MR was able to provide examples of the intrusive thoughts, uncomfortable feelings, and compulsive behaviors he experiences, and fit these
into the three-component model to better understand these relationships. We discussed the role
of negative reinforcement, such that his compulsive behaviors are reinforced, or are more likely
to happen recurrently, because they take away the
uncomfortable feelings of anxiety and disgust he
experiences as a result of his intrusive thoughts.
We also discussed the source of the uncomfortable feelings associated with fear and anxiety as
being related to his sympathetic nervous system,
or fight-or-flight system, and characterized
these physiological reactions as a false alarm:
The sympathetic nervous system is the bodys
alarm system, preparing us to respond quickly in
the face of real danger by rapidly sending messages from the 5 senses to the brain to the rest
of the body. If we were faced with an intruder or
a fire in this building, our bodys alarm system
would go off so we could keep ourselves safe by
fighting the intruder, running away, or freezing
until we can assess the situation and decide how
best to respond. The fight or flight response involves several systems in the body: heightening
our senses, sending energy to our large muscle
groups for strength and speed, increasing our
heart rate and breathing, and shutting down other
systems like our digestive system that would be
less important in an emergency situation. If we
were really running away from a dangerous situation, we would not notice these changes because
we would be using the extra energy and focus to
keep ourselves safe. However, sometimes the
brain can make a mistake and interpret something as dangerous or life threatening when it is
not, thus triggering the same alarm system, only
this time it is a false alarm. In a false alarm situa-
S. M. Bennett
tion, such as fear of being contaminated by someones breath, or poisoned by cleaning products,
our brain and body systems will change in just
the same waycausing rapid heart rate, difficulty breathing, sweating, shaking, stomach distress
or feeling like we need to use the bathroom, and
a hyper-vigilance for something threatening, but
since we are not typically using that energy to run
away or fight something off, we feel very uncomfortable. It is very hard to ignore this false alarm,
because our body is trained to respond in order
to keep us safe. During the course of treatment,
we are going to work on telling the difference
between a false alarm and a real alarm, and are
going to re-calibrate your bodys alarm system
so it goes off when it needs to go off, but stops
going off when you are not actually in danger.
(Piacentini etal. 2007)
Psychoeducation included a description of
how ERP treatment works by gradually exposing the patient to anxiety-provoking situations
and resisting the urge to engage in compulsions.
This explanation included a description of the
parasympathetic nervous, or the opposing system to the fight-or-flight system, which calms the
body down once danger has passed. The rationale for exposure is based on the idea that when
one resists engaging in a compulsion in order to
decrease anxiety, one may feel anxious longer
but will ultimately learn that (a) the anxiety went
away on its own over time due to the regulating
effect of the parasympathetic nervous system;
and/or (b) even if one remained uncomfortable,
the feared outcome did not occur or was not as
bad as one imagined it would be. Sometimes one
will experience a decrease in anxiety (habituation) both within a specific exposure practice
and between repeated exposure practices (see
Fig.2.3). However, recent research suggests that
sustained arousal and variability in subjective
fear responding during exposure may predict a
better outcome than habituation over multiple exposure practices (Culver etal. 2012).
At the end of session 1, MR was asked to monitor his intrusive thoughts, feelings of discomfort
and distress, and compulsive behaviors throughout the next week, according to the three-component model to better understand his symptoms,
13
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Fig. 2.3 Illustration of avoidance versus exposure. (Adapted from Ehrenreich etal. 2008)
as well as the triggers and consequences related

to these symptoms (see Fig.2.4).
Cognitive Restructuring (Sessions 23)For
session 2, MR brought back a symptom-moni-
toring form he had completed during the week,

and we discussed what he had noticed and
learned from the monitoring exercise. We identified the maladaptive, inaccurate, and unhelpful thoughts he had written, and labeled these
14
S. M. Bennett
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Fig. 2.4 Symptom-monitoring forms
thoughts according to a list of cognitive distortions (e.g., thinking the worst, overestimating
the probability, magical thinking). MR identified that he often overestimated the probability
of bad things happening (such as getting sick or
being poisoned). He also frequently engaged in
7KLQNLQJ7UDS
magical thinking, or believing that two things are

connected that are not actually connected (such
as inhaling someones breath and inheriting
their personality traits, or not adhering to a rigid
shower routine and something bad happening
later in the day). We also reviewed psychoeducation from session 1, and discussed what MR
had learned about triggers and consequences of
his symptoms. For example, he learned that he

was more likely to engage in compulsions when
he was already feeling stressed by a task at work
and was more likely to avoid social opportunities
with his friends if someone he did not know was
going to be there.
We discussed the function of his compulsive
behaviors and avoidance as not only alleviating
anxiety about contamination but also potentially
being reinforced by underlying social and performance anxiety about meeting new people or
being judged poorly for his work. MR recognized
that when he was younger, he felt anxious about
making friends, meeting new people, having to
share his work with others, and getting grades
back from teachers, for fear that he was going to
make a mistake or would not be good enough. We
worked on using the same set of cognitive distortions to identify unhelpful thinking patterns related to sharing his work or meeting new people
(e.g., fortune-telling, mind reading, ignoring the
positive, focusing on the negative). MRs homework following session 2 included monitoring his
symptoms and labeling cognitive distortions, or
thinking traps, when present. We also reviewed
and re-rated MRs symptom hierarchy toward
the end of session 2 and discussed an exposure
practice from the list that MR could try on his
own, which would not be too taxing for him but
would allow him to begin changing the way he
responds to his symptoms. While re-rating, MR
explained that shortening his time in the shower
in the morning was probably going to be easier
than trying to not wipe off his phone or computer
and agreed to shorten his time in the shower by
5min, using a timer to track his progress. In general, he noticed a few changes in his ratings when
he thought about actually selecting these for exposure practices (see Fig.2.1, week 2).
At the start of session 3, we discussed MRs
progress throughout the week decreasing the
amount of time he spent in the shower, and catching and labeling his thinking traps. He reported
that most days it was manageable to decrease
his morning shower to 25min, and noted he decreased his morning shower time to 22min toward the end of the week, admitting there were
2 days during the week that were more challeng-
15
ing. MR reported that he found it helpful to identify and label thinking traps, but noted that while
helping him to remember that the thoughts were
unrealistic and a product of OCD, it did not help
to decrease the frequency of the thoughts or the
urge to complete compulsions. We discussed how
(a) it would take repeated practice of cognitive
strategies to experience a difference in how he responds to intrusive thoughts, and (b) our goal was
not necessarily to get rid of the thoughts completely, but to be able to ignore them or respond
in a different way. This was a helpful time to review that of the three components in the model
(thoughts, feelings, and behavior), our behavior
is the one over which we have the most control.
We cannot completely control what thoughts
come into our minds, and we cannot completely
control our emotional responses; however, we
can make choices about how we respond behaviorally to our thoughts and our emotional and
physical feelings.
Time was spent in session 3 reviewing strategies for cognitive restructuring, or ways to
change unrealistic, unhelpful thoughts into more
realistic, more helpful thoughts. It was important
to note that the goal of cognitive restructuring is
not to generate completely positive, optimistic
thoughts, because these may not be realistic either. For example, telling oneself I will never get
sick or I will not make a mistake is probably
not realistic and therefore not optimally helpful.
On the other hand, once we have identified cognitive distortions, or thinking traps, we can challenge the distorted aspect of the thought to come
up with a more realistic, and therefore more helpful thought. To this end, we practiced using strategies such as determining the realistic probability
of the feared outcome (e.g., the chances that I
will be poisoned by cleaning products in my dayto-day life is incredibly low), and using past experiences (e.g., I have never been poisoned in a
restaurant or heard of someone being poisoned
by cleaning products because of eating in a restaurant), and looking at the situation from another persons perspective (e.g., other people do
not worry about being poisoned in a restaurant).
We then practiced using this strategy in session
with an agreed-upon in-session exposure task.
16
Exposure and Response Prevention (Sessions 212) With some Pre-session preparation,
in-session exposure practices can be planned
early on in treatment. For MR, we selected eating something in the therapy office to approximate eating in a less familiar environment. We
varied this exposure practice according to what
MR felt comfortable doing over time (e.g., using
disposable utensils versus utensils that had been
washed, but he did not know the products used
to wash them). MR was apprehensive about this
exposure task, and opted to use a paper plate and
plastic utensils from the office kitchen, recognizing that they would not have been washed with
cleaning solution, but were still in the kitchen
with unknown cleaning products which was still
somewhat anxiety provoking. We tracked MRs
anxiety using the subjective units of distress
scale (SUDS, a 010 scale through which individuals can report their subjective experience of
anxiety where 10 represents maximum anxiety.
MR rated his SUDS at a 4 in anticipation of doing
this exposure.
We used a prewrapped muffin from the office
vending machine, and when MR unwrapped the
muffin and put it on the paper plate, he noted his
SUDS increased to a 5. MR used cognitive restructuring skills to generate coping thoughts,
such as I dont know anyone who has been
poisoned eating a muffin with plastic utensils,
but reported that while he understood this intellectually, it did not decrease his anxiety in the
moment. We discussed how this underscored the
importance of actually completing the exposure
practice in order to truly challenge his anxiety
about this situation. MR slowly ate the muffin in
session, over the course of about 10min, monitoring his SUDS ratings throughout the practice. He
found that his anxiety remained around a 4 until
close to the end of the exposure when it decreased
to a 3 and then a 2. At the end of the session, MR
was congratulated and praised for attempting the
in-session exposure, and we selected at-home
practice tasks for the week. Following session 3,
MRs homework included practicing cognitive
restructuring to challenge his intrusive thoughts,
decreasing his shower time to 20min, and going
over to a friends house to eat at least once during
S. M. Bennett
the week. He agreed to monitor these exposure

practices using the form we had used for the insession exposure task (see Fig.2.5).
Ideally, ERP begins as early as possible in the
course of treatment. For MR, this included creating a symptom hierarchy at the intake assessment, discussing the rationale for exposure in
session 1, assigning a relatively easy at-home exposure practice following session 2, and completing the first in-session exposure practice during
session 3. Other patients may need a slower start
to ERP, with additional emotion regulation skills
provided before initiating the exposure practices.
For example, patients who engage in unsafe behaviors (e.g., self-harm) when experiencing intense emotions would first need practice in using
adaptive emotion regulation strategies before
initiating exposure practice. However, the theory
behind exposure practice can be discussed as
early and often as appropriate. That is, decreasing distress and anxiety through compulsions or
avoidance may feel better in the short term, but
it serves only to maintain or increase anxiety in
the long term. Exposure corrects for this by experiencing and tolerating anxiety long enough to
learn that the feared outcome did not come true,
or that one could handle the situation even if it
was less than ideal.
MR returned to session 4 feeling positive
about the progress he had made during the week
with his assigned exposures. In session 4, and the
sessions that followed, we continued to work together to complete in-session exposure practices
that approximated the anxiety he experienced
in his day-to-day life and then assign ERP tasks
to practice during the week. In session 4, MR
practiced touching the counters, sink, and other
surfaces in the office kitchen (exposure) without
washing his hands (response prevention), to tolerate the anxiety of not knowing what products
were used to clean these surfaces. After several
minutes of managing this anxiety, he touched
his face and feet without washing afterward to
approximate the anxiety around his pre-shower
washing ritual. His home practice goal following
session 4 was to resist rinsing off the shower before getting into the shower, and resist washing
his hands, feet, and face before and after shower-
17
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Fig. 2.5 Exposure practice monitoring form. (Adapted from Bennett and OConnor 2008)
ing in the morning. To this point, MR had primarily been targeting his morning shower because it
was less challenging than the evening shower, so
we also added a goal of starting to reduce his time
in the shower in the evening if possible.
In session 5, MR reported that he was successful at his ERP goals around the morning shower,
but that the evening shower continued to be more
challenging, given the extent of contamination
anxiety he experienced at the end of the day.
18
He was able to resist rinsing off the shower in

the evening, and stopped washing his hands and
feet and face on some days before the evening
shower, but continued to take longer showers in
the evening. We agreed to keep working on this
goal, while also tackling other symptoms. Having not yet addressed his fear of inhaling other
peoples breath, we discussed a hierarchy of exposures to address this symptom. These included
my breathing into a bottle, and then having MR
inhale air from the bottle after waiting a designated period of time that would get shorter with
more practice. We discussed ways to make this
more challenging, and MR provided SUDS ratings for each task, including having other people
breathe into the bottle, decreasing the amount of
time before he inhaled air from the bottle, and
over time blowing air in his direction without
using the bottle. The response prevention exercise would include MR inhaling the contaminated air without washing his face or exhaling the
air out. During session 5, we worked to decrease
the amount of time between my breathing into
the bottle and MR inhaling the air from the bottle, without then washing his face and hands. He
agreed to practice resisting washing his face and
hands throughout the week after having conversations with people with whom he felt relatively
comfortable (i.e., not strangers).
At the start of session 6, MR again re-rated his
exposure hierarchy and noted for which symptoms his anxiety was decreasing, including those
which we had not yet directly targeted with exposure practice. At this point, MR was spending less
time in the shower both in the morning and in the
evening, he felt more comfortable eating over at
friends homes or in familiar restaurants, and he
had stopped rinsing the shower off before every
use. He was washing his hands and face somewhat less frequently, though there was still room
for improvement. We continued working on inhaling air contaminated by other peoples breath
without washing. In the session, we practiced
my blowing air in MRs direction, and MR practiced having conversations with other unfamiliar
people in the office without washing afterward.
He continued to work on having conversations
without washing afterward in between sessions.
S. M. Bennett
He also agreed to resist wiping his phone, laptop, and workbag at the end of the day, and instead would practice using them at home without
cleaning first.
During sessions 711, we continued in-session
exposure practices including leaving the office to
eat in an unfamiliar restaurant, eating off a plate
cleaned with a nonorganic product, having MR
use nonorganic cleaning products to wipe down
the counter in the office kitchen, purposely contaminating his phone and workbag with nonorganic cleaning products and/or other peoples breath
without wiping them down afterward, and having
conversations with store clerks and other strangers without washing afterward. As MR worked his
way up the hierarchy, we often worked together
to find ways to break down the more challenging
symptoms into exposures involving smaller steps
that made them feel more manageable. In regularly re-rating his hierarchy, MR found that his highest symptom ratings were decreased even before
we directly addressed those symptoms, and he was
feeling more confident that he could handle challenging exposures in between sessions.
In addition, we also designed exposures to
help MR gradually become more comfortable
with meeting new people, and with handing in
less-than-perfect work. For example, MR practiced making small talk with staff in the office
and people in the neighboring businesses, to help
him feel more comfortable and less avoidant
when meeting new people in social situations.
He wrote a short essay on a topic he did not know
very much about and handed it in to be graded
in the session, to help him tolerate discomfort
with feedback on his work. In later sessions (sessions 10 and 11), MR practiced coming up with a
myriad of different exposure practice options for
different potential contamination symptoms to
ensure that he would be able to utilize this technique on his own in the future should any new
symptoms emerge.
Relapse Prevention In our final sessions (sessions 11 and 12), we focused on reviewing
everything that MR had learned throughout the
course of treatment. We waited 2 weeks, instead
of 1 week, in between sessions 10 and 11, and
sessions 11 and 12, to give MR more time to

practice on his own. We identified the progress
that had been made across a number of contamination symptoms, and set goals for those symptoms that still needed some additional work. We
made a plan for how MR could continue to use
ERP strategies to target these symptoms and
decrease his anxiety. We also set up a schedule
for booster sessions, with the first check-in session scheduled for about a month after the last
regular session. We discussed the importance
of staying alert for any increase in avoidance or
compulsions and to look out for any new compulsions. We discussed how to prevent a relapse in
his symptoms by continuing to practice exposure
exercises, and staying alert to any circumstances
that might lead to increased anxiety, such as a
period of prolonged stress or a big life change.
MR worked with his psychiatrist to come up with
a plan for his medication, and agreed to continue
taking the medication for at least 6 months after
completing ERP. At that point, if MR continued
doing well he would work with his psychiatrist to
gradually decrease his medication, while resuming regular CBT sessions to manage any residual
anxiety.
Conclusion
At the end of 12 sessions of ERP, MR was reporting far less anxiety, avoidance, and impairment
as a result of contamination fears. His YBOCS
score at the end of the 12 sessions of treatment
was a 13, which accounted for the fact that MR
still had frequent thoughts of contamination
(about an hour or more per day), but found these
19
thoughts far less distressing and felt more in control of his behavior in response to these thoughts.
The time he spent on compulsions and rituals was
less than an hour per day, but when he did engage
in washing behavior he still found it to be somewhat distressing and interfering. However, MR
endorsed feeling like he had learned the strategies necessary to continue making gains in his
control over and resistance of the compulsions
and felt ready to keep practicing on his own with
periodic check-in sessions.
Key Practice Points The most important principles for success in treating contamination OCD
are related to the effective practice of ERP (see
Table2.1). This means starting exposure practices
early on in the course of treatment and repeating these practices often. The same exposure
practice can be done repeatedly to demonstrate
decreases in or tolerance of anxiety both within
and between exposure practices. In order to best
address the symptoms that are interfering in realworld, day-to-day life, it is most often necessary
to leave the therapy office and find real-world
situations in which to engage the patient in ERP.
For example, for MRs treatment, it was helpful to use the office kitchen, to go to other locations outside of the office like a restaurant, and
to find other people in the office or outside of the
office with whom to practice. To keep MR, and
other patients motivated throughout the course
of exposure therapy, it is often useful to review
the theory behind and rationale for exposure. It
is important that patients understand the potential long-term benefit that comes from learning to
tolerate uncomfortable emotions, such as anxiety,
fear, disgust, anger, or sadness.
Table 2.1 Key practice points for working with adults with contamination OCD
Practice exposure and response prevention exercises early and often
Exposure exercises should be done in the context of real-world anxiety-provoking situations and stimuli, which
often means leaving the office to directly address contamination-related situations
Review psychoeducation about OCD and the theory behind exposure as much as is needed to help the patient understand the rationale for feeling uncomfortable in the short term for long-term benefit
Assess function of compulsive and avoidant behaviors that may maintain these symptoms, and address any outside
reinforcement patterns (e.g., attention from family members, escape from work, etc.)
Work with the patient collaboratively and creatively to find the pace of exposures that is tolerable (according to
SUDS ratings), and the content of exposures that will best address each symptom
OCD obsessive-compulsive disorder, SUDS subjective units of distress scale
20
For MR, it was useful to expand his exposure

practices beyond contamination-related themes
and include exposures pertinent to social and
performance anxiety as well. This was straightforward to do once MR understood the rationale,
design, and practice of exposure techniques. The
same principles we had applied to his contamination fears were also relevant for the social and
performance fears that were potentially maintaining and reinforcing his avoidance and rituals. Similarly, it is crucial to assess and address
any external reinforcement of OCD symptoms,
such as attention or accommodation from others, in order to uncover any additional areas for
intervention. For MR, this meant working with
his parents later in treatment to understand that
it was not helpful to send him special cleaning
products that he felt comfortable using, and encouraging MR to tell his family and close friends
they did not have to go only to the restaurants
where he felt most comfortable.
To effectively initiate ERP and to maintain the
patients motivation and engagement in therapy,
one of the most important factors is communicating with the patient about the pace, content, and
intensity of exposures. Check in regularly with
the patient for their anxiety level (or SUDS rating) and work collaboratively with the patient to
select and titrate exposure practices. Designing
appropriate exposures often requires creativity in
order to break situations into manageable steps or
to find the right in-session approximation of the
patients real-world distress and impairment that
will lead to sustained symptom relief over time.
References
Abramowitz, J. S. (2006). The psychological treatment of
obsessive-compulsive disorder. Canadian Journal of
Psychiatry, 51, 407416.
Adams, T. G., Brady, R. E., & Lohr, J. M. (2010). Disgust in contamination-based obsessive compulsive
disorder: A review and model. Expert Review of Neurotherapeutics, 10, 12951305.
Albert, U., Maina, G., Bogetto, F., Chairle, A., & MataixCois, D. (2010). Clinical predictors of health-related
quality of life in obsessive-compulsive disorder. Comprehensive Psychiatry, 51, 193200.
S. M. Bennett
Alonso, P., Menchon, J. M., Mataix-Cols, D., Pefarre, J.,
Urretvizcaya, M., Crespo, J. M., etal. (2004). Perceived parental rearing style in obsessive-compulsive
disorder: Relation to symptom dimensions. Psychiatry
Research, 127, 267278.
American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.).
Arlington: American Psychiatric.
Ball, S. G., Baer, L., & Otto, M. W. (1996). Symptom subtypes of obsessive-compulsive disorder in behavioral
treatment studies: A quantitative review. Behaviour
Research and Therapy, 34, 4751.
Barlow, D. H., Farchione, T. J., Fairholme, C. P., Ellard,
K. K., Boisseau, C. L., Allen, L. B., etal. (2011). Unified protocol for the transdiagnostic treatment of emotional disorders: Therapist guide. New York: Oxford
University Press.
Bennett, S. M., & OConnor, M. (2008). The ABC CBT
program. Unpublished treatment manual and workbook for use in the UCLA ABC child day treatment
program.
Blanco, C., Olfson, M., Stein, D. J., Simpson, H. B., Gameroff, M. J., & Narrow, W. H. (2006). Treatment of
obsessive-compulsive disorder by U.S. psychiatrists.
Journal of Clinical Psychiatry, 67, 946951.
Cherian, A. V., Naravanaswamy, J. C., Srinivasaraju, R.,
Viswanath, B., Math, S. B., Kandavel, T., etal. (2012).
Does insight have specific correlation with symptom
dimensions in OCD? Journal of Affective Disorders,
138, 352359.
Culver, N. C., Stoyanova, M., & Craske, M. G. (2012).
Emotional variability and sustained arousal during
exposure. Journal of Behavior Therapy and Experimental Psychiatry, 43, 787797.
Diefenbach, G. J., Abramowitz, J. S., Norberg, M. M., &
Tolin, D. F. (2007). Changes in quality of life following cognitive-behavioral therapy for obsessive-compulsive disorder. Behavior Research and Therapy, 45,
30603068.
Ehrenreich, J. T., Buzzella, B. A., Trosper, S. E., Bennett, S. M., Wright, L. R., & Barlow, D. H. (2008).
The unified protocol for treatment of emotional disorders in adolescents. Unpublished manuscript: Boston
University.
Foa, E. B., Franklin, M. E., & Moser, J. (2002). Context
in the clinic: How well do cognitive behavioral therapies and medications work in combination? Biological
Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S.,
Campeas, R., etal. (2005). Randomized, placebocontrolled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of
obsessive-compulsive disorder. American Journal of
Fontenelle, I. S., Fontenelle, L. F., Borges, M. C., Prazeres, A. M., Range, B. P., Mendlowicz, M. V., etal.
(2010). Quality of life and symptom dimensions of
patients with obsessive compulsive disorder. Psychiatry Research, 179, 198203.

Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure,
C., Fleischmann, R. L., Hill, C. L., etal. (1989). The
yale-brown obsessive compulsive scale. I. Development, use, and reliability. Archives of General Psychiatry, 46, 10061011.
Guy, W., & Bonato, R. (Eds.). (1970). CGI: The clinical
global impression scale. Chevy Chase: National Institute of Mental Health.
Jacoby, R. J., Leonard, R. C., Riemann, B. C., &
Abramowitz, J. S. (2014). Preditors of quality of life
and functional impairment in obsessive-compulsive
disorder. Comprehensive Psychiatry. doi:10.1016/j.
Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., & Walters, E. E. (2005). Lifetime
prevalence and age-of-onset distributions of DSM-IV
disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62, 593602.
Liebowitz, E. R., Panza, K. E., & Bloch, M. H. (2012).
Family accommodation in obsessive compulsive
disorder. Expert Review of Neurotherapeutics, 12,
229238.
Monzani, B., Rijsdijk, F., Harris, J., & Mataix-Cois, D.
(2014). The structure of genetic and environmental
risk factors for dimensional representations of DSM-5
obsessive compulsive spectrum disorders. Journal
of the American Medical Association Psychiatry, 71,
182189.
Murray, C. J. L., & Lopez, A. D. (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries, and risk
factors in 1990 and projected to 2020. Cambridge:
Harvard University Press.
Patel, S. R., & Simpson, H. B. (2010). Patient preferences
for obsessive-compulsive disorder treatment. Journal
of Clinical Psychiatry, 71, 14341439.
Peris, T. S., Sugar, C. A., Bergman, R. L., Chang, S., Langley, A., & Piacentini, J. (2012). Family factors predict
21
treatment outcome for pediatric obsessive-compulsive

disorder. Journal of Consulting and Clinical Psychology, 80, 255263.
Piacentini, J., Langley, A., & Roblek, T. (2007). Cognitive behavioral treatment of childhood OCD: Its only
a false alarm, therapist guide. New York: Oxford University Press.
Rasmussen, S. A., & Eisen, J. A. (1988). Clinical and
epidemiological findings of significance to neuropharmacologic rituals in OCD. Psychopharmacology
Bulletin, 24, 466470.
Simpson, H. B., Foa, E. B., Liebowitz, M. R., Ledley, D.
R., Huppert, J. D., Cahill, S., etal. (2008). A randomized, controlled trial of cognitive-behavioral therapy
for augmenting pharmacotherapy in obsessive-compulsive disorder. American Journal of Psychiatry, 165,
621630.
Simpson, H. B., Foa, E. B., Liebowitz, M. R., Huppert,
J. D., Cahill, S., Maher, M. J., etal. (2013). Cognitive-behavioral therapy vs risperidone for augmenting
serotonin reuptake inhibitors in obsessive-compulsive disorder: A randomized clinical trial. Journal of
the American Medical Association Psychiatry, 70,
11901199.
Skoog, G., & Skoog, I. (1999). A 40-year follow-up of
patients with obsessive-compulsive disorder. Archives
of General Psychiatry, 56, 121127.
Vorstenbosch, V., Hood, H. K., Rogojanski, J., Antony,
M. M., Summerfeldt, L. J., & McCabe, R. E. (2012).
Exploring the relationship between OCD symptom
subtypes and domains of functional impairment. Journal of Obsessive-Compulsive and Related Disorders,
1, 3340.
Woody, S. R., & Tolin, D. F. (2002). The relationship
between disgust sensitivity and avoidant behavior:
Studies of clinical and nonclinical samples. Journal of
Anxiety Disorders, 16, 543559.
Treatment of Sexual
Symptoms During Exposure
and Response Prevention
Adam M. Reid, Cindy Flores, Brian Olsen,
Megan A. Barthle, Mariam Rahmani,
Andrew C. Rakhshani, Mathew Nguyen,
Gary R. Geffken and Joseph P. H. McNamara
Nature of Problem and Associated
Research Basis
A.M.Reid() C.Flores B.Olsen M.A.Barthle
A.C.Rakhshani M.Nguyen G.R.Geffken
J.P.H. McNamara
Division of Medical Psychology, Department of
Psychiatry, University of Florida, P.O. Box 100234,
1600S Archer Rd, Gainesville, FL 32611, USA
e-mail: reidam@phhp.ufl.edu
C.Flores
e-mail: cgflores@ufl.edu
B.Olsen
e-mail: bolsen@phhp.ufl.edu
M.A.Barthle
e-mail: meganbarthle@ufl.edu
A.C.Rakhshani
e-mail: andrewuf11408@ufl.edu
M.Nguyen
e-mail: mlnguyen@ufl.edu
G.R.Geffken
e-mail: geffken@ufl.edu
J.P.McNamara
e-mail: jpm2@ufl.edu
A.M.Reid G.R.Geffken
Department of Clinical and Health Psychology,
University of Florida, P.O. Box 100165,
G.R.Geffken
e-mail: geffken@ufl.edu
M.Rahmani M.Nguyen
Division of Child and Adolescent Psychiatry, Department
of Psychiatry, University of Florida, P.O. Box 100234,
e-mail: rahmanim@ufl.edu
Sexual obsessions occur in approximately

813% of adults with obsessive-compulsive disorder (OCD), more often in males than in females
(Pinto etal. 2008; Williams and Farris 2011).
Symptoms tend to be characterized by the fear
of committing inappropriate or improper sexual
acts or gestures such as, I will get my mother
pregnant, or I will sexually molest a child or
adolescent. Sexual obsessions can be related
to fear of ones own behavior, as the examples
just provided, or others behavior, such as repetitively obsessing about others sexual viability or
practices (e.g., Is my wife cheating on me?).
Resembling other nonsexual obsessions, the
thoughts are unwanted, distressing, and viewed
as unreasonable. However, some clinical distinctions between sexual and nonsexual obsessions
exist. Most notably, the fear caused by sexual
obsessions comes more from the internal interpretation of the occurrence/content of the thought
(e.g., feelings of immorality, insanity) rather than
the reality of the external world (e.g., every door
knob has feces on it; Aardema etal. 2013; Aardema and OConnor 2007). Additionally, sexual
obsessions may be more time consuming and impairing than other domains (Williams and Farris
2011).
Sexual compulsions are behaviors one may
engage in to temporarily alleviate anxiety related to the sexual obsession because the individual wants to rid themselves of these unwanted

DOI 10.1007/978-3-319-17139-5_3
23
24
thoughts. When compulsions are present, they

may manifest as an overt observable behavior or
as a covert mental ritual. Some examples of overt
and covert sexual compulsions include asking
others for reassurance to disprove the distressing
sexual thought (overt), checking for self-arousal
(overt), reciting prayers (covert), or counting
(covert). Avoidance and mental rituals are two
compulsions that are challenging to recognize
clinically but commonly occur in response to
sexual intrusive thoughts. An individual may
also attempt to avoid situations that trigger the
sexual thoughts or conduct mental compulsions
that may provide self-reassurance or be believed
to counter the unwanted thought. Often no
sexual compulsions will be reported, but further
probing by the clinician will reveal that these
patients engage in mental/behavioral avoidance or mental rituals (Abramowitz etal. 2003).
Sexual compulsions differ from other nonsexual
compulsive behaviors by being more oriented
towards thought-control techniques rather than
behavioral coping strategies that are implemented to circumvent feared consequences (Lee and
Kwon 2003). Identifying the function of certain
sexual behaviors (e.g., masturbation) is also clinically important. If they occur in response to an
anxiety-producing intrusive thought and provide
a temporary reduction in anxiety, they likely are
compulsions; however, clinicians should also
assess if they are instead occurring in response
to an intense unwanted urge (i.e., impulse control disorder) or desire for sexual pleasure (e.g.,
hypersexuality; Kafka 2010). The phenomological difference between impulsive behavior and
compulsive behavior can be challenging and is
beyond the scope of this chapter (see Grant and
Potenza (2006) for an illustrative case vignette
and review of the literature on this topic).
An area that can pose difficulty for mental
health professionals and medical providers is
discriminating between OCD and paraphilias
(American Psychiatric Association 2013), especially since intrusive sexual thoughts regarding
children can occur in adult OCD (Goodman etal.
1989a). In terms of pedophilia, the individual
with pedophilia may not experience negative feelings about sexual thoughts about children. In fact,
A. M. Reid et al.
they may experience sexual pleasure and arousal

from their sexual thoughts as well as relief from
sexual acts relating to their sexual thoughts at
some point in their life (Gordon 2002; Gordon
and Grubin 2004). Pedophiles may even justify
their behavior by attributing their behavior to the
child or claiming that the child found pleasure in
their behavior or wanted the behavior to occur.
This is very distinct from OCD, where individuals describe the intrusive thoughts about children
as very emotionally distressing and inconsistent
with their self-concept. In short, sexual cognitions
in those with pedophilia present as ego-syntonic,
whereas sexual cognitions about children in OCD
present as ego-dystonic (Aardema etal. 2013). In
addition to the emotional response to the cognition, it is also crucial to take into consideration the
patients sexual history, presence of other obsessive-compulsive symptoms, and if the individual
intends to willingly act on the sexual thoughts.
When differentiating between obsessivecompulsive symptoms and a patients uncertainty
about their sexual orientation, therapists should
use a similar set of procedures outlined above
(e.g., determining if thoughts are ego-syntonic
vs. ego-dystonic). For those who are negotiating their sexual orientation, they may experience
sexual fantasies, arousal, or masturbate when
thinking about others who are of the same sex.
Their fears related to homosexuality may be
based in reality such as concerns about how their
family or society will respond to their sexual
orientation. While an individual with OCD may
identify as being homosexual, they tend to not report intrusive and persistent unwanted thoughts
related to being homosexual (Williams and Farris
2011). For a heterosexual individual with OCD,
they have a tendency to engage in thoughtaction fusion (TAF) about homosexuality (Shafran
etal. 1996), which is the notion that experiencing
an intrusive cognition is equivalent to actually
engaging in a feared behavior. For example, the
mere act of having a thought about being homosexual must mean that they are in fact attracted
to people of the same sex. Thus, those with OCD
want to rid themselves of these thoughts and
engage in behaviors to reassure themselves that
they are heterosexual. These individuals do not
3 Treatment of Sexual Obsessive-Compulsive Symptoms During Exposure and Response Prevention
report an urge or desire to engage in homosexual

behavior (Gordon 2002; ONeil etal. 2005).
OCD is commonly treated with psychotherapy, such as cognitive behavioral therapy (CBT)
with exposure and response prevention, and/or
psychopharmacological interventions, such as
selective serotonin reuptake inhibitors (SSRIs).
CBT is where the patient is exposed to a fear/
distress-provoking stimulus while any distressreducing responses are prevented. These exposures occur throughout treatment and are
conducted in a hierarchal manner; patients start
with lower anxiety-producing challenges that get
progressively more challenging. Through these
challenges, clinicians aim to help their patients
reduce avoidance of fear-provoking stimuli and
learn cognitive strategies to utilize in response
to intrusive cognitions. This approach has been
shown by numerous studies to be an efficacious
treatment for OCD (e.g., Olatunji etal. 2013).
The implementation of this treatment can be
difficult when treating sexual obsessions and
compulsions, as therapists own anxiety or negative beliefs about CBT (Deacon etal. 2013; Farrell etal. 2013) could cause them to avoid certain
sexual content, conduct exposures inappropriately, or even avoid exposures altogether. In fact,
despite being the first-line treatment for OCD
(see Jordan etal. (2012) for a review), CBT is
estimated to be utilized in only 30% of treatment
provided by community clinicians for adults with
OCD (e.g., Hipol and Deacon 2013). Community
clinicians likely avoid CBT for OCD because of
unjustified ethical concerns (Olatunji etal. 2009),
lack of training (Hipol and Deacon 2013), and
their own anxiety or disgust sensitivity (Deacon
etal. 2013; Olatunji etal. 2009). Unfortunately,
all of these factors amplify interference in the
treatment of sexual obsessions or compulsions
as therapists must be willing to discuss sexually
explicit content and conduct exposures that are
challenging to design and implement due to their
sexual nature. Taken together, it is not surprising
that sexual (as well as religious) obsessions and
compulsions have worse response to behavioral
treatment than other domains such as harm, contamination, and symmetry (Mataix-Cols etal.
2002) in adult OCD.
25
Description of the Presenting Problem

in the Particular Case That Will Be
Presented
In order to illustrate CBT treatment for an adult
with sexual obsessions and compulsions, a discussion of a difficult but ultimately successful
case of an African American male in his early
30s who self-referred to our clinic is presented.
For the sake of confidentiality and adherence to
the American Psychological Association Ethics
Code and Health Insurance Portability and Accountability Act (HIPAA) guidelines on privacy,
the patient will be referred to as Kyle (pseudonym), and several noncritical details about this
case have been altered. Kyle presented to the
clinic after prompting from his wife.
Kyle arrived for an intake session alone. Kyle
reported that his obsessive-compulsive symptoms were distressing and caused substantial
impairment in his personal and social life, thus
he desired to seek psychological and/or psychopharmacological treatment for his symptoms. He
was polite throughout the intake, although was
notably anxious and responded to questions directly, with minimal elaboration or details. When
this was processed by the therapist, it was apparent that Kyle had low expectations about the ability of treatment to help improve his symptoms.
He also conveyed that he has difficulty discussing his symptoms with strangers because it can
sound really odd.
In order to properly assess Kyles obsessions
and compulsions, the YaleBrown ObsessiveCompulsive Scale (YBOCS) and Dimensional
YaleBrown Obsessive-Compulsive Scale (DYBOCS) were administered at intake. The YBOCS
was given to assess total obsessive-compulsive
symptom severity (Goodman etal. 1989a), and
the DYBOCS was given to assess dimensional
severity (Rosario-Campos etal. 2006). As is
common with pediatric or adult OCD, Kyles presenting symptoms involved multiple symptom
domains (Rasmussen and Eisen 1987). Kyles
obsessions were in the sexual, harm, and contamination dimensions. Specifically, Kyle was
concerned with aggressively harming others, hitting others with his car, and contracting illnesses
26
from blood-contaminated materials. Compulsions related to the obsessions listed above were
primarily excessive hand washing, checking
stoves and locks, and avoidance (e.g., of the color
red, driving, needles).
Initially, Kyle denied any sexual-related obsessions or compulsions until the DYBOCS was
administered, where he briefly described severe
sexual obsessive-compulsive symptoms. However, by session six of treatment (see below),
Kyle began to discuss his sexual obsessions and
compulsions openly and was willing to target
these symptoms in treatment. Although not discussed in detail at the intake, Kyle later rated his
sexual obsessive-compulsive symptoms as his
most severe problem that caused the most impairment. Kyles sexual obsessions were primarily that he was physically attracted to children,
that he would act on this attraction, and that he
was a bad person for having these obsessions.
Sexual compulsions were primarily avoidance
of children (especially his niece) and counter
thoughts where Kyle actively thought of attractive women to assure himself that he was not attracted to children.
Case Information
The following case information was collected via
a review of medical records and a 90-min semistructured interview with Kyle during his intake
session. Notably, our clinic staff had requested
that Kyles wife also attend the intake but Kyle
reported he desired to attend the session alone.
The case information presented below is the information that was deemed relevant to Kyles
case conceptualization and treatment. Kyle was
an African American, heterosexual male in his
mid-30s who was married, employed in insurance administration, and lived in a large metropolitan area several hours from the clinic.
Kyle reported that he was recently married to
a wife he described as all I could ever want in a
female. He reported that his wife was very supportive and did whatever it took to make me feel
better. She worked a full-time job in the medical field and barely had time for herself. As is
common with supportive spouses, Kyle provided
A. M. Reid et al.
several examples of how his wife inadvertently

accommodated his obsessive-compulsive symptoms. For example, she reportedly always drove
them places, purchased excess cleaning products
(e.g., hand soap), and even was willing to wait
to have children until Kyle was ready because
of Kyles clear fear to hold young children (e.g.,
their niece). In terms of her knowledge of Kyles
obsessive-compulsive symptoms, Kyle stated
that he tells her anything. As reported above,
Kyle did not openly discuss his sexual obsessions
or compulsions at intake, and later in treatment it
was clear that Kyles wife was unaware of any
sexual obsessions-compulsions and thought that
his avoidance of children was related to contamination concerns.
When asked about Kyles symptom history,
Kyle reported that he has always been one of
those high anxiety guys. Kyle reported he first
experienced multiple symmetry-related symptoms that developed from a very young age but
lessened as Kyle hit his teenage years. At the age
of 13, Kyle described an event where he learned
about how blood can transfer multiple diseases
and described how this triggered a multitude of
intrusive cognitions related to harm coming from
blood exposure. For example, Kyle constantly
worried about touching objects that may have
blood on them and worried about accidently
being stabbed by needles. He reported that he
developed avoidance of places where blood exposure is more probable (e.g., hospitals, schools)
and excessive hand washing to reduce risk of illness from possible blood exposures (e.g., after
touching door knob). He reported that by age
17, his obsessions were 24/7 and had spread
to other concerns such as accidently harming
others (e.g., running over someone with car, poisoning someone), being poisoned (e.g., battery
fluid, raw foods), and sexual-related obsessions
and compulsions (e.g., concerns about violent
sexual intrusive thoughts; avoidance of physical
contact).
While these sexual obsessions and compulsions were less severe or impairing than other
symptoms in his teens and early 20s, Kyle had
a clear triggering event approximately 6 months
before he arrived for treatment that caused his
sexual obsessive-compulsive symptoms to spike
and become the most severe and impairing symptom domain. Kyles older sister who lived in the
same city as Kyle had a child whom Kyle frequently helped care for on weekends. There was
an incident where Kyle was changing and cleaning his niece and had an intrusive thought about
intentionally touching the childs genitalia. This
event triggered multiple intrusive cognitions and
compulsions that worsened over the following
months until Kyle began treatment at our clinic.
Kyle had a complex treatment history that
involved multiple unsuccessful psychopharmacological and/or psychotherapeutic treatments.
Kyle reported that he had previously been prescribed both paroxetine and alprazolam at various times in his life by his general practitioner.
He described that both medications were stopped
after only a few weeks due to ineffectiveness and
fear of sexual side effects. He also described that
he had seen a psychologist for 6 months when he
was in his 20s who was reportedly a specialist
and conducted CBT. When probed further, Kyle
described that this provider occasionally (once
every three to four sessions) would ask him to
imagine what it would be like to do things like
giving blood and that these exercises lasted about
15min. Kyle reported that this experience did not
help reduce his symptom severity and made him
doubt the benefit of seeking out treatment.
Kyle denied a history of any other severe psychopathology. He reported he occasionally experienced minor depressive symptoms during the
history of his obsessive-compulsive symptoms
but conveyed these symptoms occurred for only
a few hours at a time every couple of months.
Kyle did report a family history of OCD; his father struggled with OCD for several decades but,
according to Kyle, rarely discussed his symptoms
with his family. Kyle denied any relevant medical history (e.g., strep throat).
Case Conceptualization
and Assessment
The last three coauthors concurred that Kyle
met Diagnostic and Statistical Manual of Mental
Disorders (DSM)-V diagnostic criteria for OCD
27
(American Psychiatric Association 2013). This

diagnosis was supported by a score of 33 on the
YBOCS (obsessions total score=19; compulsion
total score=14) at intake and the various severe
and impairing obsessive-compulsive symptoms
reported by Kyle on the DYBOCS. Kyles OCD
spanned across multiple domains of obsessivecompulsive symptoms, specifically sexual (DYBOCS sexual score=19), harm (DYBOCS harm
score=16), and contamination (DYBOCS contamination score=16) concerns. Since Kyle was
willing to seek treatment and met criteria for
OCD, he was recommended to begin 3 weeks of
intensive (daily, 5/week) CBT. Based on several
factors Kyle presented with that have been associated with worse CBT outcome, specifically low
treatment expectancy (Westra etal. 2007) and his
family history of OCD (Jakubovski etal. 2013),
Kyle was also referred for consultation with a
psychiatrist in our clinic to evaluate psychopharmacological management with an SSRI. While
some have suggested that severe presenting sexual symptoms are associated with worse treatment
outcome, this likely results from therapist factors
interfering with proper treatment implementation
(Farrell and Boschen 2011). Thus, this was not
a reason for Kyles psychopharmacological augmentation.
The etiology and course of Kyles OCD were
not remarkable in the sense that obsessive-compulsive symptoms are often linked to a clear triggering event (e.g., Lochner etal. 2002; McKeon
etal. 1984), often start with symmetry-related
concerns and develop in other domains (Kichuk
etal. 2013), and waxed and waned within but not
between dimensions as he grew older (Kichuk
etal. 2013; Rufer etal. 2005). Sexual obsessions
and compulsions also commonly develop during teenage years, likely triggered by biological
changes in hormone levels, and are not uncommon
in those with early-onset OCD (Narayanaswamy
etal. 2012). With his long history of obsessivecompulsive symptoms, Kyles denial of any major
depressive symptoms was surprising (Anholt etal.
2011). The minimal presence of depressive symptoms likely stemmed from how relatively high
functioning Kyle was despite his severe obsessivecompulsive symptoms (Storch etal. 2013).
28
Kyles high avoidant behavior, which was the

most common compulsive behavior he endorsed
(especially related to sexual obsessions), was a
notable maintaining factor identified to target in
treatment. Avoidance is common in OCD and
is an important compulsion to extinguish during treatment in order to improve outcome (e.g.,
Steketee etal. 1996). Kyles avoidance was notable even during the intake session where he endorsed sexual symptoms but refused to elaborate
on them despite the clinicians efforts. During the
intake, Kyle reported both behavioral (e.g., refusing to give blood, not touching his niece) and
cognitive (e.g., trying to distract himself from
intrusive thoughts) avoidance. For these reasons,
Kyles avoidance was targeted in treatment by
prescribing behavioral and cognitive non-avoidance and modeling non-avoidance, especially related to sexual obsessions and compulsions. This
required assigning a veteran team of therapists to
Kyles case who would not be hesitant to discuss
explicit sexual content during exposures and had
the expertise to appropriately design exposure
sessions to target these symptoms. Similarly, selecting therapists who would be able to develop
therapeutic alliance quickly was crucial, since
alliance is strongly linked to treatment outcome
and was likely to facilitate Kyles willingness to
discuss and target his sexual symptoms in treatment (see Keeley etal. 2008 for a review).
Another relevant treatment factor, which also
provides insight into why Kyle was so avoidant of
even discussing sexual content during the intake,
was the notable TAF Kyle experienced in relation to his intrusive thoughts. TAF is described
in OCD as a tendency to believe the physical
or moral consequences of mental thoughts are
equivalent to behavioral actions (Shafran etal.
1996). Especially related to his sexual symptoms,
Kyle experienced both likelihood TAF (thinking
or talking about an occurrence increases the probability of that outcome) and moral TAF (thoughts
and intentions carry moral weight corresponding
to enacting those mental states behaviorally).
TAF has been hypothesized as a maintaining
mechanism of obsessive-compulsive symptoms;
TAF leads to thought suppression and subsequently higher obsessive-compulsive symptoms
A. M. Reid et al.
(Rassin etal. 2000). Thus, TAF was targeted during treatment. His high TAF was notable because
prior research indicates that patients with OCD
generally only have high TAF when present with
comorbid depression (Thompson-Hollands etal.
2013). However, sexual obsessions and compulsions are theorized to be highly associated with
TAF compared to other domains (Clark etal.
2000; Smith etal. 2009).
Family accommodation has been linked to attenuated treatment outcome for adult OCD (Amir
etal. 2000) and therefore a thorough assessment
of accommodation during the intake was conducted and was made an early target of treatment. Family accommodation is strongly associated with contamination-related concerns (Albert
etal. 2010), and not surprisingly, Kyle reported
several examples about his wife accommodating
these symptoms (e.g., buying large quantities of
hand soap). Notably, Kyles wife also was inadvertently accommodating the sexually obsessivecompulsive symptoms of Kyle by allowing him
to avoid contact with children and even delaying
her own desire to have children.
Finally, Kyles low treatment expectancy was
noted. Kyle displayed low treatment expectancy
at intake, which is understandable based on his
previous unsuccessful treatment. As discussed
above, his unsuccessful CBT treatment history
likely stemmed from little or poor use of exposure therapy. Expectancy is linked to outcome in
the behavioral treatment of adult anxiety disorders (e.g., Westra etal. 2007) and thus was targeted in our treatment.
Illustrative Treatment Course

Kyle completed 20 sessions of intensive (daily
5/week) CBT at our clinic. Treatment sessions
lasted 90min and, with the exception of the first
session where psychoeducation and exposures
hierarchies are completed, followed the format
of (1) reviewing adherence of at-home exposures
assigned during the previous session, (2) discussing any barriers to treatment and reviewing treatment progress, (3) conducting exposures, and (4)
assigning at-home exposures to be completed
29
Fig. 3.1 Kyles treatment response during 20 sessions of multimodal treatment. (Note: scores are approximate trajectories of symptoms based off DYBOCS and YBOCS scores measured at session 1, 6, 11, 16, and 20)
before the next session. The approach to daily

CBT in our clinic utilizes a treatment team including several clinicians seeing the patient at
each session. This prevents clinician burnout and
allows for diversity in expertise and therapeutic
style. Our assessment of therapeutic alliance has
found this approach does not hinder the development of therapeutic alliance.
Our review of treatment begins with sessions
16 and discusses the application of CBT to treat
Kyles nonsexual symptoms of OCD. Session 6
was a pivotal point in treatment as it was the first
time Kyle began to discuss his sexual symptoms
and was willing to begin sexual-related exposures. However, it is also important to highlight
how session 15 laid the foundation for what occurred in session 6. As is displayed in Fig.3.1,
Kyles overall obsessive-compulsive severity had
been slowly dropping up until session 6 but, once
treatment began to focus on sexual symptoms, a
large reduction in overall severity was observed
(which paralleled the reduction in sexual symptom severity observed). Kyles expectancy about
treatment outcome appeared to increase during
the implementation of CBT in sessions 15. In
addition, his avoidance behaviors decreased, his
TAF lowered, and his alliance with his therapists
increased, all of which enabled the initiation of
targeting Kyles sexual symptoms in session 6.
While aspects of session 15 described below,
such as psychoeducation, were in the context of

other treating his harm and contamination symptoms, they were easily applied to Kyles sexual
symptoms when treatment reached this point.
Conducting CBT for OCD begins with psychoeducation about the effectiveness of CBT and
the mechanisms underlying symptom reduction
in treatment. The development of Kyles contamination symptoms were explained to him in
terms of the cognitive-behavioral model. The experience of intrusive cognitions was normalized
as it was explained how these cognitions could
cause mild anxiety and lead to anxiety-reducing
behaviors. Learning theory and behavioral reinforcement principles were used to illustrate how
a thoughtbehavior cycle reinforces increased
anxiety and how anxiety-reducing behaviors develop over time. It was highlighted how these
mechanisms can explain how a person with OCD
can quickly go from having occasional intrusive
thoughts with minimal anxiety responses to frequent distressing intrusions and compulsions.
Psychoeducation also included an explanation of
how OCD symptoms are therapeutically reduced
through CBT. It was ensured that Kyle understood how exposure with response prevention
would result in short-term distress or increased
anxiety for a long term within and between session habituation and relearning.
30
Session 1 with Kyle concluded by developing exposure hierarchies that would be used to
guide conducting exposures. The ultimate goal
with Kyle was to develop three hierarchies, one
for each of the three dimensions of the obsessivecompulsive symptoms Kyle endorsed at intake.
The symptoms Kyle reported on the DYBOCS
were used to facilitate plans for potential exposures. Since Kyle was initially reluctant about
discussing sexual symptoms, initial hierarchies
focused on the overestimation of harm and contamination. The concept of subjective units of
distress (SUDS) was introduced to gauge Kyles
assessment of the difficulty of an exposure task
or how much anxiety he thought he would experience during an exposure. Kyle was asked
to rate the difficulty of each proposed harm or
contamination-related exposure on a 100-point
SUDS scale. Some example of harm-related exposures, from least anxiety provoking to most
included: (1) holding a battery for 5min without immediately washing hands (SUDS=20), (2)
not checking light switches after leaving house
(SUDS=50), and (3) holding a needle close to
skin (SUDS=90). Some examples of contamination-related exposures included: (1) drinking
out of a soda can after a male drank (SUDS=30),
(2) touching a restaurant glass without washing
(SUDS=60), and (3) touching the outside of a
biohazard bin without washing (SUDS=90). As
illustrated above, including the ritual prevention
portion of each exposure is important when proposing exposures, which may just be non-avoidance but could also involve refraining from hand
washing, seeking reassurance, checking, etc. At
the end of session 1, Kyle was given his first
homework assignment to develop five to ten
potential exposures for each domain.
For session 2, various maladaptive cognitions that relate to anxiety (e.g., snowballing)
were discussed, and an example maladaptive
cognition was provided to Kyle to demonstrate
how to conduct thought challenging (e.g., looking for the gray area). Kyle was encouraged to
monitor for these maladaptive cognitions and
practiced thought challenging during exposures
throughout treatment. Thought challenging was
especially useful with the sexual obsessions addressed later in treatment (e.g., does having an
A. M. Reid et al.
anxiety-producing sexual thought about a child

in one moment mean someone is a pedophile?),
since it facilitates cognitive diffusion (i.e., perceived believability of a thought) which is often
difficult with early-onset sexual symptoms (Fontenelle etal. 2013).
The remainder of session 2 was spent conducting the first exposure with Kyle. Kyles
harm-specific obsessive-compulsive symptoms
were targeted for the first exposure as these were
the least severe for Kyle and tend to provide the
most flexibility in exposure design. Flexibility is
key as it is important for the first exposure to illicit enough anxiety to demonstrate the habituation process but not too much anxiety to where
there is a risk of an unsuccessful exposure (e.g.,
patient stops exposure due to difficulty). Thus,
in accordance with the theoretical rational provided by Foa and Kozak (1986), an exposure that
caused a top SUDS of 50 and concluded after a
50% reduction in anxiety (i.e., 20) was the goal
for the initial exposure. Kyle was asked to hold a
battery in his hand without washing immediately
after, a task originally ranked as a 20. During the
exposure, behavioral (e.g., I cant believe you
are holding that battery) and cognitive (e.g.,
think of all the ways this battery could harm you)
avoidance deterring statements were emphasized
(Benito etal. 2012). Kyle was constantly encouraged and validated for how difficult of a challenge he was conducting, in order to increase
Kyles confidence in his ability to conduct exposures. After 20min, Kyles anxiety with holding
the battery reduced to a 5, and Kyle was challenged to hold the battery to his face without
washing immediately after (rated a 50). Kyle,
who was surprised at how quickly his concerns
about holding the battery decreased, did not hesitate to hold the battery to his face. After 20min,
Kyles anxiety habituated to a 20 and the exposure was terminated. For homework, Kyle was
asked to repeat these two exposures with AA instead of AAA batteries, as well as not washing his
face before he went to bed and carrying around a
battery in his pocket for the rest of the treatment.
Sessions 35 were conducted in a similar way
to session 2. Session 3 continued to build upon the
previous exposure by having Kyle touch pieces
of machinery around the hospital, and by session
4, Kyle was able to drive around campus (a location with multiple walkers) without stopping to
check if he ran over anyone. For session 5, Kyle
was told to bring in his wife for the first time, and
she was asked to participate in a similar exposure
where we drove around campus. During this exposure, confederates were placed around campus
who strategically yelled or bumped the outside of
the car as Kyle slowly drove by. This exposure
was the first time Kyles anxiety reached an 8,
an important goal for session 5. Involving Kyles
wife helped her learn how to act when Kyle conducts exposures at home and gave us a chance
to spend time discussing the importance of limiting accommodation. At this point in treatment,
homework assignments that involved his wifes
participation were given.
Kyles expectancy about treatment had notably changed by the end of session 5. He began to
appear almost excited to conduct more exposures
and repeatedly conveyed his enthusiasm about
the treatments effectiveness. His ability to recognize subtle rituals had greatly improved, and he
repeatedly would convey how he needed to push
himself to perform exposures and not interpret
the anxiety they caused him as a sign to avoid.
During these early exposures, Kyles TAF was
challenged by Socratic questioning or repeated
exposure to emotionally charged cognitions (e.g.,
Kyle would repeat thinking about hitting a person means I want to hit someone during driving). Kyle displayed that he was beginning to un-
31
derstand that a thought is just a thought. Importantly, Kyle had clearly become comfortable with
the therapist team and understood the rational for
the treatment the therapists were conducting (i.e.,
therapeutic alliance was high). These factors created a therapeutic environment that facilitated an
important shift in treatment at session 6 where
Kyle finally opened up about his sexual obsessions and compulsions and was willing to target
these symptoms in treatment. This was a crucial
point in treatment as Kyles sexual symptoms
were the most severe presenting symptoms and
treatment response at session 6 was below what
was expected (see Fig.3.1).
After reviewing homework, Kyle spontaneously conveyed to the therapists that he desired
to push himself harder in treatment by tackling
his sexual obsessive-compulsive symptoms.
Since the therapists knew little about these symptoms beyond the sparse information reported on
the DYBOCS during intake, a quick assessment
of Kyles sexual symptoms was conducted (and
served as an exposure for Kyle, who became notably anxious describing these symptoms). Kyle
reported that his primary obsessions were intrusive sexual cognitions about children and his primary compulsions were avoidance of children or
counter thoughts where Kyle actively thought
of attractive women to assure himself that he was
not attracted to children. A hierarchy was developed and a brief version of this hierarchy is displayed in Table3.1. In this table, the preexposure
Table 3.1 Kyles sexual exposure hierarchy

Pre-SUDSa
Post-SUDSb
Final SUDSc
10. Being alone with niece
99
50
15
9. Repeating I will enjoy molesting my niece
99
40
25
8. Repeating I will touch my nieces nipple
99
40
20
7. Repeating I want to touch that child
90
40
5
6. Holding a young child
85
40
5
5. Looking at pictures of niece naked
80
25
20
4. Visualizing giving a bath to niece
80
35
15
3. Sitting in room full of children
75
35
0
2. Looking at pictures of niece
75
30
0
1. Looking at pictures of children
70
10
5
a Pre-SUDS is the level of anxiety rated by Kyle during the intake session
b Post-SUDS is the level of anxiety rated by Kyle at the end of the exposure session that involved the item on the
hierarchy listed
c
Final SUDS is the level of anxiety rated by Kyle at the end of treatment
SUDS subjective units of distress
32
SUDS ratings, the final SUDS rating taken at the

end of the exposure, and the SUDS rating given
at the end of treatment are reported.
It is worth noting that Kyle rated all hypothetical sexual exposures as a 70 or above. Thus,
instead of having Kyle view pictures of children (the exposure at the bottom the hierarchy),
Kyle was challenged to first just repeat the word
child out loud. Kyles anxiety peaked at a 20,
so the therapists quickly escalated the exposure
to repeating I like children, which caused his
anxiety to peak at 50 before quickly habituating.
At this point, Kyle reported he felt up to viewing
the pictures of children, which caused his anxiety to only reach 30. These first exposures helped
Kyle realize that anticipating a sexual exposure
(or any exposure for that matter), such as viewing
pictures of children, results in more anxiety than
actually completing the task. Throughout implementation of this and the other sexual exposures
described below, Kyle was reminded of the importance of resisting any counter thought compulsions that Kyle reported he often engages in
response to sexual intrusive thoughts. Kyle was
asked to say certain intrusive sexual thoughts
repeatedly out loud because this makes several
common covert compulsions or avoidance strategies difficult (e.g., counter thoughts, seeking
reassurance, distraction) and is an effective strategy to increase cognitive diffusion (e.g., Masuda
etal. 2010).
For sessions 715, the therapists continued to
work primarily on Kyles sexual symptoms in the
similar, structured manner of the exposure conducted in session 6. These exposures required
extreme skill in design and implementation. Any
exposure, especially sexual-related exposures
where patients can feel uncomfortable, should
be designed in a way to be as engaging to the
patient as possible (i.e., make it fun). Similar to
how habituation during an exposure can reinforce non-avoidance, matching an exposure to
the personality of the patient is beneficial as this
helps the patient learn the importance of being
creative in the design of exposures and having
fun with these challenging, sometimes awkward, tasks. For example, Kyle was a fan of the
movie about the creation of Facebook; thus, for
A. M. Reid et al.
the first exposure during session 7, the therapists and Kyle played the hot or not game that
Facebook originated from but used childrens
pictures instead of college students. Additionally, exposures should involve similar triggers
to those that will be encountered in real-world
situations. Behavioral research supports that introducing a wide variety of stimuli in a variety of
contexts supports the best generalization of treatment gains from exposure (Bouton 2002; Rowe
and Craske 1998), especially important since one
drawback of intensive treatment is potentially
higher relapse than weekly therapy (Storch etal.
2007). Thus, throughout these sexual exposures,
Kyle conducted exposures with multiple triggering stimuli and repeat exposures (often for
homework) in new contexts different than the
one conducted in session. For example, Kyle and
the therapists conducted an exposure where Kyle
sat in the playroom at the hospital and repeated
various anxiety-producing intrusive thoughts to
himself (e.g., I will be aroused if I had to hold
that child; I must be a pedophile for having a
sexual thoughts about that child). Kyle was told
to repeat this exposure in a more commonly encountered context, such as a mall play area or a
childrens recreational sports game.
As previously stated, treatment focused primarily on Kyles sexual obsessive-compulsive
symptoms for session 715. As discussed in the
introduction, an important barrier to successfully
treating sexual obsessive-compulsive symptoms
can be the therapists willingness to discuss explicitly sexual content and not allow their own
anxiety or disgust sensitivity to get in the way. In
treating any type of obsessive-compulsive symptoms, the therapist must be willing to conduct exposures that over practice situations that could
happen in the real world. Just as day-to-day encounters with public bathrooms would be more
manageable if a patient practiced a difficult contamination exposure such as putting their hand
in a toilet, conducting exposures like discussing
which childs genitalia Kyle would prefer made
typical intrusive sexual thoughts about children
more manageable. In fact, the latter exposure was
conducted with Kyle and after 30min his anxiety
had habituated from a 95 to a 40. Kyle received
psychoeducation that discussing children in that

manner would always cause some discomfort (for
the patient and the therapist), but his ability to do
that exposure and prove that he can manage even
the most distressing sexual intrusive thoughts
supports that, as Kyle put it, there is nothing
OCD can throw at me I cant handle. Similar
sexual exposures were conducted during sessions
717, including an imaginal exposure where
Kyle descriptively described washing every part
of his nieces body while giving her a bath (bathing was a common task asked of Kyle that he had
persistently avoided) and having Kyle play touch
football with several female confederates while
mentally repeating a script I touched her privates inappropriately. No matter the exposure,
the therapist had to be experienced enough to design these challenges and comfortable enough to
do each challenge with the patient.
The severity of Kyles harm- and contamination-related OCD was also dropping during
these sessions. This can be credited to generalization of treatment gains for sexual symptoms to
other domains, via mechanisms such as reduced
family accommodation or avoidance of anxietyproducing situations. By session 15, Kyles wife
had become an at-home therapist and had mastered the difficult balance of not accommodating Kyles symptoms and pushing Kyle during
at-home exposures, while still remaining emotionally supportive. In terms of the sexual obsessions, Kyle desired to not reveal these symptoms
to his wife. The therapists respected this request
but discussed with Kyle how to make his wife
aware of his sexual symptoms without explicitly
calling them sexual obsessive-compulsive symptoms. For example, Kyle told his wife that his
fear of germs made him scared to hold children
and thus his wife was able to limit her accommodation of his symptoms. More so, the gains
resulted because the sexual exposures were often
designed in a way to target multiple domains at
once. For example, when Kyle conducted an exposure where he had to hold a small child in session, Kyle was asked to touch the bathroom door
without washing his hands beforehand (mother
was a therapist at the clinic and consented to all
aspects of exposure). Thus, he practiced an expo-
33
sure with both sexual and harm-related anxieties,

a situation likely to occur in Kyles day-to-day
life (e.g., changing a dirty diaper). Additionally,
homework assigned each night involved assignments related to the harm- or contamination-related domains.
Sessions 1620 involved a mix of exposures
that targeted the top of Kyles hierarchies and beyond for each symptom dimension. For each of
these challenges, Kyle was very impressed at his
progress in treatment and that challenges which
originally seemed impossible were actually manageable. In terms of Kyles sexual symptoms, the
top challenges required the physical presence of
his preschool-aged niece and involved being left
alone in a dark room at the clinic with his niece
(SUDS reduced from 9950 over 15min), holding his niece (SUDS reduced from 9950 over
20min), and helping his niece change her clothes
(SUDS reduced from 9920 over 20min).
The only new barrier that arose during this
portion of treatment was that Kyle repeatedly
conveyed feeling very disgusted with the content
of his intrusive cognitions and at times that he
might have to terminate the exposure. Disgust
is common in obsessive-compulsive symptoms,
and one treatment method is reframing, where
a disgusting stimuli is framed as a less disgusting stimuli. For example, Kyle had disgust with
curdled milk so it was highlighted how similar it
is to cottage cheese. In the context of these sexual exposures, the notion of touching his nieces
genitalia when bathing her was reframed as very
similar to touching any other part of her body.
Disgust, like anxiety, will habituate during an
exposure although sometimes slower than anxiety (Cougle etal. 2007; Olatunji etal. 2011). For
homework, the treatment team had Kyle repeat
each of these exposures at home. When Kyle
arrived for session 20 he was ecstatic. Kyle reported that the worst-case scenario happened
and that overtraining works! He elaborated that
he was walking with his sister and his niece on a
busy street and his niece began to cross the street
at a dangerous time. Kyle immediately grabbed
her and pulled her back to safety. Kyle reported this experience confirmed he had conquered
his OCD because he did not hesitate to grab his
34
niece. This was even more impressive because he

had accidently put his hand on her chest when
grabbing her and experienced minimal anxiety in
response to the intrusive thought that told him he
secretly desired to grab her there.
Kyles YBOCS and DYBOCS score at session 20 confirmed that he had successfully responded to CBT. His total score on the YBOCS
had dropped from a 33 to a 10, a 70% reduction in symptoms, which meant that his symptom severity was in the mild range (Goodman
etal. 1989a). The treatment team conveyed this
to Kyle and came to the decision with him that
terminating treatment and allowing Kyle to take
his learned skills and apply them in his normal
life would be most therapeutic next step. Psychoeducation on remission was conducted, which
focuses on the normalization of continued (all
though less frequent) intrusive thoughts, equating continued exposures to the best preventative
medicine, and the likelihood of a waning and
waxing course of symptoms over time. While
Kyle was scheduled to come back for a booster
session, 6 months after session 20, Kyle called
the treatment team to convey that his symptoms
has remained in remission and that he and his
wife were now planning to have a baby.
As stated earlier, a decision was made to
augment CBT with psychopharmacological
treatment because several factors suggested the
need for augmentation due to their association
with worse behavioral therapy outcome. As described above, Kyle was referred to a psychiatrist because of Kyles low treatment expectancy
and family history of OCD. Due to their modest
side effect profile and effectiveness (Bloch etal.
2010), SSRIs are a common psychopharmacologic treatment of OCD. Thus, our conceptualization was that augmenting with an SSRI would
facilitate faster symptom relief and help prevent
relapse after treatment when Kyle had to return
home (Fineberg etal. 2007). SSRI augmentation
can be especially useful when patients are highly
avoidant and resistant to exposures (Franklin and
Simpson 2005); it was apparent from the intake
that Kyle was reluctant to even discuss his sexual
symptoms let alone conduct exposures. Thus,
psychopharmacological augmentation was uti-
A. M. Reid et al.
lized with the therapeutic techniques discussed

above to facilitate engagement in CBT for his
sexual symptoms.
Kyle began psychopharmacological treatment
at the same time as CBT (sessions with his psychiatrist were 1h before the 1st, 11th, and 20th
therapy sessions). Kyle was not taking any other
medications, so Kyle started sertraline at a dose
of 25mg daily for 1 week, which he tolerated
without problems. Kyle was started at a relatively
low dose because starting SSRIs at a high dose
could have potentially caused serotonergic activation which could have worsened anxiety. The
following week (session 6), the sertraline dose
was titrated to 50mg daily. After four weeks of
CBT and sertraline at 50mg daily, Kyle reported
minimal obsessive-compulsive symptoms but
was maintained at this dose to decrease risk of
relapse and facilitate generalization of treatment
effects as Kyle returned back home and to work.
At this time, Kyles psychopharmacological care
was transferred to a psychiatrist who specialized
in anxiety in Kyles home town. It was recommended Kyle maintain his 50mg dose for a year
before tapering down his dosage if symptoms remain low.
Complicating Factors
As with all treatment cases, a few complicating
factors about Kyles case had to be addressed
in treatment. Most notably, Kyle had extremely
high avoidance associated with his severe sexual obsessive-compulsive symptoms. If not addressed, patients will often conduct fewer exposures in session or conduct them while engaging
in covert rituals and this avoidance is associated
with worse treatment outcome. Kyles avoidance was addressed by thorough psychoeducation (including labeling avoidance as a compulsion), constantly deterring both cognitive and
behavioral avoidance during exposures, modeling non-avoidance during exposures, designing
exposures to be as realistic as possible (e.g., only
using imaginal exposures as a last resort), and
augmenting treatment with a SSRI.
As discussed above, his avoidance hindered

our ability to immediately address Kyles sexual
obsessive-compulsive symptoms until Kyle was
willing to discuss them in session 6. If Kyle had
continued to not bring up these symptoms, the
therapists would have directly addressed this
avoidance. The therapists believed that treatment could move forward effectively by addressing other presenting symptoms and that giving
Kyle time to gain confidence in the effectiveness
of CBT was important due to his low treatment
expectancy. Avoidance, as rated by the YBOCS,
went from the highest possible score at intake to
the lowest possible at session 20.
A second major barrier to Kyles treatment,
and one common during CBT for sexual obsessive-compulsive symptoms, was the challenge of
designing exposures to effectively target Kyles
sexual symptoms. Ideal exposures are ones that
utilize stimuli and environments as similar as
possible to what the patient will encounter outside of treatment. With sexual symptoms, where
the obsessional triggers are often specific people,
this can be a challenge. For Kyle, it was evident
from the etiology, course, and phenomenology of
his sexual symptoms that his niece was the primary trigger for his obsessional symptoms. Thus,
while imaginal exposures and in vivo exposures
involving children are helpful, it was critical to
bring his niece for the final part of treatment.
This was accomplished because his niece lived
only a few hours from the treatment center, and
Kyle was willing to have them come to treatment
sessions (e.g., his sister already knew of his OCD
and was willing to participate). Additionally, he
was able to maintain the level of privacy he desired because he could explain that the treatment
was for contamination obsessive-compulsive
symptoms rather than sexual symptoms. In addition to in-session exposures, several homework
assignments were given that incorporated doing
exposures with his niece. In situations where the
primary stimulus can be brought to treatment,
therapists can have patients do exposures via videoconferencing and/or take time off from treatment to return back to their home environment
for a period of time.
35
A third primary barrier to treatment was the

difficulty in addressing family accommodation.
Kyle was initially resistant to bringing in his
spouse to treatment because of his fear of her
learning of his sexual symptoms. Furthermore,
Kyles wife remained back in Kyles hometown
since she had a full-time job and was caring for
a sick parent. While spouse involvement in most
exposures is ideal, Kyles wife was only able to
drive into town for a handful of sessions. To ensure that Kyles wife understood OCD and the
importance of not accommodating, a book on
OCD was assigned to her and Kyle was instructed to call her at times during session to explain
important parts of treatment. During the sessions
she attended, she was involved as much as possible in the exposure to maximize her chance
to observe how the therapists implement exposures, including how to limit accommodation and
model non-avoidance.
Conclusions and Key Practice Points

Kyles treatment was a success and provides a
helpful demonstration about how to treat sexual
obsessive-compulsive symptoms in adults. All
cases of patients with OCD who seek treatment
do not see a response like what Kyle had, but this
reflects the need for additional treatment outcome
research that investigates various augmentation
strategies that clinicians can utilize to tailor this
manualized treatment and maximize outcome.
While exciting research on this topic is emerging,
such as using a pharmacological agent to increase
new memory formation after successful exposures
which may increase speed of response and overall
outcome (e.g., Norberg etal. 2008), more research
is especially needed on improving outcomes
for sexual OCD since this dimension has worse
treatment outcome compared to other domains
(Mataix-Cols etal. 2002). More so, research needs
to focus on the process of designing and implementing exposures, as little research exists to educate clinicians about which aspects of exposure
design and implementation have the strongest association with outcome. This lack of research on
design and implementation contributes to the poor
36
A. M. Reid et al.
Table 3.2 Key practice points displayed in Kyles treatment

Be willing to discuss sexually explicit content during treatment; monitor your own disgust and anxiety during sexual
exposures and discuss in supervision
Use creativity to design exposures to maximize engagement by patient (i.e., make it fun) and over practice with
sexually explicit content during exposures
Monitor patient disgust and allow to habituate during exposures; use reframing technique to facilitate habituation
Use verbal repetition of intrusive cognitions to increase diffusion and limit covert compulsions during exposures
Conduct exposures with multiple sexual anxiety triggers in a variety of contexts
dissemination of CBT to community clinicians

described in the introduction.
Thus, the overall goal of this chapter is to provide a case report of a successful use of CBT to
treat primarily sexual adult OCD. The chapter
intends to emphasize specific elements of exposure design and implementation that, if ignored
or done incorrectly, can hinder outcome and lead
clinicians to avoid utilizing CBT. Primarily, clinical experience and preliminary research supports
the theory that therapists who are more prone to
anxiety or disgust, in situations such as discussing
sexual thoughts about a young child for example,
are less likely to conduct appropriate CBT (Deacon etal. 2013; Olatunji etal. 2009). Thus, this
chapter displayed the importance of therapists
non-avoidance of treating sexual obsessive-compulsive symptoms by conducting exposures that
often involve explicit sexual content. This is a requirement. Without it, therapists will be unable to
replicate the content of intrusive cognitions patients experience and may actually model avoidant behavior to the patient. As is mention in the
first bullet point in Table3.2, therapists should
monitor their own anxiety or disgust sensitivity
and discuss with their supervisor any concerns
they may have about these sensitivities interfering with treatment for their patient. Group supervision was utilized throughout the treatment of
Kyle, as this is useful in exposing therapists to
multiple cases of CBT at one time and also facilitates brainstorming of creative and appropriate
exposure design and implementation.
Additionally, Table3.2 lists several other key
points that were exemplified in Kyles treatment
and are pivotal for therapists to consider when
treating sexual OCD. CBT is an effective treatment modality, but applying it to the treatment
of sexual OCD requires skill and experience. The
authors highly recommend seeking out additional

training, shadowing experiences, or expert consultation before attempting to utilize CBT for
sexual OCD. For example, Deacon etal. (2013)
found that a 1-day in-person training seminar on
exposure therapy reduced negative beliefs about
exposure therapy and increased proper implementation. There is even more potential to use
web-based trainings, such as that used by Kobak
etal. (2013). These researchers used online readings and demonstrations of exposure therapy, in
addition to role playing via videoconference and
found that this training increased knowledge and
use of exposure therapy. Harned etal. (2013)
conducted a similar online training and echoed
Kobak and colleagues results. OCD, especially
primarily sexual OCD, is a highly disabling disorder, and it is important for clinicians to seek resources to enable them to appropriately treat this
condition and increase access to care for these
patients.
References
Aardema, F., & OConnor, K. (2007). The menace within:
Obsessions and the self. Journal of Cognitive Psychotherapy, 21(3), 182197.
Aardema, F., Moulding, R., Radomsky, A. S., Doron,
G., Allamby, J., & Souki, E. (2013). Fear of self and
obsessionality: Development and validation of the fear
of self questionnaire. Journal of Obsessive-Compulsive and Related Disorders, 2(3), 306315.
Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., &
Furr, J. M. (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessivecompulsive disorder. Journal of Consulting and
Clinical Psychology, 71(6), 1049.
Albert, U., Bogetto, F., Maina, G., Saracco, P., Brunatto,
C., & Mataix-Cols, D. (2010). Family accommodation
in obsessive-compulsive disorder: Relation to symptom dimensions, clinical and family characteristics.
Psychiatry Research, 179(2), 204211.

Washington, DC: American Psychiatric Association.
Amir, N., Freshman, M., & Foa, E. B. (2000). Family
distress and involvement in relatives of obsessivecompulsive disorder patients. Journal of Anxiety Disorders, 14(3), 209217.
Anholt, G. E., Aderka, I. M., van Balkom, A. J., Smit, J.
H., Hermesh, H., de Haan, E., etal. (2011). The impact
of depression on the treatment of obsessive-compulsive disorder: Results from a 5-year follow-up. Journal of Affective Disorders, 135, 201207.
Benito, K. G., Conelea, C., Garcia, A. M., & Freeman,
J. B. (2012). CBT specific process in exposure-based
treatments: Initial examination in a pediatric OCD
sample. Journal of Obsessive-Compulsive and Related
Disorders, 1(2), 7784.
Bloch, M. H., McGuire, J., Landeros-Weisenberger, A.,
Leckman, J. F., & Pittenger, C. (2010). Meta-analysis
of the doseresponse relationship of SSRI in obsessive-compulsive disorder. Molecular Psychiatry,
15(8), 850855.
Bouton, M. E. (2002). Context, ambiguity, and unlearning: Sources of relapse after behavioral extinction.
Biological Psychiatry, 52(10), 976986.
Clark, D. A., Purdon, C., & Byers, E. S. (2000). Appraisal
and control of sexual and non-sexual intrusive
thoughts in university students. Behaviour Research
and Therapy, 38, 439455.
Cougle, J. R., Wolitzky-Taylor, K. B., Lee, H. J., & Telch,
M. J. (2007). Mechanisms of change in ERP treatment
of compulsive hand washing: Does primary threat
make a difference? Behaviour Research and Therapy,
45(7), 14491459.
Deacon, B. J., Farrell, N. R., Kemp, J. J., Dixon, L. J.,
Sy, J. T., Zhang, A. R., etal. (2013). Assessing therapist reservations about exposure therapy for anxiety
disorders: The therapist beliefs about exposure scale.
Journal of Anxiety Disorders, 27, 772780.
Farrell, L. J., & Boschen, M. (2011). Treatment outcome
in adult OCD: Predictors and processes of change.
Asia Pacific Journal of Counselling and Psychotherapy, 2(1), 8297.
Farrell, N. R., Deacon, B. J., Kemp, J. J., Dixon, L. J., &
Sy, J. T. (2013). Do negative beliefs about exposure
therapy cause its suboptimal delivery? An experimental investigation. Journal of Anxiety Disorders, 27(8),
763771.
Fineberg, N. A., Tonnoir, B., Lemming, O., & Stein, D.
J. (2007). Escitalopram prevents relapse of obsessivecompulsive disorder. European Neuropsychopharmacology, 17(6), 430439.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing
of fear: Exposure to corrective information. Psychological Bulletin, 99(1), 20.
Fontenelle, J. M., Harrison, B. J., Santana, L., do Rosrio,
M. C., Versiani, M., & Fontenelle, L. F. (2013). Correlates of insight into different symptom dimensions
in obsessive-compulsive disorder. Annals of Clinical
Psychiatry, 25(1), 1116.
37
Franklin, M. E., & Simpson, H. B. (2005). Combining

pharmacotherapy and exposure plus ritual prevention
for obsessive compulsive disorder: Research findings
and clinical applications. Journal of Cognitive Psychotherapy, 19(4), 317330.
C., Fleischmann, R. L., Hill, C. L., etal. (1989a). The
YaleBrown obsessive compulsive scale: I. Development, use, and reliability. Archives of General Psychiatry, 46(11), 10061011.
Gordon, W. M. (2002). Sexual obsessions and OCD. Sexual and Relationship Therapy, 17(4), 343354.
Gordon, H., & Grubin, D. (2004). Psychiatric aspects
of the assessment and treatment of sex offenders.
Advances in Psychiatric Treatment, 10(1), 7380.
Grant, J. E., & Potenza, M. N. (2006). Compulsive aspects
of impulse-control disorders. The Psychiatric Clinics
of North America, 29(2), 539.
Harned, M. S., Dimeff, L. A., Woodcock, E. A., & Contreras, I. (2013). Predicting adoption of exposure therapy
in a randomized controlled dissemination trial. Journal of Anxiety Disorders, 27(8), 754762.
Hipol, L. J., & Deacon, B. J. (2013). Dissemination of
evidence-based practices for anxiety disorders in
Wyoming: A survey of practicing psychotherapists.
Behavior Modification, 37(2), 170188.
Jakubovski, E., Diniz, J. B., Valerio, C., Fossaluza, V.,
Belotto-Silva, C., Gorenstein, C., etal. (2013). Clinical predictors of long-term outcome in obsessivecompulsive disorder. Depression and Anxiety, 30(8),
763772.
Jordan, C., Reid, A. M., Mariaskin, A., Augusto, B., &
Sulkowski, M. L. (2012). First-line treatment for pediatric obsessive-compulsive disorder. Journal of Contemporary Psychotherapy, 42(4), 243248.
Kafka, M. P. (2010). Hypersexual disorder: A proposed
diagnosis for DSM-V. Archives of Sexual Behavior,
39(2), 377400.
Keeley, M. L., Storch, E. A., Merlo, L. J., & Geffken, G.
R. (2008). Clinical predictors of response to cognitivebehavioral therapy for obsessivecompulsive disorder.
Clinical Psychology Review, 28(1), 118130.
Kichuk, S. A., Torres, A. R., Fontenelle, L. F., Rosrio,
M. C., Shavitt, R. G., Miguel, E. C., etal. (2013).
Symptom dimensions are associated with age of onset
and clinical course of obsessive-compulsive disorder.
Progress in Neuro-Psychopharmacology and Biological Psychiatry, 44, 233239.
Kobak, K. A., Craske, M. G., Rose, R. D., & WolitskyTaylor, K. (2013). Web-based therapist training on
cognitive behavior therapy for anxiety disorders: A
pilot study. Psychotherapy, 50(2), 235.
Lee, H. J., & Kwon, S. M. (2003). Two different types of
obsession: Autogenous obsessions and reactive obsessions. Behaviour Research and Therapy, 41(1), 1129.
Lochner, C., du Toit, P. L., Zungu-Dirwayi, N., Marais,
A., van Kradenburg, J., Seedat, S., etal. (2002). Childhood trauma in obsessive-compulsive disorder, trichotillomania, and controls. Depression and Anxiety,
15(2), 6668.
38
Masuda, A., Twohig, M. P., Stormo, A. R., Feinstein, A.
B., Chou, Y. Y., & Wendell, J. W. (2010). The effects
of cognitive defusion and thought distraction on emotional discomfort and believability of negative selfreferential thoughts. Journal of Behavior Therapy and
Experimental Psychiatry, 41(1), 1117.
Mataix-Cols, D., Marks, I. M., Greist, J. H., Kobak, K.
A., & Baer, L. (2002). Obsessive-compulsive symptom dimensions as predictors of compliance with
and response to behaviour therapy: Results from a
controlled trial. Psychotherapy and Psychosomatics,
71(5), 255262.
McKeon, J., Roa, B., & Mann, A. (1984). Life events and
personality traits in obsessive-compulsive neurosis.
The British Journal of Psychiatry, 144(2), 185189.
Narayanaswamy, J. C., Viswanath, B., Veshnal Cherian,
A., Bada Math, S., Kandavel, T., & Janardhan Reddy,
Y. C. (2012). Impact of age of onset of illness on clinical phenotype in OCD. Psychiatry Research, 200(2),
554559.
Norberg, M. M., Krystal, J. H., & Tolin, D. F. (2008). A
meta-analysis of D-cycloserine and the facilitation of
fear extinction and exposure therapy. Biological Psychiatry, 63, 11181126.
Olatunji, B. O., Deacon, B. J., & Abramowitz, J. S.
(2009). The cruelest cure? Ethical issues in the implementation of exposure-based treatments. Cognitive
and Behavioral Practice, 16(2), 172180.
Olatunji, B. O., Tart, C. D., Ciesielski, B. G., McGrath, P.
B., & Smits, J. A. (2011). Specificity of disgust vulnerability in the distinction and treatment of OCD.
Journal of Psychiatric Research, 45(9), 12361242.
Olatunji, B. O., Davis, M. L., Powers, M. B., & Smits,
J. A. (2013). Cognitive-behavioral therapy for obsessive-compulsive disorder: A meta-analysis of treatment outcome and moderators. Journal of Psychiatric
Research, 47(1), 3341.
ONeil, S. E., Cather, C., Fishel, A. K., & Kafka, M.
(2005). Not knowing if I was a pedophile-diagnostic questions and treatment strategies in a case of
OCD. Harvard Review of Psychiatry, 13(3), 186196.
Pinto, A., Greenberg, B. D., Grados, M., Bienvenu III, O.
J., Samuels, J., Murphy, D. L., etal. (2008). Further
development of YBOCS dimensions in the OCD collaborative genetics study: Symptoms vs. categories.
Psychiatry Research, 160, 8393.
Rasmussen, S. A., & Eisen, J. L. (1987). Clinical and epidemiologic findings of significance to neuropharmacologic trials in OCD. Psychopharmacology Bulletin,
24(3), 466470.
Rassin, E., Muris, P., Schmidt, H., & Merckelbach, H.
(2000). Relationships between thought-action fusion,
thought suppression and obsessive-compulsive symptoms: A structural equation modeling approach.
Behaviour Research and Therapy, 38(9), 889897.
A. M. Reid et al.
Rosario-Campos, M. C., Miguel, E. C., Quatrano, S.
S., Chacon, P. P., Ferrao, Y. Y., Findley, D. D., etal.
(2006). The dimensional YaleBrown obsessive-compulsive scale (DY-BOCS): An instrument for assessing obsessive-compulsive symptom dimensions.
Molecular Psychiatry, 11(5), 495504.
Rowe, M. K., & Craske, M. G. (1998). Effects of varied-stimulus exposure training on fear reduction and
return of fear. Behaviour Research and Therapy,
36(7/8), 719734.
Rufer, M., Grothusen, A., Ma, R., Peter, H., & Hand, I.
(2005). Temporal stability of symptom dimensions
in adult patients with obsessive-compulsive disorder.
Journal of Affective Disorders, 88(1), 99102.
Shafran, R., Thordarson, D. S., & Rachman, S. (1996).
Thought-action fusion in obsessive compulsive disorder. Journal of Anxiety Disorders, 10(5), 379391.
Smith, A. H., Burgess, A. J., Minarcik, J., Hart, J., & Wetterneck, C. T. (August 2009). Distress from sexually
intrusive thoughts: The impact of thought content
and real-life experience. Poster presented at the 16th
annual obsessive-compulsive foundation conference.
Minneapolis, MN.
Steketee, G., Frost, R., & Bogart, K. (1996). The Yale
Brown obsessive compulsive scale: Interview versus
self-report. Behaviour Research and Therapy, 34,
675684.
Storch, E. A., Geffken, G. R., Merlo, L. J., Mann, G.,
Duke, D., Munson, M., etal. (2007). Family-based
cognitive-behavioral therapy for pediatric obsessivecompulsive disorder: Comparison of intensive and
weekly approaches. Journal of the American Academy
of Child & Adolescent Psychiatry, 46(4), 469478.
Storch, E. A., Arnold, E., Lewin, A., Nadeau, J., Jones,
A., De Nadai, A., etal. (2013). The effect of cognitive-behavioral therapy versus treatment as usual for
anxiety in children with autism spectrum disorders: A
randomized, controlled trial. Journal of the American
Academy of Child & Adolescent Psychiatry, 52(2),
132142.
Thompson-Hollands, J., Farchione, T. J., & Barlow, D. H.
(2013). Thought-action fusion across anxiety disorder
diagnoses: Specificity and treatment effects. The Journal of Nervous and Mental Disease, 201(5), 407413.
Westra, H. A., Dozois, D. J., & Marcus, M. (2007). Expectancy, homework compliance, and initial change in
cognitive-behavioral therapy for anxiety. Journal of
Consulting and Clinical Psychology, 75(3), 363.
Williams, M. T., & Farris, S. G. (2011). Sexual orientation
obsessions in obsessive-compulsive disorder: Prevalence and correlates. Psychiatry Research, 187(1),
156159.
Treatment of ScrupulosityRelated Obsessive-Compulsive

Disorder
Jedidiah Siev and Jonathan D. Huppert
Treating Scrupulosity: An Illustrative

Case Study
Scrupulosity refers to obsessive-compulsive
disorder (OCD) when obsessional fears and
compulsive rituals have religious or moral content. Although sometimes referred to as an OCD
subtype by itself, or grouped as a symptom dimension along with sexual and aggressive obsessions (e.g., Abramowitz etal. 2003; Pinto etal.
2007), scrupulosity can actually take the form
of any OCD subtype. For example, a scrupulous
individual might fear contamination and engage
in decontamination rituals, all with a religious
theme, such as excessive cleaning after using
the bathroom before prayers. Another individual
might have sexual obsessions, with the fear that
the thoughts are sinful or blasphemous. Yet another might obsess about accidental errors and
engage in repeating or checking rituals, again
with a religious fear, such as an individual who
reconfesses or checks that religious ritual objects
are used or aligned properly. Therefore, scrupulosity is best characterized as a category of core
fear that can be associated with any OCD symptom subtype.
J.Siev()
Center for Psychological Studies, Nova Southeastern
University, Maltz Psychology Building, 3301 College
Avenue, Fort Lauderdale, FL 33314, USA
e-mail: js3088@nova.edu
J.D. Huppert
The Hebrew University of Jerusalem, Jerusalem, Israel
Obsessional themes vary by culture (e.g.,

Okasha etal. 1994; Rasmussen and Tsuang
1986), and religious symptoms are more common in more religious cultures and subcultures.
In Western cultures, 1033% of individuals with
OCD have religious symptoms (Eisen etal. 1999;
Mataix-Cols etal. 2002), and 56% have primary scrupulosity (Foa and Kozak 1995; Tolin etal.
2001). However, in some Middle Eastern countries, 4060% of those with OCD report religious
obsessions (for a review, see Greenberg and Huppert 2010). Similarly, members of religious subcultures with OCD are more likely to have religious symptoms than are those in the greater culture (e.g., Greenberg and Shefler 2002). There is
no evidence that religion confers a risk for OCD;
rather, religious individuals with OCD are likely
to experience religious symptoms. Ironically, the
large majority of scrupulous individuals experience their symptoms as interfering with their
religious practice or relationship with God (Siev
etal. 2011), even though those symptoms are
often motivated by the desire to fulfill religious
requirements or avoid sin or offending God.
In some studies, the presence of religious
obsessions predicts poor treatment outcome for
behavioral and pharmacological treatments (e.g.,
Alonso etal. 2001; Ferro etal. 2006; MataixCols etal. 2002; Rufer etal. 2005). In others,
however, they do not (e.g., Abramowitz etal.
2003). Nevertheless, clinicians encounter several difficulties implementing effective exposure
and response prevention (ERP) with scrupulous
patients. Patients may hesitate more with moral

DOI 10.1007/978-3-319-17139-5_4
39
40
than physical risks, and moral fears are often

less easily disconfirmed than are physical ones.
Moreover, clergy and co-religionists may reinforce and even encourage compulsions, mistaking them for piety (Huppert and Siev 2010). Indeed, clergy members of certain denominations
and holding certain beliefs may be more likely
than others to offer recommendations that are incompatible with ERP and potentially confusing
to a scrupulous patient (Deacon etal. 2013). Patients may perceive their symptoms as religious
rather than psychological or psychiatric and
doubt the authority of therapists in this domain
(Ciarrocchi 1995; Greenberg and Shefler 2008).
Therapists are challenged to disentangle religious
from compulsive ritual and help patients violate
the latter but not the former, which often involves
becoming acquainted with unfamiliar and complex religious norms and working collaboratively
with clergy. Taken together, effective ERP requires skilled psychotherapy technique and creativity along with cultural sensitivity and respect
of patient values.
Several papers and books describe modifications of ERP for scrupulosity in general and
for use with specific religious populations (e.g.,
Abramowitz 2001; Bonchek 2009; Bonchek and
Greenberg 2009; Ciarrocchi 1995; Deacon and
Nelson 2008; Huppert and Siev 2010; Huppert
etal. 2007). Many religions have existing literatures on the nature and religious response to scrupulosity, often consistent with an ERP approach.
Authors of clinical treatment guides and case
studies typically encourage therapists to integrate
these sources into treatment or incorporate them
in psychoeducation and motivational phases. For
example, Ciarrocchi (1995) describes the writings of John Bunyan and Saint Ignatius Loyola
about their own scrupulosity, Greenberg and
Shefler (2008) review Ultra-Orthodox Jewish responses to scrupulosity in the rabbinic literature,
and Besiroglu etal. (2014) offer Islamic sources
consistent with ERP.
Although secular moral scrupulosity is not
uncommon (e.g., Siev etal. 2011), we focus this
chapter on a case that illustrates the application
of ERP to an individual with religious scrupulosity. In accordance with American Psychological
J. Siev and J. D. Huppert
Association (APA) ethical standards, we have altered case information sufficiently to protect the
individuals confidentiality without sacrificing
the clinical utility of the case presentation.
Case Study
Presenting Problem
David is a 42-year-old Ultra-Orthodox Jewish
man, who was referred by his father for OCD
treatment. David reported OCD symptoms related to prayer, ritual purity, and charitable donations. He obsessed about not fulfilling his prayer
requirements by making a mistake, not enunciating the words properly, or not having proper
concentration. As a result, David ritualized by
repeating prayers and saying them excessively
slowly. Although these concerns were triggered
throughout the day (e.g., when reciting blessings over food), they were particularly prominent
mornings and evenings when reciting the cardinal prayer, the Shema, the obligation for which is
considered most serious and requires concentration. Moreover, when saying a prayer on behalf
of a group, David often repeated the prayer to
ensure that others heard every word completely
and accurately.
In addition, Orthodox Jewish men wear phylacteries (tefillin, small black boxes containing
biblical passages that are fastened and wrapped
with leather straps) during morning prayers on
the arm and head, where they are supposed to
be placed precisely at the hairline and aligned
between the eyes. Tefillin are mentioned in the
Shema prayer, and the Talmud (Berachot 14b)
alleges that one who recites the prayer without
tefillin bears false witness. David obsessed about
his tefillin being accidentally misaligned, causing him not to fulfill the obligation to don them
and also to bear false witness with the prayer. His
associated compulsions included checking the
alignment of his tefillin (e.g., with a pocket mirror he brought to synagogue for this purpose) as
well as repeating prayers when he adjusted them.
David also obsessed about being ritually impure. Upon awakening, one is required to wash
4 Treatment of Scrupulosity-Related Obsessive-Compulsive Disorder
ones hands by pouring water alternately over

them (usually three times on each hand). A similar ritual is completed after touching ritually unclean surfaces (e.g., areas of the body normally
covered, shoes, etc.) or using the bathroom, before one can recite prayers or passages from the
Bible. David obsessed about accidentally becoming ritually impure and compulsively washed and
wiped his hands before and even during prayers,
and he even washed his shoes after using the bathroom. He also worried that he had not wiped himself sufficiently after using the bathroom, leading to excessive, repetitive, and time-consuming
wiping. David was a full-time Talmudic student
and scholar, and he was constantly involved with
Bible study. Therefore, obsessional doubts about
ritual purity were present throughout most of the
day.
In addition to physical purity, David was
also concerned about spiritual purity. He obsessed that inappropriate thoughts could make
his prayers ineffective or invalid. These potentially blasphemous thoughts included that maybe
Christianity was the true religion or that maybe
the last generations greatest Torah scholar was
actually God. Although David believed that these
thoughts were absurd and untrue, they intruded in
his mind during prayers and distressed him greatly. Consequently, he avoided looking at anything
that could be perceived as a cross, including the
lowercase letter t. He would always either
alter the letter or write it in capitals. In order to
deal with his obsessional concerns, David would
spend hours daily looking up in Jewish legal
texts to check whether he was sinning, engaging
in discussions with other scholars, or seeking answers from rabbis.
Finally, David compulsively donated money
to charity in amounts that his family could not
afford. He had great difficulty refusing beggars
or discarding solicitations in the mail without
sending money. In the year prior to intake, David
donated approximately US$9000, depleting most
of their savings. At intake, his wife was aware
of this, although he had hidden it from her many
months. In addition, David actively solicited and
collected charity on behalf of others.
41
Background and History

David was raised in America in a traditional,
conservative Ultra-Orthodox family, the oldest
of six children. His father was a rabbi and teacher
in a religious high school, and his mother was a
homemaker. David attended single-sex religious
schools, where the study of religious texts was
primary, and secular studies were limited to the
minimal legal requirements. Although many students eventually entered the secular workforce,
David aspired from a young age to become a fulltime religious scholar and legal expert. Following
high school, he studied in a renowned seminary
in England for 2 years, after which he moved to
Israel to continue his religious studies.
At age 23, David began dating. Prospective
matches were arranged, and the couple went on
several dates after both families agreed the match
seemed suitable. Davids wife was English and
from a family similar to his. They were engaged
after seven dates and married 3 months later.
After marrying at age 24, they remained in Israel
where he continued full-time religious studies,
and she worked as a teacher in a seminary for
post-high-school girls. Although the specifics of
this arrangement have changed somewhat over
the years, at intake, David continued full-time
religious studies, for which he earned a modest
stipend, and his wife continued to teach at several
institutions to support the family. With the exception of conflict related to OCD symptoms, they
both reported satisfaction with their marriage and
with this arrangement. They had eight children
ranging from 1 to 15 years old.
In retrospect, David reported mild OCD symptoms beginning in his early teens; however, they
did not cause significant impairment at the time,
and others interpreted them as righteous attempts
to ensure completion of religious rituals, rather
than signs of OCD rituals. The symptoms worsened in his 20s. For example, extensive and elongated prayer rituals sometimes resulted in him
coming late for morning studies, and he began
to experience religion as more burdensome than
fulfilling. David had been in therapy twice, once
focused primarily on analytic dream work and
once in unspecified supportive psychotherapy.
42
Both times he terminated within 3 months. Over

the course of several years, he had sought council
from several rabbis, all of whom opined that he
was exceeding appropriate standards and offered
reassurance. However, they did not offer specific treatment recommendations, and they often
encouraged him to attempt to eliminate anxiety
by avoiding situations that triggered obsessions
or generally to strengthen his faith in God. For
example, one rabbi suggested he avoid making
blessings on behalf of others. Davids father
urged him to seek ERP for OCD after his wife
tearfully reported to him her husbands excessive charity, and he observed Davids worsening
prayer and ritual washing compulsions on a recent visit.

David met criteria for OCD, but denied symptoms of all other disorders during a structured
clinical interview covering most Diagnostic and
Statistical Manual of Mental Disorders (DSM)IV-TR (American Psychiatric Association 2000)
axis I disorders (Mini-International Neuropsychiatric Interview; Sheehan etal. 1998). On the
YaleBrown Obsessive-Compulsive Scale (YBOCS; Goodman et al. 1989), he initially endorsed mild symptoms and received a Y-BOCS
score of 19, largely due to his lack of attempts
to control his rituals and the potential anxiety he
would feel not completing them. However, it became apparent in the second session that this was
a clear underestimation of his actual symptoms
due to David minimizing them. Davids wife was
requested to attend the second session with him,
and she reported that he spent hours daily seeking
answers to questions, soliciting charity for others, and washing. Initially, David disagreed that
this was a problem or that he took more time than
he should, but upon inquiry from the therapist,
David agreed that he took much more time in
these activities than others around him and that it
took away from his Torah studies. In addition, he
acknowledged that it was a problem that he had
given away his familys savings. Although the
therapist did not readminister the Y-BOCS dur-
ing the second session, a score of approximately

25 probably more accurately reflected Davids
pretreatment severity.
David completed a battery of self-report measures including the revised Obsessive-Compulsive Inventory (OCI-R; Foa etal. 2002), the Penn
Inventory of Scrupulosity (PIOS; Abramowitz
etal. 2002), and the Beck Depression InventoryII (BDI-II; Beck etal. 1996). He endorsed contamination, checking, ordering/arranging, and
obsessional concerns on the OCI-R, resulting in
an elevated total score, as well. He reported high
levels of scrupulosity on the PIOS, but suggested
to the therapist that this simply indicated his religious devotion and not pathology. He scored a 3
on the BDI-II.
Individuals may fear the same stimulus for
many different reasons, so it is crucial to identify the patients idiosyncratic, core obsessional
fears. For example, using the downward arrow
technique (Burns 1980), the therapist asks about
the meaning or cost associated with a fear and
then continues to ask about meaning and cost
(e.g., And what would be the worst thing about
that?) until the core fear is evident. David had
several core obsessional fears. He was concerned
about divine punishment after death, although his
image was not of a fire and brimstone hell, but
rather losing his share in the afterlife (the world
to come). Moreover, the very state of living in
sin and shirking the yoke of his religious obligation was itself a core fear. He had fears, as well, of
intolerable and unceasing negative emotions that
would result from his obsessions, were he not to
ritualize, such as guilt and shame and thoughts
of being a cruel person. Finally, he feared that
God would cause him and his family to lose their
money and sustenance were he to be stingy and
withhold his resources from those in need.
Overall, Davids initial depiction of his own
symptoms suggested an individual struggling to
understand the interaction of his own religious
beliefs and practice with OCD. On the one hand,
he was aware that his behavior exceeded community standards and rabbinical advice, was often
motivated by anxiety, and interfered with some
aspects of his life (e.g., religious and marital). On
the other hand, he minimized the symptoms and
downplayed the extent to which several apparently religious behaviors were in fact symptoms
of OCD. This is a struggle for many scrupulous
patients, who may be concerned or unclear about
where sincere devotion becomes obsessional fear
and where religious ritual becomes compulsion.
For these reasons, the therapist incorporates cognitive work to allow the patient to examine moral
and religious decision making, as well as motivational work throughout. The staple of treatment
remains ERP, with a focus on learning to accept
doubt and uncertainty, which always exist but are
sometimes particularly difficult for patients to
tolerate in religious or moral domains.
Treatment Course
The treatment began with psychoeducation. During the first treatment session, the therapist reviewed the difference between obsessions and
compulsions, emphasizing that the latter includes
covert rituals and, for all intents and purposes,
avoidance and reassurance seeking. David was
able to identify several examples of such compulsions, such as efforts to ensure perfect concentration during prayers. The therapist then discussed
the long-term versus short-term consequences of
compulsions and avoidance and helped David
understand the role of negative reinforcement in
maintaining anxiety over time. With prompting,
David was able to infer the basic premise of ERP.
The remainder of the first, and the entire second session, were devoted to discussing risk,
uncertainty, and motivation. Most of Davids obsessional fears did not lend themselves to direct
observation or disconfirmation; therefore, less
emphasis was placed on exposures as behavioral
experiments in which he would discover information about the fears, per se. Nonetheless, in
addition to a purely behavioral rationale about
reinforcement, conditioning, and habituation, the
therapist suggested that ERP would allow David
to find out whether he could tolerate risk of sin
and the intense guilt and anxiety he experienced
in response to obsessional triggers.
This led to questions about uncertainty, when
to risk sin, and how to gauge acceptable risk:
43
Therapist: How did you come to session today?

David: I drove.
Therapist: Are you aware of any statistics about
traffic accidents?
David: Not specifically, but obviously they happen sometimes.
Therapist: Yes. Did you hesitate about driving
here today because of this?
David: Honestly no, it didnt really occur to me.
Therapist: Why were you willing to risk something so serioussome accidents are fatal, even
without giving it much thought?
David: Well I suppose I hadnt thought about it
before, but you really cant live a normal life without tolerating some amount of serious risk.
Therapist: And if you did avoid driving, would
that guarantee that youd be safe?
David: No, all kinds of other things happen.
Therapist: So how do you decide which, and
how much, risk is appropriate? I dont suppose this
would be reason to prick yourself with dirty needles because, hey, I cant be sure anything is safe?
David: In general, I guess people try within
reason to minimize risks to whatever extent allows
them to live regular lives. So they do what most
others do.
Therapist: How about with davening [prayer]?
David: That seems different, though. Its one
thing to risk your own happiness or safety, but how
can you risk not fulfilling Gods law? Its not something I or society can decide is okay, like risking
my life by driving. Its Gods will. The Torah says to
distance oneself from aveiros [sin].
Therapist: So risks about mitzvos [commandments] seem different.
David: Yes. Also, other people without OCD
avoid risking issurim [prohibitions] when theyre
in doubt, not just if theyre sure.
Therapist: Do other people have the same kinds
of doubts you do? Are they as frequent?
David: No.
Therapist: What do you make of that?
David: I suppose I worry about things they
dont consider shaylos [legitimate questions], but
Im not sure how to distinguish between them.
Therapist: So if Im understanding correctly,
you have two concerns about taking risks with religion. One is that it is forbidden to do so and the
other is that you dont know how to decide which
are acceptable. Is that right?
David: Yes.
David and the therapist spent the last part of

the first session exploring Davids beliefs about
whether it is acceptable to take religious risks
or whether one must attempt to avoid all uncertainty. The therapist adopted a Socratic style
designed to explore Davids own beliefs and
reasoning and was careful to avoid offering his
44
own beliefs. There were several reasons for this

approach. Aside from the wish to respect patient
values, debates about religious requirements are
typically futile with scrupulous individuals in the
same way that debates about immunology are unlikely to help a patient with obsessional fears of
contracting HIV (especially with a patient with
a PhD in cell biology or immunology and infectious disease). In addition, such debates are likely
to encourage the patient to defend and justify his
or her OCDs position, even when they are ambivalent about it (e.g., Miller and Rollnick 2013).
The opportunity to clarify his own beliefs is
also a step toward developing the skills to make
decisions about uncertainty. Finally, although
frequently drawing on the rabbinic literature to
facilitate motivation, overall the therapistwho
was also an observant Jewwas careful to deemphasize any religious authority or expertise
the patient might perceive him to have so as not
to provide reassurance implicitly.
Without labeling it such, the therapist asked
David to consider various inconsistencies in
his religious practice vis--vis tolerance of risk.
For example, whereas he compulsively repeated
prayers to avoid even the small likelihood that he
did not have requisite concentration, David recognized that he could not be 100% certain that he
would not inadvertently cross-contaminate dairy
and meat products (which, according to Jewish
law, are not to be cooked or eaten together). The
therapist asked why he is willing to tolerate such
risks. David answered with reference to the Jewish legal principle of bittul, by which mechanism
accidental cross-contamination of trace amounts
is considered nullified and insignificant.
Therapist: But you still might mix them.
David: It doesnt matter; its still permissible
according to halacha [religious law] whether or not
there is a physical trace.
Therapist: Oh, ok. So you are required to follow
the guidelines articulated by halacha regardless of
the certainty that you physically didnt mix dairy
and meat?
David: Yes.
Therapist: How do you know how far you
are expected to go to fulfill obligations or avoid
transgression?
David: In the case of dairy and meat, the guidelines are fairly well known. But otherwise, Id ask
my rabbi for something more complex.
Therapist: Well, how about for prayer? It sounds

like you believe that halachic requirements are not
always the same as physical facts, like with trace
amounts of dairy and meat. Are there guidelines
for how to ensure sufficient concentration and
adequate articulation? Have you ever consulted
your rabbi?
David acknowledged that he had and that he was

not sufficiently reassured, which led to further
exploration of the difference between religious
and obsessional doubt, particularly in terms of
his difficulty tolerating the latter.
David requested that they continue the aforementioned discussion during the second session.
Referring to stories about pious historical rabbinic figures, he noted the communal reverence
for individuals who exceeded minimal requirements to avoid potential sin even when not required to do so. The therapist inquired about Davids motivation and emotional experience while
engaging compulsions that exceed requirements,
and David recognized that in the domains of his
OCD, his extra-legal religious behavior was driven more by anxiety and fear than fulfillment or
devotion. He also acknowledged feeling a need
or being compelled to act as he did, more than a
desire to do so. The therapist and David reviewed
part of a published discussion of this point by
Grinwald (1991, as cited by Greenberg and Shefler 2008), who published correspondence with
a renowned and revered Jewish legal authority, Rabbi Kanievsky, on psychological issues.
Drawing on biblical literature, Grinwald argues
that religious behavior motivatedand usually
infectedby distress is itself evidence that it is
not Gods will:
The person who, whenever he performs the will
of the Creator, finds his soul and his energies
contorted by feelings of discomfort, fear, tension
and misery over the carrying out of the commandmentand, on the contrary, this is his usual state,
and to carry out commandments out of joy is the
exceptionthis then is clear proof that this was
not Gods intention. (Grinwald 1991, as cited by
Greenberg and Shefler 2008, p.186)
In response to Davids observation that exceeding minimal standards is often viewed as righteous, the therapist drew analogies to eating
behavior and hand washing. Whereas there is
public health benefit in encouraging people to

eat healthy, exercise, and monitor caloric intake,
that message can be quite unhelpful for an individual with an eating disorder. Similarly, public
service announcements may encourage hand
washing and hand sanitizing (e.g., in hospital settings), but individuals with contamination-based
OCD need instead to practice facing perceived
contamination that is not objectively hazardous.
Indeed, earlier in his life Davids peers had interpreted his scrupulosity as piety and had inadvertently reinforced it. The therapist wondered aloud
whether this was similar to people complimenting a young woman with an eating disorder for
initial weight loss (e.g., Oh my goodness, you
look great. Did you lose weight?) before it became evident that the weight loss was excessive
and the behavior pathological.
During the rest of the second session, David
and the therapist explored how to differentiate
obsessional doubts from bona fide religious questions and agreed on a treatment plan. The therapist posed an esoteric Jewish legal dilemma to
David, who did not know the religious legal solution. The therapist challenged David to consider
whether his concerns about prayer, ritual purity,
and charitable donations felt similar, and David
acknowledged that, whereas he did not know the
answer in the hypothetical case, he was fairly
confident about the answers to his typical obsessional fears, which were experienced more as
but what if? doubts. The therapist asked what
threshold of possible transgression led Davids
peers to repeat, avoid, or seek consultation, and
he suggested that treatment would require David
to risk transgression by assuming there was no legitimate concern unless there was clear evidence
of one. This is consistent with Foa and Kozaks
(1985) observation that, whereas most individuals assume safety unless there is evidence of danger, individuals with OCD assume risk in their
obsessional domains until they have sufficient
proof of safety.
Research has demonstrated that the large majority of scrupulous individuals perceive their
symptoms as interfering with their religious experience and relationship with God (Siev etal.
2011). With reference to that research, the thera-
45
pist articulated the goal of helping disentangle

OCD and religion so that David can violate OCD
but not religious rules, and thereby live a life
more consistent with his values in a more meaningful, spiritual way. The therapist assured David
that they would not intentionally violate religious
law, but that it would be important to refrain from
explicit or implicit reassurance seeking throughout the course of therapy. In session, the therapist
and David called a rabbi whom David respected
as a legal authority and who had familiarity with
OCD and had reviewed several of Davids previous scrupulous doubts. The rabbi indicated that
they were not bona fide concerns, and after the
therapist reviewed the basic premise and goal of
ERP with the rabbi, the rabbi agreed to the suggestion that David assume his doubts were obsessional rather than religious, unless he was certain
otherwise. Instead of repeating, clarifying, or
consulting, David was to act in good faith, but
accept the possibility that his judgment was not
accurate, and that if so, he was responsible for
his actions.
We encourage consultation with clergy in this
way for many patients at the outset of treatment
and do not consider it compulsive. If a single
consultation were sufficient to eliminate anxiety,
most patients would have overcome their anxiety
without treatment. Rather, they continue to doubt
whether the answers apply to any given situation,
whether they remember correctly, whether they
explained sufficiently, whether the clergyperson
understood completely, and so forth. The therapist sought Davids agreement that he would not
reask or clarify the guidelines after receiving
them initially. Moreover, we distinguish between
assurance and reassurance, the latter implying
that it was once received. Finally, this approach
aligns the therapist with the patient in a common
goal of ridding the OCD in a manner consistent
with the patients values and in service of the patients goals.
Throughout the first two sessions (and beyond), the therapist elicited personally relevant
examples from David as much as possible. For
example, when referring to research that scrupulosity often interferes with patients religious
observance and relationship with God, the ther-
46
Table 4.1 Hierarchy for David

Situation
Shemain morning prayer, not repeating
Looking at a cross before praying
Saying no to someone who asks for charity
Putting on tefillin in 2min without checking
Looking at a picture of a church before praying
Shemaevening prayer, not repeating
Saying no to someone asking for charity after he gave them the week before
Writing a lowercase (uncurled) t
Using only four sets of toilet paper and then praying after
Putting on tefillin in 2min checking once with mirror
Shema in bed - when evening prayer felt questionable, not repeating
Saying a prayer after touching face
General blessings over food
Saying a prayer after touching pants
Shemain bedwhen evening prayer felt valid, not repeating
SUDS
10
10
10
9
8
7
7
6
6
5
5
4
3
2
1
SUDS subjective units of distress
apist asked whether David experienced that.

When David affirmed that he did, the therapist
asked him to elaborate, and David acknowledged
dreading prayers and experiencing several areas
of daily religious ritual as stressful and burdensome. At the end of the second session, the therapist gave David a self-monitoring form and asked
him to record his compulsions throughout the
next week, noting the situation and time, degree
of anxiety, compulsive behavior, and length of
time for each one.
The focus of the third session was to build an
exposure hierarchy and to begin in vivo exposure. The initial exposure hierarchy is provided
in Table4.1. The patient agreed that there were
no items on the hierarchy that would need rabbinical approval or that he believed were actually
problematic according to Jewish law. Therefore,
he agreed not to ask questions about any exposures, and that if a specific Jewish legal question
arose, he would first discuss it with the therapist
to determine if this was a real question or an
OCD question.
The therapist and patient commenced in vivo
exposure with blessings over food and other
common blessings, which the patient could easily recite in the therapy office. After filling a cup
of water for the patient to drink, the therapist and
patient discussed how strong the patients anxi-
ety would be if he made a blessing and drank

the water. The patient had not washed his hands
since coming into the office and reported feeling
somewhat contaminated. He was also not sure
that he was clean from his last use of the bathroom. Thus, he reported a subjective unit of distress (SUDS)1 of 5 in anticipation of making the
blessing before drinking the water. The therapist
asked David to articulate explicitly the risks he
was taking by making the blessing in his current
state and also why he was taking the risk. With
some coaching, David stated:
I am about to make a blessing even though I am
not sure I am completely clean. I am taking a risk
that my blessing will not be valid due to my impure
state, which would mean that I would be sinning
by drinking without first acknowledging Gods
role in providing all things via a blessing. Therefore, I am taking a risk that God may punish me
and my family due to my insolent behavior, as I
had an easy way to ensure I was pure and I did
not do so. I am taking this risk so that I can lead
a normal Jewish life and make decisions without
considering my anxiety, which prevents me from
being the person I want to be both spiritually and
with my friends and family.
Subjective units of distress, used as shorthand to gauge

degree of anxiety from 0 (none) to 10 (extreme).
He then made a blessing and drank the water.

He reported anxiety of 4, which was a bit lower
than he had anticipated, but was unsure why. The
therapist congratulated David on his courage in
engaging in his initial exposure, which they continued to process:
Therapist: How does it feel now that you took the
risk?
David: I dont know. It is weird, on the one
hand, and it feels bad. Why should I have taken the
risk when it would be so easy to just wash first?
Therapist: Go on
David: But on the other hand, it feels good to do
something I know is normal and right.
Therapist: Uh huh. Thats great. So how does
the second hand respond to the doubt?
David: I am not sure. I feel it is risking a lot.
Maybe something bad could happen that I could
have prevented. I am feeling more anxious now.
Therapist: That is natural. You are thinking
more about the possible negative consequences
of having taken the risk. How bad is your anxiety
now?
David: 3.
Therapist: OK, and if we focus on why you took
the risk again
David: I know I need to get over this. I need to
stop this nonsense. But it is hard.
Therapist: Yes, it is hard. And you are doing it.
Allow the anxiety to be there. Allow the thoughts
to be there.
David: OK.
Therapist: How does it feel to challenge the
OCD?
David: It feels scary, but empowering.
Therapist: Good. Remember, the anxiety is one
of the best medicines for the OCD.
After 10min, David reported feeling an SUDS

of 1. The therapist asked David how anxious he
would be to make the blessing after drinking, and
he estimated a 2. David made the blessing, but
experienced minimal anxiety (SUDS of 1). The
therapist asked David what he learned from the
experience, and David replied, I guess when I
confront my anxiety, it gets easier. But that would
be true for a sin, too. This then returned David
and the therapist to a discussion about using
exposures in the service of his values and not
against them, and that unlike obsessional anxiety about potential sin, anxiety about actual sin
(if David knew he were truly sinning) would be
less likely to habituate, certainly not as quickly.
David accepted this rationale and was asked to do
47
similar exercises for homework twice daily until

the next session.
In the next session, David identified another
potential exposure with an SUDS of 4 that was
not included in the original exposure hierarchy:
saying a prayer while potentially unclean to absolve someone else (i.e., on behalf of someone
else). The therapist and David decided to begin
with this exposure and then make a blessing after
touching his face (from the original hierarchy) if
there was sufficient time. The therapist took out
a chocolate bar, suggesting (humerously) that
David might as well make the exposure tastier
than water if he was going to push himself. David
laughed. David agreed to recite a blessing over
the chocolate, which he and the therapist would
then share, with the therapist relying on Davids
blessing. In this session, as well, David became
less anxious than he predicted and his anxiety declined relatively quickly, so he agreed to touch his
face and upper arm and then recite the blessing
after eating for himself and the therapist. David
hesitated at first, voicing concern that this was
too much, but agreed when the therapist encouraged him to take the risk and was successful in
so doing. The therapist and David then planned a
number of similar exposures for homework until
the next session.
In other sessions, David prayed in session,
put on tefillin in session, and the therapist and
David went to a synagogue where David could
pray with a quorum while practicing ERP (e.g.,
not adjusting tefillin or repeating prayers, leading the services on behalf of others, not borrowing a second pair of tefillin after prayers in case
his own were defective, etc.). David practiced
similar assignments throughout the week. For
the most part, in vivo exposures of these types
were straightforward, albeit sometimes difficult
for David, and he progressed steadily up the exposure hierarchy. One issue that came up about
prayer was that David insisted on adding specific
prayers for his health and to get over his OCD.
He did so with intensity and fervor and believed
that if he did not do so, he would not get better. In
addition to compulsive prayer, in our experience,
scrupulous individuals often seek religious solutions to their OCD. Although religious coping
48
can be helpful, exclusive reliance on divine intervention or blessings from religious figures can
indicate a fundamental lack of recognition of the
nature of OCD and the steps necessary to treat
it. It is critical that patients abandon hope of any
type of quick or easy fix (religious, in this case,
but the same is true for attempts to cure OCD
by means such as changing diet), which undermines ERP. Indeed, individuals efforts to cure
OCD, eliminate obsessions, or reduce anxiety
via specific religious behaviors are functionally
compulsive. When David objected that God controls everything in the world, the therapist asked
him to imagine hiring a plumber, who sat and
prayed for the toilet to unclog and then demanded
payment. David acknowledged that he, like the
plumber, was expected to make reasonable effort to address his problem using an intervention
known to be efficacious. At the same time, the
therapist conceded that someone who believes in
the efficacy of prayer might pray even for things
that require human effort. For example, someone
might pray for success in business, but still need
to work. Therefore, the therapist suggested that
rather than praying to get over OCD, David pray
instead for Gods will vis--vis his health, whatever it should be. This led to a discussion about
fear versus awe of God and that, while both are
found in Biblical sources, fear is typically balanced with mercy. David, however, said that he
felt that there was a notion in Judaism of spirituality from the depths of misery. The therapist
asked David if it meant that one was supposed to
cause suffering to himself or others to help them
be more spiritual, or rather that even if one is suffering, one should turn to God. He acknowledged
that it was more likely the latter.
In one session, David reported that someone
to whom he had been giving charity for some
time approached him and said that he had no
means to feed his family. He pleaded with David
to help him provide for his family so that his children would not go hungry. David posited that it
is against all morals and Jewish law to turn away
someone in such need. The therapist asked David
whether he had encountered other, similar circumstances since the beginning of treatment, and
David reported that he had and had resisted giving charity only if he was certain that the person
could readily obtain funds elsewhere. Even so,
he felt very guilty and angry with himself after
resisting. At other times, he gave the money and
did not tell anyone. The therapist asked David
whether he considered the long-term consequences of his actions. David said he had. The
therapist then encouraged David to consider his
decision-making process and the core emotions
and fears related to charitable efforts that he
could not afford with a series of questions. First,
the therapist raised the question of whether one is
allowed to give away so much charity that in the
end the giver needs to petition others for money.
David said that it is forbidden by Jewish law. The
therapist further asked whether giving charity directly to someone who asks is considered a high
level of charity. David answered that providing
a means to obtain future funds (teaching a man
to fish) and giving anonymously to an unknown
person are famously considered higher forms of
charity according to Maimonides. The therapist
then asked David to consider his excessive charity contributions in the context of the totality of
his religious and moral responsibilities. Specifically, he asked whether David believed that the
time and energy he invested in giving much charity was the best allocation of his time to fulfill the
many commandments to which he is meant to adhere. David said that he was clearly taking away
from other commandments in his perseverance
on giving charity, and that he should invest himself in his studies more, in his family more, and
in his prayers more; however, he reported intense
negative emotions whenever refusing someone
in need for any reason. David elaborated that he
experienced similar emotions of guilt, sadness,
and anger after praying when feeling impure and
after allowing an impure thought to pass while he
prays without purifying his thoughts.
Here were two issues that the therapist thought
were important to address: the lingering feelings
of guilt for having possibly committed a sin and
the long-term consequences of doing so. David
said that both issues (emotional and real consequences of sin in his words) were important to
him.2 Regarding the former, the therapist worked

with the patient to understand that guilt is a feeling that is hard to tolerate because it has an approach action tendency. That is, guilt typically
leads people to want to do something active to
correct the moral infraction. However, in the context of scrupulous concerns about possible sin,
where one is not aware of a definite moral infraction, sitting with the guilt is a necessary part of
getting through it. Often the individual is tempted
instead to repent just in case, but conditional
religious behavior to alleviate negative emotions
is compulsive and indicates OCD masquerading
as religion. It is precisely the line at which the patient must separate OCD from religion. The patient must participate in normal religious rituals
of penitence (e.g., for Jews, in their daily prayers
and on Yom Kippur; for Catholics, in confession;
etc.) without any elaboration on doubt and potential sin, while tolerating the risk that not all actual
sins were delineated or acknowledged.
In terms of the long-term consequences of
sin, the therapist decided to work with David via
imaginal exposure. Imaginal exposure allows the
patient to confront feared consequences as if they
came to fruition. Therefore, a good imaginal scenario portrays the actualization of the patients
greatest obsessional fears in the most extreme
form that activates the patients anxiety. Because
in vivo exposure assignments often carry the
perceived risk of leading to the consequences
depicted in the imaginal scenario, the scenario is
best constructed such that the very act of defying
OCD and engaging in ERP leads to catastrophe.
In addition, the scene must be vivid and engaging, but need not be gruesome except to the extent
that gruesome imagery is part of the fear itself.
The therapist built the imaginal scenario
on the basis of in-depth inquiries regarding the
feared consequences of not ritualizing, as well
as areas in which David was still having trouble
2 It is important to note that many individuals who suffer
from scrupulosity do not describe having ultimate fears
of eternal damnation or divine punishment, per se. For
many, simply living in a feeling of a state of sin is simply
unacceptable. At times, there are fears that there will be
punishments in this world if not in the world to come,
but even this is not uniform.
49
with in vivo exposure. The therapist explained

the rationale for conducting imaginal exposure
and, along with David, outlined the elements,
imagery, and consequences to include. He then
instructed David to close his eyes and imagine
the events unfolding in real time as the therapist
spoke. The therapist recorded the imaginal exposure so that David could listen to it throughout
the upcoming week.
You wake up and decide that you are going to have
a ritual-free day. You say modeh ani [prayer upon
wakening] quickly and are not sure you had sufficient focus, but you do not repeat. You immediately wash negel vasser [ritual hand washing] only
three times on each hand even though you are not
sure you really covered your hand fully each time.
The thought flashes in your head, Why take such a
risk? Surely it is worth an extra pour on each hand
to ensure fulfilling Gods will, but OCD has turned
religion into a source of distress, and you say to
yourself, I cant give in. I will take the risk that it is
not enough and that I will make things impure by
my touch. You feel the anxiety rise in your stomach to your chest, but you continue on.
When you arrive at synagogue, you wonder
whether your hands are sufficiently clean to put on
tefillin, but you cant remember touching anything
impure. Your legs almost impel you toward the
sink, but you stop. I will not let OCD infect my
relationship with God. I need to take this risk. In
the main sanctuary you put your tefillin on quickly,
feeling like they might be out of place. You touch
the head box and knot quickly and have the sense
that they are probably ok and resist the urge to
attempt to center them more.
As you begin to pray, you obsess about your tefillin. Maybe I am not fulfilling the law. Maybe I will
bear false witness. You can almost feel the sensation on your hairline of the tefillin being off-center,
and, distracted, you cannot remember reciting
the previous paragraph. I muttered it mindlessly,
and didnt have sufficient focus because of these
thoughts, you think. You feel things spinning out
of control. Its all because of my selfishness and
arrogance, you think. It started with modeh ani
and then not making sure my hands were pure,
and its a slippery slope. You are scared and wonder how far this will go, and have an image of tearing off your tefillin, dropping them on the bench,
and walking out of synagogue without completing
the prayers. Again, you remind yourself with difficulty, I cannot give in to my OCD. I will tolerate
the risk, and live with whatever consequences God
sees fit. But you are more distracted by the minute and have a thought about praying to the Rebbe
instead of to God. As you begin to recite the Shema,
the thought intrudes that you might be praying to
50
Table 4.2 Davids relapse prevention sheet

Obsessions:
I dont control my thoughtsDavid
Living with obsessions and anxious thoughts is the goal. Not getting rid of them or proving they are not true.
When you have the thought that maybe you are sinning, accept the possibility. Do not engage in the thought process
trying to figure it out either way. Just say, Yeah, its possible I am.
If you want to be bothered by a thought less, think about it more.
Do not wait for obsessions to do exposures. Systematically plan and do exposures to all areas of your OCD. When
the obsession comes against your will, take the opportunity to face the fear and think about it more, on purpose.
Even if something has not come up frequently and you have not been obsessing about it, if it causes anxiety when it
does come up, that is a sign that you need to do more exposures in that area. If it would bother you, you need to
work on it.
Triggers come in many forms; some are harder than others. But the main, core fears are the same for them all, just
some trigger that fear more easily and powerfully than others.
Compulsions:
No more rituals!
When you realize something is a ritual or avoidance (for example, avoiding reciting a blessing because you are
potentially unclean), do not just stop the ritual (for example, not avoid), but use the opportunity to do the opposite
as an exposure (for example, eat several snacks to make several blessings).
If you slip up and do a ritual, do the opposite (in other words, undo it).
Sometimes you are not sure that avoidance is really avoidance and what looks like OCD is really OCD. Take the
risk. OCD wants you to avoid risks, including the risk that it is not really OCD. Do not give in to the voice of
OCD. Learn to live with risk and tolerate anxiety.
Jesus. You turn red and your muscles tense, but you
do not cancel the thoughts. It feels like heresy, but
you allow the thoughts to be there.
As you leave the sanctuary, a man approaches
you for charity. You say you are sorry, but you
cannot. You may be causing him tremendous suffering, and you feel guilty. He says that he has no
money for food for his family. You resist, feeling
even worse. It occurs to you that he must be desperate to face the shame of publicly collecting for
himself. You have money in your pocket that you
could give him. But you dont. How far will I go to
fight OCD? you wonder. All I seem to care about
is myself. You are anxious and feel guilt and shame
surge through your body.
You leave the synagogue, and as you turn the
corner, you see the bus pulling away. You run after
it, are hit and killed by a car you did not see, and
immediately face the heavenly tribunal for judgment. You are acutely aware that this last day of
your life you cast aside your responsibilities in a
selfish effort to overcome your OCD. Your fears
practically unfold before your eyes. You had previously merited a share in the world to come, but
your heresy throughout the morning, the fact that
you did not heed your conscience, and your selfish
insistence on being a sinner to feel better changed
your eternal fate. You were killed by the car to
prevent you from continuing your heresy, and
along with the blasphemers, you lost your share
in the world to come. You are told that worst was
your calculated disregard for avoiding potential
sin when the cost of doing so was so low. You are
shown the poor mans house and discover in fact
that his family has nothing. You watch from the

heavens as he is denied assistance by everyone. You
were his only hope. You are told that his family will
become sick, he will fall into a deep despair, and
one of his children will die from hunger. You could
have prevented it. All because you wouldnt take
the time to pour water on your hands one more
time, check the alignment of your tefillin one more
time, undo the blasphemous thoughts and repeat
the prayers one more time, and offer the money in
your wallet that you have no use for now anyway.
Because of your actions, your family is condemned to poverty and you must observe your
children with tattered clothes and insufficient
food. They are weak. They grow up sad and resentful. They cannot afford to continue their religious
studies or arrange marriages with scholarly families, so your children become less religious. As a
result of your callousness toward a beggar and flippant attitude toward halacha [religious law], your
family falls into poverty and shirks their religious
responsibilities. It is all too fitting. And you have
lost your share in the world to come and observe
helplessly and with shame the damage you caused.
David experienced a peak SUDS of 8 during

the initial imaginal exposure, which reduced
to 4 after 20min. David agreed to listen to the
recording of the imaginal script repeatedly for
4560min every day over the next week, in addition to continuing in vivo exposure homework.
At the following session, David reported that the
recording no longer caused significant anxiety

and that after several days, the notion that accidental sin in a good faith effort to adhere to Jewish law while fighting OCD could lead to such
severe consequences seemed rather absurd.
By the 14th session, David reported behavior
that was for the most part normative. He still experienced obsessional doubts and concerns, especially about prayer and charity, but described
them as soft, like the volume is turned down on
them, and was able without much difficulty to
disregard them and tolerate the uncertainty without ritualizing. The therapist suggested two more
sessions spaced every two weeks, with a focus
on consolidating treatment gains and relapse
prevention. The therapist and David created a
review sheet of the principles for overcoming
OCD for Davids reference. Although the therapist prompted David, the items on the cheat sheet
were predominantly generated and articulated by
David, giving him the opportunity explicitly to
be his own coach. See Table4.2.
At termination, Davids Y-BOCS score was
nine, and his PIOS score had dropped considerably.
There were several complicating factors in Davids case that illustrate common difficulties
that arise when providing ERP for scrupulosity.
The first relates to Davids prayer rituals and is
similar whenever a patient performs normative
religious behaviors excessively or in compulsive
ways. Non-scrupulous patients are often asked to
refrain altogether from normative behaviors that
have become compulsive. For example, a patient with compulsive showering rituals might be
asked to cease showering altogether for periods of
time longer than most individuals do (e.g., Franklin and Foa 2014). However, the therapist and
patient are in a bind for several reasons when it
comes to normative religious behavior, especially
that required by religious law. First, most patients
would not accept an approach that explicitly violates religious requirements, which would be inconsistent with their values and goals. Second, to
51
the extent that the patient obsessionally fears sin,

causing actual sin is not tolerating acceptable
but anxiety-provokingrisk, but rather generating a feared consequence that others would not
accept. We take the stance, as well, that seeking
religious dispensation to violate religious requirements is detrimental (even were the patient to
agree) because it combines avoidance of obsessional triggers with reassurance that it is not sinful. It also makes the patient feel lesser than his
co-religionists, as if he is so ill so as to have a full
dispensation from adhering to religious dictates.
Had David simply received rabbinic dispensation
to stop praying, he would not have learned to disentangle OCD and religion or tolerate the anxiety
associated with potentially praying incorrectly;
instead, his anxiety would have been mitigated
by the reassurance that someone in his position
did not have to pray. Instead, the therapist worked
with David to find creative ways to violate the
rules of his OCD while practicing the minimal
requirements of his religion.
A second complicating factor also has to do
with prayer. David prayed specifically and fervently that God heal his OCD and believed that
the prayers were necessary (and perhaps sufficient) to overcome the symptoms. In a sense,
this seems reasonable for someone who believes
in the efficacy of prayer. Indeed, it would seem
appropriate for a religious individual to pray for
health or healing during an illness or following
an injury. In the case of OCD, however, efforts
to eliminate symptoms without facing anxiety
can be seen as avoidant or even compulsive and
certainly inconsistent with the fundamental principles of ERP. This is particularly the case when
those efforts are made in the domain of symptom
expression, as is the case when a scrupulous individual uses optional religious ritual to attempt to
alleviate anxiety and reduce symptoms. As previously elaborated, we suggest the patient pray
that God execute His will however He sees fit,
whether or not that includes alleviating the patients OCD, rather than praying for a cure. In
this way, the patient is able to turn to God and
place trust in God in a way that does not undermine ERP or function as a ritualistic attempt to
reduce symptoms.
52
A final complication in Davids case that is

common in scrupulosity was the inherent conflict between his life-long training to avoid sin
and to fulfill religious mandates with extra-legal
enhancements (i.e., to go above and beyond the
letter of the law) and the necessity to risk potential sin and push the limits of what is permissible according religious law (without actually
violating it). Patientsand especially those with
seminary training and post-graduate scholarshiphave considerable expertise in satisfying
all opinions (e.g., in a medieval rabbinic debate
about a point in Jewish law) and avoiding potential problems. Members of clergy habitually find
solutions that circumvent doubt and ambiguity.
Strategic attempts to come as close to sin as technically permissible are certainly uncommon outside of the context of ERP. For David, ERP was
quite a paradigm shift in this way because were
it not for his OCD, extensively researching how
best to fulfill a requirement in the rabbinic literature and consulting with Jewish legal experts
would have been considered normative. In fact,
the process of halachic study itself, even aside
from the practical conclusion, would have been
considered admirable, as Judaism places great
religious significance on the process of religious
study as an inherently valuable pursuit. Careful
psychoeducation about the rationale of treatment
and motivational work are crucial in allowing the
scrupulous patient to adopt an approach that may
seem foreign, even if technically permissible,
outside of treatment.

OCD is a heterogeneous disorder, and the application of ERP is always necessarily tailored to
each individuals idiosyncratic obsessions, core
fears, and compulsions. Therefore, in one sense,
ERP for scrupulosity is no different from ERP
for any other OCD presentation. Nevertheless,
there are several unique challenges the therapist
faces when working with the scrupulous patient,
including understanding normative versus compulsive religious behavior, disentangling OCD
from religion and framing and conducting treat-
ment that is consistent with the patients religious

values without compromising its efficacy. These
require a respectful and open style, willingness
to learn about the patients culture, and careful
attention to obsessional themes and core fears,
which may be prototypically scrupulous (e.g.,
going to hell) or not (e.g., seeing ones family
impoverished). The therapist facilitates engagement in treatment by framing treatment with
cultural sensitivity, incorporating motivational
enhancement throughout treatment, and supplementing ERP with cognitive therapy, as appropriate, particularly in helping the patient examine his or her own religious and moral decisionmaking processes. In addition, the therapist often
collaborates with clergy members. Finally, ERP
requires the patient to accept risks of potentially
terrible consequences, but risks that others tolerate. For example, the patient who refuses to
wear open-toed sandals for fear of stepping on
a contaminated needle does not face the fear by
pricking himself or herself with a contaminated
needle, but rather by wearing open-toed sandals
and taking that risk. Similarly, the patient who
fears accidental sin does not engage in exposures
by sinning, but rather by taking risks that others
take of possible sin.
Key Practice Points for Treating

Scrupulosity
The therapist conducts a careful assessment
not only of symptom presentation but also the
interface between OCD symptoms about religion and religious practice. The less insight
the patient has, the more crucial to understand
clearly the religious community norms. The
therapist and patient work to disentangle OCD
and religion.
The therapist communicates clearly that OCD,
not religion, is the problem and that the goal
of treatment is not to take religion away from
the patient, but to give it back (as OCD has
encroached on religion). Throughout treatment, the patient is motivated to overcome
OCD in service of a more fulfilling and genuine religious experience, not at the expense
of one. Often, cognitive and motivational
work are useful initially and then reinforced
throughout treatment, as the motivation not to

sin conflicts with the motivation to get better.
The treatment plan should not, and need not,
violate religious requirements or prohibitions.
Patients exceed community standards, and
obsessional fears are usually related to doubt,
uncertainty, and risk, rather than concerns
about overt sin. Therefore, exposures are
designed to tolerate risks, but not purposely
to sin. More generally, care is taken to design
and implement a treatment plan that is consistent with patient values, without compromising the integrity of the treatment.
The therapist helps the patient examine his
or her religious or moral decision-making
processes (e.g., How do you decide when
something is dishonest?). The process often
involves attention to religious law, community
standards, and personal inconsistencies (e.g.,
between domains of religious experience,
or with respect to the standards to which the
patient holds himself or herself vs. others).
Consultation with clergy should be bidirectional, with the therapist explaining the principles of ERP respectfully while seeking religious guidance as to what are allowable ways
to push religious boundaries without violating
them.
References
Abramowitz, J. S. (2001). Treatment of scrupulous obsessions and compulsions using exposure and response
prevention: A case report. Cognitive and Behavioral
Practice, 8, 7985.
Abramowitz, J. S., Huppert, J. D., Cohen, A. B., Tolin,
D. F., & Cahill, S.P. (2002). Religious obsessions and
compulsions in a non-clinical sample: The penn inventory of scrupulosity. Behavior Research and Therapy,
40, 825838.
Clinical Psychology, 71, 10491057.
Alonso, P., Menchon, J. M., Pifarre, J., Mataix-Cols,
D., Torres, L., Salgado, P., etal. (2001). Long-term
follow-up and predictors of clinical outcome in
obsessive-compulsive patients treated with serotonin
reuptake inhibitors and behavioral therapy. Journal of
Clinical Psychiatry, 62, 535540.
53
American Psychiatric Association (2000). Diagnostic and

statistical manual of psychiatric disorders (4th ed.,
text revision). Washington, DC: American Psychiatric.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual
for the Beck depression inventory-II. San Antonio:
Psychological Corporation.
Besiroglu, L., Karaca, S., & Keskin, I. (2014). Scrupulosity and obsessive compulsive disorder: The cognitive
perspective in Islamic sources. Journal of Religion
and Health, 53, 312.
Bonchek, A. (2009). Religious compulsions and fears: A
guide to treatment. Jerusalem: Feldheim.
Bonchek, A., & Greenberg, D. (2009). Compulsive prayer
and its management. Journal of Clinical Psychology,
65, 396405.
Burns, D. D. (1980). Feeling good: The new mood therapy. New York: Signet.
Ciarrocchi, J. W. (1995). The doubting disease: Help for
scrupulosity and religious compulsions. Mahwah:
Paulist.
Deacon, B., & Nelson, E. A. (2008). On the nature and
treatment of scrupulosity. Pragmatic Case Studies in
Psychotherapy, 4, 3953.
Deacon, B. J., Vincent, A. M., & Zhang, A. R. (2013).
Lutheran clergy members responses to scrupulosity:
The effects of moral thought-action fusion and liberal
vs. conservative denomination. Journal of ObsessiveCompulsive and Related Disorders, 2, 7177.
Eisen, J. L., Goodman, W. K., Keller, M. B., Warshaw,
M. G., DeMarco, L. M., Luce, D. D., etal. (1999).
Patterns of remission and relapse in obsessive-compulsive disorder: A 2-year prospective study. Journal
Ferro, Y. A., Shavitt, R. G., Bedin, N. R., De Mathis,
M. E., Lopes, A. C., Fontenelle, L. F., etal. (2006).
Clinical features associated to refractory obsessivecompulsive disorder. Journal of Affective Disorders,
94, 199209.
Foa, E. B., & Kozak, M. J. (1985). Treatment of anxiety
disorders: Implications for psychopathology. In A. H.
Tuma & J. D. Maser (Eds.), Anxiety and the anxiety
disorders (pp.421452). Hillsdale: Erlbaum.
Foa, E. B., & Kozak, M. J. (1995). DSM-IV field trial:
Obsessive-compulsive disorder. The American Journal of Psychiatry, 152, 9096.
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic,
R., Hajcak, G., etal. (2002). The obsessive-compulsive inventory: Development and validation of a short
version. Psychological Assessment, 14, 485496.
Franklin, M. E., & Foa, E. B. (2014). Obsessive-compulsive disorder. In D. H. Barlow (Ed.), Clinical
handbook of psychological disorders: A step-by-step
treatment manual (5th ed., pp.155205). New York:
Guilford.
YaleBrown obsessive compulsive scale, I: Development, use, and reliability. Archives of General Psychiatry, 46, 10061011.
54
Greenberg, D., & Huppert, J. D. (2010). Scrupulosity:
A unique subtype of obsessive-compulsive disorder.
Current Psychiatry Reports, 12, 282289.
Greenberg, D., & Shefler, G. (2002). Obsessive compulsive disorder in ultra-orthodox Jewish patients: A
comparison of religious and non-religious symptoms.
Psychology and Psychotherapy: Theory, Research and
Practice, 75, 123130.
Greenberg, D., & Shefler, G. (2008). Ultra-orthodox rabbinic responses to religious obsessive-compulsive
disorder. Israel Journal of Psychiatry and Related Sciences, 45, 183192.
Huppert, J. D., & Siev, J. (2010). Treating scrupulosity in
religious individuals using cognitive-behavioral therapy. Cognitive and Behavioral Practice, 17, 382392.
Huppert, J. D., Siev, J., & Kushner, E. S. (2007). When
religion and obsessive-compulsive disorder collide:
Treating scrupulosity in Ultra-Orthodox Jews. Journal
of Clinical Psychology, 63, 925941.
A., & Baer, L. (2002). Obsessive-compulsive symptom dimensions as predictors of compliance with and
response to behaviour therapy: Results from a controlled trial. Psychotherapy and Psychosomatics, 71,
255262.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York:
Guilford.
Okasha, A., Saad, A., Khalil, A. H., El Dawla, A. S., &
Yehia, N. (1994). Phenomenology of obsessive-com-

pulsive disorder: A transcultural study. Comprehensive Psychiatry, 35, 191197.
Pinto, A., Eisen, J. L., Mancebo, M. C., Greenberg, B.
D., Stout, R. L., & Rasmussen, S. A. (2007). Taboo
thoughts and doubt/checking: A refinement of the factor structure for obsessive-compulsive disorder symptoms. Psychiatry Research, 151, 255258.
Rasmussen, S. A., & Tsuang, M. T. (1986). Clinical characteristics and family history in DSM-III. Obsessivecompulsive disorder. American Journal of Psychiatry,
143, 317322.
Rufer, M., Grothusen, A., Ma, R., Peter, H., & Hand, I.
(2005). Temporal stability of symptom dimensions
in adult patients with obsessive-compulsive disorder.
Journal of Affective Disorders, 88, 99102.
Sheehan, D. V., Lecrubier, Y., Sheehan, K. H., Amorim,
P., Janavs, J., Weiller, E., etal. (1998). The mini-international neuropsychiatric interview (M.I.N.I.): The
development and validation of a structured diagnostic
psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 2233.
Siev, J., Baer, L., & Minichiello, W. E. (2011). Obsessivecompulsive disorder with predominantly scrupulous
symptoms: Clinical and religious characteristics.
Journal of Clinical Psychology, 67, 11881196.
Tolin, D. F., Abramowitz, J. S., Kozak, M. J., & Foa, E.
B. (2001). Fixity of belief, perceptual aberration, and
magical ideation in obsessive-compulsive disorder.
Journal of Anxiety Disorders, 15, 501510.
Treatment of Aggressive
Obsessions in an Adult
with Obsessive-Compulsive
Disorder
Ashleigh Golden, William C. Haynes,
Melanie M. VanDyke and C. Alec Pollard
Nature and Treatment of Aggressive

Obsessions
Obsessivecompulsive disorder (OCD) is characterized by obsessions, unwanted intrusive
thoughts (UITs) an individual experiences as anxiety-provoking and distressful, and compulsions,
repetitive mental or physical acts undertaken to
lessen perceived distress (American Psychiatric
Association 2013). Aggressive obsessions are
intrusive thoughts or images that include content related to harm of the self or others, such as
physical assault, using a weapon to injure, or performing a harmful action (e.g., opening the emergency exit door of a plane while in flight). OCD
has been found to have a lifetime prevalence rate
of 2.3% for adults, with a 12-month prevalence
rate of 1.2% (Ruscio etal. 2010). However, epidemiological data specifically on the prevalence
of aggressive obsessions are not available.
Although the prevalence of aggressive obsessions has not been established, the subtype of
OCD involving unwanted intrusive thoughts is
commonly identified in the literature. Unacceptable thoughts is one of four subtypes of OCD
C.A.Pollard() A.Golden M.M.VanDyke
Saint Louis Behavioral Medicine Institute, Saint Louis
University, Saint Louis, MO, USA
e-mail: pollarda@slu.edu
W.C.Haynes
St. Louis Clinical Trials, LC, Saint Louis, MO, USA
M.M.VanDyke
St. Louis College of Pharmacy, Saint Louis, MO, USA
included in the Dimensional Obsessive-Compulsive Scale (DOCS; Abramowitz etal. 2010).

A similar subtype has emerged in several factor
analytic studies (e.g., Denys etal. 2004; Landeros-Weisenberger etal. 2010; Pinto etal. 2007)
of the YaleBrown Obsessive-Compulsive Scale
(YBOCS; Goodman etal. 1989), and forbidden
thoughts is one of four factors of OCD found in
a meta-analysis of 21 studies (Bloch etal. 2008).
OCD involving intrusive thoughts has been
referred to by a number of different names. In this
chapter, we refer to this category of OCD as UITs
(Abramowitz etal. 2011). Aggressive UITs differ
from non-OCD aggressive thoughts in part because the individual is troubled by them, and the
aggression is typically uncharacteristic of how
the individual would normally act. The aggressive UIT may take the form of an image, idea,
doubt, or urge that is difficult for the individual
to neutralize, control, or avoid despite efforts to
the contrary. Aggressive obsessions are usually
either thoughts or images of physically injuring
another person, the self, or animals or impulses
to act out aggressively against the self or others.
Fear of aggressive obsessions typically leads
to avoidance, reassurance seeking, and other
compulsions. For example, an individual may
avoid situations in which aggressive impulses
could be acted upon, such as being alone with
sharp objects or weapons or not driving for fear
of impulsively driving into a pedestrian. Thought
suppression or replacement may be used to undo,
counter, or substitute for these intrusions and to
conceal their true nature from others (Rachman

DOI 10.1007/978-3-319-17139-5_5
55
56
2007). Asking relatives or close friends for reassurance if an aggressive act did not or will not
occur may be employed as well as checking behavior and covert mental compulsions such as
analyzing the purpose of thoughts and potential
motives.
From time to time, almost all people have
UITs, including violent or frightening thoughts or
images of impulsively committing an aggressive
act. People unafflicted by OCD dismiss images
and thoughts of this nature with relative ease. In
contrast, individuals with OCD respond with distress and become preoccupied with the thoughts
and images. The distress and preoccupation are
usually associated with perception of the UIT as
inherently dangerous (e.g., If I think it, I will do
it), damaging (e.g., Thinking it makes me a bad
person), or otherwise unbearable. Unlike nonOCD sufferers, individuals with OCD respond
with cognitive or behavioral compulsions intended to neutralize the obsession and relieve their
distress. Although UITs associated with OCD are
typically pervasive, even infrequent occurrences
of unacceptable thoughts can trigger hours of
compulsions in some individuals.
Exposure and response prevention (ERP) has
been demonstrated to be an effective treatment for
OCD in general (Franklin etal. 2000). The goal
of ERP for aggressive obsessions is to weaken
the connection between UITs and the anxiety response. This is accomplished not by thought control or attempts at logical argument or reassurance
but by exposure to the aggressive thoughts in the
absence of compulsions to learn that the thoughts
are not dangerous in and of themselves. This approach also promotes acceptance of uncertainty
and risk. Response prevention includes strategies
to end safety behaviors and reassurance seeking
so that the individual may learn that these behaviors are not necessary to reduce anxiety or prevent
feared events from happening.
Though most outcome studies have focused
on OCD in general, there is some evidence that
ERP is effective for harm obsessions specifically
(Abramowitz etal. 2003a). A cluster analysis
examining treatment for the various subtypes of
OCD, including a group with UITs, found no significant differences between successful treatment
A. Golden et al.
groups. Support for the use of ERP in the treatment of aggressive obsessions also comes from
several case studies reported in the literature, including successful use of ERP for a child with
stabbing obsessions (Cassano etal. 2009) and
mothers suffering from postpartum obsessions
about harming their baby (Christian and Storch
2009; Hudak and Wisner 2012). Abramowitz
etal. (2003b) reviewed the literature and found
that postpartum OCD-related concerns most
often feature aggressive content against the infant. Effective treatments included both medications, specifically serotonin reuptake inhibitors
(SRIs), and cognitive behavior therapy specifically using the procedures of ERP.
Although prior research supports the effectiveness of ERP in the treatment of OCD in general and UITs specifically, detailed descriptions
of the implementation of ERP with aggressive
obsessions are not available. The purpose of this
chapter is to describe the successful treatment of
aggressive obsessions using ERP in a case study
format. We will describe the course, methods,
and outcome of treatment; address complicating
factors encountered and discuss several key clinical issues of relevance to this case and aggressive
obsessions in general.
A Case of Aggressive Obsessions:

Molly
Molly presented for treatment as a 35-year-old,
married, unemployed, Caucasian female with obsessions about harming her husband, Josh, and her
dog, Candy. She was seeking treatment because
she had been struggling with bad thoughts that
were causing her significant distress and an uncomfortable feeling of butterflies.
Molly was also experiencing difficulty sleeping due to those horrible thoughts. She often
left the bed that she shared with Josh and slept
on the living room couch when the thoughts occurred in the middle of the night. Some nights she
avoided sharing the bed altogether. When Molly
presented for treatment, Josh was an IT techni-
5 Treatment of Aggressive Obsessions in an Adult with Obsessive-Compulsive Disorder
cian who worked the nightshift while she tended

to housework during the day. Her anxiety was especially high when her husband was home from
work and sleeping during the day. During these
times, Molly avoided being in the bedroom at all.
She also avoided being in the dark, watching scary
television shows and movies, and looking at and
handling sharp objects such as knives. She feared
playing with and walking Candy, her beagle. In
addition to avoiding situations in which she felt
anxious, Molly also engaged in compulsions like
reassurance seeking. She would ask her sisters if
they thought that she would ever hurt anyone and
would reconfirm future social plans with relatives
to feel accountable to them in case she felt tempted to act on her thoughts. Whenever possible, she
tried to ignore and suppress her thoughts because
she believed that they were dangerous and would
lead her to harm her loved ones. In addition,
Molly used mental rituals intended to figure out
and confirm that she was not the kind of person
who would kill someone whom she loved.
Molly reported depressed mood, difficulty
concentrating, reduced appetite, diminished interest in social activities, and passive suicidal
ideation, such as wishing that she were dead and
thinking that her husband may be better off without her. However, she denied intent, means, or a
plan. At the time of initial evaluation, Molly was
diagnosed with OCD and depression.
When asked about her goals for treatment,
Molly said she wished to learn how to deal with
OCD and how not to be so preoccupied with
thoughts. She hoped to decrease the frequency
and intensity of her scary thoughts about violence, diminish the distress that accompanied
these thoughts, be able to sleep in the same bedroom as her husband, become more comfortable
using knives, and resume working full time.
Case Information
Background
On a patient history questionnaire given to all
patients at the clinic, Molly reported a happy
childhood in which she was raised Christian and
enjoyed sports and socializing with friends. She
57
adjusted well to school situations and enjoyed

living in a rural community where she had many
opportunities to be active outdoors.
Mollys father was a 65-year-old retired accountant whom she perceived as an orderly,
kind, and religious man who scolded her as
a deterrent and used verbal praise as a reward.
She observed that he was a good person but his
expectations were high. Her father reportedly
struggled with OCD, scrupulous type, in addition
to depression. Molly endorsed a history of mental
illness on her fathers side. Her paternal grandfather and uncle had been institutionalized for
reasons unknown to her.
Mollys mother was a 62-year-old retired high
school teacher. Molly portrayed her mother as a
disorganized, religious, and easy-going woman
who used to lecture Molly in private as a deterrent and congratulate her as a reward. Molly
added that her mother expressed a lot of love and
affection and that she was always supportive of
Molly.
Molly reported that her mother had a difficult
pregnancy, including a drop in heart rate several
times during the delivery. She had a difficult time
nursing in her first few days of life, but otherwise
was healthy. Molly reported having had chicken
pox as a child. She denied present physical ailments, and her blood work was reportedly normal at the time of her last physical examination.
Molly possessed a bachelor of arts degree in
elementary education. She attended church services on Sunday and enjoyed hiking and biking
in the country. Molly had two older sisters with
whom she felt very close and also spent a significant amount of time with her niece. Molly denied
fear of harming any of her sisters, her niece, or
anyone else other than her husband and her dog.
She described her husband, Josh, who was 32
years old at the time, as accepting, dependable,
upright, and loyal. She and her husband had no
children. Molly and Josh went out socially about
two to three times per month. Molly reported
feeling somewhat satisfied with her relationship and sometimes expressed her honest opinions and feelings to Josh. There were some areas
of dissatisfaction in the marriage. She occasionally became annoyed with him for being sloppy
58
and because he collected too much junk. Molly

noted she would prefer to be sexually intimate
with her husband more frequently.
Treatment History
Molly recalled first seeking psychological treatment while in college. During that time, she had
harm obsessions focused on her roommate and
scrupulous concerns about being a sinful person.
She talked to the school counselor a few times
about feeling anxious and depressed, but felt
too ashamed to discuss her harm obsessions.
Molly was prescribed fluoxetine 40mg and functioned well enough to graduate and secure a position teaching third-grade students near her small
hometown.
Mollys symptoms worsened shortly after
she married. Molly presented for treatment to a
generalist psychologist, to whom she expressed
intrusive ego-dystonic thoughts of killing her
husband for the past few months that had intensified and were getting worse every day. She
described these thoughts as very upsetting and
denied having a violent history or any current
violent intent. She reported often sleeping at her
parents house on nights when the thoughts were
most intense to prevent the possibility of something bad happening. Josh was upset when she
left, wondering what he had done, as Molly
had a difficult time talking with him about her
fears. Molly had been feeling more depressed
and hopeless and had experienced fleeting suicidal ideation concerning thoughts of overdosing
on her medication. In addition, her scrupulous
thoughts had returned, and she reported feeling
a darkness inside. She felt guilty praying because God probably wouldnt want anything to
do with [her]. Molly was triggered by thoughts
of worshiping the devil (e.g., I adore Satan.)
and blasphemy (e.g., Jesus is a fake.). In response to these distressing obsessions, she would
pray for forgiveness repeatedly.
Molly reported that she saw several therapists
off and on over 10 years for depression and
OCD and had been hospitalized twice during that
time for depression with suicidal ideation, though
she denied any prior attempt or ever having a
specific plan. In reference to both hospitaliza-
A. Golden et al.
tions, Molly indicated, the OCD had worn me

down. She had been prescribed various medications, which included several antidepressants,
benzodiazepines, and atypical antipsychotics.
Her depression occasionally lifted but the OCD
had not responded to medication.
Mollys therapist referred her at age 35 to the
authors facility for specialized OCD services.
Mollys obsession had worsened, and she had
just resigned her teaching position. At this time,
her medication regimen included clomipramine
200mg as prescribed by her psychiatrist. She
had been becoming increasingly distressed by her
thoughts and was experiencing difficulty sleeping,
including sleep onset delays of 2h or more. At intake, Molly scored a 36 on the YBOCS, indicating
that her OCD was quite severe. She was spending
approximately 6h/day responding to obsessions by
engaging in behavioral and cognitive compulsions.
and Assessment
Guiding Impressions Prior to Treatment
The therapist sought evidence to help determine
whether Mollys thoughts represented homicidal
ideation or homicidal obsession. Molly demonstrated a balanced view of her husband, describing both unflattering and positive traits. She denied homicidal ideation, intent, means, plan, or
history of violence. With Mollys permission, the
therapist consulted with Mollys parents, sisters,
and husband, who all verified her report. The
information obtained revealed no history of violence and strongly indicated that Mollys homicidal preoccupation was obsessional in nature.
One notable complication with Mollys case
was the presence of non-obsessional suicidal ideation, a symptom she had encountered in the past.
Her report suggested passive suicidal ideation
represented by statements like Id be better off
dead and My husband would be better off if I
were dead. She also reported often feeling worthless and sad. She did not report responding to the
suicidal thoughts with compulsions but did deny
59
Table 5.1 Mollys core fear

If I am exposed to this trigger
And I do not neutralize the threat by taking this
action
Then this outcome will happen
Thoughts about killing my husband or dog

Doing something to make me feel that I will not kill my
husband or dog
I will kill my husband or dog or be overwhelmed with anxious
uncertainty about killing them
any intent to act on the thoughts. Nonetheless, suicidality was monitored throughout treatment.
The therapist used a cognitive behavioral
model to conceptualize Mollys case. Mollys
most difficult triggers involved situations in
which her loved ones were most vulnerable; for
example, when Josh was sleeping and Candy was
lying on her back exposing her belly. She feared
that she would harm or kill her husband and dog
by stabbing them with a knife. In response to
these obsessions, Molly experienced significant
distress and anxiety in addition to the physical
sensation of butterflies in her stomach. Molly
reacted to her aggressive intrusive thoughts by
trying to suppress them and avoiding triggering
situations by engaging in behaviors like sleeping
on the couch instead of with her husband in bed,
refraining from interacting with Candy, and staying away from knives. She tried to circumvent
triggering situations by avoiding the news and
other media that might contain violent content.
Other avoidant coping strategies included reassurance-seeking compulsions (for example, calling her family members and requesting that they
tell her that she would not physically hurt anyone) and reconfirming future social obligations to
help her feel protected and accountable. Though
her avoidance and reassurance seeking provided
temporary relief from anxiety, this behavior denied Molly the opportunity to learn whether the
thoughts led her to harm Josh or Candy. Molly
believed that if she were capable of having violent thoughts about loved ones, then she must be
capable of acting on these thoughts, a classic example of thoughtaction fusion (i.e., If I think it,
I will do it) common in OCD sufferers with UIT.
When asked about her ultimate fear, Molly responded, Im going to snap and lose control and
kill Josh or Candy. To keep her loved ones safe,
Molly felt that she had to be sure that they were
protected from her potential loss of control and
that she distance herself from items that could be

used as weapons. By neutralizing her aggressive
thoughts and avoiding situations in which her
husband and dog would be vulnerable if she lost
control, Molly never learned whether or not she
would act on the thought. Thus, Mollys avoidance precluded the opportunity to learn that aggressive thoughts, though unpleasant, were safe.
Instead, she continued to respond as if she were
going to lose control in the presence of the aggressive thought.
Table 5.1 summarizes the core components
(obsession trigger, compulsions, and feared outcome) comprising the formulation of this case.
In this model, Mollys fear of acting on intrusive thoughts was maintained by her avoidant
and compulsive behavior, which prevented her
from having a corrective experience. To learn
that her thoughts were not dangerous, the model
proposed that Molly would have to experience
the thoughts without engaging in compulsions in
situations that she perceived as threatening.

Rationale for Treatment
The central component of Mollys treatment was
ERP. Treatment was designed to help Molly deliberately encounter her feared situations without
engaging in avoidant coping strategies and thereby provide the opportunity to learn the thoughts
were not dangerous. The therapist implemented
ERP with Molly by having her expose herself to
harm thoughts in the presence of triggering situations while decreasing compulsive behavior that
had served to bring about relief, albeit temporary.
The therapist also prepared Molly to tolerate her
feelings of doubt, uncertainty, and anxiety without having to resort to avoidant coping strategies
60
such as reassurance seeking and waking her

husband. Additionally, there was consideration
of Mollys comorbid depression. The therapist
believed that Mollys depression was a result of
OCD and therefore decided to work on the harm
obsessions directly. Nonetheless, behavioral activation strategies and regular monitoring of depressive symptoms, including suicidality, were
also incorporated into Mollys treatment to help
address her depressed mood.
Sessions 13: Introduction,

Psychoeducation, Refining Goals,
and Developing Response Prevention
Guidelines
After the initial evaluation, the therapist provided psychoeducation about OCD and ERP. Molly
and the therapist collaborated to develop a case
formulation to elucidate the factors maintaining
A. Golden et al.
Mollys disorder. They refined her goals in behavioral terms (e.g., being able to handle knives
around her husband and dog, sleeping in the same
bed as her husband, and eliminating calls for reassurance). A coping script was developed to increase Mollys self-reliance, motivate participation in ERP, and interfere with cognitive compulsions and reassurance seeking. The script Molly
used appears in Table5.2. Note that the script did
not attempt to relax or reassure Molly. On the
contrary, it was designed to help her complete
ERP sessions successfully. The script reminded
her of the futility and harmful impact of compulsions and made it more difficult for her mind to
slip into cognitive activity pursuing the illusion
of reassurance that she will not kill someone.
Molly was also provided guidelines for what
to do and what not to do during exposure and
throughout the rest of the day. These response
Table 5.2 Coping script

I do not know what will happen in the future. I have little reason to believe that I will kill anyone but I can never
know that for sure. Seeking reassurance and avoiding my thoughts are not going to clarify anything and it will not
prevent me from killing. But I do know compulsions have ruined my life. I am tired of letting OCD tell me what to
do. I want the life I had with Josh and Candy. I will embrace the thoughts of killing and stand up to my OCD. I will
resist the urge to seek reassurance and, instead, live with uncertainty, recognizing that I cannot know for sure what
will happen 1min, 1 day, or 1 year from now. Nothing I do now can provide certainty that I am not a person who
could snap and kill my loved ones. But I can learn to get on with my life and live with the uncertainty
OCD obsessive-compulsive disorder
Table 5.3 Response prevention guidelines
Compulsion
Alternative response
During planned exposures
Seeking reassurance from family Resist seeking reassurance; if needed, read
coping script
members to determine whether I
will harm or kill Josh or Candy
Reconfirming future events with
Initially: confirm future events one time only
sisters
with my sisters, use my coping script as needed
Waking Josh up in the middle of
Remain in bed without waking husband; if
the night
necessary, get out of bed briefly to read coping
script, but return to bed as soon as possible
Embrace the thought, think the thought on
Suppressing or replacing an
intrusive thought with a reassuring purpose, write it down, or listen to a recording
of the thought
thought
Trying to figure out whether I am Read coping script
capable of violence
Outside of planned exposures

Label the thought as OCD
and redirect my attention to
the task at hand
prevention guidelines (see Table5.3) differentiated

between time spent in a planned exposure and
time spent outside of planned exposures. During
planned exposures, the importance of focusing on
the obsession trigger was emphasized. However,
when engaged in normal activities of living (i.e.,
when not engaging in a planned exposure), Molly
was instructed to label intrusions as OCD, avoid
ritualizing, and refocus her attention on the task
at hand.
The therapist and Molly agreed that, as homework for the next three sessions, Molly would
review her coping script written on an index card
when she was triggered outside of the ERP practice. She would also go on a daily walk as a pleasurable activity consistent with the behavioral
activation component of her treatment.
Sessions 48: Low Challenge Exposures

and Development of a Monitoring Form
During the fourth session, Molly and her therapist began constructing a trigger hierarchy, in
which Molly listed in vivo and cognitive triggers
and then assigned each trigger either to a lowchallenge, medium-challenge, or high-challenge
category (see Table5.4). Because creating a hierarchy involved a great deal of anxiety, this task
was delayed until session 4. Molly feared that the
process would elicit intrusive thoughts that could
lead her to snap and kill the person whom she
loved. Throughout treatment, this hesitancy was
addressed by reaffirming the importance of accepting uncertainty.
To get Molly started with ERP, the therapist
simply wrote the word thought on the whiteboard. Molly experienced anxiety just seeing this
word, despite the absence of any violent content.
During this initial exposure session, Molly was
encouraged to focus on the word and to refrain
from seeking reassurance or engaging in any
other neutralizing behavior. The therapist then
wrote the word on a note card for Molly to use
for exposures during the week. For homework,
Molly agreed to expose herself to the note card
for one half-hour daily, during which time she
was to follow her response prevention guidelines. Although the therapist would have preferred more time for each exposure, Molly felt
61
that 30min was the amount of time that she could

reliably complete. Her homework continued to
include a daily walk as part of her behavioral
activation plan. Over the next several sessions,
based on Mollys hierarchy, the therapist added
full sentences with anxiety-provoking content on
the whiteboard. Examples included I might cut
Candy, I might cut Josh, I might kill Candy,
and I might kill Josh. Molly continued to engage in ERP daily via her note cards. As Molly
was able to remain exposed to a particular item of
the hierarchy without engaging in compulsions,
another item from the low-challenge section was
selected for ERP. This process was repeated until
she had completed ERP with all items from the
low-challenge category.
During this phase of the treatment, the therapist provided psychoeducation and cognitive
interventions as needed; for example, illustrating how intrusive thoughts tend to decrease in
frequency as a patient engages in exposures and
practices response prevention. The concept of
thoughtaction fusion (e.g., having a thought will
lead to the content of the thought occurring) was
introduced and used to help Molly challenge her
fear of thoughts about harming Josh and Candy.
To keep track of Mollys progress and encourage adherence, the therapist and Molly designed
a treatment activity checklist for the week that included her specific homework assignments: participating in daily exposures; following response
prevention guidelines; reading a coping statement
as needed; and engaging in self-care activity such
as gardening, biking, and walking. Both ERP and
behavioral activation assignments were included
on this checklist. Molly continued to read her
coping script when spontaneously triggered and
take walks as part of behavioral activation for
homework as she worked her way through all of
the low-challenge items during scheduled ERP
sessions. Near the end of this phase of therapy,
she began incorporating some of the items from
the medium-challenge category, such as walking
Candy, reading violent headlines in the newspaper, and looking at scissors and a steak knife.
Molly and the therapist reviewed Mollys adherence to her checklist activities at the beginning of
every session.
62
A. Golden et al.
Table 5.4 Feared trigger hierarchy. (Anxiety scale of 0 (none)10 (extreme))

Low challenge tasks (anxiety=13)
Looking at the word thought on a whiteboard
Looking at Candy on a whiteboard
Looking at Josh on a whiteboard
Therapist using a butter knife in the office
Molly using a butter knife in the office
Molly using scissors in the office
Reading the Letters to the Editor in the newspaper (for fear of violent content)
Medium challenge tasks (anxiety=46)
Looking at the words violent thought on a whiteboard
Looking at I might cut Candy on a whiteboard
Looking at I might cut Josh on a whiteboard
Looking at I might kill Candy on a whiteboard
Looking at I might kill Josh on a whiteboard
Using a steak or paring knife at home (not around Candy or Josh)
Using a pair of scissors at home (not around Candy or Josh)
Looking at a big knife in office
Looking at a nonviolent newspaper headline
Watching the national news on mute
Watching violent shows
Walking Candy with thought card
Reading imaginal exposure script in head
Reading imaginal exposure at home with Josh awake
High-challenge tasks (anxiety=710)
Molly writing a violent thought on paper
Molly writing a violent thought on a whiteboard
Molly telling her husband a violent thought
Rubbing Candys belly
Imaginal exposure to cutting Candy with a knife
Using a knife around Candy
Using a pair of scissors around Candy
Molly using a big knife
Being alone in a room with Candy
Looking at a violent newspaper headline
Watching the national news with the volume on
Reading a newspaper article about intimate partner violence
Sleeping in the same bed as Josh
Leaving the cabinet door open
Reading an exposure script out loud
Reading an exposure script at home with Josh sleeping
By session 6, Molly was feeling a bit better.

Her level of conviction that she would act on her
obsessions was a 5 on a 10-point scale (0=no
conviction; 10=complete conviction), compared
to a baseline conviction level of 8. She felt less
anxious when Candy was present despite intrusive thoughts. By session 8, Molly was spontaneously hugging Candy and spending less time
reacting to intrusive thoughts outside of exposure
situations. Her functioning had improved sufficiently that she was able to obtain a part-time job
as a substitute teacher at an elementary school,
which was one of her treatment goals.
Session 917: Mid-Range Exposures

Molly continued to engage in medium-challenge
exposures in session with the therapist, such as
sitting next to a large dull knife while reading
thoughts that she found to be disturbing that were

written on a whiteboard. Her treatment activity
checklist was modified to reflect daily exposures
of moderate difficulty, such as watching the national news on low volume, watching a violent
crime show, and holding a paring knife at home.
Sometimes Mollys exposures were reported
to be more anxiety producing than intended. For
example, she was watching a television drama
depicting the murder of a sleeping man. She became exceptionally anxious at the thought that
someone could sleep through such a violent act.
The therapist and Molly agreed to add this element to future exposure scripts: for example, If
I lose control, my husband might not even wake
up. There would be nothing to stop me.
The therapist used within- and outside-of-session events that emerged in ERP as opportunities
to reiterate important concepts, such as the role
of avoidance in maintaining OCD, over importance of thoughts, thoughtaction fusion (in the
words of the therapist, a scary thought does not
equal a dangerous action), and the paradoxical
effect of thought suppression. The guiding principle throughout was to help Molly challenge
her misconceptions about the danger of thoughts
and to encourage her to discover what happened
if she embraced the violent thoughts rather than
avoiding or neutralizing them.
Molly and the therapist continued to refine
and review overarching treatment goals, emphasizing the importance of acceptance of uncertainty, living with (vs. neutralizing) the thoughts,
and resuming normal routines. At this point,
Molly could only sleep in the same bedroom as
her husband if she fell asleep first. Upon waking,
she would go to the couch for the remainder of
the night.
To help address Mollys compulsive reassurance seeking, her husband, mother, and sister
were invited to a treatment session to view Mollys written request of decreasing reassurance.
Mollys mother and sisters were happy to help
but confused about their changing role. Specifically, they were concerned Molly would become
inconsolable and depressed without reassurance. The therapist explained the cognitive
behavioral treatment model of OCD, the detri-
63
mental effects of providing reassurance, and that

Molly now had coping strategies for handling
anxiety on her own. With Mollys consent, the
family agreed to stop providing reassurance. The
therapist instructed the family, should Molly call
them in a moment of anxiety, to remind Molly
she had asked them not to provide reassurance.
Around session 12, Molly acknowledged
daily fleeting suicidal ideation but denied intent,
plan, or history of suicide attempts. Molly acknowledged feeling better overall despite having
recently viewed an anxiety-provoking television
show involving a woman slitting her husbands
throat in the middle of the night. By session
14, she acquired a full-time job teaching at an
elementary school, which she said was going
well. She reported during session 17 that her
psychiatrist had commented that this was the
best that he had seen [her] in a long time.
Sessions 1824: Highest-Level Exposures

and Thought Acceptance
By session 18, Molly was also able to identify
the areas in which she had improved, such as the
ability to use knives and being able to spend more
time around Candy and Josh. Her husband was
receptive and agreed to attend future sessions as
needed. Molly began to engage in the high-challenge exposures both inside and outside the therapy office. With the therapist, she practiced writing and looking at thoughts about harming Candy
(Im stabbing her with a knife while shes sleeping) and imagining her worst fear scenario (e.g.,
Your husband is fast asleep and vulnerable. He
does not awaken as you approach or even as you
are stabbing him to death). For homework, she
slept in the same bed as her husband, used a knife
while Candy was in the kitchen, stayed alone in
a room with Candy, and snuggled next to Josh
while they watched television.
Molly updated some items on the high-challenge section of her hierarchy. She continued
to engage in exposures and practiced freely allowing her intrusive thoughts to emerge. The
therapist reminded Molly to allow the intrusive
thoughts to come and go, without trying to control them, when they occurred outside of designated exposure times. In addition, Molly began
64
carrying her violent thoughts written on a card in

her pocket to demonstrate that she could tolerate
anxiety about her thoughts while living her dayto-day life. Molly continued completing highlevel exposures, such as watching violent scenes
in films, imagining her worst fear (i.e., killing
her husband and dog), and leaving the kitchen
cabinet door open with all the knives fully accessible. She progressed from reciting an exposure
script at home alone to reading it out loud while
Josh was at home. As Molly mastered her higherlevel anxiety targets, she concurrently reported
amelioration of depressive symptoms and markedly improved functioning. She began to report
feeling better once again, which included a decreased number of intrusive thoughts, being less
bothered when the thoughts did occur, and feeling
less depressed and anxious overall. Her intrusive
thoughts had become limited to the middle of
the night. When the thoughts occurred, she was
able to go back to sleep, remain in bed with Josh,
and refrain from waking him the few times when
she felt anxious at night. While she had initially
engaged in ERP only in the sun room, the room
furthest from Josh and Candy, she started to do so
in the living room and subsequently the bedroom,
where she had previously felt her family would
be most at risk if she lost control. Overall, avoidance and reassurance seeking were negligible. By
session 24, Molly was able to reduce her sessions
with the therapist to once a month.
Sessions 2528: Maintenance of Gains

and Relapse Prevention
The final four sessions focused on maintenance
and relapse prevention. Although Molly continued to do some exposures in therapy sessions,
the emphasis continued to be on Molly practicing
ERP independently. During this phase of treatment, Molly performed the few remaining items
on her hierarchyhugging and cuddling Josh
and planning more outings together as well as
talking about the news and watching television
together.
As part of relapse prevention, Molly identified warning signs of setbacks (i.e., increases in
avoidance or compulsions or renewed sensitivity
to triggers) and developed a reexposure hierarchy
A. Golden et al.
that she would implement in the event of a future

setback. She also agreed to contact her therapist
if the reexposure trial was unsuccessful.
Molly continued to report infrequent intrusive
thoughts that no longer bothered her. She still
experienced mild anxiety when watching violent
televised news reports but did not turn off the
television. She was enjoying a better mood, napping less, reading more books, watching movies
more often, having more conversations with her
husband, spending more time with her family, and
initiating intimacy with Josh. She even went on a
camping trip in a secluded area and slept next to
Josh in a tent. At home, she was sleeping without fear. Molly estimated that she was comfortable using a knife around her husband and was
routinely sleeping in bed with him. Her YBOCS
score at the end of treatment was a 12, representing a substantial decrease in OCD symptoms. In
addition, she was performing well and enjoying
her full-time job as an elementary school teacher.
A signature moment of pride came when Molly
invited her family over, cooked a turkey, and
used a knife in front of them to slice it.
Around the tenth session, it became apparent
Molly was experiencing difficulty completing
therapy homework consistently. The therapist
therefore designed a treatment activity checklist that included every therapeutic activity that
Molly had agreed to complete with a yes or
no check box beside each activity. The checklist served as an at-home reminder for Molly and
also held her more accountable to the therapist
for completing her homework. Molly understood, as the therapist had stressed, that betweensession homework was essential to making and
maintaining gains. Molly filled out the checklist
in anticipation of each session.
Early in treatment after a car accident, Molly
suffered injuries that required her taking time
off work. At first, this did not seem to present an
impediment to participating in ERP, as Molly reported a manageable amount of pain. However,
her depression and obsessional thinking seemed
to worsen after the operation and time off from

her routines. While recovering from surgery,
Molly took a break from therapy for a few weeks.
During this time, she stopped engaging in ERP
and began spending more time worrying about
her intrusive thoughts. When therapy resumed,
the therapist took time to review the treatment
model and the principles of ERP and to reconfirm
Mollys commitment to therapy. Fortunately, she
was able to reengage in treatment and proceed
with minimal disruption to her progress.
Another complicating factor was the presence
of a significant level of family accommodation,
a term referring to how family members respond
to and often reinforce the OCD. One major accommodation of Mollys family was providing
reassurance. Like most family accommodations,
providing reassurance reinforced the patients
dependence on others and jeopardized her successful participation in ERP. Providing the family
with an alternative way of handling Mollys reassurance seeking eliminated one potential obstacle
to recovery. Mollys family was responsive to the
therapists relatively brief consultation. However,
in some cases, managing family accommodation
involves a substantial time commitment.

This case illustrates several issues commonly
associated with unacceptable intrusive thoughts
(UIT), and also addresses some complications
unique to Molly. One issue frequently associated
with cases of OCD involving intrusive thoughts
is the presence of marked shame or embarrassment. The perceived unacceptability of the content of the obsession coupled with a belief that
no one else experiences these kinds of thoughts
often discourages people with aggressive obsessions from openly disclosing their obsessions, information vital to the development of a cognitive
behavioral treatment plan. Because of this issue,
it was important for Mollys therapist to create an
atmosphere of acceptance. The therapist educated Molly about the nature and variety of intrusive
thoughts commonly experienced in the general
population and disclosed examples of aggres-
65
sive thoughts that she had experienced. A helpful

tool to dispel the notion that intrusive thoughts
are unique to OCD sufferers is a list of intrusive
thoughts common in nonclinical samples (Wilhelm and Steketee 2006). We routinely distribute
the list to our patients experiencing UIT. They are
usually surprised to learn of the ubiquitous nature
of intrusive thoughts.
Another common issue in the treatment of
UIT is the challenge of addressing an array of
triggers that includes both internal (e.g., intrusive
thoughts) as well as external (e.g., situations in
which experiencing the thought is perceived as
threatening) stimuli. UIT-related obsessions are
more likely to include both kinds of triggers compared, for example, to contamination obsessions
for which external triggers (e.g., objects perceived as contaminated) may be the sole target
of exposure. The challenge of incorporating both
types of triggers can be handled in various ways.
One approach is to expose the patient initially
to an internal trigger in a situation perceived as
relatively safe (e.g., listening to a recording of
aggressive thoughts in the therapists office),
subsequently repeating exposure to the internal
trigger in situations representing moderate levels
of threat (e.g., listening to the same recording in
the presence of a weapon with the feared victim
in a separate room), followed by exposure to the
internal trigger in situations perceived as high
threat (e.g., listening to the same recording while
holding a weapon sitting next to the victim). In
Mollys case, the therapist elected to create a hierarchy that effectively mixed internal and external triggers in various combinations. Whatever
method is used, it is important ultimately to capture as many of the triggers as possible during
the course of ERP to promote generalizability
and enhance resistance to relapse.
Another aspect of this case worth noting is
the importance of developing thorough response
prevention guidelines. Though brief instructions
to resist compulsions may be adequate for some
individuals, many OCD patients need more direction. Like many patients, Molly found it helpful to have response prevention guidelines that
specifically addressed all her prominent compulsions. In addition, for each compulsion, the
66
A. Golden et al.
Table 5.5 Feared trigger hierarchy. (Anxiety scale of 0 (none)10 (extreme))

Clinicians may need to take extra steps to manage their patients shame about having aggressive obsessions that can
sometimes interfere with willingness to openly discuss the content of his or her thoughts
Exposure will typically have to include internal triggers (e.g., the aggressive thoughts or images) as well as external
triggers (e.g., situations in which the feared thoughts are perceived as particularly threatening)
Response prevention guidelines should address all behavioral (e.g., reassurance-seeking) and cognitive (e.g.,
thought replacement) compulsions and, when possible, prescribe an alternative behavior incompatible with the
compulsion
guidelines prescribed an alternative response that

was incompatible with expression of the urge.
For example, when experiencing the urge to engage in a cognitive ritual, Molly was instructed
to resist the urge and instead focus her attention
on the coping script until her anxiety reduced.
The coping script was designed to motivate her
to complete the exposure, remind her of the futility of compulsions, and keep her attention focused on living with uncertainty. We believe that
the thoroughness and specificity of her response
prevention guidelines were vital to Mollys successful treatment outcome.
Mollys treatment also highlights the importance of assessing and managing mood-related
issues. The initial evaluation of OCD sufferers
should routinely include assessment of the potential presence of depression and suicidal ideation.
Though most cases of OCD can be successfully
treated without direct attention to comorbid depression, severe levels of depression can preclude
an individuals ability to participate adequately in
active treatment and may need to be addressed
before proceeding with ERP. It is also important
to distinguish between suicidal obsessions and
suicidal ideation because the treatment implications of these two phenomena are quite different.
ERP including exposure to thoughts of suicide
would be indicated for individuals with suicidal
obsessions. However, there is no evidence that
exposure to such thoughts is helpful or safe for
people experiencing suicidal ideation. In the latter situation, strategies specifically designed for
managing suicidal ideation would be indicated
(Simon 2011). Thorough assessment of suicide
thoughts should include detailed questions about
the OCD sufferers response to the thoughts: for
example, Are you afraid that the thought itself

will lead you to take your life? Do you engage
in compulsions in response to the thought? Standardized questionnaires (e.g., Beck Depression
Inventory) and, perhaps most importantly, a thorough history of the patients behavior can be instructive.
Mollys obsession involved thoughts about
harming people and anxious attempts to neutralize her thoughts with various behavioral and
cognitive compulsions. These are typical features
of aggressive obsessions. It is common for clinicians inexperienced with this type of OCD to be
uncomfortable with the unpleasant nature of the
obsessions or lack confidence in their diagnosis
and worry about the patients potential for violence. It is of course necessary to perform a thorough evaluation to distinguish between homicidal
ideation and homicidal obsessions, similar to the
process we described earlier to distinguish between suicidal ideation and suicidal obsessions.
A comprehensive history is essential in making
both distinctions. As was the case with Molly,
family members can be included in the interview
if the clinician determines that corroboration of
past behavior patterns is needed. Even after ruling out homicidal ideation, clinicians still may
have reservations about treating individuals with
homicidal obsessions. Concerns of this nature are
understandable, but therapists must be willing to
address their own fears if they are to help patients
like Molly have a better life. Despite some treatment challenges, Molly eventually reduced her
symptoms significantly and reached a high level
of functioning. Hopefully, her case will encourage clinicians to work with OCD sufferers disturbed by aggressive obsessions.
References
Furr, J. M. (2003a). Symptom presentation and outcome of cognitive-behavioral therapy for obsessivecompulsive disorder. Journal of Consulting and
Abramowitz, J. S., Schwartz, S. A., Moore, K. M., &
Luenzmann, K. R. (2003b). Obsessive-compulsive
symptoms in pregnancy and the puerperium: A review
of the literature. Anxiety Disorders, 17, 461478.
Abramowitz, J. S., Deacon, B. J., Olatunji, B. O.,
Wheaton, M. G., Berman, N. C., Losardo, D., etal.
(2010). Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the
dimensional obsessive-compulsive scale. Psychological Assessment, 22, 180198.
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P. H.
(2011). Exposure therapy for anxiety: Principles and
practice. New York: Guilford.
Arlington: American Psychiatric.
Bloch, M. H., Landeros-Weisenberger, A., Rosario, M.
C., Pittenger, C., & Leckman, J. F. (2008). Metaanalysis of the symptom structure of obsessive-compulsive disorder. American Journal of Psychiatry, 165,
15321542.
Cassano, M. C., Nangle, D. W., & OGrady, A. C. (2009).
Exposure-based treatment for a child with stabbing
obsessions. Clinical Case Studies, 8, 139157.
Christian, L. M., & Storch, E. A. (2009). Cognitive behavioral treatment of postpartum onset: Obsessive compulsive disorder with aggressive obsessions. Clinical
Case Studies, 8, 7283.
Denys, D., de Geus, F., van Megen, H. J. G. M., & Westenberg, H. G. M. (2004). Symptom dimensions in
obsessive-compulsive disorder: Factor analysis on a
clinician-rated scale and self-report measure. Psychopathology, 37, 181189.
67
Franklin, M. E., Abramowitz, J. S., Kozak, M. J., Levitt, J.

T., & Foa, E. B. (2000). Effectiveness of exposure and
ritual prevention for obsessive-compulsive disorder:
Randomized compared with nonrandomized samples.
Journal of Consulting and Clinical Psychology, 68,
594602.
Goodman W.K., Price L.H., Rasmussen S.A., Mazure,
YaleBrown obsessive compulsive scale. I. Development, use, and reliability. Archive of General Psychiatry, 46, 10061011.
Hudak, R., & Wisner, K. L. (2012). Diagnosis and treatment of postpartum obsessions and compulsions that
involve infant harm. American Journal of Psychiatry,
169, 360363.
Landeros-Weisenberger, A., Bloch, M. H., Kelmendi, B.,
Wegner, R., Nudel, J., Dombrowski, P., etal. (2010).
Dimensional predictors of response to SRI pharmacotherapy in obsessive-compulsive disorder. Journal of
Affective Disorders, 121, 175179.
Pinto, A., Eisen, J. L., Mancebo, M. C., Greenberg, B.
D., Stout, R. L., & Rasmussen, S. A. (2007). Taboo
thoughts and doubt/checking: A refinement of the factor structure for obsessive-compulsive disorder symptoms. Psychiatry Research, 151, 255258.
Rachman, S. (2007). Treating religious, sexual, and
aggressive obsessions. In M. M. Antony, C. Purdon,
& L. J. Summerfeldt, (Eds.), Psychological treatment
of obsessive-compulsive disorder: Fundamentals and
beyond (pp.209230). Washington, DC: American
Psychological Association.
Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R.
C. (2010). The epidemiology of obsessive-compulsive
disorder in the national comorbidity survey replication. Molecular Psychiatry, 15, 5363.
Simon, R. I. (2011). Preventing patient suicide: Clinical
assessment and management. Washington, DC: American Psychiatric.
Wilhelm, S., & Steketee, G. S. (2006). Cognitive therapy
for obsessive-compulsive disorder. Oakland: New
Harbinger.
Treatment of SymmetryObsessive-Compulsive
Disorder
Kiara R. Timpano, Julia Y. Carbonella,
Shelby E. Zuckerman and Demet ek

Research Basis
Obsessive-compulsive disorder (OCD) is a distinctively heterogeneous condition with symptomatology falling across several dimensions,
including obsessions, checking, contamination,
symmetry, and hoarding (Maltby and Tolin
2003). In particular, the symmetry symptom dimension, characterized by concerns over asymmetry and ordering compulsions, has been consistently highlighted in the literature on pediatric
and adult OCD (Coles and Pietrefesa 2008; Radomsky and Rachman 2004). Symmetry obsessions and compulsions were depicted in even the
earliest phenomenological descriptions of OCD
(Pitman 1987) and have been reliably identified
as a discrete symptom cluster across multiple factor analytic studies (McKay etal. 2004). In addition, symmetry symptoms tend to be among the
most commonly endorsed by OCD patients. In
one epidemiological study, 28 and 32% of OCD
patients experienced symmetry-based compulsions and obsessions, respectively (Rasmussen
K.R.Timpano()
Department of Psychology, University of Miami,
5665 Ponce de Leon Blvd., Coral Gables,
FL 33146, USA
e-mail: kiaratimpano@gmail.com
J.Y.Carbonella D.ek
University of Miami, Coral Gables, FL, USA
S.E.Zuckerman
Nova Southeastern University, Fort Lauderdale, FL, USA
and Eisen 1992). Another study found that ordering and arranging were the most common compulsions in an adolescent OCD sample, with over
50% of participants reporting symmetry symptoms (Valleni-Basile etal. 1994). Symmetry and
ordering obsessions and compulsions have also
been frequently observed in children with OCD
(Swedo etal. 1989)
Symmetry symptoms are unique from other
OCD symptom dimensions in several key regards. First, the emotional motivations underlying ordering and arranging behaviors are often
quite distinct from those associated with other
types of OCD. Individuals with contamination
concerns, for example, may engage in excessive
cleaning or avoidant behaviors as a way to prevent harm (e.g., illness or disease) and will report
experiencing severe anxiety and fear in relation
to these symptoms. By contrast, individuals with
symmetry obsessions frequently cannot pinpoint
any feared negative consequences that should be
prevented through the means of a compulsion.
Instead, they report strong desires for uniformity
or intense urges to resolve feelings of incompleteness. Rituals and compulsions are therefore
aimed at reducing feelings of dissatisfaction or
uneasiness (rather than anxiety) that arise from
a subjective sense of an experience that is not
quite right, referred to as not just right experiences (NJREs; Coles etal. 2003). The discomfort
associated with these intangible NJREs can cause
considerable distress, and individuals often go to
great lengths to resolve perceived imbalance or
asymmetry. One classic example, as described by

DOI 10.1007/978-3-319-17139-5_6
69
70
Rasmussen and Eisen (1991), is a woman who

felt compelled to let the telephone ring continuously without picking upoften up to 40 times
until she felt that the pitch was just right to her
ears. These clinical observations have been bolstered by findings from self-report studies and
experimental investigations, which examined
NJREs and the reactive urges that accompany
them. Results have consistently demonstrated a
strong association between NJREs and symmetry
concerns, along with subsequent ordering or arranging behaviors (Coles etal. 2003, 2005).
A second key difference between patients with
symmetry concerns and those with other manifestations of OCD is that arranging and ordering
symptoms are often perceived as ego-syntonic.
This stands in sharp contrast to other symptom
clusters (e.g., sexual and religious obsessions),
which are experienced as highly aversive and inconsistent with ones perception of self (Starcevic
and Brakoulias 2008). This additional difference may be directly in relation to perfectionistic tendencies and to NJREs linked with symmetry symptoms; in other words, obsessions are
not experienced as aversive, and compulsions
are viewed as helpful responses aimed at making things right. A final difference between the
symmetry symptom dimension and other forms of
OCD has to do with underlying brain morphology. Preliminary evidence suggests that symmetry
and ordering symptoms may have unique neural
correlates, characterized by distinctive activation
patterns (van den Heuvel etal. 2009) as well as
white matter abnormalities (Koch etal. 2012).
An important consideration for understanding and treating symmetry concerns is that they
appear to be captured on a dimension ranging
from nonclinical, normative concerns about exactness and order, to severe manifestations that
characterize clinical OCD (Olatunji etal. 2008).
It is possible that those with clinical levels of
symmetry-type OCD share a common preference
for orderliness and balance endorsed by many
healthy individuals, yet this generally adaptive
desire becomes poorly regulated and/or overly
expressed to an extreme. In support of this notion, Radomsky and Rachman (2004) found in a
healthy, nonclinical population that ordering and
K. R. Timpano et al.
arranging behaviors were characterized by a wide

continuum. Those who endorsed higher levels
of ordering concerns also reported significantly
more anxiety when asked to complete a stressful task in a disorderly workspace, compared to
those who did not strongly prefer order in their
environment.
In line with this notion that symmetry symptoms are not inherently abnormal, research has
found that ordering and arranging behaviors are
among the top five most common (nonclinical)
rituals endorsed across different cultures (Fiske
and Haslam 1997). Furthermore, developmental research has revealed that symmetry-related
concerns are quite normative at different points
in ones lifespan, and that children frequently
display preferences for balance, order, and symmetry (Leonard etal. 1990). Across a large sample of healthy children, one study observed that
just right experiences and behaviors emerged
as early as 22 months of age (Evans etal. 1997).
It may be the case that symmetry-focused behaviors are rituals that occur within a developmental context throughout adolescence (Leonard etal. 1990), the frequency and intensity of
which may taper off over time as one progresses
into adulthood (Radomsky and Rachman 2004).
This raises the possibility that symmetry symptoms have roots in socially prescribed or evolutionarily adaptive rituals (Leckman and Mayes
1998), but may become dysfunctional in certain
at-risk individuals (Coles and Pietrefesa 2008).
In other words, an inability to temper these habits
and rituals that emerge normatively in childhood,
may subsequently give rise to an incapacitating
state of repetitive, time-consuming obsessions
and compulsions.
The current treatments of choice for individuals with symmetry obsessions and ordering compulsions are the same as the recommended interventions for OCD in general. Within the cognitive behavioral tradition, both exposure and response prevention (ERP), and cognitive therapy
have been found efficacious in reducing obsessions and compulsions (e.g., Abramowitz 2006;
Franklin etal. 2002) whereas selective serotonin
reuptake inhibitors (SSRIs) represent the firstline option for pharmacological approaches to
6 Treatment of Symmetry-Obsessive-Compulsive Disorder
the treatment of OCD (e.g., Soomro etal. 2008).

In practice, ERP is often combined with SSRI
pharmacotherapy, though individual patient characteristics (e.g., tolerance of side effects; ability
to comply with exposure exercises) help direct
these decisions. Despite the extensive literature
supporting the efficacy of these interventions for
OCD broadly construed, relatively few studies
have examined whether there could be differential treatment effects across the symptom dimensions. The extant research suggests that symmetry patients do not, in fact, significantly differ
from other OCD subtypes in their symptom reductions before and after ERP (Abramowitz etal.
2003; Mataix-Cols etal. 2002). These findings
notwithstanding, symmetry-type symptoms have
been linked with lower rates of treatment seeking
(Mayerovitch etal. 2003) and may therefore have
been under represented in treatment outcome research (Sookman etal. 2005), thus complicating
the understanding of relative efficacy across subtypes. Additional investigations of differential
risk and maintenance factors for the OCD symptom dimensions may shed light on how to best
refine treatment approaches for symmetry, ordering, and arranging symptoms.

The remainder of this chapter discusses the case of
Natalie X, a patient who endorsed primary symmetry OCD and who was treated effectively with
cognitive behavioral therapy (CBT), including
ERP and elements of cognitive therapy. Natalie
was a 27-year-old, single, Caucasian female who
presented at a specialty anxiety disorders clinic.
She was self-referred and was seeking treatment
for her struggles with OCD, which included
constant worries about things not matching up
and complicated routines. More specifically,
she reported categorizing objects, thoughts, and
experiences into the gender classes of boy or girl
based on a subjective feeling, and indicated that
she felt the strong urge to always have a balance
between these classes. This resulted in having to
match every situation, object, or thought linked
with one gender in kind to a situation, object, or
71
thought of the other gender. The patient reported

that she became extremely anxious and uncomfortable if things were not symmetrical in this
particular manner.
Natalie stated that even though she had these
symptoms for as long as she could remember,
they were getting progressively worse. She noted
that the urges and rituals had grown so extreme
that they permeated every domain of functioning, and she was increasingly distressed by the
disruptions they caused to her daily life. In particular, she experienced substantial impairment
across social, work, and family spheres. In addition to difficulty making and maintaining friendships, Natalies graduate schoolwork and her job
as a graduate teaching assistant were suffering
due to these symptoms. She also reported significant financial strain, since she often had to purchase objects twice in order to achieve a girl/boy
balance. Natalie reported that because she was so
unhappy and distressed about her situation, she
wanted to be closer to her family (who did not
live near her) for greater social support. This desire resulted in repeated trips home, which were
complicated by the need to fly in and out of particular girl/boy airports; Natalie was spending an
inordinate amount of time and money to try and
achieve equilibrium.
Case Information
Family HistoryNatalie was born in a large
northeastern US city to an upper-middle-class
family. Her mother was a teacher and the primary
stay-at-home parent, while her father had a successful career as an architect. Natalie additionally
had two younger siblings: one brother and one
sister. The patient reported that she was very close
to her family members growing up and always
felt supporteda sentiment she equally held in
adulthood. Natalie reported that her parents divorced when she was 12 years old. Although she
did not want her parents to be separated, Natalie
felt her mother and father handled the situation
in the best way possible and that the divorce
was amicable. Her mother had primary custody
of all the children, but Natalie and her siblings
72
spent at least 23 days per week with their father.

Natalie denied any history of physical, verbal, or
sexual abuse. She also denied any abuse of alcohol or use of illicit drugs. She reported that she
rarely drank alcohol and did so only for social
purposes.
Although the patient indicated that there were
no known psychiatric or medical illnesses in her
family, she described her siblings and mother as a
generally anxious bunch. In particular, Natalie
characterized her mother as a worrier who always seemed to imagine the worst case scenario. The patient reported that her brother started
hanging out with the wrong crowd in his late
teens, and subsequently started smoking a lot
of marijuana. Natalie suspected that her brother
used marijuana to relax, but that this was not
a problem for him and that he was functioning
well in other respects. According to Natalie, her
sister was the sanest of the three siblings, but
also a certified overachiever who was doing
very well in a competitive medical school. Natalie stated that her sister was always extremely
perfectionistic growing up, but that her sister
grew out of it and became more healthy during college.
Background and Course of Symptoms Natalie reported that her mother remembered some of
Natalies OCD symptoms emerging when she was
still a toddler. In particular, her primary symptom
of classifying objects and situations as boy/girl
and her need to balance everything between those
categories began at this time, along with some
checking behaviors and rituals around eating.
As an example, Natalie showed her therapists
a picture of when she was approximately three,
in which she wore several pink bracelets on one
wrist and the exact same number of blue bracelets on the other wrist. A similar example was if
she played a board game that she categorized as
a girl game, she would purposely think of one
that she considered a boy game to play thereafter. Natalie noted that as a child these eveningout behaviors were often not that problematic
and she could easily hide her actions from others.
However, if by chance she could not make things
even, she would become extremely uncom-
fortable and distressed. Per her mothers report,

Natalie would frequently tantrum in response to
what appeared to be harmless situations or occurrences; as an adult, Natalie hypothesized that
these situations were likely exacerbations of her
asymmetry concerns.
Natalie reached all developmental milestones
within normal limits. As a whole, Natalie stated
that she felt generally normal, but also a little
different growing up. She engaged in social
activities and maintained friendships throughout her school years. Natalie stated that her
symptoms started to worsen around the time she
reached puberty. At age 14, she was diagnosed
with OCD, but she did not respond to treatment
(see Treatment History below). Natalie reported
that her OCD symptoms, including both checking and symmetry concerns, escalated during
high school and prevented her from fulfilling
her potential. She felt that she could have done
much better academically if it were not for her
obsessions and compulsions, which at this point
had permeated most of her day-to-day activities.
During this time, Natalie started feeling sad and
depressed and avoided many social activities. At
age 17, Natalie had a verbal altercation about her
OCD symptoms with a male friend in whom she
was interested romantically. The patient reported
that this argument acutely exacerbated her feelings of sadness, and that she also started thinking
she was truly crazy. Directly after the quarrel,
Natalie refused to go to school for 3 days and became locked in an OCD cycle of counting, ordering, and checking compulsions. Her parents
became highly alarmed about the sudden and
intense deterioration and convinced her to voluntarily go to an in-patient hospital where she
stayed for 2 days under observation. Natalie denied experiencing any suicidal ideation and was
not deemed a risk to herself or others. Reflecting
back, Natalie did not find her stay in the hospital
helpful, but she stated that it did motivate her to
better hide her symptoms from others.
Despite the difficulties Natalie experienced
throughout high school, she gained admission to
a good university in her home city. She continued
to live at home with her mother while pursuing
her undergraduate degree. Her OCD symptoms
followed a waxing and waning course throughout

her undergraduate years. Natalie reported feeling
freer in college and gained more autonomy.
Natalie successfully graduated with a bachelors
degree in political science. After working in a
law firm as an aid, Natalie subsequently applied
to, and was accepted into, law school. This required her to move across the country, and it was
during this transition and the start of her graduate studies that her OCD symptoms, particularly
her symmetry concerns, once again worsened.
After a year of significant struggles, she began to
research local treatment options online, identifying the specialty anxiety disorders clinic that she
eventually attended.
Treatment History The patients symptoms
worsened throughout her adolescent years and
became particularly unmanageable around
puberty. At that time, her parents sought out an
evaluation with a local psychiatrist, who recommended a course of talk therapy, which Natalie did not find helpful. Starting at age 16 and
throughout her early 20s, Natalie was prescribed
a range of psychiatric medications to help treat
her OCD, including escitalopram, alprazolam,
paroxetine, sertraline, aripiprazole, citalopram, clomipramine, and fluvoxamine. In each
instance, she stopped taking the medications
due to negative side effects (e.g., headaches,
increased appetite, and dizziness) and stated she
did not believe medications could help her; she
expressed no desire to pursue future pharmacotherapy. During a bout of symptom exacerbation
during college, Natalie was referred to a therapist
who provided biofeedback training as a therapy
for OCD. Although initially hopeful, Natalie
noted no change in her symptoms after 14 weekly
sessions of biofeedback. Natalie underwent one
more attempt at talk therapy while she was still
in her early 20s; however, she subsequently did
not find it helpful. Her therapist at that time suggested that ERP may be the specific type of psychotherapy that could be beneficial for reducing
her symptoms. Natalie reported that she did not
immediately pursue identifying a trained therapist, in part because she did not feel optimistic
that psychotherapy would be effective, given the
73
many treatment failures she had experienced in

the past.

A comprehensive intake evaluation was conducted, which included a structured diagnostic
interview and a battery of self-report measures
(see Table6.1). As determined by the Structured
Clinical Interview for DSM-IV-TR (SCID; Miller
and Rollnick 2002), as well as the YaleBrown
Obsessive-Compulsive Scale (YBOCS; Goodman etal. 1989), Natalie presented with clinically
significant symptoms of OCD. She endorsed recurrent and persistent intrusive thoughts, which
included obsessions linked with her tendency
to assign any and all aspects of her life to boy/
girl categories, and her subsequent urge to even
things out. Natalie also endorsed mental compulsions and overt rituals designed to organize and
rearrange any thought, image, or situation to a
boy/girl category. These behaviors or mental acts
were aimed at reducing the distress Natalie felt
at leaving things asymmetrical; she did not fear
asymmetry, but rather, the resulting discomfort.
One fitting behavioral observation during the
intake was that from one moment to the next, Natalie became acutely distracted. When questioned
about this change in her attentiveness, Natalie
explained that she had noticed a tissue box in the
therapy room and had the intrusive thought that
it belonged to the boy category. She then felt the
intense urge to try and remember a time where
she had seen a girl tissue box, and explained that
if she failed in that quest she would grow increasingly distressed and anxious that things were not
right. Natalie explained that she was afraid that
the anxiety and discomfort would prove too much
for her and that it would be too hard to handle
if things were not perfect. The patient stated that
she recognized that her obsessional thoughts and
impulses were a product of her own mind. While
she did not find the thought that things needed to
be symmetrical ego-dystonic, she was distressed
about how severe the symptoms had gotten and
how much impairment they were causing her. As
74
Table 6.1 Battery of measures used for initial assessment and treatment monitoring
Measure
SCID (Miller and
Rollnick 2002)
Format
Assessment
purpose
Axis I diagnoses
Semistructured
interview
OCD symptom
SemiYBOCS (Swedo
structured severity
etal. 1989)
interview
Self-report OCD symptom
DOCSsymseverity: symmetry,
metry subscale
completeness, and
(Abramowitz etal.
the need for things
2010)
to be just right
BDI-II (Beck etal. Self-report Severity of depres1996)
sion symptoms
Score range (clinical Pretreatmean or cut off)

ment score
n/a
OCD;
subclinical
MDD
040
27
(cut off: 16)
080
(cut off:18)
45
063
(moderate clinical
symptoms: 2028)
063
(mean: 25)
1680
(high worry: 6080)
072
(mean: 26)
24
Repeated
Post-treatassessments ment score
No
4
Yes
(Every 6
weeks)
5
Yes
(Every 23
weeks)
5
Yes
(Every 23
weeks)
No
10
Self-report Severity of anxiety

31
symptoms
Self-report Severity of worry
62
No
37
symptoms
55
No
17
Self-report Fear of arousalrelated sensations
(physical, social,
and cognitive
subscales)
SIAS (Mattick and Self-report Severity of social
080
33
No
15
Clarke 1998)
anxiety symptoms (cut off: 34)
040
32
No
5
NJRE-QR (Coles Self-report Level of uncomfortable sensations
etal. 2003)
related to things not
being just right
153
182
Yes
44308
Self-report OCD beliefs
OBQ-44 (ObsesEvery 6
(responsibility for (1.25 SD above
sive Compulsive
weeks
threat, importance community mean:
Cognitions Work139)
of the control of
ing Group 2005)
thoughts, and
perfectionism
subscales)
OCD obsessive-compulsive disorder, MDD major depressive disorder, SCID structured clinical interview for DSMIV-TR, YBOCS YaleBrown Obsessive-Compulsive Scale, DOCS Dimensional Obsessive-Compulsive Scale, BDI-II
Beck depression inventory, BAI Beck anxiety inventory, PSQW Penn State Worry Questionnaire, ASI3 Anxiety Sensitivity Index 3, SIAS Social Interaction Anxiety Scale, NJRE-QR Revised Not Just Right Experiences Questionnaire,
OBQ-44 Obsessive Beliefs Questionnaire
BAI (Beck etal.
1988)
PSWQ (Meyer
etal. 1990)
ASI-3 (Taylor
etal. 2007)
a result, she was caught in a cycle of repeated attempts to control or remove the thoughts and then
failing to do so. This was followed by a compulsive ritual designed to balance out the boy/girl
ratio, which would subsequently extinguish her
distress for a short period of time. At the time of
the intake, Natalie was spending 34hours each
day focused on her obsessions and compulsions.
The SCID also revealed that Natalie met criteria for recurrent major depressive disorder
(MDD). The patient endorsed two discrete, previous episodes of major depression and met partial criteria for a depressive episode at the time
of the intake. Natalie did not meet diagnostic
criteria for any other disorder. Several self-report
questionnaires were used to measure the severity
of associated OCD features (e.g., NJREs, OCD
beliefs) and to ascertain whether Natalie experienced difficulties with symptoms that are frequently comorbid with OCD (e.g., worry, fear of
anxiety-related sensations, social anxiety symptoms). As noted in Table6.1, the patient elevated
OCD-related beliefs, particularly perfectionism
and the need to control thoughts, and also reported high frequency and severity of NJREs. She
also scored in the clinical range on measures of
depression, the fear of anxiety-related sensations,
and worry.
Based on the general information gathered
during the intake, Natalies primary OCD symptoms, associated features, and her treatment
history, it was recommended that she pursue a
course of CBT for OCD, specifically incorporating elements of ERP and cognitive therapy. Natalie agreed to this suggestion and proceeded to
attend weekly therapy sessions, for a 11.5hour
session each visit. An initial course of 18 sessions
was planned, but Natalies symptoms were continually monitored using validated assessment
instruments to help inform the treatment progress (see Table6.1). The manual Exposure and
Response Prevention for Obsessive-Compulsive
Disorder by Foa etal. (2012) was used as the
primary guide for treatment, though Natalies
therapist also relied on the cognitive therapy for
the OCD treatment manual developed by Wilhelm and Steketee (2006). As described in the
next section, the treatment included the following components: (a) psychoeducation on OCD
and the cognitive-behavioral model of emotions,
along with a functional analysis to better understand the exact relationship between triggers,
cognitions, emotions, and behavioral responses,
(b) response prevention and exposures, which included both in vivo and imaginal exercises, (c) a
range of different cognitive techniques, and (d)
relapse prevention.
In line with cognitive behavioral conceptualizations of OCD (Foa and Kozak 1985; Rachman
1997, 1998; Salkovskis 1985), the overarching
goal of treatment was to decrease and eventually
eliminate Natalies compulsions and to reduce
the distress she experienced in relation to her
obsessions. More specifically, the treatment plan
was designed to (1) break the reinforcing cycle
between Natalies compulsions and discomfort/
anxiety relief, (2) to provide her with corrective
experiences through repeated exposure and re-
75
sponse prevention, which would in turn help her

process information more adaptively and effectively, and (3) to examine and restructure Natalies beliefs and automatic thoughts that were
maintaining her symptoms.

General Psychoeducation and Functional
AnalysisFollowing the intake, Natalie was
given psychoeducation about OCD, the recommended treatment plan, and the cognitive behavioral model of emotion. First, Natalies therapist
normalized her experiences with OCD and associated features, including her struggles with
depression. They then discussed the negative
impact that Natalies symptoms were having on
her life, in order to get a better sense of her motivations for the treatment. It was noted during
this conversation that Natalie expressed marked
feelings of shame regarding her OCD; she also
articulated feelings of sadness and disappointment with the fact that she had to struggle with
this diagnosis. The therapist next outlined the
general model of emotions and provided a rationale for how behavioral and cognitive interventions could be used to target Natalies symptoms.
Specifically, the multidirectional relationship
between thoughts, feelings, and actions was
described, and it was explained how changing
ones behavioral and cognitive responses to any
given situation has a direct impact on subsequent
emotions. The therapist emphasized that Natalie
would slowly but surely get back into the drivers seat, and that she would remain in control
throughout the treatment. Finally, the overarching treatment process was outlined for Natalie,
along with the reasons for continued outcome
monitoring and the need for weekly homework
assignments. The therapist explained that Natalie should consider her a coach who would help
teach Natalie skills and design practices, but
that it was ultimately Natalies role to take ownership of these tools and incorporate them into
her daily life. At the end of the session, Natalie
and her therapist discussed what she wanted to
accomplish in therapy, and together they set out
76
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detailed goals, which were specific, measureable,

and within the patients control.
Natalies first homework assignment was
a thought and behavior log, which she completed between her first and second session (see
Fig.6.1). This log served as a springboard from
which to revisit the model of emotion and adapt
it specifically to OCD. One of the central tenets
of the cognitive behavioral model of OCD is the
realization that there is a functional link between
obsessions and compulsions. For example, when
experiencing an obsession, individuals will feel
distress or anxiety, which will give rise to some
type of behavioral reaction, which in turn, has the
express purpose of reducing the negative emotions experienced. This tenet resonated with Natalie and her experience, in that she could see how
her avoidance and equalizing rituals did, in fact,
reduce her distress about asymmetry. Her therapist then explained that this was precisely the
reason why her avoidance behaviors and compulsive rituals were reinforcing and maintaining her
obsessions. Although avoidance and her rituals
worked well in reducing her anxiety in the moment, they unfortunately also provided her with
a false sense of safety, enhanced the perceived
threat, and disallowed Natalie from gathering disconfirming evidence. As a result, a vicious cycle
had been activated: Whenever she was exposed
to a situation that was deemed asymmetrical, or
not right, Natalies fear structure was activated,
and she would consequently continue to interpret
asymmetry as something dangerous that needed
to be remedied.
Once Natalie demonstrated understanding of
the behavioral principles underlying her OCD
symptoms, the therapist proceeded to outline the
second central tenet of the cognitive behavioral

model of OCD. Specifically, it was explained
that particular beliefs and assumptions play a key
role in interpreting situations, thoughts, or sensations as being inherently dangerous, thereby
giving rise to an anxious or distressed emotional
response. These beliefs, in turn, are strengthened
when neutralizing behaviors or avoidance lead to
a decrease in anxiety. To demonstrate this point,
Natalie and her therapist talked about how asymmetry was not inherently good or bad; rather,
asymmetry is perceived one way or the other depending on how the viewer thinks about it.
Using the information from Natalies homework log, along with further discussion during
the session, Natalies therapist next completed
a patient-specific functional analysis designed
to shed more light on the direct relationship between Natalies obsessions and compulsions.
As detailed in Fig.6.2, Natalie and her therapist explored connections between: (1) different
types of symptom triggers, including external or
internal cues and bodily sensations, (2) beliefs
or thoughts that Natalie held and were directly
linked to her feelings of distress, (3) her emotional responses, including distress at feeling NJREs,
and (4) her behavioral responses, which included
avoidance, behavioral compulsions, and mental
rituals. Key triggers identified for Natalie were
situations that required her to make a choice, specific objects that felt subjectively more feminine
or masculine to her, or the general feeling that
something was not quite right and/or asymmetrical. Building upon her responses on the OBQ-44,
Natalie and her therapist also explored automatic
thoughts and beliefs that were associated with
her symptoms. In particular, Natalie placed great
77
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Fig. 6.2 Functional analysis model of patients triggers, beliefs, emotional response, and behavioral responses
value on needing to control her thoughts and felt

that her thoughts were very important. She also
endorsed high levels of perfectionism and the
belief that she could not tolerate discomfort or
negative emotions. For homework, Natalie was
instructed to continue monitoring her symptoms,
but to also view them more explicitly within the
parameters of the cognitive behavioral model.
Response Prevention and Exposures During
her third session, Natalie was given psychoeducation about ERP, in line with the recommendations made by Foa etal. (2012) and Antony etal.
(2007). In addition, Natalie and her therapist
developed a fear hierarchy (Table6.2) to help
guide subsequent exposures. It was explained
that the first priority of therapy was to break the
cycle of reinforcement between obsessions and
compulsions by preventing or extinguishing
OCD-maintaining behavioral responses. In addition to having Natalie try to eradicate compulsions in her day-to-day life, she and her therapist
would select specific situations known to cause
distress and have Natalie experience these situations without resorting to avoidance or a ritual.
The therapist explained that Natalie would realize that her anxiety would naturally subsidea
process called habituationand that this would
provide her with new and disconfirming evidence regarding her assumptions and beliefs
about asymmetry. Furthermore, over time, and
with repeated exposures, she would learn to
be comfortable and would not experience the
intense anxiety and distress she associated with
the current situation.
With respect to response prevention, Natalie
expressed serious concerns about going cold
turkey with her rituals, and so the therapist
explained that while that was the ultimate goal,
Natalie should proceed with a more intermediate step. At this point, the therapist personified
OCD and suggested to Natalie that the objective
was to mess with OCD: OCD was demanding
a ritual to be performed just so and Natalies
goal was to do it the wrong way (e.g., leaving
some asymmetry, postponing the ritual, making
it difficult to complete the ritual, restricting the
time devoted to the ritual, etc.), if she could not
resist not doing it at all. The personification of
OCD was extremely helpful to Natalie insofar as
78
Table 6.2 Sample items from the patients fear hierarchy

Exposure
Taking down the boy painting in my room back home that was symmetrical with the girl
painting in my current room
Going to the same restaurant two days in a row
Ordering the same sushi that I ordered last week
Choosing shaving gel based on price, not gender
Having the nail technician choose my nail polish color for me
Leaving the background of my phone to be female
Not planning what Im going to eat for lunch
Purposefully wearing something that breaks the rules
Painting my nails in a nonsymmetrical way
Booking flights home from the two most convenient girl airports
Purposefully organizing my living space in an asymmetrical way
SUDs Subjective Units of Distress
it gave her something concrete to imagine fighting against, and so she and her therapist used this
type of phrasing for the remainder of the treatment course.
For Natalies first exposure, her therapist suggested starting with an exercise that would provoke low-to-moderate levels of anxiety, as measured by subjective units of distress (SUDs) on
a 0 (no distress) to 10 (extreme distress) scale.
A situation linked with a SUD level of 4 was selected as something that would reliably provoke
distress, but would not be so overwhelming that
Natalie could not resist the urge to ritualize. Natalie and her therapist agreed on the following exposure: Have Natalie go to a nearby convenience
store and buy several items (e.g., gum, ice tea,
lip balm) based on the lowest price, regardless
of into which category the item fit. Importantly,
Natalie agreed that she would not go back to the
store to balance out the boy/girl ratio after the
session was over. Despite Natalies initial expectations, her distress habituated, and she did not
experience this exposure as torture. At the conclusion of the session, Natalies therapist asked
her to narrow down the experience into one take
home nugget, or lesson learned. Natalie stated
that she was amazed to realize that her anxiety
did indeed subside as promised, and that she also
was able to tolerate the anxiety without engaging
in rituals. For her initial homework, Natalie was
instructed to practice ERP each day.
SUDs
2
2.5
3
3
4
5
5
6
7
8
10
Subsequent exposures were structured in a

similar manner. Natalie and her therapist would
jointly choose the exposure, always using insession practice to move up slightly on her fear
hierarchy (Table6.2), followed by daily practice
for homework. At the conclusion of each exposure exercise, Natalie was always asked to formulate a succinct, key lesson learned. Exposures
were initially selected in such a way that the
outcome could either be symmetrical or asymmetrical, the important aspect being that Natalie
did not have control over the situation. In all of
these cases, Natalie was asked to make a decision
about something using a rule other than the boy/
girl classification system. For example, rather
than Natalie choosing the color of her nail polish, she would ask the nail technician to choose a
color randomly. After Natalie was able to tolerate
the distress associated with these types of exposures, her therapist suggested exposures in which
Natalie purposely made things asymmetrical. For
example, she would purposely choose the same
gender nail polish to wear for several weeks,
or would purposely order asymmetrical food at
restaurants.
Exposures towards the end of therapy were
exclusively focused around the upper quadrant
of Natalies fear hierarchy, which was expanded
as treatment progressed. One example exposure
was having Natalie purposefully organize her living space in an asymmetrical manner. The patient
was very interested in art, and she would hang

pictures in a particular manner to achieve a boy/
girl balance. Together with her therapist, Natalie proceeded to print out copies of the various
pictures she owned and then proceeded to hang
them in an asymmetrical manner in the therapy
room. She was then asked to complete the same
procedure with her pictures at home. Another exposure involved having Natalie curate her art by
selecting her favorite posters and then discarding
or donating the others, regardless of the resulting imbalance between boy/girl art. A final set
of exposures were designed to address Natalies
fear regarding asymmetry and her worry that she
would always experience her obsessions. Specifically, Natalies therapist guided her in an imaginal exposure on what it would be like to live in an
asymmetrical world forever.
Complicating Factor A main complicating factor in Natalies treatment was that after initial
treatment gains, she experienced fluctuating levels of motivation with regard to her willingness
to do exposures and to continue with therapy. As
often occurs with patients with OCD, as ones
symptoms wax and waneboth naturally and
throughout the course of treatmentthe individuals ambivalence regarding change may also
fluctuate, which can contribute to the treatment
refusal and drop out (Maltby and Tolin 2003).
The nature of exposure exercises is intrinsically frightening and demanding; as progress is
achieved on lower steps of the fear hierarchy,
patients may be resistant to tackling more challenging exposures as entailed in the full treatment plan. In Natalies case, her motivation
faltered because she experienced less impairment
after she responded to the first phase of ERP. As
described in the overview section, she did not
find her concerns with asymmetry inherently
ego-dystonic, so once she was able to participate
more fully in day-to-day activities without interference from her symptoms, she experienced less
impetus to continue with treatment.
Natalies therapist became aware of the fact
that Natalie was not completing her weekly
homework and had become less focused on
therapy (e.g., tardy to sessions, less enthusias-
79
tic, refusing to comply with planned in-session

exposures). The therapist responded by directly
discussing these observations with Natalie, along
with the potential reasons for her nonadherence.
Several possibilities for why Natalie may have
had difficulty completing the homework exposures were explored, including level of exposure
difficulty (i.e., Were the exposures too difficult
to complete alone?) and logistical reasons (i.e.,
Was she running out of time during the week?
Was there some external reason that was preventing her from completing the homework?). Natalie stated that none of these issues were causing
interference, and that she simply was no longer
bothered as much by her symptoms as when she
first entered therapy.
At this point, Natalies therapist shifted into
several sessions of modified motivational enhancement training (MET; Miller etal. 1994).
MET is a motivational interviewing (MI; Miller
and Rollnick 2002) technique that can be applied
in conjunction with ERP to increase and maintain motivation for change throughout ERP. The
integration of MI with CBT has been found to
be successful for those individuals with anxiety
disorders (Westra 2004) and has also been shown
to be effective in increasing adherence to exposure therapy in particular (Slagle and Gray 2007).
Originally developed to target alcohol addiction,
MI includes a range of strategies to help explore
and resolve ambivalence about change, such as
demonstrating empathy and fostering discrepancy regarding beliefs, while avoiding a confrontational stance (Westra 2004). It can first be applied
at the start of the treatment to help change maladaptive beliefs, minimize reluctance to attempt
exposures, and instill self-confidence in treatment goals (Riccardi etal. 2010). Furthermore,
therapists can continue to employ MI techniques
at points throughout ERP where hesitance about
further exposures becomes evident. While allowing the patient to explore his or her own positive
and negative feelings about personal symptoms
and the direction of treatment, therapists can
guide him/her to bolster his/her own motivation
by raising questions about discrepancies between
the pros and cons of treatment adherence (i.e., a
mismatch between remaining OCD-related im-
80
pairment vs. personal priorities and goals). As

such, MI can help maintain momentum and help
increase treatment adherence and retention (Riccardi etal. 2010). In the case of Natalie, MET was
highly effective in helping her refocus her treatment efforts. It was also instrumental in helping
Natalies therapist recognize that a greater focus
on cognitive work would be helpful in addressing
some of Natalies attributions and beliefs about
her symptoms.
Cognitive Restructuring At the start of therapy,
Natalie and her therapist identified four primary
cognitions that were integral to maintaining her
symptoms. The first was that anxiety was dangerous, intolerable, and that it would not dissipate unless she made things symmetrical. She
also believed that living an asymmetrical life was
dangerous because it evoked anxiety and distress,
and that she would therefore be unable to cope
with a lack of symmetry. Both of these beliefs
were addressed non-directly through Natalies
experiences with ERP. Over time and repeated
exposures, Natalie learned that she could in
fact tolerate the anxiety related to experiencing
NJREs, and that her distress faded with time.
The other two cognitions that were central to
Natalies OCD included the belief that she needed to control her thoughts, and the fact that she
placed a marked value on symmetry and perfection. These beliefs did not change in response to
ERP and shifted into greater focus as a result of
the MET/MI-focused sessions. To target these beliefs, Natalies therapist used a range of different
cognitive strategies flexibly and on an as-needed
basis to try and encourage Natalie to achieve a
more helpful or rationale response (Wilhelm and
Steketee 2006). Example techniques included
Socratic dialogue to highlight logical inconsistencies in Natalies thinking patterns, discussion
of the advantages and disadvantages of her beliefs, the continuum technique to highlight the
implications of only focusing on extremes, and
behavioral experiments to test Natalies assumptions. Two behavioral experiments that were particularly helpful were testing the consequences of
asymmetry and the classic white bear thought
suppression exercise. These experiences allowed
Natalie to test the validity of her assumptions, by

contrasting her feared outcome to actual consequences. Another helpful cognitive technique
was the use of metaphors, stories, and analogies,
which were designed to promote acceptance of
her intrusive boy/girl classification thoughts and
her need for symmetry. This latter technique was
particularly helpful in addressing the shame and
sadness Natalie felt in response to having OCD.
Therapy Conclusion and Relapse Prevention After 19 sessions, Natalie and her therapist
agreed that she had made sufficient progress to
no longer need weekly sessions and that therapy
could possibly be terminated soon. The next two
sessions focused on relapse prevention. First,
Natalie and her therapist created a handout that
incorporated and summarized all of the behavioral and cognitive tools that Natalie had learned.
The therapist also spent time evaluating Natalies
thoughts about treatment termination. Together,
they discussed potential difficulties that may
arise, along with possible solutions. After a
1-month hiatus, Natalie returned to therapy and
provided an update on her symptoms and her use
of CBT. The patient was pleased to report that
she had felt confident addressing any symptoms
that emerged and had successfully navigated two
minor setbacks. The therapist used the latter situations to help Natalie differentiate between lapses
and relapses and underscored the importance of
engaging in helpful thinking about how best to
react towards symptom flare-ups. At this point,
Natalie and her therapist agreed that it was an
appropriate time to terminate treatment, though
the possibility of booster sessions was discussed.

On the whole, the cognitive behavioral approach
to treating Natalies symmetry symptoms was
very effective. During the first phase of treatment,
which was more strongly rooted within a behavioral framework, Natalie was able to substantially reduce her compulsions and was also able to
tackle the vast majority of the original fear hierarchy she and her therapist had outlined. Follow-
81
Table 6.3 Key practice points for treating the primary problem
Key practice points
Careful assessment at intake and continued monitoring of symptoms
Response prevention combined with exposures using a carefully captured fear hierarchy
Cognitive techniques to target dysfunctional automatic thoughts and core beliefs
Managing obstacles, including difficulties with habituation during exposures, waxing and waning motivation
ing the MI-focused sessions that were used after

the first wave of ERP, more and more cognitive
techniques were woven into the treatment plan.
This shift in treatment approach was important
for Natalie, as it allowed her to evaluate a number of her thinking patterns relevant to both OCD
and her symptoms of depression. The final phase
of treatment included a combination of cognitive
and ERP techniques to tackle the upper limits
of her fear hierarchy. Throughout the course of
treatment, Natalies therapist continually monitored the patients symptoms and any treatment
interfering behaviors. This allowed for a flexible
use of cognitive and behavioral techniques that
best fit Natalies needs at any given point in time.
Another key element of the treatment approach
was that Natalie and her therapist worked very
collaboratively in selecting exposures, designing
homework, and identifying next treatment targets. Over time, this approach allowed Natalie to
become her own therapist, an important element
in helping to prepare her for the time following
the termination of therapy (Table6.3).
At the end of the treatment, Natalies therapist once again had her complete the battery of
questionnaires and interviews listed in Table6.1.
Across the board, the assessment indicated that
she no longer became anxious when things were
uneven or asymmetrical. Natalie also reported
not engaging in avoidance of situations that previously had provoked anxiety and had almost
completely eliminated her mental compulsions
and physical rituals. Most importantly, Natalie
expressed satisfaction and happiness that she
could finally make decisions in her life based on
her personal preferences, rather than basing decisions on her OCD. Her YBOCS score decreased
throughout the treatment and was determined
to meet criteria for symptom remission, as evidenced by a reduction of over 4550% (Storch
etal. 2010). Additionally, Natalie no longer met

criteria for OCD and endorsed only mild depressive symptoms. Natalie reported that although
she still struggled from time to time with feeling
discouraged when she experienced an obsession,
overall she felt proud of the work she had done
and the fact that she had learned to live in an
asymmetrical world.
References
Abramowitz, J. S. (2006). The psychological treatment of
obsessive-compulsive disorder. Canadian Journal of
Psychiatry, 51(7), 407416.
Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., etal. (2010).
Assessment of obsessive-compulsive symptom dimensions: Development and evaluation of the dimensional
obsessive-compulsive scale. Psychological Assessment, 22(1), 180198. doi:10.1037/a0018260.
Antony, M. M., Purdon, C., & Summerfeldt, L. J. (2007).
Psychological treatment of obsessive-compulsive disorder: Fundamentals and beyond. Washington, DC:
American Psychological Association.
Beck, A. T., Epstein, N., Brown, G. K., & Steer, R. A.
(1988). An inventory for measuring clinical anxiety:
Psychometric properties. Journal of Consulting and
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). BDIII, Beck depression inventory: Manual (2nd ed.). San
Antonio: The Psychological Corporation.
Coles, M. E., & Pietrefesa, A. S. (2008). Symmetry, ordering, and arranging. In J. S. Abramowitz, D. McKay
& S. Taylor (Eds.), Obsessive-compulsive disorder:
Subtypes and spectrum conditions (pp.3652). New
York: Elsevier.
Coles, M. E., Frost, R. O., Heimberg, R. G., & Rhaume,
J. (2003). Not just right experiences: Perfectionism,
obsessive-compulsive features and general psychopathology. Behaviour Research and Therapy, 41(6),
681700.
82
Coles, M. E., Heimberg, R. G., Frost, R. O., & Steketee,
G. (2005). Not just right experiences and obsessivecompulsive features: Experimental and self-monitoring perspectives. Behaviour Research and Therapy,
43(2), 153167.
Evans, D. W., Leckman, J. F., Carter, A., Reznick, J. S.,
Henshaw, D., King, R. A., & Pauls, D. (1997). Ritual,
habit, and perfectionism: The prevalence and development of compulsive-like behavior in normal young
children. Child Development, 68(1), 5868.
Fiske, A. P., & Haslam, N. (1997). Is obsessive-compulsive disorder a pathology of the human disposition
to perform socially meaningful rituals? Evidence of
similar content. The Journal of Nervous and Mental
Disease, 185(4), 211222.
Foa, E. B., & Kozak, M. J. (1985). Treatment of anxiety
disorders: Implications for psychopathology. In A. H.
Tuma & J. D. Maser (Eds.), Anxiety and the anxiety
disorders (pp. 421452). Hillsdale: Erlbaum.
Foa, E. B., Yadin, E., & Lichner, T. K. (2012). Exposure
and response (ritual) prevention for obsessive compulsive disorder: Therapist guide (2nd ed.). New York:
Oxford University Press.
Franklin, M. E., Abramowitz, J. S., Bux, D. A. Jr., Zoellner, L. A., & Feeny, N. C. (2002). Cognitive-behavioral
therapy with and without medication in the treatment
of obsessive-compulsive disorder. Professional Psychology: Research and Practice, 33(2), 162168.
C., Delgado, P., Heninger, G. R., & Charney, D. S.
(1989). The yale-brown obsessive compulsive scale:
II. Validity. Archives of General Psychiatry, 46(11),
10121016.
Koch, K., Wagner, G., Schachtzabel, C., Christoph
Schultz, C., Straube, T., Gllmar, D., etal. (2012).
White matter structure and symptom dimensions in
obsessive-compulsive disorder. Journal of Psychiatric
Research, 46(2), 264270.
Leckman, J. F., & Mayes, L. C. (1998). Understanding
developmental psychopathology: How useful are evolutionary accounts? Journal of the American Academy
Leonard, H. L., Goldberger, E. L., Rapoport, J. L., Cheslow, D. L., & Swedo, S. E. (1990). Childhood rituals:
Normal development or obsessive-compulsive symptoms? Journal of the American Academy of Child &
Adolescent Psychiatry, 29(1), 1723.
Maltby, N., & Tolin, D. F. (2003). Overview of treatments
for obsessive-compulsive disorder and spectrum conditions: Conceptualization, theory, and practice. Brief
Treatment and Crisis Intervention, 3(2), 127144.
A., & Baer, L. (2002). Obsessive-compulsive symptom dimensions as predictors of compliance with
and response to behaviour therapy: Results from a
controlled trial. Psychotherapy and Psychosomatics,
71(5), 255262.
Mattick, R. P., & Clarke, J. C. (1998). Development and
validation of measures of social phobia scrutiny fear
and social interaction anxiety. Behaviour Research
and Therapy, 36(4), 455470.
Mayerovitch, J. I., du Fort, G. G., Kakuma, R., Bland, R.
C., Newman, S. C., & Pinard, G. (2003). Treatment
seeking for obsessive-compulsive disorder: Role of
obsessive-compulsive disorder symptoms and comorbid psychiatric diagnoses. Comprehensive Psychiatry,
44(2), 162168.
McKay, D., Abramowitz, J. S., Calamari, J. E., Kyrios,
M., Radomsky, A., Sookman, D., etal. (2004). A
critical evaluation of obsessive-compulsive disorder
subtypes: Symptoms versus mechanisms. Clinical
Psychology Review, 24(3), 283313.
Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec, T. D. (1990). Development and validation of the Penn State Worry Questionnaire.
doi:10.1016/0005-7967(90)90135-6.
Miller, W. R., & Rollnick, S. (2002). Motivational interviewing: Preparing people for change (2nd ed.). New
York: Guilford.
Miller, W. R., Zwebeen, A., DiClemente, C. C., & Rychtarik, R. G. (1994). Motivational enhancement therapy
manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence.
Rockville: National Institute on Alcohol Abuse and
Alcoholism.
Obsessive Compulsive Cognitions Working Group.
(2005). Psychometric validation of the obsessive
belief questionnaire and interpretation of intrusions
inventorypart 2: Factor analyses and testing of
a brief version. Behaviour Research and Therapy,
43(11), 15271542.
Olatunji, B. O., Williams, B. J., Haslam, N., Abramowitz, J. S., & Tolin, D. F. (2008). The latent structure of
obsessive-compulsive symptoms: A taxometric study.
Depression and Anxiety, 25(11), 956968.
Pitman, R. K. (1987). A cybernetic model of obsessivecompulsive psychopathology. Comprehensive Psychiatry, 28(4), 334343.
Rachman, S. (1997). A cognitive theory of obsessions.
Rachman, S. (1998). A cognitive theory of obsessions:
Elaborations. Behaviour Research and Therapy, 36(4),
385401.
Radomsky, A. S., & Rachman, S. (2004). Symmetry,
ordering and arranging compulsive behaviour. Behaviour Research and Therapy, 42(8), 893913.
Rasmussen, S. A., & Eisen, J. L. (1991). Phenomenology
of OCD: Clinical subtypes, heterogeneity and coexistence. In J. Zohar, T. Insel & S. Rasmussen (Eds.),
The psychobiology of obsessive-compulsive disorder
(pp.1343). New York: Springer.
Rasmussen, S. A., & Eisen, J. L. (1992). The epidemiology and clinical features of obsessive compulsive
disorder. Psychiatric Clinics of North America, 15(4),
743758.
Riccardi, C. J., Timpano, K. R., & Schmidt, N. B. (2010).
A case study perspective on the importance of motiva-

tion in the treatment of obsessive compulsive disorder.
Clinical Case Studies, 9(4), 273284.
Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour
Research and Therapy, 23(5), 571583.
Slagle, D. M., & Gray, M. J. (2007). The utility of motivational interviewing as an adjunct to exposure therapy
in the treatment of anxiety disorders. Professional
Psychology: Research and Practice, 38(4), 329337.
Sookman, D., Abramowitz, J. S., Calamari, J. E., Wilhelm, S., & McKay, D. (2005). Subtypes of obsessivecompulsive disorder: Implications for specialized
cognitive behavior therapy. Behavior Therapy, 36(4),
393400.
Soomro, G. M., Altman, D., Rajagopal, S., & OakleyBrowne, M. (2008). Selective serotonin re-uptake
inhibitors (SSRIs) versus placebo for obsessive compulsive disorder (OCD). Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD001765.
pub3.
Starcevic, V., & Brakoulias, V. (2008). Symptom subtypes
of obsessive-compulsive disorder: Are they relevant
for treatment? Australian and New Zealand Journal of
Psychiatry, 42(8), 651661.
Storch, E. A., Lewin, A. B., De Nadai, A. S., & Murphy, T.
K. (2010). Defining treatment response and remission
in obsessive-compulsive disorder: A signal detection
analysis of the childrens yale-brown obsessive compulsive scale. Journal of the American Academy of
Child & Adolescent Psychiatry, 49(7), 708717.
83
Swedo, S. E., Rapoport, J. L., Leonard, H., Lenane, M., &

Cheslow, D. (1989). Obsessive-compulsive disorder
in children and adolescents: Clinical phenomenology
of 70 consecutive cases. Archives of General Psychiatry, 46(4), 335.
Taylor, S., Zvolensky, M. J., Cox, B. J., Deacon, B.,
Heimberg, R. G., Ledley, D. R., etal. (2007). Robust
dimensions of anxiety sensitivity: Development and
initial validation of the anxiety sensitivity index-3.
Psychological Assessment, 19(2), 176188.
Valleni-Basile, L. A., Garrison, C. Z., Jackson, K. L.,
Waller, J. L., McKeown, R. E., Addy, C. L., & Cuffe,
S. P. (1994). Frequency of obsessive-compulsive disorder in a community sample of young adolescents.
Journal of the American Academy of Child & Adolescent Psychiatry, 33(6), 782791.
van den Heuvel, O. A., Remijnse, P. L., Mataix-Cols, D.,
Vrenken, H., Groenewegen, H. J., Uylings, H. B., etal.
(2009). The major symptom dimensions of obsessivecompulsive disorder are mediated by partially distinct
neural systems. Brain, 132(4), 853868.
Westra, H. (2004). Managing resistance in cognitive
behavioural therapy: The application of motivational
interviewing in mixed anxiety and depression. Cognitive Behaviour Therapy, 33(4), 161175.
Wilhelm, S., & Steketee, G. (2006). Cognitive therapy for
obsessive compulsive disorder: A guide for professionals. Oakland: New Harbinger.
Treatment of Perfectionism-Related
Obsessive-Compulsive Disorder
Heather K. Hood and Martin M. Antony
Perfectionism-Related ObsessiveCompulsive Disorder in an Adult

Perfectionism has been defined as the tendency
to believe that there is a perfect solution to problems, that doing something without mistakes is
possible and desirable and that even minor errors will have serious consequences (Steketee
1999, p.146). Although numerous definitions
exist (Egan etal. 2014), most emphasize the
multidimensional nature of perfectionism. At its
broadest level, perfectionism takes both adaptive
and maladaptive forms, with only maladaptive
perfectionism associated with psychopathology
(Bieling etal. 2004a). More precise definitions
of the construct have characterized perfectionism by the focus or target of the perfectionistic
behaviors (Hewitt and Flett 1991) and by the
content of the perfectionistic beliefs (Frost etal.
1990). Hewitt and Flett (1991) described perfectionism along the dimensions of self-oriented
perfectionism, other-oriented perfectionism, and
socially prescribed perfectionism, whereas Frost
etal. (1990) described six dimensions of perM.M.Antony()
Department of Psychology, Ryerson University,
350 Victoria Street, Toronto, ON M5B 2K3, Canada
H. K. Hood
Homewood Health Centre, 150 Delhi Street, N1E 6K9
Guelph, ON, Canada
Department of Psychiatry and Behavioural Neurosciences,
McMaster University, 1280 Main Street West, L8S 4K1
Hamilton, ON, Canada
fectionistic beliefs, including concern over mistakes, personal standards, parental expectations,
parental criticism, doubts about actions, and organization. Despite the obvious differences in
how these two models conceptualize the nature
of perfectionism, there is considerable overlap
among the dimensions, and they can be seen as
complementary, rather than contradictory, ways
of understanding a complex phenomenon.
Perfectionism is not a diagnostic category in
the fifth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-5; American
Psychiatric Association 2013), nor is it a diagnostic criterion of any disorder, except obsessive-compulsive personality disorder (OCPD).
Clinically, however, many therapists recognize
the prevalence and impact of perfectionism in
obsessive-compulsive disorder (OCD). OCPD
and OCD are overlapping, but distinct, diagnostic entities, although there appears to be a subtype or phenotype of OCD that is characterized
by elevated perfectionism (Mancebo etal. 2005).
In fact, perfectionism has recently been identified
as one of the core dimensions of OCD. The Obsessive Compulsive Cognitions Working Group
(OCCWG) developed a comprehensive cognitive
model of OCD in which they identified three primary domains of cognitions that are prominent in
OCD: (1) responsibility and threat estimation, (2)
perfectionism and intolerance for uncertainty, and
(3) importance and control of thoughts (OCCWG
1997, 2001, 2005). Within OCD, the working
group described perfectionism as holding unrealistically high standards for oneself and others,

DOI 10.1007/978-3-319-17139-5_7
85
86
with mistakes being perceived as intolerable, and

intolerance of uncertainty as beliefs in the need
for certainty and that one has little ability to cope
with unpredictability.
Although perfectionism has been implicated
as a transdiagnostic risk and maintaining factor,
studies indicate that perfectionism is particularly
elevated in OCD (Egan etal. 2011). In several
studies, individuals with OCD report elevated
concern over mistakes and doubts about actions
compared to nonclinical controls (Antony etal.
1998; Buhlmann etal. 2008; Frost and Steketee
1997); however, only doubts about actions tend
to distinguish OCD from other anxiety disorders
(Antony etal. 1998; Frost and Steketee 1997).
Perfectionism in OCD manifests as difficulty
in making decisions and doubts about the accuracy of ones decisions, taking longer to categorize items, and experiencing extreme distress
when faced with ambiguous situations. This is
evidenced by a greater frequency of obsessions
and compulsions related to symmetry, ordering,
repeating, cleaning, and hoarding associated with
high perfectionism (Coles etal. 2008).
Other OCD presentations have also been hypothesized to be motivated by perfectionism, including incompleteness (Rasmussen and Eisen
1989; Summerfeldt 2004) and not just right
experiences (Coles etal. 2003; Leckman etal.
1994), in which compulsions are performed until
an internal felt sense is achieved that the outcome
is just right, with no anticipated consequences
or expectations of harm. These conceptualizations are thought to be underlying factors that cut
across overt symptom profiles; however, they are
often observed among individuals with symmetry, ordering, and arranging compulsions.
Given that perfectionism is often recognized
as a transdiagnostic process that confers a vulnerability for a variety of psychological disorders
(Egan etal. 2011), it is unsurprising that elevated
levels of perfectionism are associated with higher comorbidity (Bieling etal. 2004b) and poorer
treatment prognosis (Chik etal. 2008). Chik etal.
(2008) found that doubts about actions, the dimension of perfectionism that appears to be particularly pronounced in OCD, predicted poorer
response to group and individual behavioral and
cognitive therapy for OCD. Possible explanations
H. K. Hood and M. M. Antony
for this effect on treatment outcome include the

interfering effects of perfectionism on a persons
ability to tolerate exposure, consider alternative evidence, or complete homework exercises
(Frost etal. 2002). Despite these complications,
individuals with elevated perfectionism in OCD
can and do respond to psychological interventions, often associated with a somewhat attenuated treatment response. Thus, clinical outcomes
may be enhanced when perfectionistic beliefs
and behaviors are the focus of clinical attention
(e.g., Pleva and Wade 2007; Riley etal. 2007) .
An evidence-based approach to the treatment
of perfectionism OCD incorporates a multimodal
assessment and cognitive behavioral strategies
for targeting perfectionistic beliefs and behaviors
early in treatment (Egan etal. 2011). Although
ERP is the treatment of choice for perfectionismbased OCD, it may be augmented with cognitive strategies directed at challenging rigid, allor-nothing, perfectionistic beliefs with the use
of thought records, identifying and challenging
double standards, cost/benefit analysis of striving
for perfectionism, and psychoeducation about the
elusiveness of perfection. Behavioral experiments,
such as deliberately making errors to see if predicted catastrophic consequences occur, should be
designed to test out perfectionistic cognitions. The
following case illustrates the implementation of
a comprehensive cognitive behavioral treatment
plan for OCD, specifically addressing prominent
perfectionistic beliefs and behaviors.
Case Vignette
Presenting Problem
Andrew was a 31-year-old married man who had
recently moved to a new city with his wife of
3 years, and worked as a pediatric surgeon. Although he endorsed long-standing difficulties with
low mood and anxiety, he indicated that the move
triggered a significant increase in his symptoms
of OCD. At the time of his assessment, Andrews
reported symptoms met DSM-5 criteria for OCD,
social anxiety disorder, and major depressive disorder, recurrent episode, in partial remission. In
addition, significant OCPD traits were noted, par-
7 Treatment of Perfectionism-Related Obsessive-Compulsive Disorder
ticularly perfectionism and a preoccupation with

details, order, organization, and lists.
In terms of his OCD symptoms, Andrew endorsed obsessional doubt and a felt need to have
things just right. He reported that his obsessional thoughts and checking, counting, sequencing, and symmetry compulsions were continuous throughout much of the day. For example,
he stated that he checked locks, appliances, and
lists to ensure that he did not miss anything. He
described needing things to be in line, symmetrical, or organized by precise criteria, such as
aligning his shoes and clothing by type, color, and
coordinating pieces. He also sought to achieve
symmetry in his environment while mowing the
lawn, vacuuming floors, and wiping counters.
These rituals were often associated with certain
numbers, such as 5, 9, and 13. This significantly
interfered with writing computer programming
code, because he strove to create code in blocks
of 5, 9, and 13 lines, which rendered much of his
work undecipherable.
Andrews obsessional doubting was evident
in his need to obtain perfect photographs. He
described taking photographs of everyday events
and items in order to be sure that he remembered
perfectly. Andrew disclosed that he had over
10,000 pictures saved in his phone and computer of unsentimental and unimportant events
and items because of doubts about the accuracy
and longevity of his memory. Similarly, he maintained exhaustive lists, with items in multiples of
5, 9, and 13, to ensure that he did not forget important thoughts or activities.
Andrews need for exactness and precision
was also evident in his language. He struggled
to find the perfect word to express his thoughts,
which often manifested in over inclusiveness in
his speech. His need to understand concepts and
meanings exactly contributed to conflict in his
marriage, as his wife became increasingly frustrated with his requests for clarification and reassurance. His insight and judgment were good;
however, he endorsed strong and rigid beliefs
about the possibility and necessity of achieving a
perfect standard. He stated that his life was guided by the principle that there is always a perfect
decision, outcome, or right way to do things.
87
Case History
Andrew is the eldest of three children. He recalled having a happy childhood, with loving and
supportive parents. His father is a lawyer, whom
he described as a loyal, caring, ambitious man,
but a stern disciplinarian. His mother worked as
a certified accountant. He described his mother
as loving, supportive, dedicated, and selfless. Although he denied any family history of psychiatric difficulties, he described his parents as neurotic with some obsessive-compulsive traits
that, to his knowledge, were never diagnosed or
treated. He also denied any history of trauma,
abuse, or neglect.
His twin brothers were born several weeks
premature, and, at a young age, he assumed the
role of assisting his mother with their care and
ensuring not to cause increased stress during the
challenging times when the twins were young.
Otherwise, Andrew indicated that his early development was unremarkable. He described his
temperament as outgoing and playful, and he
enjoyed normal peer relationships until the onset
of his psychological symptoms at the age of 15.
His intrusive thoughts and compulsive behaviors
greatly impacted his comprehension of the class
material, his ability to maintain focus on lessons,
and his ability to complete schoolwork on time.
As such, he became socially insecure and made
efforts to hide his struggles from his peer for fear
of ridicule.
Since that time, Andrew reported that school
has been a significant source of stress for him.
He recalled struggling with the quality of his
work and required extra help due to his anxiety
symptoms. Despite 3 years of university business studies, he was only able to complete one
course. Feelings of worthlessness were compounded as he watched his peers navigate effortlessly through the university curriculum.
Further, he recalled parental messages about the
importance of university education and interpreted his brothers ease in completing their education as evidence that he was a disappointment
to his family. Andrew subsequently completed a
1-year computer programming applications certificate with the assistance of intensive tutoring
88
and accommodations for note-writing and testtaking. He believed that his symptoms of OCD
would be an asset in a profession that depends on
exactness and attention to detail.
After completing his education, Andrew obtained a position as a computer programmer with
a large database management company. As one
of many programmers within the organization, he
had hoped to maintain a low profile and avoid
drawing attention to his difficulties. He described
excessive checking and rewriting blocks of computer code to ensure that the code contained no errors and was elegant. He was initially applauded for the quality of his work and the minimal
revision or troubleshooting required of his computer code. However, he was unable to maintain
the excessively long hours needed to compensate
for his checking and rewriting. The harder he
persisted in striving for perfection, the more he
struggled with increased anxiety and depressive
symptoms. He was plagued by chronic self-doubt
and a sense that he could never achieve perfection. Andrew maintained his job for several years
but was fired for persistent missed deadlines. He
is currently unemployed and seeking consultation from a vocational counselor to retrain for a
less demanding career.
Andrew was diagnosed with OCD at the age of
15, when he was struggling to complete schoolwork. At that time, he received eight sessions of
individual cognitive behavioral therapy (CBT)
for OCD, which led to a partial decrease in his
symptoms and enabled him to complete high
school. Since then, he has engaged in several
courses of supportive and cognitive therapy over
the years with minimal symptom improvement.
However, he acknowledged that therapy rarely
involved behavioral strategies, and he has been
reluctant to challenge his beliefs because of the
feared consequences (e.g., failing classes, embarrassment, disappointing his parents). In addition,
Andrew tried several antidepressant medications
over the years, including clomipramine, as well
as several selective serotonin reuptake inhibitors
(SSRIs) and mood stabilizers. Under the supervision of his treating psychiatrist, he attempted to
discontinue his medication use but experienced
an increase in OCD symptoms, and, as such, he
had been on a stable dose of an SSRI for the past

5 years.
Cognitive Behavioral Case Conceptualization and Assessment

Prior to beginning treatment, Andrew received a
comprehensive diagnostic assessment consisting
of a structured diagnostic interview to assess for
a broad range of psychological difficulties. The
Structured Clinical Interview for DSM-5 Disorders- Clinician Version (SCID-5-CV; First etal.
2015) was chosen as it provides a good balance
of breadth of diagnostic coverage with a reasonable administration time. Results indicated that
Andrews reported symptoms met diagnostic criteria for OCD, social anxiety disorder, and major
depressive disorder, recurrent episode, in partial
remission. In addition, the OCPD module of the
Structured Clinical Interview for DSM-IV Axis II
Personality Disorders (SCID-II; First etal. 1997)
noted OCPD traits, although full diagnostic criteria were not met. After determining that OCD
was his principal presenting problem, specific
symptom-based measures of OCD severity and
associated beliefs were incorporated to contribute to the case formulation.
Andrews baseline Yale-Brown ObsessiveCompulsive ScaleSecond Edition (Y-BOCS-II;
Goodman etal. 2006) obsession subscale score
was 22, and his compulsion subscale score was
21, which correspond to the severe range. Of
note, on item 11 of the Y-BOCS-II, Andrew had
excellent insight into his symptoms of OCD, acknowledging that his symptoms were excessive
and unreasonable. In terms of self-report measures, Andrew completed the Obsessive-Compulsive InventoryRevised (OCI-R; Foa etal.
2002), at baseline and weekly throughout treatment as a measure of symptom change. His baseline OCI-R yielded a total score of 47, which was
well above the clinical cutoff of 21 (Foa etal.
2002). Additional baseline measures included the
Obsessive Beliefs Questionnaire44-item measure (OBQ-44; OCCWG 2005) to assess beliefs
relevant to his obsessive-compulsive symptoms.
Although his total score on the OBQ-44 was high,
his scores were remarkable for significant elevations on the perfectionism/uncertainty subscale.
Andrew stated that completing the questionnaires
was extremely anxiety provoking, noting that he
required hours to check his work because of
doubts about making mistakes or providing inaccurate responses. This was observed throughout
the interview as he was often overly inclusive
in his responses to avoid giving the therapist incorrect or incomplete information. In the final
phase of the assessment, Andrew was also asked
to complete self-monitoring forms of his obsessions and compulsions to gather more detailed
information about the specific triggers, rituals,
avoidance, and distress. These forms (e.g., see
Clark 2004) were used to establish baseline data
about the frequency and distress associated with
his obsessional thoughts and use of compensatory behaviors, including avoidance, neutralizing,
and compulsions.
Andrews difficulties can be understood to
have emerged out of the interplay between biological and psychosocial factors. Given his description of his parents neurotic personalities
and obsessive traits, it is possible that there was
a biological predisposition to develop perfectionistic obsessive-compulsive symptoms (Jang etal.
1996; Samuels etal. 2000). In addition, his description of his father as a harsh disciplinarian
suggests that parental criticism and overcontrol
may have contributed to his underlying perfectionistic beliefs and OCD symptoms. Andrew received the message that university is extremely
important and working hard is crucial to ones
self-worth. Thus, despite an otherwise secure upbringing, in the context of developing OCD, he
developed underlying beliefs around failure and
the sense that others will be disappointed in him
if he is unsuccessful. His efforts to work hard and
produce high-quality work have reinforced his
beliefs that perfectionism is attainable and desirable.
Andrews obsessions and compulsions were
related to a sense of incompleteness and the need
to achieve perfection. Although he could not articulate any specific threat associated with failing
to achieve this perfection, he was motivated to
avoid a profound sense of dissatisfaction, dis-
89
appointment, and shame associated with a substandard outcome. He identified the underlying
belief that a perfect decision, outcome, or right
way to do things exists and is attainable with
hard work, and therefore, he was justified in his
pursuit of perfection. He endorsed a broad, but
nonspecific, range of triggers that activated compulsions intended to achieve certainty and reduce
discomfort. This interfered with his completion
of most day-to-day activities as he struggled, in
vain, to get things just right. Consequently, Andrew was becoming increasingly frustrated and
self-critical because, despite his best efforts, his
OCD symptoms interfere with his capacity to
succeed.
Treatment Plan
Although no cognitive behavioral treatment
protocols have been specifically designed and
evaluated for the treatment of perfectionismrelated OCD, CBT has demonstrated efficacy
in the treatment of OCD (Olatunji etal. 2013).
Given that ERP has robust evidence for its efficacy and has been suggested to be relevant for
targeting the discomfort associated with perfectionistic checking, ordering, arranging, and incompleteness (Freeston etal. 1997; Summerfeldt
2007), a time-limited course of ERP based on
protocols described by Franklin and Foa (2008),
Steketee (1999), and Summerfeldt (2007) was
chosen. Challenging perfectionistic beliefs occurred throughout treatment and was usually accomplished with behavioral experiments to test
out predictions and alternative beliefs. Treatment
consisted of 6090-min sessions once weekly
for 15 weeks accompanied by daily homework
practices between sessions. Broadly, treatment
followed three phases, which focused on psychoeducation, building motivation and treatment
planning, ERP, and relapse prevention planning.
Phase 1: Psychoeducation, Building

Motivation, and Treatment Planning
During the initial sessions, psychoeducation was
provided regarding the nature of the treatment
and the rationale for ERP. Specifically, the first
90
session reviewed the case conceptualization and

treatment plan. Andrew had good insight into
his beliefs and symptoms, and he agreed with
the therapists formulation of his symptoms. Although he was amenable to the treatment plan,
he was reluctant to consider giving up his perfectionistic behaviors because of the intense discomfort he experienced when things were not
just right. Further, he described fears that giving
up his compulsions and striving for perfection
would mean that he was lazy, careless, and undisciplined.
To address his ambivalence, early discussions
focused on enhancing motivation to change. Incorporating motivational enhancement strategies
with ERP has been shown to improve engagement
and symptom improvement when combined with
ERP for OCD (Simpson and Zuckoff 2011). We
collaboratively created a decisional balance to
examine Andrews motivation for change. Specifically, he was asked to consider pros and cons
of challenging perfectionistic beliefs and eliminating compulsions versus maintaining the status
quo (see Table7.1). Andrew had no difficulty articulating the benefits of eliminating his compul-
sions; he was acutely aware of why he wanted to

change. However, the reasons for maintaining his
beliefs and behaviors were less clear in the face
of his distress. On reviewing the decisional balance, Andrew acknowledged that the costs of not
engaging in treatment, in terms of time, energy,
relationship satisfaction, and constant self-doubt
and criticism, outweighed the elusive feelings
of satisfaction that he currently experiences. It
was important to validate his fears about changing long-standing beliefs and behaviors that
had become fundamental to his self-perception;
however, the therapist reinforced that the goal of
treatment was not to change his personality, but
to gain control over his distressing behaviors.
The next sessions focused on psychoeducation
about the behavioral model of OCD. Specifically,
it was explained that engaging in compulsions is
one of the primary maintaining mechanisms of
OCD because the short-term reduction in distress
after engaging in compulsions is highly reinforcing. Not only did compulsions alleviate discomfort and anxiety, they prevented him from learning that the discomfort would abate naturally
over time. Further, he never learned to tolerate
Table 7.1 Decisional balance illustrating pros and cons of eliminating compulsions
Continue with compulsions
Pros
Cons
Elation when finally taking the perfect picture
The elation doesnt last long
May be able to achieve the desired perfect outcome
I am rarely able to achieve the perfect outcome and then
I feel more anxious
It is time-consuming and exhausting
I have planned for difficult scenarios and have systems
in place to make it easier (e.g., lists, phone apps, taking
photos to alleviate doubt)
I feel good about myself for working hard
My wife is frustrated and disappointed in me
Others will respect me for striving for perfection
I cant work
I always doubt myself and lack self-confidence
I am missing out on life and distancing myself from
others
It is expensive (I often buy several things to get the
perfect one)
Eliminate compulsions
I might actually be able to get my life back
My anxiety will get worse before it gets better
It might get easier over time
It may be too intense to handle
It will save time in the long run
It will take a long time to get better
It may improve my relationship with my wife
I will become lazy or unmotivated
I will eventually be able to get back to work
I will learn to not judge myself so harshly
the uncomfortable emotions and sensations and

to develop more adaptive beliefs and behaviors.
Treatment was framed as eliminating the behaviors (i.e., compulsions, avoidance, and escape)
that keep this cycle alive. In Andrews case, this
meant reducing list-making, reassurance seeking,
taking excessive photographs, completing activities until things felt just right or in multiples
of 5, 9, and 13. For homework, he was asked to
begin to continue identifying items that would be
suitable targets for ERP.
Constructing a hierarchy proved challenging
for Andrew because of the nature of his OCD.
The list that he had generated for homework
was overly inclusive and contained 104 exposure targets. He explained that he had difficulty
determining what should be included and discarded because every item seemed relevant and
important. Making lists, with items in multiples
of 13, was a compulsion driven by the desire to
remember everything accurately and completely.
Because Andrew identified near-constant obsessional thoughts, it became apparent that a list of
all relevant triggers would be impractical. Rather,
a core group of environmental triggers was identified that represented his underlying beliefs,
91
and three smaller hierarchies were organized by

theme (making lists, mowing the lawn, limiting
photographs; see Table7.2). Finalizing the items
on the hierarchy was reframed as the first exposure exercise.
Andrew also had difficulty attaching a number to his distress and avoidance. It became apparent that he struggled to rate his distress and
avoidance accurately; each item had been given a
precise rating and had been edited several times.
As he rated one item, he would change others to
ensure that they maintained their relative position. To allow him to complete the hierarchy and
begin exposures, the scale was changed from a
100-point scale to a 10-point scale to narrow the
rating options and prevent reinforcing his desire
for precision. The scale was converted back to
a 100-point scale as a measure of progress in a
later session.
Phase 2: Exposure and Response

Prevention
Although Andrew expressed doubt that his exposure hierarchy was complete, he acknowledged
that the lists did not need to be perfect before beginning exposures. Further, he and his therapist
Table 7.2 Fear and avoidance hierarchy of eliminating photographs

Rank
Situation/trigger
Distress (0100)
1
Delete photographs of his
100
honeymoon
2
95
parents
3
90
baby nephew
4
Delete photographs of new 80
house
70
5
Spend 30min deleting
unimportant photographs
65
6
Spend 15min deleting
unimportant photographs
7
Spend 5min deleting unim- 60
portant photographs
8
Create list, take no photo- 50
graphs of lists
45
9
Go to grocery store, take
no photographs while
shopping
10
Go to mall, limit to ten
40
photographs
Avoidance (0100)
100
100
100
90
80
70
65
40
50
30
92
generated ideas for in-session exposure exercises

intended to trigger his need for perfection and
completeness. For example, Andrew agreed to
rewrite lists and intentionally leave items off, fill
out forms and symptom measures inaccurately or
incompletely, disorganize items on the therapists
desk, and read a magazine paragraph without rereading or checking.
Once Andrews exposure hierarchies, organized by thematic content, were adequately
complete, the guidelines for exposure practices
were reviewed. Specifically, it was emphasized
that he was to rate his distress every 510min
on the same scale of 0100 in order to monitor
his progress over time. He was encouraged to
practice planned exposures to a variety of triggers daily between therapy sessions to generalize
his learning.
For the first in-session exposure, Andrew
agreed to complete his weekly symptom measure
inaccurately, and not to provide a response for
two items. Prior to the exposure, he did not anticipate feeling much distress about an inaccurate
questionnaire because this scenario rarely occurred in his day-to-day life and rated his anticipated distress at about 25. The therapist observed
him complete the forms and then monitored his
discomfort at 5-min intervals. Initially, Andrew
reported that he felt uncomfortable and silly
and began asking the therapist for clarification
about how he may be doing it wrong. The therapist focused his attention on the questionnaire
and elicited Andrews thoughts about the inaccurate items to continue to activate his discomfort during the exposure. His distress peaked at
approximately 40 and decreased within 20min,
until he experienced little to no anxiety. He was
surprised to learn that his discomfort could be
relieved so quickly without doing anything to
correct his mistake. Andrew was able to translate
the evidence that he gained from this experience
to other situations in which similar beliefs and
sensations are elicited. He readily acknowledged
that he could not remember a time in which he
did not attempt to neutralize his discomfort. He
agreed to complete daily exposures to items that
were lower on his hierarchy related to intention-
ally making errors (i.e., missing a small patch of

grass while mowing the lawn, leaving one item
off grocery list).
Throughout the following several sessions,
Andrew continued with in-session and betweensession exposure practices. With each planned
exposure practice, his immediate distress typically alleviated within 4560min, even as he
continued to challenge himself with progressively more difficult items on his hierarchy.
Throughout in-session exposure practices, the
role of the therapist is to act as a coach, focusing the clients attention to the exposure exercise
and the associated distress or discomfort. This is
to prevent emotional avoidance, draw attention
to the gradual reduction in distress, and enhance
learning about the process of change. This may
be facilitated by taking distress ratings at regular
intervals and engaging in discussion about the
feared consequences (if any) and underlying beliefs. However, conversation should be limited if
the discussion distracts the client from engaging
in the task or leads to avoidance of the discomfort
associated with exposure.
Early in-session exposures consisted of deleting irrelevant pictures on Andrews phone,
whereas later sessions focused on deleting increasingly more sentimental pictures. As the pictures became more difficult to delete, Andrew expressed concerns that he would forget important
moments or delete an irreplaceable picture. The
therapist helped him to explore his beliefs about
the need to take pictures as a memory aid. He
was able to provide, in exquisite detail, several
memories of important events and people in his
life, which challenged his lack of confidence in
his memory. With the use of Socratic questioning, Andrew came to the conclusion that events
and people are more than the detailed images
contained in pictures, but rather a lived experience on which he was missing out when he hid
behind a camera lens. He generated the statement
that If I stop taking pictures, I can spend time
enjoying the moment.
After session 7, his weekly symptom measures
indicated that the reduction in distress that was
occurring between sessions had plateaued. Upon
inquiry, it became apparent that Andrew was engaging in between-session exposures from only
one of his three hierarchies related to list-making
and had not generalized his ERP practices to
other daily activities. ERP was reconceptualized
as a lifestyle strategy, in which he was mindful
of the motivation for his behavior throughout his
daily activities. For example, he was encouraged
to intentionally select a mismatched outfit when
getting dressed in the morning, brushing his top
teeth longer than his bottom teeth, and leaving
his bed unmade throughout the day. With this
new approach to ERP, Andrew described a feeling of agitation and discomfort that continued
throughout the day as new situations continually arose that triggered his obsessive thoughts.
Because monitoring distress for each instance
quickly became impractical, monitoring forms
were amended to track his average distress per
day, rather than in briefer intervals.
After ten sessions of in-session exposure
with frequent and generalized practice throughout the week, Andrews distress ratings peaked
at 50 and decreased within a few minutes. His
weekly OCI-R had decreased to 29, and he was
reporting considerable increase in his confidence
to approach triggers, resist compulsions, and tolerate discomfort. However, he reported that his
obsessive thoughts continued to be triggered frequently, and he had developed abbreviated rituals
in order to get on with his day. For example, he
followed the same morning routine and ate similar foods for breakfast, but reduced the routine to
the most important elements and completed them
quickly. The therapist helped Andrew to regard
this form of ritual abbreviation as an intermediate step in complete response prevention. As his
alternative beliefs about the need for symmetry,
exactness, and certainty were internalized, he
was able to gradually reduce his reliance on compulsive behaviors.
As he continued to challenge himself to engage in ERP practices throughout the day, Andrew developed a series of adaptive statements
derived from the evidence gained through previous exposures. For example, when struggling to
make a decision, he would remind himself it is
93
more important to me to make a decision than

the perfect decision. When trying to complete
his household tasks with complete precision, he
would acknowledge that the payback does not
justify the time and energy required to get it just
right. Finally, he often reminded himself that
being certain is unnecessary and unachievable.
Consequently, Andrew noticed a gradual but important change in his self-esteem and self-efficacy as his productivity improved and his reliance
on reassurance from his wife decreased.
Phase 3: Relapse Prevention

Despite the efficacy of ERP for OCD, many
clients with primarily obsessional thoughts remain partially symptomatic at the end of treatment (Freeston etal. 1997). In the final sessions,
treatment should focus on planning long-term
ERP practices to continue symptom reduction,
maintaining gains, planning for newly emergent symptoms, and relapse prevention. Andrew
was aware of the significant improvements that
he had seen in his daily life, but struggled with
acceptance that he may continue to experience
obsessional doubt and discomfort with imperfection. He also reported having difficulty determining normal, healthy standards to strive for. Normalizing residual symptoms can reduce distress
related to perceived failure to improve with treatment. In addition, together with the therapist, Andrew evaluated the strength of his beliefs at the
beginning of the treatment and at the end and determined that his beliefs felt less extreme, rigid,
and unreasonable. His new beliefs (e.g., I do
not need to be perfect in order to be considered a
worthwhile person) were more consistent with
his values and goals for the future and provided a
roadmap for guiding future behavior. Further, he
reviewed weekly symptom measures, monitoring
forms, and exposure hierarchies to see that the
general pattern was a reduction of distress, which
increased his motivation for continued practice.
Although symptom drift is not common in
adult OCD, some clients report symptoms emerging from different clusters over time (MataixCols etal. 2002; Rufer etal. 2005). More commonly, individuals report emergent symptoms
94
from within the same cluster. Because of the

pervasive pattern of situational and environmental triggers for Andrews perfectionistic thoughts,
he reported that he found it difficult to identify
the many ways in which his behavior was being
guided by OCD. As such, he reported that he
noticed new rituals emerging in the absence of
old ones. For example, as he continued to delete
photographs on his phone and reduce the number
of new pictures that he took, he found himself
reviewing the retained pictures daily to ensure
that he kept the most significant ones. In addition, although he limited list-making to 10min
each morning, he reviewed the list frequently
throughout the day. Therefore, it is important to
assess for newly emergent symptoms that may or
may not be related to the symptoms for which the
client sought treatment.
Andrew was encouraged to make a plan for
ongoing monitoring of his symptoms and behaviors and for developing new hierarchies for
ERP practice should he identify new rituals and
beliefs. Although he was minimally engaging in
rituals, he noted that he would like to slow the
rate of ERP self-practice now that he had gotten
the hang of it. The therapist discussed with Andrew the advantages and disadvantages of retaining any rituals, and he acknowledged that even
small compulsive behaviors can be highly reinforcing. To assist with maintenance of his gains
and prevent relapse, Andrew was encouraged to
attend monthly booster sessions for at least the
first year following treatment for monitoring and
troubleshooting. In addition, preliminary evidence indicates that mindfulness-based cognitive
therapy (MBCT) can lead to enhanced treatment
outcomes following ERP for OCD (Key etal.
2013). Therefore, he was provided with information about an MBCT for OCD program that was
offered at our center to assist him in developing
skills useful for monitoring, identifying, and acting independently of his obsessive thoughts. He
agreed to consider attending the group in the future; however, for the time being, he expressed a
preference to focus on continuing ERP practices,
challenging his beliefs, and developing a return
to work plan.
At the final treatment session, the Y-BOCSII, OCI-R, and OBQ-44 were re-administered
to provide indicators of treatment outcome. Andrews total Y-BOCS-II score was 20, which was
approximately half his pretreatment score. Although his symptoms still met diagnostic criteria
for OCD at the final session, the intensity of distress, time, and interference associated with his
obsessive-compulsive symptoms was markedly
reduced. Importantly, his posttreatment OBQ-44
showed that, although he had a significant elevation on the perfectionism/uncertainty subscale,
the degree of endorsement was significantly diminished.
Although Andrew made considerable progress in
his ability to tolerate imperfection, incompleteness, and uncertainty without engaging in compulsions, there were several factors that complicated the therapy process. He often reported having difficulty starting exposure practices until he
understood the details perfectly. While this was
initially observed in his difficulty in generating
an exposure hierarchy and rating distress levels,
this was also observed in session when he would
ask for exhaustive clarification about the theory
and plan for exposures. Although this was initially tolerated as part of socialization to treatment, a functional analysis showed that it paralleled other compulsive and reassurance-seeking
behaviors. It also served as a means of engaging
in an intellectual discussion to avoid feelings of
discomfort. As sessions progressed, Andrew was
encouraged to label these questions as passive
avoidance and attempts to reduce uncertainty,
rather than efforts at understanding. Further, he
was encouraged to draw on his experience from
previous exposures to answer his own questions,
rather than being provided with reassurance from
the therapist.
Perhaps most significantly, Andrews perfectionistic beliefs were highly ego-syntonic and,
while he was willing to modify his behaviors,
he was reluctant to eliminate rituals entirely
and challenge his perfectionistic beliefs. He frequently challenged the therapist about the need
to challenge his beliefs if he was able to reduce
the compulsions to a reasonable time in his day.
He pointed to professional athletes who practice
for hours to develop muscle memory and are respected for their dedication to striving for perfection. Further, he recalled times in which he
was reinforced for his high standards, pointing
to the cultural and familial messages about positive striving. At times, he asked Whats wrong
with wanting to be perfect? Everyone wants to be
perfect. Compulsions driven by perfectionism
and just right feelings are subject to negative reinforcement associated with anxiety reduction, as
well as positive reinforcement related to feelings
of elation and praise when the desired outcome
is achieved, making them particularly resistant
to modification. Ongoing motivational enhancement can ensure that the client sustains their efforts to engage in exposures despite these positive reinforcers. To remind him of his reasons for
change, Andrew created a decisional balance in
his phone that he referred to and updated regularly, when struggling with motivation for ERP
practices.
As treatment progressed and Andrew gradually reduced the amount of time spent ritualizing,
he was unsure of how to spend the time previously occupied by compulsions. He was resolved not
to return to a career in computer programming
because of his perceived vulnerability to relapse.
The therapist worked with Andrew to determine
activities (e.g., jogging, socializing) that he enjoyed even when he did not do them perfectly. He
was encouraged to focus time and energy each
95
day on activities that bring him pleasure and a

sense of accomplishment in the absence of a perfect outcome as healthy alternatives to engaging
in compulsions. Finally, a referral for a vocational assessment was initiated to help him identify
and pursue a preferred career direction.

Perfectionism has been identified as a vulnerability factor in the onset and maintenance of
several psychological disorders; perfectionism is
particularly prominent in OCD. Although doubts
about actions tend to be particularly elevated
across OCD symptom subtypes, there appears to
be a subgroup or phenotype of OCD characterized by greater frequency of obsessions and compulsions related to symmetry, ordering, repeating, cleaning, and hoarding associated with high
perfectionism. OCD driven by perfectionism and
incompleteness can be particularly resistant to
modification because symptoms are subject to
both the negative reinforcement associated with
anxiety reduction and the positive reinforcement
related to feelings of elation and praise when the
desired outcome is achieved. However, ERP has
been shown to be an efficacious psychological
intervention.
The case vignette described in this chapter illustrates the implementation of a comprehensive
cognitive behavioral treatment plan for OCD
characterized by perfectionism-driven symmetry,
ordering, checking, and reassurance seeking (see
Table7.3). Andrews partial response to treatment
was typical of treatment progress, that is, indi-
Table 7.3 Key practice points

Key practice points
Perfectionism is one of the core cognitive features of OCD and is more prominent among OCD presentations related
to symmetry, exactness, doubting, and incompleteness
Given the long-standing, pervasive, and often ego-syntonic nature of perfectionism-based OCD, it may be more
resistant to treatment
Motivational enhancement strategies may be important to increase engagement
A comprehensive, multimodal assessment is necessary to identify a broad range of treatment targets
A time-limited course of exposure and response prevention should be implemented, with emphasis on generalizing
exposure practices across domains
96
viduals with perfectionism-based OCD present

with distinct challenges due to the long-standing,
pervasive, and often ego-syntonic nature of their
difficulties. In addition, some perfectionism can
be adaptive and culturally normative, leading to
the challenges in developing new, more adaptive
beliefs and behaviors. Thus, careful and continuous monitoring of his symptoms was required to
ensure that the core beliefs were being targeted
with exposure practices.
A standard course of treatment begins with
a multimodal assessment of symptom severity
and beliefs, including a diagnostic interview,
self-report measures, and monitoring forms.
The first phase of treatment focuses on psychoeducation and treatment planning, including the
creation of exposure hierarchies. Because perfectionism-driven OCD often manifests across
domains, it is not uncommon to require several
smaller exposure hierarchies targeting a broad
range of triggers. The mainstay of CBT for
such cases is ERP, incorporating cognitive challenges as necessary to dispute unhelpful beliefs.
However, caution should be exercised to avoid
reinforcing subtle avoidance by engaging in intellectual discussions about the utility of such
beliefs. As therapy progressed, ERP evolved
from circumscribed exposure practices to a
broad lifestyle-management approach to challenge his obsessive thoughts across a range of
situations and triggers throughout the day. Although complete symptom remission is unlikely, the final phase of treatment should focus on
generalizing and maintaining gains, and planning for recurrence of old symptoms or newly
emergent symptoms.
References
Antony, M. M., Purdon, C. L., Huta, V., & Swinson, R. P.
(1998). Dimensions of perfectionism across the anxiety disorders. Behaviour Research and Therapy, 36,
11431154.
Bieling, P. J., Israeli, A. L., & Antony, M. M. (2004a).
Is perfectionism good, bad, or both? Examining models of the perfectionism construct. Personality and

Individual Differences, 36, 13731385. doi:10.1016/
S0191-8869(03)00235-6.
Bieling, P. J., Summerfeldt, L. J., Israeli, A. L., & Antony,
M. M. (2004b). Perfectionism as an explanatory construct in comorbidity of axis I disorders. Journal of
Psychopathology and Behavioral Assessment, 26, 193
201. doi:10.1023/B:JOBA.0000022112.27186.98.
Buhlmann, U., Etcoff, N. L., & Wilhelm, S. (2008).
Facial attractiveness ratings and perfectionism in
body dysmorphic disorder and obsessive-compulsive
disorder. Journal of Anxiety Disorders, 22, 540547.
doi:10.1016/j.janxdis.2007.05.004.
Chik, H. M., Whittal, M. L., & ONeill, M. L. (2008). Perfectionism and treatment outcome in obsessive-compulsive disorder. Cognitive Therapy and Research, 32,
676688. doi:10.1007/s10608-007-9133-2.
Clark, D. A. (2004). Cognitive-behavioral therapy for
OCD. New York: Guilford.
J. (2003). Not just right experiences: Perfectionism,
obsessive-compulsive features and general psychopathology. Behaviour Research and Therapy, 41, 681
700. doi:10.1016/S0005-7967(02)00044-X.
Coles, M. E., Pinto, A., Mancebo, M. C., Rasmussen, S.
A., & Eisen, J. L. (2008). OCD with comorbid OCPD:
A subtype of OCD? Journal of Psychiatric Research,
42, 289296. doi:10.1016/j.jpsychires.2006.12.009.
Egan, S. J., Wade, T. D., & Shafran, R. (2011). Perfectionism as a transdiagnostic process: A clinical
review. Clinical Psychology Review, 31, 203212.
doi:10.1016/j.cpr.2010.04.009.
Egan, S. J., Wade, T. D., Shafran, R., & Antony, M. M.
(2014). Cognitive-behavioral treatment of perfectionism. New York: Guilford.
First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B.
W., & Benjamin, L. S. (1997). Structured clinical
interview for DSM-IV Axis II personality disorders
(SCID-II). Washington, DC: American Psychiatric.
First, M.B., Williams, J. B. W., Karg, R. S., & Spitzer,
R.L. (2015). Structured clinical interview for DSM-5
disordersClinician version (SCID-5-CV). Arlington: American Psychiatric.
Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic,
R., Hajcak, G., & Salkovskis, P. M. (2002). The obsessive-compulsive inventory: Development and validation of a short version. Psychological Assessment, 14,
485496. doi:10.1037/1040-3590.14.4.485.
Franklin, M. E., & Foa, E. B. (2008). Obsessive-compulsive disorder. In D. H. Barlow (Ed.), Clinical
handbook of psychological disorders: A step-by-step
treatment manual (pp. 164215). New York: Guilford.
Freeston, M. H., Ladouceur, R., Gagnon, F., Thibodeau,
N., Rhaume, J., Letarte, H., & Bujold, A. (1997).
Cognitive-behavioral
treatment
of
obsessive
thoughts: A controlled study. Journal of Consulting and Clinical Psychology, 65, 405413.
doi:10.1037/0022-006X.65.3.405.
Frost, R. O., & Steketee, G. (1997). Perfectionism in
obsessive-compulsive disorder patients. Behaviour

Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R.
(1990). The dimensions of perfectionism. Cognitive
Therapy and Research, 14, 449468. doi:10.1007/
BF01172967.
Frost, R. O., Novara, C., & Rhaume, J. (2002). Perfectionism in obsessive compulsive disorder. In R. O.
Frost & G. Steketee (Eds.), Cognitive approaches to
obsessions and compulsions: Theory, assessment, and
treatment (pp. 91105). Amsterdam: Pergamon/Elsevier Science.
Goodman, W. K., Rasmussen, S. A., Price, L. H., &
Storch, E. A. (2006). Yale-Brown obsessive-compulsive scalesecond edition (unpublished manuscript).
Hewitt, P. L., & Flett, G. L. (1991). Perfectionism in the
self and social contexts: Conceptualization, assessment, and association with psychopathology. Journal
of Personality and Social Psychology, 60, 456470.
doi:10.1037/0022-3514.60.3.456.
Jang, K. L., Livesley, W. J., & Vernon, P. A. (1996). Heritability of the big five personality dimensions and their
facets: A twin study. Journal of Personality, 64, 577
591. doi:10.1111/j.1467-6494.1996.tb00522.x.
Key, B., Rowa, K., Drvaric, L., Bieling, P., & McCabe, R.
(2013 June). Mindfulness-based cognitive therapy for
residual anxiety symptoms in obsessive-compulsive
disorder. In B. Key (Chair), Mindfulness and anxiety:
Innovative applications of mindfulness interventions
for anxiety disorders. Symposium conducted at the
meeting of the Canadian Psychological Association,
Quebec, QC.
Leckman, J. F., Walker, D. E., Goodman, W. K., Pauls,
D. L., & Cohen, D. J. (1994). Just right perceptions
associated with compulsive behavior in Tourette's
syndrome. American Journal of Psychiatry, 151,
675680.
Mancebo, M. C., Eisen, J. L., Grant, J. E., & Rasmussen, S. A. (2005). Obsessive compulsive personality
disorder and obsessive compulsive disorder: Clinical characteristics, diagnostic difficulties, and treatment. Annals of Clinical Psychiatry, 17, 197204.
doi:10.1080/10401230500295305.
Mataix-Cols, D., Rauch, S. L., Baer, L., Eisen, J. L., Shera,
D. M., Goodman, W. K., etal. (2002). Symptom stability in adult obsessive-compulsive disorder: Data
from a naturalistic two-year follow-up study. American Journal of Psychiatry, 159, 263268. doi:10.1176/
appi.ajp.159.2.263.
(1997). Cognitive assessment of obsessivecompulsive disorder. Behaviour Research and Therapy, 35,
667681. doi:10.1016/S0005-7967(97)00017-X.
Obsessive Compulsive Cognitions Working Group. (2001).
Development and initial validation of the obsessive
beliefs questionnaire and the interpretation of intrusions inventory. Behaviour Research and Therapy, 39,
9871006. doi:10.1016/S0005-7967(00)00085-1.
97

inventory-part 2: Factor analyses and testing of a brief
version. Behaviour Research and Therapy, 43, 1527
1542. doi:10.1016/j.brat.2004.07.010.
Olatunji, B. O., Davis, M. L., Powers, M. B., & Smits,
J. A. J. (2013). Cognitive-behavioral therapy for
obsessive-compulsive disorder: A meta-analysis
of treatment outcome and moderators. Journal of
Psychiatric Research, 47, 3341. doi:10.1016/j.
jpsychires.2012.08.020.
Pleva, J., & Wade, T. D. (2007). Guided self-help versus
pure self-help for perfectionism: A randomised controlled trial. Behaviour Research and Therapy, 45,
849861. doi:10.1016/j.brat.2006.08.009.
Rasmussen, S. A., & Eisen, J. L. (1989). Clinical features
and phenomenology of obsessive compulsive disorder. Psychiatric Annals, 19, 6773.
Riley, C., Lee, M., Cooper, Z., Fairburn, C. G., & Shafran,
R. (2007). A randomised controlled trial of cognitivebehaviour therapy for clinical perfectionism: A preliminary study. Behaviour Research and Therapy, 45,
22212231. doi:10.1016/j.brat.2006.12.003.
Rufer, M., Grothusen, A., Ma, R., Peter, H., & Hand,
I. (2005). Temporal stability of symptom dimensions in adult patients with obsessive-compulsive
disorder. Journal of Affective Disorders, 88, 99102.
doi:10.1016/j.jad.2005.06.003.
Samuels, J., Nestadt, G., Bienvenu, O. J., Costa, P. T., Jr.,
Riddle, M. A., Liang, K., etal. (2000). Personality
disorders and normal personality dimensions in obsessive-compulsive disorder. British Journal of Psychiatry, 177, 457462. doi:10.1192/bjp.177.5.457.
Simpson, H. B., & Zuckoff, A. (2011). Using motivational interviewing to enhance treatment outcome in
people with obsessive-compulsive disorder. Cognitive
and Behavioral Practice, 18, 2837. doi:10.1016/j.
cbpra.2009.06.009.
Steketee, G. (1999). Overcoming obsessive-compulsive
disorder: A behavioral and cognitive protocol for the
treatment of OCD. Oakland: New Harbinger.
Summerfeldt, L. J. (2004). Understanding and treating incompleteness in obsessive-compulsive disorder. Journal of Clinical Psychology, 60, 11551168.
doi:10.1002/jclp.20080.
Summerfeldt, L. J. (2007). Treating incompleteness,
ordering, and arranging concerns. In M. M. Antony,
C. Purdon, & L. J. Summerfeldt (Eds.), Psychological
treatment of obsessive-compulsive disorder: Fundamentals and beyond (pp. 187207). Washington, DC:
Part II
Pediatric ObsessiveCompulsive
Disorder
Treatment of Contamination in
Childhood Obsessive-Compulsive
Disorder
Amy Przeworski, Jennifer Freeman, Abbe Garcia,
Martin Franklin and Jeffrey Sapyta
Nature of the Problem and Research

Base
Contamination is an intense and persisting feeling of having been polluted or infected or endangered as a result of contact, direct or indirect,
with a person/place/object that is perceived to be
soiled, impure, infectious, or harmful. (Rachman 2004, p.1229). Contamination is the most
common concern in obsessivecompulsive disorder (OCD; Steketee etal. 1985), with 5055% of
those with OCD exhibiting contamination fears
(Rachman and Hodgson 1980; Rasmussen and
Eisen 1992). Similarly, cleaning compulsions,
the compulsions most linked to contamination
OCD, are the second most common OCD symptom, second to compulsive checking (Rachman
and Hodgson 1980).
Various maladaptive cognitions, disgust sensitivity, emotion dysregulation, and neural charA.Przeworski()
Department of Psychological Sciences,
Case Western Reserve University,
10900 Euclid Avenue, Cleveland, OH 44106, USA
e-mail: axp335@case.edu
J.Freeman A.Garcia
Warren Alpert Medical School of Brown University,
Providence, RI, USA
M.Franklin
University of Pennsylvania Medical School,
Philadelphia, PA, USA
J.Sapyta
Duke University Medical Center, Durham, NC, USA
acteristics have been associated with contamination OCD. However, the majority of the research
body consists of studies of adults and little research has examined contamination OCD in children or adolescents.
Maladaptive Cognitions
For those who experience contamination OCD,
perceived contamination frequently spreads
from one object to another and from one person to another, usually by contact (Rachman
2004). Individuals who suffer from contamination OCD often experience beliefs about the ease
of the spread of contamination, such as the law
of contagion: a belief that once something is in
contact with something that was contaminated, it
will always be contaminated (Rozin and Fallon
1987). In this manner, contamination may quickly spread from one source to another and may
encompass all of ones belongings within a short
time of contact with the original object perceived
to be contaminated.
Additionally, there is often little to no loss
of intensity as contamination spreads from one
object to another, and objects that are multiple
steps removed from the original contaminant
are perceived as being equally contaminated as
the original contaminant. This was illustrated
in a study by Tolin etal. (2004) who touched a
pencil to a contaminated object, then touched a
second pencil to the first pencil and asked individuals with contamination OCD, those with

DOI 10.1007/978-3-319-17139-5_8
101
102
panic disorder, and non-anxious participants to

indicate the degree of contamination of the pencil that was one-step removed from the original
contaminant. They continued this process, touching each subsequent pencil to the pencil that preceded it, leading to the final pencil being 12 steps
removed from the original contaminated object.
Those with panic disorder and non-anxious control participants demonstrated 100% reduction in
contamination concerns about pencils from the
first pencil to the last pencil; in other words, each
pencil that was one step farther removed from
the original contaminant was perceived to be less
contaminated than the previous pencil. Individuals with contamination OCD showed only a 40%
reduction in contamination concerns to the final
pencil, demonstrating that the intensity of contamination diminished only moderately despite
the final pencil being many steps removed from
the original contaminant.
Overestimation of threat, such as having
exaggerated beliefs about the likelihood and
consequences of becoming sick and inflated responsibility for harm, has been associated with
contamination OCD in most (ObsessiveCompulsive Cognitions Working Group 2005; Tolin
etal. 2003, 2008; Wheaton etal. 2010), but not
all studies (Julien etal. 2006). However, such
characteristics are not unique to contamination
OCD and also serve as significant predictors of
OCD related to unacceptable thoughts concerning violent, sexual, and religious themes (Wheaton etal. 2010).
Disgust
Disgust sensitivity has also been identified as
an important characteristic associated with contamination OCD (Cisler etal. 2009b, for a review) and may play a role in the overestimation
of threat (Deacon and Olatunji 2007; Olatunji
etal. 2009). Disgust is a basic emotion that, as
Davey (1993) theorized, serves an evolutionarily
beneficial role of protecting people from eating
or touching items that may make one ill. Disgust
propensity explains 43% of the variance in con-
A. Przeworski et al.
tamination scores on one measure of OCD (Burns

etal. 1996), and the association between disgust
and contamination is present even after controlling for negative affect (Cisler etal. 2008, 2009a;
Moretz and McKay 2008; Olatunji etal. 2007).
Disgust sensitivity may lead to the development of contamination fears through increased
avoidance of items that induce disgust reactions.
Those with contamination fears avoid items that
are elevated in disgust relative to those with high
anxiety and low anxiety (Tsao and McKay 2004)
and those who are low in contamination fears
(Olatunji etal. 2007). Similarly, children with
contamination-related OCD have high avoidance
scores on the Child Version YaleBrown Obsessive-Compulsive Scale (CY-BOCS; Mataix-Cols
etal. 2008).
Contamination OCD is also associated with
attention, memory, and judgment biases towards
disgust (Charash and McKay 2002, 2009; Charash etal. 2006), all of which may reflect higher
disgust sensitivity in individuals with contamination OCD. Such elevations in disgust propensity
in individuals with contamination fears may be
related to increased activation in structures of the
brain related to disgust, including the right insula
(Shapira etal. 2003). Additionally, disgust habituates at a slower rate in individuals with contamination fears versus those with other types of
OCD fears (McKay 2006), thereby maintaining
the experience of disgust in individuals with contamination fears for a greater duration.
Emotion Regulation
Anxiety sensitivity and emotion regulation difficulties may also play a role in the development of
contamination fears, specifically when combined
with disgust propensity (Cisler etal. 2007, 2008).
Increased reactions of disgust may only lead to
contamination fears in individuals who experience fear in response to the physiological reactions that accompany negative emotion. This was
supported by data indicating that disgust predicts
contamination fears more strongly in individuals with poor emotion regulation (Cisler etal.
2009a).
8 Treatment of Contamination in Childhood Obsessive-Compulsive Disorder
Treatment
Similar to other types of OCD, treatment for
contamination-related OCD typically consists
of exposure and response prevention (ERP).
ERP has been demonstrated to reduce the fear
of contamination as well as the experience of an
item as contaminated (Abramowitz 1997; Clark
2004; Rachman and Hodgson 1980). However,
individuals with contamination fears respond less
well to treatment than those with other types of
compulsions (Coelho and Whittal 2001; McLean
etal. 2001), suggesting the need for therapists
treating contamination-related OCD to be vigilant for signs of treatment resistance and relapse
in clients.
To date, little research has examined disgust in
children and adolescents. Similarly, no research
has examined family factors which may play a
role in the development and maintenance of contamination-related OCD, such as family expressions of disgust and encouragement of avoidance
of potentially contaminated items. In the pages
that follow, we describe the symptoms and treatment of an adolescent with contamination OCD.
The case illustrates many of the factors that empirical evidence has indicated are associated with
contamination OCD, but also other factors that
may also be important in the development and
maintenance of contamination OCD, such as
family expressions of disgust, family negativity,
and encouragement of avoidance of potentially
contaminated objects.
Presenting Problem
Molly was a 13-year-old girl who was referred by
a local area psychiatrist and presented for an assessment and treatment for OCD. Molly primarily expressed concerns about becoming sick and
making other people ill. She washed her hands
for several hours each day with a specific type
of soap, resulting in red, chapped skin on her
hands and wrists. Molly also avoided touching
objects that she believed may be contaminated,
including doorknobs, car door handles, and the
arms of chairs in public places. She refused to use
103
public restrooms or to touch anything in a public

restroom. Molly also was concerned about objects touching the floor because she believed that
the floor was contaminated. She was especially
concerned with her book bag, which touched the
floor at school, and her shoes.
For Molly, contamination spread from objects
that touched the floor to objects that were in close
proximity. For example, Molly felt that the tops
of her shoes were contaminated because the bottom of her shoes touched the floor, and she was
concerned that she may have touched the bottom
of one shoe to the top of the other shoe. She felt
that her socks and the hems of her pant legs were
contaminated because they touched her shoes.
Touching her shoes, socks, or the bottoms of her
pant legs would immediately lead to a desire to
wash her hands. Mollys book bag and anything
that touched her book bag were similarly a cause
of concern to her.
Molly expressed fear that she would get a virus
or flu and a concern that she would spread an illness to her family. She was unable to express a
specific concern about what would happen if she
or her family were to get sick or whether she was
concerned that the illness would be fatal.
Case Information
Mollys mother reported that her OCD symptoms
probably began when she was around 8 years
old and had been increasing in severity. Mollys
mother reported that she noticed that Molly was
frequently asking for hand sanitizer when entering the car, and that after months of this Molly
began experiencing rashes and irritation on her
hands. Mollys mother reported that Molly began
to wash her hands quite frequently, and she noticed that hand washing took an increasingly longer amount of time. Mollys mother reported that
they attempted to treat the rashes on her hands
by taking her to a dermatologist, but no dermatologic treatment seemed to have an effect.
At age 11, Molly was diagnosed with OCD
by a psychiatrist and prescribed numerous different selective serotonin reuptake inhibitors
(SSRIs). Despite trying various medications, she
104
continued to experience symptoms of OCD and

had recently begun to experience symptoms of
depression and hopelessness. Her family was
interested in exposure therapy as Mollys psychiatrist reported that he had exhausted the list of
medications that are usually effective in treating
OCD and therapy was one of the few remaining
options.
Molly did not have a family history of OCD,
but several family members were anxious and
depressed. Mollys mother reported that she herself had suffered from depression for years and
was currently prescribed an SSRI.
Mollys mother also reported that she maintained a scrupulously clean home and encouraged her children to be clean. Mollys father was
a surgeon, and her mother reported that he liked
the home to be as clean as his operating room.
Mollys mother was a stay-at-home mother and
reported that she spent much of her time when
her children were not home, cleaning the house.
Molly had three sisters and two brothers, and
there was a significant family conflict and distress. Molly got along well with her youngest sister but frequently argued with her other siblings.
The siblings reported frustration that the family revolved around Molly and her OCD and
said that they did not understand why they were
forced to change the way that they did things to
make Molly happy. The entire family reported
that Molly asked them to wash their hands or use
sanitizer frequently. Mollys mother reported that
Mollys siblings frequently antagonized Molly
by touching her after they arrived home and before they washed their hands. That often led to
her dissolving in tears and running into the bathroom to shower, change her clothes, or wash her
hands. Mollys mother reported that she was unable to stop Mollys siblings from antagonizing
her, and said that she wishes that Molly would
just get over her germ issues so there could be
more peace in the household.
Behavioral Observations
Molly presented as quite shy and anxious. She
made poor eye contact and looked down for
much of the initial meeting. Molly participated

in the initial interview only when directly spoken to, and her mother dominated the interview.
Mollys mother reported some hesitation to
begin talk therapy and reported that she was
surprised that Molly had not responded to medication. She described Mollys symptoms with a
somewhat critical and negative tone of voice and
stated that Mollys symptoms were disrupting the
entire household.
When Mollys mother left the room so Molly
could be interviewed individually, she continued
to be shy but gradually warmed up and began
smiling towards the end of the interview. While
Molly admitted that her OCD had caused disruption in the home and that she asked her family
to change their behaviors to accommodate her
symptoms, she reported that she and her siblings
had been experiencing conflict for many years
and stated that her OCD was only a small part of
the problem. She stated that she and her siblings
argued over everything and that her mother did
little to attempt to resolve the arguments. She reported that the family conflict often led her to retreat to her bedroom, but that because she shared
the room with one of her sisters, she did not find
her room to be much of an escape.
Molly reported that her OCD symptoms worsened during the winter months, especially during
flu season and also at times when the family discord was particularly bad. She reported that she
usually spent approximately 2 hours a day washing her hands and that she was plagued with concerns about germs and illness throughout much
of her day at school, leading her to use hand sanitizer several times an hour throughout the day.
Molly also reported that she had five different backpacks and that she used a different backpack every day so she would not need to use a
contaminated backpack 2 days in a row. Each
backpack was laundered after a day of use. She
reported that she often changed her clothing as
many as three times a daywearing one outfit to
school, changing it when she arrived home, and
then wearing a clean pair of pajamas every night.
She also changed her pillowcase every night out
of concern that she would be laying in contamination at night. She had her own laundry ham-
per because she did not like for her clothing to

come into contact with the rest of her familys
clothing. She also indicated that she had recently
begun doing her own laundry because her mother
was frustrated by the amount of laundry that she
generated, and because she wanted to keep her
own clothing separate from the rest of the familys clothing.
Molly reported that she deliberately isolated
herself within the household, and said that she
tried not to touch or hug her family for fear of
spreading an illness. Molly became tearful when
describing how little physical contact she had
with her family and how isolated she had become.
Case Conceptualization and

Assessment
Assessment
Molly and her mother completed the Anxiety
Disorders Interview Schedule and Child Yale
Brown Obsessive-Compulsive Scale at pre-therapy and post-therapy.
Anxiety Disorders Interview Schedule for
DSM-IVChild Version (ADIS-IV-C; Silverman
and Albano 1996) is a diagnostic interview that
assesses for the presence of a majority of psychological diagnoses in children, including anxiety
and depression. A clinical severity rating ranging from 0 to 8 may be given for each diagnosis
with 03 indicating subthreshold or no symptoms
and 48 indicating clinical-level symptoms. The
ADIS-IV-C has excellent psychometrics (Silverman etal. 2001) and is sensitive to treatment
change (Ginsburg and Drake 2002).
Molly and her mother jointly completed this
interview. Results indicated that she was suffering from major depressive disorder and social
anxiety disorder in addition to her primary diagnosis of OCD. Mollys major depressive symptoms included dysphoria, anhedonia, increased
appetite, hypersomnia, fatigue, difficulty concentrating, and hopelessness. She reported that
she was anxious when interacting with peers as
well as adults. She said that she had few friends
and entirely avoided social outings with peers.
105
She also reported feeling that she was awkward

and odd and that peers did not like her. Molly
reported that she was extremely lonely.
CY-BOCs: The CY-BOCS is a ten-item clinician-rated measure, which assesses OCD severity (Scahill etal. 1997). Items are rated on 04
scales. Total scores range from 0 to 40 (07: subclinical; 815: mild; 1623: moderate; 2431:
severe; 3240: extreme). The CY-BOCS has
good interrater reliability, validity, and internal
consistency (=0.87) and is sensitive to treatment change (Scahill etal. 1997). Molly and her
mother completed this measure in a joint interview. Prior to therapy, Molly scored a total of 29
(obsessions: 15, compulsions: 14), which is in
the severe range.
Clinical Impressions
Molly was experiencing both a genetic predisposition to anxiety and related disorders and significant family conflict and parental behaviors
that likely contributed to her OCD symptoms.
Although there was no known family history of
OCD, the significant family history of depression and anxiety likely led to a predisposition to
internalizing disorders. Mollys parents both emphasized the importance of cleanliness and obliterating germs, and her mother spent a significant
amount of time cleaning the home. This emphasis on cleanliness likely contributed to the development of Mollys obsessions and compulsions
and could be an obstacle during treatment as her
family needed to embrace exposure to germs and
illness and reduce cleaning behaviors.
Additionally, the family conflict and her
mothers critical and negative attitude towards
her may have contributed to the severity of her
OCD and depressive symptoms. Criticism, hostility, and negativity are characteristics consistent
with high expressed emotion, a family characteristic that has been demonstrated to be related to
greater pretreatment severity of OCD and poorer
posttreatment OCD-related functioning (Chambless and Steketee 1999; Leonard etal. 1993;
Przeworski etal. 2012). The degree of family
hostility and rejection from Mollys siblings and
106
her mother likely increased Mollys stress and

anxiety, potentially increasing the severity of
Mollys OCD and depressive symptoms.
Molly seemed starved for encouragement,
emotional warmth, and positive social interactions. She experienced little of this within her
family interactions and had very few interactions with peers. Mollys demeanor changed
greatly when her mother left the room during
the initial assessment. During the time when
her mother was in the room, she made poor eye
contact, slouched, and appeared to want to disappear. When her mother left the room, she gradually warmed to the assessor and appeared more
comfortable. She expressed her own views of
her family and her OCD symptoms, sometimes
disagreeing with her mothers report, a behavior
that she did not engage in during the time that
her mother was in the room. Molly seemed grateful for even a small encouraging comment and
flashed a broad smile when the assessor complimented her on insight into her OCD symptoms.
Mollys father was not present for the assessment and was barely mentioned by Molly and her
mother. When directly asked about his involvement in OCD rituals and his relationship with
Molly, it was reported that he was rarely present
within the home and that when he was at home,
he was often in his home office or tinkering in the
basement. It appeared that Mollys mother was
the primary caregiver and that her mother participated in Mollys rituals and also expressed negativity and criticism of Molly for her OCD and the
impact that it had had on the family.
Molly was experiencing depression, secondary to OCD and social anxiety. Her conflict with
her siblings, anxiety during peer interactions, and
views of herself as odd and unlikeable led to significant isolation, exacerbating her sadness and
loneliness.
Mollys family was somewhat skeptical of
therapy as a treatment and tended to rely on
pharmacological intervention for psychological
symptoms, as indicated by her mothers use of
medications for her depression and her parents
expectation that medication would significantly
reduce Mollys OCD symptoms. Her parents
disappointment in the failure of medication to
reduce her symptoms likely increased Mollys

sense of hopelessness. Additionally, Mollys
mothers skepticism about the efficacy of talk
therapy served as a potential obstacle to treatment.

Treatment roughly followed March and Mulles
(1998) manualized therapy protocol. The first
two sessions of therapy included both Molly and
her mother and relied primarily on psychoeducation about OCD and CBT for OCD. Given Mollys mothers skepticism of therapy, it was important to include her in these sessions in order
to attempt to get buy-in from her. It was also important to provide her with information regarding
the genetic predisposition to OCD and biological
underpinnings due to her critical and negative attitude towards Mollys OCD and to the familys
reliance on biological interventions for psychological symptoms.
Molly and her mother listened attentively and
asked questions during the explanation of OCD
and CBT. Molly seemed quite concerned about
exposure exercises and shifted uncomfortably
during the discussion about ERP. Mollys mother
expressed disgust and disbelief during the therapists explanation of the importance of exposure
to sources of contamination such as bathroom
floors, the bottom of ones shoe, and the office
floor. Her mother openly expressed disgust, disbelief, and criticism of the notion of exposure exercises including behaviors that are not typically
engaged in by individuals who do not have OCD,
but which may be essential to effective treatment
of OCD to fully expose the individual to their
feared stimuli.
For example, the therapist described eating
off of the floor, touching the soles of shoes, and
touching the bathroom floor as behaviors that
might be at the top of the hierarchy, and which
were necessary to tackle in order to ensure that
there was no room for OCD to begin to creep
back in. Molly seemed taken aback by this idea
but reserved judgment. Mollys mother, on the
other hand, shuddered in disgust and grimaced.
She instantly stated that she thought that idea

was ridiculous and that she saw no reason for her
daughter to engage in a behavior that normal
people would not engage in. She said that she
would never eat off of a floor in her home, let
alone off of the therapists office floor and that
the idea of touching a public bathroom floor was
inconceivable.
The therapist stated that it is necessary to
reach the top of the hierarchy in order for clients
to improve and that often the top of the hierarchy included behaviors such as eating off of the
floor in order to expose individuals with OCD
to the most extreme level of contamination that
they could imagine. Mollys mother continued
to express disgust and stated that she did not
agree with the idea, would never participate in
those types of behaviors, and did not believe
that Molly should do those things either. Sensing
the potential for Mollys mother to discontinue
treatment altogether, the therapist reported that
this issue could be revisited once the rest of the
hierarchy had been tackled and asked if Molly
and her mother could agree to do other items on
the hierarchy and reserve judgment about the last
several items until some progress had been made.
Molly agreed, but looked down and appeared
uncomfortable about the disagreement between
the therapist and her mother. Mollys mother begrudgingly agreed but stated that she could not
imagine any circumstance in which Molly engaging in exposure to those top items on the hierarchy would be beneficial.
Additionally, parental involvement in therapy was discussed. Mollys mother reported that
she saw no need for her to be heavily involved
in treatment and indicated that she had no one
else to watch Mollys siblings and did not feel
comfortable leaving them all in the waiting room
for the duration of the session. She indicated that
Molly was old enough to deal with this on her
own and that she was content to be updated on
Mollys progress for a few minutes at the end of
each session. Mollys therapist reported that it
may be important for Mollys mother to be present for some sessions in order to learn how to
coach Molly through particularly difficult exposure exercises. Her mother agreed to this.
107
During session 2, Molly began mapping

OCD, which involved identifying OCD triggers
and times when she felt that she was in control of
OCD, times when OCD was in control, and times
when she sometimes, but not always had control
of OCD. The goal of mapping OCD is to help
to visually illustrate the degree to which OCD is
controlling the childs life and to help to identify
which symptoms may be early targets for exposure exercises and which will be more challenging (March and Mulle 1998). Mapping OCD also
helps the child to create an exposure hierarchy to
be used in subsequent sessions. Ultimately, much
of the work of engaging in exposures occurs in
the transition zone, where OCD sometimes has
control over the childs behaviors, and the child
sometimes has control.
The majority of Mollys OCD symptoms fell
in the area of the map where OCD was entirely
in control, including touching door knobs, public restrooms, and anything that had touched the
floor, and only a few symptoms fell in the transition area of the map (touching the arms of chairs,
light switches, and car door handles).
Molly also identified some mantras to say to
herself during exposure exercises, including Its
just OCD. I can handle this, I will not let OCD
boss me around, and I can do this. These mantras are used as a way to empower the child during exposure exercises.
The first exposure exercise occurred during session 3 and involved touching the light
switches in the therapists office. Molly usually
pulled her shirt sleeve down over her hand to
touch light switches or used her elbow to turn
on a light switch in order to avoid the germs that
she believed were on the light switch. Under the
therapists direction, Molly was able to touch her
fingertips and eventually her entire palm to the
light switch in the therapists office as well as an
adjacent office. Molly reported that this exposure
exercise was not extremely anxiety provoking
because she knew that relatively few people were
touching the light switches. Molly was able to
tolerate the slight elevation in her anxiety during
the exposure exercise and to touch her contaminated hands to her clothing and hair to spread the
contamination from her hands to her belongings.
108
This ensured that she continued to be in contact

with contaminated items even once she eventually washed her hands several hours after the
session. This also ensured that the contamination
was not limited to her hands, but was instead all
over her body.
Mollys therapist provided enthusiastic positive reinforcement for Mollys bravery, and Mollys affect improved each time that positive statements were made. By the end of the session, she
appeared quite at ease and was smiling broadly.
Molly was instructed not to wash her hands or use
hand sanitizer for at least an hour following the
exposure exercise and not to change her clothes
when she arrived home. She was also instructed
that if she did wash or use sanitizer, she must recontaminate her hands by touching a light switch.
Mollys homework was to touch light switches in
her home and not to wash her hands after doing
so and to spread the contamination on her clothing and personal items, including her bed.
Mollys mother was not present for the majority of the session, but attended the last 5min
of the session in order to be updated on Mollys
progress and to be informed of Mollys homework assignment. Mollys therapist asked Molly
to describe to her mother the goals that were accomplished during the therapy session, and Molly
shyly but enthusiastically told her mother of her
success in touching light switches. Mollys mothers response was Thats great but you have a really long way to go. Mollys excitement deflated
instantly. She began looking down at her hands
and simply nodded in response to this comment.
Mollys therapist immediately stated that
Mollys success in the initial exposure exercise
was a huge step towards tackling OCD and that
she had confidence that Molly would continue to
beat OCD in subsequent sessions. Mollys therapist continued to praise Molly about her participation in exposure exercises and suggested that
Mollys mother could help to support her daughter by praising Molly for her successes.
Molly was successful in completing her homework assignment, and during the next session she
appeared happy that she had conquered one of
her fears so early in therapy. Mollys therapist
continued to be enthusiastic and to provide Molly
with high levels of positive feedback during and

after exposure exercises in order to motivate
Molly and to combat Mollys depressive style.
The next exposure exercise involved touching the arms of an infrequently used chair in the
therapists office using Mollys fingertips and
eventually using her entire hand. Molly was also
able to touch the arms of a more frequently used
chair in the therapists office and eventually to
touch the arms of the chairs in the waiting room.
Mollys anxiety became quite elevated during the
exposure exercise, but she was able to tolerate
the anxiety and eventually habituated to it. For
homework, Molly was asked to touch the chair
arms at her local library, coffee shops, and other
public places, and she was instructed not to wash
her hands or use sanitizer for at least an hour
after engaging in the exposure exercise. Again,
she was instructed to recontaminate after washing her hands. Mollys mother agreed to drive her
to public places so she could engage in the homework exposure exercises.
Molly was successful in completing her
homework exposure exercises and reported that
despite not having engaged in a formal exposure
exercise to touching car door handles, she was no
longer experiencing anxiety regarding this. She
and her therapist conducted an exposure exercise
to verify this and Mollys anxiety did not become
significantly elevated.
Subsequent exposure exercises involved
touching the therapists office door knob, door
knobs to other offices in the suite, the doorknob
to the public restroom, touching Mollys backpack (which had touched the floor), and touching the tops of Mollys shoes. Molly was able to
complete each of these exposure tasks and to tolerate the related anxiety without needing to wash
her hands.
Eventually, Molly and her therapist conducted
an exposure exercise to touching the sink and
floor in the public restroom in the therapists
suite. Molly experienced extremely elevated anxiety during these exposure exercises but completed the exposure exercises nonetheless. Mollys
biggest fear was that she would make a family
member or friend sick due to spreading contamination. Throughout the course of therapy, none
of Mollys family members became sick; however, Mollys therapist came down with a cold in
the week after the bathroom floor exposure, and
Mollys therapist was so sick that she needed to
cancel the following weeks session.
During the next session, Molly appeared quite
anxious and fearful and would barely make eye
contact with her therapist. She reported that she
attributed the therapists illness to the bathroom
exposure that they had done a few days before
the therapist became ill. Molly said that she had
been wracked with guilt and that she believed
that it was her fault that her therapist had become
sick. She reported that she had been washing and
sanitizing her hands frequently throughout the
week and was terrified that she would make one
of her family members sick. She also reported
that she had been changing her clothes frequently
in order to avoid others becoming ill. In short, her
ritualizing, which had been drastically reduced
prior to the therapist becoming ill, had returned
to pre-therapy levels.
Despite the return of Mollys symptoms, the therapist becoming ill was a fortuitous event because
it provided the therapist with the opportunity to
delve deeper into Mollys feared consequence.
Molly had reported that she was afraid that she
would spread germs by touching contaminated
items and would make others sick; however, she
had not been able to elucidate the feared consequence if someone did become sickdeath, serious illness, discomfort. After much discussion,
Molly realized that her core fear was that others
would die if they became ill due to her spreading germs. The therapist becoming sick and experiencing only a week of discomfort served as
evidence that her core fear was inaccurate. It was
discussed that the therapist could very well become ill again in the future, and that Molly and
her family members would likely catch viruses in
the future, but that usually the worst that would
happen is simply a brief period of discomfort.
Molly appeared relieved once this was discussed,
and she recognized that her feared consequence
had not occurred. Thus, the therapists illness was
a corrective emotional experience for Molly.
Mollys ritualizing returned to a relatively
low level, and she and the therapist continued to
109
work on exposure to items on her hierarchy. The

next item on her hierarchy involved touching the
bottom of her shoe. Mollys therapist modeled
this exposure for Molly and then repeated the
exposure along with Molly. Molly experienced
an extreme increase in her anxiety upon doing
this exposure but was able to tolerate the anxiety
without washing her hands and to spread the contamination to her hair, face, and belongings. At
this point, Molly had completed 16 sessions of
therapy, and there were only a few items remaining on the hierarchy.
During the following session, Molly was supposed to touch the bottom of her shoe and then
lick her hand. Mollys mother was informed that
this was the hierarchy item on the agenda for the
day, and she immediately reported that she was
revolted by the idea and did not understand why
this would be therapeutic. The therapist reviewed
the idea that the goal of ERP is to fully expose
the individual to their fears and to ensure that the
individual does not attribute a lack of feared consequences to avoidance.
It was explained that, at times, this required
an individual with OCD to engage in behaviors
that go beyond what most people would do (Gillihan etal. 2012). For example, if a person fears
contamination by germs, touching the bottom of
ones shoe and then licking ones hand or even
licking the bottom of ones shoe may expose the
individual to the highest level of germs imaginable. This could help the individual to most effectively habituate to the anxiety caused by contamination and germs, and also teach the individual
that their feared consequences (dying, contracting a serious illness, etc.) do not occur. Although
most people do not lick the bottom of their shoe
or touch the bottom of their shoe and then lick
their hand, it is a common experience for people
to adjust their shoe or tie their shoe (touching
the sole of their shoe in the process) and then eat
without washing their hands. People may also
touch the bottom of their shoe to their furniture
or clothing when crossing their legs or propping
their feet up on a coffee table and later eat after
touching the furniture of clothing that has come
into contact with the shoe sole. Most people do
not even notice that they have done this.
110
Similarly, it is sometimes necessary to eat off

of the floor to fully expose an individual with
contamination-related OCD to their feared consequences. Although most people do not eat off
of the floor on a regular basis, children drop food
on the floor and eat it frequently, and some restaurant workers will serve food after it has fallen
on the floor. So, it is likely that most individuals
have eaten food that touched the floor at some
point in their life, and few have become seriously
ill or died from this. Thus, although these exposures go beyond what most people deliberately
do on a daily basis, they do expose individuals to
their most feared consequence and do not put clients at risk beyond the risk experienced by most
people who do not have OCD.
If an individual with OCD does avoid an item
at the top of the hierarchy, they may attribute the
lack of a feared consequence as being the result
of avoidance. For example, if an individual fears
contracting a terrible illness by being contaminated by dirt on the bottom of ones shoes and the
person does not touch the bottom of their shoe,
they may attribute their lack of illness as being
due to avoidance of the bottom of their shoe.
Later, the person may start to avoid items that
their shoes have come into contact withsocks,
pant legs, furniture, etc. Then the contamination
may spread from these items to adjacent items,
shirts, hands, coats. The contaminated items
may continue to grow, and the items that may be
touched without consequence will continue to reduce until the individuals OCD is guiding their
life. Thus, it is essential for clients to engage in
exposures to the top items on their hierarchy to
fully extinguish the fear.
Such an explanation was provided to Molly
and her mother, however, Mollys mother continued to report disgust, and she even went so far
as to say that she did not even want to be near
her child if her child were to engage in such an
exposure. Although Molly had previously been
compliant with all therapy requests, she reported
that she did not want to complete this exposure
exercise. The therapist attempted to find ways to
introduce the exposure in a more gradual manner
(touching her shoe sole, then touching her hand
to another item, and licking that item or touching

her shoe sole with her fingertip and then licking
her fingertip), but Molly continued to refuse to
engage in the exposure. Mollys therapist asked
her if she would be willing to eat off of the floor
instead, and Mollys mother again expressed revulsion at the idea. When the therapist explained
the idea that children often eat off of the floor,
Mollys mother reported that no child of hers had
ever eaten anything off of the floor and that she
ensured that her home floor was extremely clean
(unlike the floor of the therapists office), but she
still would not permit her children to eat off of
her home floor. At this point, the therapy was at
an impasse. Several sessions were spent discussing the idea of licking her hand after touching
her shoe and eating off of the floor, but Mollys
mother continued to express disgust and Molly
continued to refuse to engage in the exposure exercises.
The therapist had no choice but to work on
relapse prevention and to continue to bring up
the topic of the incomplete items on the hierarchy
and risk for relapse because the fear had not entirely been extinguished. During relapse prevention, Molly was able to indicate that she would
conduct exposure exercises if OCD symptoms
began to return or if new symptoms emerged.
She had guided the last several completed exposures on her own and appeared to understand the
process of engaging in exposures independently.
She also reported understanding the importance
of contaminating herself after washing her hands
and spreading contamination to all of her belongings so she could begin to avoid certain items that
she felt were contaminated.
After 24 sessions, therapy was terminated with
the promise that the family would call the therapist for a booster session if necessary. At posttherapy Mollys OCD symptoms had reduced to
a 9 on the CY-BOCS, and she was no longer suffering from depression or extreme social anxiety.
She appeared happier, more carefree, and more
confident. Additionally, her family conflict had
been dramatically reduced, and she reported that
she was getting along much better with her siblings.
Three months later, Molly called the therapist

reporting that her OCD symptoms had returned,
and she requested a booster session. She reported
that she was washing her hands several times a
day and spent 3040min washing her hands each
time. She was also showering when she returned
home at the end of the day and changing her
clothes several times a day. Her concerns about
her backpack contaminating items had returned
as well. Molly was tearful during the phone call,
and stated that she was disappointed that she had
relapsed and knew that she had disappointed her
family.
During Mollys booster session, she reported
that her OCD fears had gradually begun to creep
back in and that she had attempted to conduct
ERP but had been unable to do so on her own.
She stated that her mother had been less negative
and critical of her as of late, but that now that
her symptoms had returned, her mother was expressing disappointment in her. Mollys mother
reported that she had noticed that Mollys OCD
symptoms were returning, but said that she was
unaware that they had become so severe. She
said that she wasnt surprised that the talk therapy hadnt really worked given that medication
hadnt worked but was willing to give it one
more try.
A new hierarchy was created (based on Mollys old hierarchy and her report of her current
symptoms). Molly was quickly able to complete
exposures to her backpack, the top of her shoe,
and the bathroom floor over the course of one
therapy session. Even more encouraging was
that Molly was able to complete these exposures
without the therapist needing to do anything
other than being present during them. Molly still
remembered how to do exposures and was able
to do so in a graded manner. She was also able
to tolerate the resulting anxiety during exposures
and experienced only mild-to-moderate anxiety
during the exposures. However, Molly reported
that she would experience a severe level of anxiety if she had to touch the bottom of her shoe and
lick her hand or eat off of the floor.
Molly was asked if she would be willing to
complete those exposures, and the rationale for
111
tackling those items at the top of her hierarchy

was reviewed. Molly agreed to complete the exposures but stated that she did not believe that her
mother would be on board with them. Molly was
correct in this assumption and when her mother
was brought into the therapy session, she again
expressed disbelief and disgust that this would be
included as a target in therapy. The rationale was
reviewed again, and this time Molly stepped in
and told her mother that she understood that her
mother did not agree with this course of action
but that she believed that she needed to complete
these exposures in order to fully recover from
OCD. Her mother indicated that she would support Molly if that was what Molly thought was
best.
Another booster session was scheduled and
Molly brought in several types of food items to
eat off of the floor. She was able to complete
the exposure of touching the bottom of her shoe
and licking her hand. In fact, she reported that
she only became moderately anxious when doing
this exposure and that it was not as bad as she
had expected. Molly was also able to eat off of
the floorinitially, she was able to eat foods
that touched a napkin that had been placed on
the floor and eventually was able to eat foods
that sat on the floor, including foods that were
placed on a stain that was on the therapists office
floor. Again, Molly reported that her anxiety was
lower than she had expected and that even though
she did feel contaminated, she was able to tolerate the anxiety, and it peaked and passed much
faster than she expected it to. Molly was given
homework to continue to eat items that touched
the floor and to touch the bottom of her shoe to
items in her bedroom such as her pillowcase and
clothing.
Molly followed up with a telephone call 2
weeks later, and reported that she had completed
her homework and was not experiencing OCD
symptoms. Follow-up assessments completed 3
months and 9 months later indicated that her CYBOCS score was in the normative range (8 at 3
months and 6 at 9 months), and she did not meet
criteria for depression or OCD.
112
There were numerous obstacles to treatment including Mollys parents skepticism about the efficacy of therapeutic interventions, the value that
her parents placed on cleanliness, the degree of
family conflict, and Mollys mothers negative
and critical attitude. Although these obstacles
may have slowed the progress of therapy, ultimately many of them were addressed over the
course of treatment, or Molly was able to succeed in completing therapeutic exercises in spite
of them.
Mollys family dynamics were a significant
hindrance to therapy progress. Mollys mother
often undermined Mollys confidence by conveying that Molly was not improving rapidly enough
and that Molly still had a lot to work on. Mollys
mother often pushed her to complete more difficult exposure exercises for homework the instant
that she had successfully tackled one exercise
sometimes urging Molly to go several steps up
the hierarchy without consulting with Mollys
therapist. This set Molly up for failure and invalidated the work that Molly had accomplished.
When Mollys therapist praised Molly, her mother often said Yes, but and pointed out times
that OCD was guiding Mollys life or criticized
Molly for her symptoms. At these moments,
Mollys affect would shift from one of happiness
and pride to looking depressed and ashamed. It
was clear that Mollys mother had a critical and
negative style that likely contributed to Mollys
depression and may have maintained her OCD
by increasing her overall stress and anxiety.
After six sessions of therapy, Mollys therapist decided that it was important to have a therapy session with Mollys mother to describe the
importance of praising Molly for her successes
and the impact of critical and unsupportive statements on OCD. Mollys therapist described the
impact that OCD can have on the family through
accommodation and the often resulting negativity on the part of some family members. Mollys
mother appeared unaware that she was being
negative and stated that she was simply trying to
be realistic and did not like when people candycoated situations. She agreed to try to be more
positive, encouraging, and supportive of Molly.

Mollys therapist modeled these behaviors of
Mollys mother in the hopes that Mollys mother
would follow suit. In subsequent sessions, Mollys mother no longer openly criticized Molly,
but she also did not praise her. She would simply
nod her head and smile when Mollys therapist
praised Molly.
Additionally, it became clear that Mollys siblings were antagonizing Molly by touching her
when she believed that they were contaminated
and mocking her for her OCD symptoms. In one
therapy session, Molly tearfully reported one
particularly bad interaction with her sister during
which her sister called her a freak for having
OCD, and said that she was embarrassed to be
related to Molly. Molly reported that her mother
did little to intervene and saw it as the childrens
job to learn how to get along with one another.
Mollys therapist asked Molly whether she would
like to have her sister brought into a therapy session in order to provide her sister with more information about the biopsychosocial nature of
OCD, including the genetic and neurological
underpinnings of the disorder, describe the impact of stress on OCD symptoms, and ask for the
sisters assistance in Molly bossing back OCD.
Molly agreed to this, as did her mother, however,
Molly was pessimistic about the outcome of such
a meeting. Mollys mother also divulged to the
therapist that Mollys sister suffered from panic
attacks and anxiety but had a difficult time relating to Mollys OCD.
Mollys sister attended the following therapy
session and sheepishly admitted that she had
made such statements to Molly and that she
thought that it was fun to push Mollys buttons
by touching her when Molly believed her to be
contaminated. Mollys therapist described the
biological components of OCD, excessive anxiety that accompanies OCD, goals of exposure
therapy, and the impact of stress on OCD, and
asked Mollys sister if she wanted to help Molly
or exacerbate Mollys symptoms. The therapist
also compared the experience of OCD sufferers to that of individuals with anxiety disorders
such as panic disorder in an attempt to increase
Mollys sisters empathy for Mollys experience.
Mollys sister agreed to attempt to help Molly

with exposure exercises, and reported that she
would try not to antagonize Molly in the future.
Although Molly and her sister continued to have
a rocky relationship at times, Mollys sister actually began to support Molly when she was bossing back OCD and no longer mocked Molly for
her OCD symptoms.
The most challenging obstacle to overcome in
therapy was Mollys mothers expression of disgust and refusal to participate in the exposure involving eating off of the floor. This colluded with
Mollys OCD and brought into question the logic
underlying completing an exposure exercise that
went beyond what individuals unaffected with
OCD would typically do. Further, Mollys mothers outright rejection of the idea and refusal to
listen to the rationale behind completing such an
exposure undermined Mollys therapists authority and put Molly in a situation in which she had
to choose to avoid contamination and side with
her mother or side with the therapist and expose
herself to what she considered to be extreme contamination. Unfortunately, this is also likely one
factor in why Molly relapsed soon after the termination of treatment and required two booster
sessions. Even during the booster sessions, Mollys mother continued to express disgust over the
idea that Molly would eat off of the floor. Molly
completed the exposure in spite of her mothers
lack of support of the idea and completed her exposure hierarchy.

Contamination-related OCD is one of the most
common forms of OCD (Rachman and Hodgson
1980; Rasmussen and Eisen 1992; Steketee etal.
1985), but also one of the more treatment-resistant forms of OCD (Coelho and Whittal 2001;
McLean etal. 2001). The disorder may be especially resistant when maladaptive family factors,
such as modeling avoidance, encouraging cleaning, negativity/criticism, and expressions of family members disgust, are present. Additionally,
these family factors may contribute to the devel-
113
opment of comorbid disorders, such as depression.

The above-described case illustrates the importance of addressing these family factors
through direct communication with family members about the behaviors that they are engaging in
that may exacerbate an adolescents OCD symptoms and through therapists modeling more supportive and appropriate behavior. Parental modeling of avoidance and cleaning and expressions
of disgust may particularly interfere in therapy
when therapy requires child and adolescent clients to engage in exposure exercises that involve
engaging in behaviors not typically engaged in
by individuals without OCD, such as not showering for days, eating off of the floor, and touching
the bottom of ones shoe. Without appropriate parental buy-in, child clients may refuse to engage
in these exposure exercises, therein not entirely
accessing their fear structure and leading the client to attribute the lack of feared consequences to
being the result of avoidance. Such a continued
belief in the safety value of avoidance may leave
the door open for OCD symptoms to return, as
they did in the aforementioned case.
However, this case also illustrates the resilience present in some adolescents with OCD,
who may be so motivated to be rid of OCD symptoms that they may complete exposure exercises
to items at the top of the hierarchy despite family
members lack of support for the idea. In the case
described in this chapter, the adolescent actively
pursued booster sessions and completed exposure
exercises to eating off of the floor and licking her
hand after touching her shoe despite her mothers
expression of disgust regarding these exposures
and her lack of support for Molly completing
these exposures. Molly recognized that she relapsed after not completing these exposures, and
she was willing to tolerate the associated anxiety
of completing these exposures and of doing so
despite lack of family support.
Key practice points:
It is important to reach the top of the exposure
hierarchy when conducting ERP for OCD.
Parental approach to exposures, including
expressions of disgust, may be a key factor in
an adolescents participation in exposure exer-
114
cises and ultimately in the success of therapy.

It may be essential to have family buy-in from
the beginning of therapy or to address the lack
of buy-in early in treatment and before family
factors have interfered in therapy.
Family conflict and parental criticism should
be addressed in treatment in order to optimize
outcome.
References
Abramowitz, J. S. (1997). Effectiveness of psychological and pharmacological treatments for obsessivecompulsive disorder: A quantitative review. Journal of
Consulting and Clinical Psychology, 65(1), 44.
Burns, G. L., Keortge, S. G., Formea, G. M., & Sternberger, L. G. (1996). Revision of the Padua Inventory
of obsessive compulsive disorder symptoms: Distinctions between worry, obsessions, and compulsions.
Chambless, D. L., & Steketee, G. (1999). Expressed emotion and behavior therapy outcome: A prospective study
with obsessivecompulsive and agoraphobic outpatients. Journal of Consulting and Clinical Psychology,
67(5), 658665. doi:10.1037/0022-006x.67.5.658.
Charash, M., & McKay, D. (2002). Attention bias for disgust. Journal of Anxiety Disorders, 16(5), 529541.
Charash, M., & McKay, D. (2009). Disgust and contamination fear: Attention, memory, and judgment of
stimulus situations. International Journal of Cognitive
Therapy, 2(1), 5365.
Charash, M., McKay, D., & Dipaolo, N. (2006). Implicit
attention bias for disgust. Anxiety, Stress, and Coping,
19(4), 353364.
Cisler, J. M., Reardon, J. M., Williams, N. L., & Lohr,
J. M. (2007). Anxiety sensitivity and disgust sensitivity interact to predict contamination fears. Personality
and Individual Differences, 42(6), 935946.
Cisler, J. M., Olatunji, B. O., Sawchuk, C. N., & Lohr, J.
M. (2008). Specificity of emotional maintenance processes among contamination fears and bloodinjectioninjury fears. Journal of Anxiety Disorders, 22(5),
915923.
Cisler, J. M., Olatunji, B. O., & Lohr, J. M. (2009a).
Disgust sensitivity and emotion regulation potentiate
the effect of disgust propensity on spider fear, bloodinjection-injury fear, and contamination fear. Journal
of Behavior Therapy and Experimental Psychiatry,
40(2), 219229.
Cisler, J. M., Olatunji, B. O., & Lohr, J. M. (2009b). Disgust, fear, and the anxiety disorders: A critical review.
Clinical Psychology Review, 29(1), 3446.
Clark, D. A. (2004). Cognitive-behavioral therapy for
OCD. New York, NY: Guilford.
Coelho, J. S., & Whittal, M. L. (2001). Are sub-types of
OCD differentially responsive to treatment. Paper presented at the World Congress of Behavioral Therapies.
Davey, G. C. L. (1993). Factors influencing self-rated
fear to a novel animal. Cognition & Emotion, 7(5),
461471.
Deacon, B., & Olatunji, B. O. (2007). Specificity of disgust sensitivity in the prediction of behavioral avoidance in contamination fear. Behaviour Research and
Therapy, 45(9), 21102120.
Gillihan, S. J., Williams, M. T., Malcoun, E., Yadin, E.,
& Foa, E. B. (2012). Common pitfalls in exposure
and response prevention (EX/RP) for OCD. Journal of Obsessive-Compulsive and Related Disorders, 1(4), 251257. doi:http://dx.doi.org/10.1016/j.
jocrd.2012.05.002.
Ginsburg, G. S., & Drake, K. L. (2002). School-based
treatment for anxious African-American adolescents:
A controlled pilot study. Journal of the American
Academy of Child & Adolescent Psychiatry, 41(7),
768775.
Julien, D., OConnor, K. P., Aardema, F., & Todorov, C.
(2006). The specificity of belief domains in obsessivecompulsive symptom subtypes. Personality and
Individual Differences, 41(7), 12051216.
Leonard, H. L., Swedo, S. E., Lenane, M. C., Rettew,
D. C., etal. (1993). A 2- to 7-year follow-up study
of 54 obsessive-compulsive children and adolescents.
Archives of General Psychiatry, 50(6), 429439.
March, J. S., & Mulle, K. (1998). OCD in children and
adolescents: A cognitive-behavioral treatment manual. New York, NY: Guilford.
Mataix-Cols, D., Nakatani, E., Micali, N., & Heyman, I.
(2008). Structure of obsessive-compulsive symptoms
in pediatric OCD. Journal of the American Academy
McKay, D. (2006). Treating disgust reactions in contamination-based obsessivecompulsive disorder. Journal
37(1), 5359.
McLean, P. D., Whittal, M. L., Thordarson, D. S., Taylor, S., Schting, I., Koch, W. J., etal. (2001). Cognitive versus behavior therapy in the group treatment of
obsessive-compulsive disorder. Journal of Consulting
and Clinical Psychology, 69(2), 205.
Moretz, M. W., & McKay, D. (2008). Disgust sensitivity
as a predictor of obsessive-compulsive contamination
symptoms and associated cognitions. Journal of Anxiety Disorders, 22(4), 707715.
inventoryPart 2: Factor analyses and testing of
43(11), 15271542.
Olatunji, B. O., Williams, N. L., Lohr, J. M., Connolly, K.
M., Cisler, J., & Meunier, S. A. (2007). Structural differentiation of disgust from trait anxiety in the prediction of specific anxiety disorder symptoms. Behaviour

Olatunji, B. O., Wolitzky-Taylor, K. B., Willems, J., Lohr,
J. M., & Armstrong, T. (2009). Differential habituation of fear and disgust during repeated exposure to
threat-relevant stimuli in contamination-based OCD:
An analogue study. Journal of Anxiety Disorders,
23(1), 118123.
Przeworski, A., Zoellner, L. A., Franklin, M. E., Garcia,
A., Freeman, J., March, J. S., & Foa, E. B. (2012).
Maternal and child expressed emotion as predictors of
treatment response in pediatric obsessivecompulsive
disorder. Child Psychiatry & Human Development,
43(3), 337353.
Rachman, S. (2004). Fear of contamination. Behaviour
Rachman, S., & Hodgson, R. J. (1980). Obsessions and
compulsions. Englewood Cliffs: Prentice-Hall.
Rasmussen, S. A., & Eisen, J. L. (1992). The epidemiology and clinical features of obsessive compulsive
disorder. Psychiatric Clinics of North America. 15(4),
743758.
Rozin, P., & Fallon, A. E. (1987). A perspective on disgust. Psychological Review, 94(1), 23.
Scahill, L., Riddle, M. A., McSwiggin-Hardin, M.,
Ort, S. I., etal. (1997). Childrens Yale-Brown
obsessive compulsive scale: Reliability and
validity. Journal of the American Academy of
Child & Adolescent Psychiatry, 36(6), 844852.
doi:.1097/00004583199706000-00023.
Shapira, N. A., Liu, Y., He, A. G., Bradley, M. M., Lessig, M. C., James, G. A., etal. (2003). Brain activation
by disgust-inducing pictures in obsessive-compulsive
disorder. Biological Psychiatry, 54(7), 751756.
Silverman, W. K., & Albano, A. M. (1996). Anxiety disorders interview schedule for DSM-IV.: Parent interview
115
schedule (vol. 1). London, UK: Oxford University

Press.
Silverman, W. K., Saavedra, L. M., & Pina, A. A. (2001).
Test-retest reliability of anxiety symptoms and diagnoses with the anxiety disorders interview schedule
for DSM-IV: Child and parent versions. Journal of the
American Academy of Child & Adolescent Psychiatry,
40(8), 937944.
Steketee, G. S., Grayson, J. B., & Foa, E. B. (1985).
Obsessive-compulsive disorder: Differences between
washers and checkers. Behaviour Research and Therapy, 23(2), 197201.
Tolin, D. F., Woods, C. M., & Abramowitz, J. S. (2003).
Relationship between obsessive beliefs and obsessivecompulsive symptoms. Cognitive Therapy and
Research, 27(6), 657669.
Tolin, D. F., Worhunsky, P., & Maltby, N. (2004). Sympathetic magic in contamination-related OCD. Journal
35(2), 193205.
Tolin, D. F., Brady, R. E., & Hannan, S. (2008). Obsessional beliefs and symptoms of obsessivecompulsive
disorder in a clinical sample. Journal of Psychopathology and Behavioral Assessment, 30(1), 3142.
Tsao, S. D., & McKay, D. (2004). Behavioral avoidance
tests and disgust in contamination fears: Distinctions
from trait anxiety. Behaviour Research and Therapy,
42(2), 207216.
Wheaton, M. G., Abramowitz, J. S., Berman, N. C., Riemann, B. C., & Hale, L. R. (2010). The relationship
between obsessive beliefs and symptom dimensions in
obsessive-compulsive disorder. Behaviour Research
and Therapy, 48(10), 949954.
Treatment of Sexual
Obsessions in Childhood
Disorder
Danielle Ung, Chelsea M. Ale
and Stephen P. H. Whiteside
Background
Phenomenology
Nature of the Problem
Although sexual obsessions have been extensively studied in adult populations (Williams
etal. 2011), only a few case studies have specifically focused on sexual obsessions in youth
(Singh and Coffey 2012). Since sexual behaviors
(e.g., touching ones genital area publicly; Friedrich etal. 1998) become more taboo throughout
childhood, it is not surprising to find that sexual
obsessions become more prevalent and more distressing in later childhood and adolescence (Selles etal. 2014). Boys are more likely than girls
to experience sexual obsessions (Mataix-Cols
etal. 2008). Compared to youth with OCD without sexual obsessions, those with sexual obsessions often report more severe and frequent OCD
symptoms including aggressive and religious obsessions, magical thinking, repeating rituals, and
the need to tell, ask, or confess and also report
more severe depression (Fernndez de la Cruz
etal. 2013).
Sexual obsessions include intrusive sexual images that can lead to sexual orientation fears and
pedophiliac fears. Examples of intrusive sexual
images in children and adolescents include sexual acts with family members, strangers, holy figures, dead people, or aggressive sexual acts (e.g.,
rape). Obsessions regarding ones sexual orientation has been referred to in past literature as homosexual OCD (Williams etal. 2011; Williams
2008). Youth may seek reassurance about intrusive thoughts about their sexual orientation from
parents and significant others. Pedophiliac fears
About 25% of youth diagnosed with obsessivecompulsive disorder (OCD) experience repetitive
and unwanted obsessive thoughts about sexual
acts (Fernndez de la Cruz etal. 2013; Geller et
al. 2001a; McKay etal. 2006). In stark contrast
to arousing, pleasant sexual fantasies, youth with
sexual obsessions often feel disgusted, embarrassed, shameful, and experience intense anxiety
when these obsessive thoughts occur (Gordon
2002; Montgomery etal. 2003; Singh and Coffey
2012). Individuals who experience sexual obsessions become highly distressed and often experience thoughtaction fusion, worrying that they
may have engaged in these acts (Siev etal. 2011).
For example, youth with sexual obsessions may
think that simply looking, hugging, or touching
another person in a nonsexual manner means that
they had sex. Every day behaviors that do not
have sexual associations for most people often
conjure up perverse sexual thoughts and images
in youth with sexual obsessions.
S.P.H.Whiteside() C.M.Ale
Department of Psychiatry and Psychology, Mayo Clinic,
200 First Street SW, Rochester, MN 55905, USA
e-mail: Whiteside.Stephen@mayo.edu
D.Ung
Department of Psychology, University of South Florida,
Tampa, FL, USA

DOI 10.1007/978-3-319-17139-5_9
117
118
are obsessions of molesting or engaging in sexual activities with a child. Youth with pedophiliac
obsessions may avoid being around younger children because they are afraid they may act upon
these obsessions.
Impact
Sexual obsessions can cause great distress, confusion, and fear and trigger depression and anxiety symptoms for children, adolescents, and their
families (Fernndez de la Cruz etal. 2013; Williams 2008). Youth who have sexual obsessions
often engage in compulsions to relieve these intrusive thoughts including the frequent need to
ask, tell, and/or confess or, alternatively, hide
these unpleasant thoughts (Fernndez de la Cruz
etal. 2013; Montgomery etal. 2003). Other compulsions include avoidance of the sexually arousing or feared stimuli, hyper vigilance of feared
stimuli, mental reassurance, monitoring arousal
level, and checking (Gordon 2002). These compulsions can be covert or overt and are often
time-consuming, lasting for hours, and leaving
the child feeling isolated and fearful (Fernndez
de la Cruz etal. 2013; Williams 2008).
Sexual obsessions may be misinterpreted as
indicating a history of abuse, risk of intent, or sexual identity and orientation conflicts, resulting in
a reluctance of patients to disclose symptoms and
a delay of appropriate treatment (Fernndez de la
Cruz etal. 2013; Williams 2008). Consequently,
extensive investigations and assessments have
been performed (Veale etal. 2009) with a majority of these cases being unsubstantiated but
nonetheless causing undue stress on the individual and family members throughout the process
(Fernndez de la Cruz etal. 2013; Healy etal.
1991). Sexual obsessions in youth with OCD do
not imply an increased risk of abuse (Healy etal.
1991).
Evidence-Based Treatment
Cognitive-Behavioral Therapy with Exposure
and Response Prevention)Cognitive-behav-
D. Ung et al.
ioral therapy (CBT) aimed at addressing OCD

symptoms is as effective for addressing sexual
obsessions as it is with treating other obsessional
content (Fernndez de la Cruz etal. 2013). In the
largest study investigating sexual obsessions in
youth, Fernndez de la Cruz etal. (2013) examined a total of 383 patients with (n=102) and
without (n=281) sexual obsessions who were
treated with CBT. They found similar rates of
statistically significant decreases in OCD symptom severity for both groups, suggesting that the
presence of sexual obsessions does not decrease
the efficacy of CBT. However, results from studies specifically examining predictors of CBT
response (Mataix-Cols etal. 2002; Rufer etal.
2006) suggest that exposures to sexual obsessions may be more challenging for children and
families to engage with and therefore may have
attenuated CBT response in contrast to other
OCD symptoms.
Pharmacotherapy Serotonin reuptake inhibitors (SRIs) are the first-line medication recommended for pediatric OCD (Geller and March
2012). The efficacy of these medications compared to placebo in pediatric OCD has been supported by several randomized studies (Geller
etal. 2003). However, no studies to our knowledge have examined the response of sexual
obsessions to SRIs.
Case Example: Presenting Problem

In order to protect patient privacy, the following
case example is a composite of multiple patients
created to represent a prototypical clinical presentation and treatment course. Jacob (pseudonym)
was a 12-year-old sixth grader who initially presented for treatment because of repetitive behaviors and intrusive thoughts that were interfering
with his functioning. Jacobs primary presenting
concerns were intrusive thoughts about sexual
contact. These thoughts included worries that he
might be trying to have sex with someone, was
trying to touch someone in a sexual manner, or
that he had prior sexualized contact. Jacob stated
that whenever he had such thoughts he felt the
9 Treatment of Sexual Obsessions in Childhood Obsessive-Compulsive Disorder
need to engage in repetitive behaviors (walking

in and out of rooms, sitting up and down, picking
items up and putting them down, repetitive reading and writing, and hand washing) until he could
complete the given task without the thought. At
other times, he would confess the thoughts to his
parents who assured him that he had not done
anything inappropriate. Jacob also reported intrusive thoughts about swearing and germs to which
he responded with confessing and washing rituals, respectively.
At the time of the initial assessment, Jacobs
symptoms were occurring in all settings including home and school as well as causing significant distress and impairment. The rituals were
also very stressful for his parents and sister.
Jacob reported having sexual thoughts constantly
throughout the day and his parents described his
repetitive behaviors as occurring at all times.
Repeating rituals while changing his clothes and
washing led to him being late for school and for
bed. Rereading and rewriting rituals were increasing the amount of time he needed to complete school work which led to a significant drop
in his grades and uncharacteristic resistance to
school work. Because the sexual thoughts were
particularly upsetting when he was around peers,
Jacob was much less social than he was typically.
Case Information
Jacob and his parents reported that his sexual
thoughts had been problematic for approximately
the past year. However, they described him as
having a variety of OCD and other symptoms
before beginning elementary school. Jacob reportedly had difficulty separating from his parents, particularly in kindergarten and first grade.
During early elementary school, he worried frequently about other students breaking the rules
and would often discuss his concerns with his
parents. At a young age, he had been concerned
with germs and would wash his hands frequently.
At the time, these symptoms were not impairing
or particularly distressing. When symptoms increased, his parents were typically able to handle
them through limiting setting. For example, if
119
his hands became chapped they would explain

that it was only necessary to wash after using the
bathroom and remove access to hand sanitizer.
Similarly, when his obsession with peer behavior
became excessive, his parents explained that they
wanted to hear about how his day at school went.
Although Jacob responded positively to this approach, in retrospect, his parents acknowledged
that his symptoms were more significant than
they had realized.
Despite chronic mild-to-moderate anxiety and
OCD symptoms, Jacob functioned well. He lived
at home with his parents and older sister. Jacob
and his parents described the family environment
as warm and supportive. However, Jacobs symptoms were associated with a significant increase
in family tension and interference with his mothers work schedule in the morning. At the time
of the initial assessment, Jacob was in the sixth
grade, the first year of middle school. He generally enjoyed school and the transition to middle
school had gone well. His parents described him
as a good student, receiving As and Bs without
excessive effort. However, as his symptoms became more problematic, his grades had slipped
to Cs and Ds primarily because of incomplete
assignments. Jacob was an active child who participated in sports year-round. His favorite sport
was hockey in which he was fairly successful.
His parents described him as having a few close
friends and getting along well with most peers
from school and sports. As noted above, his participation in enjoyable activities had decreased
recently due to his OCD symptoms.
Jacobs parents sought therapy for behavioral
and emotional concerns on two occasions prior to
the course of treatment described here. In the first
grade, Jacob experienced anxiety about going
to school and was displaying anger outbursts at
home. He was diagnosed with separation anxiety
disorder. The content of treatment was not clear,
but appeared to include parent training. After a
few sessions, he began to separate more easily
and the outbursts decreased. Approximately, 4
months prior to the initial evaluation, Jacob received an evaluation and six therapy sessions for
his sexual obsessions and repetitive behaviors.
The therapy sessions were primarily individual
120
sessions with Jacob. By the familys report, treatment consisted of relaxation strategies (breathing
and guided imagery), and instructions to boss
back OCD (i.e., saying I do not have to listen
to you, OCD). After Jacobs symptoms did not
improve, the family sought a second opinion.
Conceptualization and Assessment

The breadth and severity of Jacobs symptoms
were assessed with the Childrens YaleBrown
Obsessive Compulsive Scale (CYBOCS). In
addition to intrusive sexual thoughts, Jacob and
his parents reported thoughts of hurting others
and swearing, as well as fears of becoming contaminated from public surfaces. Jacobs sexual
obsessions included thinking he tried to touch
someone inappropriately when he was in close
proximity, he wanted to have sex with girls in his
class, he was trying to have sex with someone
by sitting with his legs apart, and he might have
touched someone inappropriately in the past. The
severity of his obsessions led to a score of 13 on
the CYBOCS five-item obsessions scale. Jacobs
primary compulsion was repeating daily activities, but the family also endorsed reassurance
seeking, avoidance, hand washing, and praying.
With a CYBOCS compulsions subscale score of
15, his total CYBOCS score of 28 was above average for treatment-seeking youth.
Jacobs symptoms were conceptualized using
a cognitive-behavioral framework of OCD. The
cycle of obsessions and compulsions was initiated by an intrusive thought regarding sex. These
thoughts were often precipitated by external stimuli such as seeing a classmate, physical contact
(e.g., incidental bumping in a crowded hallway,
hugging, or wrestling), or media related to sex
(e.g., pictures of models, people kissing in movies). However, many intrusive thoughts appeared
to occur spontaneously without a clear trigger. As
such, the thoughts themselves were understood
to be the feared stimulus, whereas situations and
activities were seen as prompting thoughts, rather
than being primary fear cues.
Jacob interpreted the intrusive sexual thoughts
as being dangerous. His beliefs about his thoughts
D. Ung et al.
included a number of misinterpretations common

to OCD including: (a) thoughtaction fusion,
(b) believing that good or normal people do not
have such thoughts, (c) intolerance of anxiety,
the belief that the distress associated with the
thoughts will be unmanageable unless a ritual
is completed, and (d) the belief that trying hard
enough should stop the thought from occurring.
In short, he believed that having sexual thoughts
meant that he was a bad person who was likely
to act inappropriately. Given the importance and
consequences that Jacob associated with his intrusive thoughts, it was understandable that he
experienced intense anxiety when they occurred.
Given that the content of thoughts do not differ
between people who have OCD and those who
do not (Rachman 2007), the interpretation rather
than the thoughts themselves was identified as
the source of the pathology.
Jacobs ritualizing behaviors were understood
to reduce the anxiety and distress associated with
his obsessions in the moment, but to maintain
these obsessions through negative reinforcement. Most frequently, if he had a sexual thought
while doing some action, he would repeat that
action until he could do the action without the
thought. Through this ritual, he felt he was erasing the thought by replacing the tainted action
with a clean action. Additionally, Jacob would
ask his parents if he was a bad person, had done
something sexually inappropriate, or was likely
to do something sexually inappropriate. His parents would reassure him that he had not, remind
him that he does not need to have thoughts like
that, and encourage him to boss back OCD or
concentrate on positive thoughts. Because both
of these rituals effectively relieved his immediate anxiety, he performed them with increasing
frequency. However, these rituals stopped him
from learning that (a) the chances that he would
act on his thoughts were acceptably low, (b) his
anxiety would decrease without rituals, and (c)
he can tolerate these thoughts independently.
Unfortunately, as long as he continued to believe
that these thoughts were dangerous, he remained
stuck in a cycle of obsessions that led to anxiety
and compulsions that relieved the distress.
Understanding the function of Jacobs symptoms provided a road map for treatment. Because
the response to the thoughts is seen as the central
dysfunction, treatment was designed to address
these beliefs. In other words, Jacob would benefit
from learning that he could handle these intrusive
sexual thoughts independently without negative
consequences. Thus, treatment would consist of
exposure to sexual thoughts with response prevention. The initial goal was for Jacob to learn in
a structured setting that repetitive sexual thoughts
did not cause him to act inappropriately and that
his anxiety would decrease without ritualizing.
The next goal was for him to generalize this
learning to daily situations without assistance.
The cognitive-behavioral conceptualization
provided a context for understanding why previous interventions by his parents and his therapist
had not been successful, while providing hope
that exposures could be. Specifically, although
well intentioned and successful for keeping daily
life from grinding to a halt, Jacobs parents responses and accommodations inadvertently
maintained his symptoms. Specifically, providing reassurance informed him that the specific
instance was not dangerous, but prevented him
from learning that he could handle those thoughts
independently. As such, the next time a thought
occurred, he needed to return for more reassurance. In addition, the message that he did not
need to think about such topics and should try
and think about something positive potentially
reinforced his belief that the sexual intrusive
thoughts were bad and needed to be avoided.
Similarly, the failure of the recent therapy
likely reflected the lack of exposure, rather than
intractable symptoms. To begin with, the therapists focus on relaxation strategies and bossing back OCD missed the misinterpretations
that are the source of the pathology. In addition,
this focus may covertly give the message that the
OCD intrusive thoughts and associated physiological sensations of anxiety are powerful stimuli
to be avoided, as opposed to tolerable ones to be
experienced and dismissed as unimportant.
An essential component of assessment and
conceptualization is determining whether the
thoughts are indeed intrusive obsessions as op-
121
posed to accurate reflections of the patients

desires. The key to making this distinction lies
within the patients emotional response to the
thought, which may or may not be clear. In the
case of Jacob, the thoughts were clearly intrusive as he responded with immediate fear to
the thoughts. However, a patient who finds the
thoughts pleasurable, arousing, or exciting even
if he fears acting on them would have negative
consequences is likely not experiencing OCD.
Instead the latter patient is describing sexual desires that either are unacceptable to society, such
as pedophilia and sexual violence, or he is not
ready to accept within himself, such as homosexuality. Exposure therapy would not be appropriate for such patients.
Treatment Course
OverviewJacob and his parents began ERP
shortly after the initial assessment. The general
structure of treatment begins with psychoeducation, then creation of a fear hierarchy, and then
conducting exposure with response prevention
(ERP). As there are some differences between
treatment manuals, there are a few aspects to the
treatment with Jacob that need to be clarified.
First, exposure was initiated early, in the third
treatment session. Second, nonexposure techniques were minimized. Specifically, psychoeducation was introduced during the initial interview
and reviewed in detail during the first session.
Cognitive restructuring (e.g., likelihood estimates) was introduced during psychoeducation
and then implemented judiciously during exposure exercises. Relaxation strategies were never
included. Finally, Jacobs parents were included
during the majority of all sessions to learn to be
exposure coaches. Overall, Jacob and his parents
attended 12 5060min treatment sessions.
Session 1During the first session, the therapist presented the cognitive-behavioral model
of OCD. Jacob and his parents participated in
using this model to understand his symptoms.
During this discussion, the therapist addressed
Jacobs (and to a lesser extent his parents) desire
122
and expectation for treatment to reduce or eliminate the sexual thoughts. The therapist began by
explaining the research suggesting that the content of the thoughts that people with OCD have
do not differ from the thoughts of people without OCD (Ladouceur etal. 2000). To illustrate
his point, the therapists shared her own intrusive
thoughts of pushing down an elderly relative
when she notices how frail the woman is. The
therapist explained that she has no desire to hurt
her relative and believes that doing so would be
inexcusable. Although the thought is unpleasant,
the therapist explained that it does not get stuck
in her head because she knows that thoughts are
just thoughts and they cannot control her.
The therapist further explained that humans
have a great ability to generate thoughts, some
of which are helpful, some less helpful. The
value of a thought can only be judged after it
occurs to you. As such, it is not possible to turn
off unhelpful thoughts, because you do not know
which to turn off until you have them. In addition, the therapist noted that efforts to stop, or
suppress, thoughts are usually unsuccessful. To
illustrate the point, the therapist instructed Jacob
to not think about a purple bear and then asked
him what he was thinking about. When Jacob
answered not a purple bear, the therapist explained that since it is necessary to think about
what you are trying not to think about, thought
suppression does not work well. The therapist
concluded that rather than ridding Jacob of his
sexual thoughts, the goal of therapy was to reduce his fear of the thoughts. Because fear focuses our attention, once the fear was decreased
the thoughts would likely occur less often and not
get stuck in his head.
The first session was primarily didactic and
covered a large amount of information. The therapists goal was to help the family understand
the factors that maintain OCD and why exposures will likely lead to symptom improvement.
To break up the didactic nature of the session, it
is helpful to elicit input from the family. This is
particularly important when using the cognitivebehavioral model to understand the patients
symptoms. Other points of engagement such as
having parents validate the experience of upset-
D. Ung et al.
ting thoughts or the thought suppression demonstration should be approached thoughtfully and
set up to be successful. Specifically, some parents may be unable or unwilling to share their
unpleasant thoughts, especially without warning.
Thus, the therapist can either talk with them beforehand or phrase the questions in a yes or no
format. Similarly, children have a variety of responses to the thought suppression exercise including saying nothing, random other thoughts,
or the target of suppression. The therapist should
be prepared to communicate the point of the exercise regardless of how the child responds.
Session 2The therapist began the second session by quickly reviewing the psychoeducation
regarding the maintenance of OCD through
avoidance and the treatment with exposures.
The goal for the second session was to create
a fear hierarchy. Because of the delicate nature
of addressing sexual thoughts with children, the
therapist first met with the parents without Jacob
to give them an opportunity to discuss any reservations they might have. First, the therapist
asked the parents how they felt about beginning
exposure therapy for their son. She then clarified
that the target of exposure would be whatever
thoughts Jacob had and that treatment would consist of repeating those thoughts out loud. It was
clarified that, this process likely will include listening to him say things of a sexual nature that
we do not usually expect to hear from children.
The rationale was to make sure that Jacobs parents understood the rationale and consented to
this course of treatment. Both of Jacobs parents
indicated their understanding and agreement.
After the therapist brought Jacob back into
the room they began working on his fear hierarchy. The fear ladder (minus many of the nonsexual thoughts items) is presented in Table9.1.
The therapist began by explaining that the fear
ladder was a list of thoughts and activities that
make him nervous because of OCD and that
they would repeat each of the items until they no
longer bothered him. She then asked Jacob for
something that he thought was easy enough to
start with next session. He replied that one of his
nonsexual obsessions, fear that he would swear

Table 9.1 Jacobs fear ladder
#
Item
1
Silently think I want to have sex with Emily while she is around
2
3
4
5
6
7
8
9
10
Repeat I want to have sex with Emily in office

Hug a family member and think I am trying to be inappropriate
Touch someone and think I am trying to be inappropriate
Think: I touched someone in a sexually inappropriate way
Sit with my legs open and think I am trying to have sex with someone
Sit next to people and think that I will touch them sexually
Walk close to people in the hallway even though I might try to rub against them
Leave hands out of pockets even though I might give people the finger
Thinking swear words in public
in public, bothered him, only a little. This item

was added to the bottom of his fear ladder. The
therapist then asked Jacob what would be the
most difficult thing to do and placed this item at
the top of the ladder. The therapist then worked
with the family to fill in enough additional items
to cover the full breadth of his symptoms. The
family was asked to think about thoughts he had,
reassurance questions he asked, rituals he did,
and situations in which he had ritualized or had
avoided. The therapist worded these items as an
exposure on the fear ladder. She then worked
with Jacob to rate his anticipated anxiety from
0, calm, to 10, terrified, and put them in order
from easier to more challenging items. Finally,
the therapist asked the family to review the fear
ladder prior to the next session and add items as
needed.
When making a fear ladder for sexual obsessions, typically nobody, not the child, the parents, nor the therapist, feels comfortable with the
topic, which can make communication difficult.
There are a number of strategies that can ease this
tension. To begin, always make sure that the parents understand and consent to therapeutic procedures. Specifically, let them know that you will
be encouraging the child to share his thoughts
and eventually repeat them. Having the parents
in the session with you gives a clear message
that treatment is progressing within appropriate
boundaries. There will be times when the therapist needs to meet with the child individually,
especially if he has thoughts that he is not ready
to share with his parents. When this occurs, it is
123
Rating
9
8.5
8
8
7.5
6
5
5
4
3
advisable to have the therapist and child debrief

the parents as to the session content on what they
worked, even if the content of specific thoughts
remains private.
Secondly, it can help to use the childs own
words when developing a fear ladder focused on
OCD-related sexual obsessions. This also allows
the development of scripts. In terms of designing effective exposures, these scripts will have
to accurately reflect the childs thoughts. This
means if the childs thoughts are vague (e.g.,
doing something inappropriate), or explicit (e.g.,
having sex) the imaginal script should use that
language. Children may, not surprisingly, be reluctant to share their thoughtsespecially in
explicit detail. In these cases, the therapist can
ask questions and cautiously provide educated
guesses. For example, a therapist might ask the
child if he has thoughts about people kissing,
being naked, or doing anything that the child
deems to be inappropriate. Such questions are
likely understandable to most children and inoffensive if a patient does not have such thoughts.
If the therapist has an idea of the content of the
thoughts, such as from information provided by
the parents, she may decide to ask more specific
questions or provide examples of thoughts. Once
the thoughts are understood, the therapist and
family should use the childs vocabulary, whether
that is correct terminology, for example, penis,
or less precise language, for example, private
parts or pee-pee. To determine what terms to use,
the therapist should ask the child what specific
thoughts come into his head, ask him to state the
124
specific words, repeat the words back for clarification, and ask if the thought ever involved other
words, especially words that might bother him
more. The goal is not to tiptoe around the issue
out of fear of saying something that might lead
to more OCD obsessions, because that would be
counter to the exposure model; rather, the caution
reflects an understanding that there are sexual
concepts that are not appropriate to introduce to
children.
Session 3 The therapist began the third session
by reviewing Jacobs fear ladder. The family had
not added or edited the items since the last session. Jacob had experienced a lot of distress and
impairment and asked if there were medication
he could take or other treatments that would help
[him] feel better more quickly. The family was
aware of medication as a treatment option but
was uninterested in this possibility. The therapist
validated Jacobs feelings and expressed confidence that he would begin to feel better soon
with treatment. Jacob accepted this response and
was eager to get started. Jacob decided to do his
first exposure to the lowest item on his fear ladder, Thinking swear words in public. This item
was selected as an appropriate likely to cause
enough distress to be a good learning experience,
but would not be overly challenging. Since it was
also an imaginal exposure with a situational component, it would provide a good opportunity to
introduce the family to the format for conducting exposure to his sexual thoughts. The therapist conducted the exposure with Jacob while his
parents observed to begin learning to be exposure
coaches.
Jacob and the therapist decided that Jacob
would repeat the word shit in his head over
and over while walking around the clinic. They
identified (and recorded) his fear that he would
accidently swear out loud. He was able to estimate that this was unlikely to happen and rated
his initial anxiety level at a 4. To prepare for
the exposure the therapist had Jacob repeatedly
say shit out loud in the office. This initially
caused some discomfort so they had him repeat
it until his anxiety dropped from a 3 to a 0. After
agreeing to continually repeat shit silently in
D. Ung et al.
his head, the therapist, Jacob and his parents left

the office. As they walked around the lobby and
desks, the therapist periodically asked Jacob for
a rating. When his anxiety returned to zero, they
returned to the office. The therapist asked Jacob
whether he had blurted out shit and what happened to his anxiety. Jacob was able to confirm
that his fear did not come true and that his anxiety decreased. The therapist emphasized that the
only thing Jacob did to reduce his anxiety was to
face his fear.
With this initial success, Jacob asked to complete a second exposure that was more directly
related to the symptoms that were bothering
him. The therapist and family decided to do an
exposure to the next item on his ladder, Sitting
with legs open. Jacob explained that if his legs
were open and his private parts were pointed at
someone, he had the thought that he was trying
to have sex with that person. He responded to the
fears primarily through avoidance, for example,
crossing his legs, and less frequently with repeating rituals. Jacob was able to say that it was
unlikely that this was an accurate thought, and
he acknowledged that other people often sit with
their legs uncrossed. As a first step toward exposure coaching, his mother filled out the exposure
sheet based on the therapists questioning. Jacob
then sat with his legs open across from the therapist and periodically repeated, I am being inappropriate. His anxiety rating peaked at eight and
decreased to 3, when the session was coming to
an end. Jacob was able to state that his anxiety
decreased and that nothing bad happened from
doing the exposure. He and his parents agreed
that they would repeat the open-legs exposure
daily, and if successful, add the more distressing
thought, I am trying to have sex with ____.
Session 4 Between sessions, Jacob and his parents conducted multiple exposures to sitting
with his legs uncrossed while thinking that he
was doing something inappropriate. They were
all pleased that sitting with his legs open and
thinking about swear words were no longer distressing. The therapist and the family decided to
repeat the legs uncrossed exposure with a more
distressing thought. His mother (his father did
not attend this session) increased her role as an

exposure coach, by asking Jacob the preparatory
questions and completing the exposure record.
Jacob again sat facing the therapist with his legs
uncrossed and repeating the thought I am trying to have sex. Although Jacobs anxiety again
peaked at eight, it decreased more quickly than
during the previous session. Again Jacob realized
that his anxiety decreased merely by facing his
fear and that it was easier this time because of his
practice over the week.
At the end of the session, the therapist discussed response prevention. She first highlighted
that Jacob (and his parents) had now learned
from their own experience that Jacobs thoughts
and anxiety decreased without ritualizing. Thus,
from now on, Jacob should try to resist all rituals. However, the therapists understood that
since there were many thoughts that Jacob had
not yet mastered it was likely to be difficult for
him to discontinue all rituals. So, once he had
successfully completed an exposure (or two) to
a thought, he should no longer ritualize to that
thought and his parents would no longer provide reassurance to that thought. At this point in
therapy, they would apply response prevention to
fears of swearing in public and sitting with his
legs uncrossed. For other thoughts, for example,
I want to have sex with Emily, Jacob should try
to resist ritualizing and if he comes to his parents
they should encourage him not to give in to OCD.
If he is unsuccessful and ritualizes, he should immediately repeat a mastered thought (e.g., swear
words) to maintain a level of contamination
from thoughts despite his ritualizing. Following
a similar progression, the therapist decided with
the family that avoidance of some activities, for
example, inviting friends over, was tolerable in
the short term to decrease overall stress and allow
him time and energy to complete exposures.
However, the plan was to reintroduce those activities as soon as he had completed the related
exposures, and that other activities, for example,
school attendance, would not be decreased as this
would be too much of a concession to OCD.
The family was asked to repeat exposures to
the items that had been addressed during the sessions and to attempt exposures to fears of giv-
125
ing people the finger. Completing an exposure to

something that had not been initially addressed
in session was intended to increase the familys
confidence in conducting exposure independent
of the therapist. Since this item was low on Jacobs list and did not involve his primary fear,
sexual thoughts, it seemed manageable to the
family. The therapist helped the family plan how
to conduct the exposure and fill out the beginning
of an exposure record.
During the exposure, the therapist discussed
different methods for conducting thought exposures. Jacob had begun with repeating thoughts
aloud which made it apparent to the therapist
that he was completing the expected action. Repeating thoughts aloud can be more challenging
if they are embarrassing, but can also lead to a
speedier decrease in anxiety, potentially because
there is more immediate feedback from the environment (the reaction of those around) that
nothing bad is happening or because verbalizing
words repeatedly takes effort and becomes tiresome. However, the lack of reaction from others
while repeating thoughts aloud may provide reassurance that interferes with the goals of exposure.
Some children report that verbalizing thoughts
is less vivid, and thus less upsetting, than thinking the thoughts silently. Thus, having a patient
sit quietly concentrating on the thoughts can
be more effective than verbalizing the thoughts
aloud. The pros and cons of repeating thoughts
silently are generally the converse of verbalizing, that is, the process is more difficult for the
therapist to monitor, anxiety may take longer to
decrease, but it may be a more realistic and effective approach. In general, it is typically best to introduce both methods to determine which is more
effective. Vocalizing thoughts should be included
if the child is embarrassed by them, is afraid to
say them out loud, or if anxiety is not decreasing
with silent exposures. Silent thought exposures
should be used when they are a more realistic approximation of the symptoms, the child appears
motivated to comply with exposure, or they invoke more anxiety than verbalizing aloud. Recordings can also be used, but typically are not
necessary.
126
Session 5 The session began with a review of the

previous week with Jacob and his mother. They
reported that they had successfully completed
exposures to fears of giving people the finger, as
well as his fears of sitting with his legs uncrossed.
Although his mother had fairly well-developed
coaching skills by this point in therapy, the therapist interjected suggestions and questions, as
well as praise, during the exposure preparation
and assumed control as the exposure progressed.
For this exposure, Jacob hugged his mother while
thinking that he was being inappropriate. At the
beginning, he hugged her loosely while keeping
his body pulled away. When the therapist pointed
out his body position, Jacob acknowledged that
he was avoiding full contact. Jacob spent the
first portion of the exposure gradually working
toward hugging his mother in a natural position.
During this time, his anxiety did not decrease.
Once he hugged her with his body relaxed into
hers, as a child would naturally hug his mother,
his anxiety peaked and then gradually decreased.
The exposure took the majority of the session.
Following the exposure, the therapist discussed how Jacobs success that day could be
translated to his daily life. They agreed that the
hugging exposure was very challenging and
would have to be repeated multiple times with
various people and in various settings. Because
it was one of the more difficult items on this fear
ladder, his success suggested that he could handle
situations lower on the ladder, such as walking
in a crowded hallway. As such, the therapist and
family decided that Jacob would try to eliminate avoidance and rituals in response to fears
of contact being inappropriate. In addition, his
parents would stop providing reassurance to any
fears that he may have had inappropriate contact
through bumping, sitting by, or generally being
close to someone. Instead, they would respond
with Would you like help conducting an exposure? Finally, Jacob and his parents decided
to focus planned exposures on hugging family
members.
Jacob was very cooperative and motivated as
evidenced by his decision to move up his fear ladder quickly. This session illustrates that the fear
ladder is merely a guide. Patients often decide
D. Ung et al.
that certain items are easier or harder than anticipated and that certain steps are unnecessary. The
therapist should not feel bound by the fear ladder
or a need to hold patients back to protect them
from anxiety. Conducting a challenging exposure
can accelerate progress and potentially generalize to lower items, eliminating the need to address the latter directly. Conversely, there may be
times that a therapist believes the childs chances
of success with a chosen exposure are slim due
to the childs particularly low insight, impulsive
decision making, or lack of understanding of the
model. In such cases, the therapist may recommend beginning with an easier exposure.
Jacobs anxiety level during the exposure
demonstrates another potential limitation of approaching a feared stimulus through successive
approximations. Specifically, his anxiety likely
did not decrease until he hugged his mother completely, because he was worrying about that contact as he was working up to it. At times, the challenge of anticipatory anxiety can be addressed by
explicitly stating the limits of an exposure (i.e.,
only a partial hug) or instructing a child to separate his anxiety about the current step from that
for the final step (i.e., full hug). However, such
an approach may not be feasible if it results in
an excessive number of steps, is difficult to anticipate, or if the child has difficulty parsing his
anxiety. In those cases, it is important to explain
to the family why the childs anxiety is likely not
decreasing so that he either completes the exposure or views the partial exposure as a successful
step forward despite continued anxiety.
Session 6 Jacob attended the next session with
his father. They reported that he had felt much
better after the last session, but after a few days
the severity of his symptoms increased. In addition, the family had a busy week with visitors
from out of town and had not completed exposures. The therapist and the family decided to
repeat the hugging exposure from the last session with his father. The therapist had Jacobs
father take the lead to planning and beginning
the exposure while frequently providing recommendations and assistance. As in the last session,
Jacob needed some time to give his father a full
hug, but overall was able to progress through the

exposure more quickly. During the exposure,
Jacob agreed to repeat out loud I am being inappropriate. When Jacobs anxiety had decreased
to one, his father (with the therapists assistance)
led him through the post-exposure review questions. The therapist then worked with the family
to plan for daily exposures over the next week.
They decided that the thought about wanting to
have sex with a peer was related the majority of
Jacobs rituals and should be addressed in the
next session.
Session 7Jacob and his mother attended this
session and reported a successful week of exposure. He had practiced hugging his parents, his
sister, and an extended family member. In addition, he was ritualizing less at home and was generally accepting of his parents refusal to provide
reassurance. The therapist encouraged Jacobs
mother to take the lead, coaching Jacob through
the exposure for that session to repeating I want
to have sex with Emily. Jacobs anxiety began
at a 9 and he was visibly uncomfortable, speaking quietly, hesitating, mumbling, and looking
down. The therapist pointed out these behaviors to Jacob and asked him what he thought he
should do. Jacob was able to state that he needed
to state the words clearly and gradually began to
do so. Given the difficulty of the exposure, Jacob
required continued prompting from the therapist.
At first, the therapist would state I want to have
sex with Emily, and then Jacob would repeat it.
As the exposure progressed, the therapist asked
him to repeat it twice in a row, then three to five
times, and finally continuously with the therapist
interrupting to ask for an anxiety rating. When
Jacobs anxiety had decreased by half and he was
able to repeat the statement in a natural voice, the
therapist asked him whether thinking the thought
silently would be different than saying it aloud.
Jacob did not think there was a difference, so
they continued aloud.
During the exposure, the therapist varied the
delivery of the feared statement to facilitate the
exposure and emphasize the innocuous nature of
the thoughts. These included having Jacob repeat
the statement quietly, loudly, fast, and slow. Such
127
variations can help a child feel more comfortable with a challenging exposure and make the
exposure more enjoyable. Although the therapist
must refrain from techniques or humor that allows the child to avoid the distress of the thought,
exposures do not need to be dour, overly serious endeavors. In contrast, if a child can laugh
and make light of himself while focusing on a
thought, it strongly suggests that thoughts are
not as dangerous as OCD makes him believe.
As such, by the end of the exposure, Jacob was
laughing while singing the words I want to have
sex with Emily.
The therapist concluded the session by discussing how to apply that days success to his
difficulties at school. Although Jacob did not
require the reminder, the therapist pointed out
that even though thoughts are not dangerous, it
is inappropriate to say I want to have sex with
so-and-so in any context other than exposures.
As such, they rehearsed how Jacob would repeat
the thought in his head while at school. The family planned to do daily verbal exposures to the
sex thought at home and for Jacob to do silent
exposures at school.
Sessions 811 Sessions focused on exposures to
various items on his fear ladder such as sitting
next to people, walking in crowded hallways,
and touching people. These were accomplished
in the office, for example, sitting close enough to
parents to touch, out of the office, for example,
swinging his hands toward people when walking around the clinic and thinking he was trying to touch them, and planning for exposures at
school, for example, having contact with peers
in a natural way through playing tag or tapping
them on the shoulder to get their attention. In
addition, the between session emphasis shifted
from planned exposure, during which the family completed an exposure record, to on-the-fly
exposures conducted less formally when intrusive thoughts arouse spontaneously. Finally, the
therapist encouraged the parents to lead the exposures more independently during the session to
develop their competence and comfort coaching
Jacob through exposures outside of the sessions.
128
Session 12 By the 12th session, Jacob and his

mother described him as virtually OCD free over
the month since the previous appointment. The
therapist reviewed the expected course of OCD
including periodic increases in symptoms. She
encouraged them to respond to these increases
calmly with a return to exposures early before
symptoms had a chance to become more serious.
Reassessment with the CYBOCS led to a score of
11, which fell in the mild range. Jacob acknowledged that he still had intrusive sexual thoughts,
but they typically did not bother him and he was
able to manage them independently. Both Jacob
and his parents thought treatment had been successful and that further appointments were not
needed.
Jacobs case provides an example of treatment
for sexual obsessions that is relatively free of
complicating comorbidity and external factors.
The primary complicating factor was the reassurance provided by Jacobs parents. Including
the parents in exposure was deemed important
because they would need to help Jacob with
conducting exposures outside of sessions, they
needed to decrease their accommodations, they
needed to learn firsthand that exposure worked,
and they needed to help him maintain his gains
over time. However, having them hear Jacobs
thoughts during exposure without recoiling in
horror provided him with a level of reassurance
that he was not acting inappropriately. Although
this was a valuable lesson to learn, if Jacob relied on his parents lack of response to manage
thoughts it would function as a ritual to maintain
OCD. Thus, as treatment progressed, Jacob was
assigned to do exposures alone and to handle
some thoughts without ever telling his parents
what thought he worked on.
Another common complication for treating
sexual obsessions involves the therapists and parents comfort exploring the content of the childs
thoughts and generating related exposures. For
many of Jacobs exposures, the thought of doing
something inappropriate was sufficient. How-
D. Ung et al.
ever, if he had more explicit sexual obsessions

that were not addressed because he did not share
them or the therapist was uncomfortable with the
exposure, it is unlikely that his symptoms would
have improved. The measure of what is appropriate to do an exposure lies completely with the
childs thoughts.

This chapter discussed the nature, phenomenology, impact, and treatment of intrusive, recurring
sexual obsessions in youth with OCD. It is essential that clinicians working with youth with sexual obsessions understand the phenomenology of
these thoughts so that they do not misinterpret
and misidentify them as risky behaviors (e.g.,
being a pedophile) or indicative of a past or present history of sexual abuse. Careful assessment
may include questions about family relationships
and dynamics, observations of the childs behavior and affect when questioned about abuse or
being burdened by a secret, and a careful examination of the contents of the childs thoughts.
These assessments, however, should not involve
excessive questioning or leading questions because this can lead to the misidentification and
misdiagnosis of sexual abuse. Consequently, a
correct diagnosis of sexual obsessions in youth is
essential for the proper treatment and alleviation
of these symptoms.
Under the cognitive-behavioral model of
OCD, sexual obsessions are caused by the individuals misinterpretations of the significance of
the unwanted sexual thoughts, images, and impulses (i.e., giving it great personal significance),
and thereby causing distress and doubt. Avoidance of these sexual obsessions relieves anxiety
in the short term, but in the long term fears are
strengthened through negative reinforcement
(Franklin and Foa 2002; Lewin etal. 2005). In
line with this explanation, CBT addresses sexual
obsessions by engaging the individual in the collection of evidence through behavioral experiments (e.g., exposure to environmental triggers
for obsessions) and formation of alternative interpretations (Rachman 2007). Youth are taught
to tolerate these obsessions which in turn decrease the frequency and associated impairment.
Practice parameters stress the importance that
families are involved so that treatment gains are
maintained and generalized outside of treatment
(Geller and March 2012).
For sensitive sexual topics, it is important for
therapists to use their clinical judgment about the
engagement of parents and understand the limits
of conducting exposures. It may be uncomfortable for clinicians, parents, and youth to identify
sexual obsessions. For young children, it is likely
important to have parental consent and close involvement when conducting sexual obsession
exposures. For older adolescents, it may be more
therapeutic to have parents less involved. Treatment of sexual obsessions in youth using a CBT
model including ERP and SRIs have been effective at relieving these symptoms with recommendations that medications be used in conjunction
with CBT for more moderate-to-severe OCD
symptoms (Geller and March 2012)
The case study of a 12-year-old male, Jacob,
who had sexual obsessions and other OCD symptoms, detailed how ERP could be used to successfully decrease obsessions and rituals. Through
repeated exposure to his distressing thoughts
and prevention of rituals, Jacobs OCD symptoms and associated impairments significantly
decreased. Also, the inclusion of Jacobs parents
in every therapy session was essential to increase
family support, generalize treatment gains, and
decrease family accommodations (e.g., providing reassurance).
Several key practice points are suggested for
clinicians working with youth with sexual obsessions:
The pathology lies in the interpretation and
reaction to sexual thoughts, not in the presence of the thoughts themselves.
Determine that sexual thoughts provoke anxiety, as opposed to reflecting sexual desires,
ambivalence regarding sexual orientation, or
sexual abuse.
Design exposures to the content of patients
thoughts, no more and no less, regardless of
the level of explicitness.
129
Always involve parents, at a minimum for

informed consent to treatment, ideally as
exposure coaches.
References
Fernndez de la Cruz, L., Barrow, F., Bolhuis, K., Krebs,
G., Volz, C., Nakatani, E., etal. (2013). Sexual obsessions in pediatric obsessive-compulsive disorder:
Clinical characteristics and treatment outcomes.
Depression and Anxiety, 30, 732740.
Franklin, M. E., & Foa, E. B. (2002). Cognitive behavioral treatments for obsessive compulsive disorder. A
guide to treatments that work, 2, 367386.
Friedrich, W. N., Fisher, J., Boughton, D., Houston, M.,
& Shafren, C. R. (1998). Normative sexual behavior
in children: A contemporary sample. Pediatrics, 4, e9.
Geller, D. A., & March, J. (2012). Practice parameter for
the assessment and treatment of children and adolescents with obsessive-compulsive disorder. Journal of
the American Academy of Child & Adolescent Psychiatry, 51, 98113.
Geller, D. A, Biederman, J., Faraone, S., Agranat, A., Cradock, K., Hagermoser, L., etal. (2001a). Developmental aspects of obsessive compulsive disorder: Findings
in children, adolescents, and adults. The Journal of
Nervous and Mental Disease, 189, 471477.
Geller, D. A, Biederman, J., Stewart, S. E., Mullin, B.,
Martin, A., Spencer, T., & Faraone, S. V. (2003).
Which SSRI? A meta-analysis of pharmacotherapy trials in pediatric obsessive-compulsive disorder. American Journal of Psychiatry, 160, 19191928.
Gordon, W. M. (2002). Sexual obsessions and OCD. Sexual and Relationship Therapy, 17, 343354.
Healy, N., Fitzpatrick, C., & Fitzgerald, E. (1991). Clinical note: Childhood neurotic disorders with a sexual
content need not imply child sexual abuse. Journal of
Child Psychology and Psychiatry, 32, 857863.
Ladouceur, R., Freeston, M. H., Rhaume, J., Dugas, M.
J., Gagnon, F., Thibodeau, N., & Fournier, S. (2000).
Strategies used with intrusive thoughts: A comparison
of OCD patients with anxious and community controls. Journal of Abnormal Psychology, 109, 179187.
Lewin, A. B., Storch, E. A., Merlo, L. J., Adkins, J. W.,
Murphy, T., & Geffken, G. A. (2005). Intensive cognitive behavioral therapy for pediatric obsessive
compulsive disorder: A treatment protocol for mental
health providers. Psychological Services, 2, 91104.
Mataix-Cols, D., Marks, I. M, Greist, J. H., Kobak, K.
A., & Baer, L. (2002). Obsessive-compulsive symptom dimensions as predictors of compliance with and
response to behaviour therapy: Results from a controlled trial. Psychotherapy and Psychosomatics, 71,
255262.
Mataix-Cols, D., Nakatani, E., Micali, N., & Heyman, I.
(2008). Structure of obsessive-compulsive symptoms
130
in pediatric OCD. Journal of the American Academy
of Child & Adolescent Psychiatry, 47, 773778.
McKay, D., Piacentini, J., Greisberg, S., Graae, F., Jaffer, M., & Miller, J. (2006). The structure of childhood obsessions and compulsions: Dimensions in an
outpatient sample. Behaviour Research and Therapy,
44, 137146.
Montgomery, J. H., Waller, D. A., & Robinson, R. (2003).
Persistent, unwanted erections in an 8-year-old boy.
Psychopathology, 36, 5254.
Rachman, S. (2007). Treating religious, sexual, and aggressive obsessions. In M. M. Anthony (Ed.), Psychological treatment of obsessive-compulsive disorder:
Fundamentals and beyond (pp. 209229). Washington, DC: American Psychological Association.
Rufer, M., Fricke, S., Moritz, S., Kloss, M., & Hand, I.
(2006). Symptom dimensions in obsessivecompulsive disorder: Prediction of cognitive-behavior therapy outcome. Acta Psychiatrica Scandinavica, 113,
440446.
Selles, R. R., Storch, E. A, & Lewin, A. B. (2014). Variations in symptom prevalence and clinical correlates in
younger versus older youth with obsessivecompulsive disorder. Child Psychiatry & Human Development, 45, 19.
D. Ung et al.
Siev, J., Steketee, G., Fama, J. M., & Wilhelm, S. (2011).
Cognitive and clinical characteristics of sexual and
religious obsessions. Journal of Cognitive Psychotherapy, 25, 167176.
Singh, G., & Coffey, B. J. (2012). Sexual obsessions,
compulsions, suicidality and homicidality in an adolescent diagnosed with bipolar disorder not otherwise
specified, obsessive-compulsive disorder, pervasive
developmental disorder not otherwise specified, and
mild mental retardation. Journal of Child and Adolescent Psychopharmacology, 22, 250253.
Veale, D., Freeston, M., Krebs, G., Heyman, I., &
Salkovskis, P. (2009). Risk assessment and management in obsessivecompulsive disorder. Advances in
Psychiatric Treatment, 15, 332343.
Williams, M. T. (2008). Homosexuality anxiety: A misunderstood form of OCD. In L. V. Sebeki (Ed.), Leading-edge health education issues (pp. 195205). New
York: Nova Science.
Williams, M. T., Crozier, M., & Powers, M. (2011).
Treatment of sexual-orientation obsessions in obsessive-compulsive disorder using exposure and ritual
prevention. Clinical Case Studies, 10, 5366.
Treatment of Scrupulosity
in Childhood ObsessiveCompulsive Disorder
10
Tara S. Peris and Michelle Rozenman
Treating Scrupulosity in Child and

Adolescent OCD
The symptoms of child and adolescent obsessivecompulsive disorder (OCD) are impressively diverse. As with adults, the content of these symptoms can vary widely across affected individuals requiring skill and flexibility of the treating
clinician. One particularly challenging presentation involves scrupulosity, the class of symptoms
centering on themes of religion and morality.
In this chapter, we provide an overview of the
phenomenology, impact, and treatment of scrupulosity in children and adolescents. We discuss
unique issues related to the assessment of these
symptoms, recognizing that they often overlap
with deeply held religious and cultural beliefs.
We then summarize current evidence-based treatment for scrupulosity and provide an illustrative
case that was successfully treated with behavioral intervention.
Scrupulosity is defined as a form of OCD involving religious or moral obsessions. Affected
individuals may be excessively concerned that
they have committed sins, violated religious or
T.S.Peris() M.Rozenman
Division of Child and Adolescent Psychiatry, UCLA
Semel Institute for Neuroscience and Human Behavior,
Los Angeles, CA, USA
e-mail: tperis@mednet.ucla.edu
T.S.Peris
760 Westwood Plaza, Rm. 67-439, Los Angeles,
CA 90095, USA
moral dictates, or thought or behaved in a way

that indicates that they are dishonest or immoral.
As with other OCD symptom clusters, scrupulosity symptoms are heterogeneous and can take
many forms. Some youths may have persistent
concerns about offending religious figureheads.
Others may exhibit pathological doubt or worry
about having sinned or transgressed. Still others
may engage in compulsive praying, confessing,
or other excessive religious behavior. Notably,
although the majority of scrupulosity symptoms
involve obsessions and compulsions related to
religion, they need not be contained to this topic
(Abramowitz etal. 2002); other forms of scrupulosity may involve excessive concern with
morality, including worries about wastefulness,
dishonesty, and other forms of ethical rightness
or perfection.
There has been relatively little systematic
study of scrupulosity in child and adolescent
populations. In adults, scrupulosity is the fifth
most common class of OCD symptoms (Foa and
Kozak 1995), making it a somewhat common
part of the clinical presentation. Meta-analysis
of the YaleBrown Obsessive-Compulsive Scale
(YBOCS; Goodman etal. 1989) indicates that
scrupulosity clusters with symptoms involving
forbidden thoughts, including aggressive, sexual,
and somatic obsessions (Bloch etal. 2008). This
symptom cluster has received additional support
from confirmatory factor analysis with a mixedage sample of children, adolescents, and adults
(Stewart etal. 2008). Other studies of mixed-age
participants, including children and adolescents,

DOI 10.1007/978-3-319-17139-5_10
131
132
reveal that scrupulosity occurs in nearly a quarter of individuals affected by OCD (Antony etal.
1998). Although there has yet to be research directly assessing its prevalence in pediatric OCD,
there is much to suggest that scrupulosity occurs
with some degree of frequency in youth populations.
What is perhaps more clear is that scrupulosity is among the more difficult OCD symptoms to
treat (Nelson etal. 2006). For individuals of any
age, there are challenges of parsing normative
religious practice (e.g., prayer, confession) or
spiritual fervor from that which is obsessive or
compulsive. In general, this distinction is made
based on the extent to which specified religious
behavior is out of line with that of other observers of the faith. Scrupulous behavior exceeds
what a given religion calls for, and it may even
be focused on aspects of ideology that are considered trivial. In addition, an individual with
scrupulosity may selectively pick and choose
which aspects of religion to observe and which
to disregard in ways that appear arbitrary and irrational.
Because the distinction between religiosity
and scrupulosity often falls within a grey area,
the treating clinician must demonstrate sensitivity for both the individual and his or her cultural
beliefs and practices. They must have sound understanding of the religions practiced by their
patients and be familiar with their basic tenets,
while remembering that, even within a given
religion, there is variability in practices and beliefs from person to person. Moreover, clinicians
must be adroit at working with individuals who
view their deep commitment to their faith as a
defining feature of their identity. Insight about
these symptoms may be limited and the act of
challenging religious beliefs may be viewed as
akin to total defection from faith and values.
These challenges are common to working with all scrupulosity symptoms. However,
children and adolescents present with a unique
set of issues that may further complicate assessment and treatment. Youths are embedded
in a family context in which religion has been
chosen for them and issues of morality learned
through formal lessons and/or parental model-
T. S. Peris and M. Rozenman
ing. Taught to listen to their elders, children and

adolescents may feel a particular sense of obligation to carry through with ritualistic practices.
Moreover, their developmental status may limit
their ability to think abstractly about the issues
at hand (e.g., What does it mean to really offend God? Does thinking something mean
that you mean it?).
Exposure-based cognitive behavioral therapy (CBT), currently the gold standard for most
forms of OCD, is an efficacious psychosocial
treatment approach for symptoms of scrupulosity. Used alone or in conjunction with pharmacotherapy (i.e., selective serotonin reuptake
inhibitors), it is the cornerstone of treatment
(for practice parameters, see Geller and March
2012). As detailed elsewhere in this volume, traditional CBT for OCD involves triggering obsessive thoughts via exposure tasks and prompting patients to resist the corresponding urge to
ritualize. In addition, some CBT protocols include cognitive restructuring (i.e., identifying
irrational or intrusive thoughts and challenging
them with more realistic thoughts). Although
useful in many cases, we urge caution with cognitive restructuring techniques when treating
scrupulosity, given that some youths may have
difficulty mastering the abstract reasoning skills
they require (Kingery etal. 2006; Weisz and
Weersing 1999). Moreover, thought challenging may be used by some youngsters as a type
of mental compulsion wherein they attempt to
neutralize or combat an intrusive thought with
a competing, alternate thought. In light of these
considerations, we recommend that use of cognitive restructuring as a symptom management
technique be limited or excluded from treatment
altogether.
Case Description
The complexities of assessing and treating scrupulosity are illustrated through our work with
Sarah, an 11-year-old Caucasian female who was
brought by her mother to a specialty treatment
clinic for evaluation of worries and chronic reassurance-seeking. Sarah lived with her parents
10 Treatment of Scrupulosity in Childhood Obsessive-Compulsive Disorder
and three older siblings, all of whom practiced

Orthodox Judaism, and she presented with concerns that were specific to her faith as well as
those that were more generally concerned with
conscientious, ethical behavior.
The Presenting Problem

When Sarah first came to our clinic, she reported that she was committing sins all the time.
This was because she experienced intrusive
thoughts about offending God by using his name
in vain (e.g., Oh my god, God damn) and
other thoughts that made her question whether
she was complying with the principles of the
Ten Commandments (e.g., not believing in God,
disrespecting her parents, offending others when
she spoke). She described significant distress
because she believed God would punish her
for transgressing against the Torah. Sarah felt
that the only way to compensate for her moral
transgressions was to engage in prayer, and she
prayed multiple times per day, including up to
2h before bed. This prayer took on a particularly
ritualistic form in that if she became distracted
or made a mistake, she would need to begin her
prayers from the beginning to make sure they
were delivered perfectly. Similarly, if she asked
her mother to pray aloud and she experienced an
intrusive thought during her mothers prayer, she
would ask her mother to repeat that portion of the
prayer over multiple times until Sarah felt that
she had adequately paid attention to the prayer.
Sarah indicated that the intrusive thoughts were
bothersome and upsetting to her. At the same
time, she viewed her prayer and other compulsive behavior as an appropriate and normal part
of her religious faith.
Sarahs mother corroborated much of this account. She indicated that Sarah constantly sought
reassurance from family members and that she
confessed throughout the day to her parents and
her eldest brother. Sarahs mother also described
compulsive confessing related to doubting God,
reassurance-seeking about the Torahs principles
of faith, and frequent petitions for someone to
pray with her. Importantly, Sarahs mother was
133
less concerned with Sarahs religious practices

than she was with Sarahs preoccupation with a
strict moral code. In particular, she reported that
Sarah was terrified of wastefulness and engaged
in a variety of unusual behaviors to prevent it.
For example, she would repeatedly check faucets to ensure that no drops of water escaped,
pick up trash as she walked outside in order to
recycle it, refuse to use paper towels to clean up
spills or paper napkins during meals, and complete multiple school assignments in tiny writing
on the same sheet of paper so as not to waste
paper. Her mother indicated that Sarah sought
reassurance about her perceived wastefulness
many times per day and that she never appeared
to be satisfied with how her family members responded.
Background
At the time of the initial interview, Sarah lived
with her parents and three older siblings. Her
father worked as a teacher at a non-secular high
school, and her mother was a homemaker. Her
family described themselves as very observant
and noted that her oldest brother was studying
to be a rabbi. All of Sarahs immediate and extended family practiced Orthodox Judaism, and
all were actively involved in their synagogue, including attending temple for weekly services and
all holidays. Sarah also attended a weekly Hebrew school class on Sundays. Thus, the familys
immediate and extended community was similarly observant. Interestingly, this made it somewhat easy for Sarahs mother to note that Sarahs
behavior was distinct from that of her siblings.
Although Sarahs siblings and peers prayed and
strove to uphold the principles of their faith, they
did not seem to need reassurance or to become
upset if something was inadvertently wasted.
Sarah attended a Jewish day school, where
students participated in prayer and a religion
class daily. She obtained good grades and received generally good feedback from her teachers. Over the last school year, however, teachers
had begun to comment that Sarah often used
the same sheet of paper for multiple homework
134
assignments, writing in tiny script on both sides

of the page. When asked to use separate sheets of
paper for different assignments, Sarah agreed initially but then continued to submit assignments
on the same paper. Both parents and teachers
noted that Sarah recently spent more time alone
despite being a popular, well-liked girl.
Sarahs parents had different approaches for
responding to her requests for reassurance or
prayer. Her mother described increasing frustration as Sarahs requests began to occur multiple
times per day. Her father felt that it was his responsibility to teach his children to abide by
and be faithful to religious tenets, including the
morals and values of upstanding citizenship. He
was not concerned about Sarahs prayer. He was,
however, concerned by reports from her teachers
describing her recent social withdrawal and the
degree to which she tried to conserve paper in the
classroom.
Sarahs parents initially responded by seeking guidance from their rabbi on how to handle
her worries and reassurance-seeking. Their rabbi
discussed Jewish orthodoxy with the family and
provided support for Sarahs desire to be a faithful member of their community. However, he expressed concerns about Sarahs recent isolation
and her preoccupation with preventing wastefulness. He noted that her reassurance-seeking from
family members was unusual in its frequency and
persistence. Having some knowledge of anxiety
and OCD, he encouraged the family to seek further evaluation.

During their initial visit to our specialty clinic,
Sarah and her mother completed an evaluation
that included two semi-structured interviews:
the Childrens YaleBrown Obsessive-Compulsive Scale (CYBOCS; Scahill etal. 1997)
and the Anxiety Disorders Interview Schedule
(ADIS)Parent/Child Version (Silverman and
Albano 1996). The CYBOCS was used to assess
the full range of OCD symptomatology and to
obtain information on severity and impairment.
The ADIS, a comprehensive semi-structured diagnostic interview, was used to confirm an OCD
diagnosis and to assess for the presence of other
mental health issues requiring treatment. The
therapist conducted the interviews with Sarah
and her mother separately, recognizing that youth
may not always feel comfortable reporting on
symptomsparticularly those in the internalizing spectrumin front of their parents.
When the therapist met with Sarah to administer the CYBOCS and ADIS, she reported intrusive thoughts that she was committing sins by not
meaning it when she prayed and offending God
(e.g., doubting God or religion; thinking of God
while simultaneously thinking of a curse word
or negative event, and doubting whether she was
following the tenets of Orthodox Judaism). The
compulsions that corresponded to these religious
obsessions included praying many times per day,
repeating a phrase from a prayer until it felt just
right, and asking family members for reassurance about her prayer and whether she had committed sins by doubting God. Sarah also reported
that she often asked her mother to pray with her
and, if Sarah had an intrusive thought while her
mother prayed out loud, Sarah would insist that
her mother repeat portions of the prayer. When
queried about whether her prayer interfered with
her life, Sarah reported that she believed prayer
was necessary in order to compensate for her
sins. She acknowledged that she spent less time
with her friends as the amount of time devoted to
prayer increased. She said that this allowed her
to compensate for her sins, to avoid contaminating her friends if she had sinful thoughts in their
presence, and to atone or punish herself if she
had bad thoughts. When the therapist met with
Sarahs mother individually for the parent interview, Sarahs mother corroborated the reassurance-seeking and prayer behavior, but had little
knowledge of the specific intrusive thoughts that
Sarah experienced.
The CYBOCS also revealed worries about
being a wasteful person and a desire to save
materials and environmental resources. Sarah
and her mother both reported that Sarah was concerned about saving paper, throwing away objects
in the appropriate receptacles (e.g., recycling
biodegradable containers), and refusing to use

paper goods for food items. Sarah reported intrusive thoughts about herself and others being
wasteful with water, paper, and other environmental resources, and reported she viewed herself as an upstanding citizen who should be able
to reduce her own and others wastefulness. She
described that several times per day she experienced intrusive thoughts about the world coming to an end because environmental resources
had run out; she engaged in the above-described
behaviors of using the same paper for many assignments, not wanting to use paper napkins or
towels, and a desire to save water as attempts to
compensate for these intrusive thoughts. Moreover, she viewed this wastefulness as immoral
and contradictory to her goal of being a conscientious girl. Because some of these symptoms were
related to saving material, the therapist carefully
queried about hoarding. As Sarah appeared to
be focused on trying to save environmental resources and how her efforts reflected on herself
as a person, rather than acquisition and saving of
material, the therapist identified these symptoms
as a part of morality concerns that often present
as part of scrupulosity OCD, and not as hoarding symptoms. At intake, Sarahs total CYBOCS
score was 24, which indicates OCD symptom
severity in the moderate-to-severe range (Lewin
et al. 2014).
During the ADIS, Sarah and her mother also
reported symptoms consistent with a secondary
generalized anxiety disorder (GAD) diagnosis.
These symptoms were distinct from her OCD
symptoms and included daily worries about doing
well in school, getting into college, the health of
her family members, and a desire to be perfect
in her academics. Sarah reported that she could
not control these worries and that she often experienced stomachaches and difficulty sleeping
when she worried. Sarah was able to differentiate between her OCD obsessions and these more
generalized worries because the obsessions were
more distressing, nearly constant, and needed to
be fixed with compulsions, whereas the GAD
worries were only mildly distressing and did not
require specific action on her part. Given that
Sarah and her mother reported significant dis-
135
tress and increasing impairment related to the

scrupulosity symptoms, the family and therapist
agreed that OCD would be the primary treatment
target and that GAD would be addressed at a later
point in time.
The next step of the assessment process focused on obtaining additional information on
Sarahs family and religious life in order to place
her beliefs and practices in context. This information included the familys specific religious beliefs and practices, time and activities spent with
their Orthodox Jewish community, and the ways
in which her parents and other religious figures
provided support around academic, developmental, and cultural issues. When the therapist met
with Sarah and her mother individually to assess
OCD symptoms, she also asked questions about
how Sarahs recent changes in behavior and beliefs were perceived by the family and how family members responded. Recognizing the role of
their broader faith community, the therapist also
inquired about how extended family members,
family friends, and peers responded to Sarahs
behavior. The therapist knew that in order to
successfully treat Sarah, she would need to consider what Sarah perceived as normal and also
what others in the same community perceived as
normative. This in turn required further consultation with a rabbi to understand where Sarahs
behaviors were in line with religious doctrine and
where they crossed over into illness.
The assessment also focused on understanding recent peaks in OCD symptomatology, a
challenge because Sarah herself did not believe
that her praying was problematic. Despite these
views, Sarah acknowledged that she began to
devote more time to prayer following two important events. The first was the start of the sixth
grade school year, which included more homework and greater academic demands. The second was the approach of her bat mitzvah in eight
months. Sarah reported that, in preparation for
her bat mitzvah, she was doing a community service project (called a mitzvah) in which she was
working to organize a community-wide recycling
program in her neighborhood.
The final portion of the assessment involved the
therapist meeting with Sarahs parents separately
136
to explore their views of her symptoms and to

discuss the treatment rationale. This piece was
essential given the need for their buy-in to treatment, and, not surprisingly, it highlighted some
challenges. First, although Sarahs mother had
some preliminary knowledge of exposure-based
therapy, she was concerned that Sarah might
lose her faith if she did exposures to challenge
the familys Orthodox beliefs. Both parents reported concerns that community members may
learn about Sarahs participation in therapy,
which might result in stigma for the family.
These concerns notwithstanding, Sarahs mother
provided important information about Orthodox
Judaism, namely that even within the familys
community, there was great variability in how
people practiced, what they believed in, and the
types of behaviors that were (or were not) considered appropriate. This provided the therapist with
some leeway to probe exposure tasks that were
likely to run counter to the familys typical religious practices. With this in mind, the therapist
worked separately with Sarahs parents to negotiate the range of potential exposures that might be
introduced in session. She also obtained consent
to speak with the familys rabbi in order to seek
his expertise and consultation and to share information on the goals of exposure-based therapy.
Taken together, we viewed Sarah as an
11-year-old female with a primary diagnosis of
OCD and a secondary diagnosis of GAD. Her
OCD symptoms fit within the scrupulosity cluster
and involved intrusive thoughts related to being
sinful or not following the rules of her religion, as
well as concerns of being a wasteful and amoral
person. Her related compulsive behaviors included significant praying and reassurance-seeking,
as well as efforts to avoid wasting water, paper,
or other objects that might impact availability of
environmental resources. These symptoms had
been present for some time with more recent exacerbation, and they created substantial distress
and impairment for Sarah and her family. Her
symptoms emerged in the context of a family and
community environment that was very observant
and encouraging of daily prayer and a focus on
abiding by Gods tenets as ascribed in the Torah.
In this context, the role of the rabbi not only as
religious leader but as mental health and family

counselor was paramount. As described below,
the therapist utilized Sarahs strong religious belief system, her familys cohesion, and the rabbis
expertise in order to work with Sarah within an
exposure/response prevention (ERP) framework.
Treatment Course
Session 1: Psychoeducation and Reward System During the first session, the therapist met
with Sarah and her mother together. The therapist provided psychoeducation on pediatric OCD
including its definition, causes, and prevalence.
As many families are not familiar with scrupulosity as a form of OCD, the therapist also provided psychoeducation on that particular cluster
of symptoms and how it fit into the OCD cycle.
Because Sarah believed that her symptoms were
a normal and necessary part of religious observance, the therapist focused on the degree to
which they interfered in her life as a starting point
in the collaboration. She used a cognitive-behavioral model to describe how OCD symptoms
become reinforced over time, and Sarah was able
to articulate how it seemed that prayer no longer relieved her anxiety when she had done or
thought something sinful. After discussion of the
ways in which OCD pulls parents into the cycle
of symptoms (i.e., accommodation), Sarah was
also able to identify how, even though she felt
that she needed to ask for reassurance or doublecheck her behavior with family members, they
rarely provided the answer that felt just right.
The therapist also described ERP and its rationale. Sarah was able to identify ways in which
she had previously refrained from engaging in
compulsions at school and how eventually the
thought would go away or that she would experience a reduction in associated distress. She
reported a willingness to try treatment. However, she also expressed concerns that she as a
person and/or her belief system would inherently
change as a function of doing exposures, such
that she would no longer be a faithful member of
the Jewish community or a good person. With
this in mind, the therapist spent a substantial portion of the session describing that her goal was
not to change Sarahs beliefs, but to provide her
with the tools to participate in her community
and practice her faith without interference from
OCD. This distinction between fighting OCD
and changing Sarahs personality or religious beliefs would emerge throughout therapy for both
Sarah and her parents. Finally, the therapist assigned Sarahs first therapy homework: to identify a reward with her parents that Sarah would
earn points towards each week by participating
in session and by completing therapy homework
and to begin monitoring her symptoms. As they
each reported different symptoms during intake,
Sarah and her mother were each provided with
their own monitoring sheets.
Parent-Only SessionMost treatments for child
and adolescent OCD involve some degree of
family involvement (Barrett etal. 2008; Lewin
and Piacentini 2010). In cases where youngsters
present with scrupulosity, we find it particularly
important to engage parents in treatment early in
the process because exposure tasks are certain to
tread in delicate territory. Accordingly, Sarahs
first treatment session was followed by a parentonly session with both of her parents. This session included a review of the psychoeducation
material that was covered in the initial session
and an opportunity to ask questions. However,
the main focus was on continued discussions of
what the family viewed as typical for someone of
their faith and on better understanding the parents expectations of their children (e.g., weekly
attendance at synagogue services, daily prayer at
school and weekly prayer at Friday, and Saturday
night Shabbat dinner). During this session, both
parents agreed that Sarahs prayer and attempts
to preserve environmental resources had become
excessive, and both agreed that they would like
for Sarah to reconnect with her family and peers.
There were, however, some differences in these
goals. While Sarahs mother perceived Sarahs
prayer as excessive, her father expressed worries that if Sarah was encouraged to pray less,
she might perceive this as encouragement to stop
other practices in their faith. As with session 1,
137
the therapist stressed that her goal was not to

change Sarah or the familys belief system, but
rather to provide Sarah with tools to engage in
prayer because it was meaningful to her, rather
than engaging in prayer in an attempt to reduce
anxiety. The therapist also reframed Sarahs current prayer behavior as a relationship with OCD
rather than God. She provided examples of other
patients with scrupulosity OCD who successfully participated in ERP, noting that many experienced an improvement in their relationship with
God as a function of OCD symptom reduction.
This active collaboration early on was important
for building rapport, trust, and credibility as the
therapist prepared for later exposure sessions.
Finally, the therapist also discussed the role of
parental accommodation in maintaining the OCD
cycle and interfering with exposures. Sarahs
mother quickly identified her accommodation
as praying with Sarah and providing reassurance
that Sarah was not a bad person or wasteful.
The therapist identified that Sarahs father might
inadvertently accommodate Sarah by quoting the
Torah when she sought reassurance. The therapist
and parents agreed that, for the time being, they
would continue responding to Sarah as they had
in the past, but that as Sarah did more exposures,
reduction of accommodation would also be assigned as part of the familys homework. By the
end of the session, Sarahs mother appeared to be
ready and willing to do her part in ERP for Sarah.
Sarahs father was still hesitant, so the therapist
encouraged him to contact her whenever he had
questions and also to continue consulting with
their rabbi.
Session 2: Initial Development of Exposure Hierarchy and Relaxation When Sarah presented for
her second session, she identified her desired
reward as wanting to have a sleepover at her
house with her four closest friends. The therapist
was pleased with Sarahs selection of this reward,
as it could directly be worked towards with exposures related to Sarahs friends, whom she had
been avoiding. Sarah and her mother had each
completed their symptom-monitoring sheets,
and these were reviewed in session. The therapist noted that Sarah had only listed intrusive
138
thoughts and no rituals, while her mothers sheet

listed rituals. The therapist used this as an opportunity to review psychoeducation about scrupulosity and ERP. Once again, Sarah reported that
she believed her behaviors were normal for someone of her faith. The therapist responded to this
with, My goal is to help you have a relationship
with God and have time to be a good person, not
to have a relationship with OCD and be a person
who is only focused on intrusive thoughts. This
particular language appeared to impact Sarah, as
she agreed to write down several compulsions
from the previous day on her homework sheet
and seemed to trust the therapist a bit more.
The therapist reviewed the goal of exposures
as purposefully eliciting intrusive thoughts so as
to provide an opportunity to practice resisting
the urge to engage in compulsive behavior. The
therapist showed Sarah an example hierarchy for
an individual who washed her hands in response
to intrusive thoughts about cleanliness and discussed that the hierarchy would be a working
document throughout treatment. Sarah and her
mother both requested that her mother remains
in session for the development of the initial hierarchy.
The therapist started the hierarchy development process by asking Sarah what she wanted
and needed to do that she currently could not do.
Sarah identified spending time with her friends,
not writing multiple school assignments on the
same page, and being less concerned about wasting water, food, and napkins and other paper
goods. Sarahs mother identified reassuranceseeking and excessive prayer as her primary concerns. The therapist created specific exposures
for each of these areas and asked Sarah to provide
a 110 rating for each item, where a 1 indicated
no discomfort and 10 equaled most anxious I
ever felt. In this way, the therapist, Sarah, and
her mother began to build the exposure hierarchy.
Sarah became visibly anxious, as evidenced by
tearfulness and avoiding eye contact, when the
therapist began asking about items that were obviously more difficult and would be listed as high
on the hierarchy (e.g., going to bed without praying at all, thinking a blasphemous thought while
in the presence of all of her friends); therefore,
the therapist focused on items for which Sarah

might provide lower-to-moderate ratings for this
session, with the verbal acknowledgement to
Sarah that she would return to discussion of the
more difficult items later in treatment. Sarah was
able to participate in an initial set of exposures,
where she wasted a few drops of water from a
water bottle onto the ground. With the therapists
guidance, she practiced this same exposure ten
times in a row in session and reported increased
ability to tolerate wasting the drops of water.
Finally, the therapist taught Sarah and her
mother diaphragmatic breathing and progressive muscle relaxation as relaxation techniques.
The therapist did not specifically advise Sarah
to use these skills while experiencing intrusive
thoughts, as she did not want these to replace
other rituals later in treatment. Indeed, she
wanted Sarah to learn to tolerate the distress
evoked by these thoughts. Instead, the therapist
described deep breathing and muscle relaxation
as something Sarah might use to soothe herself
during times of general upset or worry. The therapist also cautioned that sometimes individuals
experience intrusive thoughts while they participate in relaxation exercises and that the intrusive
thought can just sit in your mind while you finish the relaxation exercise. Sarah and her mother actively participated in the breathing exercise
and appeared to enjoy it. The therapist provided
an audio recording of 10min of diaphragmatic
breathing and progressive muscle relaxation, and
Sarah agreed to listen to and participate with the
recording each night before bed. Homework was
also assigned to continue symptom monitoring,
and Sarah was encouraged to identify both obsessions and rituals.
Session 3: ERP At the start of session 3, Sarah
reported that the relaxation strategies were useful
in helping her to fall asleep, but that she often experienced intrusive thoughts. The therapist praised
Sarah for her ability to refrain from responding
to the intrusive thoughts with compulsions during the relaxation exercises and encouraged her
to continue using relaxation before bed. Sarah
also had completed her homework-monitoring
sheet, listing both obsessions and compulsions.
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Table 10.1 In-session exposures conducted during session 3

Exposure description
SUDSa
1. After each exposure, write down exposure on hierarchy messily
5
2. Turn faucet on and off quickly to drip water into the bathroom sink
3
3. Drip water into the sink, wait 5s before confessing to mom
3
4
4. Drip water into the sink, wait 10s before confessing to mom
5. Leave one blank line on paper in between written exposures on hierarchy
5
4
5. Drip water into the sink for 5s, wait 2min before confessing
4
4
9. Leave two blank lines in between exposures written messily on hierarchy
6
4
10. Watch therapist, take paper towel from dispenser, and throw it away without using it.
Wait 5min before confessing to mom
11. Rip small piece of paper towel from dispenser and throw it away without using it. Wait 5
2min before confessing to mom
12. Rip paper towel into quarters. Throw away one piece at a time, wait 5min before con- 5
fessing to mom after each piece is thrown away
13. Leave four blank lines in between exposures written messily on hierarchy. Try to make 7
writing larger font and more messy
14. Throw away paper towel sheet without using. Do not confess to mom
5
15. Drip water into the sink for 15s and throw away an unused paper towel. Do not confess 6
to mom
16. Wash hands under running water for 1min. Use three pieces of paper towel to dry
6
hands. Do not confess to mom
17. Throw away crust from therapists uneaten sandwich half. Do not confess to mom
7
18. Cut sandwich half into small pieces. Throw away one piece at a time. Do not confess to 7
mom
Note that each exposure was completed multiple times until Sarah either reported anxiety reduction or improved ability
to tolerate distress
a
SUDS subjective units of distress, rating from 1 to 10, where 1=no discomfort and 10=most anxious ever felt
(In each subsequent session, the therapist always

started with homework review, significant events
of the week, and providing a sticker on Sarahs
behavioral reward chart for Sarahs effort in
attempting homework. As Sarah was very compliant with her homework throughout treatment,
we limit discussion of homework review from
this point forward except to highlight significant
gains made or in regard to identifying exposures
for the next ERP session.)
In order to gain trust and help Sarah to build
mastery, the therapist agreed to start exposures
with Sarahs desire to work on reducing concerns
about wastefulness (see Table10.1 for the ordered list of exposures conducted during session
3). Exposures began with dripping water into the
sink, wasting or throwing away unused paper
towels, and eventually using several paper towels at once to wipe her hands after Sarah washed
them. Each exposure was conducted many times
over until either Sarah reported that she could

tolerate the distress of the exposure without confessing or asking reassurance from her mother
and/or she reported symptom reduction. Sarahs
mother stood outside of the bathroom, and the
therapist and Sarah checked in with her after each
exposure, with the goal of Sarah waiting longer
amounts of time before confessing or seeking reassurance from her mother. After several sets of
exposures, Sarah was able to move on with the
next set of exposures without checking in to see
whether her mother was outside of the bathroom.
Near the end of the session, Sarah was able to
run water in the sink for several seconds at a
time, throw away several unused paper towels,
and throw away the leftovers from her therapists
lunch without confessing to her mother. In addition, each time that Sarah completed an exposure,
she was instructed to write it down on a piece of
paper, as well as her discomfort rating before and
140
after the exposure. While keeping track of each

item on the hierarchy in such detail is not necessarily relevant to treatment, the therapist wanted
to maximize the number of exposures conducted
per session by also addressing Sarahs difficulties
with writing. The therapist began requesting that
Sarah leave a small space, and eventually several
blank lines, between the listed exposure steps in
order to conduct wasteful writing exposures.
This integration of different exposure targets
(i.e., compound exposure) has demonstrated
benefit in the OCD literature (see Craske etal.
2008) and it appeared useful for this particular
patient.
By the end of the session, Sarah reported that
she was less distressed by the waste of paper and
resources and also proud of herself for being able
to wait 15min near the end of the session without
confessing any of her exposures to her mother.
Homework was assigned to continue practicing
the in-session exposures at home. Sarah was assigned to do the following each day: (1) let water
drip in sink for 10s, ten different times, (2) use a
paper napkin at every meal and discard it in the
trash when the meal is over, (3) leave a blank
line after every written line on homework assignments, and (4) attempt to refrain from seeking reassurance regarding wasted materials or
instructing others on how to preserve resources.
Sarahs mother was also instructed that she was
only allowed to provide reassurance about wastefulness five times per day; otherwise, she should
provide a stock phrase (That sounds like OCD)
if Sarah did seek reassurance. Sarah agreed that
if she wanted to seek reassurance, she would only
attempt to seek it from her mother and not from
other family members from this point forward,
while her mother agreed to notify other family
members to not respond if Sarah attempted to
seek reassurance from them. The goal was to use
a scaffolding approach to gradually disentangle
the familys involvement in her symptoms.
Session 4: Continuing ERP for Wastefulness Preliminary gains were evident at the start
of session 4. In particular, Sarah remained compliant with homework and her mother reported
that she had sought less reassurance about
whether she or others were being wasteful. The

session began by reviewing and repeating the
most difficult exposures from session 3. As she
did this without much difficulty, it was clear that
Sarah felt proud and that her buy-in to treatment
was increasing.
In this session, exposures continued to focus
on wasting resources, including throwing
away unused paper and paper goods and saying
and writing statements such as, Im a wasteful
person, Wasting something means Im a bad
person, and The world wont have enough
resources because of me. When Sarah felt the
need to seek reassurance from or confess to her
mother, she wrote down the question or statement
on a notepad instead of asking (again requiring
her to use paper resources she would ordinarily
conserve). The therapist and Sarah also walked
to a nearby fast food restaurant and watched as
other individuals threw away unused napkins
and utensils from their meals, while Sarah made
written and verbal statements such as We are all
terrible people and were going to ruin the environment.
Throughout the session, the therapist also
requested that Sarah write down each exposure
completed, but only write on every fifth line of
the page, without writing in smaller print. In subsequent sessions, Sarah would write fewer and
fewer lines on each page. As part of her at-home
practice, she was instructed to conduct parallel
exposures with her homework assignments. The
therapist continued to assign such wastefulness and writing exposures for homework each
week, slowly increasing the level of difficulty.
For homework, Sarah was asked to write down
her confessions and attempts to seek reassurance
in a notepad (using the same writing technique
described above) and was only allowed to show
her mother the notepad once per day. Such inand out-of-session exposures continued to be assigned, increasing in the level of difficulty each
week.
Session 5: Exposures for ReligiosityBy session 5, Sarah reported that writing down intrusive thoughts was not as burdensome to her. As
a result, she began to refrain from reassurance
seeking and confessing on her own. This included

writing down her obsessive questions because
she knew that her mother would no longer provide reassurance. Sarah also began attempting to
refrain from asking her peers not to waste classroom materials. To ensure that she was not simply compensating by trying to save more materials during her community service project, the
therapist, Sarah, and her mother all decided, after
consultation with the rabbi and Sarahs Hebrew
school teacher, that Sarah would take a managerial role for her mitzvah project and allow each
of the community businesses to which she had
provided pamphlets on recycling to manage their
own recycled materials. Sarah initially expressed
some resistance about not checking each business recycle bins each week, but eventually
agreed to modify her project.
Because Sarah had demonstrated great success with exposures at this point in treatment,
the therapist felt that it was appropriate to return to discussion of religiosity and concerns
about contaminating her friends by thinking
sinful thoughts in their presence. The therapist used Sarahs desire for a reward sleepover
to provide a rationale for reengaging with her
friends. Exposures during this session began with
Sarah purposefully thinking sinful thoughts or a
thought contradictory to the Ten Commandments
in the presence of the therapist alone, and then
the therapist and her mother together. Again, the
therapist prompted Sarahs mother to not provide
reassurance and redirected Sarah to her notebook
to write down confessions and reassurance questions rather than ask them out loud.
In the latter half of this session, the therapist
utilized Sarahs concerns about contaminating
her friends if she had sinful thoughts in their
presence and her desire to have a sleepover with
her friends as her treatment reward, to encourage Sarah to do exposures relevant to her friends.
Sarah text messaged three of her friends about
schoolwork and made a sinful statement out
loud prior to sending each text. She also posted
on her friends social media sites while making
sinful comments, followed by the statement
Im going to turn [friends name] into a bad
person. Homework included continued focus on
141
wastefulness, limiting confessions/reassuranceseeking to her notebook rather than asking her

mother and texting three of her friends at least
once per day while thinking a sinful thought that
might contaminate those friends. The therapist
and Sarah reviewed the rationale for not undoing
her exposures by engaging in rituals or neutralizing behavior (e.g., following sinful thoughts
with positive thoughts). In subsequent sessions,
the therapist had Sarah call one of her friends
briefly on the telephone to obtain school homework assignments and eventually spend time
with her friends outside of school while purposefully thinking sinful thoughts. After a few more
sessions, Sarah reported that she was better able
to refrain from engaging in rituals related to contaminating her peers and also experienced intrusive thoughts less frequently when in the presence of her friends.
Family and Expert ConsultationAt this point
in treatment, the therapist made separate calls to
Sarahs parents and rabbi in order to discuss her
progress. Although the family reported noticing
a decline in Sarahs rituals related to wastefulness, they had concerns about religiosity exposures, particularly as they related to prayer or
behavior that might go against religious tenets.
The therapist consulted with both parents and
the rabbi to identify appropriate exposures. Both
parents agreed that blasphemous statements did
not concern them, as they had begun to trust the
therapist in treatment and felt fairly confident
that Sarah would not begin to believe such statements. Both parents also agreed that Sarah did
not need to repeat phrases from or entire prayers;
her parents recognized that this behavior was
unrelated to communicating with God. Her father
did express concerns that Sarah might be asked
to break from orthodoxy (e.g., Sarah wearing
clothing that was against custom, not attending
synagogue, and not praying at school). Sarahs
parents and the therapist agreed that there were
some things that Sarah would not be asked to do,
as the family felt these were the utmost violation of their beliefs. (For example, it is typical
practice for some Jewish individuals to not write
Gods true name in Hebrew and instead use other
142
names and for orthodox Jewish women to wear

tops that cover their arms or skirts that cover
their knees.) The therapist took care to listen to
the familys concerns, seek consultation from the
rabbi about how far she could push exposures,
and reassure the family that she would typically
discuss exposures with them prior to introducing
them to Sarah.
Sessions 610: Religiosity Exposures The therapist introduced a wide variety of exposures to
address Sarahs religiosity compulsions. For
example, Sarah and her parents purposefully
triggered Sarahs prayer symptoms by reading
portions of the Torah and skipping or mispronouncing words, reading backwards, reading a
passage very quickly, and inserting blasphemous
statements into the prayer, all without rereading
portions or starting over when Sarah felt that the
prayer was read incorrectly. The therapist often
caught Sarah starting to ask her mother for reassurance and continued to coach her mother on
either ignoring Sarah or providing a stock phrase
identifying the reassurance-seeking as OCD.
Over the course of treatment, Sarah was able to
cut her evening prayer down from 2h to 20min.
Similarly, Sarah used curses involving the word
God, created scripts to read out loud (i.e., imaginal exposures) about how she was leaving the
Jewish faith and her community because she was
an atheist, and read about other religions on the
Internet. Sarah also increased her contact with
her peers, as described above, and continued her
wastefulness exposures.
As exposure sessions continued, Sarah was intermittently resistant to the idea of purposefully
triggering intrusive thoughts in more difficult
exposures. The therapist addressed Sarahs resistance in several ways. First, she intermittently
checked in with Sarahs mother to ensure that her
mother understood the rationale for the exposures
as a means to treat OCD, particularly if the family felt the exposures might be in conflict with
their faith. Second, the therapist referred back to
Sarahs prior hierarchies and homework sheets as
concrete evidence of the gains Sarah had made
in treatment. Next, the therapist reviewed the
OCD cycle, rationale for ERP, and Sarahs goals
for treatment (to strengthen her relationship with

God by reducing her compulsive behavior). Finally, whenever Sarah expressed resistance, the
therapist asked Sarah to work collaboratively and
to negotiate an easier set of exposures to try first.
In this way, Sarah made significant gains over
the course of treatment and, by continuing exposures from prior sessions each week, was able
to function better at home (reduced reassuranceseeking), with peers (increased engagement with
her friends), and in school (ability to complete
her homework assignments as requested by her
teachers).
Sessions 11 and 12 The final two ERP sessions
were staggered and occurred every other week in
order to increase expectations for Sarahs independent completion of exposures. The exposures
in these sessions included a review of several
exposure tasks previously practiced in session.
They also challenged Sarah to attempt some very
difficult exposures that included making statements to both of her parents that she might be
less religious, stating that she no longer considers
herself a member of the Orthodox Jewish community and changing the words to some Torah
passages to include statements that she was no
longer religious. These exposure exercises were
designed in consultation with the rabbi and her
parents, who were coached to voice disappointment but maintain neutral tone and facial expressions as part of the exposure. During these most
difficult exposures, Sarah initially attempted to
neutralize with statements such as, But I dont
really mean it, and the therapist had to provide
rationale and encouragement for Sarah to really
imagine that these statements were actually true
in order for her to experience distress and obtain
the full benefit of the exposures.
At session 12, Sarah continued to report intrusive thoughts, yet described an increased ability
to tolerate them without feeling overly anxious
or the need to compensate with compulsions. At
school, she received feedback from her teachers that they were glad her assignments were
being turned in one assignment per page, and her
friends expressed that they were glad she was
spending more time with them. Sarahs parents
reported that she seemed much more relaxed at

home, and her mother reported that Sarah had all
but stopped using her notebook to write down
confessions or reassurance requests. Her mother
reported that each member of Sarahs immediate family was more adept at identifying reassurance-seeking and confessions and that they
refused to provide it whenever Sarah did ask or
confess. Sarah herself reported improvement in
her symptoms and in her general functioning.
She still felt anxious when managing intrusive
thoughts about religiosity without engaging in
compulsions when she felt tired or stressed about
school, but these thoughts were generally less
frequent. Sarah and the therapist problem-solved
about how she might identify when she felt tired
or stressed and what her family could do to help
her continue challenging the intrusive thoughts
with response prevention rather than compulsions.
As Sarah also had significant worries consistent with GAD, which were not a treatment target and did not improve much over the course
of ERP, her family and the therapist agreed to
transition to a traditional CBT framework to
address the GAD after session 12 of ERP. Because of their continued work together, relapse
prevention was focused on Sarah knowing when
to speak with her parents and/or therapist if she
noticed an increase in rituals, developing additional exposures for Sarah to continue at home
that would be reviewed during CBT for GAD
sessions and reorienting Sarah and her family to
a shift in the focus of therapy. Upcoming stressors and their potential impact on OCD symptoms
were also discussed, including Sarahs practice
of reading Torah with her Hebrew school teacher
during preparations for her bat mitzvah. While
at pretreatment, Sarahs CYBOCS score was 24
(moderate-to-severe range), at posttreatment her
CYBOCS total was 12 (within the mild range),
indicating a substantial decrease in OCD symptoms.
Treatment Challenges Although Sarah benefited
from a relatively smooth treatment course, therapy was not without its challenges. Several key
themes emerged throughout her treatment that
143
required ongoing attention. They included the

ability to craft effective exposures while remaining respectful of the familys belief system,
addressing intermittent resistance to ERP, family accommodation, and the role of Sarahs home
and community contexts in triggering potential
relapse. Each of these challenges is discussed
below.
From the initial assessment visit, the therapist was aware that Sarahs scrupulosity symptoms presented in a specific religious, cultural,
and community context with which the therapist
was not very familiar. The familys willingness
to consider ERP was, in part, contingent on the
therapists ability to balance between her expertise in OCD and collaborative dialogue with the
family and their rabbi. Several strategies promoted cultural and religious sensitivity. First, as
noted earlier, the therapist devoted substantial
time talking to the family about their religious
and cultural background so that she might become better educated about Orthodox Judaism
as practiced by the family. This consultation
continued throughout therapy. It facilitated good
understanding of this particular familys context
and allowed Sarahs parents to feel heard and
respected by the therapist. Sarahs fathers concerns about exposures that might directly or indirectly challenge the familys faith, as well as
his worries about stigma associated with therapy,
were also eventually overcome as the therapist
continued to collaborate with the family and seek
their feedback about Sarahs treatment course. By
consulting with the familys rabbi, who served as
their primary support for religious and mental
health issues, the therapist learned about Sarahs
familys Orthodox practices specifically and the
communitys practices and expectations more
generally, which increased the familys trust in
the therapist. The rabbi also became an ally who
supported exposures that the therapist may have
otherwise had a difficult time proposing.
Beyond this ongoing consultation, therapy
also benefited from the way in which scrupulosity symptoms were framed. In discussing scrupulosity and ERP with the family, the therapist
focused on compulsions as religion-interfering
behaviors (e.g., prayer to reduce anxiety) and
144
continually reminded Sarah throughout treatment

that the goal was to improve her relationship with
God and her ability to be a present and faithful
member of her community.
The therapist also faced challenges in Sarah
and her fathers initial resistance to ERP. In
nearly every session, Sarah had concerns that
ERP would turn her into a bad person who
was amoral and unfaithful to her religion. These
concerns were especially salient during exposures involving prayer and what it meant for
her to refrain from prayer when, outside of her
symptomatology, prayer was viewed in her family and community as a means of maintaining a
connection with God. Had the therapist engaged
in philosophical discussions of religiosity with
Sarah and/or her parents or maintained a neutral
stance about religion, the family might have felt
offended or that the therapist did not understand
their background. Instead, the therapist focused
on supporting Sarahs religiousness, encouraged
her to participate in the familys belief system,
and reframed the treatment goals as providing
Sarah with the tools to be a practicing member
of their faith. This placed everyoneSarah, her
parents, their rabbi, and the therapiston the
same team, working together towards the goal
of providing Sarah with the tools to practice Orthodox Judaism without interference from OCD.
Next, the therapist faced the challenge of
working with Sarahs parents to reduce accommodation. As with many families affected by
OCD, Sarahs parents engaged in behavior that
reinforced OCD: providing reassurance, praying with Sarah, and, in the case of Sarahs father, quoting the Torah in response to Sarahs
reassurance-seeking or confessing. However,
unlike some other forms of accommodation,
her parents responses to Sarahs reassuranceseeking and confessing were embedded in their
religious background (e.g., most parents in their
community prayed with their children weekly
and spoke about their beliefs regularly). Thus,
it was especially important for the therapist to
clarify for Sarahs parents that they were being
asked to change their behavior because it reinforced Sarahs symptoms, even though what they
were doing might be normative and appropriate

for a child without OCD. This was particularly
difficult for Sarahs father in the early weeks of
treatment, as he strongly believed in educating
his children with the word of God and raising
them as outstanding citizens in their community.
The therapist credited her communication with
and support from the familys rabbi as a major
reason that Sarahs father reduced his behavior of
referring to the Torah when Sarah sought him out
for reassurance.
Finally, this case required particularly careful planning for the transition out of treatment.
Following her work in our clinic, Sarah would
continue to be immersed in a very observant religious environment that had the potential to trigger
symptoms (e.g., daily prayer at school, finishing
her mitzvah project, practicing her Torah portion
for her bat mitzvah). Decisions about whether
the family should modify any of their typical
traditions and whether Sarah would continue exposures even after her completion of ERP were
important aspects of relapse prevention planning.
Perhaps most challenging was how Sarah should
respond when she became triggered as a function
of participating in a family or school religious
tradition (e.g., Shabbat dinner prayer). In considering these issues, the therapist worked closely
with Sarahs parents and the family rabbiall of
whom now had ample familiarity with her treatment courseto develop an action plan that both
respected the familys traditions and promoted an
exposure-based approach to handling new symptoms.
Concluding Remarks
Child and adolescent OCD encompasses a diverse array of symptoms. To date, the research
literature has grouped these disparate symptoms
when examining issues of treatment efficacy or
effectiveness (see Freeman etal. 2014 for review). Research aimed at understanding outcomes for specific symptom clusters has been
virtually nonexistent in the pediatric OCD literature. Thus, it is not surprising that there are
145
Table 10.2 Key practice points for the treatment of scrupulosity in youth
Recommended strategies
1.
Comprehensive evidence-based assessment
2.
Careful consideration of relevant contextual factors
3.
Provision of a clear rational for ERP treatment, and review of ERP throughout therapy
4.
Consultation with religious leaders where appropriate
5.
Consultation and collaboration with primary caregivers in developing exposures
6.
The use of optimally challenging exposure tasks
7.
Focus on ERP as improving youths ability to engage with their community
ERP exposure and response prevention
currently no systematic studies of treatment outcome for scrupulosity in youth. As illustrated in

this clinical account, there is much to suggest that
traditional ERP techniques remain an efficacious
choice.
All exposure-based treatments work best
when they are administered with flexibility and
creativity (Kendall etal. 1998). As described
here, the treatment of scrupulosity is no exception. Exposure tasks themselves must be crafted
to tackle core fears (e.g., offending god, sinning)
from several different angles. They may be repeated within and across sessions with slight
variations to increase potency, and they must be
designed to activate central symptoms (Craske
etal. 2008). The challenge of developing exposures for scrupulosity comes from the need to
balance adequate activation of fears with sensitivity to religious and cultural norms that may
constrain what is permissible to practice. The result is intrinsic variation in how these techniques
are applied from one child to the next and the
opportunity for therapists to think creatively in
expanding their repertoire of strategies.
This case study also highlights questions about
how to progress along the symptom hierarchy.
Research on inhibitory learning has challenged
the traditional exposure paradigm advocating a
stepwise approach to ERP (Craske etal. 2008;
Kircanski etal. 2012). Indeed, such research
points to the benefits of going out of order
along the hierarchy and it has paved the way for
a new approach to exposure therapy that focuses
more on achieving variability in distress during
exposure and less on habituation. The merits of
this new approach for scrupulosity in youth re-
main to be tested. However, a separate set of considerations argue for at least some adherence to
the traditional stepwise approach when treating
scrupulosity. More specifically, when designing
exposures that address deeply held religious or
ethical beliefs, the gradual progression along the
hierarchy may promote better trust and compliance at least in the early stages of treatment.
Finally, although the treatment of child and
adolescent OCD always includes some degree of
parent involvement, the treatment of scrupulosity is unique in its inclusion of a broader set of
relevant individuals from the youngsters community. Although by no means a requirement,
we have found it extremely useful in our clinic
to consult with rabbis, priests, imams, and other
relevant leaders as a way to build trust, understanding, and ultimately, more effective exposure
tasks. These religious leaders provide a critical
source of education for therapists and they can
become valued allies in developing optimally
challenging exposure tasks.
As these considerations make clear, the treatment of scrupulosity presents a number of challenges for the treating clinician. However, in this
challenge lies an exciting opportunity for collaboration, flexibility, and creativity. As detailed in
Table10.2, practicing clinicians would be wise to
conduct careful and detailed assessment of symptoms, as well as family and community practices
and expectations. Consultation with expert clinicians who have successfully treated patients for
scrupulosity symptoms and with religious figures
to whom the family looks for support and direction may provide enhanced understanding of
where symptoms overlap with belief systems and
146
guidance on appropriate exposure tasks. Family

involvement throughout assessment and treatment may lead to increased parental commitment
to reducing accommodation and increasing treatment effectiveness, as well as guidance on how
to balance sensitivity to and understanding of the
family belief system with an effective exposure
hierarchy. Review of ERP rationale at the start
of and throughout treatment may increase youth
motivation and willingness to participate in exposures. Finally, a focus on exposure-based intervention as improving the ability to effectively
participate in religious practice and community
activity may increase youth and parent commitment to and compliance with treatment. Together, these practices are likely to create a culturally sensitive, optimally efficacious intervention
package for treating scrupulosity in youth.
Acknowledgments This research was supported by grants
from the International Obsessive Compulsive Disorder
Foundation (Peris) and NIMH K23 MH085058 and R03
MH099199 (Peris).
References
Abramowitz, J. S., Huppert, J. D., Cohen, A. B., Tolin,
D. F., & Cahill, S. P. (2002). Religious obsessions
and compulsions in a non-clinical sample: The penn
inventory of scrupulosity (PIOS). Behaviour Research
Antony, M. M., Downie, F., & Swinson R. P. (1998). Diagnostic issues and epidemiology in obsessive-compulsive disorder. In R. P. Swinson & A. M. Martin (Eds.),
Obsessive-compulsive disorder: Theory, research, and
treatment (pp. 332). New York: Guilford.
Barrett, P. M., Farrell, L., Pina, A. A., Peris, T. S., & Piacentini, J. (2008). Evidence-based psychosocial treatments for child and adolescent obsessive-compulsive
disorder. Journal of Clinical Child & Adolescent Psychology, 37, 131155.
Bloch, M. H., Landeros-Weisenberger, A., Rosario, M. C.,
Pittenger, C., & Leckman, J. F. (2008) Meta-analysis
of the symptom structure of obsessive-compulsive
disorder. The American Journal of Psychiatry, 165,
15321542.
Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy.
Behaviour Research & Therapy, 46, 527.

Freeman, J., Garcia, A., Frank, H., Benito, K, Conelea, C.,
Walther, M., etal. (2014). Evidence base update for
psycosocial treatments for pediatric obsessive-compulsive disorder. Journal of Clinical Child & Adolescent Psychology, 43, 726.
Geller, D. A., March, J., & AACAP Committee on Quality Issues. (2012). Practice parameter for the assessment and treatment of children and adolescents with
obsessive-compulsive disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51,
98113.
yale-brown obsessive compulsive scale. I. Development, use, and reliability. Archives of General Psychiatry, 46, 10121016.
Kendall, P. C., Chu, B., Gifford, A., Hayes, C., & Nauta,
M. (1998). Breathing life into a manual: Flexibility
and creativity with manual-based treatments. Cognitive and Behavioral Practice, 5, 177198.
Kingery, J. N., Roblek, T. L., Suveg, C., Grover, R. L.,
Sherrill, J. T., & Bergman, R. L. (2006). Theyre not
just little adults: Developmental considerations for
implementing cognitive-behavioral therapy with anxious youth. Journal of Cognitive Psychotherapy, 20,
263273.
Kircanski, K., Mortazavi, A., Castriotta, N., Baker, A. S.,
Mystkowski, J. L., Yi, R., etal. (2012). Challenges
to the traditional exposure paradigm: Variability in
exposure therapy for contamination fears. Journal of
Behavior Therapy and Experimental Psychiatry, 43,
745751.
Lewin, A. B., & Piacentini, J. (2010). Evidence-based
assessment of child obsessive compulsive disorder:
Recommendations for clinical practice and treatment
research. Child & Youth Care Forum, 39, 7389.
Lewin, A. B., Piacentini, J., De Nadai, A. S., Jones, A. M.,
Peris, T. S., Geffken, G. R., Geller, D. A., Nadeau, J.,
Murphy, T. K., & Storch, E. A. (2014). Defining clinical severity in pediatric obsessive compulsive disorder. Psychological Assessment, 26, 679684.
Nelson, E. A., Abramowitz, J. S., Whiteside, S. P., & Deacon, B. J. (2006). Scrupulosity in patients with obsessive-compulsive disorder: Relationship to clinical and
cognitive phenomena. Journal of Anxiety Disorders,
20, 10711086.
Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort, S.
I., King, R. A., Goodman, W. K., etal. (1997). Childrens yale-brown obsessive-compulsive scale: Reliability and validity. Journal of the American Academy
of Child & Adolescent Psychiatry, 36, 844852.
Silverman, W. K., & Albano, A. M. (1996). The anxiety
disorders interview schedule for DSM-IV child and
parent versions. London: Oxford University Press.

Stewart, S. E., Rosario, M. C., Baer, L., Carter, A. S.,
Brown, T. A., Scharf, J. M., etal. (2008). Four-factor
structure of obsessive-compulsive symptoms in children, adolescents, and adults. Journal of the American Academy of Child & Adolescent Psychiatry, 47,
763772.
147
Weisz, J. R., & Weersing, V. R. (1999). Developmental

outcome research. In W. K. Silverman & T. H. Ollendick (Eds.), Developmental issues in the clinical treatment of children (pp. 457469). Needham Heights:
Allyn & Bacon.
Treatment of Aggressive
Obsessions in Childhood
Disorder
11
Ella L. Milliner-Oar, Jacinda H. Cadman

and Lara J. Farrell
In this chapter, we discuss aggressive obsessions,

which are obsessions related to violence or harm
towards the self or others. Aggressive obsessions are highly distressing and prevalent, with
reports of 30 to 70% of youth obsessive-compulsive disorder (OCD) sufferers experiencing
these symptoms. We outline the phenomenology
and background literature on aggressive obsessions and then describe the case of a 16-year-old
male experiencing aggressive obsessions. Case
conceptualization, assessment, and treatment
using cognitive behavioural therapy (CBT) with
exposure and response prevention (ERP) are presented, followed by a discussion of complicating
factors, conclusions, and key practice points.
OCD is characterized by the presence of unwanted or intrusive thoughts (e.g. obsessions)
and behaviours or rituals (e.g. compulsions),
that are performed to reduce distress or prevent
a feared outcome (American Psychiatric Association 2013). OCD is highly heterogeneous in
nature with sufferers typically presenting with
an array of symptoms. Both children and adults
with OCD commonly report experiencing aggressive obsessions. Aggressive obsessions include unwanted thoughts, images, or impulses
related to harming oneself or defenceless others (e.g. stabbing oneself or a family member,
smothering a baby or beloved pet, poisoning a
E.L.Milliner-Oar() J.H. Cadman L.J.Farrell
School of Applied Psychology and Behavioural Basis of
Health, Griffith University, and Menzies Health Institute
Queensland, Gold Coast Campus, QLD, Australia
family member, or throwing themselves off a

balcony) (Moulding etal. 2014 ; Purdon 2004).
Moreover, they are often associated with a range
of overt (e.g. checking, seeking reassurance)
and covert (e.g. thought neutralizing, praying)
compulsions. For example, checking online
newspapers for reports of hit-and-run accidents,
ensuring knives are locked away, and seeking
reassurance by repetitively asking loved ones
if they are feeling okay. Covert mental rituals
may include thinking safe words, phrases, or
prayers in order to neutralize unacceptable or
dangerous thoughts (Abramowitz etal. 2003),
or mentally reviewing ones own behaviour to
manage an obsessional doubt related to mistakenly hurting. Aggressive obsessions are typically associated with significant avoidance of
triggers of intrusive thoughts, such as avoiding
using knives or driving, spending time with
loved ones, or even certain colours (black because it is associated with death), places (e.g.
hotels with balconies, or cemeteries), or numbers (e.g. number 6).
Within the current OCD literature, a number
of studies have examined whether OCD can
be categorized into different subtypes/dimensions based on patient symptom content. Factor
analytic studies of the YaleBrown ObsessiveCompulsive Scale (YBOCS; Goodman etal.
1989) have produced generally consistent results with four and five solutions including the
following dimensions: (1) symmetry and ordering, (2) contamination and cleaning, (3) sexual/
religious obsessions, (4) aggressive and check-

DOI 10.1007/978-3-319-17139-5_11
149
150
ing, and (5) hoarding dimensions (Mataix-Cols

etal. 2005; Storch etal. 2008). Notably, across
research groups, aggressive or harm-related
OCD symptoms have been conceptualized differently. It is currently unclear whether sexual/
religious obsessions and aggressive/checking
symptoms load onto a single factor (e.g. repugnant obsessions, forbidden thoughts, taboo
thoughts) or two separate factors (harming
and unacceptable thoughts). Similar symptom
dimensions have been found in children, with
the exception of checking which, in adult studies, tends to load on the aggressive dimension,
compared to the symmetry subtype in children
(Bloch etal. 2008).
Aggressive obsessions are both highly prevalent and disturbing for sufferers. Estimates suggest approximately 4550% of adult OCD sufferers (Pinto etal. 2008; Rasmussen and Tsuang
1986) and 3070% of children and adolescents
with OCD experience aggressive obsessions
(Geller etal. 2001; Storch etal. 2008). Moreover,
2030% of OCD patients report that forbidden
obsessions (e.g. aggressive, sexual, or religious
obsessions) are their primary concern (Freeston
etal. 1997; Stein etal. 1997). Indeed, those who
report experiencing harm-related or unacceptable obsessions have greater obsessional symptom severity in comparison to those who have
contamination, symmetry, or hoarding-related
OCD (Abramowitz etal. 2003). Some research
suggests that the forbidden thoughts OCD subtype is associated with a unique demographic and
comorbidity pattern. In adult samples, a number
of studies have found that the aggressive, sexual
and religious, somatic obsessions, and checking
compulsions subtype are more likely associated
with being male, having early-onset OCD (<16
years) and comorbid anxiety (in particular social
phobia), depression, alcohol and substance use
disorders, and body dysmorphic disorder (Denys
etal. 2004; Hasler etal. 2005). In a recent study,
Brakoulias etal. (2013) found that unacceptable/taboo thoughts were associated with higher
scores on the YBOCS obsession scale, being
male, having a past history of non-alcohol-related
substance dependence, and previously received
E. L. Milliner-Oar et al.
OCD treatment (either medication or behavioural

intervention).
The cognitive behavioural theory of OCD
proposes that cognitive content and processes,
such as beliefs related to inflated responsibility,
overestimating threat, need for perfectionism
and certainty, over importance, and the need to
control thoughts, are related to the development
and maintenance of OCD (Obsessive Compulsive Cognitions Working Group 2005). To date,
several studies have examined the specific relationships between obsessional beliefs and OCD
symptom dimensions. In a large sample of adult
OCD sufferers (n=135), Wheaton etal. (2010)
found that responsibility and threat overestimation beliefs predicted responsibility for harm
symptoms, whereas importance/control of
thoughts beliefs were associated with the unacceptable thoughts dimension of OCD. In a
more recent study of 154 adult OCD sufferers,
Brakoulias etal. (2014) found that responsibility and threat overestimation had a strong association with the OCD symptom dimension of
doubting or checking. Consistent with Wheaton
etal. (2010), the importance/control of thoughts
obsessive belief was related to the unacceptable/
taboo thoughts symptom dimension. These studies suggest that obsessive-compulsive (OC) beliefs, specifically those related to the importance/
control of thoughts and responsibility/ threat estimation, are particularly salient for patients with
aggressive obsessions and are likely to be important targets in treatment.
CBT which includes ERP is considered the
first-line treatment for mild to moderate OCD
in children and adults (Geller and March 2012;
National Institute for Health and Clinical Excellence 2005). For those sufferers with moderate
to severe OCD, CBT in combination with serotonergic (serotonin reuptake inhibitor, SRI)
medication is recommended. Several studies
have examined differential responding to CBT
as a function of OCD subtype. Early research
in this area proposed that OCD sufferers who
engaged in covert rituals, such as mental ritualizing, would respond less favourably to CBT
(Baer 1994; Lee and Kwon 2003). However,
11 Treatment of Aggressive Obsessions in Childhood Obsessive-Compulsive Disorder
this does not appear to be the case with multiple

studies in adults and children finding no differences in treatment responding in relation to this
OCD symptom. Abramowitz etal. (2003) examined response to ERP in a sample of 123 adults
with a primary diagnosis of OCD. Patients were
categorized on the basis of their symptom presentation with five patient clusters identified
(e.g. harming, contamination, hoarding, unacceptable thoughts, and symmetry). Mental compulsions had the greatest prevalence among patients within the unacceptable thoughts group,
who experienced intrusive and distressing religious, violent, or sexual thoughts. The results revealed that across the OCD subtypes only those
with hoarding symptoms responded less favourably to ERP in comparison to the other OCD
subtypes. Similarly Rufer etal. (2006) found
that those who presented with primarily hoarding symptoms were significantly less likely to
be treatment responders than those with other
obsessions (e.g. symmetry/ordering, contamination/cleaning, aggressive/checking, sexual and
religious obsessions). In a paediatric sample
(n=92), Storch etal. (2008) found trends consistent with the adult literature with youth who
presented primarily with symptoms of hoarding, displaying the poorest treatment response;
however, due to limited power, significant differences were not observed between the groups.
Interestingly, the results also showed that youth
presenting with aggressive/checking symptoms
were significantly more likely than youth presenting with other symptoms (e.g. symmetry/
ordering, contamination/cleaning, sexual/religious, and hoarding) to respond positively to
treatment, with children and adolescents in aggressive/checking group exhibiting greater pre-/
posttreatment change on a clinical impression
of severity rating. In summary, research suggests that patients with aggressive obsessions
appear to have a similar treatment response to
other OCD subtypes despite the use of mental
compulsions. In fact, it appears that aggressive/
checking symptoms in children and adolescents
may be associated with an improved treatment
outcome. The following case example describes
the assessment and treatment of a youth who
151
presented with aggressive obsessions and associated compulsions.
Presenting Problem
Daniel, a 16-year-old Caucasian male, in his final
year of high school (grade 12), was referred to
the Griffith University OCD Program by his general practitioner for treatment. During his initial
assessment, Daniel reported that he was plagued
by thoughts that he would hurt himself. He feared
that he would walk in front of cars and buses on
his way to and from school, that he would hurt
himself if he was at home alone (either by taking
a knife to his wrist or by jumping out of a window), and that he would drown himself when out
surfing with his friends. Daniel was also learning
to drive and worried that he would drive his car
off the road or into the oncoming traffic. Daniels
most pressing concern was how he would cope
with his upcoming Schoolies Week (a rite of
passage for school leavers who travel from across
Australia to stay at the Gold Coast for 1 week to
celebrate the end of their schooling), where he
feared that he would throw himself off the balcony of a hotel. Daniel had seen a news story the
previous year about a school leaver who had died
after falling from a balcony whilst partying with
friends at Schoolies Week.
Daniels thoughts about hurting himself
caused him significant distress, and he reported
having to engage in various rituals to neutralize
the anxiety they caused, such as repeating safe
thoughts (i.e. I am safe and alive, and my family
protects me); engaging in lengthy checking routines (including checking for reassurance from
his mother that he would not hurt himself or anyone else); avoiding being home alone; and avoiding drinking at parties in case alcohol caused him
to act on his aggressive thoughts. Daniels fear of
hurting himself was starting to cause some difficulties with his peers as he was frequently avoiding social activities such as surfing and going to
parties and would repeatedly ask annoying questions to seek reassurance.
In addition to the fears of hurting himself,
Daniel also worried about harm coming to others,
152
Table 11.1 Summary of Daniels presenting obsessive-compulsive symptoms

Obsessions
Compulsions
Driving into oncoming traffic
Gripping steering wheel and tensing arms
Harm to self
Checking car mirrors
Driving in lane furthest from oncoming traffic
Mental ritualprayer
Checking that the car is not damaged
Walking in front of oncoming traffic
Walking on the inside of the footpath
Asking his mother to drive him to school
Jumping off a balcony or out of windows Checking windows and balcony doors locked
Family accommodationparents checking locks
Avoiding standing on balconies
Avoiding attending parties or drinking alcohol
Slashing wrists when using knife or
Avoiding using a knife
scissors
Checking knives are put away in lockable kitchen
draws
Avoiding being home alone
Drowning himself
Avoiding surfing and fishing
Family member being hurte.g. mother Check whether the house is locked
Harm to others
violently attacked by an intruder or dying Neutralizing thoughts
in a car accident
Stopped fishing
Parents repeating sentences before bed
Accidently driving into someone, hit
Checking the car for damage, checking mirrors,
and run
checking Internet
Strangling his pet bird
Moving bird cage to laundry
Not interacting with birdfeeding and cleaning
cage
Bad karma
Avoid fishing and killing fish
Feel uncomfortable or not right
Repetitively wax his surfboard
Just right
Illness or disease (e.g. skin cancer)
Check his body
Somatic
Check health websites
Ask his mother for reassurance
especially to loved ones. He worried about being

responsible for his families wellbeing, for example, he would worry that if he did not check
the front door was locked then he would be responsible for an intruder breaking into the house
and violently attacking his mother. He also had a
belief that his favourite past time, fishing, might
lead to bad karma (for killing fish), which
would cause something terrible to happen to his
parents. Daniel had recently stopped fishing because of this, which upset him considerably and
led to more social avoidance. Daniel was worried
about hitting people with his car and was avoiding taking driving lessons to get his licence. He
was also fearful of having a bad thought about
a loved one in case it came true, and he would
spend much time suppressing these thoughts

throughout the day. Daniel also had a fear that
he would hurt the family peta bird named Kai.
Daniel reported having intrusive thoughts that he
would strangle the bird to death and had therefore asked his mother to move the bird cage to the
laundry to avoid seeing it.
Daniel involved his family in several of his
rituals, such as asking them to repeat certain
sentences before bed to ensure their safety and
asking his mother to lock the windows so that he
would not be able to jump from them. He also
sought excessive reassurance from his parents
and sister that nothing bad would happen. Please
refer to Table11.1 for a summary of Daniels presenting symptoms.
Case Information
Background
Daniel was born on the Gold Coast, Australia,
and he and his older sister Maggie (19 years)
lived with their mother in a middle-class beachside suburb. Daniels father had moved away
from the Gold Coast 8 years earlier, after he and
Daniels mother separated. Daniel stayed with
his father mostly during the school holidays and
some weekends. Daniel described his family relationships as close and explained that his parents
had always been very supportive of him. Daniel
attended a private school and performed well
academically. He particularly enjoyed physical
education and hoped to be a physical education
teacher after leaving school. Daniel had a close
group of school friends, but described himself as
one of the quieter ones in the group.
History
Daniel first experienced OCD-like symptoms
when he was in primary school at 9 years of age.
He would ask his mother to repeat saying certain
things, like have a good day and love you,
when she dropped him off at school. He also remembered having to get into bed at night a certain way to avoid bad things from happening and
retracing his steps until he felt just right. These
behaviours caused him only minimal distress and
did not impact significantly on his daily life.
According to his mother, Daniel suffered from
separation anxiety at 5 years of age when he first
started school; however, this resolved within the
first 12 months of his schooling. When Daniel
was 8 years old, his parents separated, and although Daniel was upset, he generally coped well
with the situation.
The onset of his current OCD symptoms was
at 15 years of age (one year prior to presenting).
The onset coincided with the tragic accident
of his sisters best friend who was involved in
a car accident where she was killed and her father severely injured. Daniels mother recalled
that Daniel would ask for reassurance that she
153
would drive safely following this incident. Daniels symptoms had progressively worsened over
the year before seeking treatment. He identified
his senior school exams and the pressure to get
his licence as ongoing stressors that exacerbated
his symptoms. In the few months prior to starting treatment, Daniel noticed a dramatic increase
in symptoms triggered by him and his friends
starting to organize their Schoolies Week accommodation in the Surfers Paradise on the Gold
Coast.
Daniels mother reported that she also suffers
from significant anxiety. She worries about the
future, performing at work, her children, and her
health, and she indicated that she finds it difficult
to control these worries. She expressed concern
that her worries about her family may have led
her to be overprotective of her children.
Treatment History
Daniel had never received treatment for OCD and
was first diagnosed at our initial assessment at 16
years of age. He was very reluctant to consider
taking medication for OCD due to concerns that
it might cause him to commit suicide by overdosing. He had never received any psychological
or medical treatment previously for any mental
health problem.

Assessment
Conceptualization
Daniel may have had a biological vulnerability
to developing OCD given that his mother has a
history of persistent anxiety. Furthermore, Daniel appeared to have an anxious temperament; as
a young child he experienced separation anxiety
and engaged in ritualized behaviours when feeling anxious about separating from his mother
and at bedtime. In combination with a biological vulnerability, stressful life events such as the
separation of his parents may have predisposed
Daniel to developing psychopathology. Despite
154
some subclinical OC symptoms during middle

childhood, Daniel appeared to have had an abrupt
onset of clinical OCD following the death of his
sisters friend. His symptoms were exacerbated
by the stressors of finishing his schooling, planning for his upcoming Schoolies Week and, not
surprisingly, his experience of learning to drive
was a salient trigger for his current episode.
Daniel held numerous dysfunctional beliefs in
regard to the experience of intrusions as well as
in relation to the content of his intrusions. Given
the relentless nature of obsessions, coupled with
poor inhibitory control associated with OCD, it
is proposed that appraisals about the occurrence
and meaning of intrusions develop and serve to
perpetuate the experience of these intrusions,
such that they become obsessional in nature and
therefore are associated with escalating distress,
and attempts to neutralize through overt and covert avoidance, and ritualizing.
It was hypothesized that Daniels fear associated with his obsessions resulted from his dysfunctional beliefs regarding the presence and
significance of his aggressive thoughts, and following this, his efforts to control these thoughts.
Daniel believed that he was responsible for his
own and his mothers safety (i.e. inflated responsibility bias). Moreover, he believed that simply
thinking about harming himself (e.g. cutting his
wrist, jumping off the balcony) would increase
the probability that he would indeed harm himself (i.e. thoughtaction fusion beliefs). Because
of this, Daniel tried to suppress his aggressive
obsessions (i.e. control of thoughts), exerting
mental control and ineffective suppression techniques, which in turn served to maintain these
dysfunctional beliefs about harm and responsibility for preventing harm, which led to Daniel
experiencing his intrusive thoughts more often
and with heightened anxiety and intensity.
Daniel avoided external fear triggers (e.g.
surfing, driving, patting his bird) to prevent himself from having to experience his aggressive
thoughts and the related distress they caused.
Moreover, Daniel engaged in rituals, such as repeating neutral thoughts, checking locks, checking that he had not been involved in a car acci-
dent, and seeking reassurance from his parents,

to decrease the anxiety associated with these
situations and the experience of intrusions. In
the short term, Daniels distress was reduced
when he could avoid his triggers or engage in
rituals. However, these strategies prevented him
from acquiring corrective evidence that he could
indeed tolerate uncertainty and discovering that
his obsessions, although unpleasant, were inaccurate. Hence, Daniels avoidance and ritualizing served to maintain his fear of these disturbing intrusive thoughts. Furthermore, the anxiety
associated with these thoughts was continuing to
worsen given the significant attention and preoccupation Daniel had with trying to not think
about them.
Despite the vicious cycle of obsessions and
fear that Daniel was caught up in, he had numerous protective factors present in his life, including a supportive mother and sister and a close
group of friends. He was also achieving well at
school and is of at least average intelligence.
Assessment
Diagnostic Interviews Daniel was administered
the Childrens YaleBrown Obsessive-Compulsive Scale (CYBOCS; Scahill etal. 1997), and
his score (30) fell within the severe range of OCD
symptomology. He scored a 17 on the obsessions
subscale and 13 on the compulsions subscale.
Additionally, Daniel and his mother were interviewed using the Anxiety Disorder Interview
Schedule for Children (ADIS-IV-C/P; Silverman
and Albano 1996). Based on Daniels report and
that of his mothers during the diagnostic interviews, Daniel was diagnosed with a primary
diagnosis of OCD, with a clinician severity rating
(CSR) of 7 (on a scale of 08) and major depressive disorder (MDD) with a CSR of 4 (on a scale
of 08; Fig.11.1).
Behavioural Approach Task (BAT)BATs are
standardized and controlled tasks designed to
assess how someone responds when exposed to

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Fig. 11.1 A cognitive-behavioural formulation of Daniels OCD. OC obsessive compulsive
feared stimulus. In particular, when avoidance is

pathological, a BAT provides a valid assessment
of both fear and avoidance behaviours in a standardized and systematic way. Moreover, once
exposed to the stimuli that elicit fear and avoidance, a child is more accurately able to gauge their
degree of distress, along with any dysfunctional
beliefs that they may experience in the context
of arousal. A BAT task for OCD can be set up as
a series of steps to measure approach/avoidance
or an ERP task whereby the child is instructed to
withhold ritualizing for a period of time (usually
5min only) to measure resistance and control,
as well as fear and fear-related beliefs. The child
is instructed that they can stop the BAT at any
time, and that following the BAT they are free to

engage in rituals to alleviate any distress.
A number of potential BATs were considered
for Daniel. For example: (1) taking Kai (Daniels
pet bird) out of his cage and holding him with
two hands around his body for 5min; (2) holding
a knife against his wrist for a period of 5min;
and (3) leaning over a three-storey balcony, dangling his arms over the edge. Given that during
the diagnostic interview Daniel indicated that
jumping off a balcony at Schoolies Week was
his most worrying OCD symptom at the time, it
was determined that he complete a BAT related
to this. During the BAT conducted on the university campus, Daniel was asked to enter a room
156
(by himself), walk towards a balcony door, open

the door, walk over to the railing of the seventh
floor balcony, dangle his arms, and lean over the
side of the balcony for 5min. Prior to commencing the BAT, Daniels obsessional beliefs and
fear level were assessed. Daniel reported that he
was afraid that if he leant over the balcony, he
would experience a strong urge to climb over the
balcony railing and end his life. Belief ratings
were assessed before and after the BAT, using
a 9-point Likert scale to measure intensity (i.e.,
0=not at all, to 10=extreme). Following these
pre-BAT ratings, Daniel was asked to enter the
room and try his best to compete as many steps
as possible, without seeking reassurance. Daniel
was able to enter the room and approach the balcony door; however, he was not able to open the
door. He rated his subjective anxiety at an 8 (on
a scale ranging from 0 to 10). He then rated his
belief that he would have the urge to jump (truth
rating=8), the chance his belief would actually
occur (probability=9), how bad it would be for
him if he did actually have the urge to jump off
the balcony (severity=9), and how sure he was
that he could cope if he did have the urge to jump
off the balcony (estimation of coping=2).
Self-Report Questionnaires In addition to diagnostic interviews and a behavioural approach
task, Daniel completed a number of self-report
measures. To assess for comorbid anxiety symptomology, the Multidimensional Anxiety Scale
for Children (MASC; March 1997) was used,
and to assess for comorbid depressive symptoms, the Childrens Depression Inventory (CDI;
Kovacs 1992) was used. Daniels scores on both
the MASC (total score=84) and the CDI (total
score=82) were very elevated. To assess for
OC-related dysfunctional beliefs, the Obsessive
Beliefs QuestionnaireChild Version (OBQCV; Coles etal. 2010) was also given as part of
a comprehensive assessment. This is a 44-item
self-report scale that measures belief domains
linked to OCD, including responsibility/threat
estimation, perfectionism/certainty, and importance/control of thoughts. Daniels score on
the OBQ-CV was above clinical norms (total
score=132).
Risk AssessmentGiven that Daniel presented

with thoughts of harming himself and others, a
brief risk assessment was conducted with Daniel. As previously discussed, a large proportion
of people who suffer from OCD report having intrusive violent, sexual, and death-related
thoughts. It is essential for clinicians to have
a sound knowledge of OCD phenomenology
in order to be able to differentiate between
thoughts and urges in people with OCD, in comparison to the thoughts experienced by those
who may be sexual or violent offenders or people who are actively suicidal (Veale etal. 2009).
If a child or adult is presenting with OCD, there
is almost a negligible risk that they will carry
out their obsession. Obsessions by definition are
intrusive and unwanted thoughts, which are ego
dystonic to the person. Moreover, an obsession
represents a fear that the person wishes to avoid
at all costs (Veale etal. 2009). To further assist
in differential diagnosis when assessing someone who has aggressive thoughts the following factors should be considered (adapted from
Veale etal. (2009)): (1) Are the thoughts ego
dystonic? (2) Does the person avoid situations
that trigger the thoughts? (3) Does the person
attempt to suppress or neutralize the thoughts?
(4) What is the dominant emotion the person
experiences when they have the thoughts (e.g.
anxiety, distress, or guilt vs pleasure)? (5) Does
the person have other symptoms of OCD? (6)
What other comorbid diagnoses does the person
have? (7) What is the persons motivation for
seeking help? and (8) Does the person have a
history of harming themselves or others? Whilst
minimizing the actual risk of a patient acting
on an obsessional thought, one must always be
diligent of the possible secondary risk of suicidal ideation, that might arise as a result of (a)
the sufferer choosing to hurt themselves rather
than endure the obsessional belief that they
might hurt someone else or (b) the sufferers
experience of hopelessness and despair associated with severe comorbid depression.
Daniel reported feeling extremely distressed
by thoughts of harming himself and others and
went to great lengths to avoid situations which
triggered his intrusive thoughts (e.g. stopping
157
Table 11.2 Overview of Daniels treatment

Session number
Session content
12
Psychoeducation
Nature and symptoms of OCD
Cycle of OCD
Treatments for OCD including CBT
Fear thermometer and monitoring OCD
Role of family accommodation in the maintenance of OCD
3
Introduction to ERP
Rationale for treatmentERP
ERP hierarchy development
Practice of ERP in session and at home
412
ERP and cognitive therapy
In session ERP practice: harm to self and others
In session exposure to obsessional thoughts
Thinking traps of OCDthoughtaction fusionmorality
Thinking traps of OCDthoughtaction fusionlikelihood
Thinking traps of OCDinflated probability of danger
Thinking traps of OCDinflated sense of responsibility
Thinking traps of OCDcontrol of thoughts
Home practiceERP to aggressive beliefs and stimuli being avoided
1314
Relapse prevention and planning for life without OCD
OCD obsessive-compulsive disorder, CBT cognitive behavioural therapy, ERP exposure and response prevention
surfing, fishing, not driving, and no longer caring for or spending time with the family pet).
Moreover, Daniel engaged in mental rituals in
an attempt to neutralize his thoughts. Daniel
also reported other OCD symptoms including
feeling just not right when waxing his surfboard and checking related to health and illness
concerns. Daniel presented with comorbid depression. Daniels risk of suicide was further
assessed. He reported having a low mood most
of the day, anhedonia, and lacking energy
symptoms that developed after his OCD worsened and during his current episode. Again he
reported that he did not wish to end his life. He
indicated that he felt his mood would improve if
he no longer had OCD symptoms. Daniel has no
history of depression, suicide attempts, or harming others.
Treatment
Daniel attended the Griffith University OCD
clinic for 141hour weekly sessions of CBT
(see Table11.2 for summary).
Treatment Modules
Psychoeducation
Daniels treatment commenced with psychoeducation. Both Daniel and his mother attended these
initial appointments during which they were provided with education regarding:
The nature of obsessions and compulsions
The cycle of OCD, including the role of neutralizing and avoidance
Externalizing OCD in order to cultivate
detachment and motivation for ERP
Treatment approaches for OCD, including
ERP
Using a fear thermometer (010) to rate Daniels level of distress or avoidance
Monitoring OCD symptoms and building a
fear hierarchy
The role of family accommodation in the
maintenance of OCD
Daniel was provided monitoring forms to record
the different faces (i.e. symptom clusters) of
his OCD symptoms for home practice. His parents were also encouraged to monitor ways in
which they accommodated to the demands of
158
OCDincluding modifying their routines and/

or expectations, assisting with the completion of
rituals, or facilitating avoidance behaviours.
Exposure and Response Prevention

The majority of Daniels treatment consisted of
ERP, which was graded and completed at a pace
that Daniel found manageable. Daniel completed
most ERP sessions on his own, but on occasion it
was helpful to include his mother in sessions to
illustrate the nature of anxiety, specifically that
Daniel could cope with and would habituate to
the anxiety, reinforcing that she did not need to
accommodate OCD and protect him from these
feelings. Some sessions also involved his mother
as part of the ERPsuch as holding a butchers
knife whilst having a coffee with his mother.
From Daniels OCD monitoring and the information elicited from the CYBOCS, we formed
exposure hierarchies for each symptom cluster
of his OCD, and broke down steps as necessary.
Daniels fear of harming was broken into two hierarchies: one for fear of harm to self and one
for his fear of harming others. These are detailed
below in Figs.11.2 and 11.3.
Daniel was encouraged to address the least
distressing symptom from each hierarchy to
begin with. These behaviours were broken down
into smaller steps where required so that steps
were manageable and achievable. Once Daniel
chose a symptom that he wanted to work on, we
discussed potential ERP steps which he could use
to fight against OCD and finally agreed on a specific task to practice. ERP tasks ideally always
involved complete response prevention, although in some cases when this was too difficult
for Daniel (e.g. such as resisting his covert prayer
ritual), his exposure task could involve changing
the compulsion in some way, such as reducing
the number of repetitions of the compulsion, delaying the compulsion, or doing it differently
which was termed messing with OCD. For
example, if he engaged in his prayer ritual, help
me God stay safe and alivehe would then say
aloud something opposed to this, which left him
in a state of uncertainty, such as or let me die
whatever will be, will be. To ensure he did not
develop a new ritual, Daniel made a list of OCD
antagonizes that he could use to spoil any covert

ritualizing that occurred.
Behavioural experiments were carried out
during ERP sessions, whereby Daniel would give
his OCD predictions about what would happen,
as well as his expectation regarding how anxious
he would feel, and to what degree he would cope.
Subjective units of distress (SUDs) ratings were
taken immediately after the ERP commenced and
at regular time intervals during the task. If Daniels anxiety had not reduced by at least half by
the end of the session, he was asked to wait in the
clinic waiting room until it had. Through ERP,
Daniel gained corrective evidence that the feared
outcome did not occur, or that there was no way
of knowing whether everything would be okay or
not. What he did learn was that he could indeed
tolerate the anxiety and that the anxiety always
did pass (via habituation) and, moreover, that his
actual anxiety was usually lower in intensity than
expected and reduced faster than anticipated.
After making significant progress with his exposure hierarchies to address his fear of harming
himself and others, an additional hierarchy was
developed to directly expose Daniel to the content of his obsessions and intrusive thoughts. At
this point in time, Daniel had already been taught
a number of cognitive strategies to address his
dysfunctional beliefs associated with OCD and
additionally he had a good understanding of the
rationale for exposure therapy and had experienced success following earlier exposures. When
working with a patient who experiences intrusive
violent or sexual obsessions, it is important to
ensure exposure is gradual and under the control
of the patient. By saying a particular word aloud
that the patient is avoiding (e.g. funeral), the therapist may inadvertently flood the patient, and if
this were to occur early in therapy, it may lead to
patient drop out or treatment refusal.
Daniels hierarchy for these obsessional symptoms was broken down as detailed in Fig.11.4.
The exposure to obsessional content generally
begins by having the patient record single words
that elicit fear over a period of a week. Then the
therapist builds upon this to successively have
the patient write the words in session, to say the
words aloud, to yell the words, and eventually
159
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Fig. 11.2 Example steps from Daniels exposure hierarchyharm to self
write detailed scripts of obsessional content. The

goal is then to have the patient expose himself or
herself to the thought content continuously using
loop recording technology, so that they can ultimately experience habituation to their dreaded
obsessions. It is important that this task only occurs when the patient is ready and able to tolerate
this exposure, and that they understand that each
exposure can only cease when their SUDs ratings
decrease to a 1 or 2 on their SUDs scale from 0
160
STEP 6
Enclose hands completely around the bird body and
head for 2 minutes, saying I will kill you
Do not check house is locked and do not say
goodnight to mum
Go fishing alone and kill and eat any fish caught
No checking related to harming other when driving
STEP 5
In session
Sit with butchers knife against mums neck in room alone
At home practice
Do not check house is locked. Mum to repeat silly goodnight
saying hope I see you in the morning.
Go fishing alone. If catch a fish kill it.
Hold bird and say I hope I dont accidently break your neck
STEP 4
In session
Pat bird while on your finger say I might hurt you
Go for a drive whilst talking about hitting people and not checking
At home practice
Do not check house is locked.
Mum to not say goodnight
Go out fishing and fish yourself. If catch a fish have friend kill it
STEP 3
In session
Pat the bird while mum holds him in session
Sit with butcher knife against mums wrist
At home practice
Mum to say goodnight I love you, the family is safe 1x per night no note to check
No checking car for damage, or internet for accidents
Pat bird each day
STEP 2
In session
Hold butcher knife while having a coffee with mum, therapist present
Read newspaper articles about pedestrian hit and run accidents without asking Qs for reassurance
At home practice
Feed bird and change water. Clean the bird cage while mum holds the bird
Go out in a boat with friends and fish. If catch fish release it without performing any rituals.
Do not check car for pedestrian damage after parking the car
STEP 1
In session
Hold butcher knife while talking to therapist
At home practice
Move birdcage from laundry to family room
Check house is locked 1x at night. Mum to say goodnight ritual once I love you, the family is safe & direct
Daniel to a poster note that mum had the ritual written on.
Go out in a boat with friends who are fishing to observe only
Fig. 11.3 Example steps from Daniels exposure hierarchyharm to others
to 10. Mistakes in ERP to obsessions occur when

patients escape exposure too early, when they do
not practice regular daily ERP, and when they
engage in distraction or neutralizing during the

ERP practice. Once the patient has accomplished
these steps, their behavioural ERP tasks should
161
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also include ERP to intrusion for maximum effectivenesssuch as listening to a loop tape
about purposefully running down an unsuspecting pedestrian whilst driving the car.
Towards the end of the treatment and to maximize ERP learning, we involved Daniels mother in ERP to obsessional content. For example,
during one session we asked his mother to walk
across the road whilst Daniel remained in the
therapy room and imagined that she would be hit
by a car, then being rushed to hospital, and dying
(his biggest fear). Although this understandably

caused Daniel some distress, it occurred during
a stage in treatment where he was able to agree
that the likelihood of this tragedy occurring was
negligible and that there was no logical connection between his thoughts and endangering those
he loved.
A home practice ERP for Daniels fear that he
would cause his mother a bad accident by thinking bad thoughts occurred via an audio-taped
ERP task. This involved Daniel recording himself
162
saying his worst imaginable fears about harm to

his mother, as a result of his actions or thoughts.
We randomly scheduled his smartphone alarm
for various times throughout the week at which
point he would be required to listen to the 1min
recording repeatedly until he habituated to his
anxiety. The script is presented below:
After a big day fishing and my selfish act of killing
a fish, I have brought bad karma on my family. I had
a thought of mum being killed right at the moment
I killed the fish. Mum was driving home from
work along the highway. The traffic was building
up and she didnt notice the car in front slowing.
She slams her breaks on too late and although she
tries to veer to the right, she hits the back of the
car in front of her, which sends her sliding into
the concrete barrier. She is trapped in her car and
unconscious. Her head has hit the windscreen and
is split open. Blood is pouring down her face. Her
arm is facing an unnatural angle and her legs are
trapped by the dashboard. She's barely breathing.
A witness calls the ambulance who arrive as soon
as they can. The fire brigade have to free mum
from the car. She has lost a lot of blood and the
paramedics carefully move her to the ambulance
and she's rushed to the emergency department at
the Gold Coast Hospital. I'm called shortly after
arriving home from fishing by a nurse who asks me
to come into the hospital immediately. I see mum
lying on a hospital bed with her eyes closed and
cuts over her face. There is a very deep gash on
her forehead. She doesn't know that I'm there and I
can't speak to her because she's rushed by the staff
into surgery as soon as I arrive. There are lots of
noises (machines beeping and people yelling) and
it smells like disinfectant. After an hour the doctors tell me that mum has died due to her extensive
injuries. I no longer have my mum.
Other Cognitive Treatment Approaches

In addition to ERP, cognitive techniques were
used to augment ERP and address Daniels
dysfunctional beliefs related to his aggressive
thoughts. Daniel was provided with education regarding the various thinking traps of OCD (i.e.
beliefs pertaining to the core obsessional beliefs
domains referred to by the obsessive-compulsive
cognition working group (OCCWG; 2005). Over
the course of therapy, he completed activities and
behavioural experiments aimed at challenging
his dysfunctional beliefs. Daniel was taught to be
aware of OCD thought traps and to use smart
thoughts to fight back against OCD. Through-
out the therapy, Daniel was encouraged to write

his smart thoughts onto post-it notes and stick
them in places where his obsessions were triggered (e.g. window locks, on the edge of his rear
view mirror in the car) to remind him to fight
OCD.
Inflated Estimates of the Probability of Danger Daniel was taught that OCD tricks him by
making him believe the likelihood of something
bad happening, which was in fact far greater than
it actually was. To challenge these beliefs, Daniel
and his therapist generated a list of all the steps/
events that would have to happen for his mother
to be violently attacked by an intruder. This exercise assisted Daniel to realistically estimate the
probability of his mother being attacked. For
home practice, Daniel was encouraged to use his
smart thoughts (There goes OCD exaggerating again) and to check the chances of his
feared outcome actually occurring when he felt
anxious.
Inflated Estimates of the Responsibility for Danger Daniel was informed that another thought
trap of OCD was his exaggerated sense of responsibility for preventing harm (e.g. Salkovskis
1985). OCD led Daniel to believe that he was
responsible for protecting his family, and that
he had to engage in ritualizing to prevent them
from being harmed. He completely believed that
it would be his fault if something bad happened
to his mother or sister. Moreover, Daniel believed
he needed to keep other drivers and pedestrians
safe from himself, because he feared he would
cause an accident, and therefore be responsible
for harming someone. The therapist discussed
with Daniel that occasionally bad things do happen; however, there are multiple reasons for
accidents and danger, most of which are outside
our controland hence, not our responsibility.
Together Daniel and the therapist made a list
of reasons that might lead to someone hitting a
pedestrian or having a car accident. For example,
the therapist highlighted to Daniel that some reasons for a car accident may include a pedestrian
not looking before crossing the road, a pedestrian being drunk or having taken drugs and fall-
ing onto the road, being rear-ended by another

car, another car merging into your lane without
checking, or another car running a red light.
The therapist pointed out to Daniel that all these
reasons for having a car accident would not be
the drivers fault. With the therapists assistance
Daniel made a pie chart of all the causes of car
accidents that they had identified (e.g. van Oppen
and Arntz 1994). Each reason was assigned a proportion of the pie chart in terms of the likelihood
that each would be responsible for an accident.
Lastly, Daniel assigned a segment of the chart to
his OCD fear (e.g. that he would cause a car accident because he had the thought that he might).
This activity assisted Daniel to understand that
there are multiple reasons that may lead to an
event occurring, which are not under his control or his fault, and which ritualizing would not
help prevent. For home practice, when driving,
Daniel was encouraged to use his smart thoughts
(I cannot control everything, Bad things DO
sometimes happen but doing an OCD habit cannot stop them from happening, and OCD habits
only make OCD stronger).
ThoughtAction FusionMorality Daniel learnt
that another trap of OCD was his belief that he
was a bad person because of having aggressive
thoughts. To challenge this cognitive bias, the
therapist discussed with Daniel normative information about experiencing violent and repugnant
thoughts. Daniel was given a list of aggressive
and intrusive sexual thoughts reported by university students who did not have OCD (Clark 2004;
Purdon 2004). Additionally, Daniel was encouraged to complete a survey of practitioners in our
OCD clinic and trusted others (e.g. mother, sister,
close friend) about whether they ever experienced
intrusive aggressive thoughts (e.g. jump off a balcony or drown yourself). From this experience,
Daniel learnt that the content of his thoughts was
no different from others. The therapist explained
to Daniel that the only difference between himself and others was his appraisal of the thoughts
as threatening and personally relevant. Additionally, it was brought to Daniels attention that his
obsessions (particularly those related to strangling his bird) caused him significant distress and
163
that instead of indicating he was bad, disturbed,

or dangerous for thinking this way, his distress
paradoxically highlighted his morality (e.g. if
you were a psychopath you would enjoy having
these thoughts and would not be distressed when
they entered your mind; see Rachman 2007). For
home practice, Daniel was encouraged to use
his smart thoughtsthis is just another OCD
thought trap; my thoughts are no different to
anyone else; and that is an odd thought that
just popped into my mind. Over the course of
therapy, the personal meaning behind Daniels
intrusive thoughts changed for Daniel from being
appraised as threatening, to being interpreted as
benign and random events. At the conclusion of
treatment, the frequency of Daniels intrusive
thoughts had declined significantly, and, most
importantly, when they did occur, they were no
longer appraised with alarm and/or avoidance or
attempts to neutralize.
ThoughtAction FusionLikelihood Daniel was
taught that OCD trapped him by making him
believe that his thoughts can influence external
events and make them more likely to happen. For
example, OCD led Daniel to believe that if he
thought about his mother being in a car accident,
this increased the chance of her actually having
a car accident. The concept of thoughtaction
fusion was demonstrated to Daniel by having
him picture in his mind leaving the psychology
clinic, walking to the car park, picking up a rock,
and smashing the windscreen of his therapists
brand new car. Daniel was instructed to imagine engaging in this activity in vivid detail and
to hold this thought and/or image in his mind.
Following this imaginal exposure, a discussion
followed about whether there was an increased
risk of Daniel damaging his therapists car, since
he had thought so intently about doing this. This
exercise taught Daniel that thoughts were not
magical and could not make something happen.
As previously discussed, behavioural experiments were conducted with Daniel in session and
at home to test out whether Daniels beliefs were
correct, that is, that thinking about harm coming
to others actually increased the likelihood of this
occurring. The latter steps of Daniels exposure
164
hierarchy to his obsessions specifically involved

him writing a worry script, which gave a
detailed account of his mother being killed in a
car accident. Daniel listened to the script on his
smartphone daily. This assisted him to learn that
thinking about something does not make it more
likely to happen. For home practice, Daniel was
encouraged to use his smart thoughts to manage
his dysfunctional beliefs as well as test the limits
of OCD by purposefully saying I will probably
kill someone today and mum might die today.
Control of ThoughtsDaniel learnt that OCD
tricked him by making him believe he should
be able to control his thoughts. Because of
Daniels appraisal of thoughts of being harmful
and personally relevant to him, he would go to
great efforts to suppress his obsessions. Daniels subsequent failure to suppress his obsessions served to maintain his anxiety and resulted
in him placing further emphasis on the importance of these thoughts (e.g. I cant stop thinking about strangling the birdI must be going
crazy). The therapist pointed out to Daniel that
despite all the energy he was investing into not
thinking about his obsessions, the thoughts kept
returning. Daniel was provided with education
about thought suppression and the paradoxical
effects, whereby there is a resurgence of the
thoughts being avoided following suppression.
He was informed that suppressing his unwanted
thoughts was actually having the opposite effect
with the thoughts becoming more frequent,
rather than less frequent. This was demonstrated
to Daniel by having him engage in a suppression
experiment. David was first instructed to imagine a pink, fluffy elephant, and to visualize this
image in detail, in his mind for a period of 2min.
He was then instructed to try to not think about
the pink elephant for 2minusing all of his
mind power and suppression attempts. During
the 2-min period, Daniel was required to tally
the frequency with which thoughts about a pink
elephant entered his mind. Daniel indicated that
he found the task very challenging. The therapist highlighted to Daniel that his OCD thoughts
were just like the pink elephant thoughts. The
more he tried to avoid them, and push them out
of his mind, the more frequently they entered his

mind. Instead of suppressing, fighting, or trying
to cancel his thoughts, Daniel learnt strategies to
respond differently when the obsessions entered
his mind. He was encouraged to stay calm,
acknowledge the thought, take a slow breath,
smile, refocus on what he was doing, and simply allow the thought to pass. When his intrusive thoughts entered his mind over the week
Daniel practiced using his smart thoughts and
responding differently to his intrusions by telling himselfAn OCD thought just popped into
my mind, I dont need to do anything. I just have
to wait until it goes (Fig.11.5).
Relapse Prevention
Daniels final sessions focused on understanding
that lapses or setbacks were normal and assisted in teaching Daniel strategies for managing
relapse prevention. To assist in the generalization
of his skills, the therapist described to Daniel and
his mother symptoms of contamination-related
OCD, for Daniel to try and recognize the onset of
different OCD symptoms. Following this, Daniel and his mother practised generating exposure
hierarchies for this alternate face of OCD and
discussed how Daniel could also apply the cognitive strategies he had learnt to this type of OCD.
Daniel was encouraged to identify stressful times
over the next few months, which may put him at
higher risk for an OCD setback. Daniel indicated
that transitioning to university in the New Year
would be stressful for him. He was encouraged to
be aware of any OCD symptoms returning during
this time, and if this did happen, to address his
symptoms immediately by reviewing his OCD
fighting strategies, developing new exposure
hierarchies with his mother, and, if necessary,
contacting his therapist for a booster session. As
Daniel had significantly more time available to
him, given he was no longer spending hours engaging in his compulsions, the remainder of the
final session was focused on generating ideas
with Daniel for new healthy habits and rituals
for his life free from OCD. Daniel decided that
three times a week, even if he was busy with
grade-12 school work, he would make a point
of going surfing, as this helped reduce his stress.
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Fig. 11.5 Patient handout obsessive-compulsive disorder (OCD) busters program. (Farrell and Waters 2008)
On weekends, Daniel also aimed to catch up with

his school friends on at least one occasion, and
go Friday-afternoon fishing, and to enjoy regular
fish and chips on Friday night (hopefully Daniels catch!). Additionally, Daniel and his mother
decided once a month to have a family movie
marathon night, where they would order take
away and watch DVDs.
Post Assessment
Following treatment Daniels OCD symptoms
had reduced significantly. His CY-BOCS score
was 5, indicating OCD within subclinical/normal
range. Furthermore, on the basis of the ADIS-P,
Daniel no longer met criteria for OCD (CSR=2),
and his CSR rating for MDD was at a 1 (subclinical level). Daniel completed all steps involved in
the post-assessment BAT. He walked over to the

railing of the seventh floor balcony and dangled
his arms and leant over the side of the balcony for
5min without any difficulty (SUDs rating=0).
Indeed, he even sang a rap song about jumping
off the balcony and bouncing on the boardwalk.
Daniel reported no longer having to avoid surfing or driving. He indicated that he no longer
suppressed or neutralized his thoughts. Daniels
mother stated that Daniel did not check locks at
home or ask her for reassurance. We received
an email from Daniel in December that year. He
reported that he had attended Schoolies Week
and had the time of his life! He was able to stand
on the balcony of the 16th storey of their building. He also indicated that he had successfully
passed his drivers licence test.
166
A number of challenges arose over the course of
Daniels treatment due to his reluctance to discuss the content of his obsessions and the high
levels of distress he experienced when his obsessions were triggered. During Daniels initial
assessment the therapist summarized Daniels
OCD symptoms and whilst doing so commented
you worry that your mother will be killed.
Hearing the word killed spoken aloud caused
substantive distress for Daniel. He became tearful and indicated that he wanted to leave and
that he did not believe therapy would assist him.
Fortunately, the therapist had been able to build
rapport with Daniel throughout the CYBOCS interview and was able to assist him to calm down.
She then used the incident as an opportunity to
teach Daniel about the strength of OCD and
to help him to understand that his OCD would
weaken as he became stronger and more able
to tolerate OCD thoughts and resist OCD habits throughout treatment. The therapist arranged
with Daniel to say something bad instead of
kill or die until he developed more strategies
to help him cope with his anxiety.
Creating a trusting environment is essential
for effective therapy with patients who report
aggressive obsessions. When commencing
therapy patients may be reluctant to disclose the
full extent of their intrusive thoughts for fear
of being judged or due to concerns related to
thoughtaction fusion (e.g. If I hear the word
die my mother will be more likely to die). It
is essential from the outset of an OCD assessment to normalize the range of symptoms an
OCD sufferer may have and to begin to cultivate detachment from the OCD thoughts (e.g.
It must be really distressing/annoying when
OCD makes those thoughts get stuck in your
mind). If, however, a patient has been unable to
disclose these thoughts during the assessment,
then it is important over the course of therapy,
as part of exposure, to have the patient disclose
these thoughts in more detail. During the initial assessment, however, clinicians need to be
careful of the language they use when probing
patients for information and, if unsure, ask patients whether there are words they feel uncomfortable hearing.
As previously discussed, towards the end of
Daniels treatment an exposure hierarchy was developed to specifically target Daniels intrusive
thoughts (refer Fig.11.3). Daniel made steady
progress with step 1 and 2 of this hierarchy; however, he experienced considerable difficulty with
step 3 (e.g. make a voice recording of how he
might kill himself). Daniel was able to successfully complete the step in session with his therapist, recording a script about slashing his wrists
with a knife. For home practice, his therapist requested he listen to the recording once a day continuously until his anxiety had declined. Daniel
returned the following week and reported that his
OCD symptoms had significantly worsened and
that he was feeling depressed. When reviewing
Daniels home practice, he reported that 3 days
after his previous session he had listened to his
recording and that he became so distressed he
had stopped half way through. He indicated that
he tried again the next day and was also unsuccessful, and he indicated that his SUDS were a
9/10. To manage this set back, Daniels therapist
re-educated him about the process of habituation
and informed him that listening to the recording
only once and escaping prior to habituation may
have potentially increased his anxiety and reinforced his fear of his intrusive thoughts. Daniel
and the therapist problem solved how to break
this exposure step into smaller, more manageable
steps. Daniel indicated that initially it would be
easier if his mother could sit near him whilst he
was practising, and then he would work towards
practising alone. It was agreed that Daniels
mother would sit quietly in the next room so as
not to be distracting during exposure. Moreover,
it was decided that Daniel would use a voice-altering application on his smart phone and record
his script in Donald Ducks voice. He would then
listen to this for a few days and once he felt comfortable, would progress to listening to his own
voice reading the script.
Those OCD sufferers who experience aggressive or sexual obsessions find their intru-
sive thoughts highly distressing and go to great

lengths to avoid triggers of their thoughts. When
exposing patients to their obsessions, it is important that they have a sound understanding of the
rationale for these tasks and that they are aware
of the importance of listening to the recording
until their anxiety habituates. If patients practise
inconsistently or finish practising before their
anxiety has habituated, the fear and avoidance
associated with the obsession may actually increase, and there is then a risk on patient disengaging from treatment.

In sum, treatment of aggressive obsessions
requires systematic and comprehensive clinical assessment, followed by data-driven, individualized formulation and treatment planning.
Understanding the patients unique underlying
fear beliefs, their emotional responses and neutralizing strategies informs the development of
targeted ERP to their core fears and obsessional
beliefs. The experience of aggressive obsessions is usually extremely distressing, as well
as shameful for a patient, and the pathological
avoidance of these thoughts, usually for some
time before seeking treatment, means that patients are very scared about disclosing these
often disturbing and violent thoughts and images. Taking time to carefully assess, formulate, and educate the patient about their OCD,
presents a major therapeutic opportunity to
normalize their symptoms and elicit some hope
for recovery. Therapy for OCD, and indeed aggressive obsessions is by no way a walk in the
park. Providing a good rationale for therapy
and socializing both the child and parent to
what therapy involves (i.e. gradual and therapist-assisted ERP) provides a solid base for effective, family-based treatment. Therapists who
are steadfast in their beliefs that OCD can be
overcome, who show no fear in reaction to a
childs often extreme anxiety about their OCD
symptoms, and who are warm, supportive, and
can relate to the child and family, are likely to
167
experience great success with evidence-based

exposure-based therapy to repugnant and violent, aggressive obsessions.
Key practice points to consider for the treatment of aggressive obsessions include:
Conduct a thorough assessment of obsessions
and compulsions using the gold-standard
CYBOCS checklist , in combination with
clinical interviews, BATs, self-report measures of associated symptomatology, and child
and parent monitoring of symptoms.
Develop a data-driven cognitive-behavioural
formulation of symptoms, identifying and
differentiating intrusions, from pathological
appraisals and faulty beliefs related to the
occurrence and meaning of intrusions, avoidance strategies (overt and covert), ritualizing
and family accommodation.
Provide psychoeducation on the nature of
OCD, the role of family accommodation, the
cognitive-behavioural model of OCD, the
rationale for treatment, and the nature of OCD
thinking traps in maintaining and exacerbating intrusions, fear, avoidance, and the urge to
ritualize.
Target obsessional content using gradual,
imaginal, and in vivo, therapist-assisted ERP,
along with daily practice of ERP at home and
across context.
Start slowly with exposure to obsessional contentdo not assume that the child can tolerate
discussing their most severe obsession early
in therapy. Ask the patient to begin with writing down obsessional thoughts (using just one
word to begin with) to begin exposure to their
obsessions. When the patient is ready, progress exposure to audio-taped (their voice)
narratives of their worst obsessional fears
without neutralizing, until the child achieves
habituation, at regular practice intervals.
To maximize ERP outcomes, use in vivo
ERP as much as possible, focus on response
prevention (rather than delaying or reducing
compulsions), aim for over learning (push
the OCD limits), combine exposure to obsessional content with active ERP to stimuli that
elicits fear or uncertainty (i.e. have the patient
168
say they are going to kill themselves, whilst

holding a knife to their wrist) .
Ensure the patient does not solely rely on
covert coping narratives as a strategy for
neutralizing obsessions or fear (e.g. its just
OCD, it wont hurt me)instead, encourage
the patient to poke fun at OCD, talk back with
more extreme or bizarre self-statements (e.g.
go on OCDgive me your best; I think I
want to be a serial killer when I grow up),
with the aim to learn to cope with discomfort
and uncertainty.
Towards the end of treatment (when the child
is ready), encourage them to make fun of their
obsessional fearsfor example, use smartphone apps to change the voice of recorded
fear narratives, have the child sing a rap song
about their obsessions, write a poem about
their worst fears, or draw cartoons depicting
the child destroying OCD or OCD thoughts.
References
Abramowitz, J., Franklin, M., Schwartz, S. A., & Furr, J.
(2003). Symptom presentation and outcome of cognitivebehavioral therapy for obsessivecompulsive disorder. Journal of Consulting and Clinical Psychology,
71(6), 10491057. doi:10.1037/0022-006X.71.6.1049.
and statistical manual of mental disorders, 5th edition (DSM-5). Washington, DC: American Psychiatric
Association Task Force.
Baer, L. (1994). Factor analysis of symptom subtypes of
obsessive compulsive disorder and their relation to
personality and tic disorders. Journal of Clinical Psychiatry, 55(Suppl.3), 1823.
Bloch, M. H., Landeros-Weisenberger, A., Rosario, M. C.,
Pittenger, C., & Leckman, J. F. (2008). Meta-analysis
of the symptom structure of obsessive-compulsive disorder. The American Journal of Psychiatry, 165(12).
doi:10.1176/appi.ajp.2008.08020320.
Brakoulias, V., Starcevic, V., Berle, D., Milicevic,
D., Moses, K., Hannan, A., etal. (2013). The
characteristics of unacceptable/taboo thoughts
in obsessivecompulsive disorder. Comprehensive Psychiatry, 54(7), 750757. doi:http://dx.doi.
org/10.1016/j.comppsych.2013.02.005.
Brakoulias, V., Starcevic, V., Berle, D., Milicevic, D.,
Hannan, A., & Martin, A. (2014). The relationships
between obsessivecompulsive symptom dimensions
and cognitions in obsessivecompulsive disorder.
Psychiatric Quarterly, 85(2), 133142. doi:10.1007/
s11126-013-9278-y.
Clark, D. A. (2004). Cognitive behavioural therapy for
OCD. New York: Guilford.
Coles, M. E., Wolters, L. H., Sochting, I., de Haan, E.,
Pietrefesa, A. S., & Whiteside, S. P. (2010). Development and initial validation of the obsessive belief
questionnaire-child version (OBQ-CV). Depression
and Anxiety, 27(10), 982991. doi:10.1002/da.20702.
Denys, D., de Geus, F., van Megen, H. J. G. M., & Westenberg, H. G. M. (2004). Use of factor analysis to
detect potential phenotypes in obsessive-compulsive
disorder. Psychiatry Research, 128(3), 273280.
doi:http://dx.doi.org/10.1016/j.psychres.2003.11.005.
Farrell, L. J., & Waters, A. M. (2008). OCD Busters: A
cognitive behavioural group treatment manual for
children and youth with OCD. School of Applied Psychology, Griffith University.
N., Rhaume, J., Letarte, H., & Bujold, A. (1997).
Cognitivebehavioral treatment of obsessive
thoughts: A controlled study. Journal of Consulting and Clinical Psychology, 65(3), 405.
doi:10.1037/0022006X.65.3.405.
Geller, D. A., & March, J. S. (2012). Practice parameter for the assessment and treatment of children
and adolescents with obsessive-compulsive disorder.
Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 98113. doi:http://dx.doi.
org/10.1016/j.jaac.2011.09.019.
Geller, D. A., Biederman, J., Faraone, S., Agranat, A., Cradock, K., Hagermoser, L., etal. (2001). Developmental aspects of obsessive compulsive disorder: Findings
in children, adolescents, and adults. The Journal of
Nervous and Mental Disease, 189(7), 471477.
C., Fleischmann, R. L., Hill, C. L., etal. (1989).
The Yale-Brown Obsessive Compulsive Scale: I.
development, use, and reliability. Archives of General Psychiatry, 46(11), 10061011. doi:10.1001/
archpsyc.1989.01810110048007.
Hasler, G., LaSalle-Ricci, V. H., Ronquillo, J. G., Crawley, S. A., Cochran, L. W., Kazuba, D., etal. (2005).
Obsessivecompulsive disorder symptom dimensions
show specific relationships to psychiatric comorbidity. Psychiatry Research, 135(2), 121132. doi:http://
dx.doi.org/10.1016/j.psychres.2005.03.003.
Kovacs, M. (1992). Childrens Depression Inventory
(CDI). Tonawanda: Multi-Health Systems.
Lee, H. J., & Kwon, S. M. (2003). Two different types
of obsession: Autogenous obsessions and reactive obsessions. Behaviour Research and Therapy, 41(1), 1129. doi:http://dx.doi.org/10.1016/
S00057967(01)00101-2.
March, J. S. (1997). Multidimensional anxiety scale for
children. North Tonawanda: Multi-Health Systems.
Mataix-Cols, D., Rosario-Campos, M. C., & Leckman,
J. F. (2005). A multidimensional model of obsessivecompulsive disorder. The American Journal of Psychiatry, 162(2), 228238.

Moulding, R., Aardema, F., & OConnor, K. P. (2014).
Repugnant obsessions: A review of the phenomenology, theoretical models, and treatment of sexual
and aggressive obsessional themes in OCD. Journal of Obsessive-Compulsive and Related Disorders, 3(2), 161 -168. doi: http://dx.doi.org/10.1016/j.
jocrd.2013.11.006.
National Institute for Health and Clinical Excellence.
(2005). Obsessive-compulsive disorder: Core interventions in the treatment of obsessive-compulsive
disorder and body dysmorphic disorder. (Clinical
guideline 31). London: NICE.
inventoryPart 2: Factor analyses and testing of
43(11), 15271542. doi:http://dx.doi.org/10.1016/j.
brat.2004.07.010.
Pinto, A., Greenberg, B. D., Grados, M. A., Bienvenu Iii,
O. J., Samuels, J. F., Murphy, D. L., etal. (2008). Further development of YBOCS dimensions in the OCD
collaborative genetics study: Symptoms vs. categories. Psychiatry Research, 160(1), 8393. doi:http://
dx.doi.org/10.1016/j.psychres.2007.07.010.
Purdon, C. (2004). Cognitive-behavioral treatment of
repugnant obsessions. Journal of Clinical Psychology,
60(11), 11691180. doi:10.1002/jclp.20081.
Rachman, S. (2007). Treating religious, sexual, and
aggressive obsessions. In A. Martin & C. Purdon
(Eds.), Psychological treatment of obsessive-compulsive disorder: Fundamentals and beyond (pp.209
229). Washington, DC: American Psychological
Association.
Rasmussen, S. A., & Tsuang, M. T. (1986). Clinical
characteristics and family history in DSM-III obsessive-compulsive disorder. The American Journal of
Psychiatry, 143(3), 317322.
Rufer, M., Fricke, S., Moritz, S., Kloss, M., & Hand, I.
(2006). Symptom dimensions in obsessivecompulsive disorder: prediction of cognitive-behavior ther-
169
apy outcome. Acta Psychiatrica Scandinavica, 113(5),

440446. doi:10.1111/j.1600-0447.2005.00682.x.
Salkovskis, P. M. (1985). Obsessional-compulsive problems: A cognitive-behavioural analysis. Behaviour
Research and Therapy, 23(5), 571583. doi: http://
dx.doi.org 10.1016/0005-7967(85)90105-6.
I., King, R. A., Goodman, W. K., etal. (1997). Childrens
Yale-Brown Obsessive Compulsive Scale: Reliability
and validity. Journal of the American Academy of Child
and Adolescent Psychiatry, 36(6), 844852. doi:http://
dx.doi.org/10.1097/00004583-199706000-00023.
disorders interview schedule for DSM-IV-Child and
Stein, M. B., Forde, D. R., Anderson, G., & Walker, J.
R. (1997). Obsessive-compulsive disorder in the
community: An epidemiologic survey with clinical
reappraisal. American Journal of Psychiatry, 154(8),
11201126.
Storch, E. A., Merlo, L. J., Larson, M. J., Bloss, C. S.,
Geffken, G. R., Jacob, M. L., etal. (2008). Symptom dimensions and cognitive-behavioural therapy
outcome for pediatric obsessive-compulsive disorder. Acta Psychiatrica Scandinavica, 117(1), 6775.
doi:10.1111/j.1600-0447.2007.01113.x.
van Oppen, P., & Arntz, A. (1994). Cognitive therapy for
and Therapy, 32(1), 7987. doi:http://dx.doi.
org/10.1016/0005-7967(94)90086-8.
Veale, D., Freeston, M. H., Krebs, G., Heyman, I., &
Salkovskis, P. (2009). Risk assessment and management in obsessivecompulsive disorder. Advances in
Psychiatric Treatment, 15(5), 332343. doi:10.1192/
apt.bp.107.004705.
Wheaton, M. G., Abramowitz, J. S., Berman, N. C., Riemann, B. C., & Hale, L. R. (2010). The relationship
between obsessive beliefs and symptom dimensions in
and Therapy, 48(10), 949954. doi:http://dx.doi.
org/10.1016/j.brat.2010.05.027.
Treatment of Symmetry
in Childhood ObsessiveCompulsive Disorder
12
Brittany M. Rudy and Sophia Zavrou
In the Diagnostic and Statistical Manual of Mental Disorders (5th edition; DSM-5), obsessivecompulsive disorder (OCD) is defined as the
presence of obsessions and/or compulsions that
are time-consuming, cause considerable distress, or lead to impairment in functioning. Even
though the definition of the compulsions requires
that they are aimed at preventing or reducing
anxiety/distress or preventing a dreaded outcome,
young children may be unaware of or unable to
articulate this function of their compulsions (APA
2013). Approximately 80% of OCD cases have
a pediatric onset (Riddle 1998) with point-prevalence rates for pediatric OCD ranging from 1 to
42% (Zohar etal. 1997). Pediatric OCD is more
common in males than females and likely to be
comorbid with tics and attention-deficit/hyperactivity disorder (ADHD; Kalra and Swedo 2009).
The content of the obsessions and compulsions
varies considerably among patients with OCD with
factor-analytic studies suggesting the presence of
up to five separate obsessive-compulsive dimensions (Leckman et al. 1997; Mataix-Cols et al.
2005; Stewart etal. 2007). This chapter focuses
on the symmetry dimension of OCD, keeping in
mind that the symptoms of pediatric OCD are
heterogeneous (Mataix-Cols et al. 2005; Rettew
B.M.Rudy() S.Zavrou
Department of Pediatrics, Rothman Center for
Neuropsychiatry, University of South Florida,
Box 7523, 880 6th St. South Suite 460, St. Petersburg,
FL 33701, USA
e-mail: brudy@health.usf.edu
et al. 1992), and individuals may present with

symptoms consistent with more than one dimension. Children displaying symptoms within the
symmetry dimension often have obsessions about
things being symmetrical, perfect, or right. As
a result of this need for symmetry, children may
repeat tasks until they are perfect or just right,
perform acts in a symmetrical manner as to even
out, engage in compulsions of putting things in
a certain order, or engage in counting compulsions. Individuals with symmetry OCD also have
a higher rate of the compulsive need to touch,
tap, or rub, and fear of not saying just the right
thing (Leckman etal. 1997, p.914). These compulsions are oftentimes time-consuming and may
lead to considerable impairment, such as being
late due to lengthy morning routines involving
matching, evening out, and/or repetitive actions.
Symmetry OCD is more common in males than
females and is more commonly comorbid with tic
disorders than other OCD dimensions (Leckman
etal. 1997; Mataix-Cols etal. 2005; Storch etal.
2008c), with younger children exhibiting greater
just not right and other symmetry compulsions
(e.g., touching, tapping, repeating) than older cohorts (Garcia etal. 2009).
Evidence-Based Treatments for

Pediatric OCD
Pediatric OCD can be quite debilitating for the
child as well as the family; therefore, it is important for children with OCD to receive effective

DOI 10.1007/978-3-319-17139-5_12
171
172
treatment for their symptoms. The gold standard

treatment for OCD in both adults and children
is cognitive-behavioral therapy (CBT) with exposure and response prevention (ERP) either
alone or in combination with pharmacotherapy
(AACAP 2012; Lewin and Piacentini 2009). The
Journal of the American Academy of Child and
Adolescent Psychiatry (AACAP; 2012) practice
parameters recommend using a combination of
pharmacotherapy and CBT for older children
and adolescents and with individuals who experience moderate-to-severe OCD, while CBT
alone is recommended to be more appropriate
for use with younger children and with iOCD
of mild-to-moderate severity (AACAP 2012).
Further, combined treatment (pharmacotherapy
inclusive) may not always be considered an acceptable approach for parents (Stevens etal.
2009), with parents demonstrating preference for
CBT over pharmacotherapy (Lewin etal. 2014).
ERP, the primary component of exposurebased CBT for OCD, aims at identifying the
childs triggers for obsessions and compulsions
and creating a hierarchy of feared situations
that can be practiced in and outside of therapy
sessions (March and Mulle 1998). As part of
ERP, the child is exposed to the triggering stimuli or situations but is prevented from carrying
out the compulsions, with repeated exposures
leading to habituation to associated anxiety and
discomfort (Bouton 2004; Jordan etal. 2012).
Exposure-based CBT has been shown to be superior to placebo (POTS 2004), attention-control conditions (Freeman etal. 2008; Piacentini
etal. 2011), and in some studies, antidepressant medications (POTS 2004; POTS-II 2011;
Storch etal. 2013).
Factors for Consideration with

Treatment of Younger Children
Factors such as family functioning and accommodation (Storch etal. 2007a; Rapee 2012), lack of
insight and motivation (Lewin etal. 2010; Selles
etal. 2014; Storch etal. 2008b), and associated
behavior problems (e.g., anxious oppositional or
tantrum behaviors) may also play a significant
B. M. Rudy and S. Zavrou
role in prognosis and treatment response; therefore, as part of ERP-based treatment, these factors must be addressed appropriately. In youth,
and especially younger youth, sessions oftentimes are delivered in a family-based format
(e.g., Barrett etal. 2004; Lewin etal. 2014) to
facilitate understanding of treatment principles,
recruit the parent as a coach outside of sessions, decrease family accommodation (i.e.,
any behavior on behalf of family members that
is aimed at decreasing the childs OCD-related
distress, but inadvertently leading to reinforcement of the OCD symptoms; Storch etal. 2007b;
Lewin etal. 2014), and help increase the childs
efforts during exposures (Lebowitz etal. 2013;
Rudy etal. 2014; Lewin etal. 2014). Cognitive
components of CBT (e.g., challenging cognitive
distortions) may be less appropriate for younger
populations due to developmentally appropriate
lack of insight and metacognitive abilities, or
thinking about thinking, (Freeman etal. 2008;
Lewin etal. 2014; Kuhn 2000; Wellman et al.
2001); therefore, a greater emphasis is made on
behavioral strategies such as participant modeling, reinforced practice, and contingency management in combination with ERP (Lewin etal.
2014; May etal. 2013; Rudy etal. 2014). Provision of external motivation through participant modeling (i.e., the child observes another
individual interacting with a feared situation or
stimulus in a non-fearful way; Bouton 2004)
and reinforced practice (i.e., the provision of reinforcement of small gains for participating in
exposure activities; Davis and Ollendick 2005)
can be especially helpful (Hirshfeld-Becker and
Biederman 2002; Hirshfeld-Becker et al. 2010).
Behavior management strategies such as timeout or response cost are also useful for addressing disruptive behaviors that often accompany
anxious symptoms (i.e., anxious oppositionality;
Hirshfeld-Becker and Biederman 2002; Hirshfeld-Becker etal. 2010; Rudy etal. 2014). Thus,
with these considerations in mind, the purpose
of this chapter is to elucidate how to treat commonly occurring symmetry OCD in a child, aged
7 years, using exposure-based CBT with a heavy
emphasis on behavioral strategies and family involvement.
12 Treatment of Symmetry in Childhood Obsessive-Compulsive Disorder
173
Presenting Problem
Case Information
The following is a case example of a 7-year-old

boy, Sam (a pseudonym), with symmetry OCD.
Sams presenting symptoms were predominately
compulsive in nature and included needing to
match almost every purposeful action with a
paired action. He engaged in a large amount of
morning, bedtime, and separation (i.e., saying
goodbye when separating from significant others in certain ways) rituals which involved his
parents and grandparents. As part of these rituals,
Sam required his parents to reproduce his actions
or motions; for example, repeating words, waving in the same way, or touching objects the same
way. The rituals would need to restart, should his
parents or he not perform an exact replication of
the action/motion. Sam also engaged in other,
similar matching actions throughout the day.
Sam touched or wiped objects (e.g., furniture before sitting, doors before opening) with his right
and then his left hand in the same fashion and
the same number of times. He counted steps so
that his right and left foot took the same amount
of steps. He needed to enter and then reenter
rooms or use different doors (e.g., car doors,
house doors) to even out his actions. Should any
of Sams rituals, matching, or counting actions
be done in a way other than the way he deemed
just right, he would need to restart the ritual
process. According to his parents, morning and
separation (e.g., goodbye at preschool) rituals as
well as bedtime rituals could last up to 2+ h each
day, especially for days that were deemed bad.
Sams parents described a myriad of matching
behaviors that occurred without warning every
day and were cumbersome and time-consuming
for Sam and his family. Further, should his parents attempt to stop his ritual or matching action or refuse to participate, Sam reportedly
engaged in excessive tantrum behaviors (e.g.,
yelling, crying, hitting, kicking) that lasted up to
an hour or more. Given the high level of family involvement and time-consuming nature of
the rituals, as well as the disruptive behaviors
that occurred in the absence of the rituals, Sams
compulsions were highly interfering with his
own and his family functioning.
Background and Psychological History

At the time of the intake session, Sam was a
7-year-old Caucasian/Latino male who was referred by his parents to a university-based anxiety specialty clinic due to significant anxiety
and ritualistic behaviors. Sam lived in a suburban community with his biological parents and
younger brother. He attended preschool 3 days
per week and was cared for by his grandmother
in the afternoons and on days that he did not attend school. No developmental delay or deficits
in intellectual, language, or adaptive functioning
were noted. All milestones were met on time.
Sams parents indicated that Sams ritualistic
behaviors began between ages 3 and 4 years and
had increased in severity since that time. Sams
early rituals and compulsive behaviors included
a strict bedtime routine and schedule-dependent
sleep, tapping and touching just right, texture
sensitivities with clothing, and counting and
goodbye rituals (e.g., blowing four kisses for
each goodbye). His rituals reportedly progressed
in number and severity with increasing age.
Sams parents reported that Sam had previously
received a diagnosis of OCD by his pediatrician
and had been seen by a licensed professional
counselor (LPC) for play therapy for approximately five sessions without benefit. His parents
reported that they were not involved in his therapy sessions and did not know the content of the
sessions. No other previous assessment or treatment services and no current or previous psychotropic medication use were reported.
Assessment
An initial semi-structured diagnostic interview
was conducted by a clinical psychologist to gather information regarding Sams emotional and
behavioral symptoms. During the interview, the
psychologist was also able to gather observational information regarding Sams obsessive-compulsive symptoms as well as his hyperactive and
disruptive behaviors. Following the interview,
174
Sams parents completed a battery of questionnaires concerning Sams emotional and behavioral difficulties, and family history and functioning. A list of measures and assessment results is
provided in the section below. Procedures were
consistent with evidence-based assessment for
childhood OCD (Lewin and Piacentini 2010).
Measures
Anxiety Disorders Interview Schedule: Parent
Schedule (ADIS-IV:P; Silverman and Albano
1996). The ADIS-IV:P is a semi-structured diagnostic interview designed to aid the clinician in
determining the presence, severity, and significance of emotional and behavioral difficulties,
and in particular anxiety, in children and adolescents. The clinician assigns a Clinician Severity
Rating (CSR; ranging from 0 to 8) for each potential diagnosis. Ratings of 4 or greater are considered to indicate clinically significant levels of
impairment.
Sams parents endorsed significant obsessivecompulsive symptoms, including matching
and evening out rituals, routine rigidity, and
repeating behaviors. According to Sams parents, these behaviors were timely and interfered
with his own functioning as well as his familys
functioning. Therefore, a CSR of 6 for symptoms
consistent with OCD was warranted. Sams parents also indicated that Sam experienced a significant amount of disruptive behavior; however,
they noted that such behaviors occurred mainly
within the context of his rigidity and ritualistic
behaviors (e.g., if a ritual was not followed appropriately, if prevented from evening out, if
a parent failed to accommodate a ritual request).
Sam was otherwise reportedly compliant with
directives and respectful of requests. Sams willingness to comply with requests, particularly
with playing with toys and cleaning up at the end
of session, were observed by the clinician. Therefore, an additional disruptive behavior disorder
was not rated (i.e., CSR of 0). Further, Sams parents endorsed hyperactivity and impulsivity (e.g.,
interrupting, inability to finish tasks, excessive
energy) and some associated difficulty focusing
and paying attention at an excess of what would

be considered age-appropriate; clinical observation corroborated parent report. Therefore, a CSR
of 4 was rated for attention-deficit/hyperactivity
disorder, combined type (ADHD-C).
Clinical Global ImpressionSeverity (CGISeverity; National Institute of Mental Health
1985) The CGI-severity is a 7-point clinician rating of severity of the childs psychiatric problems
anchored by 0 (no illness) and 6 (extremely
severe symptoms). At the pretreatment assessment, Sam received a CGI-severity rating of 5
(Severe symptoms) for his obsessive-compulsive symptoms by the assessing clinician.
Clinical Global Improvement (CGI-Improvement; Guy 1976) The CGI is a 7-point rating of
treatment response anchored by 0 (very much
worse) and 6 (very much improved). Youth
who are rated 5 (much improved) and 6 (very
much improved) are considered treatment
responders. The treating clinician provided this
rating at the posttreatment assessment.
Global Assessment of Functioning (Jones etal.
1995) The Global Assessment of Functioning
(GAF) is a numerical rating based on the attending psychologists assessment of the patients
severity of psychopathology. Ratings range from
0 to 100 with higher scores corresponding to better functioning. At the pretreatment assessment,
Sam received a rating of 55.
Child Behavior Checklist (Achenbach and
Rescorla 2000)The Child Behavior Checklist
(CBCL) is a broadband parent report measure of
emotional and behavioral symptoms for children
aged 616 years. The CBCL produces a total
problems scale, two broad ratings of internalizing
and externalizing problems, and eight additional
symptom subscales. For the purposes of this
case, the internalizing and externalizing scales
were examined. Items are rated in Likert format
from 0, not true, to 2, very true. Scores at or
above the 95th percentile (T>65) are considered
clinically significant. Sams mother endorsed
significant difficulties for the total problems
scale (T=85), and both the internalizing (T=75)

and externalizing scales (T=70), with specific
items endorsed suggesting problematic anxiety,
thought problems, attention problems, and oppositionality.
Family AccommodationThe family accommodation (FAM) is a measure of obsessive-compulsive symptoms that assesses degree of accommodation, interference with family functioning,
and distress. Sams mother and father endorsed
a significant amount of family accommodation
(i.e., frequently engaging in rituals and providing
assistance for symptoms to avoid tantrum behaviors) as well as significant interference in family
routines and functioning and associated distress
concerning the need to accommodate Sams
OCD behaviors.
Peabody Picture Vocabulary Test, fourth edition (Dunn and Dunn 2007) The Peabody Picture Vocabulary Test (PPVT) is a standardized
nonverbal test of vocabulary skills that is said to
correlate highly with intellectual ability. Given
Sams age and constraints of time, the PPVT was
chosen as a brief estimate of general ability. Sam
scored at the 77th percentile, or high average
range compared to other children his age.
Based on the initial assessment, Sams primary
emotional and behavioral symptoms reflected ritualized matching and evening out behaviors and
routine rigidity performed to reduce or alleviate
anxiety, as well as associated defiance and tantrum behaviors, which resulted in inability to appropriately engage in social, school, and family
settings. Sam also exhibited significant hyperactivity and impulsivity in an excess of what would
be expected for his age that occurred across settings (e.g., home, school, in office) with some
accompanying inattention and trouble focusing.
Therefore, Sam received diagnoses of OCD and
ADHD-C. His oppositional and tantrum behaviors were noted to be contained mostly within
anxiety-provoking situations, generally related to
175
inability to complete a matching ritual or deviation from daily routines. Therefore, an additional
disruptive behavior disorder diagnosis was not
given.
Sams case was complicated by numerous environmental and family factors, including family
participation in and accommodation of rituals and
routines, parental provision of reassurance, and
avoidance of situations that may provoke tantrum
behaviors. These factors likely contributed to and
maintained his obsessive-compulsive symptoms
by failing to allow extinction learning to occur,
as well as reinforcing attention-seeking and ritualistic behaviors. In other words, Sams parents
apprehension to allow Sam to experience anxiety
and to appropriately handle his tantrum behaviors related to that anxiety further perpetuated
or maintained his obsessions and compulsions
via a negative reinforcement cycle. Collectively,
Sams obsessive-compulsive symptoms appeared
to develop from a combination of biological factors and conditioned experiences (e.g., anxious
modeling, ritual reinforcement, allowed avoidance) and were subsequently maintained by family accommodation, low parental distress tolerance, and related environmental variables.
Treatment
Drawing from literature supporting the combination of the strategies mentioned in the Introduction of this chapter, Sams treatment was
designed to be behaviorally based, with considerable family involvement. In combination with
the primary behavioral component of treatment,
ERP, family-based psychoeducation, participant
modeling, reinforced practice, and contingency
management were used to treat Sams symmetry
OCD and related anxiety and behavioral difficulties. During session 1, the entire family (i.e.,
Sam, his mother, and father) met with the treating clinician, who provided psychoeducation
and treatment rationale for Sam and his parents.
Information, including reasons surrounding the
presence and purpose of anxiety (e.g., biological bases, environmental factors), definitions
for obsessions and compulsions, and a descrip-
176
tion of habituation and extinction learning, was

provided for Sam and his parents. The therapist
spent time discussing the treatment process with
Sams parents and explaining anxiety and OCD
to Sam. Supplemental materials such as drawings
of the physical feelings of anxiety were used to
help Sam understand anxiety in a concrete manner. Handouts about anxiety, OCD, and parenting
children with anxiety and anxious oppositional
behaviors were given to Sams parents.
Following the first treatment session, Sams
parents participated in two, parent-only sessions
(sessions 2 and 3). The goal of these sessions
was to provide Sams parents further education
on the accommodation of symptoms, behavioral management techniques, and their roles in
the treatment process, and to create a fear hierarchy from which to base future exposures.
Sams parents were taught strategies such as
praising positive and brave behaviors, ignoring repeated questioning, whining, and fussing,
and using time-out for tantrum behaviors such
as yelling, hitting, kicking, refusal to follow directions, and elopement (i.e., running away). A
specific time-out protocol adapted from two empirically supported effective time-out protocols,
Barkleys time-out model (Barkley 1997) and
ParentChild Interaction Therapy (PCIT; McNeil etal. 1999), was demonstrated for Sams
parents using a stuffed animal. The protocol is
as follows: disruptive behaviors result in 3min
(+5s of silence) in a time-out chair. The 5-s-ofsilence rule implies that Sam would be required
to remain in the chair until quiet for at least 5s,
even following the end of the 3-min time-out.
He would be informed that he could not leave
the chair until quiet before the time-out begins.
Should Sam leave the chair prior to the 3-min
duration, he would be required to sit in a timeout room for 1min (+5s of silence) and then return to the time-out chair, where the 3-min (+5s
of silence) time-out would restart. At the end of
the time-out, he would be required to complete
the requested task or provide retribution (depending on the reason for the time-out) before
returning to play or other activities.
His parents were also taught how to help
Sam cope with feelings of anxiety in a gradu-
ated manner without avoiding or accommodating anxious situations and how to reduce
excessive reassurance. Each of the two parent
sessions included verbal examples, handouts,
and time for questions and further explanation
of each topic. Additionally, facilitated by the
therapist, Sams parents were able to create a
fear hierarchy for feared or anxious situations.
Sams hierarchy consisted of situations in which
he was driven to perform rituals and/or matching behaviors (see Table12.1) with his anxiety
being rated from 0no anxiety to 10very
severe anxiety should he be asked to refrain
from completing the compulsive behaviors. The
therapist discussed with Sams parents how the
hierarchy would be used as a guide for the treatment process and could be adjusted throughout
treatment as necessary as Sam conquered each
step and moved to more difficult items/situations. Sams parents were also informed that although the therapist would begin as the leader
of each exposure, a primary goal of treatment
was to transfer the lead of exposures to them so
that greater generalization could occur through
practice at home.
During session 4, the therapist discussed with
Sam red and green behaviors and time-out.
Sam was informed that even though feeling
scared or uncomfortable may be difficult, red
behaviors (e.g., yelling, hitting, kicking, refusing
to participate or follow directions) are not acceptable and that he would have to go to time-out if
he displayed any of those behaviors during the
session. The therapist used a stuffed animal to
specifically describe to Sam the time-out procedure that had been taught to his parents. The therapist explained to Sam that he would never have
to go to time-out for feeling nervous, scared, or
uncomfortable as long as he displayed brave,
green behaviors (e.g., stating that he feels upset,
asking to take a few minutes to calm down or
asking for help, taking a deep breath) and asked
for confirmation of understanding of green
and red behaviors, and associated rewards and
consequences, prior to moving forward with the
treatment.
For the second half of session 4, Sam and his
parents participated together in Sams first ERP
177
Table 12.1 Sams fear hierarchy

Fear rating (010)
3
Touching objects (e.g., furniture, doorknobs) with the right, but not with the
left hand
4
Going into and out of the car using only the door on one side of the car
(instead of going out the opposite door from which he entered to make it
even)
4
Parents not repeating words back to Sam as part of his rituals
4
Parents not waving at Sam when this is asked of them as part of his rituals
4
Parents not touching objects when Sam asks them to do so as part of his
rituals
5
While walking down the hallway, taking an uneven number of steps
5
Waving goodbye using only his right hand
6
Brushing his hair using only one hand
6
Brushing his teeth with only one hand
6
Brushing his teeth with uneven number of brush strokes
7
Completing bedtime routine in a different order
7
Completing morning routine in a different order
7
Putting clothes on in the morning only once as opposed to taking them off and
putting them back on again until it feels just right
8
Walking from his bedroom to the kitchen without tapping on the walls on
either side of the hallway
8
Walking into his kindergarten class or the front door of his house only once
using either his right or left foot first (as opposed to using his right foot first
and then going outside to come back inside using his left foot first to even
out)
9
Parents preparing his plate of food without arranging food items so that they
are symmetrical on the right and left side of the plate
10
Refraining from repeating words until it feels just right
10
Refraining from speaking certain phrases in the same way as a response to
rituals and/or small talk questions
Ratings range from 0no fear or anxiety to 10very severe fear and anxiety and rated with the help of a fear
thermometer as a visual aid
exercise. Techniques such as participant modeling and reinforced practice were used to help
Sam accomplish each exposure task. Sams first
listed item on his hierarchy was touching objects
such as door handles and toys with the need to
even out his touches. Sam was informed that, to
help him feel less uncomfortable and anxious, he
would be practicing experiencing these emotions
a little at a time but not matching or evening
out like he normally did, so that he would no
longer feel the need to do so after a while. He was
informed that he needed to earn three stickers to
earn a prize and that each time he participated in
an activity as requested by the therapist he would
earn one sticker. The therapist then demonstrated
for Sam what she would like him to do to earn
the first sticker. She asked Sam to open the door
to her office using only his right hand. She then

opened the door using only her right hand and
closed the door. Sam was very excited to earn his
prize so he promptly went to the door, opened it
only with his right hand, and shut the door, mimicking the therapist. The therapist then requested
that Sam complete two similar, uneven tasks
with his parents watching each task and the therapist demonstrating the task before Sam completed it. Sam was able to earn each of his three
stickers and his prize for the first portion of the
session. The therapist then provided a break for
Sam and discussed with his parents any questions
about the exposure activities. The exact protocol
described herein was then repeated following the
break for the last portion of the session, with Sam
completing three short exposure activities (i.e.,
178
touching the couch with only one hand, picking

up a toy with only one hand, playing with blocks
with uneven touches for each hand; see Sams
fear hierarchyTable 12.1) to earn three stickers and then a prize. Sams parents were asked
to participate by serving as models during two
of the three activities. Sam was able to earn both
prizes (i.e., a small toy and playground time) during the session and did not require the time-out
procedure. For homework, Sam and his parents
were instructed to practice for at least 10min
a day completing the same exposure exercises
completed in session at home using the same
sticker/prize structure.
During session 5, the therapist chose a slightly
more difficult set of activities to practice with
Sam and his parents using ERP, participant modeling, and reinforced practice. The same protocol
for ERP was utilized with Sam being told that he
would need to complete three activities and earn
three stickers for a prize. Sam was also reminded
that red behaviors would require time-out. The
therapist first asked Sam to place only his right
hand on his right knee and to leave it there for
2min. Sam was able to complete the activity
and earn his sticker. During the second activity,
however, when asked to tap only one foot (right
foot), Sam began to perform his ritual of tapping
his right and then left foot in even numbers (e.g.,
two taps, four taps). The therapist reminded Sam
of the importance of practice and asked him to
repeat the activity without the ritual. Sam began
to cry and yell at the therapist that he would not
do it and that he wanted to go home. The therapist provided one warning for Sam that he would
have to go to time-out if he continued to have red
behavior. When his mother stepped toward Sam
to calm him, he reached out and struck her. The
therapist instructed Sams mother to pick him up
and take him to the time-out chair (already set
up in the therapists office). Sam refused to sit
in the chair and was then taken to the time-out
room, per the time-out protocol. Sam was taken
between the time-out chair and room several
times before sitting in the time-out chair for the
full allotted time. The total time of the time-out
was approximately 35min; however, Sam was
eventually able to return to the ERP situation and
complete the activity. Due to the lengthy time-out

and the time constraints of the session, the third
activity was not completed, and Sam did not earn
his daily prize.
Sessions 6 through 8 followed a similar structure to sessions 4 and 5. During each session, the
therapist set up ERP activities with increasing
difficulty for Sam (e.g., using only one car door,
changing goodbye and waving rituals, completing activities in uneven numbers; see Sams fear
hierarchy; Table12.1). For each activity that Sam
completed, he was able to earn a sticker and a
number of predetermined stickers resulted in a
prize. Typically, 23 prizes were provided per
session, with prizes ranging from small toys, to
games, to playground time, to preferred snacks.
Sam had to go to time-out once more during
sessions 6 through 8 (session 7) for refusing to
complete an activity (i.e., starting a word ritual
with his parents but allowing his parents not
to repeat words as he requested) and throwing
himself to the floor while yelling, Repeat it!
Repeat it! Sams time-out lasted no more than
15min during that session, and he was still able
to complete all activities requested, including an
additional activity, to earn enough stickers for a
prize (no sticker was rewarded for completion of
the activity during which the time-out occurred).
In between each session, Sams parents were instructed to practice exposure activities mirroring
those completed in session and to no longer avoid
situations for activities that had already been
practiced in session or engage in rituals that had
been practiced/changed in session. At the end of
session 8, Sams parents were informed that they
would lead the remainder of the sessions with
coaching from the therapist. They were instructed to begin thinking of activities taken from the
mid- to upper-levels of Sams hierarchy to complete, beginning at the next session.
At the beginning of session 9, the therapist
met with Sams mother alone (his father stayed
with Sam in the waiting room) to discuss the sessions activities. Sams mother stated that she
planned to have Sam walk down the hallway
with an uneven number of steps and walk back to
her with a different uneven number of steps. She
described it as a game to see how many times he
could go back and forth between his mother and

father with uneven steps in 3min. The therapist
praised Sams mother for her creativity and provided a few adjustments including counting the
steps out loud for accuracy, and having him do an
even number once or twice to be sure the ritual
does not change to uneven numbers only. Sam
and his father then joined for the remainder of
the session. Sams mother described the activity
to Sam (who was excited for the game) and asked
him to take his place in the hallway to begin the
activity. The therapist prompted Sams mother to
remember to set the reward and stickers in advance, coaching her to mirror the structure of the
therapist-led sessions. Sam was able to complete
the activity to earn his sticker. Following four
stickers, he earned a reward and a break was provided. The therapist used the time in the break to
provide praise to Sams mother for leading the exposures and to answer questions. After the break,
Sams father was asked to lead three activities
of his choice, which he completed successfully.
Sessions 10 and 11 were structured similarly to
session 9. Sams parents were asked to lead the
exposures for Sam with therapist coaching. Sam
engaged in anxious oppositional behavior during
session 10, for which he required time-out. The
time-out lasted 46min and the time-out room
was not required (i.e., Sam never left the time-out
chair). It is also noted that activities for session
10 were exceptionally difficult for Sam (top of
the hierarchy), including putting socks on only
once and walking through doors only once. During session 11, Sam participated in high-level,
difficult items from his hierarchy with great success and no instances of time-out needed. When
queried by the therapist, Sams parents also reported that home behaviors had improved, with
fewer instances and shorter duration of time-out,
as well as minimal ritual participation or instances of matching behaviors.
Given Sams significant progress as well as
his parents increased proficiency in parenting
techniques and taking the lead for exposures, session 12 was set to be Sams graduation session.
During session 12, the therapist reviewed Sams
progress in session and at home, including all
tasks mastered on his fear hierarchy and many of
179
the challenges he conquered. The therapist also

spent time reviewing Sams parents accomplishments with his parents and discussing relapse
prevention strategies (e.g., continued practice at
home, goals toward reduced accommodation).
The possibility of booster sessions was also discussed and Sams parents were encouraged to
call should any further questions arise. The therapist provided a graduation certificate for Sam
and a final reward (i.e., playground timeSams
favorite). For session-by-session objectives and
content chart, see Table12.2.
Posttreatment Results
Following session 12, Sams parents participated
in a posttreatment assessment session. The OCD
and ADHD sections of the ADIS-IV-P were administered and Sams parents completed the
CBCL and FAM. Sams parents endorsed a significant decrease in obsessive-compulsive symptoms with reduced anxiety, nearly-absent rituals,
greater overall flexibility, and tantrum behaviors
occurring less than once per week. His parents
did, however, continue to report significant hyperactivity and impulsivity (e.g., jumping from
one subject to another, interrupting, constantly
busy) and some difficulty maintaining focus.
Therefore, CSR ratings of 2 and 4 were given
for OCD and ADHD-C, respectively. Further,
observations of Sams behaviors in session were
consistent with parent report of reduced overall
obsessive-compulsive symptoms and ritualistic behavior. Sam no longer appeared to need to
match every action and demonstrated greater
flexibility and overall ability to participate in
exposure activities. Therefore, a CGI-severity
rating of 1 (illness slight) and a CGI-improvement rating of 6 (very much improved) were
also given by the treating clinician. Sam also received a GAF rating of 75.
On the CBCL, Sams mother endorsed significant difficulties for the total problems scale
(T=70), and externalizing scale (T=70); however, her ratings for the internalizing scale (T=55)
were no longer significant. Specific items suggested that attention problems and hyperactivity
180
Table 12.2 Session content

Session
1
2 (parent only)
3 (parent only)
10
11
12
Time-out required
Objectives and content

Treatment initiation session
Explanation of treatment rationale
Psychoeducation about anxiety
Explanation for parents
Developmentally appropriate activities and explanations for Sam
Parent training
Praising positives
Rewarding positive and brave behaviors
Ignoring negative, nondestructive behaviors
Decreasing reassurance and accommodation
Parent training
Review of skills from previous session
Giving effective directions
Time-outexplanation and demonstration
Creating the fear ladder
Explanation of green and red behaviors with Sam
Time-outexplanation and demonstration with Sam
Therapist-led exposures
Low-level exposures (3) with rewards
Touching the door with only one hand
Break
Low-level exposures (3) with rewards (therapist led)
Low-level exposures with rewards (therapist led)a
Only 2 of 3 exposures completedstickers but no prize earned
Moderate-level exposures (3) with rewards (therapist led)
Breakparent questions answered
Moderate-level exposures (3) with rewards (therapist led)
Moderate-level exposures with rewards (therapist led)a
Extra exposure completedprize earned
Moderate-level exposures with rewards (therapist led)
Brief discussion with parents about transition to parent-led exposures
Transition to parent-led exposures
Prep with mother
Moderate-level exposures with rewards (mother led) with coaching
Breakexplanation to father
Moderate-level exposures with rewards (father led) with coaching
Parent-led exposures
High-level exposures (parent led) with coachinga
All activities were able to be completed following time-outall rewards earned
Parent-led exposures
High-level exposures (parent led) with very minimal coaching
Termination session
Information on maintenance of gains and relapse prevention (handouts provided)
Graduation certificate and celebration with Sam
remained problematic, but Sam no longer experienced significant difficulties in the areas of
thought problems, anxiety, or oppositionality.
Sams mother also endorsed a significant reduction in the amount of family accommodation
present, with her ratings no longer reaching the
clinical cutoff per the FAM. Overall, Sam appeared to demonstrate a significant reduction in
OCD symptomology, no longer meeting criteria
for a diagnosis of OCD following 12 sessions of
behavioral therapeutic techniques, including participant modeling, reinforced practice, and ERP,
along with parent training and integration of parent-led exposures into treatment.
Sams younger age and subsequent developmentally appropriate lack of insight, metacognition,
and intrinsic motivation were complicating factors in his treatment. Therefore, education materials and treatment rationale had to be exceptionally concrete in nature (see Hirshfeld-Becker and
Biederman 2002; Hirshfeld-Becker etal. 2010)
so as to facilitate his understanding of OCD.
Techniques such as externalizing and bossing
back OCD were used (see March and Mulle
1998) to help Sam understand and resist his OCD
symptoms. Finding and providing external motivation through the use of praise and rewards
for exposure completion (activity rewards, tangibles) was also a large component of treatment. In
addition to his age, Sams level of hyperactivity
and impulsivity interfered with the progression
of sessions at times, making completion of therapy goals challenging. The structured nature of the
sessions and accompanying rewards enhanced
Sams motivation to remain focused on exposure
tasks. Further, small breaks with free time and
games were provided throughout each session for
Sam. Such breaks were utilized as time to discuss
parenting strategies and any difficulties at home,
address parent questions, and provide adjustment
suggestions during the parent-led sessions.
The severity of tantrum behaviors and level
of family accommodation present at the beginning of treatment also complicated Sams prog-
181
ress and made considerable family involvement

in sessions necessary. Parent training for behavioral management of anxious oppositional
(tantrum) behaviors and reduction of symptom
accommodation were incorporated into the treatment through several parent-only sessions and
follow-up phone calls. Additionally, at least one
parent attended and participated in each session
in its entirety, and as previously mentioned, spare
moments in session were directed at increasing
parent competence in managing anxious and
anxious oppositional behaviors (see Creswell
and Cartwright-Hatton 2007; Lewin etal. 2014;
Rudy etal. 2014). Strategies used to augment
basic CBT treatment for pediatric OCD were
based in previous literature regarding treatment
of younger children (e.g., Ale and Krackow
2011; Hirshfeld-Becker and Biederman 2002;
Hirshfeld-Becker etal. 2010; Lewin etal. 2014;
May etal. 2013; Rudy etal. 2014) and proved
quite effective for combating the primary factors
that complicated Sams treatment process. Finally, it is worth mentioning that several family factors such as proximity to the clinic and difficulty
taking time off from work to attend sessions were
significant barriers to treatment, as multiple sessions had to be canceled or rescheduled. Though
not a primary focus of treatment, these barriers
did complicate treatment delivery and consistency in homework completion, and continuity of
care. To minimize these barriers, sessions were
scheduled up to a month in advance and brief
(10min or less) phone consultations were provided as needed with Sams mother throughout
the treatment process.
Conclusions
Despite multiple challenges associated with
Sams age, disruptive behavior, family involvement in symptoms, and barriers to care, Sams
treatment was successful in reducing his OCD
symptoms, ritualistic behaviors, associated oppositional behaviors, and family accommodation. As suggested by the literature (Storch etal.
2008a), ERP proved to be an effective treatment
for pediatric symmetry OCD in this patient. Of-
182
tentimes, in cases of pediatric OCD, such factors

as developmentally appropriate lack of insight
and metacognition, lack of motivation, anxious
oppositional behaviors, and family accommodation have to be considered in treatment. This case
has demonstrated the importance of incorporating empirically based behavioral strategies such
as participant modeling, reinforced practice, parent training in behavior management, and parentled exposures into the treatment of younger children to address these complicating factors and
maximize treatment gains (May etal. 2013; Rudy
etal. 2014).
Parent involvement in Sams treatment and
parent training (see Lewin 2011) regarding both
the use of exposures and behavioral management techniques for anxious oppositional behaviors, helped decrease family accommodation
and nearly eliminate Sams disruptive behaviors.
The use of reinforcers for completion of exposures provided Sam with extrinsic motivation to
complete the tasks assigned to him. In general,
family involvement proved crucial in the success
of Sams treatment. Family involvement and parental coaching in session, particularly during the
parent-led exposure portion of therapy, allowed
Sams parents to more easily transition exposures
to home practice, increasing generalization, and
maintenance of gains. Results of this case example are consistent with and provide further
support for the use of family-based interventions
in treating pediatric OCD (Barrett etal. 2004;
Freeman etal. 2008; Lewin etal. 2014; Lebowitz
2013; Lebowitz etal. 2012; Storch etal. 2007b;
Rudy etal. 2014).
There is substantial research on the efficacy
of ERP for the symmetry and other dimensions
of OCD; however, a greater understanding and
dissemination of treatment strategies for younger
children exhibiting OCD symptoms, especially
given the commonality of compulsions among
the younger pediatric OCD population, and symmetry-related (just not right) compulsions, in
particular (Garcia etal. 2009; Selles etal. 2014),
and the great likelihood of treatment success.
The complicating factors associated with pediatric OCD mentioned throughout this chapter
should be examined more thoroughly in terms of
both effect on treatment progress and how such

effects can be combated. Future research should
also focus on enhancing and improving treatment
gains as well as long-term outcomes of treatment;
that is, how long treatment gains are maintained,
the likelihood of symptoms recurring, and ways
to extend the duration of treatment gains.
Key Practice Points

Below is a list of key practice points in the treatment of symmetry OCD in a child, based on the
extant literature and demonstrated by this case
example:
Provide psychoeducation for OCD and rationale for treatment
Provide parent training about family accommodation and how to reduce it as well as
appropriate reactions to anxiety
Provide parent training in behavioral management techniques for management of anxious
oppositional behaviors
Create a fear hierarchy
Engage in graduated exposures with response
prevention in session, using participant modeling and reinforcement
Assign home exposures for practice inbetween sessions
Coach parents in parent-led exposures
Provide relapse prevention information before
termination.
References
AACAP. (2012). Practice parameter for the assessment
and treatment of children and adolescents with obsessive-compulsive disorder. Journal of the American
Academy of Child and Adolescent Psychiatry, 51(1),
98113.
Achenbach, T. M., & Rescorla, L. (2000). Child behavior
checklist for ages 1 1/25. Burlington: University of
Vermont.
Ale, C. M., & Krackow, E. (2011). Concurrent treatment
of early childhood OCD and ODD a case illustration.
Clinical Case Studies, 10, 312323.
and statistical manual of mental disorders: DSM-5.
Washington, DC: American Psychiatric.

Barkley, R. A. (1997). Defiant children: A clinicians
manual for assessment and parent training. New
York: Guilford Press.
Barrett, P. M., Healy, L. J., & March, J. S. (2004). Cognitive-behavioural family treatment for childhood
obsessive-compulsive disorder: A controlled trial.
Journal of the American Academy of Child and Adolescent Psychiatry, 43, 4662.
Bouton, M. (2004). Context and behavioral processes in
extinction. Learning and Memory, 11, 485494.
Creswell, C., & Cartwright-Hatton, S. (2007). Family
treatment of child anxiety: Outcomes, limitations and
future directions. Clinical Child and Family Psychology Review, 10, 232252.
Davis, T. E., & Ollendick, T. H. (2005). Empirically supported treatments for specific phobia in children: Do
efficacious treatments address the components of a
phobic response? Clinical Psychology: Science and
Practice, 12, 144160.
Dunn, L. M., & Dunn, D. M. (2007). Peabody picture
vocabulary test, (PPVT-4). Minneapolis: Pearson
Assessments.
Freeman, J. B., Garcia, A. M., Coyne, L., Ale, C., Przeworski, A., Himle, M., Compton, S., & Leonard, H.
L. (2008). Early childhood OCD: Preliminary findings
from a family-based cognitive-behavioral approach.
Journal of the American Academy of Child and Adolescent Psychiatry, 47(5), 593602.
Garcia, A. M., Freeman, J. B., Himle, M. B., Berman, N.
C., Ogata, A. K., Ng, J., etal. (2009). Phenomenology of early childhood onset obsessive compulsive
disorder. Journal of psychopathology and behavioral
assessment, 31(2), 104111.
Guy, W. (1976). Clinical global impressions. In: W. Guy
(ed). ECDEU assessment manual for psychopharmacology, revised (pp.218222). Rockville: National
Institute of Mental Health.
Hirshfeld-Becker, D. R., & Biederman, J. (2002). Rationale and principles for early intervention with young
children at risk for anxiety disorders. Clinical Child
andFamily Psychology Review, 5, 161172.
Hirshfeld-Becker, D. R., Masek, B., Henin, A., Blakely,
L. R., Pollock-Wurman, R. A., McQuade, J., etal.
(2010). Cognitive behavioral therapy for 4- to 7-yearold children with anxiety disorders: A randomized
clinical trial. Journal of Consulting and Clinical Psychology, 78, 498510.
Jones, S. H., Thornicroft, G., Coffey, M., & Dunn, G.
(1995). A brief mental health outcome scale: Reliability and validity of the global assessment of functioning. British Journal of Psychiatry, 166, 654659.
Jordan, C., Reid, A., Mariaskin, A., Augusto, B., &
Sulkowski, M. L. (2012). First-line treatments for
pediatric obsessive-compulsive disorder. Journal of
Contemporary Psychotherapy, 42(4), 243248.
Kalra, S. K., & Swedo, S. E. (2009). Children with obsessive-compulsive disorder: Are they just little adults?
Journal of Clinical Investigation, 119(4), 737746.
Kuhn, D. (2000). Metacognitive development. Current
Directions in Psychological Science, 9, 178181.
183
Lebowitz, E. R. (2013). Parent-based treatment for childhood and adolescent OCD. Journal of ObsessiveCompulsive and Related Disorders, 2, 425431.
Lebowitz, E. R., Panza, K. E., Su, J., & Bloch, M. H.
(2012). Family accommodation in obsessivecompulsive disorder. Expert Review of Neurotherapeutics, 12,
229238.
Lebowitz, E. R., Woolston, J., Bar-Haim, Y., Calvocoressi, L., Dauser, C., Warnick, E., etal. (2013). Family accommodation in pediatric anxiety disorders.
Leckman, J. F., Grice, D. E., Boardman, J., Zhang, H.,
Vitale, A., Bondi, C., etal. (1997). Symptoms of
Lewin, A. B. (2011). Parent training for childhood anxiety. In D. McCay & E. A. Storch (Eds.), Handbook of
child and adolescent anxiety disorders (pp.405418).
New York: Springer.
Lewin, A. B., & Piacentini, J. (2009). Obsessive-compulsive disorder in children. In B. J. Sadock, V. A. Sadock,
& P. Ruiz (Eds.), Kaplan and Sadocks comprehensive
textbook of psychiatry (9th ed., pp. 36713678). Philadelphia: Lippincott, Williams & Wilkins.
research. Child and Youth Care Forum, 39(2), 7389.
Lewin, A. B., Bergman, R. L., Peris, T. S., Chang, S.,
McCracken, J. T., & Piacentini, J. (2010). Correlates
of insight among youth with obsessive-compulsive
disorder. Journal of Child Psychology and Psychiatry,
51(5), 603611.
Lewin, A. B., Park, J. M., Jones, A. M., Crawford, E. A.,
DeNadai, A. S., Menzel, J., Arnold, E. B., Murphy, T.
K., & Storch, E. A. (2014). Family-based exposure
and response prevention therapy for preschool-aged
children with obsessive-compulsive disorder: A pilot
randomized controlled trial. Behaviour Research and
Therapy, 56, 3038.
March, J. S., & Mulle, K. (1998). OCD in children and
adolescents: A cognitive-behavioral treatment manual. New York: Guilford.
Mataix-Cols, D., Conceicao do Rosario-Campos, M., &
Leckman, J. F. (2005). A multidimensional model of
May, A. C., Rudy, B. M., Davis, T. E., & Matson, J. L.
(2013). Evidence-based behavioral treatment of
dog phobia with young children two case examples.
Behavior Modification, 37, 143160.
McNeil, C. B., Capage, L. C., Bahl, A., & Blanc, H.
(1999). Importance of early intervention for disruptive behavior problems: Comparison of treatment and
waitlist-control groups. Early Education and Development, 10, 445454.
National Institute of Mental Health. (1985). Clinical
global impressions. Psychopharmacology Bulletin,
21, 839843.
184
Pediatric OCD Treatment Study team. (2004). Cognitivebehavioral therapy, sertraline, and their combination
for children and adolescents with obsessive-compulsive disorder: The Pediatric OCD Treatment Study
randomized controlled trial. JAMA, 292, 19691976.
Pediatric OCD Treatment Study II team. (2011). Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: The
Pediatric OCD Treatment Study II randomized controlled trial. JAMA, 306(11), 12241232.
Piacentini, J., Bergman, R. L., Chang, S., Langley, A.,
Peris, T., Wood, J. J., & McCracken, J. (2011). Controlled comparison of family cognitive behavioral
therapy and psychoeducation/relaxation training for
child obsessive-compulsive disorder. Journal of the
American Academy of Child and Adolescent Psychiatry, 50(11), 11491161.
Rapee, R. M. (2012). Family factors in the development
and management of anxiety disorders. Clinical Child
and Family Psychology Review, 15, 6980.
Rettew, D. C., Swedo, S. E., Leonard, H. L., Lenane, M.
C., & Rapoport, J. L. (1992). Obsessions and compulsions across time in 79 children and adolescents with
obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 31,
10501056.
Riddle, M. (1998). Obsessive-compulsive disorder in
children and adolescents. British Journal of Psychiatry, 35, 9196.
Rudy, B. M., Storch, E. A., & Lewin, A. B. (2014). When
families wont play ball: A case example of severe
family accommodation and its effect on anxiety symptoms and treatment. Unpublished Manuscript.
Selles, R. R., Storch, E. A., & Lewin, A. B. (2014). Variations in symptom prevalence and clinical correlates in
younger versus older youth with obsessive-compulsive disorder. Child Psychiatry and Human Development, 45, 666674.
disorders interview schedule for DSM- IV-child and
parent versions. San Antonio: Graywind Publications,
A Division of The Psychological Corporation.
Stevens, J., Wang, W., Fan, L., Edwards, M. C., Campo,
J. V., & Gardner, W. (2009). Parental attitudes toward
childrens use of antidepressants and psychotherapy.
Journal of Child and Adolescent Psychopharmacology, 19, 289296.
Stewart, S. E., Rosario, M. C., Brown, T. A., Carter, A.
S., Leckman, J. F., Sukhodolsky, D., Katsovitch, L.,
King, R., Geller, D., & Pauls, D. L. (2007). Principal

components analysis of obsessive-compulsive disorder symptoms in children and adolescents. Biological
Storch, E. A., Geffken, G. R., Merlo, L. J., Jacob, M.
L., Murphy, T. K., Goodman, W. K., Larson, M. J.,
Fernandez, M., & Grabill, K. (2007a). Family accommodation in pediatric obsessive-compulsive disorder.
Journal of Clinical Child and Adolescent Psychology,
36(2), 207216.
Duke, D., Munson, M., Adkins, J., Grabill, K. M.,
Murphy, T. K., & Goodman, W. K. (2007b). Family-based cognitive-behavioral therapy for pediatric
obsessive-compulsive disorder: Comparison of intensive and weekly approaches. Journal of the American
469478.
Storch, E. A., Merlo, L. J., Larson, M. J., Marien, W. E.,
Geffken, G. R., Jacob, M. L., Goodman, W. K., &
Murphy, T. K. (2008a). Clinical features associated
with treatment-resistant pediatric obsessive-compulsive disorder. Comprehensive Psychiatry, 49, 3542.
Storch, E. A., Milsom, V. A., Merlo, L. J., Larson, M., Geffken, G. R., Jacob, M. L., Murphy, T. K., & Goodman,
W. K. (2008b). Insight in pediatric obsessive-compulsive disorder: Associations with clinical presentation.
Storch, E. A., Stigge-Kaufman, D., Marien, W. E., Sajid,
M., Jacob, M. L., Geffken, G. R., Goodman, W. K., &
Murphy, T. K. (2008c). Obsessive-compulsive disorder in youth with and without a chronic tic disorder.
Storch, E. A., Bussing, R., Small, B. J., Geffken, G. R.,
McNamara, J. P., Rahman, O., Lewin, A. B., Garvan,
C. S., Goodman, W. K., & Murphy, T. K. (2013). Randomized, placebo-controlled trial of cognitive-behavioral therapy alone or combined with sertraline in the
treatment of pediatric obsessive-compulsive disorder.
Wellman, H. M., Cross, D., & Watson, J. (2001). Metaanalysis of theory-of-mind development: The truth
about false belief. Child Development, 72, 655684.
Zohar, A. H., Pauls, D. L., Ratzoni, G., Apter, A., Dycian,
A., Binder, M., King, R., Leckman, J. F., Kron, S., &
Cohen, D. J. (1997). Obsessive-compulsive disorder
with and without tics in an epidemiological sample of
adolescents. American Journal of Psychiatry, 154(2),
274276.
Treatment of Perfectionism in
Childhood Obsessive-Compulsive Disorder
13
Dean McKay and Lauren Mancusi
Introduction and Background

Perfectionism is conceptualized as a multidimensional construct that can be with both adaptive
and maladaptive qualities (Rice etal. 1998; Stoeber and Otto 2006). Both adaptive and maladaptive perfectionists pursue high performance standards and orderliness (Slaney and Ashby 1996).
However, adaptive and maladaptive perfectionists differ with regard to their self-esteem, affective regulation, and coping abilities. Individuals
who identify as adaptive perfectionists exhibit
positive self-esteem and good affective regulation when performance expectations are not met
(Ashby etal. 2012; Stoeber and Otto 2006). Conversely, high levels of perfectionistic strivings
and feelings of failure mark maladaptive perfectionism when standards are not met. Further, the
standards are typically impossibly high for anyone to reach. Maladaptive perfectionists show
concern over mistakes (CM), worry about others
evaluations, have doubts about actions, low selfesteem, poor affective regulation, and poor coping skills (Ashby and Burner 2005; Stoeber and
Otto 2006).
A diverse range of psychological problems
are marked by maladaptive perfectionism. Perfectionism has been associated with worry and
processes underlying generalized anxiety disD.McKay() L.Mancusi
Department of Psychology, Fordham University,
441 East Fordham Road, Bronx, NY 10458, USA
e-mail: mckay@fordham.edu
order and as a general liability for anxiety and

depressive affect (Fergus and Wu 2011). In the
case of obsessive-compulsive disorder (OCD),
there has been considerable speculation regarding the role of perfectionism, and it is among
the primary cognitions that form the basis for
comprehensive treatment models for the condition (Taylor etal. 2007). More specifically,
maladaptive perfectionism has been associated
with obsessive beliefs and compulsive behaviors related to concern over mistake, doubting,
intolerance of uncertainty, and checking (Ashby
and Bruner 2005; Rice and Pence 2006). Perfectionism may develop as a way of avoiding
negative experiences. In an effort to cope with
uncertainty, individuals may attempt to perform
tasks perfectly. This contributes to the development of certain obsessions (e.g., doubts about
whether a task was done correctly) and compulsions (e.g., repeated checking) often seen in
individuals with OCD (Frost etal. 2002). Perfectionism is frequently seen in individuals with
OCD who report the need for certainty. Uncertainty can lead to doubting whether an action
was performed correctly. Individuals with OCD
may believe that performing an action perfectly
will avoid criticism by others and divert aversive outcomes (Chik etal. 2008). Though perfectionism among individuals with OCD has
been well established, the majority of the research has been with adults with OCD; research
examining the role of perfectionism in children
with OCD is limited.

DOI 10.1007/978-3-319-17139-5_13
185
186
Perfectionism in Children with Obsessive-Compulsive Disorder

Few researchers have examined the role of
perfectionism in children and adolescents with
OCD. However, perfectionism figures prominently in contemporary cognitive-behavioral
models of OCD regardless of age (Abramowitz etal. 2007). In one evaluation, cognitive
appraisals were compared among adolescents
(1118 years old) with OCD, anxiety disorders,
and nonclinical controls. Results showed CM as
measured by the Multidimensional Perfectionism Scale (MPS; Frost etal. 190) was significantly higher in adolescents with OCD as compared to those with an anxiety disorder and nonclinical controls. Furthermore, adolescents in
the OCD group reported higher rates of inflated
sense of responsibility as compared to the anxiety and control groups (Libby etal. 2004). These
results are congruent with previous findings in
an adult OCD sample, showing that concern
over mistake and doubts about actions were associated with OCD symptoms and differentiated
individuals with OCD from individuals with
other anxiety disorders (Antony etal. 1998).
Similarly, sensitivity to mistake as measured
by the AdaptiveMaladaptive Perfectionism
Scale (AMPS; Rice and Preusser 2002) emerged
as a significant predictor of OCD symptoms in
children and adolescents with OCD (718 years
old; Ye etal. 2008). These findings are consistent with previous studies (Libby etal. 2004)
showing that concerns over mistakes is a salient
matter related to perfectionism in children with
OCD. Additionally, striving for perfectionism
is associated with increased symptom severity,
which may reflect an increased sense of responsibility and an overestimation of the need to
make things just right. Previous research shows
that children with OCD report high rates of a
sense of responsibility (Barret and Healy 2003;
Libby etal. 2004). Perfectionistic strivings may
function as a means to prevent feared events.
However, when unrealistic expectations are not
met, obsessive-compulsive symptoms are exacerbated.
D. McKay and L. Mancusi
Maladaptive perfectionism negatively impacts

quality of life and interpersonal relationships in
children. Perfectionism has been significantly
associated with depression, anxiety, anger, and
social stress (Hewitt etal. 2002). Sensitivity to
mistake as measured by the AMPS was related to
decreased happiness, increased emotional difficulties, and decreased popularity in a nonclinical
sample of children (Rice etal. 2004). Children
with OCD frequently experience problems with
peer relationships, academic difficulties, and diminished quality of life (Lack etal. 2009; Piacentini etal. 2007). Difficulties associated with perfectionism, such as concern over mistake, may
intensify these already challenging impairments.
Sensitivity over mistakes was related to more severe symptoms of depression and negative peer
relationships, including more social isolation in
children with OCD. Furthermore, perfectionistic
beliefs were associated with increased feelings of
loneliness (Ye etal. 2008). These results are consistent with findings in adults showing that perfectionists experience difficulties in social situations and interpersonal relationships (Rice etal.
2006). Children may be concerned about others
being aware of their mistakes, which may lead
to obsessive concerns about their flaws and increase avoiding social interactions, thus resulting
in social isolation. However, it may be possible
that OCD symptoms, depression, and social isolation contribute to a child feeling the need to be
perfect as a means to increase social relationships
(Ye etal. 2008). While it appears apparent that
maladaptive perfectionism is involved in OCD,
the direction of the relationship is not clear and
further research is needed in this area.
Perfectionism and Treatment Response

Cognitive behavioral therapy (CBT) with exposure and response prevention (ERP) has demonstrated robust efficacy in reducing symptoms of
OCD in children and adolescents (Abramowitz
etal. 2005). However, elevated levels of perfectionism are believed to negatively affect treatment outcome. CBT requires some flexibility,
13 Treatment of Perfectionism in Childhood Obsessive-Compulsive Disorder
and the rigidity associated with perfectionism

may be related to decreased ability to identify
alternative interpretations of cognitive appraisals and beliefs (Whittal and ONeill 2003). Additionally, perfectionism may interfere with the
ability to successfully engage in ERP (Frost etal.
2002). Reassurance-seeking behaviors associated with uncertainty may prevent direct exposure
to feared situations (Abramowitz etal. 2003). In
fact, doubts about actions predicted poorer treatment response in adults with OCD whether they
received cognitive therapy or ERP (Chik etal.
2008).
While perfectionism negatively influences
treatment response in adults with OCD, the impact of perfectionism on treatment outcome in
children with OCD has not been examined. The
effects of perfectionism in treatment outcome
have centered on anxiety in children with a particular focus on gifted children, test anxiety, and
anxiety sensitivity (Mitchell etal. 2013). Nobel
et al. (2012) examined the impact of perfectionism on a school-based treatment program for
anxious and depressive symptoms in a nonclinical sample of school-aged children. Greater levels of pretreatment self-oriented perfectionism
significantly predicted poorer levels of depression post treatment. However, this relationship
was not found for anxious symptoms. More recently, the impact of perfectionism on treatment
outcome has been investigated in clinically
anxious children (Mitchell etal. 2013). Treatment consisted of weekly 2h CBT sessions for
children and their parents over ten consecutive weeks. Results showed that higher levels
of pretreatment perfectionism predicted poorer
treatment outcome. Symptoms of anxiety and
perfectionism decreased following treatment
suggesting that while perfectionism may negatively impact treatment outcome, CBT may be
an appropriate treatment to target symptoms
of perfectionism as well as anxiety. This is the
first known study to examine the impact of perfectionism on treatment outcome in a clinically
anxious group; results need to be extended to
children with OCD.
187
Description of the Current Case

As we have described here, perfectionism is not
necessarily a primary symptom of OCD but instead is an underlying appraisal process which
results in specific manifest symptoms of the disorder. In children, this appraisal may be present
and is therefore worth investigating to determine
its causal role in symptom presentation.
The case that will be described here involves
a 12-year-old female (pseudonym: Alexandra)
who had extensive obsessive-compulsive symptoms. According to the Childrens YaleBrown
Obsessive-Compulsive Scale (CY-BOCS; Scahill etal. 1997) symptom checklist, she reported
the following major symptoms: contamination
fears, specifically of potentially causing others
illness; intrusive sexual images; excessive concerns with right and wrong, especially potentially offending others; confessing of intrusive
images or concerns over perceived wrongs committed toward others; and intrusive melodies,
especially contemporary music containing foul
language. On the last item, related to music,
because Alexandra was so concerned with her
image, she only listened to music with spiritual
or religious themes in order that she would avoid
possibly enjoying music with foul language or
mature themes.
In addition to these major symptoms, Alexandra reported being preoccupied that others view
her as a good girl, which she defined as being
pure and kind to anyone who might cross her
path. This included classmates who might potentially bully her or mistreat her. As a result, other
classmates did occasionally bully her, which she
reported to her mother, but then defended the actions of the aggressors by indicating it was not
likely intentional or that she may have inadvertently offended the aggressors by answering too
many questions in class. She also reported feeling
panicky when faced with the possibility that
she committed a wrong and described symptoms
of panic including dizziness, heart palpitations,
numbness in her extremities, and feeling that she
would go crazy.
188
Alexandra denied any suicidal ideation, and

careful assessment revealed that the reason she
reported that she would not commit suicide was
out of extreme concern for her parents mental
health. She did reveal that, had she not been concerned about her parents reactions, she would
seriously consider suicide. According to Alexandra, she also worried extensively about her
academic performance, often committing several
hours of time each evening to her homework.
Her academic performance was high, with no
grades lower than A in any course. Nonetheless, she completed additional work that was not
required and frequently exceeded by many pages
the limits for assigned essays. Exams as part of
her ordinary education process were often completed by excessive answers (i.e., short answers
that far exceeded the required information). Alexandra even provided explanations in the margins for multiple-choice tests for why the choices
she did not select were incorrect. At the time she
presented for treatment, Alexandra had already
begun thinking about colleges she might like to
attend (despite only being in seventh grade at the
start of treatment). Aside from her excessive academic efforts, she spent much of her remaining
time preoccupied with postgraduate aspirations.
Her sleep was very limited, and she often went to
bed late (frequently past 11:00 p.m.) and awoke
early, sometimes as early at 4:00 a.m. to continue
extra work for school. She would then allocate
approximately 50min to shower to be sure not to
contaminate others. As a result of her abbreviated
sleep cycle and excessive washing, she missed a
good deal of school due to illness.
Case Information
When treatment was initiated, Alexandra lived
at home with both biological parents and her
younger brother (age 9). The family, Caucasian,
lived in an affluent area in a New York City
suburb.
According to Alexandras mother, there was
limited family stress in the home. In general, Alexandra was agreeable with her younger brother,
although occasionally her mother reported that
frustration was evident in what was deemed routine sibling rivalry. Alexandras father was out a
great deal, as he worked long hours and his job
required significant travel. As a result, most of
the child care was the mothers responsibility.
Indeed, to illustrate, in order to have a parent session (see Illustrative Treatment Course below),
an appointment had to be scheduled an hour later
than was ordinarily the case for the treating clinician in order to have the father present. Both parents earned undergraduate and postbaccalaureate
degrees from top-ranked collegiate institutions.
At the time of treatment, Alexandra was not
taking medication, although she had previously
been administered trials of fluvoxamine, fluoxetine, and sertraline, all with minimal benefit. Alexandra reported significant somnolence on each
medication but little benefit in her acute OCD
symptoms. The course of medication was administered from age 8 until 11 years.
Prior to the course of treatment to be presented here, Alexandra had two prior therapists
administer psychotherapy. As described to the
clinician by the mother, the first course of therapy was traditional in nature. The mother was not
involved in the therapy, and Alexandra reported
that mostly she played games with the therapist
with no specific between-session exercises. The
second course of therapy, administered when
Alexandra was age ten and continuing for 35
sessions, involved primarily relaxation therapy
with guided imagery. There was no discernable
benefit. This latter course of therapy was verified
in contact between the treating clinician and the
prior therapist.
While the mother did not report familial discord per se, she did report significant frustration
with her husband for his extremely long work
hours and the child-care burden she had to shoulder. This issue was a source of frequent conflict
between them, and in a discussion without the
mother present, Alexandra likewise reported
that her parents often quarreled about this issue,
sometimes with the argument so severe that she
was concerned her parents would divorce. She
was quite fearful of this occurring, and worried
that: (a) she would be responsible because of her
mental health needs taking up so much of her
mothers time, and (b) that she would have less

access to her mother, upon whom she was quite
dependent for support, beyond that typical for a
child her age.

Assessment
Based on the prior information, Alexandras
symptom presentation appeared to be primarily
a result of appraisals due to perfectionism. This
was evident most prominently in her academic
efforts but can be observed in her self-presentation (that she be perceived by others as pure and
well-liked by others), in her concerns over contamination of others, and her confessing of intrusive sexual imagery out of a concern that she
would perceive herself as a bad person.
Following the initial evaluation, psychoeducation was covered with Alexandra and her mother.
In this instance, specific emphasis was paid to
how perfectionism influences her symptoms and
the scope of impact this would have should she
go untreated. Exposure with response prevention
was described and presented as an approach that
would be implemented gradually and in a manner
whereby success would be emphasized over intensity of experience. That is, all exercises would
be implemented at a pace Alexandra would tolerate well, and between-session exercises would be
structured to maximize successful completion.
Although perfectionism was a primary appraisal, attention was also paid to concerns
with excessive responsibility given Alexandras
symptoms of concerns with contaminating others. Briefly, responsibility appraisals are hypothesized to contribute to obsessional symptoms by
creating the belief that one may cause adverse
outcomes, which in turn can lead to ritualized
behaviors to alleviate the anxiety about the potential negative events (Abramowitz etal. 2007).
As will be shown below, responsibility was not a
major contributing appraisal in the treatment of
Alexandra.
At baseline, Alexandra was administered the
CY-BOCS severity rating scale. Her obsessions
score was 13, and her compulsions score was 12
189
(total CY-BOCS=25). She was also administered the Childrens Depression Inventory (CDI;
Kovacs 1982), on which she scored 35. Finally,
she was also administered the Childrens Anxiety
Sensitivity Index (CASI; Silverman etal. 1991),
and she had a total score of 31. The CASI was administered due to her reported panic sensations.

Alexandra was treated over a course of 22 sessions. After the psychoeducation session, a series of hierarchies were constructed for exposure
with response prevention. These hierarchies are
presented in Table13.1. Hierarchies were constructed only for fear of offending, committing
mistakes on schoolwork, and for contaminating
others. The other two domains, intrusive sexual
thoughts, and music with foul or suggestive
content, were difficult for Alexandra to address
in hierarchies. Instead, these two domains were
viewed in absolute (black-or-white) terms.
Accordingly, in-session exposure for these two
domains were initiated gradually with ad hoc hierarchies used to devise exercises. These last two
were also conducted only with her mother present. See more on this portion of treatment below.
Hierarchy-Guided Exposure
Hierarchy-guided exposure was conducted beginning with fear of offending. This was chosen
first because: (a) it was a distal concern, and so
there was a higher likelihood of success on exposure and greater buy-in for treatment with
the child and (b) the clinician (first author of this
chapter) wanted to establish early that interventions could be effective for the parent (in this
case, Alexandras mother), who was a bit skeptical about the course of therapy. Sessions began
with the child thinking of mildly offensive words
(which she whispered to her mother in session),
and quickly, within the same session, progressed
to thinking of more offensive words. During that
initial session, Alexandra was able to begin using
mildly offensive words in session, in the pres-
190
Table 13.1 Hierarchies for exposure in the case of Alexandra

Feared situation
Fear of offending
Thinking of a mildly offensive word while in the presence of an adult
Thinking of a strongly offensive word while in the presence of an adult
Stating out loud a mildly offensive word while in the presence of another person
(child or adult)
Stating out loud a mildly offensive word while in the presence of another person
(child or adult)
Directing an insult at another person, child or adult, including a mildly offensive
word
Directing an insult at another person, child or adult, including a strongly offensive
word
Mistakes on schoolwork
Misspelling a word on a homework assignment
Deliberately answering an item incorrectly on a homework assignment that will not
be graded
Deliberately answering an item incorrectly on a homework assignment that will be
graded
Answering multiple-choice items without any additional explanation for the wrong
choices
Answering questions in short sentences, and only giving the essential information,
on any work (homework or exam)
Deliberately answering one item incorrectly on a multiple choice test
Deliberately scoring poorly enough to earn a grade less than A- in a course
Contaminating others
Coming in contact with a stranger after only washing hands briefly using soap and
water
Coming in contact with a friend after only washing hands briefly using soap and
water
Coming in contact with a young healthy family member after only washing hands
briefly using soap and water
Coming in contact with a young healthy family member without washing hands but
where no contact has been made with perceived contaminants
Coming in contact with a young healthy family member without washing hands but
where no contact has been made with perceived contaminants
Coming in contact with an elderly family member without washing hands but where
no contact has been made with perceived contaminants
ence of the therapist. A mechanism for making

this enjoyable for Alexandra and yet still consistent with the aims of exposure, the therapist
and child played blackjack, and the loser of each
game had to blurt out one of three predetermined
foul words. Figure13.1 shows an approximate
graphical display of Alexandras anxiety reaction
over the course of the session involving mildly
offensive words.
Following the initial session involving exposure to foul language, Alexandra was instructed
to practice at home on a daily basis, particularly
Predicted subjective units

of distress (0100)
20
40
65
80
85
95
10
30
50
55
70
80
95
15
25
35
50
65
80
creating images of herself emitting foul language

in school, in the presence of teachers, and other
adults. The next session, the parent was coached
on how to respond to Alexandras confessions
about the use of foul language. This included
encouraging statements (i.e., Its great that you
were able to think of so much foul language
today.) and humorous statements (i.e., Thats
the best you could come up with? Surely you
have more foul words available.). This led to
significant improvement in Alexandras concerns
over offending others.
191
Fig. 13.1 Response during first exposure session (response shown in subjective units of distress scale
(SUDS), rated from 0 to 100. Spikes in ratings occurred
for each repeted exposure trial. Spike at point number 11

corresponds to the beginning of game of exposure-based
blackjack)
While the fear of offending concerns including more intense potential exercises, it was determined that Alexandras other areas of functioning required attention, and given her response to
handling foul language led to significant buyin for treatment, exposure moved to contamination of others. This was chosen next because it
was challenging for Alexandra to entertain the
idea, and her washing was causing considerable
distress. Treatment started with an item higher
than the lowest item since, at this point, it was
necessary to practice in-session. The opening approach involved asking Alexandra to touch the
floor in the therapists office and then touch her
mother on the back of her hand. This exercise
took place several sessions after the hierarchy
was constructed, so she was asked to predict how
anxious she would feel with this exercise. She
predicted this would provoke subjective units of
distress scale (SUDS) of 55, since the floor was
deemed fairly contaminated, but not as bad as
the floor in the hallway or areas in the bathroom.
Since it was determined from prior sessions that
Alexandra could easily tolerate an SUDS of 55,
she proceeded to touch the floor and then contact
her mothers hand. Once she completed this, she
reported an SUDS of 40, which quickly dissipated. In light of the potential that she was avoiding the contingencies around this exposure, such
as through freezing (i.e., her mother is safe so

long as she does not have that part of her hand
come in contact with any other area of her body;
see Foa and Kozak (1986) for a discussion of this
complication in exposure), her mother was asked
to wipe her hand across her face. Alexandra reported her SUDS rose to 65, but it again quickly
dissipated, dropping to 40.
The next four sessions comprised primarily
exposure for additional areas on the hierarchy as
described above. Following this, a parent-only
session was held. The aims of this session were
as follows: first, to evaluate Alexandras progress
to this point; second, to cover ways the parents
could ensure that they were not accommodating
to her symptoms; and third, to ensure both parents were consistent in how they responded to
Alexandra when situations arose that might interfere with treatment. The importance of evaluating
progress was in order that any potential problems
that were difficult to report when Alexandra was
present could be covered. The second, regarding accommodation, is a significant challenge
in OCD treatment in general. Indeed, in a recent
multi-site treatment trial, lower levels of family accommodation were associated with better
outcomes (Garcia etal. 2010; Merlo etal. 2009).
As Alexandras symptoms involved her parents,
it was important that this problem be addressed
192
Table 13.2 Hierarchy of parental accommodations

Accommodation
Allowing Alexandra to stay up past reasonable hour to complete
a dditional schoolwork
Providing incorrect answers to Alexandras requests for reassurance
over cleanliness
Avoiding correction of Alexandras homework
Avoidance of contact of school personnel to provide excuses
for Alexandras absences when up late for excessive homework
completion
in the course of treatment. Finally, ensuring that

the parents are consistent with one another was
deemed an essential ingredient for treatment success in order that Alexandra could not find ways
to satisfy obsessive-compulsive symptoms with
one parent by avoiding the other. The parental involvement component will be discussed further
in the complications section.
Treatment continued for an additional 18 sessions, with four of those additional parent sessions to cover the same items listed for the first
parent session. By the end of session 22, Alexandra showed considerable improvement. Her
CY-BOCS score had dropped to a total of 5 (obsessions=3; compulsions=2), her CDI scored
dropped to four. Although no sessions were directly aimed at her panic symptoms, her CASI
score dropped to 18 at this point in treatment.
However, as will be discussed below, in addition
to parental matters serving as a complicating factor, conducting exposure around academic performance was likewise a complication.
Parental Accommodation
During the course of treatment, there were a
total of five parent sessions. While the parents
were cohesive in their interests in participating
in treatment and fully understood the tenets of
exposure, there was difficulty in both parents
engaging in treatment to the same degree. During the first parent session, the focus was on
education regarding the nature of accommodation, the process of how accommodation devel-
Maternal anticipatory Paternal anticipatory

anxiety
anxiety
20
35
40
30
55
80
70
75
ops, and what steps could be taken to reduce

it as part of treatment. Briefly, accommodation
was defined as an otherwise well-intentioned
behavior (i.e., parents believe that by accommodating to symptoms it will alleviate distress
and reduce symptoms) that has a pernicious effect on OCD.
In the case of Alexandra, an informal hierarchy of areas of accommodation that would be targeted for reduction was designed with the parents
(see Table13.2). The most challenging aspect of
treatment revolved around academic achievement and Alexandras perfectionistic approaches.
Specifically, her parents reported that they were
both graduates of very competitive universities
and expected their daughter to likewise succeed.
Given her academic talents, they were reluctant
to engage in treatment that might foster a loosening of academic standards as they worried it
would jeopardize her collegiate future. The degree of willingness to engage in treatment around
this particular problem was unequal, with Alexandras father expressing significant concern. In
the first session, he ultimately agreed to participate when the therapist indicated that Alexandra
would be encouraged to start simply by completing one to two questions incorrectly on a math
homework assignment.
In the second parent session, the father reported that while he understood the rationale for the
intervention around the academic based exposure, he nonetheless was uncomfortable with the
uncertainty around whether therapy would have
a deleterious effect on her odds of admission to
a competitive college. To remind the reader, significant discussion about Alexandras collegiate
future took place in the treatment of a 12-year-
old. Her parents intolerance of uncertainty created a significant barrier to alleviating symptoms
around perfectionism.
Parental expectations around perfectionism
have been shown to influence childrens perfectionistic behavior (i.e., Cook and Kearney 2009).
Further, intolerance of uncertainty is a significant
contributor to anxiety-related problems (Gentes
and Ruscio 2011), which in this case, was evident
in the parents expression of hesitancy around the
goals of treatment.
The following sessions with the parents,
therefore, focused on attempting to address their
concerns around intolerance of uncertainty. This
resulted in cognitive therapy involving behavioral experiments for the parents around tolerating
uncertainty in other areas unrelated to academic
concerns. For example, one exercise involved
tolerating the uncertainty associated with each
other, such as the father calling the mother when
he left his office for the evening. An additional
aspect that developed from this involved evaluation of certainty around their daughters academic success and the perceived necessity of attending what they defined as a competitive college. It
was only at this point that the parents were able
to fully engage in exposure exercises and successfully stop engaging in accommodation of her
academic-oriented perfectionism.
Academic-Relevant Exposure
Like her parents, Alexandra was reluctant to
engage in exposure related to academic performance. She was willing to participate in all other
exposures except this one domain. However, as
her parents began to tolerate uncertainty, Alexandra began to show a greater willingness to engage in academic-based exposure exercises. As
exposure began to move to areas that carried real
consequences (i.e., deliberately answering one
multiple choice question incorrectly on an exam),
her ability to tolerate the uncertainty of long-term
deleterious effects became very high. It was on
this point that cognitively focused efforts around
tolerating uncertainty were implemented with
Alexandra as well.
193
Whereas Alexandra exhibited hesitancy

around exposure for academic perfectionism,
her concerns began to alleviate as she developed
greater tolerance of uncertainty around the future
and her parents expectations. She also showed
greater flexibility in how she engaged in exposure exercises once she observed that occasional
incorrect answers in her school work did not seriously affect her overall academic performance.

Perfectionism is a serious problem that, in some
cases, is associated with OCD. Treatment of perfectionism involves carefully crafting a hierarchy but also developing cognitive interventions
aimed at addressing core beliefs that maintain the
drive for perfectionism. Accordingly, a combined
approach becomes warranted to alleviate anxiety
symptoms and to reduce excessive behaviors designed to maintain perfectionistic standards.
Development of a hierarchy that evaluates
all the major anxiety-evoking domains serves
as a useful guide in determining starting points
in treatment. In the present case, areas targeted
initially were those unrelated to the primary presenting symptom as a means to engage the child
and family given their doubts about the efficacy
of treatment, and in an effort to promote a buyin on the approach through anticipated early
successes. This fortunately proved successful in
the case presented here. In the event that these
initial targeted areas failed, alternative strategies
for engagement would have been necessary, such
as motivational interviewing (see, for example,
Simpson and Zuckoff 2011).
Youth with perfectionism-based OCD warrant
a combined approach that incorporates parental
involvement. This is true in many cases of OCD,
as it specifically relates to reducing accommodating behaviors that serve to maintain symptoms
(i.e., Garcia etal. 2010). In the present case,
parental accommodation emerged due largely
to parent beliefs around perfectionism and their
own inability to tolerate distress and uncertainty.
While other symptoms of OCD were fairly readily targeted using exposure with response pre-
194

Development of hierarchies, particularly for separate domains of problem behaviors, ensure that domains that allow
for higher treatment engagement may be targeted
Parental accommodation requires direct and specific attention in the course of treatment
Identification of cognitive biases present in parents, and alleviation of these biases, are useful in ensuring parental
compliance with the demands of treatment for youth
Inclusion of exposure exercises that creatively engage the child assist in promoting significant change
vention, the primary presenting problem related

to perfectionism in academic performance was
more difficult to address given the beliefs about
perfectionism held by the parents (Table13.3).
Finally, exposure exercises with youth, particularly in the case of perfectionism-based OCD,
benefits from an intervention style that balances
addressing the symptoms as well as structuring
around humor. In the case of Alexandra, many of
the exposure exercises in session had an element
of absurdity (i.e., blackjack designed to elicit foul
language). While it is possible to construe this as
provoking emotional responses other than anxiety, this method is in keeping with more recent
analyses of the mechanisms underlying exposure
therapy. Specifically, in the inhibitory learning
model, fear evocation is secondary over experiencing the avoided stimuli in a new context (i.e.,
Craske etal. 2008). This holds promise for promoting anxiety reduction methods whereby it is
not essential to provoke fear in participants, but
instead that determining methods for presenting otherwise feared stimuli in non-fear inducing contexts may also have therapeutic effects.
In cases involving perfectionism associated with
OCD, this model may be particularly useful.
References
Abramowitz, J. S., Franklin, M. E., & Cahill, S. P. (2003).
Approaches to common obstacles in the exposurebased treatment of obsessive-compulsive disorder.
Cognitive and Behavioral Practice, 10, 1422.
Abramowitz, J. S., Whiteside, S. P., & Deacon, B. J. (2005).
The effectiveness of treatment for pediatric obsessivecompulsive disorder: A meta-analysis. Behavior Therapy, 36, 5563. doi:10.1016/S0005-7894(05)80054-1.
Abramowitz, J. S., Taylor, S., & McKay, D. (2007). Psychological theories of obsessive-compulsive disorder.
In E. A. Storch, G. R. Geffken, & T. K. Murphy (Eds.),
Handbook of child and adolescent obsessive-compulsive disorder (pp.109129). Mahwah: Erlbaum.

Antony, M. M., Pudon, C. L., Huta, V., & Swinson, R. P.
(1998). Dimensions of perfectionism across the anxiety disorders. Behaviour Research and Therapy, 36,
11431154.
Ashby, J. S., & Burner, L. P. (2005). Multidimensional
perfectionism and obsessive-compulsive behaviors.
Journal of College Counseling, 8, 3139.
Ashby, J. S., Slaney, R. B., Noble, C. M., Gnilka, P. B.,
& Rice, K. G. (2012). Difference between normal
and neurotic perfectionists: Implications for mental
health counselors. Journal of Mental Health Counseling, 4, 322340.
Barrett, O. M., & Healy, L. J. (2003). An examination of the cognitive processes involved in childhood obsessive-compulsive disorder. Behaviour
Research and Therapy, 41, 285299. doi:10.1016/
A0005-7967(02)00011-6.
Chik, H. M., Whittal, M. L., & ONeill, M. L. (2008). Perfectionism and treatment outcome in obsessive-compulsive disorder. Cognitive Research and Therapy, 32,
676688. doi:10.1007/s10608-007-91332.
Cook, C. L., & Kearney, C. A. (2009). Parent and youth
perfectionism and internalizing psychopathology. Personality and Individual Differences, 46, 325330.
Craske, M. G., Kircanski, K., Zelikowsky, M., Mystkowski, J., Chowdhury, N., & Baker, A. (2008). Optimizing inhibitory learning during exposure therapy.
Behaviour Research and Therapy, 46, 527.
Fergus, T. A., & Wu, K. D. (2011). Searching for specificity between cognitive vulnerabilities and mood and
anxiety symptoms. Journal of Psychopathology and
Behavioral Assessment, 33, 446458.
Foa, E. B., & Kozak, M. J. (1986). Emotional processing
of fear: Exposure to corrective information. Psychological Bulletin, 99, 2035.
Frost, R. O., Marten, P., Lahart, C., & Rosenblate, R.
(1990). The dimensions of perfectionism. Cognitive
Therapy and Research, 14, 449468.
Frost, R. O., Novara, C., & Rhame, J. (2002). Perfectionism in obsessive compulsive disorder. In R. O. Frost
& G. Steketee (Eds.), Cognitive approaches to obsessions and compulsions-theory assessment, and treatment (pp.91105). Amsterdam: Elsevier.
Garcia, A. M., Sapyta, J. J., Moore, P. S., Freeman, J. B.,
Franklin, M. E., March, J. S., & Foa, E. B. (2010).
Predictors and moderators of treatment outcome in
the pediatric obsessive-compulsive treatment study
(POTS I). Journal of the American Academy of Child
and Adolescent Psychiatry, 49, 10241033.

Gentes, E. L., & Ruscio, A. M. (2011). A meta-analysis
of the relation of intolerance of uncertainty to symptoms of generalized anxiety disorder, major depressive
disorder, and obsessive-compulsive disorder. Clinical
Psychology Review, 31, 923933.
Hewitt, P. L., Caelin, C. F., Flett, G. L., Sherry, S. B.,
Collins, L., & Flynn, C. A. (2002). Perfectionism in
children: Associations with depression, anxiety, and
anger. Personality and Individual Differences, 32,
10491061.
Kovacs, M. (1982). The childrens depression inventory:
A self-rated depression scale for school-aged youngsters. Unpublished manuscript, Pittsburgh: University
of Pittsburgh.
Lack, C. W., Storch, E. A., Keeley, M. L., Geffken, G. R.,
Ricketts, E. D., Murphy, T. K., & Goodman, W. K.
(2009). Quality of life in children and adolescents with
obsessive-compulsive disorder: Base rates, parentchild agreement, and clinical correlates. Social Psychiatry and Psychiatric Epidemiology, 44, 935942.
doi:10.1007/s00127-009-0013-9.
Libby, S., Reynolds, S., Derisley, J., & Clark, S. (2004).
Cognitive appraisals in young people with obsessivecompulsive disorder. Journal of Child Psychology and
Merlo, L. J., Lehmkuhl, H. D., Geffken, G. R., & Storch,
E. A. (2009). Decreased family accommodation associated with improved therapy outcome in pediatric
obsessive-compulsive disorder. Journal of Consulting
and Clinical Psychology, 77, 355360.
Mitchell, J. H., Newall, C., Broeren, S., & Hudson, J. L.
(2013). The role of perfectionism in cognitive behaviour therapy outcomes for clinically anxious children.
Behaviour Research and Therapy, 51, 547554.
Nobel, R. J., Manassis, K., & Wilansky-Traynor, P.
(2012). The role of perfectionism in relation to an
intervention to reduced anxious and depressive symptoms in children. Journal of Rational-Emotive &
Cognitive Behavior Therapy, 30, 7790. doi:10.1007/
s10942-011-01335.
Piacentini, J., Peris, T. S., Bergman, R. L., & Chang, S.
(2007). Functional impairment in childhood OCD:
Development and psychometrics properties of the
child obsessive-compulsive impact scale-revised
(COIS-R). Journal of Clinical Child and Adolescent
Psychology, 36, 645653.
Rice, K. G., & Pence, S. L. Jr. (2006). Perfectionism and
obsessive-compulsive symptoms. Journal of Psychopathology and Behavioral Assessment, 28, 103111.
doi:10.1007/s10862-006-74884.
Rice, K. G., & Preusser, K. J. (2002). The adapative/maladaptive perfectionism scale. Measurement and Evaluation in Counseling and Development, 34, 210221.
195
Rice, K., Ashby, J., & Slaney, R. (1998). Self-esteem as

a mediator between perfectionism and depression: A
structural equations analysis. Journal of Counseling
Rice, K. G., Kubal, A. E., & Preusser, K. J. (2004). Perfectionism and childrens self-concept: Further validation of the adaptive/maladaptive perfectionism scale.
Psychology in the Schools, 41, 279290. doi:10.1002/
pits.10160.
Rice, K. G., Leever, B. A., Christopher, J., & Porter, J. D.
(2006). Perfectionism, stress, and social (dis)connection: A short-term study of hopelessness, depression,
and academic adjustment among honors students.
Journal of Counseling Psychology, 53, 524534.
doi:10.1037/0022-0167.53.4.524.
Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., & Ort,
S. I. (1997). Childrens yale-brown obsessive-compulsive scale: Reliability and validity. Journal of the
36, 844852.
Silverman, W. K., Fleisig, W., Rabian, B., & Peterson, R.
A. (1991). Child anxiety sensitivity index. Journal of
Child Clinical Psychology, 20, 162168.
Simpson, H. B., & Zuckoff, A. (2011). Using motivational
interviewing to enhance treatment outcome in obsessive-compulsive disorder. Cognitive and Behavioral
Practice, 18, 2837.
Slaney, R. B., & Ashby, J. S. (1996). Perfectionists: Study
of a criterion group. Journal of Counseling and Development, 74, 393398.
Stoeber, J., & Otto, K. (2006). Positive conceptions of
perfectionism: Approaches, evidence, challenge. Personality and Social Psychology Review, 10, 295319.
doi:10.1207/s15327957pspr1004_2.
Taylor, S., Abramowitz, J. S., & McKay, D. (2007). Cognitive-behavioral models of obsessive-compulsive
disorder. In M. M. Antony, C. Purdon, & L. J. Summerfeldt (Eds.), Psychological treatment of obsessive-compulsive disorder: Fundamentals and beyond
(pp.929). Washington: American Psychological
Association.
Whittal, M. L., & ONeill, M. L. (2003). Cognitive and
behavioral methods for obsessive compulsive disorder.
Brief Treatment and Crisis Intervention, 3, 291215.
Ye, H. J., Rice, K. G., & Storch, E. A. (2008). Perfectionism and peer relations among children with obsessivecompulsive disorder. Journal of Child Psychiatry
and Human Development, 39, 415426. doi:10.1007/
s10578-008-00985.
Treatment of Not-Just-Right
Experiences in Childhood
Disorder
14
Jessica Schubert, Ariel Ravid and Meredith E. Coles
Not-Just-Right Experience OCD in

a Child
Obsessive-compulsive disorder (OCD) is
characterized by recurrent obsessions and/or
compulsions (American Psychiatric Association 2013). Obsessions are intrusive thoughts,
impulses, or images that are distressing. Compulsions are repetitive and ritualistic acts targeted at
reducing the distress associated with the obsessions. Although a functional pattern is inherent
in these definitions (compulsions are performed
to reduce the distress associated with the obsession), the motivation behind the distress is not
inherently specified.
Cognitive-behavioral conceptualizations of
OCD emphasize fear of harm as being associated
with obsessive thoughts (Salkovskis etal. 2000).
For example, a person might have an obsession
about being contaminated by germs after touching a public doorknob. This produces distress
associated with a fear of becoming terminally
sick. The person then engages in a compulsion
(likely hand washing), to avoid the perceived
harmful outcome, thereby temporarily reducing the distress but maintaining the compulsive
M.E.Coles() J.Schubert A.Ravid

Department of Psychology, Binghamton University,
NY139026000, USA
e-mail: mcoles@binghamon.edu
behavior in the long run. Cognitive-behavioral

therapy (CBT) treatment for OCD, exposure and
ritual prevention (ERP), creates new associations
by exposing patients to their feared situations and
resisting the urge to perform their compulsion.
By doing this, patients learn that even without
performing their compulsion anxiety decreases
naturally over time and that their feared consequences rarely happen. A wealth of data has
shown that ERP leads to substantial symptom
reductions for many patients (Foa etal. 2005).
However, sizable minorities of patients do not
respond to ERP, or other treatments for that
matter (Foa etal. 2005). Additionally, some patients fail to report feared consequences associated with obsessions (Foa et al. 2005). There is
a growing consensus that further specification of
motivating factors behind obsessive-compulsive
(OC) symptoms may lead to a better understanding of the disorder and more focused treatments
(Leckman etal. 2010; Moretz and McKay 2009;
Olatunji etal. 2011; Rosario etal. 2009). One
potential avenue for enhancing the current CBT
for OCD is to address symptoms that are not
motivated by a desire to prevent a feared consequence, but instead, are independent of any
feared consequence and are motivated by a desire
to eliminate a feeling that something is not just
right. Addressing such symptoms holds promise
for improving OCD treatment outcomes in many
cases as data show a statistical trend suggesting
that individuals who cannot specify a feared consequence benefit less from ERP (Foa etal. 1999).
Specifically, in a sample of 20 individuals treated

DOI 10.1007/978-3-319-17139-5_14
197
198
with ERP, patients who were not able to identify

feared consequences had a 44.7% reduction in
symptoms from pre- to posttreatment, in comparison to a 68.6% reduction in individuals who
did articulate a feared consequence. Although
this difference was only a trend towards statistical significance in the original paper, it is worth
noting that the study had limited power due to a
relatively small sample (N=20).
Many patients with OCD report distressing
feelings of incompleteness (Summerfeldt 2004)
and/or somatosensory feelings of things being
not just right (Ghisi etal. 2010). These notjust-right experiences (NJREs) are a subjective
sense of inner tension about things not being as
they should be. NJREs can result in an aversive
somatosensory experience, and compulsive behavior is then performed to decrease the aversive
sensation. Thus, the pattern meets the definition
for OCD; however, the distress is not associated
with fear that a terrible outcome will occur, but
rather by an aversive sense that things are not as
they should be. For example, a person may experience an NJRE after looking at a cluttered desk.
This aversive somatosensory sensation produced
by the NJRE motivates compulsive behavior
(likely ordering and arranging), aimed at decreasing the unpleasant tension that is produced by
observing something not as it should be. NJREs
can occur in relation to OCD symptoms of diverse
content, but are frequently observed in relation to
symptoms involving symmetry, arranging, slowness, and counting (Summerfeldt 2004).
NJREs lie on a continuum from benign to very
distressing and impairing (Ghisi etal. 2010). Approximately 80% of people, those with OCD
and community samples, report having at least
one NJRE (Coles etal. 2003; Ghisi etal. 2010).
Although the prevalence of NJREs appears to
be similar in clinical and community samples,
people with OCD often report that their NJREs
are much more intense and distressing than people without OCD (Coles etal. 2003; Wahl etal.
2008). NJREs can present across different sensory modalities (i.e., sight, sound, touch, taste,
and smell) and can motivate compulsions that
are phenotypically similar to those motivated
by harm avoidance (HA; Summers etal. 2014).
J. Schubert et al.
dditionally, compulsions may be initially aimed

A
at preventing a perceived harmful outcome, but
then continue well beyond the logical stopping
point because the person is attempting to achieve
the just-right feeling (Cougle etal. 2013; Summerfeldt 2007). NJREs appear to be more related
to some OC symptoms than others (Ecker and
Gnner 2008). Symmetry and ordering symptoms appear to be uniquely related to NJREs
(Ecker and Gnner 2008; Ferro etal. 2012), and
checking symptoms are related to both HA and
NJREs (Ecker and Gnner 2008).
Although much of the research on NJREs has
been conducted with adults, there is also evidence that NJREs are common in children and
adolescents with OCD. Community samples of
adolescents report NJREs at similar prevalence
and severity to community adults (Ravid etal.
2014). Additionally, parents of young children
report that behavior aimed at making the environment just right is common in young children,
especially between the ages of 2 and 5 years old
(Evans etal. 1997). For example, parents reported that children seemed very aware of and
sensitive to how clothes feel or arranged objects or performed certain behaviors until they
seem just right to him/her. Case series have also
been published in which children with OCD were
described whose primary presenting problems
included some form of intrusive and distressing
NJRE (Hazen etal. 2008). Hazen and colleagues
report on an 8-year-old female who compulsively
tied and retied her shoelaces until she found just
the right tension in the laces. Additional evidence
for a relation between NJREs and OCD symptoms
in youth comes from the observation that there is
a bidirectional association between early-onset
OCD (before 14 years of age) and tic disorders
(Diniz etal. 2006). People with early-onset OCD
report high rates of tic disorders, and youth with
tic disorders have high rates of OCD symptoms.
Tic disorders are characterized by a somatosensory experience similar to NJREs (i.e., premonitory
urge, see Woods etal. 2005). It is possible that the
association between e arly-onset OCD and tics is
due to a shared somatosensory component captured by the NJRE construct. Finally, given that
cognitive development spans across childhood
14 Treatment of Not-Just-Right Experiences in Childhood Obsessive-Compulsive Disorder
and into adolescence, younger children may be

more likely to experience somatosensory experiences such as NJREs versus intrusive thoughts.
These converging lines of evidence suggest
that NJRE-motivated symptoms are present and
common in youth. Data also suggest that symptoms related to NJREs may be less responsive
to conventional CBT and have stimulated initial efforts to develop interventions focusing on
these symptoms (Summerfeldt 2004). In one of
the few writings on the treatment of incompleteness/NJREs, Summerfeldt (2004) recommends
exploring patients interpretations of internal
experiences, rather than their interpretations of

external experiences or a feared outcome. As
a starting point, we present the case of a child
with OCD who had clinically significant NJREmotivated symptoms. We start by describing the
clients presenting problems and case history,
transitioning to our case conceptualization, specifying the course of treatment, and discussing
complicating factors. It is hoped that this adds to
a growing body of work addressing the treatment
of NJREs, as more clinical experience and treatment trials are needed to better understand how
to address these symptoms.

Jill was a 9-year-old Caucasian female who
presented to a clinic specializing in the treatment of OCD. Jills mother contacted the clinic
reporting that Jill experienced intrusive thoughts
about harm and felt compelled to tap her feet and
count in even numbers. Based on the information
provided by the mother, Jill was scheduled for a
diagnostic evaluation. Jill, her mother, and father
attended the evaluation. At the evaluation, information was gathered from Jill and both of her
parents, with some information gathered with the
entire family and additional information gathered
separately. The assessment included diagnostic interviews and questionnaires. When asked
about the primary reason for seeking treatment,
Jills parents expressed significant concern that
their daughter reported experiencing persistent,
repetitive, and distressing bad pictures in her
199
mind. Specifically, they stated that Jill reported

experiencing intrusive thoughts of stabbing the
family pet, images of her mother being decapitated, and of accidentally poisoning a neighborhood child. Both Jill and her parents reported that
these harm-related thoughts were in her mind
for approximately 1h per day. Jill reported that
in response to these distressing intrusions, she
avoided entering the kitchen when her mother
was using knives, stopped feeding the family pet
and having it sleep in her room at night, frequently asked her parents to confirm that the mother/
neighbor was ok, and stopped playing with a
neighborhood child whom she had intrusions
about poisoning.
Jill also endorsed a number of symptoms for
which she and her parents could not identify
any feared outcomes. Despite this, she and her
parents reported that these symptoms consumed
several hours per day beyond her harm-avoidant
symptoms. For example, Jill and her parents
reported that she spent at least 1h per day rereading/erasing/rewriting homework, but denied
concerns about her performance or grades on the
assignments. She and her parents also reported
that Jill frequently felt compelled to perform actions in even numbers, washed her hands repeatedly, checked/flipped light switches, went up and
down the stairs, repeated statements, and insisted
on eating in a special order. These symptoms
were characteristically different than the harmavoidant symptoms discussed above. For example, even with direct questioning, Jill and her parents denied a link between her hand washing and
contamination fears and her rewriting and fears
of getting poor grades. Instead, she and her parents reported that these actions were performed
in response to uncomfortable feelings and were
designed to correct not-just-right feelings.
Specifically, Jill reported washing her hands in
order to reduce an icky feeling on her hands
and in the pit of her stomach and rewriting her
homework until the motion of her hands felt just
right and it looked just right. As with her harmavoidant symptoms, Jill stated that these sensations of things not being just right and her efforts
to eliminate those feelings took up several hours
per day, made her feel upset, and distracted her
200
from her schoolwork. Further, despite the parents initial concern regarding their daughters
harm-avoidant symptoms, when asked which
symptom she would most like eliminated, Jill selected her persistent concerns that things be just
right. In addition to formulating diagnoses, the
Childrens YaleBrown Obsessive-Compulsive
Scale (CY-BOCS) was administered. Jills scores
were consistent with other youth with OCD (see
Table 14.1). Her initial CY-BOCS total of 28
represents symptoms in the markedly ill range,
and it is notable that her obsessions and compulsions appear to contribute equally to her overall
profile.
In addition to information gained from the
interviews, Jill and her parents also completed
several questionnaires about Jills symptoms (see
Table14.1). Consistent with the CY-BOCS, Jills
self-report of her OCD symptoms on the child
version of the Obsessive-Compulsive Inventory
also suggested severe OCD (as a basis of comparison, the mean for an OCD sample at pretreatment from Foa etal. (2010) was 17.02). Finally,
her self-report of depressive symptoms on the
Child Depression Inventory was also slightly
above the mean for prior pediatric OCD samples
(mean of 15 from Foa etal. 2010).
In addition to her primary symptoms of OCD,
Jill and her parents also endorsed symptoms of
generalized anxiety disorder (GAD) and social
anxiety disorder. Specifically, Jills parents reported that she had always worried about everything, including school, performances, social
relationships, little things, and perfectionism.
Table 14.1 Pre- and posttreatment scores on measures
of OCD and depression
Child report
Pre
Post
CY-BOCS obsessions
14
1
CY-BOCS compulsions 14
0
CY-BOCS total
28
1
OCI-CV frequency total 28
0
CDI
15
8
CY-BOCS Child YaleBrown Obsessive-Compulsive
Scale Inventory, OCI-CV Obsessive-Compulsive Inventory Child Version, CDI Child Depression Inventory
J. Schubert et al.
Additionally, both Jill and her parents indicated

that she worried more days than not and that the
worry caused Jill to have difficulty sitting still,
feel fatigued, have difficulty concentrating, and
become easily agitated. Finally, Jill also reported
substantial social anxiety. Both Jill and her parents reported that she frequently feared that others would perceive her as stupid or dumb, and
that others would laugh at her, in a variety of social situations, including answering questions in
class, giving oral reports, having conversations
with peers, talking on the phone, speaking to
adults and/or strangers, having her picture taken,
and being assertive. Jills parents reported that
social anxiety stemming from fear of negative
evaluation caused her to avoid nearly all social
interactions with peers, and that this made it difficult for Jill to make friends and do kid things.
While these symptoms of GAD and social anxiety disorder were clearly substantial, both Jill and
her parents agreed that OCD was their primary
concern.
Case Information
Family Information
Jill reported a close relationship with her parents,
especially her mother. Information gathered from
Jills parents revealed a significant family history
of anxiety and depression on both sides of the
family including both first- and second-degree
relatives. In addition, a family history of obsessive-compulsive personality disorder (OCPD)
was endorsed.
Developmental, Medical, and Psychiatric
History
According to parent report, Jill reached all of her
developmental milestones well within normal
limits. No developmental difficulties or delays
were noted. Jill and her parents reported that she
had not experienced any current or past major
medical conditions. Further, they stated that she
did not have any previous history of psychiatric
evaluation or treatment.
Academic History
Jill was a fourth-grade student who received
grades in the high-average range. No academic
difficulties were noted by Jill or her parents. Jill
reported that she kind of liked school but that
she was frequently bullied and teased by her
peers and that she often felt afraid to go to school
as a result. Jills parents reported that she did not
miss any school due to anxiety in the past year.
Psychosocial
Jills parents reported that although she was bullied by peers, and demonstrated difficulty making
new friends due to fear of negative evaluation, she
did maintain a stable group of close friends with
whom she enjoyed spending time. Both Jill and
her parents reported that she frequently called her
friends to invite them to her house and that her
friends invited her over to their home as well.
Case Conceptualization and Assessment

Overall, Jill exhibited a pattern of maladaptive
avoidance of intrusive, unwanted, and aversive
experiences, particularly those experiences characterized by a sense of things not being just right.
Although the etiology of OCD remains unknown,
several factors are implicated in its development.
Consistent with these models, Jills pattern of
avoidance likely developed as a result of genetic/
biological vulnerability, maladaptive beliefs, and
learning history (modeling, praise for avoidance
of perceived distress, negative reinforcement).
With regard to genetic influences, information
provided by Jills parents revealed an extensive
family history of internalizing disorders in both
first- and second-degree relatives on both sides
of the family. Prior data have shown that vulnerability to anxiety disorders and OCD is transmitted across generations (Beidel and Turner 1997;
Hanna etal. 2005).
In addition, Jill reported beliefs consistent with
those found in children with OCD. It is thought
that these beliefs played a role in the transition
from normative intrusive thoughts to distressing obsessive thought patterns. For
example,
she described a strong belief that tasks should
201
be completed perfectly, and she

subsequently
spent several hours per day rereading, erasing,
and rewriting homework assignments. In addition, strong beliefs that she should be able to control her thoughts led to distress when unwanted
thoughts entered her mind, and therefore, she attempted to reduce this distress by pushing the unwanted thoughts out of her mind. In a ddition, Jill
observed perfectionistic behavior in her parent(s)
and was praised for avoiding distressing situations. For example, one of Jills parents was
diagnosed with OCPD and reported spending
several hours per day cleaning and organizing. In
addition, Jills parents reported that the efforts to
keep things perfectly clean were often extended
to Jill (e.g., encouraging Jill to wash her hands
frequently, keep her room clean, and spend considerable time organizing).
In summary, this combination of biological
predisposition, maladaptive beliefs, and learning
experiences, likely all contributed to Jill developing a pattern of avoidance behaviors across a
variety of situations. This pattern of avoidance
can be seen in symptoms of OCD, social anxiety disorder, and GAD. For example, Jill experienced aversive sensations related to things being
not just right. Unlike HA symptoms, no feared
consequence was articulated in relation to the
NJREs. However, experiencing NJREs was so
aversive for Jill that she endorsed a belief that
she would not be able to function effectively if
she did not engage in behavior designed to bring
about a sense of completeness, thereby stopping
the NJRE. Hence, she spent several hours per
day attempting to eliminate these NJREs via actions such as redoing tasks, washing her hands,
and counting and tapping her feet until she felt
just right. Lastly, avoidance of distress likely
also contributed to Jills symptoms of worry and
social anxiety. For example, Jill consistently
avoided situations in which she feared negative
evaluation (e.g., interacting with peers, speaking in class), and her chronic worry (e.g., about
school, family) was likely to blunt experiences of
negative affect.
This conceptualization was based on the results of separate parent and child interviews
using the Anxiety Disorders Interview Schedule
202
for Diagnostic and Statistical Manual of Mental

Disorders, 4th edition (DSM-IV)Child Version
(ADIS-IV-CV) parent and child versions, as well
as questionnaires (see Table14.1). Diagnostically, these responses indicated that Jill was experiencing clinically significant symptoms of anxiety
across a variety of domains. Further, Jill and her
parents provided numerous examples of how her
symptoms were disrupting her academic performance and social functioning.
Treatment Course
Given that intrusive thoughts and sensations, and
associated compulsive behaviors, were causing
the greatest interference and distress for Jill, it was
recommended that she participate in a course of
CBT with ERP for OCD. While Jill did meet diagnostic criteria for GAD and social anxiety disorder, the primacy of her OCD led to the decision to
focus initially on ERP for her OCD with the intent
to devote several sessions to help Jill generalize
her new skills to her social anxiety and worry after
addressing the OCD. Jills parents agreed with
this conceptualization and treatment plan.
Treatment was guided by March and Mulles
(1998) OCD in Children and Adolescents: A
Cognitive-Behavioral Treatment Manual with
additional guidance from Summerfeldt (2004)
regarding the treatment of sensations of incompleteness or NJREs. The CBT intervention focuses on several key components. The mainstay
of the treatment is enabling the child to confront
their feared situations without performing a compulsion. In support of this primary aim, children
are taught a toolbox of strategies. For example, the toolbox includes strategies such as
externalizing their OCD from themselves, talking back to OCD, and using a fear thermometer.
These strategies are then utilized to support the
child in confronting anxiety-provoking situations
and staying in the situation until his or her anxiety declines naturally. After each exposure, the
absence of something bad happening despite the
child not doing their compulsion is noted.
In addition to using these traditional CBT
methods typically applied to symptoms related
J. Schubert et al.
to anxiety regarding a feared consequence, the

therapy was augmented with strategies for addressing NJREs. First, as noted by Summerfeldt
(2004), although exposure is most often used for
anxiety, the basic principles should also hold for
other emotions and internally generated emotional states. Exposures to internal states of things not
being just right are likely to serve as the cornerstone of CBT for NJREs. With some modifications from the basic model, cognitive techniques
may serve as a useful augmentation to exposure
for NJREs. Instead of portraying problematic
emotional states as a consequence of cognitive
appraisals of a situation, for NJREs, the therapist
can help the patient recognize that their cognitive
appraisals of the situation (experiencing a NJRE)
impact the likelihood of problematic behavioral
and emotional experiences subsequent to having
an NJRE. In addition, addressing the patients
beliefs regarding the importance of not experiencing NJREs may also be useful. In summary, it
is believed that with some modifications CBT is
likely to be applicable to treating NJREs.
Treatment Overview
Jill was seen for 14 sessions of individual CBT
using ERP. Jills parents were kept abreast of the
treatment including complications and progress.
No full parent sessions were held. However, Jills
parents were consulted and given updates every
session and met with the therapist approximately
every other session, primarily to discuss how
to implement exposures outside of the session.
These discussions were particularly important,
given that Jills parents experienced their own
anxiety. A summary of Jills treatment is presented below, emphasizing interventions targeting
her NJREs.
Initial Session
Rapport was established in the first session, with
the therapist focusing on making the session rewarding for Jill by playing games and maintaining an informal atmosphere. Some information
regarding OCD was also provided, including discussion of externalizing OCD and naming it. Jill
expressed both eagerness and apprehension to
align with the therapist against her OCD. Discussion with Jills parents towards the end of session
raised the possibility that their anxiety may make
it difficult for them to assist Jill. Given this, the
therapist provided the parents with reading materials describing ERP, openly discussed the parents concerns, and directed them towards several
sources which documented the efficacy of ERP.
Both parents ultimately agreed with the treatment
model and expressed willingness to engage with
Jill in her exposures (see the section Complicating Factors for further discussion of parental
involvement).
Sessions 2 Through 5
Sessions 2 through 5 were devoted to psychoeducation about OCD symptoms and the treatment
model. Within our clinic, this material is often
covered in three sessions. However, additional
sessions were devoted to psychoeducation in this
case due to several complicating factors including suicidal ideation, transportation difficulties,
and the patient demonstrating some difficulty
sustaining attention (see the section Complicating Factors for more information). These
additional sessions were deemed to be important
to maximize Jills understanding of the treatment
model and how it would be applied to both her
harm-avoidant and NJRE symptoms. After acclimating to the therapist and establishing initial rapport, psychoeducation about obsessions,
compulsions, and the functional relationship
between the two was discussed. Further, given
that Jill reported symptoms motivated by NJREs
in addition to symptoms motivated by HA, this
distinction was presented and discussed. The
therapist used an analogy that we have found
to be effective in our clinic that describes OCD
symptoms as coming in two flavorsHA and
NJREs/incompleteness. Jill appeared to understand the model well, and her ability to generate examples of symptoms related to both HA
(e.g., bad pictures about hurting people) and
203
incompleteness (e.g., feeling the need to write

homework assignments until they were just
right) supported her understanding.
After establishing a shared understanding
of OCD, Jill and the therapist collaboratively
created a toolbox (cf. March and Mulle 1998)
including a set of cognitive skills designed to
assist Jill in effectively implementing exposure
and ritual prevention. First, Jill was encouraged
to externalize OCD by giving it a nickname. Jill
chose to name her OCD Mr. No-Fun because
OCD stopped her from enjoying things. Additionally, the toolbox included talking back to
Mr. No-Fun, which encouraged Jill not to accept
OCD thoughts as fact. Finally, Jill was taught to
use positive self-talk/coping statements in response to OCD symptoms. Jill was very creative
in using her toolbox skills. Specifically, she made
a Mr. No-Fun puppet, which she used to remind
herself that OCD is silly.
Next, the rationale for treatment was presented, and the role of avoidance in maintaining
distress was discussed. Jill expressed understanding the rationale for exposure and shared feelings
of apprehension about facing her fears. Next,
Jill worked collaboratively with the therapist to
create a fear hierarchy to serve as the roadmap
for exposures. Jill was encouraged to include all
relevant domains of OC symptoms on her hierarchy, including both flavors of OCD. For
example, obsessions regarding the need to walk
in odd numbers, intrusions of stabbing someone,
and obsessions about getting bad grades were related to efforts to avoid harm. Other symptoms
on the hierarchy, including her intrusions about
homework, bedtime routines, and touching sticky
substances, were related to feelings of things
being not just right or incomplete (see Fig.14.1).
In addition to identifying these situations, Jill
was asked to rate her predicted temperature if
doing the things on her hierarchy. The ratings for
harm-avoidant symptoms reflected Jills anxiety,
while those related to her NJREs were indicative
of sensations of discomfort or tension.
Self-monitoring was next introduced and discussed, which included Jills agreement to engage
in ritual prevention. Jill completed daily forms
to monitor her experience of symptoms of HA
204
J. Schubert et al.

Fig. 14.1 Jills symptom hierarchy
and incompleteness and associated compulsive

behavior. Jill was very engaged in psychoeducation and enjoyed being creative in making her
hierarchy and toolbox, and generating examples
of therapeutic principles.
Sessions 6 through 11 included systematic,
graduated exposure to feared and/or uncomfortable OCD situations. In session 6, the therapist
and Jill together conducted the first planned
exposure, which targeted NJREs by getting their
hands sticky and refraining from washing them.
In other words, the purpose of this exposure was
to provoke not-just-right experiences (obsession) without making it just right by washing
her hands (performing a compulsion). When queried regarding her discomfort with having sticky
hands, Jill reported concern that the icky or notjust-right experience would overwhelm her if she
did not wash her hands and denied any additional
feared consequences. Jill and the therapist then
collaboratively conducted e xposures designed to
elicit the NJRE and sit with the discomfort until
it declined naturally. Specifically, they conducted
a series of exposures including the following:
(1) holding candy that had been sucked on, (2)
squeezing white school glue onto their hands and
rubbing their hands together, (3) wrapping their
hands with packing tape, and then removing it
leaving the adhesive residue, and (4) spreading

peanut butter on their hands and rubbing their
hands together. Each of the first three exposures
provoked mild discomfort (subjective units of
distress scores, SUDS<5), and therefore the next
exposure was introduced after approximately
3min. For the final situation, using peanut butter, Jills discomfort reached a rating of 8 within
5min, and she noted that the urge to wash her
hands was a 10. The therapist and Jill drew a
graph of her discomfort throughout the exposure,
and Jill concluded that her discomfort ratings,
looks like a cliffit went down really fast.
The patient stated that she was surprised her discomfort went down, despite making the exposure
progressively more difficult (moving from candy
up to peanut butter). Before leaving at the end
of the session, Jill expressed a desire to wash
her hands as she still had peanut butter on them.
The therapist Socratically helped her recognize
the drawbacks of doing so, and in collaboration
they ultimately decided that Jill would only wash
for less than 5s without using soap. In addition,
they agreed that Jill would make her hands sticky
again as soon as she got home and would continue to practice this exposure several times before
the next session. Jills mother initially requested
that Jill wash her hands again before getting in
the car. However, Jill and the therapist collaboratively explained why washing again would be
counterproductive in addressing Jills OCD, and
the mother understood.
Jill continued to confront her NJREs over the

next few weeks both in and out of session. Due
to transportation difficulties (see Sect.6: Complicating Factors), 3 weeks passed between
sessions 6 and 7. Therefore, exposures were
conducted either over the phone or independently by Jill with the therapist providing support
and troubleshooting before and/or after. For example, between sessions 6 and 7, Jill practiced
inhibiting her urge to check light switches by
flipping them on and off. Jill reported that this
compulsion was performed to reduce an NJRE,
specifically a yucky feeling in the pit of her
stomach. Further, Jill reported that if she did not
perform the compulsion, she feared the NJRE
would keep her awake at night, but denied any
additional fears (e.g., fire, wasting electricity).
The therapist encouraged Jill to use exposure
as a test of her belief that she would never be
able to fall asleep until she checked the lights.
Additionally, the therapist Socratically helped
Jill to understand how she could use her other
toolbox skills in this situation. Jill decided that
she would externalize OCD (this is Mr. NoFun feeling the urge to check, not me) and use
positive self-talk (Im the boss, I dont have
to listen to Mr. No-Fun) to resist the urge to
check the lights. At the next check-in, Jill reported that she was able to fall asleep despite
ignoring the urge to check, and that her toolbox
skills helped her feel strong and confident in
facing Mr. No-Fun.
Unscheduled phone check-ins occasionally
occurred during situations in which Jill felt unable to successfully navigate an OCD situation
on her own. Specifically, Jills mother called the
therapist because Jill was rereading, erasing, and
rewriting a homework assignment for over an
hour and neither she nor her mother were willing to help Jill tolerate her NJREs and inhibit
her compulsive behavior. The therapist worked
with Jill and her mother on this situation via the
speakerphone. The therapist Socratically helped
Jill to recognize that Mr. No-Fun was trying to
be the boss in this situation, and to weigh the
pros (Ill feel better when I write it just right)
and cons (every compulsion makes Mr. No-Fun
stronger, it takes more time to make it just right)
205
of giving in to Mr. No-Fun. Jill was then guided

through her use of positive self-talk (Im stronger than Mr. No-Fun) and was encouraged to
focus on the NJRE in the pit of her stomach until
the yucky feeling decreased to 2 out of 10 on
her feeling thermometer. Next, Jill was encouraged to complete a separate homework sheet
without engaging in any redoing compulsions
to demonstrate that she could successfully complete an assignment while (1) experiencing the
NJRE and (2) refraining from just right compulsions. Following this over-the-phone exposure,
Jills rereading, erasing, and rewriting behavior
decreased substantially, and Jill ultimately eliminated this behavior completely.
In addition to exposures focusing on NJREs,
Jill also completed multiple in-session exposures to intrusive thoughts of causing harm
to family, friends, and pets. For example, Jill
experienced distressing, repetitive thoughts
about stabbing the familys cat. Jill reported
being afraid that she would act on her violent
thoughts and subsequently avoided situations
which tended to provoke these intrusions (e.g.,
being near the cat, touching knives, or other
sharp objects). To address these fears, a series
of exposures were conducted to expose Jill to
her fear of causing harm to loved ones without
performing the compulsive behaviors (e.g., tapping her feet) that she typically engaged in to
neutralize the effects of having these thoughts.
It was clear that Jill did not harbor negative
feelings towards any of her loved ones and that
these thoughts were ego-dystonic. Further, she
had never hurt anyone in the past. Therefore,
to address these unrealistic fears, the therapist
and Jill collaboratively created imaginal scenes
in which she stabbed the cat, drew pictures of
loved ones being stabbed, and created puppets
resembling loved ones and cut them into pieces.
During these exposures, Jill was encouraged
to experience distressing thoughts about harm
and focus on her physiological discomfort (e.g.,
knots in stomach, increased heart rate) until
her fear naturally decreased (see Fig.14.2 for a
comparison of NJRE and HA discomfort/anxiety ratings across exposure). Finally, the therapist emphasized that the intent was not to make
206
J. Schubert et al.

'LVFRPIRUW$Q[LHW\5DWLQJ
1-5(
H[SRVXUH
+$H[SRVXUH

0LQXWH
Fig. 14.2 Anxiety/discomfort ratings across HA and NJRE exposures. HA harm avoidance, NJRE not-just-right experiences
Jill like the idea of stabbing a loved one, but to

have her experience such thoughts without also
responding to the intense anxiety. Figure14.2
presents data collected during treatment, showing one exposure addressing discomfort related
to NJREs and the other showing anxiety ratings
during a HA exposure.
Sessions 12 and 13 were dedicated to generalizing skills learned in OCD treatment to her symptoms of GAD and social phobia. Two exposures
to social phobia situations were conducted in
session, and Jill practiced other social anxiety
exposures on her own. Jill reported reduction in
her social anxiety following exposures and expressed confidence in her ability to implement
these skills independently. Finally, session 14
included a pizza party to reward Jill for her hard
work and progress. Relapse prevention skills
were discussed during the party. Jill and the therapist reviewed graphs of Jills OCD scores over
time, and Jill expressed surprise at how much her
scores decreased. Jill noted that she was proud
of the progress she made and stated that she felt
confident that she had the skills she needed to
fight Mr. No-Fun again if he came back.
Posttreatment Assessment
An independent assessor evaluated Jills symptoms and functioning following termination of
therapy. This assessment revealed that Jill no
longer met DSM-IV criteria for any Axis I disorder and that her GAF improved from 50at
pretreatment to 80at posttreatment. Further, the
independent assessor assisted Jill in re-rating her
anxiety/discomfort for the items on her exposure
hierarchy, revealing a range of scores from 0 to
1 (out of 10). In addition, Jills CY-BOCS and
OCI-CV scores were dramatically reduced with
both showing 96% reductions in her symptom
totals (see Table14.1) and her posttreatment CYBOCS scores were within the normal range. In
addition to her OCD symptom reductions, Jills
depressive symptoms showed an almost 50% reduction. Both Jill and her parents reported substantial improvement in all symptoms as well as
in her overall quality of life. Jill denied any suicidal ideation at posttreatment.
As with most patients, therapy presented
unexpected detours and roadblocks. Small
complications arose throughout therapy and
were addressed, relying on clinical experience

and the case conceptualization for guidance.
Three ongoing complications are highlighted
here in hopes that they will benefit the reader
in their own clinical practice. Specifically, we
discuss issues related to parent compliance and
parental accommodation, transportation, and
remembering concepts and completing assignments. Finally, before addressing these complications, we note that Jill reported active suicidal
ideation. This was addressed with Jill and her
parents, and her suicidal ideation decreased
after beginning exposures. This is an important
reminder that even children can experience suicidal ideation and attempt or complete suicide.
Over 4000 children under the age of 14 years
attempt suicide in the USA each year, and 180
children under the age of 14 years die from suicide each year (Krug et al. 2002). Suicidal ideation should be monitored in all patients regardless of their age.
Parent Compliance and Parental

Accommodation
In developing and implementing Jills treatment,
it was important to consider that both of her
parents acknowledged their own struggles with
anxiety and perfectionism. This was acknowledged openly at the outset of treatment, and both
parents agreed to comply with the treatment
model. However, parental accommodation to
Jills symptoms (e.g., her mom encouraging her
to wash her hands frequently) quickly became a
problem. Jills parents repeatedly expressed concern about the nature of exposures conducted in
session, oftentimes in the presence of Jill. For example, Jills mother expressed distress regarding
Jill having peanut butter on her hands because it
was gross and dirty and had difficulty recognizing this behavior was an exercise to reduce
Jills OCD. Further, several instances occurred
in which Jill was encouraged to perform compulsive behavior following an exposure session.
For example, Jills mother would not allow Jill to
enter the car until she had washed her hands following sticky hands exposures, stating Thats
207
so gross! I would never do that! Encouragingly,

Jills mother was very receptive to psychoeducation and Socratic questioning regarding the utility
of the treatment model. Specifically, she was
increasingly able to understand why such behaviors interfered with treatment. The therapist regularly checked in with Jill to monitor instances of
parental noncompliance and accommodation and
addressed these issues by (1) helping Jills mother to understand her counterproductive behavior
within the treatment model and (2) helping her to
troubleshoot more effective alternative behaviors
that fit with the treatment model.
Additionally, Jills father expressed concern
that the exposures were cruel, particularly for
children. He struggled to cope with seeing his
daughter in distress and refused to assist in implementing treatment principles at home. It was
hypothesized that the treatment was difficult for
Jills father as he also reported elevated anxiety.
Therefore, the father was invited to participate in
accordance with his own comfort level, but the
outcome was that the mother participated much
more actively.
Transportation
As with many families, session attendance was
difficult at times. In this case, Jills family traveled 1h each way to attend therapy, and given
that both parents worked full-time and all of their
children had several extracurricular activities,
it was very difficult for Jill to attend sessions
regularly. In order to compensate for the fact that
there would often be several weeks between sessions, phone check-ins were routinely conducted
with Jill. Check-ins lasted typically between 10
and 30min on weeks in which Jill was not able to
attend session in person. Several goals of phone
check-ins were established: (1) monitor homework compliance, (2) troubleshoot difficulties
with assignments and exposures, (3) conduct
over-the phone exposures, if necessary, and (4)
assign independent exposures to be conducted
between sessions. Jill completed many exposures
on her own outside of session, given the familys
difficulty in providing regular transportation to
208
session. Phone check-ins were successful in helping Jill to troubleshoot difficulties in implementing exposures.
Remembering Concepts and

Completing Assignments
A final complicating factor in Jills treatment involved her having difficulty remembering concepts and forgetting to complete assignments
between sessions. Four primary accommodations
to treatment were made to address these issues.
First, extra sessions were allotted for review of
psychoeducation concepts to facilitate retention.
Second, Jill was encouraged to keep a therapy reminder book in her school folder which was used
daily for schoolwork and kept in her backpack at
all times. Third, Jill was encouraged to take brief
notes (take home messages) on session material, which she also stored in her homework folder.
Finally, Jills interests and hobbies were integrated into treatment activities as much as possible to
facilitate Jills engagement with the material and
thereby increase retention of concepts. Specifically, arts and crafts activities were used in nearly
every session. Jill made puppets to represent her
OCD symptoms (e.g., a schoolhouse represented
the urge to do her homework just right). These
puppets were used to practice identifying concepts that represented obsessions and compulsions. The puppets were also used to monitor the
severity of her feared situations. Specifically, Jill
placed the puppets on her hierarchy with Velcro,
and moved them up and down the fear ladder as
treatment progressed. These strategies were effective in helping Jill engage in session, consolidate
psychoeducation concepts between sessions, and
complete homework assignments.
Conclusion and Key Practice

In conclusion, there is increasing evidence that
when working with OCD it is beneficial to directly assess for the presence of symptoms related to
NJREs or sensations of incompleteness. In some
cases, clinicians have assumed that patients who
J. Schubert et al.
deny a feared consequence either have poor insight or are withholding the information. It is reasoned that patients may be uncomfortable sharing
their feared consequence due to fears of negative
evaluation or embarrassment. Individuals with
OCD may also have concern that saying their
fears out loud may increase their likelihood of it
happening. Finally, young children or individuals
with cognitive or intellectual impairments of all
ages may lack the cognitive capacity to articulate
the source of their fears. However, it is important for clinicians to recognize that OCD symptoms do not always stem from anxiety regarding
something bad happening. As we often explain
to patients, OCD symptoms can come in different flavors, and being vigilant for symptoms
related to NJREs may reveal a more complete
picture of the patients symptoms. In identifying
these symptoms, it may be useful to ask about experiences that cause discomfort, tension, or a
nagging feeling that something is incomplete
or not done just right. As these symptoms can
tend to be more ego-syntonic, it may also be beneficial to ask about routines, habits, or guidelines
that the patient strictly adheres to and would be
distressed by someone or something interfering
with (Fig.14.3).
Another key component to working with
youth is to appropriately involve the parents.
Therapists typically spend 12h a week with
patients over a few months, while parents spend
more time than this with the child everyday for
many years. Therefore, trying to help the child
make changes without the parents onboard is
likely to be a losing battle. Given that anxious
children are likely to have anxious parents, having a sense of the parents anxiety will inform
treatment planning. In addition to passing genetic
vulnerability to anxiety and OCD, parents may
model behaviors that contribute to the etiology
and maintenance of OCD and related beliefs. It is
posited that parents of children with OCD expose
their children to heightened levels of responsibility compared to their peers, impose rigid rules,
and are often overprotective (Salkovskis etal.
1999). Understanding the parents beliefs about
topics such as the importance of following rules,
the importance of being clean, and the benefits
209
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UHODWHGWRWHQVLRQRUGLVFRPIRUWLQDGGLWLRQWRWKRVHUHODWHGWRDQ[LHW\
*DWKHULQIRUPDWLRQUHJDUGLQJSDUHQWVV\PSWRPVDQGEHOLHIVLQRUGHUWR
GHWHUPLQHKRZWREHVWLQYROYHWKHPLQWKHWUHDWPHQW
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Fig. 14.3 Key practice points
of being organized are likely to help the therapist

to decide how much to involve the parents and
potentially which parent to involve.
Finally, patient engagement in therapy is a
strong predictor of outcome, and children are
much more likely to fully engage in activities
that are enjoyable. This is not to dismiss the courage and strength required to engage in exposure
therapy but to propose that conscious efforts be
made to make the overall experience positive.
In this particular case, several efforts were made
to increase Jills engagement with therapy. First,
arts and crafts were incorporated into every session. Jill enjoyed making puppets to represent her
OCD symptoms, creating an elaborate symptom
hierarchy out of construction paper, creating her
own fear/discomfort thermometer using her own
unique anchors, and even making her own stimuli for exposures (e.g., making stuffed cats out
of fabric and newspaper to stab). Second, praise
and access to preferred activities (e.g., playing
a game, going for a walk, or doing an art project) were provided in every session to reward Jill
for her hard work and encourage her to continue
fighting Mr. No-Fun. At the end of the therapy,
Jill had a pizza party with the therapist, her parents, and her sister to celebrate her gains.
In closing, this chapter highlights that in addition to evaluating OCD symptoms related to
anxiety and fear of negative outcomes, clinicians
should also evaluate OCD symptoms related to
feelings of tension and discomfort associated
with things not being just right or feelings of
incompleteness. Some data suggest that patients
without feared consequences may benefit less
from CBT (Foa and Kozak 1995); thus, alterna-
tive or modified interventions may be needed to

address these other symptoms. We propose that
symptoms without a feared consequence may
frequently be related to sensations of incompleteness or things not feeling just right and that assessing for this directly can be beneficial. Our
clinical experience and data from the case presented herein suggest that symptoms related to
NJREs can play a role in OCD in youth and that
exposures directly targeting these sensations can
be effective in reducing the associated discomfort and tension. This information is just the start
to elucidating how NJREs play a role in OCD
and how to best address these sensations.
References
Arlington: American Psychiatric Association.
Beidel, D. C. & Turner, S. M. (1997). At risk for anxiety:
I. Psychopathology in the offspring of anxious parents. Journal of the American Academy of Child and
Adolescent Psychiatry, 36, 918924.
J. (2003). Not just right experiences: Perfectionism, obsessive-compulsive features and general psychopathology. Behaviour Research and Therapy, 41,
681700.
Cougle, J. R., Fitch, K. E., Jacobson, S., & Lee, H. (2013).
A multi-method examination of the role of incompleteness in compulsive checking. Journal of Anxiety
Disorders, 27, 231239.
Diniz, J. B., Rosario-Campos, M. C., Hounie, A. G., Curi,
M., Shavitt, R. G., Lopes, A. C., & Miguel, E. C.
(2006). Chronic tics and tourette syndrome in patients
with obsessivecompulsive disorder. Journal of Psychiatric Research, 40, 487493.
210
Ecker, W., & Gnner, S. (2008). Incompleteness and harm
avoidance in OCD symptom dimensions. Behaviour
Evans, D. W., Leckman, J. F., Carter, A., Reznick, J. S.,
Henshaw, D., King, R. A., & Pauls, D. (1997). Ritual,
habit, and perfectionism: The prevalence and development of compulsive-like behavior in normal young
children. Child Development, 68, 5868.
Ferro, Y. A., Shavitt, R. G., Prado, H., Fontenelle, L.
F., Malavazzi, D. M., de Mathis, M. A., etal. (2012).
Sensory phenomena associated with repetitive behaviors in obsessive-compulsive disorder: An exploratory
study of 1001 patients. Psychiatry Research, 197,
253258.
Foa, E. B. & Kozak, M. J. (1995). DSM-IV field trial:
Obsessive-compulsive disorder. American Journal of
Foa, E. B., Abramowitz, J., etal. (1999). Feared consequences, fixity of belief, and treatment outcome in
patients with obsessive-compulsive disorder. Behavior Therapy, 30, 717724.
Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S.,
Campeas, R., Franklin, M. E., etal. (2005). Randomized, placebo-controlled trial of exposure and ritual
prevention, clomipramine, and their combination
in the treatment of obsessive-compulsive disorder.
American Journal of Psychiatry, 162, 151161.
Foa, E. B., Coles, M. E., Huppert, J. D., Pasupuleti, R. V.,
Franklin, M. E., & March, J. (2010). Development and
validation of a child version of the obsessive compulsive inventory. Behavior Therapy, 41, 121132.
Ghisi, M., Chiri, L. R., Marchetti, I., Sanavio, E., & Sica,
C. (2010). In search of specificity: Not just right
experiences and obsessivecompulsive symptoms in
non-clinical and clinical Italian individuals. Journal of
Anxiety Disorders, 24, 879886.
Hanna, G. L., Himle, J. A., Curtis, G. C., & Gillespie, B.
W. (2005). A family study of obsessive-compulsive
disorder with pediatric probands. American Journal of
Medical Genetics Part B (Neuropsychiatric Genetics),
134B, 1319.
Hazen, E., Reichert, E., Piacentini, J., Miguel, E. C., Do
Rosario, M. C., Pauls, D., & Geller, D. (2008). Case
series: Sensory intolerance as a primary symptom of
pediatric OCD. Annals of Clinical Psychiatry, 20,
199203.
Krug, E. G., et al. (2002). The world report on violence
and health. The lancet360.9339, 10831088.
Leckman, J. F., Denys, D., Simpson, H. B., Mataix-Cols,
D., Hollander, E., Saxena, S, etal. (2010). Obsessive
compulsive disorder: A review of the diagnostic criteria and possible subtypes and dimensional specifiers
for DSM-V. Depression and Anxiety, 27, 507527.
J. Schubert et al.
March, J. S. & Mulle, K. (1998). OCD in children and
adolescents: A cognitive-behavioral treatment manual. New York: Guilford.
Moretz, M. W., & McKay, D. (2009). The role of perfectionism in obsessivecompulsive symptoms: Not just
right experiences and checking compulsions. Journal
of Anxiety Disorders, 23, 640644.
Olatunji, B. O., Tart, C. D., Ciesielski, B. G., McGrath, P.
B., & Smits, J. A. (2011). Specificity of disgust vulnerability in the distinction and treatment of OCD.
Journal of Psychiatric Research, 45, 12361242.
Ravid, A., Franklin, M. E., Khanna, M., Storch, E. A., &
Coles, M. E. (2014). Not just right experiences in
adolescents: Phenomenology and associated characteristics. Child Psychiatry and Human Development,
45, 193200.
Rosario, M. C., Prado, H. S., Borcato, S., Diniz, J. B.,
Shavitt, R. G., Hounie, A. G., etal. (2009). Validation
of the University of So Paulo Sensory Phenomena
Scale: Initial psychometric properties. CNS Spectrums, 14, 315323.
Salkovskis, P., Shafran, R., Rachman, S., & Freeston, M.
H. (1999). Multiple pathways to inflated responsibility beliefs in obsessional problems: Possible origins
and implications for therapy and research. Behaviour
Salkovskis, P. M., Wroe, A. L., Gledhill, A., Morrison, N.,
Forrester, E., Richards, C., etal. (2000). Responsibility attitudes and interpretations are characteristic of
obsessive compulsive disorder. Behaviour Research
Summerfeldt, L. J. (2004). Understanding and treating
incompleteness in obsessive-compulsive disorder.
Summerfeldt, L. J. (2007). Treating incompleteness,
ordering, and arranging concerns. In Antony, M.,
Purdon, C., & Summerfeldt, L. (Eds.), Psychological
treatment of obsessive-compulsive disorder: Fundamentals and beyond (pp.187207). Washington, DC:
Summers, B. J., Fitch, K. E., & Cougle, J. R. (2014).
Visual, tactile, and auditory Not just right experiences: Obsessive-compulsive symptoms and perfectionism. Behavior Therapy , 45(5), 678689.
Wahl, K., Salkovskis, P. M., & Cotter, I. (2008). I wash
until it feels right: The phenomenology of stopping
criteria in Associations with obsessivecompulsive
washing. Journal of Anxiety Disorders, 22, 143161.
Woods, D. W., Piacentini, J., Himle, M. B., & Chang,
S. (2005). Premonitory Urge for Tics Scale (PUTS):
Initial psychometric results and examination of the
premonitory urge phenomenon in youths with tic
disorders. Journal of Developmental and Behavioral
Pediatrics, 26(2), 397403.
Part III
ObsessiveCompulsive Spectrum
Disorders
Treatment of a Child
with Tourette Syndrome
15
Loran P. Hayes, Michael B. Himle

and John Piacentini
Nature of Problem and Treatment

Chronic tic disorders are a class of childhood-onset (<age 18) neurodevelopmental disorders defined by the presence of involuntary motor and/
or vocal tics. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) outlines four
hierarchically arranged tic disorder diagnoses
based on symptom duration and the type of tic(s)
present (motor, vocal, or both; American Psychiatric Association 2013). Provisional tic disorder
involves motor and/or vocal tics that have been
present less than 12 months since original onset.
Persistent (chronic) motor and vocal tic disorders (CTD) involve the presence of only motor
tics or only vocal tics that may wax and wane in
number or frequency but have been present for 1
year since first tic onset. Finally, Tourettes disorder requires the presence of both multiple motor
and one or more vocal tics at some point during
the illness, though not necessarily concurrently,
which have persisted for more than 1year since
original tic onset. Although once considered to
be rare, recent research has estimated the lifetime prevalence of Tourette syndrome (TS) to
J. Piacentini()
Semel Institute for Neuroscience and Human Behavior,
University of California, 760 Westwood Plaza,
Room 67-455, Los Angeles, CA 90024, USA
e-mail: jpiacentini@mednet.ucla.edu
L.P.Hayes M.B.Himle
Department of Psychology, University of Utah,
Salt Lake City, UT, USA
be approximately 0.6%, and the lifetime prevalence of CTD to be as high as 3% (Khalifa and
von Knorring 2003; Robertson 2008; Scahill
etal. 2005). CTD has been shown to run in families (Pauls etal. 1991) and demonstrates male
preponderance at a rate of approximately 4:1
(Freeman etal. 2000).

Tics typically onset in early school-aged years,
take a waxing and waning course, and peak in
severity in adolescence (Bloch and Leckman
2009). Simple tics are usually the first symptoms
to emerge and are defined as simple, brief, purposeless movements (usually of the face), and
sounds (e.g., sniffing, throat clearing) that occur
randomly without regard to context. Throughout
the childhood years, symptoms typically fluctuate with an overall increase in tic number, frequency, and intensity and progress from the face
to also involve the head, torso, and extremities.
In some cases, tics increase in complexity and
manifest as orchestrated movements or vocalizations that appear purposeful or even carry meaning (e.g., touching, tapping, uttering complete
words or sentences). For most individuals, tics
decline in severity across the late teen years, with
many patients displaying significant reduction in
severity by adulthood, though complete remission of tic symptoms is uncommon (Bloch and
Leckman 2009).
In addition to the tics, many patients with CTD
also report unpleasant somatic sensations immediately prior to their tics (and usually localized
to the area of the tic; Banaschewski etal. 2003).
These feelings, referred to as premonitory urges,

DOI 10.1007/978-3-319-17139-5_15
213
214
are often described as a tickle, pressure, tension,

or a feeling that something just doesnt feel
right. Many individuals report that premonitory
urges buildup upon attempts to suppress tics and
are momentarily reduced or alleviated upon tic
completion. However, not all patients (especially
younger children) experience premonitory urges,
and for those who do, they may not experience
them for each of their tics (Leckman etal. 1993).
Most individuals also report that their tics are
exacerbated by contextual factors such as stress,
positive and negative mood states, specific activities or settings, and/or social reactions (e.g.,
talking about tics, teasing, or attention; Himle
etal. 2014; Silva etal. 1995). In some cases, tics
are bound to specific stimuli and occur only in response to specific triggers (e.g., a specific sound,
sight, or feeling). This later phenomenon is especially common for complex tics, which are often
difficult to distinguish from compulsions associated with obsessive-compulsive disorder (OCD
see Ramanujam and Himle, Chap.21).
Although tics are the defining feature of CTD,
psychiatric comorbidity is common. Several studies have shown that the most common comorbid
conditions are OCD, 3040% and attentiondeficit/hyperactivity disorder (ADHD, 5060%;
Khalifa and von Knorring 2006). Mood and anxiety disorders as well as aggressive and impulsive
behavior are also common (Freeman etal. 2000).
While the focus of this chapter is specifically on
the treatment of the tics, it is important that clinicians treating tic disorders assess for the presence
of co-occurring conditions because these conditions can cause additional functional impairment
(Himle etal. 2007; Storch etal. 2007) and if not
effectively managed can introduce challenges to
implementing behavioral treatment for tics.
Since the recognition of the neurological etiology of tics, pharmacotherapy has historically
been considered the first-line intervention for
CTD; however, recent research supports the use of
behavior therapy as an efficacious first-line intervention or an adjunct to medication. The behavioral treatments with the most empirical support
are habit reversal training (HRT; e.g., Azrin and
Nunn 1973) and an adapted version of exposure
and response prevention (Verdellen etal. 2011;
L. P. Hayes et al.
see Cook and Blacher (2007) for a review of

empirically supported treatments). In this chapter, we focus on HRT because it has the strongest empirical support. The most compelling
evidence for the efficacy of HRT comes from
two large randomized controlled trials showing
an expanded version of HRT (called comprehensive behavioral intervention for tics, CBIT) to be
more efficacious for reducing tics than supportive psychotherapy for both children and adults
(Piacentini etal. 2010; Wilhelm etal. 2012).

In this chapter, we present the case of David
(pseudonym), an 11-year-old boy with TS and
ADHD who was referred for CBIT for treatment
of his tics. At the time of treatment, he was exhibiting multiple motor and vocal tics. He also
reported a vague premonitory sensation (an energy feeling) prior to some of his tics that he said
worsened when he tried to stop his tics (which
he reported he could do for a few minutes) and
went away briefly after he let his tics out. Although David was doing well academically, his
tics made it hard for him to concentrate on his
schoolwork, and his grades had worsened over
the past year. In addition, his tics were, at times,
painful and also made it hard for him to play
baseball. Davids parents were particularly worried that the tics would eventually cause social
problems, though he was currently doing well
socially. Davids neurologist had recommended
that he try a course of CBIT prior to initiating
pharmacological treatment for his tics because of
the potential for negative side effects of tic-suppressing medication. In the following section, we
describe the case of David, and how he learned
to successfully manage his tics during a 12-week
course of CBIT.
Case Information
David was a physically healthy 11-year-old Caucasian male referred for treatment of his motor
and vocal tics. He entered kindergarten at age
15 Treatment of a Child with Tourette Syndrome
5 years and, although he did well academically,

he had considerable difficulty staying in his seat
and paying attention. These difficulties continued
into the first grade, at which time he was evaluated and diagnosed with ADHD. Until recently, he
had not received treatment for his ADHD because
he was attending a structured private school, and
his parents did not feel that his ADHD was interfering with his schoolwork.
Davids first recognized tic involved rapid eye
blinking first noticed by his mother at the age of 6.
As is common in tic disorders, the blinking waxed
and waned and would disappear for weeks at a
time. When it was present, the blinking occurred
in fleeting bouts during which David would blink
almost constantly. Initially, his parents attributed his eye blinking to seasonal allergies due
to their waxing and waning pattern. However, at
age 7, David began to display other facial movements (face stretching, widening of the eyes)
that increased in frequency and occurred several
times per day. David was subsequently evaluated
by a pediatric neurologist, who diagnosed a tic
disorder. Given that the tics were still relatively
mild and not causing impairment, a wait and see
approach was recommended. Between ages 7
and 10 years, Davids tics gradually increased in
number, frequency, intensity, and complexity yet
did not cause significant functional interference
or psychosocial impairment.
At age 10 years, a few weeks prior to beginning the fifth grade, Davids tics worsened rather
dramatically and seemingly overnight. His
mother described this period of time as extremely stressful because of the impending school
year, the family was moving to a new house, and
his father had been traveling frequently. At this
time, David began displaying a forceful headjerking tic and multiple vocal tics. In addition,
his parents report that his ADHD was suddenly
out of control. David and his parents both reported that the tics had begun to significantly
interfere with his academic functioning and that
peers frequently commented on his tics. Given
the worsening of his tics and ADHD, David was
reevaluated by his neurologist who prescribed
guanfacine (an alpha-2 agonist), titrated slowly
to a maximum tolerable dose of 2.5mg/day in
215
three divided doses (1mg dose in the morning,

0.5mg dose in the afternoon, and 1mg dose at
bedtime). Alpha-2 agonists have been shown
to be effective for managing ADHD symptoms
and have also been shown to modestly reduce
tics in some children with ADHD (Weisman
etal. 2012). Given the potential for adverse side
effects from more potent tic-suppressing medications (see McNaught and Mink 2011, for a review), the neurologist also recommended a trial
of CBIT prior to initiating additional psychotropic medication for his tics. At the time of initial
presentation to our clinic, David had been taking
clonidine for approximately 6 weeks with modest
improvement in ADHD symptoms but little to no
improvement in his tics.
Assessment and Case

Conceptualization
Prior to beginning treatment, David and his
mother were administered a structured diagnostic
interview and several self- and parent-report measures to assess for common comorbid conditions
as well as a collection of tic severity measures to
ascertain a better picture of his overall level tic
severity and to monitor treatment outcomes.
Assessment of Tic Severity To establish a baseline measure of Davids overall tic severity, he
and his mother were first interviewed using the
Yale Global Tic Severity Scale (YGTSS; Leckman etal. 1989). The YGTSS is a reliable and
valid clinician-completed interview and rating
scale designed to assess tic severity and impairment (Storch etal. 2005). After completing a
detailed tic checklist, the rater assigns anchored
05 point ratings along each of the five dimensions of tic severity (tic number, frequency, complexity, intensity, and interference). Each of these
dimensions is scored separately for motor and
vocal tics to produce separate motor and vocal tic
severity scores, each ranging from 0 to 25. The
motor and vocal tic severity scores then are combined to produce a total tic severity score ranging from 0 to 50, with higher numbers indicating
more severe tics.
216
Results of the tic checklist revealed that David

was exhibiting multiple motor and vocal tics.
His motor tics included forceful head jerking
(back to front), shoulder raising, rapid and forceful eye blinking, and a tic that involved jerking
one or both of his elbows out to the side, which
he described as looking like a chicken dance.
His vocal tics include sniffing (i.e., rapid inhaling through nose), throat clearing, repeating the
slang word bro, and whistling.
Davids motor tics were present virtually all
the time and tic-free intervals never lasted more
than a few minutes. Bouts of motor tics occurred
frequently throughout the day. His head-jerking
tic frequently drew attention to him and occasionally caused pain. Several of Davids motor
tics had a somewhat purposeful appearance, but
they could be rationalized as normal. Finally, his
motor tics frequently interrupted ongoing behavior (e.g., writing homework assignments) but did
not prevent him from performing intended actions or tasks. His vocal tics also occurred frequently, every hour of the day; however, brief ticfree intervals of 3060min were not uncommon.
Although his vocal tics were slightly louder than
comparable vocalizations, they were not outside
the range of normal expression and rarely drew
attention. His vocal tics were relatively simple in
nature (were not sustained in duration and did not
appear purposeful or orchestrated) and because
of their brevity caused minimal interruption to
his speech. Based on this presentation, David
was given an overall YGTSS motor tic severity
score of 20/25 and an overall YGTSS vocal tic
severity score of 12/25. His total YGTSS tic severity score of 32/50 placed him in the moderateto-severe range of tic severity.
Regarding impairment, David and his mother
reported that his tics made it difficult for him
to concentrate at school, and he was frequently
being asked to leave the classroom due to bouts
of tics. Peers were also beginning to ask him
about his tics, which caused him to avoid some
social situations. Based on this, he was assigned
a total YGTSS impairment score of 35/50.
In addition to the YGTSS, David was administered the Premonitory Urge for Tics Scale
(PUTS; Woods etal. 2005). The PUTS is a
L. P. Hayes et al.
9-item self-report measure designed to assess for

the presence of premonitory urges. Each item is
rated on a 14 point Likert-type scale (anchored
by not at all true and very much true) allowing for scores ranging from 9 to 36. On the PUTS,
David indicated that he experiences premonitory
urges for some of his tics, including feelings that
there is energy in his body that needs to get
out and something feels not just right immediately before he tics. Additionally, he indicated
that these sensations are temporarily relieved following the completion of his tics. Davids total
PUTS score at pretreatment was a 20/36.
Finally, as an additional measure of tic severity, Davids mother was administered the Parent Tic Questionnaire (PTQ; Chang etal. 2009).
The PTQ is a self-report measure, based on the
YGTSS, that measures the number, frequency,
and intensity of 28 common motor and vocal tics
(scale range=0112). The PTQ was included
along with the YGTSS because its ease of implementation makes it valuable for monitoring tic
severity on a session-by-session basis. At pretreatment, David scored a 58/112 on the PTQ,
placing him in the moderate range of severity.
Assessment of ComorbidityResults of a structured diagnostic interview revealed that David
met full diagnostic criteria for combined-type
ADHD. Consistent with his ADHD diagnosis,
he scored in the clinical range on parent-reported
indices of inattention, hyperactivity, and impulsivity; however, his scores on indices of noncompliance/oppositional and disruptive behavior
were within the normal range. His parents noted
that although his ADHD was still causing some
problems at school, his symptoms had improved
substantially over the past 6 weeks since beginning his current regimen of clonidine.
Summary and Conceptualization Given Davids
overall tic severity, the impairment he was experiencing as a direct result of his tics, and his motivation to actively work on tic reduction, he was
deemed a good candidate for CBIT. However,
his ADHD, though fairly well managed with
medication, was viewed as a potentially complicating factor. It is our experience that children
who struggle with inattention and impulsivity

often have difficulty mastering HRT tasks such
as awareness training and competing response
training (CRT), thereby requiring modifications
to the CBIT protocol. In addition to illustrating
a typical course of CBIT, in the case illustration
below, we discuss how the CBIT protocol was
modified to accommodate his ADHD.

Overview of Treatment
CBIT is a comprehensive treatment package that
combines psychoeducation, HRT, and individualized function-based assessment and intervention strategies to directly target tics (Woods etal.
2008a). HRT, which is the heart of CBIT, includes
three main components: awareness training,
CRT, and social support. In awareness training,
patients are taught to recognize discrete instances
of tics, tic antecedents (e.g., premonitory urges),
and the discrete sequence of movements that are
involved in producing the tic. After sufficient
awareness is achieved, the patient is taught to
engage in a behavior directly incompatible with
the targeted tic (i.e., a competing response, CR)
whenever they recognize a tic is about to occur in
order to prevent it from being expressed. Finally,
social support involves teaching a support person, typically a parent, to prompt and reinforce
the use of the CR. In addition to HRT, functionbased assessment and treatment strategies are
used to systematically identify and reduce or
eliminate tic-exacerbating factors in the patients
everyday life, such as anxiety, stress, and social
reactions (e.g., attention, teasing).
CBIT is typically delivered in weekly
5090min joint sessions with the child and
parent(s). The first session focuses on rapportbuilding, providing psychoeducation about CTD,
and treatment planning, while subsequent sessions focus on directly targeting tics, typically
one new tic per session and daily practice in
between. Though CBIT was originally designed
and tested in an eight-session format (plus 2
follow-up booster sessions; Woods etal. 2008a),
217
individual cases require flexibility in implementation. For example, some patients present with
only a few problematic tics that can be addressed
in relatively few sessions whereas other patients
present with many tics that require more than
eight sessions to address. In addition, we have
found that some tics are stubborn (i.e., are
slower to respond), and thus the therapist may
decide to focus on a particular tic for more than
one session. Child and family characteristics,
such as interfering comorbidity, compliance with
treatment, cognitive and developmental level,
and family involvement in treatment must also
be considered. We recommend a flexibility with
fidelity approach (Kendall etal. 2008) such
that the CBIT is provided with adherence to empiricallysupported techniques while remaining a
flexible implementation based on the patients
unique presentation and needs. Below we outline how CBIT was administered, with emphasis
on areas that required flexibility, to successfully
treat multiple motor and vocal tics in the hypothetical case of David.
Session 1
Session 1 began with a review of assessment
findings to determine whether any new tics or
tic-related problems had emerged since the first
assessment visit. With this goal in mind, Davids
mother again completed the PTQ, which was
also administered at each subsequent session in
order to track treatment progress. As tics often
do, Davids tics had changed in 2 weeks between
visits. One of his vocal tics (whistling) had been
absent for over a week, and another of his vocal
tics had changed in its presentation (instead of
saying bro he was saying combination of bro,
hey bro, go bro). We then reviewed with David
specifically what he hoped to achieve from treatment. David reported that he hoped to cure his
tics, so we emphasized that CBIT is not a cure,
but rather that we would teach him specific tic
management skills to reduce the overall severity
of his tics so that they were less bothersome. We
did note, however, that in some cases CBIT can
reduce tic severity to the point where the tics are
218
only minimally bothersome ore even no longer

bothersome at all. We then provided psychoeducation about tic disorders. The purpose of psychoeducation was to decrease blame, stigma, and
negative feelings related to the childs tics and to
help the child and family better understand CTD
and address any misperceptions about tic disorders. The topics covered in psychoeducation included diagnostic criteria, prevalence, phenomenology and course of CTD, comorbidity and
impairment, and what is known and not known
about the cause of CTD.
Following psychoeducation, it was apparent that David was disappointed to hear that he
would likely still have tics upon completion of
treatment, even if they were significantly reduced, and he was also ambivalent about the
amount of work that would be required in treatment, so we introduced two motivation techniques. First, the therapist worked with David to
create a list of the pros and cons of learning tic
management strategies with particular emphasis
on how things would be improved if his tics were
less severe (e.g., it would be easier to concentrate
on schoolwork, the tics would no longer interfere
with baseball, people would stop commenting
on them). Second, we developed a reward program in which he would earn points (that could
be exchanged for preferred activities or items) for
coming to sessions, for working hard during sessions (attending, actively practicing skills, etc.),
and completing his homework between sessions.
Recognizing that children with ADHD respond
better to immediate rewards, the therapist also
chose to set the point exchange such that David
could earn small rewards at the end of each
weekly session rather than receiving one larger
reward at the end of treatment.
After developing Davids reward program,
the therapist worked with him to develop a tic
hierarchy. This involved David and the therapist
creating detailed operational definitions of each
of Davids current tics. David then rated each
of his tics, on a 010 scale, using the subjective
units of distress scale (SUDS). His tics were then
recorded on a tracking form in order of descending SUDS scores. The primary purpose of the tic
hierarchy was to prioritize the order in which tics
L. P. Hayes et al.
would be addressed in CBIT. Generally, treatment

begins by targeting the tic with the highest SUDS
rating (i.e., the most bothersome tic), though it is
also important to balance other factors. In general, we prefer to begin working on tics that the
child is motivated to improve (a tic that is bothersome) but one for which we are likely to have
some initial success in teaching tic management
skills. For example, we have found that it is preferable to first address tics that are occurring with
some regularity during session so that the child
can learn and practice tic-management skills in
the presence of the therapist. The tic hierarchy is
revisited at each session, and new SUDS scores
are obtained. This allows the therapist and child
to monitor how bothersome the tics are on a ticby-tic basis during the course of treatment.
After finalizing the tic hierarchy, we
introduced function-based assessment and
intervention (FBAI). The purpose of FBAI is

to systematically assess factors in the childs
everyday life that make tics better or worse.
After providing a rationale and examples, the

therapist encouraged David and his parents
to monitor and record tic exacerbations during the upcoming weeks (on a structured FBAI
form) paying particular attention to where he
was, what he was doing, who was present, how
long the exacerbation lasted, and other factors
(e.g., mood states, thoughts, etc.) that were associated with any exacerbations.
The final activity in session 1 was to teach
self-monitoring for Davids head-jerking tic. The
purpose of self-monitoring is to begin to increase
awareness each time a particular tic occurs, determine the childs level of awareness of the tic
by comparing child and parent tic counts, and
provide the therapist with an estimate of how frequently the tic is occurring. During self-monitoring, David and his mother were asked to sit down
for 1015min, 46 times over the course of the
week, and to independently observe each time
his head-jerking tic occurred by recording a tally
mark on structured tic tracking form. Although
we usually instruct families to self-monitor while
the child is engaged in a high-risk tic activity (e.g., homework) and for longer durations
(2030min), given Davids ADHD, we i nstructed
the family to conduct briefer self-monitoring

sessions and also to conduct self-monitoring in
a setting that was relatively free of distraction.
In addition to these structured self-monitoring
sessions, we also encouraged David to choose a
code word or letter (e.g., T) that he could say
under his breath or in his head to indicate himself
that he had a tic and to self-monitor by himself
23 times during the week while watching television. David and his mother were asked to bring
their completed self-monitoring forms to the next
session, along with their completed FBAI forms.
Session 2
Beginning with session 2, each subsequent session began with a review of the preceding week,
including any significant changes in Davids
tics. David and the therapist then updated the
tic hierarchy (assigning new SUDS ratings to
each tic). David identified his head-jerking tic
as particularly bothersome over the past week,
indicating that it caused tension and discomfort
in his neck and shoulders. Thus, he provided a
SUDS rating of 9a 2-point increase from the
initial session. When asked about the increase,
David noted that his tic seemed to be slightly
worse, which he attributed to paying so much
attention to it. His mother, however, noted that
she believed the tic actually seemed to be less
frequent overall. The therapist then reviewed the
self-monitoring homework (which was completed as requested) and two things were apparent.
First, based on parent observations, Davids tic
did seem to show a slight decrease during selfmonitoring periods over the course of the week.
On the first day of self-monitoring, Davids
mother had observed 45 tics in a 10-min period.
The number of tics observed by his mother decreased slightly across all observations, and by
the sixth observation his mother noted 26 tics
during a 10-min period. Second, it was apparent that David was having a difficult time noticing his tics. During the first self-monitoring period, David noted only 22 tics (compared to his
mothers 45), and all subsequent observations
were similarly discrepant. When asked about the
219
discrepancy, David insisted that his mother was

seeing things that were not there. We reassured
David that parents and children often do notice
different things and that a part of treatment was
to work together so that David could learn to
recognize his tics and also help his parents learn
what is and is not a tic.
We next reviewed the FBAI forms. David and
his mother identified that his tic was particularly
bad when doing homework after school. Davids
mother noted that his tics also seemed to be worse
when he was playing videogames, which he often
played for an hour immediately after school, before starting homework. The FBAI forms also
revealed that when he experienced tic exacerbations while doing homework, Davids mother allowed him to take a break from his homework
until his tics reduced. During these breaks, David
would often go to his room and play video games
until his mother called him back to the table.
Davids mother qualified this by stating that his
tics seemed to exacerbate before he came to the
table, so he had a difficult time getting started on
his work. After reminding David and his mother
about the rationale behind FBAI, we made the
following FBAI recommendations to address
homework: (a) when David came home after
school, he was limited to 20min of video game
time after which he would practice his HRT exercises (which were taught later in the session),
(b) he would then immediately begin doing his
homework, (c) if he completed his homework
within 1h, he would earn an additional 30min of
video game time before dinner, and (d) if his tics
exacerbated during homework, he would stop
his homework, remain at the table, and spend
10min practicing HRT exercises (this time did
not count against his 1h limit) before returning
to his homework. The plan was written out, and
Davids mother was asked to tape it to the homework table as a visual reminder. Davids reward
program was then adjusted so that he would receive extra points toward his weekly reward if he
followed through with this plan.
After developing the FBAI plan, habit reversal was conducted for the first tic on Davids
hierarchy (his head-jerking tic). The first step in
HRT is awareness training (AT). The rationale for
220
AT is that if the child is to learn how to manage

his tic, he must first become aware of each time
it occurs (as opposed to a general awareness that
the tic is present). AT has two primary components: response description and response detection. Response description involves developing
a detailed description of the discrete, sequential
movements involved in the tic, beginning with
the first movement and ending with the offset
of the tic, along with any pre-tic warning signs
such as premonitory urges. To begin AT, we first
gave David the opportunity to describe his headjerking tic in detail. As children often do, David
first described his tic in vague terms, stating,
my head jerks back. Then, based on our observations, we used guided questions to help him
recognize additional movements involved in the
tic. The following dialogue between David (D)
and the therapist (T) illustrates how David came
to recognize that his head-jerking tic was more
involved than he originally thought:
T: Okay, so you say that your head jerks back. I can
see that, and thats a pretty good description. But
lets really pay attention and see if your tic involves
more than just jerking your head back. Close your
eyes and really focus on the muscles involved and
which way your head moves from start to finish.
D: Well, after it goes back, it sort of rolls to the
side and then comes forward again.
T: Right, I see that too, good job. I actually
noticed something else though, right at the beginning of your tic. Pay close attention to how your
tic starts.
D: Yeah, I guess before it goes back, it actually
comes forward first, my chin goes down toward
my chest. Ive never really noticed that before, but
I guess it makes sense. In order for it to go back so
hard, it has to come forward. Kind of like a windup. Like throwing a baseball.
T: Good, youre really getting the hang of this!
You are right; your head comes forward first, not
back. I noticed something else when you do that
too. Whats going on with your shoulders?
D (voluntarily performs the tic to check): When
my chin is coming down, my shoulders sort of
hunch forward. Then when my head goes back, I
throw my shoulders back too.
T: Great job, I see that too.
D: Ive never really noticed that before.
T: Youve had this tic for a few years and never
really paid much attention to it. It turns out that
the tic is a lot more complicated than you thought.
Its not just throwing your head back. It a ctually
involves your head coming forward first and
L. P. Hayes et al.
involves your shoulders too. I have another question for you. Do you notice any feelings in your
body, maybe in your head, neck, or shoulders right
before the tic happens?
D: Yeah, right before I do it, I get an energy feeling in the back of my neck.
T: And what happens to that feeling after you do
the tic?
D: It goes away, for a little bit, but then it comes
right back.
T: Okay, so it all starts and ends with that energy
feeling. And thats important. That energy feeling
is the give-away that tells you the tic is coming. Its
like being able to read the sign that a catcher sends
to a pitcher in baseball. It tells you what is coming.
Now tell me all of those different parts of the tic in
order, starting with the urge feeling, and then well
write that down.
D: Sure, okay. So I get the energy feeling in the
back of my neck, then I dip my chin down and my
shoulders come forward, like the wind up, and then
I throw my head straight back really hard, and my
shoulders go back too. When my head is all the
way back I roll it to the left and my shoulders come
forward. When my head rolls all the way back to
the front, it goes back to normal and the urge goes
away.
As the reader will note from the preceding

dialogue, children often initially describe their
tics in general terms, missing important aspects
of the tic sequence. One common mistake made
by therapists during AT is taking the childs
definition of his tic at face value (e.g., head jerks
back) and failing to gather an adequate description of each of the movements and sensations that
comprise the target tic, which can have implications for subsequent steps in HRT (such as selecting a CR, see CRT below).
After generating a detailed definition of
Davids head-jerking tic, the therapist initiated
the second component of AT, response detection.
The purpose of response detection is to teach the
child to recognize each instance of his tic. We
introduced this to David as the Catch The Tic
game. To play the game, David and the therapist
sat across from each other. David was instructed
to raise his index finger each time he noticed that
he ticced. The therapist would also raise his index
finger if he noticed the tic first or if David missed
a tic. Typically, response detection is practiced
for 1020 consecutive minutes or until the child
is able to catch 80% of his tics (some children
require more, some less), while engaged in a
d iscussion, and the child is simply rewarded with

praise every time he catches a tic. However, given
Davids ADHD status and to increase motivation,
several modifications were made. First, the duration of the response detection periods were reduced to four, 5-min intervals with brief breaks
in between. Second, the therapist and David sat
relatively quietly while playing catch the tic, so
to avoid distraction, although the therapist did
offer praise when David caught a tic, promoted
him when he missed a tic, and offered general encouragement and feedback. Third, it was decided
that if David caught more tics than the therapist
during three of the four 5-min periods, he would
earn 10min of access to a preferred activity at the
end of the session.
In most cases, after 20min of response
detection, children will have reached an acceptable level of awareness and the second step of
HRT, CRT, would begin. However, in Davids
case, he was catching only 4050% of his tics
by the end of the session. As such, the therapist
taught Davids mother how to play the Catch
The Tic game and asked them to practice for
20min each day during the next week. In addition, the therapist asked David and his mother
to continue self-monitoring his head-jerking tic
and to continue to use the FBAI to monitor for
tic-exacerbating factors.
Session 3
When David and his mother returned for the third
session, David and the therapist updated the tic
hierarchy and assigned new SUDS ratings to
each tic. David noted that his head-jerking tic was
slightly less bothersome and provided a SUDS
rating of 6 (a 3-point decrease from the previous session). The therapist then reviewed the
self-monitoring homework and noted that agreement between David and his mother regarding
the number of tics observed had improved. They
then reviewed and problem solved the FBAI assignment from the previous session. David and
his mother both agreed that he was getting much
better at catching his tic, so David and the therapist played a brief 5-min game of catch the tic,
221
during which David caught 85% of his tics, and

in many cases was catching the tic before it happened. When asked, David explained that he was
able to detect the feeling in his neck, so he knew
the tic was coming.
Given Davids success with AT, the therapist introduced CRT. The purpose of CRT was
to teach David to engage in a tic-incompatible
CR each time he felt the urge to tic, caught the
tic mid-stream, and/or immediately after he performed a tic. David and the therapist worked together to come up with a CR according to five
general rules. First, the CR should be something
that makes the tic impossible or difficult to perform (i.e., it should be directly incompatible with
performance of the tic). Second, the CR should
interrupt the earliest sequence in the movement.
Third, the CR should be something that is less noticeable than the tic itself. Fourth, the CR should
(ideally) be a behavior that can be done anytime
and anywhere. And finally, the CR should be
something that the child can do for at least 1min,
or until the urge to tic subsides, whichever is longer. David was provided with some general examples and then was asked to brainstorm a CR
for his neck-jerking tic.
Initially, David stated that he could hold the
back of his neck with his hands; however, when
the therapist reviewed the aforementioned rules,
he quickly realized that was more noticeable
than the tic and was not something he could do
all of the time (e.g., when doing homework).
David then suggested that he could hold his chin
down toward his sternum. Although this initially
sounded like a good option, the therapist noted
that the first movement involved in his tic was
to bring his chin down, which violated the incompatible rule and emphasizes the importance
of generating a detailed and complete description
of the tic during the response description phase
of AT (as a reminder, David first described his
tic as his head jerking back). Given that David
was having difficulty selecting a CR, the therapist suggested that he try raising his chin slightly,
tightening the muscles in the back of his neck
(with minimal tension necessary), and pulling his
shoulders down and back to avoid the windup.
After David was able to successfully demonstrate
222
this CR, the therapist and David practiced using

the CR for 20min. Similar to the Catch The
Tic game used during AT, David earned points
each time he was able to successfully implement
the CR, and the therapist prompted him to use
the CR each time he displayed a tic. In addition,
the therapist asked David to give periodic urge
ratings (on a 010 scale) while he was using the
CR and the therapist plotted these on a graph for
David to see. Initially, David was having difficulty catching some of his tics, and he required
frequent prompts to use his CR. However, by the
end of the session, David was catching most of
his tics. In addition, David learned that although
his urge ratings increased initially while using
his CR (to ratings of 910), they declined fairly
dramatically after 12min and by the end of the
session peak, ratings were lower (ratings of 56).
Davids mother was then taught how to appropriately prompt and praise use of the CR (i.e.,
social support) while otherwise ignoring the tic.
They were asked to conduct daily focused practice sessions (2030min each) each day during
the upcoming week. In addition, Davids mother
was asked to prompt David periodically throughout the week when she noticed him ticcing, and
David was asked to use the CR as many times as
possible throughout the day and record each time
he successfully used the CR in a small notebook.
Sessions 411
Sessions 49 generally proceeded in the same
manner as sessions 2 and 3, targeting a new tic
each week. At the beginning of each session,
Davids mother completed the PTQ, homework
was reviewed, and the tic hierarchy and SUDS
ratings were updated. The primary therapeutic
activities for each session included developing
and implementing new FBAI strategies and targeting each of Davids tics with HRT. Based on
the information from his weekly FBAI forms, it
became clear that Davids tics were exacerbated
by stress, so he was taught diaphragmatic breathing in the fourth session and progressive muscle
relaxation in the fifth session. His tics were also
exacerbated by attention (i.e., talking about the
L. P. Hayes et al.
tic, his sister telling him to stop), so the family

was instructed to generally ignore the tic itself,
and instead to prompt him to use his CR when
they noticed the tic.
When administering HRT for the rest of Davids tics, he was able to recognize most of his
targeted tics with 80% accuracy following a
single session of AT, so CRT for each remaining
tic were conducted within the same session as
AT (targeting one tic per session). In the fourth
session, David and the therapist initiated HRT for
his first vocal tic (saying bro). During response
description, David and the therapist focused on
the airflow patterns and muscles involved in producing the sound rather than on the actual sound
of the tic or its meaning. David came to notice that
in order to produce the tic, he first inhaled (his
chest expanded and stomach muscles tightened).
He did not experience a premonitory urge for this
tic per se, but he did report that something in
my head just knows its coming. In addition,
the therapist had David focused on recognizing
the contraction of his stomach muscles, as this
was the first movement in his vocal tic sequence.
Following a single session of AT, David was able
to catch this tic with almost perfect accuracy, so
a CR was introduced within the same session.
The CR for this tic was controlled breathing
(in through the nose and out through the mouth),
which coincided nicely with the teaching of diaphragmatic breathing to reduce stress.
When David returned for session 6, he was
able to recognize when his bro vocal tic
occurred with 80% accuracy but was still having trouble catching the tic early enough in the
sequence to implement the CR. As such, the rest
of session 6 was devoted to additional AT and
CRT on this vocal tic rather than moving on to the
next tic on his hierarchy. By session 7, David was
doing much better with his bro vocal tic, so he
asked to work on his sniffing tic, even though it
was lower in the hierarchy than some of his other
tics. Because this tic involved inhaling through
the nose, the best candidate for a CR was to teach
him to reverse the breathing pattern involved
in producing the tic (in through the mouth, out
through the nose). Given his recent difficulty implementing the CR for his bro tic (the CR for
which was to breath in through the nose and out

through the mouth), the therapist suggested that
they work on one of his other motor tics first,
in order to avoid confusion with the conflicting breathing patterns involved in his bro and
sniffing tics, respectively. David agreed with this
plan, so session 7 focused on HRT for his arm/
elbow tic. The CR for this tic involved having
David pin his elbow bone to his hipbone, which
kept his hands free for other activities. Session
8 focused on HRT for his blinking tic. The CR
for his blinking tic involved regulated blinking
(blinking at a rate of once every second). David
struggled with this CR at first, so a metronome
was used to help him time his blinking. He also
began by practicing without distraction (staring
at a spot on the wall) but was eventually able to
use the CR while looking around the room, carrying on a conversation, and doing homework. In
session 10, David learned HRT for his sniffing
tic. As noted above, the CR for this tic involved
teaching him to breathe in through his mouth and
out through his nose.
Between each session, David and his mother
were asked to practice working on his tics as
described in sessions 2 and 3 above. In addition
to working on the specific tic targeted in each
weekly session, they were also asked to continue
working on each of the previously targeted tics.
To assist with this, David and the therapist kept
an updated list of CRs for each of his tics along
with a homework binder with a detailed list of
weekly assignments and structured homework
forms.
Session 12
Two weeks later, David returned for his twelfth
and final session. During this session, David and
the therapist updated Davids tic hierarchy and
highlighted how much lower his overall SUDS
ratings were for each of his tics. They then
reviewed all of Davids targeted tics, their definitions, associated CRs, and the function-based
interventions that had been implemented. In order
to assess how well David was able to generalize
what he learned over the course of CBIT, he was
223
asked to play the role of the therapist and to walk

the therapist and parent through HRT for a hypothetical tic. This allowed David to demonstrate
that he had the necessary skills to address any
future tics that may arise.
and Summary of Outcomes
At the final treatment session, David and his
mother were readministered the YGTSS, the
PTQ, and the PUTS. Consistent with clinical
impression, the YGTSS revealed that Davids
tics were greatly diminished in frequency, intensity, and complexity. Though he continued to
occasionally have simple motor tics on a daily
basis, prolonged tic-free periods were common.
His head-jerking tic (which was most bothersome at baseline) had decreased in frequency,
intensity, and complexity. When this tic occurred,
it now involved only a slight jerking of his head
to the left and he continued to use the CR for
this tic on a daily basis. His bro vocal tic had
not been observed in several weeks. Though not
directly targeted in treatment, his shoulder and
throat clearing tics had also disappeared. Though
he continued to have occasional eye blinking and
arm/elbow tics, these tics had decreased in overall severity, were isolated (no longer occurred in
bouts), and he was no longer actively working on
them. He also reported an overall decrease in the
severity of premonitory urges as measured by the
PUTS. Davids posttreatment assessment results
are presented in Table15.1.
The most common complicating factor when
administering CBIT is the presence of comorbidity. When possible, we find it best to address
any comorbidity that might interfere with treatment (e.g., noncompliance, inattention, severe
anxiety) before implementing CBIT. In Davids
case, even though his ADHD was well managed
with medication prior to coming to treatment,
his inattention complicated aspects of CBIT,
224
Table 15.1 Pre- and posttreatment assessment results
Scale
Pretreatment
Posttreatment
score
score
YGTSS total
32
15
score
YGTSS total
20
8
motor score
YGTSS total
12
7
vocal score
YGTSS impair- 35
15
ment score
PTQ total sever- 58
22
ity score
PUTS total score 20
12
YGTSS Yale Global Tic Severity Scale, PTQ Parent Tic
Questionnaire, PUTS Premonitory Urge for Tics Scale
e specially awareness training. When this occurs,

it necessitates a flexible approach to CBIT implementation. As a general rule, if a child is unable
to recognize any given tic with 80% accuracy in
the therapy session, we prefer to send them home
to practice AT exercises before introducing CRT
for that tic, as we did with Davids first tic. The
childs ability to reliably catch tics is an essential
component of HRT and so should be emphasized
in treatment, even if it requires additional sessions to achieve. Further, attending to tic warning
signs and quickly implementing a CR to interrupt
the tic can be difficult, especially for young children and those with ADHD. When this occurs,
we typically focus on mastering HRT for the targeted tic before moving on to address additional
tics on the hierarchy.
Another complicating factor is parent and
child motivation. The CBIT protocol requires
considerable effort from both the parent and the
child. In some cases, CBIT can become a tiresome treatment after a few sessions when the format generally becomes repetitive. It is important
for the therapist to be creative in order to make
the sessions fun and interesting. In addition to
carefully assessing motivation before beginning
treatment, utilizing reinforcement programs can
help to increase child motivation. In Davids case,
given his ADHD, we chose to deliver rewards
frequently (at the end of each session) rather than
at the end of treatment. We generally prefer to
make rewards contingent upon hard work during
L. P. Hayes et al.
treatment rather than for tic reduction per se. It is

also important for therapists to use ample praise
during CBIT to reinforce the skills they are trying to teach. Finally, we suggest practicing skills
across a variety of settings (e.g., when playing
games, walking around the building, etc.) to
make sessions more engaging while also enhancing generalization.
A final complicating factor is that environmental modifications, as part of the FBAI, can be
difficult for children and families to implement.
setting
For example, if aspects of the school
(e.g., peer teasing, being sent out of the room
during tic bouts) are worsening tics, the therapist will likely need to consult with the school
to make recommended changes. Likewise, teaching parents or siblings not to react to the tics may
require that the therapist spend time alone with
the parent to generate strategies that are feasible.
Finally, it is often the case that tic-exacerbating
factors involve things that are enjoyable to the
child, such as excitement surrounding vacations,
sports, or playing videogames. In these situations,
it may not be feasible or recommended to eliminate the tic-exacerbating factor (children do not
take kindly to a therapist who recommends that
videogames be banned). Rather than eliminating
those tic-exacerbating factors, we recommend
that the therapist carefully consider whether such
exacerbations are problematic, and if so, encourage the child practice using HRT within those
activities or contexts.
Conclusion and Key Practice Points

In this chapter, we presented how CBIT was used
to successfully treat motor and vocal tics in the
case of David, an 11-year-old boy with TS and
medically managed ADHD who was experiencing significant interference and impairment from
his tics. Although his ADHD was well controlled,
his inattention posed challenges to CBIT implementation, so slight modifications to the typical
protocol were necessary. Although CBIT is not
a cure for tics, and not all children respond
to treatment with CBIT, most children will experience a substantial and lasting reduction in
the overall number, frequency, intensity, and

severity of their tics, as was the case for David.
It is important to understand, however, that CBIT
is a collection of intervention techniques that
are
administered within a broader therapeutic
context. Factors such as comorbidity, parent psychopathology, life stressors, and parent and child
motivation can complicate treatment and need to
be carefully considered prior to beginning treatment. CBIT is also a collaborative treatment
approach, requiring the patient, their caregivers,
and the therapist to work together toward agreedupon therapeutic goals. This can help to increase
compliance and resilience in the face of challenges, especially during weekly homework where
most of the therapeutic work is accomplished.
Below, we provide final key practice points for
the treatment of tics using CBIT:
1. CBIT is an efficacious intervention for reducing motor and vocal tics in children and adults.
2. It is important to carefully assess for both
tics and other symptoms to determine which
symptoms are most contributing to functional
impairment as well as symptoms that may
interfere with CBIT administration. When
comorbid symptoms are the primary concern,

other empirically based approaches to treatment are recommended.
3. Although CBIT is a relatively straightforward intervention, and a detailed session-bysession treatment manual exists (Woods etal.
2008a,b), it is important for the therapist to be
flexible with implementation while maintaining the fidelity of the treatment.
4. Create a plan to increase and maintain motivation during CBIT. While CBIT sounds
simple, it requires considerable effort on the
part of patients and caregivers, and most of
the therapeutic work is accomplished between
sessions.
References
Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A
method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619628.
225
Banaschewski, T., Woerner, W., & Rothenberger, A.
(2003).Premonitory sensory phenomena and suppressibility of tics in Tourette syndrome: Developmental
aspects in children and adolescents. Developmental
Medicine & Child Neurology, 45, 700703.
Bloch, M. H., & Leckman, J. F. (2009). Clinical course
of Tourette syndrome. Journal of Psychosomatic
Research, 67, 497501.
Chang, S., Himle, M. B., Woods, D. W., & Piacentini,
J. (2009). Initial psychometric properties of a brief
parent-report instrument for assessing tic severity in
children with chronic tic disorders. Child & Family
Behavior Therapy, 31, 181191.
Cook, C. R., & Blacher, J. (2007). Evidence-based
psychosocial treatments for tic disorders. Clinical
Psychology: Science and Practice, 14, 252267.

Freeman, R. D., Fast, D. K., Burd, L., Kerbeshian, J.,
Robertson, M. M., & Sandor, P. (2000). An international perspective on Tourette syndrome: Selected
findings from 3500 individuals in 22 countries.
Developmental Medicine and Child Neurology, 42(7),
436447.
Himle, M., Chang, S., Woods, D., Bunaciu, L., Pearlman,
A., Buzzella, B., etal. (2007). Evaluating the contributions of ADHD, OCD, and tic symptoms in predicting
functional competence in children with tic disorders.
Journal of Physical and Developmental Disabilities,
19, 503512.
Himle, M., Capriotti, M., Hayes, L., Krishnapriya, J., Scahill, L., Sukhdolsky, D., Wilhelm, S., Deckersbach, T.,
Peterson, A., Specht, M., Walkup, J., Chang, S., Piacentini, J. (2014). Functional variables associated with
tic exacerbation in children with chronic tic disorders.
Kendall, P. C., Gosch, E., Furr, J. M., & Sood, E. (2008).
Flexibility within fidelity. Journal of the American
Academy of Child and Adolescent Psychiatry, 47,
987993.
Khalifa, N., & von Knorring, A. (2003). Prevalence of tic
disorders and Tourette syndrome in a Swedish school
population. Developmental Medicine & Child Neurology, 45, 315319.
Khalifa, N., & von Knorring, A. (2006). Psychopathology
in a Swedish population of school children with tic
disorders. Journal of the American Academy of Child
& Adolescent Psychiatry, 45, 13461353.
Leckman, J. F., Riddle, M. A., Hardin, M. T., Ort, S. I.,
Swartz, K. L., Stevenson, J., etal. (1989). The Yale
Global Tic Severity Scale: Initial testing of a clinicianrated scale of tic severity. Journal of the American
Academy of Child and Adolescent Psychiatry, 28,
566573. doi:10.1097/00004583-198907000-00015.
Leckman, J. F., Walker, D. E., & Cohen, D. J. (1993).
Premonitory urges in Tourettes syndrome. American
Journal of Psychiatry, 150, 98102.
McNaught, K. S. P., & Mink, J. W. (2011). Advances in
understanding and treatment of Tourette syndrome.
Nature Reviews Neurology, 7, 667676.
Pauls, D. L., Raymond, C. L., Leckman, J. F., & Stevenson, J. M. (1991). A family study of Tourettes syn-
226
drome. American Journal of Human Genetics, 48,
154163.
Piacentini, J., Woods, D. W., Scahill, L., Wilhelm, S.,
Peterson, A. L., Chang, S., etal. (2010). Behavior therapy for children with Tourette disorder: A
randomized controlled trial. Journal of the American
Medical Association, 303, 19291937. doi:10.1001/
jama.2010.607.
Robertson, M. M. (2008). The prevalence and epidemiology of Gilles de la Tourette syndrome. Part
1: The epidemiological and prevalence studies.
Journal of Psychosomatic Research, 65(5), 461472.
doi:10.1016/j.jpsychores.2008.03.006.
Scahill, L., Sukhodolsky, D., Williams, S., & Leckman,
J. (2005). Public health significance of tic disorders
in children and adolescents. Advances in Neurology,
96, 240248.
Silva, R. R., Muoz, D. M., Barickman, J., & Friedhoff, A. J. (1995). Environmental factors and related
fluctuation of symptoms in children and adolescents
with Tourettes disorder. Journal of Child Psychology
and Psychiatry, 36, 305312.
Storch, E. A., Murphy, T. K., Geffken, G. R., Sajid, M.,
Allen, P., Roberti, J. W., etal. (2005). Reliability and
validity of the Yale Global Tic Severity Scale. Psychological Assessment, 17, 486491.
Storch, E. A., Merlo, L. J., Lack, C., Milsom, V. A.,
Geffken, G. R., Goodman, W. K., etal. (2007). Quality
of life in youth with Tourettes syndrome and chronic
tic disorder. Journal of Clinical Child and Adolescent
L. P. Hayes et al.
Verdellen, C., van de Griendt, J., Kriens, S., & van
Oostrum, I. (2011). TicsTherapist manual &
workbook for children. Amsterdam: Uitgeverij Boom.
Weisman, H., Qureshi, I. A., Leckman, J. F., Scahil, L.,
& Bloch, M. H. (2012). Systematic review: Pharmacological treatment of tic disordersEfficacy of
antipsychotic and alpha-2 adrenergic agonist agents.
Neuroscience & Biobehavioral Reviews, 37(6),
11621171.
Wilhelm, S., Peterson, A. L., Piacentini, J., Woods, D. W.,
Deckersbach, T., Sukhodolsky, D. G., etal. (2012).
Randomized trial of behavior therapy for adults with
Tourette syndrome. Archives of General Psychiatry,
69, 795803.
Woods, D. W., Piacentini, J. C., Himle, M. B., & Chang,
S. (2005). Initial development and psychometric properties of the Premonitory Urge for Tics Scale (PUTS)
in children with Tourette syndrome. Journal of Developmental and Behavioral Pediatrics, 26, 17.
Woods, D. W., Piacentini, J., Chang, S., Deckersbach,
T., Ginsburg, G. S., Peterson, A. L., etal. (2008a).
Managing Tourette syndrome: A behavioral intervention for children and adults, therapist guide. New
York: Oxford University Press.
Woods, D. W., Piacentini, J., Chang, S., Deckersbach,
T., Ginsburg, G. S., Peterson, A. L., etal. (2008b).
Managing Tourette syndrome: A behavioral intervention for children and adults, parent workbook. New
Treatment of an Adult
with Trichotillomania
16
Martin E. Franklin and Madelyn J. Silber

Trichotillomania (TTM) is an impulse-control
disorder characterized by pulling hair from the
scalp, eyebrows, eyelashes, pubic regions, or
other areas, resulting in noticeable hair loss. TTM
is associated with significant functional impairment and has high rates of psychiatric comorbidity that appear to increase with age (Franklin etal.
2008; Walther etal. 2010; Woods etal. 2006).
In terms of prevalence, estimates of TTM in late
adolescents and young adults range from 0.6 to
3.5%, with a greater preponderance in girls and
women. Examinations of hairpulling behavior
in college students suggest that TTM exists on a
spectrum, with many reporting pulling without
noticeable hair loss or distress (DellOsso etal.
2006; Duke etal. 2010). Although reports from
adults participating in clinical trials indicate that
onset in childhood or early adolescence is the
norm, the prevalence of TTM in younger samples
has not been the subject of methodologically
sound empirical research as yet.
The etiology of TTM is poorly understood,
although the extant literature provides some
potential pathways for further exploration.
TTM concordance is more common in monozygotic than dizygotic twins (Chatterjee 2011;
Novak etal. 2009), and first-degree relatives of
M.E.Franklin() M.J.Silber
University of Pennsylvania School of Medicine,
Philadelphia, PA, USA
e-mail: marty@mail.med.upenn.edu
i ndividuals with TTM have higher-than-expected

rates of obsessive-compulsive disorder (OCD)
and OCD spectrum behaviors (e.g., King etal.
1995; Lenane etal. 1992; Stein etal. 2010). Collectively, these data suggest that a gene or multiple genes might confer biological vulnerability
to impulse-control disorders, although stress also
appears to have a contributing role in TTM onset
(Chamberlain etal. 2007).
Most clinical studies involving adults with
TTM indicate that comorbidity is the norm. In
particular, TTM is associated with depression,
anxiety, OCD and impulse-control spectrum behaviors, eating disorders, alcohol and substance
abuse, personality disorders, and self-injurious
behaviors such as skin picking (DellOsso etal.
2006). In those studies that have attempted to
estimate the onset of TTM and comorbid conditions retrospectively, TTM onset is usually reported to precede onset of the comorbid conditions
(e.g., Woods etal. 2006). In youth, comorbidity
is less common than in adults; for those who do
have a comorbid disorder, anxiety and disruptive
behavior disorders are the most commonly observed (e.g., Tolin etal. 2007).
Pulling behavior can vary greatly from one
person to the next, and some individuals who
pull engage in clinically important post-pulling
behaviors such as manipulating the pulled hair,
examining it closely, biting off the root, or swallowing the whole hair. For the subset of people
with TTM who ingest hairs after pulling (trichophagia), which is believed to be approximately
20% of those who pull (Grant and Odlaug 2008),

DOI 10.1007/978-3-319-17139-5_16
227
228
there is a risk of developing trichobezoars

(i.e., hair balls), which are associated with potentially serious gastrointestinal complications.
Trichobezoars have been documented in children
as young as 4. Other less serious medical complications associated with TTM include skin irritation or infection at pulling sites, permanent loss
of hair, and repetitive stress injuries from the act
of pulling.
TTM is associated with significant functional impairment in both children and adults.
Adults with TTM report impairment across all
domains of functioning such as poor school and
work performance, reduced academic and career
aspirations, and social impairment (e.g., Keuthen
etal. 2004; Woods etal. 2006). Both adults and
children may go to great lengths to hide the evidence of their hairpulling by altering styles of
dress, spending money on concealments or treatments for missing hair, or simply avoiding social
contact. In families of children and adolescents
with TTM, the disorder is associated with disruptions in family functioning, although it is unclear
whether family conflict is primarily causal or
consequent to TTM.
Two styles of pulling, characterized by the
degree of awareness of tension and gratification
associated with pulling, have been identified.
Clinical research with TTM samples over the
past decade has indicated that not all hairpulling episodes involve identifiable urges and/or
gratification associated with pulling (e.g., Lochner etal. 2011). These episodes are referred to
as automatic, as opposed to focused pulling.
Automatic pulling occurs outside of awareness;
people report becoming aware of the pulling only
after the act is ongoing or has been completed.
Focused pulling is instrumental and goal directed. Individuals engaging in focused pulling may
search for hairs that feel different from others, or
they may pull in response to a negative emotion
or event. Focused pulling is thought to distract
individuals from negative thoughts and feelings
and thus may be more directly tied to a negative
affect.
Although most individuals with TTM report
both types of pulling episodes (Flessner etal.
2008), one subtype of pulling may predominate
M. E. Franklin and M. J. Silber
in a given individual. Indeed, multiple studies

have indicated that a significant subset of adults
with TTM experience only, or primarily, focused
or automatic pulling. Although greater pulling
severity, whether focused or automatic, is associated with greater distress and psychosocial
impairment, highly focused pulling is independently associated with greater stress, anxiety,
depression, and impairment than less focused
pulling (Flessner etal. 2008). Pulling style is
thought to have implications for the treatment
of TTM, with more focused pullers being more
likely to relapse (Flessner etal. 2008; Franklin
etal. 2011). Accordingly, treatment development work in adult TTM has centered on developing affect-management strategies to augment
the basic treatment protocol, which typically
includes habit reversal training (HRT), stimulus
control, and awareness training.
Treatments for TTM that have been evaluated
in randomized controlled trials (RCTs) include
selective serotonin reuptake inhibitors (SSRIs)
and cognitive-behavioral therapy (CBT), as well
as several other compounds including olanzapine, naltrexone, and N-acetylcysteine (NAC).
Notably, despite the fact that multiple RCTs
have found SSRIs efficacious for OCD across
the developmental spectrum, four placebocontrolled studies of SSRIs in TTM have failed
to demonstrate superiority over placebo (for a
comprehensive review see Chamberlain etal.
2007; Franklin etal. 2011). Despite the fact that
the majority of adult sufferers report pediatric
onset of TTM, there are still no published RCTs
supporting the efficacy or safety of any psychopharmacological treatment in children with TTM.
Accordingly, clinicians are forced to extrapolate
from the adult TTM literature and the OCD literature to guide pharmacotherapy.
Given positive indications from multiple
RCTs, CBT in the form of HRT is viewed as
the treatment of choice for adults with TTM
(Flessner etal. 2010). The basic CBT package for TTM focuses on improving patients
awareness of their pulling behavior, addressing positive and negative reinforcement associated with pulling, stimulus control strategies to
make the environment less conducive to pulling,
16 Treatment of an Adult with Trichotillomania
implementing competing responses instead of

pulling in the presence of an urge, and can also
include function-based interventions designed
to reduce environmental cues associated with
pulling. Cognitive components of HRT treatments focus on developing adaptive responses to
negative emotions often associated with pulling,
particularly focused pulling. Although the acute
efficacy of HRT has been established in multiple RCTs, relapse following treatment discontinuation remains an issue (Keuthen etal. 2010;
Lerner etal. 1998). More studies are needed to
establish relapse rates and identify predictors of
treatment response and relapse.
With respect to pediatric samples specifically, there is little evidence available from randomized trials. Indeed, a randomized controlled
trial conducted by Franklin etal. (2011) in 24
youths with TTM remains the only published
RCT for any treatment for pediatric TTM. In
that trial, a CBT package that focused largely
on HRT was found superior to a minimal attention control condition in reducing pulling and
functional impairment. Maintenance sessions
were administered following 8 weeks of acute
CBT. Notably, treatment gains made in acute
CBT were maintained throughout this phase
of the trial and through a 3-month follow-up
period that commenced at the end of the maintenance phase, suggesting that behavioral interventions in youth yielded significant and durable gains. Other studies of HRT in this population are currently underway (Zickgraf etal.
in preparation).
TTM remains understudied and likely underdiagnosed, and treatment options in the community are very limited because few practitioners
have trained in TTM-specific assessment and
treatment methods (Marcks etal. 2006). Psychotherapy training programs are now beginning to
offer training in HRT, but the availability of these
treatments in the community continues to lag,
particularly in pediatric populations (Franklin
etal. 2011). Early treatment of TTM appears to
be associated with lower relapse rates than treatment in adults; early interventions might address
pulling behaviors before they take on affect-regulation functions or give rise to anxiety, mood,
229
social, and substance use problems during a critical period of development.

The illustrative case described herein touches
upon a number of core issues represented in the
TTM literature. In the following section, we
present the treatment of an adult female patient
with a history of pulling since childhood, a current combination of focused and automatic pulling, comorbid anxiety and depressive symptoms
that affect pulling differently, a significant stress
component that exacerbates urges to pull, and
a history of failed treatment attempts that had
to be addressed in order to promote optimism
about the process and, by extension, between
session compliance with behavioral procedures.
The adult literature on TTM is more fully developed than what is available to guide treatment of
youth, and, accordingly, in this case we were able
to draw upon prior scientific findings to help set
realistic and yet hopeful expectations regarding
the treatment process and expected outcomes.
Katie, a 35-year-old married professional woman
with two children, came to our center after having gone without any formal TTM treatment
since receiving services while still in college.
Prior to that, Katie had been treated for TTM
when she was 12 years old, about a year after
symptoms had emerged initially. Katie was vigorously encouraged to seek treatment at this time
by her husband, who had noticed increases in her
pulling and in associated mood symptoms over
the months prior to her scheduling an initial appointment at our center. Of particular relevance,
Katie came to that appointment expressing significant skepticism about the prospect of longterm change, a view reinforced by her having had
CBT twice before for TTM. As will also be described below, maladaptive perfectionism played
a critical role in Katies view of treatment as well
as her perspective, more broadly speaking, which
contributed to the anxiety, depressive, and marital problems that made separate contributions to
her stress level and, by extension, urge strength.
In order to be successful, the therapist not only
230
needed to treat the TTM symptoms themselves

via HRT but also integrate other cognitive and
behavioral methods to address these other contributing factors.
Case Information
Information was gathered during the initial intake through informal clinical interview, semistructured diagnostic assessment modules (e.g.,
Trichotillomania Diagnostic Interview (TDI),
Rothbaum and Ninan 1994); Mini International
Neuropsychiatric Interview (MINI) modules
for generalized anxiety disorder and major depressive disorder, (Sheehan etal. 1998), and
the National Institute of Mental Health (NIMH)
Trichotillomania Severity Scale (NIMH-TSS), a
clinician-administered, TTM-specific symptom
assessment interview. Katie also completed the
Milwaukee Inventory for Subtypes of Trichotillomania-Adult Version (MIST-A), a self-report
measure of focused and automatic pulling, respectively (Flessner etal. 2008). During the
course of the informal clinical interview, Katie
reported an onset of pulling at approximately
age 11, which she recalled happened mainly in
sedentary situations (reading, watching television, sitting in the backseat of her parents cars).
At the time the pulling commenced, there were
some stressful family events occurring (e.g.,
parents divorce, moving to a new town); Katie
recalled attempting to fake good by declining
when parents asked if she was experiencing any
distress about the divorce and by throwing myself into my school work. Katie reported that
this pattern was not unusual for hereven before
middle school, she was inclined to take school
work very seriously and to stress a lot about
assignments and projects. After about a year
of symptoms, Katies mother noticed a significant bald patch on the left side of Katies head,
which Katie initially denied knowing anything
about but eventually relented and reported had
been self-inflicted. Katies mother responded by
insisting that they seek counseling to get to the
root of the problem; this counseling lasted only
briefly, as the counselor actually knew little about
TTM and focused exclusively on the recent family stressors, which led to little symptom change.
Katies mother then moved her to a behaviorally
oriented practice in which one of the clinicians
was familiar with TTM and HRT specifically.
Katie responded well to this round of CBTthe
pulling was determined to be mostly automatic
in nature, that is, happening outside of awareness
and not directly cued by negative affect. Accordingly, the behavioral method of stimulus control
was emphasized during treatment, which in Katies case included covering the thumb and index
finger of her primary pulling hand with BandAids and holding items in her hands preventively
in high-risk situations such as when she was a
passenger in a car. The therapist also taught Katie
methods to learn everything she could about her
unique pulling patterns and improve her awareness of where her hands were in space in highrisk situations. After this initial behavioral treatment, Katie reported that her pulling did not remit
entirely but it was much better; the family
stress reduced simultaneously in the wake of the
divorce, which may also have contributed to the
reduction of TTM symptoms at the time. Katies
symptoms of TTM remained subclinical through
the remainder of middle school, though they increased substantially during her junior year of
high school, where she was focused on doing everything possible to gain acceptance into an elite
college. Both of Katies parents were academics,
and her perception was that anything less than
a top twenty school would be a gross violation
of their expectations as well as her own. Katie
recognized that she was pulling more during this
periodfrom approximately twice per month to
several times per weekbut she chose not to let
her parents know and instead focused on concealing the primary pulling sites, which were on her
scalp. Katie believed that her parents would view
her as a failure if she revealed that her pulling
problem was worsening again, and she was too
anxious about compromising their view of her
by revealing the relapse. Katie attempted to manage the symptoms without using stimulus control
methods, since the presence of the Band-Aids
would be a signal to her parents that her TTM
was back. Her symptoms reduced back to their
subclinical levels after her college applications

were submitted, but increased again in the spring
of her senior year as she sorted through college
decision making and dealing with the disappointment of not getting into her top-choice school.
Katie left the next fall for an academically rigorous university that was not far from her home
and settled in well, though subclinical TTM
symptoms and a tendency towards perfectionism
remained. Katie viewed the latter as central to
her academic success, and thus was disinclined
to view it as anything other than adaptive. Katies symptoms waxed and waned throughout her
undergraduate career, but the direct connection
between stress and pulling appeared to become
more tenuous. As is often the case in adult TTM,
negative affect, more generally speaking, began
serving more prominently as a trigger for pulling,
much to Katies distress. During college I began
to notice that even when things were fine academically, like during winter break, feeling upset
or uncomfortable for any reason would lead to
urges to pull, and then pulling in response to
those urges just made it worse, Katie described.
Katies symptoms worsened again during her
senior year of college, which she attributed in
part to not only interviewing for jobs but also acknowledged was part of a more general pattern of
symptom worsening that characterized her junior
year of college. Katie found expertise in TTM in
an academically oriented clinic near campus, and
CBT this time was more broadly focused on the
techniques of competing response training. Katie
learned to better track her urges and engage in
competing responses (e.g., fist clenching, playing with fiddle toys) as a means of preventing
herself from reinforcing urges to pull by pulling.
As described above, competing response techniques may well have allowed Katie to reallocate her attention away from urges and towards
other pursuits, which permitted time to pass, and
thereby allow her to experience urge dissipation.
Katie also used stimulus control methods at this
time that make the environment less conducive to
pulling (e.g., Band-Aids, bandanas, hats). Katie
was able to use these procedures to reduce pulling substantially, but she continued to permit
herself pulling binges when she felt herself to
231
be too stressed to manage affect any other way.

By the time she graduated from college, Katies
TTM was not obvious to anyone except herself.
She was even able to conceal the pulling from
Bill, her boyfriend who would later become her
husband.
Upon presentation to our clinic, Katies pulling had returned to clinical levels, and she spent
a good deal of time daily concealing the bald
patches it created on her scalp. Bill encouraged
her to seek treatment, primarily because he felt
that TTM was interfering with her happiness and
to an extent from her active participation in family life. Katie was reluctant to reengage in therapy, mainly because of her misperception that
CBT provided only temporary relief. From her
report of the treatment history, Katie experienced
partial but substantial response following these
treatments, but at the same time was discouraged:
those effects didnt lastI slowly went back to
pulling, and then after a while it got bad again.
Part of the therapists task, therefore, was to help
create an environment in which change could be
considered possible; perhaps more importantly,
it became apparent that the therapist needed to
help redefine what constituted change, following
Marlatts concept of abstinence violation effect
(Marlatt and Gordon 1980). It had been Katies
impression that the urges should simply follow
pulling behavior in time: Once she stopped pulling, urges should have dissipated in turn. Further
discussion about this issue led to a more comprehensive view of the problem (see below) and
also an acknowledgement that Katie had never
achieved complete abstinence as a result of her
continuing to give herself permission to pull on
a somewhat regular basis.
and Assessment
Data gathered at the intake and during initial evaluation sessions revealed a number of key clinical factors that warranted attention in treatment.
First, in terms of TTM diagnosis, comorbidity,
symptom severity, and pulling style, Katie met
diagnostic and statistical manual-text
revision
232
IV (DSM IV) diagnostic criteria for TTM according to the TDI, as well as for major depressive disorder (MDD) and generalized anxiety
disorder (GAD) according to the MINI. Katies
score on the clinician-administered NIMH-TSS
was a 16, which represents moderate-to-severe
pulling that is considered by experts to be clinically relevant. Data from the MIST-A supported
what was gleaned during the informal clinical
interview, which is that Katie engaged in both
focused and automatic pulling that appeared to
be under the influence of different contextual and
affective cues. For example, Katie was vulnerable to pulling absentmindedly when engaged
in sedentary activities such as reading, watching
television and, to an extent, driving. Katie described times when she zoned out and would
look down to see a pile of pulled hair nearby
her pattern during this period typically involved
a pull and drop method in which Katie would
quickly find and isolate a scalp hair, move her
thumb and index finger towards the root of the
hair, pull it, and drop it immediately; she would
then repeat the process and could pull many hairs
in quick succession without even noticing that
she had started. These discoveries often left her
feeling out of control and as if my hand had
a mind of its own, which she found demoralizing and depressing. Depending on the intensity
of the pulling binge, this affect would often linger
throughout the day, preoccupy her, and be associated with a later focused pulling episode, usually
in the bathroom, which involved a more seemingly intentional and goal-directed process that
also included a visual inspection of the hair both
before and after pulling it.
Another clinical issue that became apparent from both Katie and Bills report (Bill participated in initial sessions to encourage Katie to
attend treatment) was the more broadly evident
pattern of maladaptive perfectionism, negative
affect, and isolation from family. Katie described
herself as a people pleaser who would at times
be so anxious about impression management that
it interfered with her ability to identify her own
viewpoints. She was careful in her attempts to
avoid offending coworkers, neighbors, and even
family members, to the point where she would

occasionally get feedback from others that they
did not know Katie or her views well because
she rarely expressed them unequivocally. Katie
wanted her house and her family to appear to be
tidy, and under control, so behaviors that deviated from these desired goals would greatly increase negative emotions and eventually resulted
in withdrawal. For example, when Bill and the
kids would rough house in their impeccably
decorated living room after dinner, Katie would
insist that they avoid putting their feet on the furniture, knocking items over, or generally creating
chaos. The children, ages 6 and 8, were both
disinclined to take these instructions seriously,
especially since their father made clear that he
did not wish to comply either when he and the
children were having fun. Katie would make
negative statements about the hooliganism in
the house and would eventually get to the point
that she would take herself out of the living room
while proclaiming I cant deal with this! and
would retreat to her bathroom for some peace
and quiet. It was in this affective state that focused pulling would ensue, and eventually simply entering the bathroom became a cue for focused pulling, in that Katie felt she deserved an
opportunity to relax alone and relieve stress. She
began to equate this emotional state with pulling urges, which would lead to longer and longer absences from family life that were noticeable to both Bill and their children. Where does
Mommy go at night?, is a question that Katie
and Bills older daughter would ask frequently at
first, but eventually she stopped inquiring since
it was clear that Mommy is in a bad mood at
night, and Mommy wants time alone. This
rift in family life had stretched out over several
years and was now simply part of the dynamic.
Bill would play with the children, put them to
bed, and then return to the kitchen to clean up the
evening meal. This process further cut into time
that the couple could spend alone and exacerbated Bills sense that Katie valued alone time more
than she did being part of everything. Katie
acknowledged as much, but said that the stress
level in the home after dinner at night was so high
that she could not stand it, especially as she saw

how the furnishings were being displaced and
dirtied throughout the process.

The initial treatment session was spent reviewing the clinical data gathered during the intake
and selecting specific treatment targetsKatie
and the therapist had already decided that TTM
would be the target of the intervention efforts
because it was causing Katie the most distress,
had been a long-standing problem, and she believed that it drove some of the anxiety, depression, and marital strain that was also identified
in the intake process. Katie described herself as
a worrier but believed that her worries were
functional, so she did not wish to address them
out of concern that she would be less effective at
work, where she was involved in both sales and
sales training at her job. Because automatic pulling is sometimes easier to address, the therapist
and Katie set up self-monitoring spreadsheets in
Excel (Katie was an expert in their use) which
were used to track dates, times, situations, pulling
behaviors, post-pulling behaviors, and whether
or not negative affect was directly related to a
particular pulling episode. In this initial session, the therapist also introduced the techniques
of response description and response detection,
which are used to improve self-awareness. Katie
was asked to describe the last automatic pulling
episode she had experienced in excruciating detail, which proved easy since it took place in her
car on the way to the session. Katie was able to
describe how her left (nondominant) hand would
work its way up to the left side of her head,
quickly isolate a hair between thumb and index
finger, pull the hair, and then drop it onto the passenger seat. Close inspection of the process indicated that these incidents were more likely to
occur while slowing down or stopped in traffic,
which is when Katie would be more comfortable
letting go of the steering wheel with her left hand.
The therapist and Katie then reviewed several
other automatic pulling episodes that occurred
233
during the week and came to notice that sedentary activity was a common cue as well as either
being alone or perceiving that others were not
watching her. Katie would very rarely pull during meetings, at work, and because her office did
not provide much opportunity for isolation; she
noted that she rarely pulled in this setting. With
respect to response detection, the therapist asked
Katie to let the therapist know when the therapists hand touched his head while they were
conversing about other topicsthis was done for
several minutes until Katie caught every touch of
the head. The therapist then asked Katie to now
track every time his hands were raised above his
shoulder, noting to Katie that the vast majority of
the pulling she reported required her own hand
to be above her shoulder. After Katie achieved
proficiency with this procedure, the therapist and
Katie then switched roles; next, Katie was asked
to track in session the number of times her own
hands were raised above her shoulders. The therapist then reviewed assignments given during the
session that included tracking her pulling on the
monitoring sheet, reading the response description created in the session and looking to see if
it needed to be modified in accordance with selfmonitoring data, and practicing the response detection exercise in 15-min intervals several times
during the week while varying the setting in
which this was done. Katie expressed optimism
that she would be able to do this and expressed
appreciation for the therapists thoroughness in
this initial session.
The next session commenced with a careful
review of the self-monitoring data that Katie had
collected since the previous visit. As seemed
typical of her approach to tasks, Katie was very
thorough and careful in the monitoring process
and asked many questions about whether she had
done the job properly. The therapist provided
assurance that the data collected were valuable
indeed, and a review of the process of collecting
said data led Katie to believe that the procedure
was valuable. I learned more about my pulling
this week than I would have expected given that
Ive been doing this so long, she remarked. In
particular, it became evident that pulling was
234
more common at night, happened only when

alone in the past week, was evident in the car
when she drove alone but not when she drove
with other people in the car and was taking up a
significant amount of time between dinner and
when the children were getting ready for bed.
Her monitoring also indicated that the pulling
in the car was not associated with much affect,
a clear urge, or intention, whereas the nighttime
pulling at home was associated with all of these
elements. Accordingly, the therapist and Katie
began to view the car as a place where stimulus
control methods would prove especially helpful, whereas the nighttime pulling would require
more awareness of moving from low- to high-risk
situations and intentionally engaging in competing responses when confronted with urges. Katies treatment began in the winter months, which
led to a decision to drive with gloves on in all
situationsgloves would preclude getting any
grip on a single hair, and so the absentminded
pulling would likely be thwarted in this specific
situation. Monitoring data indicated that pulling was daily, with approximately 3050 hairs
pulled per day. The therapist explained how focusing on stimulus control methods would help
reduce automatic pulling early on and provide
some initial momentum for treatment. Bandanas,
hats, gloves, and Band-Aids were each selected
for their ability to block initial automatic pulling
before it started, and situations were reviewed to
determine which method would be most practical and most useful across those situations identified as associated with pulling. Katie also noticed a significant difference in automatic pulling when she wore her hair down as opposed to
up in a ponytail, and thus her hairstyle decisions
were also going to be part of the stimulus control package to be implemented. Katie was given
clear instruction regarding modifying her dayto-day use of stimulus control methods, and the
therapist discussed the monitoring information
they wished to focus on during the coming week.
Katie asked that her husband Bill be brought
up to speed on the initial work being done in
treatment, and the therapist obliged by discussing initial steps with the couple. The therapist did
the majority of the communicating during this
period, as Katie appeared to still be uncomfortable speaking with her husband about the details
of her pulling; nevertheless, she encouraged the
therapist to do so on her behalf. Bill expressed
his support of his wife and of the treatment and
offered to be helpful in whatever way he could.
The therapist indicated that he would indeed take
advantage of this generous offer, and it would
turn out to be a critically important intervention
later on in treatment.
Session 3 involved review of the prior weeks
monitoring, which reflected the positive effects
of wearing gloves while drivingKatie pulled
only once in the car in the prior week as opposed
to daily, and the only day that she pulled was a
day where she forgot to bring her gloves with her
when she drove to work. The therapist and Katie
agreed that this gap could be easily closed by
keeping a spare pair of gloves in the cars glove
compartment. The remainder of this session was
spent discussing and then practicing competing
response training, or engaging in an alternative
behavior instead of pulling in the presence of an
urge to pull or at the first sign of pulling behavior.
Competing responses can not only involve the
use of manipulatives, such as koosh balls, clay,
knitting, etc., but is also taught to be used when
no such objects are available. In such cases, fist
clenching is often used, although this can also be
modified to match client preferences (e.g., dropping hands to sides and then pinching thumb and
index fingers together). Standard procedure in
HRT involves asking patients to remain in their
competing response for 1min or until they experience at least some dissipation of urge. Katie
preferred the method of pinching her fingers and
thumbs together rather than closing her entire
fist, as she thought such a posture might be too
noticeable and could be misinterpreted as hostile
or aggressive at work, which she thought would
be problematic. In reviewing the possibilities for
manipulatives that could be spread throughout
the house, Katie tested several samples in the
therapists office and came to prefer koosh balls
over clay because of the mess. Katie and the
therapist planned together when and where she
could make these purchases, what she could keep
these items in throughout the house so they were
easily accessed, and how she could explain the

use of these items to her children without having
to discuss TTM specifically.
Subsequent sessions followed a similar pattern
to the prior onesreview of monitoring data, use
of stimulus control and competing response exercises in session, tweaking the plan in response
to observations made over the prior week, and
continuation of response detection exercises
throughout these discussions. Katie reported that
the first month of HRT had indeed reduced pulling behavior substantially, especially automatic
pulling. Pulling in the car had been reduced to
zero with implementation of the backup gloves in
the car, and Katie had taken to preemptively using
manipulatives and wearing a hat when at home,
on the computer, or watching movies with her
daughters. What also emerged during these sessions was the persistence of the evening pulling
sessions between the end of dinner and bedtime
for the children; there was a reduction in their
frequency but not in their intensity in the early
going; this continuing pattern would then drive
clinical decisions to shift the focus of treatment to
address the variables that predicted these events,
which would become more evident over time.
Katie had also taken to checking for regrowth
in the most frequent pulling sites on her scalp,
the net effect of which was to increase negative
affect and pessimism about the process since regrowth was not immediately evident. Katie and
the therapist discussed this tendency, which she
viewed as part of a more general pattern of impatience she had observed in herself. This pattern
was discussed, and it was agreed upon that Katie
would refrain from such intentional checking and
would style her hair under less bright light so that
she could not check inadvertently.
HRT protocols of established efficacy for
TTM typically do not exceed ten weekly sessions
during the acute phase of treatment, but it became
clear with Katie that additional weekly sessions
would be needed. Despite a reduction in pulling
days from daily to approximately two to three
times per week and a reduction of greater than
50% in the number of hairs pulled per week and
associated decrease in her NIMH-TSS score to
a 10, Katie continued to experience urges to en-
235
gage in focused pulling several times per week.

Moreover, feelings of anxiety, depression, and
marital distress remained problematic for Katie,
and though Bill was pleased that she had begun to
get a handle on her pulling, he still felt that her
tendency to take herself away from the family in
the evening in order to pull was disruptive to the
family and hurtful to their daughters. Accordingly, the therapist began to focus interventions on
improving the family situation around these observations. It would bother me less if I knew you
were doing something productive to de-stress,
like running or yoga, Bill offered, but knowing that you are pulling during that time make me
feel like you dont value your time with us. I
do value our family time, Katie responded, but
I wish that this time could be more structured and
include me more. The therapist worked with
the couple to restructure family time on school
nights, with Katie using some of this time for
exercise in the familys basement gym, walking
with friends, or reading to the girls. In turn, the
family also worked to make sure to clean up for
dinner immediately after the meal was over and
did so as a group effort, which satisfied Katies
desire to teach the girls to take responsibility but
also allowed that time to include her. Bill also
agreed to play with the girls after dinner in the
basement area, which decreased stress and reduced noise for those days in which Katie chose
to go upstairs to relax after work on nights when
she was not using the basement space to exercise. These improvements reduced stress to an
extent, led to a more family-based approach to
the week, and reduced the burden on Bill to provide the girls with an enjoyable outlet at the end
of their day. Eventually, Katie began to take on
this role more frequently, playing with the girls
downstairs, or letting them play together while
she ran on the family treadmill. Katie reported
that these changes helped her feel closer to her
family and more involved in their lives; the girls
began to respond positively as well and started to
request Mommy time in the evenings. Family
life not only improved but also provided an alternative to Katies alone time at night, which was
the single largest opportunity for focused pulling
during the week.
236
Additional session time was devoted to address maladaptive perfectionism, which was associated with stress, anxiety, and depression for
Katie. She had long viewed herself as a worrier whose tendencies to want to do everything
perfectly was at the heart of her success at work.
However, Katie failed to view the downside of
this approach, and cognitive and behavioral
techniques designed to promote a more flexible
approach to her life were implemented. For example, Katie was asked to allow her children
to wear mismatched socks and other items to
school, which she previously viewed with dread
and with great certainty that such transgressions
would result in negative attention for her children
and for her. Initial efforts to do so were associated with significant anxiety, but when the feared
consequences did not materialize and her family responded with positive reinforcement, such
exercises gradually became easier to do. Katie
was less successful in bringing this same kind
of flexibility practice to her work life, where
she had come to believe that her extremely thorough approach to her job was the reason she was
valued and retained in her company. Katie was
asked to identify other coworkers with similar
responsibilities and to observe whether they took
the same approach that she did with respect to
meeting preparation, managing her sales force,
and spending additional time making sure that
everything goes according to plan. These observations at first led to reinforcement of her initial view, in that a sales meeting that went particularly poorly was headed up by a coworker
whose approach could best be described by Katie
as indifferent. The therapist engaged Katie in
Socratic questioning around this incident to determine whether it had actually gone as poorly as
she described, whether the coworkers approach
was consistently substandard, what occurred following the meeting, and what happened to the coworker as a result of a meeting that could best be
described as suboptimal. This discussion helped
Katie come to a different conclusion about the
meeting based on other coworkers responses
during and after the meeting, and she came to
see that the coworker in question, though indeed
not as likely to be as prepared as Katie for such
presentations, had a number of different strengths

that made her a valuable employee, nevertheless.
Katie was asked by the therapist to bring other
examples into the session in which her perception that doing things imperfectly would result
in substantial negative consequences for her or
her family, friends, and neighbors. Over time,
and albeit reluctantly, Katie began to incorporate these new observations into her view and
began to engage in further practices in which she
was asked to underprepare at work, intentionally make mistakes, and leave tasks undone such
as vacuuming carpets at home. These experiments generally resulted in disconfirmation of
her previously held beliefs, which Katie openly
acknowledged. Nevertheless, she continued to
experience, and wished not to experience, negative affect in response to these practices. Katies
tendency to avoid anxiety and related discomfort
was also targeted in treatment, as they could be
viewed both as directly related to pulling (desiring urge reduction) as well as perpetuating of
negative affect which, in turn, could give rise to
stronger urges to pull.
After 18 sessions conducted over 22 weeks,
the therapist and Katie agreed to move to a booster session schedule. By this time, Katies NIMHTSS severity score was a 5, which reflected subclinical pulling, occasional urges, and good control over urges that do arise. Perhaps of greatest
relevance in this case, though, was the change in
Katies view of whether therapy had worked.
Katie now understood that she had a vulnerability to pulling that was not simply a character
flaw, and that it was not helpful to her to view
the continuing experience of pulling urges and
even occasional pulling as signs that treatment
has not worked. The therapist endeavored to
challenge this belief by providing case examples
and clinical research data that supported the view
that some residual symptoms are the rule rather
than the exception, and that Katies responses to
her urges was far more important than their mere
presence. The therapist also shared with Katie a
quote attributed to Voltaire that the therapist was
fond of using in such situations: The perfect is
the enemy of the good. Katies task was not to
refrain from pulling foreverit was to live her
life well, to accept the presence of urges, endeavor to understand them well, and to develop a
broad array of cognitive and behavioral responses that would permit her to make fully informed
choices of how best to respond to the urges that
did emerge.
Case complexity often generates the most challenging clinical decisions, and in the case described above, this was most certainly an issue.
The patient met diagnostic criteria for TTM,
GAD, and MDD; had a history of prior relapse
following CBT; and was experiencing a good
deal of marital distress as well. Patient priorities
influence but do not dictate which of the presenting disorders to targetclinical judgment and
the extant literature also affect these choices. In
the case described here, Katies own thinking regarding what to tackle first was influenced by her
husband Bill, who noted that her problems with
mood and irritability were both affecting and affected by TTM, but that TTM had been present
on and off for over 20 years, whereas the other
problems seemed to be more intermittent. The
therapist was encouraged by Katies positive
acute responses in the past to HRT and viewed
the primary challenge as one of having to help
her change her views of maintenance treatment
and residual symptoms once the acute phase was
completed. Further, studies of OCD and related
conditions have indicated that symptoms of secondary comorbid conditions can improve when
the symptoms of the primary disorder are substantially reduced (e.g., Franklin etal. 2000),
and this perspective influenced the choice, in this
case, to target TTM first.
Katies history with HRT and what she viewed
as its, and her own, failures also needed to be addressed, since making sure that Katie came to the
treatment with a different mindset was critical
to the ultimate treatment success. The therapist
spent a good deal of time presenting Katie with
information regarding the likely course of treatment and outcome in order to reduce unrealistic
expectations that would then compromise use of
237
techniques which would then lead to a stronger

return of symptoms. Understanding that TTM is
a complex set of learned associations that likely had its roots in neurobiology was helpful to
this cause, since Katie had long viewed TTM as
damage I do to myself, self-mutilation, and
a problem for which I am entirely responsible.
Such beliefs only served to heighten her despair
and self-loathing when pulling got worse and led
to a decade-long avoidance of treatment after her
relapse following college because there was really no point to trying anymore. The therapist
not only addressed these cognitions up front but
also attended to them throughout the course of
treatment when they arose again, which was especially likely when progress proved not to be
entirely linear.

TTM is a complex disorder that is not easily
eradicated, as reflected in an extant treatment
literature that provides reason for cautious optimism regarding acute treatment outcome following a course of HRT but for little else. There is
also some reason now to believe that combined
treatment with SSRI pharmacotherapy may successfully augment HRT alone (Dougherty etal.
2006). Relapse following even successful treatment is common, although the very limited pediatric literature suggests better maintenance of
gains following CBT in youth than has been seen
in adult patients. It is in this context that treatment providers must make the fully informed
decision to offer and then provide the treatments
with the best chance of yielding a positive outcome, which is what was done in this case. The
literature may well set a context for making educated guesses about immediate and long-term
outcome, but they do not either limit or guarantee
success. Our first conclusion, therefore, is that
clinicians must glean what they can from the scientific literature and then follow their own theoretical and clinical judgments to determine which
course to pursue with TTM patients, especially
those exhibiting significant case complexity. Katies treatment outcome was successful in large
238
part due to her own compliance with betweensession monitoring and other behavioral tasks;
the therapist tried to infuse optimism into the
process up front and build upon what Katie had
already succeeded with in the past in determining
the path towards optimal outcome.
The second conclusion has to do with the
importance of therapist awareness of the literatureKaties therapist worked at a clinic in
which TTM research was actively ongoing, but
the low base rate of TTM, the relatively few
number of patients who present specifically for
TTM treatment, and the lack of focus on TTM
and its treatment in the vast majority of graduate training programs make the clinic that Katie
received services the clear exception rather than
the rule. The TTM treatment literature is by no
means vast, but, at the same time, there has been
significant progress made in the past decade regarding TTMs underlying neural mechanisms,
psychopathology, and treatment. One of the reasons to contribute chapters such as this one is to
address this issue of a lack of awareness of TTM
among clinical practitioners, since many of our
patients report that they have received prior treatments that are either unproven or already studied
and found essentially inert in research trials. We
would go as far as to say that if the practitioner
has not been exposed to any information about
TTM previously, then the patient may be best
served to seek another practitioner who has such
knowledge, since knowledge and experience may
well be the difference between a good and poor
outcome. The Trichotillomania Learning Center
(TLC; http://www.trich.org) is an organization
devoted to making information about TTM and
its treatment more readily available and would
be an excellent place to start such a search. We
have known some inexperienced practitioners
who have, when no other resources are available,
turned to TLC for psychoeducation, training opportunities, and consultation, which is likely an
advance over having a clinician who has not
heard of TTM attempt to conduct this treatment.
Efforts are underway internationally to train clinicians in the treatment of OCD and then provide
ongoing case consultation for them to promote
use of the empirically supported approaches to
the disorder (Thomsen etal. 2013); their encouraging outcomes (Torp etal. 2015) may well
serve as a readily adapted model for TTM when
resources can be marshaled to make these treatments more widely available.
The final conclusion we draw from the case
is that motivation to work at the treatment, and
to tolerate distress and discomfort, is essential.
In many cases, TTM is driven by appetitive responsespleasure and gratificationthat are
immediately proximal to the pulling behavior. Distal responses, such as negative emotion
upon viewing the effects of pulling, impact on
self-esteem, negative responses from others in
the environmentare generally less likely to
influence behavior than are proximal factors,
especially if those factors are especially salient.
Thus, in order for HRT to work, the individual in
treatment needs to give up a significant source
of pleasure that they have habitually sought in
response to urges or stress more broadly speaking, and tolerate unpleasant emotions or physical urges without resorting to a behavior that
has served to regulate these various functions in
the past. This is a tall order, and thus creating a
clear reason to do so is important in treatment.
Therapists must acknowledge as much, and they
must also explicitly instruct patients that the
competing responses chosen to engage in rather
than pulling in the presence of an urge or in highrisk situations will likely not provide the same
kind of affective or physical effects that pulling
did. Therapists must also encourage the patient
by letting them know that this process typically
gets easier over time, and that the intensity of
responses when refraining from pulling in the
beginning of treatment are typically more powerful than they will be once the ratio of pulling
behavior in response to urges is decreased. The
therapist in this case made use of analogies to
working out, which Katie was familiar with, in
explaining how the same workout process is typically less taxing 3 months after starting it than it
was in the first few days when muscle soreness
was more intense. Katie had previously expected
that she should be able to simply stop pulling and
experiencing urges quickly, so tapping into motivational resources and reinforcing her efforts to
change also proved important in this case. Had

Katie expressed great ambivalence or overtly
opposed working on TTM, the therapist could
likely have chosen other emotions or behaviors
to target since TTM treatment would likely have
been compromised in the absence of strong reasons to change. Thus, we encourage therapists to
set this motivational foundation before simply
launching into HRT when it is unclear if the patient has a lready made a firm commitment to the
process.
References
Chamberlain, S. R., Fineberg, N. A., Blackwell, A. D.,
Clark, L., Robbins, T. W., & Sahakian, B. J. (2007). A
neuropsychological comparison of obsessive-compulsive disorder and trichotillomania. Neuropsychologia,
45, 654662.
Chatterjee, K. (2011). The genetic factors influencing the
development of trichotillomania. Journal of Genetics,
91, 259262.
DellOsso, B., Altamura, A. C., Allen, A., Marazziti, D.,
& Hollander, E. (2006). Epidemiologic and clinical updates on impulse control disorders: A critical
review. European Archives of Psychiatry and Clinical
Neuroscience, 256, 464475.
Dougherty, D. D., Loh, R., Jenike, M. A., & Keuthen,
N. J. (2006). Single modality versus dual modality
treatment for trichotillomania: Sertraline, behavioral
therapy, or both? Journal of Clinical Psychiatry, 67,
10861092.
Duke, D. C., Keeley, M. L., Geffken, G. R., & Storch, E.
A. (2010). Trichotillomania: A current review. Clinical Psychology Review, 30, 181193.
Flessner, C. A., Woods, D. W., Franklin, M. E., Keuthen,
N. J., & Piacentini, J. (2008). Styles of pulling in children with trichotillomania: Exploring differences in
symptoms severity, phenomenology, and comorbid
psychiatric symptoms. Behavior Research and Therapy, 48, 10551061.
Flessner, C. A., Penzel, F., & Keuthen, N. J. (2010). Current treatment practices for children and adults with
trichotillomania: Consensus among experts. Cognitive
and Behavioral Practice, 17, 290300.
Franklin, M. E., Abramowitz, J. S., Kozak, M. J., Levitt,
J. T., & Foa, E. B. (2000). Effectiveness of exposure
and ritual prevention for obsessive-compulsive disorder: Randomized compared with nonrandomized
samples. Journal of Consulting Clinical Psychology,
68, 594602.
Franklin, M. E., Flessner, C. A., Woods, D. W., Keuthen,
N. J., Piacentini, J. C., Moore, P. S., etal. (2008). The
child and adolescent trichotillomania impact project
239
(CA-TIP): Exploring descriptive psychopathology,
functional impairment, comorbidity, and treatment
utilization. Journal of Developmental and Behavioral
Pediatrics, 29, 493500.
Franklin, M. E., Zagrabbe, K., & Benavides, K. L. (2011).
Trichotillomania and its treatment: A review and recommendations. Expert Review of Neurotherapeutics,
11, 11651174.
Grant, J. E., & Odlaug, B. L. (2008). Clinical characteristics of trichotillomania with trichophagia. Comprehensive Psychiatry, 49, 579584.
Keuthen, N. J., Dougherty, D. D., Franklin, M. E., Bohne,
A., Loh, R., Levy, J., etal. (2004). Quality of life and
functional impairment in individuals with trichotillomania. The Journal of Applied Research, 4, 186197.
Keuthen, N. J., Rothbaum, B. O., Welch, S. S., Taylor, C.,
Falkenstein, M., Heekin, M., etal. (2010). Pilot trial
of dialectical behavior therapy-enhanced habit reversal for trichotillomania. Depression and Anxiety, 27,
953959.
King, R. A., Scahill, L., Vitulano, L. A., Schwab-Stone,
M., Tercyak, K. P., & Riddle, M. A. (1995). Childhood
trichotillomania: Clinical phenomenology, comorbidity, and family genetics. Journal of the American Academy of Child & Adolescent Psychiatry, 34,
14511459.
Lenane, M. C., Swedo, S. E., Rapoport, J. L., Leonard,
H., Sceery, W., & Guroff, J. J. (1992). Rates of obsessive compulsive disorder in first degree relatives of
patients with trichotillomania: A research note. Journal of Child Psychology and Psychiatry, 33, 925933.
Lerner, J., Franklin, M. E., Meadows, E. A., Hembree,
E., & Foa, E. B. (1998). Effectiveness of a cognitive
behavioral treatment program for trichotillomania:
An uncontrolled evaluation. Behavior Therapy, 29,
381395.
Lochner, C., Stein, D. J., Woods, D., Pauls, D. L., Franklin, M. E., Loerke, E. H., etal. (2011). The validity
of DSM-IV-TR criteria B and C of hair-pulling disorder (trichotillomania): Evidence from a clinical study.
Marcks, B. A., Wetterneck, C. T., & Woods, D. W. (2006).
Investigating healthcare providers knowledge about
trichotillomania and its treatment. Cognitive Behaviour Therapy, 35, 1927.
Marlatt, G. A., & Gordon, J. R. (1980). Determinants of
relapse: Implications for the maintenance of behavior
change. In P. O. Davidson & S. M. Davidson (Eds.),
Behavioral medicine: Changing health lifestyles
(pp.410452). New York: Brunner/Mazel.
Novak, C. E., Keuthen, N. J., Stewart, S. E., & Pauls, D.
L. (2009). A twin concordance study of trichotillomania. American Journal of Medical Genetics: Neuropsychiatric Genetics, 150B, 944949.
Rothbaum, B. O., & Ninan, P. T. (1994). The assessment
of trichotillomania. Behaviour Research and Therapy,
32, 651652.
P., Janavs, J., Weiller, E., etal. (1998). The miniinternational neuropsychiatric interview (M.I.N.I.):
240
The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10.
Journal of Clinical Psychiatry, 59, 2233.
Stein, D. J., Grant, J. E., Franklin, M. E., Keuthen, N.,
Lochner, C., Singer, H. S., etal. (2010). Trichotillomania (hair pulling disorder), skin picking disorder,
and stereotypic movement disorder: Toward DSM-V.
Thomsen, P. H., Torp, N. C., Dahl, K., Christensen, K.,
Englyst, I., Melin, K. H., etal. (2013). The Nordic
long-term OCD treatment study (NordLOTS): Rationale, design, and methods. Child and Adolescent Psychiatry and Mental Health, 7, 113.
Tolin, D. F., Franklin, M. E., Diefenbach, G. J., Anderson,
E., & Meunier, S. A. (2007). Pediatric trichotillomania: Descriptive psychopathology and an open trial
of cognitive-behavioral therapy. Cognitive Behaviour
Therapy, 36, 129144.
Torp, N. C., Dahl, K., Skarphedinsson, G., Thomsen, P.
H., Valderhaug, R., Weidle, B., etal. (2015). Effec-

tiveness of cognitive behavior treatment for pediatric
obsessive-compulsive disorder: Acute outcomes from
the Nordic long-term OCD treatment study (NordLOTS). Behaviour Research and Therapy, 64, 1523.
Walther, M. R., Ricketts, E. J., Conelea, C. A., & Woods,
D. W. (2010). Recent advances in the understanding
and treatment of trichotillomania. Journal of Cognitive Psychotherapy, 24, 4664.
Woods, D. W., Flessner, C. A., Franklin, M. E., Keuthen,
N. J., Goodwin, R. D., Stein, D. J., etal. (2006). The
trichotillomania impact project (TIP): Exploring
phenomenology, functional impairment, and treatment utilization. Journal of Clinical Psychology, 67,
18771888.
Zickgraf, H., Coogan, C., Dingfelder, H., Antinoro,
D., Morris, S., & Franklin, M. E. (in preparation).
Descriptive psychopathology: Youth with trichotillomania in a randomized, controlled intervention trial.
Child Psychiatry & Human Development.
Treatment of an Adult with

Hoarding Disorder
17
Jordana Muroff and Patty Underwood

Research Basis
Hoarding is a complex and impairing psychiatric
disorder as well as a public health problem. The
initial operational definition of hoarding was established by Frost and Hartl (1996) and, at that
time, it was commonly considered an obsessivecompulsive disorder (OCD) subtype. Over the
past decade, research has indicated that hoarding
and OCD are distinct but related disorders (Mataix-Cols etal. 2010; Pertusa etal. 2010). Accordingly, hoarding disorder (HD) was added as
a separate disorder to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association 2013) among the
OC spectrum disorders. HD is defined as persistent difficulty discarding and distress associated with parting with possessions regardless of
their value which leads to a cluttered living space
that cannot be fully utilized as intended (e.g., unable to sleep in bed, eat at a table). Uncluttered
living areas do not preclude HD if the space is
controlled and/or maintained by a third party
(e.g., family member, authorities). Furthermore,
cluttered environments that are secondary to
contamination fears (e.g., inhibiting contact with
J.Muroff()
Boston University School of Social Work, 264 Bay State
Road, Boston, MA 02215, USA
e-mail: jmuroff@bu.edu
P.Underwood
Riverside Community Care, Newton, MA, USA
objects) or repetitive checking behavior are to

be understood and managed as OCD symptoms,
not hoarding. Past or present excessive acquisition of free (e.g., giveaways, trash) or purchased
items is commonly associated with hoarding and
is included as a specifier in the DSM HD criteria.
Persons who hoard may have varying levels of
awareness and insight regarding their behavior
(Frost etal. 2010); insight (e.g., good, fair, poor)
is also included as a specifier in the DSM criteria.
The estimated prevalence of hoarding in community samples is 26% (Bulli etal. 2013; Iervolino etal. 2009; Mueller etal. 2009; Samuels
etal. 2008). Among OCD patients, approximately
25% have hoarding symptoms (Frost etal. 1996,
2000; Samuels etal. 2002), while 5% report severe symptoms (Mataix-Cols etal. 1999). In a
large HD sample, 18% also had coexisting OCD
(Frost etal. 2011). This is a higher rate of OCD
than in the general population; however, other
psychiatric conditions (as compared to OCD)
have higher rates of comorbidity with HD such
as major depression (51%), attention deficit hyperactivity disorder (ADHD), inattentive subtype
(ADHD inattentive, 28%), and social anxiety
(24%; Frost etal. 2011). Persons with HD have
higher rates of traumatic life events than those
with OCD, but rates of posttraumatic stress disorder (PTSD) are comparable (Cromer etal. 2007;
Frost etal. 2011; Landau etal. 2011; Tolin etal.
2010b). These findings also support the notion
that OCD and HD are separate but related disorders.

DOI 10.1007/978-3-319-17139-5_17
241
242
The average age of onset for hoarding is

1213 years old, and the course is chronic, with
elevated severity typically at age 40 and older
(Grisham etal. 2006; Tolin etal. 2010b). HD
seems to have a genetic component and can be
heritable; multiple members of a family may
hoard (Hirschtritt and Mathews 2013; Samuels
etal. 2002). The occupational, social, family and
community costs associated with hoarding also
appear to exceed those with OCD and other anxiety disorders (Frost etal. 2000; San Francisco
Task Force on Compulsive Hoarding 2009; Tolin
etal. 2008). Hoarding sufferers report substantial occupational impairment resembling severe
mental health (MH) problems such as bipolar
disorder and schizophrenia (Tolin etal. 2008).
Additional consequences of hoarding and the
cluttered living space include health code violations, tenancy problems (e.g., evictions), fall and
fire hazards, removal of dependents (children
and elders) from the home, and family discord;
in some cases, it can be life threatening (Harris
2010; Mataix-Cols etal. 2010; Tolin etal. 2008).
Multiple agencies and diverse personnel (e.g.,
public health workers, case managers, housing,
first responders, legal) are typically involved in
addressing hoarding.
Hoarding is challenging to treat. Despite an
early onset, hoarding sufferers do not typically
seek treatment until middle age (Grisham etal.
2006). Additionally, help seeking for hoarding is
more common among women (though HD occurs among men and women). Given the more
recent understanding that HD and OCD are distinct conditions, it is not surprising that earlier
research testing behavioral (e.g., exposure and
response prevention) and medication (e.g., serotonin reuptake inhibitors, SRIs) treatments,
which were effective for OCD, were associated with less favorable outcomes among those
with HD (Abramowitz etal. 2003; Pertusa etal.
2010). Steketee and Frost (2007) developed
a specialized CBT treatment for HD that has
shown promising results. The core components
of this manualized treatment include assessment,
psycho-education and case formulation, motivational enhancement, goal setting, skills training
(organizing, problem solving, decision making),
J. Muroff and P. Underwood
behavioral exposure practice for discarding and

non-acquisition, cognitive strategies to challenge
thoughts and beliefs, and relapse prevention.
This model has been tested in various formats
including individual (Tolin etal. 2007; Steketee
etal. 2010), group (Gilliam etal. 2011; Muroff
etal. 2009, 2012), online (Muroff etal. 2010), via
webcam (Muroff 2011), and self-help and support
group modalities (Frost etal. 2011, 2012) led by
clinicians and non-clinicians. Thus, over the past
decade, psychosocial treatment for hoarding has
evolved and demonstrated greater efficacy than
prior treatments.
The case study presented here focuses on individual CBT treatment for a woman with HD.

Jocelyn (pseudonym) is a 60-year-old single,
white female who lived alone in an urban, Section 8 apartment and was referred for hoarding
treatment by the state housing caseworker, with
whom she has been working for 4 years. In that
referral, the caseworker noted that Jocelyn had
successfully avoided eviction proceedings due
to the progress she had made with de-cluttering.
He reported that the Clutter Image Rating (CIR;
Frost etal. 2008) assessments of the rooms in her
apartment began at the severe end of the scale
(CIR=8), and based on the most recent visit, the
rooms are now at a CIR of 6. He stated that while
Jocelyn was not mandated into treatment at this
time, he believed she needed continued support
so that she could pass annual housing inspections and continue to make progress. He stated
that Jocelyns individual hoarding therapist, with
whom she had been working for the past 3 years,
recently moved away.
At the suggestion of the housing caseworker,
Jocelyn voluntarily followed up with her referral
at the community-based MH clinic seeking individual and group treatment for HD. She stated, I
need to get my life together, all the stuff I have and
the time I spend thinking about it is taking away
from really living. She reported difficulty managing her belongings that have resulted in a large
amount of clutter, causing her significant distress
17 Treatment of an Adult with Hoarding Disorder
and sometimes leading to relapse in sobriety or

triggering a deep depression. Jocelyn stated that
I cant find anything in my apartment and I
get so overwhelmed that I dont know where to
begin de-cluttering! She also reported that she
struggled with acquiring items she found on the
street (e.g., discarded furniture and household
items, newspapers) and at yard sales (e.g., clothing and accessories). While she knew that she did
not have the room for more stuff in her home, she
gave in to strong urges to acquire items. Jocelyn
also reported that she had trouble staying focused
on de-cluttering. She reported that it is the fear of
forgetting memories of her travels or time with
her mother that had made it difficult to let go of
many items in her home. In addition, she reported
that she avoided filing papers away, because she
believed that she would never find them.
Jocelyn pointed out that she had individual
and group treatment to help her maintain sobriety, process and cope with her trauma history, and
manage symptoms of depression. She was seeking to add specific hoarding-focused treatment to
help her progress in de-cluttering her home.
Case Information
Course of Hoarding Treatment
Jocelyn reported, I always had this clutter problem, but that it seemed to escalate when she
went into recovery 10 years ago. While she had
cluttered homes in the past, she either owned the
home or was renting and, therefore, was not having inspections (as is the case with the Section
8 certificate). As mentioned above, she first entered treatment when mandated by the state housing agency. Jocelyn reported being a difficult
client; feeling so humiliated and pressured, she
often acted out (i.e., drinking, cutting, cancelling
appointments), or her symptoms of depression
were triggered (e.g., fatigue, poor self-esteem,
isolation). She stated that it was her individual
hoarding-focused therapist who was able to help
her gain insight into the connection between her
hoarding problem and her trauma history. She
stated, It was the patience and kindness of [the
243
therapist] that seemed to be a turning point in my

recovery. In addition, Jocelyn reported that it
truly took a village to help me, stating that she
was working on multiple problems and there was
a team of people that worked together to support
my recovery.
Mental Health and Medication History

Jocelyn reported that she has a complex trauma
history which began as a young child. Her long
history of polysubstance abuse began in her teenage years. She reported two suicide attempts
one at age 6 when she took a whole bottle of
aspirin and the second at age 14 when she reported taking a whole bunch of reds and blues
(barbiturates). She reported suicidal ideation but
denied any intent or plan. Her first experience
with MH services was over 10 years ago when
she nearly died from an overdose of cocaine and
was hospitalized. At that point, she entered into
a detox program and then a halfway house, followed by moving into her sisters home. Jocelyn
relapsed, got into a serious car accident, and entered treatment againdetox, inpatient treatment
(for 1 year), and day treatment. After living in the
Section 8 apartment for approximately 1 year,
the annual inspection revealed a serious hoarding
problem (CIR=8), and Jocelyn reported that my
house was like those you see on the TV shows.
The state housing agency provided in-home support cleanout services and supported her efforts to
avoid eviction by connecting her with individual
counseling that focused on hoarding treatment.
Medical records show that Jocelyn has had
a variety of diagnoses, including polysubstance
abuse, major depressive disorder, ADHD, and
PTSD. There is also reportedly a history of cutting and trichotillomania. Her psychotropic medication regimen had changed over the past 10
years as her psychiatrist had worked to find the
most helpful combination. At the time of presentation, Jocelyn was taking the following psychotropic medications: fluoxetine 90mg, lorazapam
PRN 1mg, bupropion 200mg SR BID, risperidone 1mg (not taken regularly), methylphenidate
60mg.
244
Family History
Jocelyn was raised in a middle class family in a
suburb in the Northeast. Her mother died of cancer when Jocelyn was in her 40s. Her father remarried. Jocelyn reported there is a history of SA
and MH problems on both maternal and paternal
sides of the family and that she had a very poor
relationship with her mother and father for most
of her life. She has not spoken to her father in
more than 6 years. Jocelyn has two younger siblings, a brother and a sister, with whom she has
tenuous, distant relationships. She reports that
she has no knowledge of any MH or SA problems
with her siblings but also stated that her sister attends Al-Anon and was obviously affected by
our family dysfunction. Jocelyns siblings have
five grown children and four have MH struggles
(major depression and bipolar disorder).
Social Support
Prior to entering recovery, Jocelyn reported being
an outgoing person with many friendships, most
of which centered around drug use and other
risky behaviors (i.e., driving under the influence, DUI). After entering recovery, she reported
having fewer friends; most being peers from her
treatment groups or programs. She had many
providers with whom she reportedly felt overly
dependent on their support. Jocelyn stated that
while she wanted to have more social contact, her
cluttered home prohibited visitors, except those
people who were helping her clean and de-clutter.
History with Eviction (Legal)

Jocelyn was threatened with eviction 8 years ago
by the state housing court. She worked with the
housing caseworker until that threat of eviction
was lifted. She has a history of DUIs, but no current legal problems.
Employment and Education

Jocelyn went to a small progressive college in
Minnesota and graduated with a nursing degree.
She worked as a nurse in a variety of settings for 20

years. She had not worked for more than 10 years.
Mental Status
Jocelyn dressed in bohemian chic style. Her
hair was dyed red, and she wore make-up. She
made intermittent eye contact, looking down
often. She was fidgety and moved quickly, and
spoke fast and in spurts. At times, she stopped
herself mid-sentence with a self-loathing or
doubtful comment. Her mood was changeable,
sometimes down or anxious, other times cheery.
Her affect was often bright and friendly. Jocelyns
thoughts were predominantly negative, specifically self-loathing. She had obsessive thoughts
about holding onto her stuff or acquiring items
that she believes has intrinsic value Emotional.
She denied hallucinations or delusions. She had
developed very strong insight about her hoarding behaviors and negative thinking patterns. She
recognized that she can be impulsive and may use
poor judgment. Despite her good insight, Jocelyn
reported continued difficulty in finding the motivation and support needed to make progress.

Assessment
Jocelyns hoarding behavior may be understood
and illustrated through the general conceptual
model of hoarding (see Fig.17.1), which include
personal and family vulnerabilities, informationprocessing problems, beliefs about possessions,
emotional responses (positive and negative), and
learned behaviors (Steketee and Frost 2013a, b).
Vulnerability Factors
Jocelyn reported that her mother exhibited
hoarding behaviors stating, She held onto everything! Additionally, Jocelyns early trauma
history led to symptoms of PTSD, major depression, ADHD, and polysubstance abuse. The core
beliefs that developed are: I am unworthy, I
am not safe, I dont fit in anywhere, and I
am a bad person. Jocelyn recently reported that
245
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Fig. 17.1 Jocelyns hoarding model. PTSD posttraumatic stress disorder, ADHD attention deficit hyperactivity disorder
while she was outgoing for much of her younger

life, she believes that she used the drugs and alcohol to mask her anxiety when in social situations.
Meaning of Possessions
These vulnerability factors led to Jocelyns beliefs about herself (e.g., I am a bad person) and
attachment to the items she acquires and saves
(e.g., I need these accessories so I look together.). She sought to change her negative beliefs
and feelings about herself by acquiring and saving items that have intrinsic value (i.e., accessories, jewelry, and travel items), sentimental
value (i.e., travel items), or instrumental value
(i.e., information, newspapers). Jocelyn sought
to find happiness and safety in surrounding herself with these items that she found beautiful.
She saved newspapers, magazines, and books
due to anxiety about missing out on an opportunity to learn something that would help her
improve herself. She also saved household items
that had belonged to her late mother, in an effort
to preserve positive memories of her. Similarly,
she saved her travel items to remain connected to
an earlier period of her life and her identity as a
world traveler of which she was proud. Although

she was using during this time, she views those
years as a more functional, interesting part of her
life because she loves exploring art and cultures
around the world.
Information Processing Problems

Jocelyns most prominent ADHD symptoms included difficulty with focus, impulsivity, and
trouble with decision making and categorization.
She had concerns about her memory, so preferred
to keep items in view so they were visible and
she did not forget about them (e.g., she feared
filing papers). She also had difficulty labeling
file folders and creating categories for her filing
system that would be intuitive for her. Everyday
decisions (e.g., what clothing to wear) were challenging for her.
Emotional Reaction
Jocelyn experienced excitement and joy when
discovering a beautiful item on the street or at
a yard sale. She found happiness and comfort in
246
holding onto the accessories and household items

that provided enjoyment. Her beliefs related to
safety and worthlessness were associated with
negative emotions (e.g., shame and fear) which
led to her excessive acquiring and saving of
items, which relieved some of the negative emotions. Jocelyn also avoided filing papers away or
throwing out paper due to the fear of the loss of
potential information.
bedroom=7, kitchen=5, hallway=6, car=6).

Jocelyns baseline score on the SCI was 96 (very
similar to the average score of 95; Steketee and
Frost 2013a), with the subscales of emotional attachment being a little lower, memory being several points higher, and control and responsibility
each being very close to published mean scores
for those with HD. Her initial average rating on
the ADL-H was 2.4, classified as moderate.
Hoarding Behaviors
Jocelyns effort to seek positive emotions and

avoid negative emotions led to the hoarding behaviors of acquiring items on the street and at yard
sales, and the difficulty in discarding that which
made her feel happy and safe. These behaviors resulted in a substantial and disabling clutter.
This section provides an illustration of several cognitive behavioral strategies for hoarding described in Steketee and Frosts Therapist
Guide (2013a) and Client Workbook (2013b).
Refer to these resources for a more comprehensive understanding of the range of CBT strategies for hoarding and a detailed description of
each method. The CBT techniques portrayed are
aimed to address specific aspects of Jocelyns
personal hoarding model. While each CBT skill
is presented as distinct and the implementation
as linear, in practice, skills were more integrated
and were presented and reviewed multiple times.
This illustration reflects ongoing CBT treatment
for hoarding which spanned more than 26 sessions and included a case management component through housing services. Our main focus is
the treatment for HD, but, as described below, the
comorbid issues (e.g., SA, trauma) were primary
at various points of the clients life and treatment
and were relevant to understanding and treating
the hoarding.
Assessment
Jocelyn completed a number of hoarding assessments during her initial evaluation including: the
Hoarding Rating Scale (HRS; Tolin etal. 2010a,
2008), the Saving Inventory-Revised (SI-R;
Frost etal. 2004), the CIR, the Saving Cognition
Inventory (SCI; Steketee etal. 2003), and the Activities of Daily Living for Hoarding (ADL-H;
Frost etal. 2013). Her therapist and home-based
support persons completed the CIR during their
home visits, as well. Jocelyns pretreatment score
on the HRS was 27 (greater than the average
score of 24.22; Steketee and Frost 2013a). Her
scores on difficulty discarding (6) and interference (5) were above average. Her total score on
the SI-R was 79 (exceeding the average score of
62; Steketee and Frost 2013a); she reported elevated scores on all three subscales (clutter, difficulty discarding, and acquisition). Jocelyns
baseline CIR scores were: living room=5, bedroom=5, kitchen=4, hallway=4, and car=4. It is
important to note that Jocelyns current in-office
CIR rating was very similar, but not exactly the
same, as the therapist rating. These CIR scores
were an improvement from the period when she
was facing possible eviction (living room=8,
Building the CBT Model

In collaboration, the therapist and client developed a cognitive behavioral conceptual working model to gain a greater understanding of the
development and the continuation of the clients
hoarding behavior within their lifes context.
While a couple of sessions were used to draft
the model, its development has been ongoing as
new information was learned, added, and revised.
This dynamic document was utilized throughout
treatment. As seen in Fig.17.1, Jocelyn and the

therapist drew the components of the model, noting specific relevant factors associated with saving, acquiring, and clutter (described in the case
information and conceptualization). Throughout
her treatment, her in-home supports and other
providers also helped the client fill-in her model.
Furthermore, as specific CBT techniques were
introduced and practiced, the therapist would
describe their relevance and connect them to the
hoarding model.
An important aspect of building the model
with Jocelyn was helping her explore factors
contributing to the hoarding, while maintaining
her focus and pacing the process so as to lessen
the likelihood of her becoming overwhelmed and
highly self-critical. This was especially important when exploring specific vulnerabilities that
predisposed Jocelyn to her hoarding problems
such as her trauma history, which she described is
part of her daily experiences. Additionally, when
conducting the hoarding interview and working
on the model, the therapist would ask structured
questions. The therapist also guided the clients
responses so that she would not recount all the
details associated with a past trauma or event
but rather help the client take some distance
from the problem and assume the role of an observer, detective, and collaborator. For example,
the therapist helped the client discuss how her
hoarding behaviors were connected to her adverse life events and family history among other
vulnerabilities. Jocelyn described how her hoarding worsened her depression, and her struggles
with depression also exacerbated her hoarding
behaviors. She also identified her past SA and
hoarding as a way she coped with her trauma, as
both provided escapes but also trapped her.
Jocelyn identified her problems with cognitive
processing and executive functioning. For example, she reported difficulties with doubting
her memory (If I put it away, I wont remember
where I put it.), indecisiveness (I am not sure
which scarf to wear.), inattention (I was in the
living room sorting papers for a few minutes and
then found myself in the kitchen.), categorization (Does the automobile body shop bill belong
in the automobile folder or insurance folder?),
247
and problem solving. The clients responses to

the SCI during the initial assessments revealed
the meanings that the client is attached to her
possessions. She was concerned about discarding
or filing items for fear that she would forget the
item or memories associated with them (e.g., her
mothers household items, travels) or be unable
to find information that she needs. Additionally,
acquiring accessories was linked to her belief that
she must always look together. These beliefs
also reflected strengths (e.g., creative, intelligent, curious, compassionate). Jocelyn identified
positive (e.g., excitement, comfort) and negative
(e.g., fear, shame) emotions that reinforced her
hoarding behaviors. Jocelyn often discussed specific thoughts (e.g., my stuff keeps me safe)
associated with emotions (e.g., fears) that reinforced her saving and acquiring behaviors.
Starting early in treatment while Jocelyn was
drafting her model, the therapist introduced her
to the Brief Thought Record. The therapist gave
a couple of examples of what information fits in
each column and then led the client to identify an
actual recent situation from her own life. Jocelyn
used the Brief Thought Record to observe her
own thoughts, emotional reactions, and behaviors during a sorting session or acquisition episode and made additions to her hoarding model.
Table17.1 illustrates one of her completed Brief
Thought Records, whereby Jocelyn described
an intense emotional response related to finding
a lamp sticking out of a dumpster a day earlier.
While completing the columns, the client linked
her response to the lamp and other items in the
hallway to her childhood trauma, noting that it
all goes back to [name]. The therapist validated the clients thoughts and emotional response
while directing her back to the Brief Thought Record exercise to help her focus on and organize
her thoughts triggered by lamp.
Enhancing Motivation
Jocelyn recalled struggling since early adulthood with hoarding behaviors and limited insight prior to treatment. She described years of
being frozen inside her house. Jocelyns first
248
Table 17.1 Jocelyns brief thought record

Situation
Automatic thought
Picking stuff out of the dump- This is really unique
ster (lamp)
I will never find anything like that
again
Its in good shape
Someone else is going to take this if
I dont
Looking at the lamp and other Im so stupid! Look at all this stuff
possessions in the hallway
that I havent brought into the house
yet. Whats wrong with me?
In bed
I really need a drink. I cant tolerate

this feeling. Im never going to get
better
Ive been in this place before, and I
need to call my sponsor
Im trying to take care of myself and
do the right thing
Emotions
Excited
Puts it in hallway outside

her door
Lucky
Anxious
Shame
Guilt
Frustration
Self-loathing
Leave it there and get into

bed to sleep (escape under
the covers)
Fights off urges to drink
Hopeless
Slight hope
A little relief
acknowledgment that her hoarding behavior was

problematic was mainly tied to external consequences; that is, receiving an eviction notice
from her landlord and being mandated to treatment to keep her housing. She did not want to
be homeless again. She continued in treatment
voluntarily but experienced regular inspections,
per procedures for all housing residents. Jocelyn
rated the importance of working on addressing
her hoarding as high (an 8 on a scale of 0 no
importance to 10 extremely important); however, she rated her confidence in her ability to
do so as 3 (0=no confidence to 10 maximum
confidence). Thus, it was essential to help Jocelyn recognize and draw on her strengths, develop
skills, and highlight self-efficacy.
Jocelyn completed the advantages/disadvantages worksheet to explore her ambivalence
about addressing this problem and better understand her goals and values (see Table17.2). It
was essential to acknowledge both the costs and
benefits of her behavior and normalize her ambivalence. For example, Jocelyn revealed that
she wanted her possessions around her because
they make me feel safe. However, she did not
want them around because I cant find the insur-
Behavior
Takes it home
Adheres to her coping plan

and calls the sponsor
ance and housing paperwork that I need. Past

signals of ambivalence also included her cancelling inspection appointments. The unwanted consequences were that the inspector sent an eviction
notice and began unscheduled visits. The therapist worked with Jocelyn to discuss her feeling
related to the inspections (e.g., humiliattion, fear,
lack of control) and problem-solve how to make
them more tolerable (e.g., have a clinician or
in-home person present; working with in-home
coach days prior, stress reduction technique). The
client decided that if the inspections were scheduled in the afternoon and her coach was present,
then she would not cancel. She role-played communicating this to the inspector.
The two visualization exercises shown below
were used to further examine Jocelyns motivation and goals for treatment and clarify aspects of the model. In the clutter visualization
(Table17.3), the client was asked to visualize the
current clutter in a room in her home and identify her thoughts and emotions. This exercise revealed the deep shame she experiences related to
her hoarding behavior and feeling overwhelmed
about how to address it. Through the unclutter visualization, she imagined the same room without
249
Table 17.2 Jocelyns advantages and disadvantages of hoarding

Advantages (benefits)
Disadvantages (costs)
Of keeping
Make me feel safe
Housing problems
I dont have to make hard decisions
Difficulty finding things
Makes me anxious to even think about letting anything go
Isolationnot being able to have people over and
entertain
Keeps me connected to my providers (I kind of save them too) Not having space to display my treasures
Ill know I have the papers and info that I need
Taking up too much of my timelittle time for
other things like volunteering, getting a job
Keeps my memories alive from my traveling days
Makes me anxious to have so much stuff
Stuff is everywhere and I cant clean up
Of acquiring:
Distraction from the drinking
Too much stuffI have nowhere to put all of it
Improves my moodin the moment
Risk of bringing in bugs, pests
Feels good to find unique items
My landlord is on my back
Stuff is free
Shame and frustration with myself afterwards
Satisfies urges
Of getting rid of items:
Will have more room to display the items I have gotten during I may lose some important information
my travels
Will make things more manageable and that will calm my
My stuff is uniqueI will never find the items
nerves
again
Will have more space in my life for other things
My home will look sterileit wont feel cozy
Will be easier to organize my stuff
It will be painful to give up my possessions
the clutter and recorded her thoughts and emotions about removing and/or organizing possessions in her home. This exercise revealed her
fears about items being out of sight and the discomfort and vulnerability she experienced when
in open space. While she expressed the relief of
being free of her landlords threats and inspections, she also revealed her attachment and dependency on her providers for support and social
contact. The secondary gain of maintaining her
hoarding symptoms may be the desired contact
with specific providers; improvement would reduce the need for contact and threaten that attachment. This highlighted the need to expand
her social network and incorporate these triggers
into her treatment.
The therapist was able to make a visit to Jocelyns home whereby the client identified specific
areas (e.g., office area, hallway, and living room)
and items (e.g., papers, clothes, household items,
and furniture) that she was motivated to work on.
The therapist and client worked together to maximize motivation and progress while prioritizing safety violations. For example, Jocelyn had
boxes stacked with teapots (many of which had

been her mothers) near her fire exit. She wanted
to display the teapots but did not have available
shelves yet. Because Jocelyn was profoundly attached to the teapots (see Tables17.4), it was too
difficult for her to engage in sorting these items
at that stage of treatment; thus, the boxes were labelled and moved so they were no longer a safety
concern and could be sorted at a later date.
While Jocelyn expressed being highly motivated to curb the inspections and get her life
back, she struggled with fluctuating motivation,
common in HD.
Planning Treatment
The motivation enhancement exercises helped
Jocelyn and the client establish the goals and
treatment plan. Jocelyn identified the following
treatment goals:
1. Continue to work toward housing requirements: To reduce clutter from CIR=5 to 3
(regular inspections)
250
Table 17.3 Clutter visualization form (Steketee and Frost 2013b, p.44)
Room: living room
Visualize this room with all of its present clutter. Imagine standing in the middle of the room slowly turning to see
all the clutter
How uncomfortable did you feel while imagining this room with all the clutter? Use a scale from 0 to 100, where
0=no discomfort and 100=the most discomfort you have ever felt
Initial discomfort rating? 50
What feelings were you having while visualizing this room?
Shame, embarrassment, irritability, frustration
What thoughts (beliefs, attitudes) were you having while visualizing this room?
Whats wrong with me? Why cant I fix this?
Im so disorganized. Im such a piece of sh*t
I cant deal with this. This is too much. I dont know where to begin
Unclutter visualization form (Steketee and Frost 2013b, p.45)
Visualize this room with the clutter gone. Imagine that all the items are in a place where you can find them, and
picture cleared surfaces and floors, tabletops without piles, and uncluttered floors with only rugs and furniture
How uncomfortable did you feel while imagining this room without all the clutter? Use a scale from 0 to 100, where
0=no discomfort and 100=the most discomfort you have ever felt
Initial discomfort rating: 50
What thoughts and feelings were you having while visualizing this room?
Feelings: anxious, proud, scared, excitement, loneliness
Thoughts
Am I going to be able to find things?
No one is going to come in to help me anymore, now that its all cleaned
This doesnt feel safeit feels too open. Im not used to this
My landlord will get off my back. I wont have to deal with those inspections anymore
Imagine what you can do in this room now that it is not cluttered. Describe your thoughts and feelings
I could have friends over to entertain
When my brother visits, it wouldnt be such a big deal
Know where to go to get paperwork
Display travel relics
Final discomfort rating: 45
2. To have a living room where I am able to have

people over and entertain
3. To display my collections from my travel
4. To set up organization systems (clothes and
paper) in my bedroom and desk area
5. To clear out car so I can give others rides
6. To reduce acquiring (newspapers/pamphlets,
move outsfurniture)
7. To break free from my stuff and develop an
independent sense of self-separate from items
(if 100% better who will I be); to be more in
touch with the me who has travelled, been a
nurse, etc.
8. To build self-esteem so I can feel more confidence in managing my MH; to learn other
coping skills and ways to take care of myself
(e.g., relaxation/ meditation; CBT)
9. To gain independence from providers shift

and focused support
An additional goal was to make some changes
in her treatment team (e.g., reduce frequency of
office visits with providers) to enhance her independence as well as increase the home-based
progress with reducing clutter. Jocelyn had an
individual therapist and support group to support her SA recovery, a housing case manager, an
individual provider to address the hoarding, and
eventually an in-home hoarding coach. The role
of the in-home coach was to help Jocelyn transfer the techniques and skills learned in her officebased sessions to her home. A central component
of the treatment for HD empowers the client to
apply and practice the skills and techniques between sessions.
251
Table 17.4 Jocelyns exposure hierarchy for discarding

General
10
9
8
7
6
5
3
2
Specific to paper
10
9
9
8
8
7
6
5
4
4
3
3
2
Gifts given to her by her mom

Travel items (baskets, figurines)
Accessories (scarfs, jewelry)
Unique household items (teapot)
Newspapers, magazines, articles, pamphlets (information)
Furniture
Bags and boxes
Containers
Cards (personal correspondence)
Housing paperwork
Financial and insurance papers
Newspapers not read (completely)
Business cards
Bills
Travel magazines
Fashion magazines
Pamphlets about mental health
Pamphlets about medical health
Articles related to healthcare
Catalogues
Junk mail (postcards for events, services; donations; credit card applications)
Reducing Acquiring Disadvantages

of Change
As noted, one of Jocelyns goals was to reduce
her excessive acquisition, mainly of free things.
Specifically, she acquired furniture and unique
household items off the street or at secondhand
stores; scarves and jewelry were purchased at tag
sales and secondhand stores; and newspapers,
magazines, and pamphlets were obtained from
others recycling. Jocelyn had not been successful
in merely avoiding her urges and triggers. She attempted to set up specific rules for herself around
acquiring (e.g., not acquiring furniture that did
not fit into her home; possessing a maximum of
ten scarves; cancelling newspaper and magazine
subscriptions). Non-acquiring practice was also
essential to help Jocelyn tolerate her urges and
associated discomfort. She developed her nonacquiring hierarchy by assigning discomfort ratings (010; 0=no discomfort and 10=maximum
discomfort) to items that she typically acquired;
for example, accessories were rated as 10, unique
household items as 7, furniture items as 5, and
newspapers as 4. A list of potential exposure

practice exercises was generated. An example of
a practice non-acquisition hierarchy for furniture
is shown (Table17.5). These exercises were first
completed with the therapist present and then repeated between sessions with a coach and then
independently. Over time she was able to tolerate
discomfort using healthy coping methods (e.g.,
calling a friend, using deep breathing).
In addition to exposure methods, cognitive
therapy was used to help Jocelyn reduce her negative problematic thinking related to her acquiring. For example, she came to recognize her unhelpful patterns of thinking (using the problematic think styles list; Steketee and Frost 2013a, b)
such as black-and-white and catastrophic think
(If I dont get the lamp, I will never find another
one like that. I will regret it forever.). She also
tended to discount positives and was very selfcritical; for example, when she did not acquire a
pretty breadbox, she remarked, Thats nothing
compared to all I still need to do. She used emotional reasoning and her desire to feel better overpowered her rational thinking, This scarf makes
252
Table 17.5 Jocelyns exposure hierarchy for non-acquisition practice

Anxiety rating Exposure activity
10
Drives around on Tuesdaytrash day. Notes furniture items that she would like to acquire. Stops
the car, gets out, and closely examines the item but then leaves it there and continues driving without taking it with her
8
Drives around on Tuesdaytrash day. Notes furniture items that she would like to acquire. Stops
the car and observes the item but leaves it there and continues driving without taking it with her
6
Drives around on Tuesdaytrash day. Notes furniture items that she would like to acquire but
continues driving without stopping to look at the item
5
Visualization of driving around on Tuesday trash day and finding a unique chair that she would like
to acquire and imagining herself driving past it without stopping
4
Drives around on Wednesday (not trash day) and observes what is out but continues to drive
me happy, so I should get it. She explored the

distinction between what she truly needed for
survival and what she wanted. This exercise also
helped her identify her emotional needs for more
joy and companionship in her life.
Jocelyn experienced intense joy when acquiring items. She equated the pleasure she experienced from acquiring to the high she experienced from drugs and alcohol in the past. She described acquiring as a quick fix when my mood
is low. In the moment, the pleasure relieved her
negative beliefs about herself and distracted her
from her daily thoughts and images associated
with past traumas. As noted in the advantages/
disadvantages exercise, the pleasure associated
with acquiring was quickly replaced by guilt and
shame. However, Jocelyn had difficulty identifying alternative pleasurable activities. Many years
of her life had included turning to drugs and alcohol as a pleasurable activity. As part of her
recovery process, she had filled her life with
regular appointments with providers; this was her
main method of coping. On the one hand, Jocelyn
made great strides in her recovery with the support of these providers; however, it also fostered
a more dependent relationship whereby she attributed her successes to the providers instead of
her own strengths and skills. Additionally, she
tended to seek out activities that focused on caring for others such as volunteering at the senior
center or animal rescue league. While these activities were rewarding, they may have served as
a distraction from focusing and caring for herself. The therapist and Jocelyn worked together
to schedule pleasant activities that were focused
on her growth and independence such as painting, yoga, and meditation, and meeting new people by attending a walking meet up and other
meet ups.
Skills Training
Jocelyn worked on gaining skills in organizing,
problem solving, and being able to sustain her
focus on sorting as well as her overall goals. She
worked with the therapist to establish specific
sorting rules and schedules (Table17.6). It was
also critical to help her develop filing categories and an organizational plan that was intuitive
Table 17.6 Jocelyns sorting rules and schedules

Set number of scarves to 10 (if any more come in, others need to leave)
Newspapers and magazines older than 2009 (automatic discard without reviewing first)
Mail brought into home is sorted at mail sorting station with recycle, folders for bills, etc.
Business cards go into binder
Articles about travels and spirituality/yoga/mindfulness are to be pulled out and filed if kept (the rest of the magazine is to be discarded)
In-home sorting practice on Monday, Wednesday, and Friday 111
Car-sorting practice on Tuesday 1112 (before going to group)
Trash and recycle goes out on Monday night (for Tuesday pickup)
Laundry scheduled on Saturdays
to her, especially given her fears with putting

her items away (e.g., out of sight) because she
doubted her ability to remember where she put
them. While she made progress with developing
a paper sorting system, she often had difficulty
putting the pile of sorted paper in the designated
place. She created an interim space (a labelled
cardboard box with hanging files that sat next to
the filing cabinet in the living room) so she could
file the sorted piles of papers. She also sorted the
contents of the filing cabinet to avail space so
that it could serve as the destination for the newly
developed filing system (temporarily in the box).
She applied problem-solving and organizational
skills by developing a mail station (the buffet behind the couch) for organizing her bills to enable
her to pay her utility bills on time. She applied the
rules for keeping paper (see Steketee and Frost
2007). To help her focus her attention on a sorting task, she listened to music using the length
of the song to delineate time and also relax. She
would sort for the length of a song or two and
not feel badly about stopping and taking a break
after that. She preferred this method to setting
a timer for 15min. She would drape a sheet to
cover adjacent piles in order to stay focused on
the pile that she was sorting. A hula hoop or jump
rope was sometimes used to designate a specific
area for sorting. She also began to learn mindfulness exercises to stay centered during the sorting
tasks. Finally, Jocelyn learned how to use a task
list and calendar to record homework, breaking
down, and noting the smaller steps for a particular task, etc.
253
Exposure
Jocelyn used exposure methods to confront her
long-term fears and avoidances associated with
hoarding. During the initial home visit, she had
identified the specific target area in her home to
begin sorting (i.e., the office area), what items
were in that area, final locations for kept items,
and preparations for sorting (e.g., boxes, markers for labels). She utilized a general exposure
hierarchy and a specific paper hierarchy (e.g., list
of possessions that are ranked easiest to hardest
with regard to discarding; Tables17.4) to organize her exposure practice.
Jocelyn brought in items from home to her sessions to sort and practiced these skills at home,
as well. The therapist and client worked on sorting items that were more moderate levels (34s;
on a scale of 0=no discomfort to 10=maximum
discomfort) to start. At home, Jocelyn sorted her
possessions (e.g., medley of paper, travel items,
clothes, magazines) while sitting on the couch
and using her coffee table as her staging area.
She used four labeled boxes, Keep/put away,
Discard, Trash, and Undecided (a temporary category, to be decided prior to the end of session).
She utilized a number of questions about possessions when sorting (Table17.7). She found it particularly helpful to have in-home support to help
her transfer the skills she learned in treatment to
the home and help her stay focused. One in-home
coach showed her that she could access online articles from her favorite magazines as well as her
cable/phone bills, enabling her to discard a pile
of them. Additionally, upon discovering that an
electronic store would take her old electronics and
wires, she was able to let them go and drop them
off at the store. After deciding to donate several
Table 17.7 Jocelyns questions about possessions and for acquiring

Do I have a specific plan to use this item in a reasonable time frame?
How does this compare to the things I value highly?
Does this just seem important because I am looking at it now?
Is it of good quality, accurate, and/or reliable?
Would I buy it again if I didnt already own it?
Do I really need it?
Could I get it again, if I found that I really needed it?
Do I have enough space for it?
Will not having this help me solve my hoarding problem?
254
bags of clothes, Jocelyn would put the bags into

her car to take to Goodwill. It was important that
she scheduled a specific time when she would
drop off the bags; otherwise, they would sometimes remain in her car for long periods of time.
Jocelyn used behavior experiments to test her
hypotheses and beliefs about discarding her possessions. One example of this strategy focused
on her furniture which was especially problematic because of their large size and presence in
the building hallway, a public space next to the
stairs and a tripping hazard. Typically, she would
move them when an inspection was imminent or
an inspector noted a safety concern. Her prediction was that If I get rid of the chair, I will miss
it and really regret it, and have trouble sleeping.
If I get too upset I may spiral and drink. She
then rated how strongly she believed that her prediction would happen from 0 to 100% (If I get
rid of the chair, I will miss it (90%) and really
regret it (70%), have trouble sleeping (60%). If
I get too upset I may spiral and drink (70%).
She then donated the chair to Goodwill, with her
initial discomfort level at 80%. She spent that
day wishing I could get it back, feeling anxious
and ruminating about it. She described that she
actually slept pretty well that night. The next
day she described that an inspector called, and
she was preoccupied with the upcoming inspection. She described that her discomfort rating was
lower, about a 40%. By the third day, she rated
her discomfort as a 10%. She noted that while
she was initially upset about the chair, it was not
as intense as she predicted and the discomfort
lasted less time than she had anticipated (3 days
vs. months). Her conclusion was that it was very

hard for her to let go of the chair but her first priority needs to be her housing.
Cognitive Therapy
Jocelyn also used cognitive strategies to help her
identify and modify thoughts related to her hoarding behaviors. Earlier we discussed the Brief
Thought Record as a tool to observe her thoughts,
emotions, and behaviors as well as identify
thoughts relevant to acquiring. It was especially
important to integrate these cognitive techniques
with the skills training and behavioral techniques.
Jocelyn found these strategies more meaningful
when their relevance was directly tied to her behavior. She often labelled herself as stupid or a
piece of sh*t. Her thoughts reflected additional
problematic thinking styles such as emotional reasoning (It feels good to have these things from
my travels, so I should keep them.; I cant file
these papers because it makes me feel uncomfortable.), catastrophizing (I am never going to be
able to find what I need later.), and should statements (I should keep it; why should I have to buy
this again one day?). She also underestimated
her ability to cope with empty space (availed as a
result of her de-cluttering efforts).
Jocelyns negative core beliefs about herself
were activated frequently during treatment. The
cognitive tool called the downward arrow was
used, applying a series of questions to uncover
her core beliefs and schema. Table17.8 illustrates
Jocelyns core beliefs that were activated when
Table 17.8 Jocelyns downward arrow

So what comes to mind when you look at this wicker chair and think about getting rid of it?
I dont want to get rid of this. I like it. Its in good shape
What would it mean to you to get rid of this?
Well, I know I have no room in the hallway. But, I can imagine fixing it up and putting it into my apartment. Its my
style
If you got rid of this what would happen?
I would be really upset, because it would mean that I didnt fix it up
If that were true, and you didnt fix it up, what does that mean about you?
It means that I cant get my life together enough to make the time, effort, and space to get it into my apartment
where I know it would look good
What does that mean about you?
I am just no good. I am worthless
making a decision about a wicker chair in the hallway outside her apartment. Her other commonly
expressed beliefs included I dont deserve to be
happy and The world is unsafe. She had spent
much of her life avoiding and masking her negative emotions and self-loathing with drugs, alcohol, and other maladaptive behaviors. While she
found it challenging to come up with alternative
interpretations to hoarding related situations, she
preferred using a behavioral approach to serve as
evidence to counter her negative thinking. She
tried out activities like mindfulness that made her
feel more competent and served as evidence that
she can manage strong emotions more than she
anticipates. She would cheer herself on to push
through [the negative thoughts and emotions].
Assessment
The hoarding assessments were repeated at the
end of treatment, approximately 1 year later.
Scores on the HRS total decreased from 27 to 19
(30% improvement). Her SIR scores improved
from 79 to 50 (37% improvement). Additionally,
Jocelyns SCI posttreatment score of 80 shows
a 15-point improvement and her posttreatment
ADL-H score fell 4 points to 2.0, within the mild
range. This level of improvement is consistent
with outcomes associated with individual CBT
for hoarding as described in the literature (Steketee etal. 2010; Tolin etal. 2007). Additionally,
she had preserved her tenancy and planned to
continue to address her hoarding by attending a
support group and continuing to work with an inhome coach.
A range of complicating factors may affect those
with hoarding such as coexisting MH and physical health problems, concerns related to the physical environment and safety, limited finances and
resources, as well as family burden or patterns
of hoarding (Bratiotis etal. 2011; Steketee and
Frost 2013a).
As mentioned earlier, Jocelyn had comorbid
problems such as SA, PTSD, major depressive
255
disorder, and ADHD. The symptoms associated

with these disorders can present complicating
factors and barriers to the treatment of HD. Importantly, Jocelyns efforts to focus on the treatment of HD sometimes needed to be paused as
she focused on SA treatment and/or PTSD treatment. The clinician frequently collaborated with
Jocelyn and her other providers in order to decide
when the hoarding treatment became secondary
to these other presenting problems.
Jocelyn often stated that she viewed her hoarding behaviors and SA similarly, both maladaptive
ways to avoid the uncomfortable emotions that
are associated with her trauma history. In collaboration, providers worked together with Jocelyn
to develop safety plans and coping skills that Jocelyn could utilize to minimize distress that lead
to urges. For example, Jocelyn was engaged in
learning mindfulness skills that included meditation, progressive relaxation, and mindful eating
and walking practices. She and her in-home provider would do a breathing practice about every
15min during the in-home sorting sessions as a
way to help her stay grounded and remain within her window of tolerance.
Jocelyn also reported that her depression
symptoms were unpredictable and debilitating,
leaving her unable to get out of bed, take a shower, do laundry, and hopeless about ever leading a
life of pleasure, productivity, and peace. Through
years of CBT treatment for depression, she had
learned to fight against the urge to stay in bed all
day, and instead, get up, take a shower, and get
to her therapy appointments. She is also learning
to allow herself to take a break from the sorting
sessions associated with de-cluttering her home
when her symptoms of depression hit a low point.
Jocelyn reported that her inattention, distractibility, impulsivity, and difficulty with focus and
concentration challenged her ability to sort. She
asserted that in home support is critical to her
maintaining focus and making progress with decluttering. As mentioned above, she also utilized
a timer set at 15-min increments and employed
methods to control her visual field (e.g., using
sheets to cover items that are not part of the target
area, as a way of reducing distraction).
Jocelyns early childhood traumatic experiences led to the development of strong nega-
256
tive core beliefs (e.g., I am unworthy, I am

unsafe) and associated negative emotions (e.g.,
shame, fear) that when activated led to increased
avoidance and undermined her ability to address
her hoarding behaviors. Cognitive strategies such
as Socratic questions and the downward arrow
were utilized to address these beliefs.

This case example of Jocelyn illustrates the manifestations and course of hoarding, as well as the
specialized CBT strategies for hoarding delivered in a community MH clinic. She developed
her own personal hoarding model to better understand factors contributing to the development
and persistence of her hoarding behaviors (e.g.,
saving paper, acquiring household items, clutter sprawling into the hallway outside her apartment) and referring to it throughout treatment.
Her treatment goals included de-cluttering so
she could entertain friends at her home, passing
her housing inspections, and developing other
healthy coping mechanisms. Jocelyns motivation wavered between the desire to improve her
living environment, feeling overwhelmed, and
fears and distress associated with letting go of
her possessions. She and the therapist engaged
in motivational enhancement strategies such as
examining the advantages and disadvantages of
saving, acquiring, and discarding items in addition to visualizing her living room cluttered
(current state) as well as free from clutter. Her
non-acquisition practice focused on not acquiring free furniture, household items, and/or buying accessories (e.g., scarves). She learned
problem-solving, organizational, and sorting
skills; for example, developing a mail station, a
paper-sorting system and specific strategies for
managing attention and distraction and demarcating time (e.g., sorting for the length of a song).
She developed an exposure hierarchy, identifying
items from her late mother, travel souvenirs, accessories and unique household items as most
challenging to discard, and containers, bags and
boxes being less challenging to discard. Jocelyn
applied various cognitive strategies, using Brief
Thought Records to identify those thoughts (If I

throw away my souvenirs from my travels I will
forget that part of my life.) that were associated
with strong emotions (e.g., anxiety), recognize
problematic thinking styles that contributed to
her hoarding behavior (e.g., fortune telling),
and develop alternative thoughts (I have other
items that remind me of my travels that take up
less room), as well as applying the downward
arrow to uncover activated negative core beliefs
(e.g., I am worthless.). These cognitive strategies addressed Jocelyns hoarding beliefs that
were related to her traumatic early life events.
Because her saving and acquiring were reinforced by the positive emotions (e.g., excitement,
comfort) and avoidance of negative emotions
(e.g., shame, fear), it was also very important
for Jocelyn to schedule other healthy pleasurable
activities that served as replacement behaviors.
Pleasant activity scheduling was also important
to her ongoing recovery from using alcohol and
drugs, and may reduce her dependency on providers, as they made up the majority of her social
contact.
As discussed, Jocelyns process of managing her hoarding symptoms was ongoing, with
periods of improvement and lapses. Although
the CBT treatment for hoarding is a 26-session weekly manualized protocol, her treatment
spanned a longer duration due to the complexities involving the comorbidities, wavering motivation and ambivalence, etc.; Jocelyn developed
considerable insight during treatment. Those
with hoarding often demonstrate limited insight
either due to perceiving that their behavior is
not excessive (Tolin etal. 2010a) or reacting defensively (which could present similarly to limited insight; Frost etal. 2010). Motivation may
waver and ambivalence is common, even among
those who voluntarily seek services. In addition
to CBT treatment, Jocelyn also received housing
and in-home services to assist her in addressing
her hoarding, at various points. Jocelyns voice
echoes others who have identified home-based
assistance with a non-judgmental clinician and/or
other human service personnel as crucial to their
ability to transfer skills from office-based treatment to the home environment, enhance focus
257
Table 17.9 Key points

CBT for hoarding features a multicomponent approach aimed to develop a case formulation, reduce saving, acquiring and associated clutter, develop skills (e.g., decision making, organizing, problem solving), enhance motivation,
and modify problematic cognitions
A vital aspect of treatment is the formation of the personal hoarding model, to better understand factors contributing
to the development and persistence of ones hoarding behaviors.
The core components of the hoarding model include personal and family vulnerabilities, information-processing
problems, beliefs about possessions, emotional responses (positive and negative), and learned behaviors (Steketee
and Frost 2013a, b)
Collaboration between hoarding sufferers and a range of human service providers seems especially important for
this complex psychiatric and public health problem
when sorting possessions, and address their complex, multifaceted needs to facilitate progress.
Jocelyn and other hoarding sufferers experience
much shame and fear; thus, successful strategies
for coaching include a non-judgmental stance,
supporting decision making (in contrast making decisions for the person), being emotionally
supportive (not a taskmaster, argumentative, demanding), and only handling items with permission (see Steketee and Frost 2013a).
While CBT-based interventions for hoarding
have shown promising outcomes, many clients
(such as Jocelyn) continue to be functionally impaired and have not reached remission. Further
treatment development is needed to maximize
outcomes, durability of improvement, and increase rates of remission. Collaboration across
human service providers (e.g., MH providers,
case managers, housing, public health, protective
services) as well as in-home assistance seems especially relevant for this home-based problem
in order to maximize resources and address the
range and complexity of the psychosocial needs
and comorbidities common among hoarding sufferers. Additional research is needed to examine
the role of non-clinicians in providing homebased comprehensive interventions prior to, in
addition to, or stand alone from CBT treatment
for hoarding (Muroff 2014). Future studies may
also examine varying non-clinician roles (e.g.,
peer) and training that are associated with the
greatest improvement (Frost etal. 2012) and are
most cost-effective.
This case example sheds light on the course,
manifestations, treatment, and collaborations relevant to Jocelyns HD and the many others who
suffer openly or behind closed doors (Table17.9).
References
Furr, J. M. (2003). Symptom presentation and outcome of cognitive behavior therapy for obsessive
compulsive disorder. Journal of Consulting and Clinical Psychology, 71, 10491057.
Washington, DC: American Psychiatric Publishing.
Bratiotis, B., Sorrentino Schmalisch, C., & Stekete, G.
(2011). The hoarding handbook: A guide for human
service professionals. New York: Oxford.
Bulli, F., Melli, G., Sara, M., Carraresi, C., Stopani, E.,
Pertusa, A., etal. (2013). Hoarding behaviour in an
Italian non-clinical sample. Behavioural and Cognitive Psychotherapy, 41, 115.
Cromer, K. R., Schmidt, N. B., & Murphy, D. L. (2007).
Do traumatic events influence the clinical expression
of compulsive hoarding? Behaviour Research and
Therapy, 45(11), 25812592.
Frost, R. O., & Hartl, T. L. (1996). A cognitive-behavioral
model of compulsive hoarding. Behavior Research
and Therapy, 34(4), 341350.
Frost, R. O., Krause, M. S., & Steketee, G. (1996). Hoarding and obsessive-compulsive symptoms. Behavior
Modification, 20(1), 116132.
Frost, R. O., Steketee, G., & Williams, L. (2000). Hoarding: A community health problem. Health & Social
Care in the Community, 8(4), 229234.
Frost, R. O., Steketee, G., & Grisham, J. (2004). Measurement of compulsive hoarding: Saving inventoryrevised. Behaviour Research and Therapy, 42(10),
11631182.
Frost, R. O., Steketee, G., Tolin, D. F., & Renaud, S.
(2008). Development and validation of the clutter
image rating. Journal of Psychopathology and Behavioral Assessment, 30(3), 193203.
Frost, R. O., Tolin, D. F., & Maltby, N. (2010). Insightrelated challenges in the treatment of hoarding. Cognitive and Behavioral Practice, 17, 404413.
Frost, R., Steketee, G., & Tolin, D. (2011). Comorbidity
in hoarding disorder. Depression and Anxiety, 28(10),
19.
258
Frost, R. O., Ruby, D., & Shuer, L. (2012). The buried in
treasures workshop: Wait list control trial of facilitated
self-help for hoarding disorder. Behaviour Research
Frost, R. O., Hristova, V., Tolin, D., & Steketee, G.
(2013). Activities of daily living scale in hoarding disorder. Journal of Obsessive-Compulsive and Related
Disorders, 2, 8590.
Grisham, J. R., & Frost, R. O., Steketee, G., Kim, H. J.,
& Hood, S. (2006). Age of onset of compulsive hoarding. Journal of Anxiety Disorders, 20(5), 675686.
Gilliam, C. M., Norberg, M. M., Villavicencio, A., Morrison, S., Hannan, S. E., & Tolin, D. F. (2011). Group
cognitive-behavioral therapy for hoarding disorder:
An open trial. Behaviour Research and Therapy, 49
(11), 802807.
Harris, J. (July, 2010). Household hoarding and residential fires. Paper presented at International Congress of
Applied Psychology, Melbourne, Australia.
Hirschtritt, M. E., & Mathews, C. A. (2013). Genetics and
family models of hoarding disorder. In R. O. Frost &
G. Steketee (Eds.), Oxford handbook of hoarding and
acquiring. New York: Oxford.
Iervolino, A. C., Perroud, N., Fullana, M. A., etal. (2009).
Prevalence and heritability of compulsive hoarding:
A twin study. American Journal of Psychiatry, 166,
11561161.
Landau, D., Iervolino, A. C., Pertusa, A., Santo, S., Singh,
S., & Mataix-Cols, D. (2011). Stressful life events and
material deprivation in hoarding disorder. Journal of
Anxiety Disorders, 25(2), 192202
Mataix-Cols, D., Rauch, S. L., Manzo, P. A., Jenike, M.
A., & Baer, L. (1999). Use of factor-analyzed symptom dimensions to predict outcome with serotonin
reuptake inhibitors and placebo in the treatment of
Psychiatry, 156(9), 14091416.
Mataix-Cols, D., Frost, R. O., Pertusa, A., Clark, L. A.,
Saxena, S., Leckman, J. F., etal. (2010). Hoarding disorder: A new diagnosis for DSM-V? Depression and
Anxiety, 27(6), 556572.
Mueller, A., Mitchell, J. E., Crosby, R. D., Heide, G., &
Martina, Z. (2009). The prevalence of compulsive
hoarding and its association with compulsive buying in a German population-based sample. Behaviour
Muroff, J. (2011). Thinking outside the box: Novel delivery methods for treating hoarding. International Journal of Cognitive Therapy, 4, 280296.
Muroff, J. (2014). Alternative modalities for hoarding
treatment. In R. O. Frost & G. Steketee (Eds.), The
Oxford handbook of hoarding and acquiring. New
Muroff, J., Steketee, G., Rasmussen, J., Gibson, A., Bratiotis, C., & Sorrentino, C. (2009). Group cognitive and
behavioral treatment for compulsive hoarding: A preliminary trial. Depression and Anxiety, 26(7), 634640.
Muroff, J., Steketee, G. H., & Frost, R. O. (2010). Delivery of
internet treatment for compulsive hoarding (D.I.T.C.H.).

Muroff, J., Steketee, G., Bratiotis, C., & Ross, A. (2012).
Group cognitive and behavioral therapy and bibliotherapy for hoarding: A pilot trial. Depression and
Anxiety, 29(7), 597604.
Pertusa, A., Frost, R. O., & Mataix-Cols, D. (2010).
When hoarding is a symptom of OCD: A case series
and implications for DSM-V. Behaviour Research and
Therapy, 48, 10121020.
Samuels, J., Bienvenu, O. J., III, Riddle, M. A., Cullen,
B., Grados, M.A., Liang, K., etal. (2002). Hoarding in
obsessive compulsive disorder: Results from a casecontrol study. Behaviour Research and Therapy, 40,
517528.
Samuels, J. F., Bienvenu, O. J., Grados, M. A., Cullen, B.,
Riddle, M. A., Liang, K. Y., etal. (2008). Prevalence
and correlates of hoarding behavior in a communitybased sample. Behaviour Research and Therapy, 46,
836844.
San Francisco Task Force on Compulsive Hoarding.
(2009). Beyond overwhelmed: The impact of compulsive hoarding and cluttering in San Francisco and
recommendations to reduce negative impacts and
improve care. San Francisco: Mental Health Association of San Francisco.
Steketee, G., & Frost, R. O. (2007). Compulsive hoarding
and acquiring: Client Workbook. New York: Oxford
University Press.
Steketee, G., & Frost, R. (2013a) Treatment for Hoarding Disorder: Therapist guide (2nd ed.). New York:
Steketee, G., & Frost, R. (2013b) Treatment for Hoarding Disorder: Workbook (2nd ed.). New York: Oxford
University Press.
Steketee, G., Frost, R., & Kyrios, M. (2003). Cognitive
aspects of compulsive hoarding. Cognitive Therapy
and Research, 27(4), 463479.
Steketee, G., Frost, R. O., Tolin, D. F., Rasmussen, J., &
Brown, T. A. (2010). Waitlist-controlled trial of cognitive behavior therapy for hoarding disorder. Depression and Anxiety, 27, 476484.
Tolin, D. F., Frost, R. O., & Steketee, G. (2007). An open
trial of cognitive-behavioral therapy for compulsive
hoarding. Behavioral Research and Therapy, 45(7),
14611470.
Tolin, D. F., Frost, R. O., Steketee, G., & Fitch, K. E.
(2008). Family burden of compulsive hoarding:
Results of an Internet survey. Behaviour Research and
Therapy, 46(3), 334344.
Tolin, D. F., Frost, R. O., & Steketee, G. (2010a). A brief
interview for assessing compulsive hoarding: The
hoarding rating scale-interview. Psychiatry Research,
178(1), 147152.
Tolin, D. F., Meunier, S. A., Frost, R. O., & Steketee, G.
(2010b). Course of compulsive hoarding and its relationship to life events. Depression and Anxiety, 27(9),
829838.

Body Dysmorphic Disorder
18
Angela Fang, Rachel A. Schwartz

and Sabine Wilhelm

Research Basis
Characterized as an obsessive-compulsive (OC)
spectrum disorder in the Diagnostic and Statistical
Manual of Mental Disorders, 5th Edition (DSM5; American Psychiatric Association 2013), body
dysmorphic disorder (BDD) involves an excessive
preoccupation with perceived defects in physical
appearance. In contrast to normal appearance
concerns, these preoccupations typically consume
between 3 and 8h of the day and can lead to significant distress and impairment (Phillips 1998).
Individuals with BDD are most often concerned
with their skin, hair, and nose, although it is not
uncommon for body parts of concern to shift over
time and for patients to be concerned about several aspects of their appearance (Phillips and Diaz
1997; Phillips etal. 2005a). To hide, correct, or
fix the perceived defect, BDD patients perform
time-consuming rituals such as mirror checking
or avoiding, excessive grooming, reassurance
seeking, and skin picking. BDD patients are often
embarrassed to be seen and therefore avoid social
S.Wilhelm()
Department of Psychiatry, Massachusetts General
Hospital/Harvard Medical School, Simches Research
Center, 185 Cambridge Street, Suite 2000, Boston,
MA 02114, USA
e-mail: wilhelm@psych.mgh.harvard.edu
A.Fang R.A. Schwartz
Massachusetts General Hospital/Harvard Medical
School, Boston, MA 02114, USA
situations (Phillips 2005; Phillips etal. 2005a;

Wilhelm 2006).
BDD may be distinguished from other OC
spectrum disorders by delusionality and poor insight (Phillips etal. 2012). One study found that
in 129 adults with BDD, 108 (84%) were delusional or had poor insight (Phillips, 2004). In addition, 60 patients (46.5%) were completely convinced that their beliefs were true, and as many as
two thirds had delusions of reference that others
took special notice of their defects. Individuals
with non-delusional BDD appear to be demographically and clinically similar to their delusional counterparts, suggesting that delusional
BDD may be a more severe form of the disorder
(Phillips etal. 1994).
Another hallmark of BDD is its association
with high rates of suicidality. Within the BDD
population, as many as 80% experience suicidal
ideation, and up to 25% actually attempt suicide
(Phillips 2007). This represents a marked departure from national rates of suicide. Recent studies
estimate that, relative to the general US population, suicidal ideation is 1025 times higher, suicide attempts are 212 times higher, and completed suicide is 45 times higher in individuals
with BDD (Phillips and Menard 2006). A more
severe lifetime course of BDD and a comorbid
diagnosis of major depressive disorder (MDD),
bipolar disorder, and borderline personality disorder have all been identified as clinical correlates
of suicidality for BDD patients (Phillips 2006).
Research examining risk factors of BDD points
to psychiatric hospitalizations, unemployment,

DOI 10.1007/978-3-319-17139-5_18
259
260
poor social support, poor self-esteem, and a history of abuse (Phillips 2007).
Population-based estimates suggest that BDD
is relatively common, with a nationwide prevalence between 1.7 and 2.4% (Buhlmann etal.
2010; Koran etal. 2008; Rief etal. 2006). Symptoms typically begin in early adolescence (average age of onset=16.7 years) and, without treatment, BDD runs a chronic and unremitting course
(Bjornsson etal. 2013; Phillips etal. 2013).
Given its chronicity and severity, it is not surprising that BDD is associated with significant
functional impairment across psychosocial domains (Phillips etal. 2005a). In terms of interpersonal relationships, individuals with BDD tend
to avoid social situations where their appearance
may be evaluated (Phillips 2005). They also commonly avoid dating and intimacy due to the belief that they look ugly or hideous, and, in severe
cases, BDD can render an individual housebound
for many years (Phillips 2005). In the occupational domain, BDD is associated with high rates
of unemployment. In one sample of 141 adults
with BDD, fewer than half worked full time and
22.7% were on disability (Didie etal. 2008).
Moreover, 39% of these individuals reported not
working in the last month due to psychopathology. On both physical- and mental-health-related
measures, BDD patients appear to have a lower
quality of life relative to the general US population, individuals with diabetes and myocardial
infarctions, and even outpatients with depression
(Phillips 2000). Furthermore, more severe BDD
and delusionality are associated with worse mental-health-related quality of life (Phillips 2000).
An additional health-related consideration for
BDD patients is the tendency to seek nonpsychiatric medical care. Given their belief in a physical, rather than psychological, issue, a majority of
patients with BDD seek and receive surgical, dermatological, dental, or other cosmetic treatments
for their perceived appearance defects (Phillips
etal. 2001). In one large study (N=289), nonpsychiatric medical treatment or surgery was sought
by 76.4% and received by 66.0% of adults with
BDD, with men and women being equally likely to pursue this avenue of care (Phillips etal.
2001). Conversely, between 7.7 and 24.5% of
A. Fang et al.
patients who seek nonpsychiatric treatment options like cosmetic surgery or dermatological
treatments have BDD (Alavi etal. 2011; Conrado etal. 2010; Lai etal. 2010). Rhinoplasty
and breast augmentation are the most commonly
received surgical treatments for BDD concerns,
comprising 37.7 and 8.2% of received surgical
procedures in one sample (N=200), respectively
(Crerand etal. 2010). As for minimally invasive
procedures, collagen injections (50%) and microdermabrasion (19.2%) were the most commonly received procedures (Crerand etal. 2010).
Despite the prevalence of seeking surgical and
nonpsychiatric solutions for BDD concerns, it is
not surprising, given the psychological origins of
the perceived defect, that only 2.3% of these procedures lead to long-term improvement in overall BDD symptoms (Crerand etal. 2010). This
pattern of requesting ineffective treatment from a
variety of health-care providers not only has the
potential to take a financial toll on patients but
also results in the inefficient allocation of large
amounts of medical services (Cotterill 1996;
Koblenzer 1985). As an additional repercussion,
some dissatisfied patients commit suicide following treatment or demonstrate aggressive behavior
towards the treating physician (Cotterill 1996;
Koblenzer 1985; Phillips 1991).
Fortunately, studies have shown that some
types of pharmacologic and non-pharmacologic
interventions can be successful in the treatment
of BDD. The first-line pharmacotherapy for
BDD is serotonin reuptake inhibitors (SRIs),
which have yielded response rates in BDD symptoms ranging from 53 to 73% (Hollander etal.
1999; Perugi etal. 1996; Phillips 2006; Phillips
etal. 1998, 2002; Phillips and Najjar 2003). Like
obsessive-compulsive disorder (OCD), BDD
may require relatively higher SRI doses and longer trial durations (Phillips and Hollander 2008).
Cognitive behavioral therapy (CBT), the most
well-studied and empirically supported form of
psychological treatment for BDD, is also effective (Rosen etal. 1995; Veale 2001; Wilhelm et
al.2011, 2013, 2014). A typical course of CBT
for BDD involves several core treatment components such as psychoeducation, motivational
enhancement, cognitive restructuring, in vivo
18 Treatment of an Adult with Body Dysmorphic Disorder
exposures and response prevention, perceptual

mirror retraining, and relapse prevention. In a recent randomized controlled trial, which tested a
22-session individual CBT for adults with BDD
against a waitlist comparison group, 81% of all
participants (those who received immediate CBT
plus waitlisted patients who were subsequently
treated with CBT) met responder criteria by posttreatment (Wilhelm etal. 2014). In addition to
BDD symptom severity, these patients saw improvements in depressive symptoms, insight, and
disability following CBT. The following sections
illustrate issues that emerge in treatment delivery, as well as effective application of treatment
principles, as applied to a representative case of
an adult with BDD.
Case Description
Carrie (pseudonym) was a 32-year-old, single,
Caucasian female, who presented with excessive
concerns about her face not looking right. Specifically, she was preoccupied with concerns that
her facial features were not proportional, that she
had facial acne, messy hair, and a crooked nose.
She reported that ever since she was a child, she
needed to wear glasses and was teased by other
students in her school about them. Ever since, she
had been fixated on ways to disguise and improve
her appearance. Carrie worked as an associate in
a marketing firm and woke up at 5:00 a.m. each
morning to begin her 2-h-long grooming rituals
to get ready for work. She described herself as
being hideous and embarrassed to be out in
public, so insisted on driving to work to avoid
public transportation, even though it took longer.
Carrie noticed that it became increasingly more
difficult to interact with clients and coworkers.
At work, she kept two mirrors in her office and
one on her phone so that she could always check
how she looked before a meeting. In addition,
Carries appearance concerns interfered with her
romantic relationship, as she would not let her
boyfriend touch her face because he might notice
that her skin was not smooth. Social interactions
had become more strenuous as Carrie found herself getting distracted by intrusive thoughts about
261
her appearance when compared to others and getting depressed by thoughts that she did not measure up.
By the time Carrie came to treatment, she had
already consulted with several different dermatologists, and 3 months before she had finally decided to receive dermabrasion treatment for her
acne. She believed that the treatment had only
worsened her skin tone and caused more scarring, which resulted in even more time spent on
her grooming rituals in the morning, as well as
researching and buying new beauty products online. Thereafter, Carrie experienced difficulties
getting to work on time as well as focusing while
at work. Her boss expressed his concerns about
her increased tardiness and decreased productivity. This dermabrasion experience led her to feel
more hopeless about her situation, such that she
began having thoughts about walking into traffic to end her life. When her cousin brought her
in for treatment, Carrie was convinced that she
looked like a monster and needed to pursue
more aggressive cosmetic procedures to improve
her appearance.
Case Information
Carrie had a socially isolated childhood. She was
an only child but spent most of her time with a
cousin who was close in age, and she described
her childhood as being a lonely time in her life.
Carrie recalled memories of her mother, who
would never let her leave for school unless she
had combed her hair, brushed her teeth, and
wore her Sundays best. Both parents were
high executives in corporate firms, who taught
her to always make a great first impression. In
grade school, Carrie was a stellar student. She
was teased by other students because she enjoyed reading and did well in her classes. Since
she needed to wear glasses by the time she entered the second grade, other students called
her Velma, the geeky character with glasses
from the Scooby Doo show. When her friends
became interested in boys, she started to become self-conscious about her body, and she
would study her face and body in photographs.
262
Throughout high school and college, she developed a rigorous makeup and hair routine, which
took her 45min each day, and she would refuse
to go out anywhere unless she could complete
her full routine. Carrie also began checking herself in the mirror frequently each day, and often
scrutinized others appearance in her classes, to
the extent that on bad days, she would just skip
class. She had close girlfriends who always told
her she looked great, but she often felt like the
ugly duck in the group, and she was always
surprised when men expressed romantic interest
in her. Carrie had many boyfriends in her 20s,
but most of them did not last longer than a year
because she was jealous of other more attractive
women who looked at her boyfriend, and she was
preoccupied with thoughts that others believed
she was much less attractive than her boyfriend.
Each breakup resulted in a depressive episode,
which worsened her appearance concerns, and
made her feel more hopeless about the state of
her face and body. Prior to her recent decline in
work performance, Carrie had functioned quite
well in her work, and she was well respected by
her coworkers and friends for her hardworking,
caring, and congenial manner. However, Carrie
had perfected the art of hiding and fixing her
perceived appearance flaws through her rituals,
without which she would not be willing to engage socially with others.
When Carrie presented to the clinic, she had
pursued nonpsychiatric treatment options, including dermatology consultations, spa treatments, expensive lotions and creams, and had
most recently undergone dermabrasion treatment. Because she was so dissatisfied with the
outcome and her dermatologist refused to redo
the procedure, she began spending 2h each night
researching more aggressive cosmetic options,
such as laser skin treatments. Carrie had no past
psychiatric hospitalizations and no other psychiatric diagnoses except for recurrent episodes of
(MDD), which were triggered by her breakups.
In addition, she expressed suicidal ideation about
ending her life, never with any formal plans and
no history of self-harm behavior. Carrie had
never taken any psychiatric medications for her
depression or appearance concerns and refused to
A. Fang et al.
try them because she believed her problem was

physical rather than psychological in nature.

Assessment
Carries rituals (including mirror checking,
grooming, comparing appearance to others, and
researching ways to improve her appearance
on the Internet) likely reinforced her delusional
beliefs about her appearance by contributing
to avoidance of situations and experiences that
would otherwise disconfirm her beliefs. Carrie
also displayed common distortions in cognitive
processing, such as all or none thinking (I look
ugly), overgeneralization (If one person reacts
badly to me due to my appearance, then others
will too), and emotional reasoning (If I feel
anxious around people, then I must be bad at
social interactions). Perhaps adding to her distress were her childhood experiences that led her
to feel abnormal around her peers and to overemphasize the importance of appearance. Carrie
would likely benefit from motivational enhancement at the start of treatment due to the rigidity of
her beliefs about her appearance and her history
of seeking nonpsychiatric solutions to her problem, which are typical features of patients with
the delusional form of BDD.
A detailed assessment of Carries symptoms was conducted during her baseline visit.
The structured clinical interview for DSM-IV
(SCID; First etal. 2002) is a semi-structured
clinician-administered instrument that assesses
Axis I disorders. Given that the SCID had not
yet been updated for DSM-5, DSM-IV criteria
were used for diagnoses. On the SCID, Carrie
received a principal diagnosis of BDD and comorbid diagnosis of MDD. The DSM-IV diagnosis of BDD requires the presence of clinically
significant preoccupation with a perceived defect in appearance, which is not better accounted
for by another Axis I disorder. The YaleBrown
Obsessive-Compulsive Scale Modified for BDD
(BDD-YBOCS; Phillips etal. 1997) is a 12-item
clinician-administered severity rating scale for
BDD-related thoughts and behaviors in the past
week. The total score ranges from 0 to 48. Carrie scored a 29 on the BDD-YBOCS at baseline,
which reflected a severe level of BDD symptoms.
Her BDD-YBOCS assessment also revealed that
she had been spending 38h per day preoccupied
with thoughts about her appearance and 13h per
day performing rituals. The Brown Assessment
of Beliefs Scale (BABS; Eisen etal. 1998) is a
seven-item clinician-administered scale that assesses the degree of delusionality (insight and
conviction) of BDD-related beliefs. The BABS
yields a total score ranging from 0 to 24. Carrie scored a 17, which was based on her stated
belief: I am ugly and indicated poor insight. In
addition, Carrie completed the BDD Symptom
Scale (BDD-SS; Wilhelm 2006; Wilhelm etal.
2013), which is a self-report questionnaire that
measures the presence, frequency, and distress of
BDD-related symptoms in the past week. There
are a total of seven symptom subscales: checking
and comparing, fixing and correcting, weight and
shape concerns, skin picking and hair pulling,
avoiding and hiding, seeking cosmetic surgery,
and beliefs about appearance. This scale was
used to assess changes in specific problem behaviors and beliefs throughout treatment. Finally,
Carrie completed the Beck Depression Inventory
(BDI-II; Beck etal. 1996), which is a self-report
questionnaire of depressive symptoms. Carrie received a score of 30 on this measure, which indicated a severe level of depressive symptoms.
Her BDI also indicated the presence of suicidal
ideation but without any intent or plan.

First Three Sessions During the first three treatment sessions, Carrie was introduced to the format and content of treatment, which consisted
of modular CBT for BDD (Wilhelm etal. 2011,
2013). Each session began with a brief mood
check (on a scale of 110) after Carrie completed
the BDI-II. This was done to track changes in
Carries mood and to assess changes in suicidal
ideation. Given that Carrie endorsed suicidal ideation about walking into traffic to end her life, her
263
therapist assessed this in further detail. The therapist learned that she would never act on these
thoughts because she loved her family and knew
that her suicide would upset them. Approaching
this topic with openness and warmth, the therapist stated that patients with BDD commonly
endorse suicidal ideation, and that it is important
to discuss at each session to learn if her thoughts
become more serious.
It was important in the first session to convey the structured format of CBT, as well as the
emphasis on skills practice and between-session
homework assignments to allow Carrie to generalize skills to her daily life. When providing an
overview of the treatment, it became clear that
Carrie had poor insight about her symptoms, as
she adamantly refused to accept that her symptoms could be consistent with a psychiatric disorder called BDD. Rather than debating with her
about the diagnosis, the therapist sided with Carrie on the distress and suffering associated with
her symptoms and agreed to call these problems
appearance concerns rather than BDD. In
addition, it was important to assess and enhance
Carries motivation for treatment by discussing
how long she had suffered with these concerns,
the outcome of past treatments that she sought,
and the costs of trying a new approach. Moreover, to address her delusionality and obvious
skepticism about the treatment, a particular emphasis was given to establish rapport and maximize buy-in to the treatment by validating Carries distress.
Aside from orienting Carrie to treatment and
discussing motivation, the first session focused
on gathering detailed information about the nature of Carries symptoms. For example, the therapist inquired about her body parts of concern,
avoidance of people, places, and activities as a
result of her appearance concerns; problematic
behaviors and rituals associated with her appearance concerns; the course of her symptoms and
circumstances surrounding their onset; past treatments (especially nonpsychiatric and medication
treatments); degree of impairment in functioning;
and other relevant aspects of medical, social, and
family history. Given Carries worsening suicidal
ideation at the time she presented for treatment,
264
priority was given in the first session of treatment

to formulate a collaborative safety plan, with detailed steps to follow should Carries suicidal
ideation increase between sessions. At the end
of the session, Carrie was given a psychoeducational handout about BDD, as well as a handout
entitled, A Message to Current Patients from
Past Patients, which included statements of support and encouragement from past patients in the
program.
Sessions 2 and 3 focused on establishing Carries goals for treatment, setting realistic expectations for treatment progress, providing psychoeducation about BDD, and formulating a personalized BDD model. When the therapist checked
in with her about her mood and reading assignments, Carrie stated that her mood had been an
8/10 (10 being the worst) in the past week, and
that she thought the message to patients handout did not apply to her. Carrie explained that
the program must treat people who think they
are ugly but are actually beautiful like Jennifer
Aniston, whereas Carrie was actually hideous so
the program was not the right place for her. The
therapist again used a motivational approach to
discuss how unhelpful past solutions had been.
Carries goals for treatment involved attending
more social events with coworkers and friends,
allowing her boyfriend to touch her face, reducing her grooming routine to 15min each morning, and reducing her negative thoughts about
herself. When discussing theories of BDD, Carrie became tearful recalling her life experiences
of being teased for her looks in grade school and
feeling so isolated as an only child without much
support. She also mentioned the influence of
media and culture on setting unrealistic ideals for
females in our society as contributory factors of
her appearance concerns. The therapist validated
her points, while also gently acknowledging that
environmental factors may only partially explain
the development of BDD, given the evidence for
biological factors (neurotransmitters and genetics data) and given that everyone is subjected to
the same exposure to media. Germane to this was
a discussion about the difference between physical appearance and body image, to highlight that
CBT would address her poor body image rather
A. Fang et al.
than her physical appearance. Carries personalized model of BDD identified potential causal
and maintaining mechanisms for her distress, by
mapping out the vicious cycle between her appearance-related obsessions (e.g., my face does
not look right), negative emotions (e.g., I feel
depressed), rituals (e.g., spending two hours putting on makeup), and avoidance behaviors (e.g.,
calling in sick to work), while also incorporating the influence of her previous life experiences
and core beliefs. By the end of session 3, Carrie
had already begun to identify negative thoughts
related to her appearance by learning the link between thoughts and feelings. Her assigned homework involved monitoring negative thoughts and
completing additional blank BDD model sheets
for situations throughout the week, which were
typical of her BDD experiences.
Sessions 4 and 5 In sessions 45, Carrie learned
about different cognitive errors associated with
her appearance concerns. The therapist handed
her a list of common cognitive errors in BDD
including all-or-none thinking, unfair comparisons, should statements, mind reading, fortune
telling, catastrophizing, personalization, emotional reasoning, labeling, selective attention/
magnification, and discounting the positives.
This initiated a discussion about whether Carrie had been making these kinds of errors. Carrie became very frustrated and despondent upon
reading the list, as she stated, Everything I think
is a distortion! The therapist gently normalized
how anyone with these kinds of thoughts would
feel terrible about themselves, and where possible, tried to externalize her appearance concerns.
Another important strategy was for the therapist to be selective about which thoughts to
evaluate by assessing which thoughts came up
frequently for her. By starting with common
negative thoughts that were barriers to engaging fully in social situations with coworkers and
friends, the therapist had a stronger rationale for
evaluating thoughts as an effective component of
treatment. Carrie reported that she had frequent
negative thoughts about other people thinking
she looked far less attractive than the people
she was with, such as her boyfriend, cousin, or
coworkers. Her specific thoughts were: They

must be thinking he is so much better looking
than her and Look at her skin; she is so ugly
compared to her cousin. Carrie correctly categorized these thoughts as mind reading and personalization errors. However, she became stuck
on evaluating the evidence for and against the
idea that people were comparing her to others
because she believed strongly that this was true.
In this case, the therapist skillfully taught her the
basic steps for deriving rational responses for her
negative thoughts such as I cant read peoples
minds (even if she did not believe them) and
then moved on to less firmly held beliefs, which
were somewhat more amenable to this evaluation process. For example, Carrie reported other
negative thoughts, such as Nobody wants to be
around me because my face is so ugly. She was
able to generate rational responses for this belief,
such as People may still enjoy being around me
because I can be a funny and kind person.
Despite her best efforts, Carrie completed very
little of the homework practice around evaluating
thoughts in sessions 4 and 5. She told the therapist that her thoughts are too painful and stated,
Its no usethis is just an intellectual exercise!
Compounding her resistance to treatment was
Carries depression, which impacted her motivation to complete the assignments. The therapist worked with her around openly discussing
thoughts, feelings, and behaviors as they applied
to her homework to help her see the relationship
between her depressed mood, her thoughts about
hopelessness, and her subsequent avoidance of
homework. Because Carrie continued to state
that she felt hopeless, the therapist pointed out
the power of emotions to make us believe feelings as facts (emotional reasoning). In addition,
they reviewed the original safety plan and discussed that her suicidal ideation had not gotten
worse so the plan did not need any revision. The
therapist continued to validate the difficulty of
this work and bring Carrie back to their earlier
discussion of expectations for progress.
Sessions 69By session 6, Carrie had adequately understood the rationale of evaluating
thoughts. It was therefore a good point to move
265
on to another core treatment component, exposure and ritual prevention. The therapist provided
a rationale for exposing herself to situations that
had been avoided. She explained that repeated
exposure will help her habituate to the fear and
extinguish her impulse to leave the situation and
may also give her an opportunity to learn something new. For example, she might learn about
how other people behave towards her if she actually interacts with them. Or, she might even learn
something about her own ability to tolerate anxiety. Carrie and the therapist referred back to Carries goals for treatment and generated a list of
avoided situations that could guide exposure exercises. In their discussion, Carrie reported skepticism that exposure would help her because she
often found that she would force herself to go to
work or get lunch with her coworkers even when
she did not feel like it and would still fear these
situations next time. The therapist responded by
educating her on the role of rituals and inquired
whether she had engaged in these rituals before,
during, or after the exposure. Carrie stated that of
course she needed to do her grooming ritual and
check in the mirror a few more times before any
social interaction. Thus, Carrie and her therapist
designed an exposure hierarchy that incorporated
a list of avoided situations along with the rituals
that needed to be prevented to guide the next several sessions. See Table18.1 for Carries distressing situations worksheet.
For the first in-session exposure, the therapist
selected a situation that mapped on well to her
hierarchy, which could be conducted in the office setting and which was relatively easier to do.
Using a structured exposure worksheet, the therapist framed the exposure as a behavioral experiment to test out Carries prediction that people
would reject her and avoid eye contact with her
if she took off one layer of makeup. The therapist asked Carrie to identify specific behavioral
goals for the exercise, which were to (1) walk
around the office floor three times, (2) make eye
contact with at least three people she passed, and
(3) remove one layer of makeup. Carrie identified her negative thoughts as, People will think
Im such a slob and People will reject me and
avoid eye contact with me. She generated some
266
A. Fang et al.
Table 18.1 Carries distressing situations worksheet

Situation
1. Going to a work meeting without checking mirrors and after messing
up hair
2. Going to work after grooming for only 30min
3. Going to the grocery store during peak hours
4. Allowing boyfriend to touch face
5. Taking the train to work rather than drive
6. Making eye contact and speaking up at a work meeting
7. Making eye contact with coworkers when walking toward them in the
office
rational responses to these thoughts, including:

Im mind reading again and wont be able to
know what people are thinking. This cognitive
preparation allowed Carrie to consider potential
outcomes of the exposure and alternative ways
of thinking about her behavior. Although she felt
extremely anxious completing it, Carrie successfully achieved all three of her goals, and even exceeded them, as she made eye contact with seven
people. When discussing what she learned at the
end of the experiment, Carrie stated that she did
not think that anyone noticed that she was wearing only a limited amount of makeup. One person
gave her a friendly smile. She also acknowledged
that nobody was openly rejecting her. It seemed
that people were mostly interested in doing whatever it was they were doing, and not in Carries
makeup.
Over the next several sessions, the treatment
was geared toward conducting in-session exposures to practice designing effective exposure
exercises, and homework assignments were designed to continue conducting exposures as well
as monitoring and reducing rituals. Specifically,
Carrie identified mirror checking, comparing
appearance with others, and researching beauty
products/procedures on the Internet as the most
time-consuming and distressing rituals. The
therapist went over the strategies with Carrie to
help her reduce her ritualizing, such as selective
ritual prevention (checking mirrors at home, but
not in the office), ritual delay (postponing the
ritual by 30min), and stimulus control (not carrying around a pocket mirror in her handbag).
By the end of session 9, Carrie had cut down her
grooming ritual each morning to 20min, and had
Degree of distress
(0100)
100
Degree of avoidance
(0100)
100
90
75
60
50
50
40
90
100
80
100
80
70
completed at-home exposures that involved initiating plans with a coworker, and allowing her
boyfriend to touch her face, which mapped onto
her stated goals at the start of treatment. When
Carrie could not identify specific predictions to
test out in her exposures, the therapist explained
that learning whether or not she could tolerate her
anxiety was a prediction she could also make.
Session 10 The next session addressed the last
core treatment strategy: perceptual mirror retraining. During this session, the therapist introduced
mirror retraining as a strategy that targets the
detailed manner of examining ones appearance,
which is exacerbated by mirror checking. She
asked Carrie whether there were any disadvantages to attending to ones appearance in this
way. Carrie responded that this type of checking
only made her overemphasize the importance of
her appearance. The therapist also added that a
detailed examination of ones appearance could
also lead to an exaggerated distortion of what
the body part looks like. She demonstrated the
problem of selective attention by having Carrie
stare at a small mole on the therapists face for
60s. Afterwards, the therapist asked Carrie what
she learned. She stated that the mole seemed to
appear bigger the longer she looked at it. The
therapist explained that the goal of mirror retraining is to develop a healthy relationship with the
mirror, rather than discontinue using the mirror,
by learning to use it only during times when it
serves a practical function, for example, when
getting dressed for work. She further explained
that mirror retraining involves a mindfulness
component such that it requires to observe and
describe each body part objectively, using nonjudgmental language and for equal amounts of
time.
The therapist taught Carrie during the session
to stand at an arms length in front of a full-length
mirror and begin by describing her appearance
from her head to her toes in neutral, objective,
and nonjudgmental terms. Carrie was extremely
uneasy about participating in this exercise, so the
therapist modeled this briefly using herself as a
model, emphasizing the equal amount of time
she spent on each body part, and the mindfulness
involved in describing qualities of her appearance in terms of color, texture, length, and width.
When it was Carries turn to begin the exercise,
she stood in front of the mirror looking at her
face and immediately began crying. The therapist asked her to identify whether any negative
thoughts came up, and Carrie responded that she
felt that today was such a bad day to do this exercise because she felt particularly ugly. The therapist helped her evaluate this thought by asking
her whether her feelings always reflected facts.
She also asked Carrie if it would help her to view
this exercise as akin to taking an Advil when she
had a bad headache, and that perhaps practicing mirror retraining on a particularly bad day
could provide even more relief for her appearance concerns than on other days. These rational
responses helped Carrie get through the exercise.
The therapist suggested that for homework, she
practice generating rational responses for negative thoughts beforehand and to practice mirror
retraining at least three times per day.
Sessions 1120These sessions provided an
opportunity to continue practicing with already
learned skills (cognitive restructuring, exposure,
ritual prevention, and perceptual retraining), as
well as to learn advanced cognitive strategies
and to introduce modular components of treatment that were specifically tailored to Carrie. For
example, Carrie benefited from an exploration of
deeper-level core beliefs through exercises such
as the downward arrow technique and self-esteem
pie, which helped her understand the negative
consequences of holding such beliefs and helped
her to evaluate the validity of these beliefs. For
267
example, using the downward arrow technique,

Carrie was asked for the meaning of her thoughts
repeatedly until she discovered her core negative
beliefs about herself (see Fig.18.1). Then, the
therapist asked her about the usefulness of having the core belief I am unworthy, and Carrie
expressed how it just makes her feel more miserable. When examining the evidence for the intermediate belief that nobody wants to be around
her, Carrie reported that even if her boyfriend or
her friends initiated plans to spend time with her,
she assumed that they were just being nice. Thus,
Carrie learned that her core beliefs served as a
lens through which all of her interpretations were
made, and she had never bothered to check out
these automatic assumptions.
Using the self-esteem pie exercise, the therapist asked Carrie to first list out all positive and
negative components of her self-esteem. Carrie
identified the following aspects: appearance, intelligence, personality, her job, and her relationships. She was then asked to draw a large circle
and carve out slices for each component of her
self-esteem. After this, it was clear that Carrie
had placed greatest importance on her appearance, which she believed was a negative component, as her appearance slice took up about 75%
of the pie. The therapist then challenged Carrie
to identify some of her strengths and talents and
even asked her if she could identify some aspects
of her appearance that she liked. Through this
discussion, Carrie learned that she believed that
she was quite smart and had a very caring personality. She actually quite liked the shape of her
2WKHUSHRSOHDUHDOZD\VWKLQNLQJDERXWKRZXJO\,DP
1RERG\ZRXOGZDQWWREHDURXQGPH
,OOHQGXSDORQHQRERG\ZRXOGFDUHDERXWPHRUORYHPH
,DPXQZRUWK\
Fig. 18.1 Carries deeper-level beliefs using the downward arrow technique
268
legs and her eye color. She was also quite proud
of her achievements at work, as her supervisors
told her that she was a conscientious worker and
had become a resourceful member of her team.
After calling upon these experiences that she
was initially quick to ignore and dismiss and
discussing the advantages and disadvantages of
overvaluing appearance, Carrie revised her selfesteem pie with more balanced slices.
Furthermore, sessions were spent on treatment
modules that were tailored to Carrie. For example, given that her depression contributed to her
avoidance of going to work and social activities,
one session was spent on strategies that could
specifically target her depression. Carrie learned
how to apply her cognitive restructuring skill to
her depressogenic negative thoughts and became
aware of her common errors in thinking related to
depression. She also learned how to plan pleasant or masterful activities into her schedule each
week, such as going to a yoga class, joining a
book club, and calling her cousin who lived in
another state.
Another module that was applicable to Carrie was the cosmetic surgery module, as Carrie
expressed strong urges to receive more aggressive dermatological treatment for her acne. The
primary approach in addressing her urges was to
use motivational interviewing and Socratic questioning techniques to discuss the pros and cons of
getting more treatment. The therapist also helped
Carrie identify cognitive errors in her thinking by
asking her about what she feared would happen
if she did not get the treatment. Despite this approach, Carrie was still pretty convinced that another dermatological treatment would resolve the
problems she had with dermabrasion and make
her feel less ugly. The therapist therefore asked
Carrie how she would feel about delaying the
treatment for another three months and taking her
time thinking it through, given her bad experience with dermabrasion before. Carrie ultimately
agreed with this plan because she was concerned
about the risks.
Sessions 2122 These final sessions constituted
the relapse prevention and termination sessions.
The purpose of these sessions was to transition
A. Fang et al.
Carries responsibilities to become her own

therapist and provide an opportunity to practice
checking in with herself about ways to maintain
her progress. In these last two sessions, the therapist assisted in reviewing strategies that Carrie found helpful and in anticipating upcoming
challenges where she could begin to practice her
skills. For example, Carrie mentioned that she
had an upcoming work-related Christmas party,
which her boyfriend would be attending with her.
She reported anticipatory anxious thoughts about
what people would think about her compared to
her boyfriend and identified rational responses to
begin evaluating the validity of these thoughts.
Posttreatment Assessment ResultsBy the end
of treatment, Carrie scored a 14 on the BDDYBOCS, which represented a 52% reduction in
BDD symptoms. She reported significantly less
time spent preoccupied with thoughts about her
appearance and engaging in rituals to relieve
her concerns. She had continued to cut down
her grooming ritual each morning to 15min and
reported having fewer negative thoughts about
herself. She also scored a 10 on the BABS for
her belief, I am ugly, which reflected a 41%
reduction in delusionality. Her BDD-SS questionnaire further indicated less avoidance of people, places, and activities; improved beliefs about
the importance of appearance; and fewer rituals
related to grooming and mirror checking.
For Carrie, the greatest complicating factor was
her delusionality. The problem with delusionality
is not just that it makes cognitive restructuring
and data gathering more challenging, but it causes
a general barrier to motivation for treatment because of a lack of buy-in to the rationale of CBT
for BDD. This likely contributed to ambivalence
about the efficacy of the CBT program and core
treatment techniques, as well as resistance to
completing between-session homework assignments. Carries degree of conviction that she was
truly ugly and that all of her problems stemmed
from this also contributed to her decision to seek
nonpsychiatric treatments. Cognitive restructuring was especially difficult for Carrie due to her
delusionality, as she was susceptible to confirmation biases when she attempted to seek out
new information in her exposure exercises, especially as it related to facial expressions. For
example, she often found that even though she
met her behavioral goals during exposures, she
was convinced that she often received dirty looks
from other attractive people and that they were
thinking negative thoughts about her appearance,
which made it difficult for her to make accurate
interpretations about having completed a successful exposure.
Another complicating factor was Carries comorbid depression and suicidality, which was
secondary to her BDD, but further contributed
to her social avoidance. Indeed, her depression had exacerbated so much at the beginning
of treatment that a detailed discussion of safety
and suicidal ideation was indicated at each early
session. The safety plan that was generated early
on in treatment was continually referred to during treatment, and emergency procedures, which
represented later steps in the safety plan, were
reviewed and defined repeatedly. To further address her depression, session content was applied
to examples of her worsened mood during her
week. For example, Carrie identified negative
thoughts about being a bad friend and girlfriend,
which were less related to her appearance concerns but were still amenable to the cognitive restructuring skills.

CBT for BDD is similar to CBT for other psychiatric disorders in terms of the basic model and
core treatment principles. However, there are
important differences. One of the key issues in
treatment is that individuals with BDD are overly
focused on the importance of appearance. BDD
patients are not able to see themselves holistically and instead focus on their perceived flaw, to
the exclusion of appreciating almost everything
else about them. A large focus of the treatment
is therefore to notice all of their features (not
269
just the ones they do not like) when they look in

the mirror and to make an effort to notice other,
nonappearance related qualities in other people.
Finally, they need to learn to base a larger part
of their self-esteem on nonappearance qualities.
Another unique clinical feature is that individuals with BDD may exhibit elaborate delusions of reference about others thinking of and
mocking their appearance. In some cases, they
may develop complex delusions about the social
and career advantages of being attractive. Rather
than engage the patient in an argument about the
validity of his or her beliefs, it is best to adopt a
curious approach to his or her interpretations and
help the patient consider the usefulness (evaluating pros and cons) of holding these beliefs.
BDD is also associated with particularly high
rates of attempted and completed suicide. In
general, CBT is efficacious for many patients
with suicidal ideation; however, some patients
(especially those with active suicidal ideation)
may require a higher level of care and some patients may need CBT augmented with psychotropic medication. For patients at a higher risk
of suicide, a safety plan (American Psychiatric
Association 2003) would be important to generate together at one of the earliest sessions, which
would describe a list of steps to take when suicidal ideation worsens and which would list the therapists emergency contact and nearest emergency
room as the last steps. Ongoing suicide assessment would be required at subsequent sessions
using both a depression self-report questionnaire
and direct questioning.
Finally, as with all psychological treatments,
it is important to begin establishing a strong alliance with the patient early on in treatment. We
have found in our experience treating patients
with BDD that a common issue involves motivation for treatment and ambivalence about receiving psychological treatment. Addressing their
ambivalence from the outset is strongly recommended, as it facilitates the discussion of advantages and disadvantages of CBT, as compared
to their past treatment approaches and promotes
readiness for change (Table18.2).
In conclusion, treating adults with BDD can
be simultaneously challenging and rewarding.
270
Table 18.2 Key practice points for treating BDD
1. Address ambivalence about treatment and motivational concerns at the outset of treatment using
motivational interviewing approaches
2. Avoid arguing with delusional patients about whether
they have BDD
3. If indicated, collaboratively generate a safety plan
early on in treatment and assess suicidal ideation at
subsequent sessions
4. Frame exposure exercises as behavioral experiments
and design experiments that are consistent with
patients stated goals for treatment
5. Be aware of patients inability to see the big picture
and tendency to overvalue the details of their
appearance
Our experience, together with empirical data

(Wilhelm etal. 2011, 2013, 2014), have shown
that CBT is acceptable and efficacious for this
patient population. Patients often achieve meaningful reductions in their BDD-related thoughts,
avoidance behaviors, and rituals, as well as greater flexibility in their beliefs about the importance
of appearance.
References
Alavi, M., Kalafi, Y., Dehbozorgi, G. R., & Javadpour,
A. (2011). Body dysmorphic disorder and other psychiatric morbidity in aesthetic rhinoplasty candidates.
Journal of Plastic, Reconstructive & Aesthetic Surgery, 64, 738741. doi:10.1016/j.bjps.2010.09.019.
American Psychiatric Association. (2003). Practice guideline for the assessment and treatment of patients with
suicidal behaviors. American Journal of Psychiatry,
160(11, Suppl.), 160.
and statistical manual of mental disorders-5. Washington: American Psychiatric Association.
for the Beck Depression Inventory-II. San Antonio:
Bjornsson, A. S., Didie, E. R., Grant, J. E., Menard, W.,
Stalker, E., & Phillips, K. A. (2013). Age at onset and
clinical correlates in body dysmorphic disorder. Comprehensive Psychiatry, 54, 893903. doi:10.1016/j.
Buhlmann, U., Glaesmer, H., Mewes, R., Fama, J. M.,
Wilhelm, S., Brahler, E., & Rief, W. (2010). Updates
on the prevalence of body dysmorphic disorder: A
population-based survey. Psychiatry Research, 178,
171175. doi:10.1016/j.psychres.2009.05.002.
Conrado, L. A., Hounie, A. G., Diniz, J. B., Fossaluza, V.,
Torres, A. R., Miguel, E. C., & Rivitti, E. A. (2010).
A. Fang et al.
Body dysmorphic disorder among dermatologic
patients: Prevalence and clinical features. Journal of
the American Academy of Dermatology, 63, 235243.
doi:10.1016/j.jaad.2009.09.017.
Cotterill, J. A. (1996). Body dysmorphic disorder. Dermatologic Clinics, 14, 457464.
Crerand, C. E., Menard, W., & Phillips, K. A. (2010).
Surgical and minimally invasive cosmetic procedures among persons with body dysmorphic disorder. Annals of Plastic Surgery, 65, 11. doi:10.1097/
SAP.0b013e3181bba08f.
Didie, E. R., Menard, W., Stern, A. P., & Phillips, K. A.
(2008). Occupational functioning and impairment
in adults with body dysmorphic disorder. Comprehensive Psychiatry, 49, 561569. doi:10.1016/j.
Eisen, J. L., Phillips, K. A., Baer, L., Beer, D. A., Atala,
K. D., & Rasmussen, S. A. (1998). The brown assessment of beliefs scale: Reliability and validity. American Journal of Psychiatry, 155, 102108.
First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B.
W. (2002). Structured clinical interview for DSM-IVTR axis I disorders, research version, patient edition.
(SCID-I/P). New York: Biometrics Research, New
York State Psychiatric Institute.
Hollander, E., Allen, A., Kwon, J., Aronowitz, B., Schmeidler, J., Wong, C., & Simeon, D. (1999). Clomipramine vs desipramine crossover trial in body
dysmorphic disorder: Selective efficacy of a serotonin
reuptake inhibitor in imagined ugliness. Archives of
General Psychiatry, 56, 10331039. doi:10.1001/
archpsyc.56.11.1033.
Koblenzer, C. S. (1985). The dysmorphic syndrome.
Archives of Dermatology, 121, 780. doi:10.1001/
archderm.1985.01660060094029.
Koran, L. M., Abujaoude, E., Large, M. D., & Serpe, R. T.
(2008). The prevalence of body dysmorphic disorder
in the United States adult population. CNS Spectrums:
The International Journal of Neuropsychiatric Medicine, 13, 316322.
Lai, C-S., Lee, S-S., Yeh, Y-C., & Chen, C-S. (2010).
Body dysmorphic disorder in patients with cosmetic
surgery. The Kaohsiung Journal of Medical Sciences,
26, 478482. doi:10.1016/S1607-551X(10)70075-9.
Perugi, G., Giannotti, D., Di Vaio, S., Frare, F., Saettoni,
M., & Cassano, G. B. (1996). Fluvoxamine in the treatment of body dysmorphic disorder (dysmorphophobia). International Clinical Psychopharmacology, 11,
247254. doi:10.1097/00004850-199612000-00006.
Phillips, K. A. (1991). Body dysmorphic disorder: The
distress of imagined ugliness. American Journal of
Psychiatry, 148, 11381149.
Phillips, K. A. (1998). Body dysmorphic disorder: Clinical aspects and treatment strategies. Bulletin of the
Menninger Clinic, 62(4 Suppl A), A3348.
Phillips, K. A. (2000). Quality of life for patients
with body dysmorphic disorder. Journal of
Nervous and Mental Disease, 188, 170175.
doi:10.1097/00005053-200003000-00007.

Phillips, K. A. (2004). Psychosis in body dysmorphic
disorder. Journal of Psychiatric Research, 38, 6372.
doi:10.1016/S0022-3956(03)00098-0.
Phillips, K. A. (2005). The broken mirror: Understanding
and treating body dysmorphic disorder. New York:
Phillips, K. A. (2006). An open-label study of escitalopram in body dysmorphic disorder. International Clinical Psychopharmacology, 21, 177. doi:10.1097/01.
yic.0000194378.65460.ef.
Phillips, K. A. (2007). Suicidality in body dysmorphic
disorder. Primary Psychiatry, 14, 58.
Phillips, K. A., & Diaz, S. F. (1997). Gender differences
in body dysmorphic disorder. Journal of Nervous and
Mental Disease, 185, 570577.
Phillips, K. A., & Hollander, E. (2008). Treating body
dysmorphic disorder with medication: Evidence, misconceptions, and a suggested approach. Body Image,
5, 1327. doi:10.1016/j.bodyim.2007.12.003.
Phillips, K. A., & Menard, W. (2006). Suicidality in body
dysmorphic disorder: A prospective study. American
Journal of Psychiatry, 163, 12801282. doi:10.1176/
appi.ajp.163.7.1280.
Phillips, K. A., & Najjar, F. (2003). An open-label study
of citalopram in body dysmorphic disorder. Journal
of Clinical Psychiatry, 64, 715720. doi:10.4088/JCP.
v64n0615.
Phillips, K. A., McElroy, S. L., Keck, P. E., & Hudson,
J. I. (1994). A comparison of delusional and nondelusional body dysmorphic disorder in 100 cases. Psychopharmacology Bulletin, 30, 179186.
Phillips, K. A., Hollander, E., Rasmussen, S. A., &
Aronowitz, B. R. (1997). A severity rating scale for
body dysmorphic disorder: Development, reliability,
and validity of a modified version of the Yale-Brown
obsessive compulsive scale. Psychopharmacology
Bulletin, 33, 1722.
Phillips, K. A., Dwight, M. M., & McElroy, S. L. (1998).
Efficacy and safety of fluvoxamine in body dysmorphic disorder. Journal of Clinical Psychiatry, 59, 165
171. doi:10.4088/JCP.v59n0404.
Phillips, K. A., Grant, J., Siniscalchi, J., & Albertini, R. S.
(2001). Surgical and nonpsychiatric medical treatment
of patients with body dysmorphic disorder. Psychosomatics, 42, 504510. doi:10.1176/appi.psy.42.6.504.
Phillips, K. A., Albertini, R. S., & Rasmussen, S. A.
(2002). A randomized placebo-controlled trial of
fluoxetine in body dysmorphic disorder. Archives
of General Psychiatry, 59, 381388. doi:10.1001/
archpsyc.59.4.381.
271
Phillips, K. A., Menard, W., Fay, C., & Weisberg, R.

(2005a). Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics,
46, 317325. doi:10.1176/appi.psy.46.4.317.
Phillips, K. A., Menard, W., Fay, C., & Pagano, M. E.
(2005b). Psychosocial functioning and quality of life in
body dysmorphic disorder. Comprehensive Psychiatry,
46, 254260. doi:10.1016/j.comppsych.2004.10.004.
Phillips, K. A., Pinto, A., Hart, A. S., Coles, M. E., Eisen,
J. L., Menard, W., & Rasmussen, S. A. (2012). A
comparison of insight in body dysmorphic disorder
and obsessivecompulsive disorder. Journal of Psychiatric Research, 46, 12931299. doi:10.1016/j.
jpsychires.2012.05.016.
Phillips, K. A., Menard, W., Quinn, E., Didie, E. R., &
Stout, R. L. (2013). A 4-year prospective observational
follow-up study of course and predictors of course in
body dysmorphic disorder. Psychological Medicine,
43, 11091117. doi:10.1017/s0033291712001730.
Rief, W., Buhlmann, U., Wilhelm, S., Borkenhagen, A.,
& Brahler, E. (2006). The prevalence of body dysmorphic disorder: A population-based survey. Psychological Medicine, 36, 877886. doi:10.1017/
S0033291706007264.
Rosen, J. C., Reiter, J., & Orosan, P. (1995). Cognitivebehavioral body image therapy for body dysmorphic
disorder. Journal of Consulting and Clinical Psychology, 63, 263. doi:10.1037/0022-006X.63.2.263.
Veale, D. (2001). Cognitive-behavioural therapy for body
dysmorphic disorder. Advances in Psychiatric Treatment, 7, 125132.
Wilhelm, S. (2006). Feeling good about the way you look:
A program for overcoming body image problems. New
York: Guilford.
Wilhelm, S., Phillips, K. A., Fama, J. M., Greenberg, J. L.,
& Steketee, G. (2011). Modular cognitivebehavioral
therapy for body dysmorphic disorder. Behavior Therapy, 42, 624633. doi:10.1016/j.beth.2011.02.002.
Wilhelm, S., Phillips, K. A., & Steketee, G. (2013). A cognitive behavioral treatment manual for body dysmorphic disorder. New York: Guilford.
Wilhelm, S., Phillips, K. A., Didie, E., Buhlmann, U.,
Greenberg, J. L., Fama, J. M., etal. (2014). Modular cognitive behavioral therapy for body dysmorphic
disorder: A randomized controlled trial. Behavior
Therapy, 45, 314327.

Excoriation (Skin-Picking)
Disorder
19
Lauren S. Hallion, Jennifer M. Park

and Nancy J. Keuthen
Nature and Epidemiology

Previously classified as an impulse control disorder, excoriation disorder was added to the
Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5; American
Psychiatric Association (APA) 2013) as a distinct obsessive-compulsive spectrum disorder.
Excoriation disorder, also known as skin-picking
disorder, acn excorie, dermatillomania, neurotic dermatosis, and psychogenic excoration
(Deckersbach etal. 2003), was first described
by Wilson in 1875, who noted that his neurotic
patients sometimes exhibited self-inflicted skin
injuries (Fruensgaard etal. 1978). In its current
instantiation in DSM-5, excoriation disorder is
characterized by skin picking that results in tissue damage, attempts to stop or decrease picking,
and clinically significant impairment or distress
(APA 2013).
Mild skin picking is a relatively common
grooming behavior; in a large community-based
study, 62.7% of participants endorsed some form
of skin picking (Hayes etal. 2009). Prevalence
rates for clinically significant skin-picking range
N.J.Keuthen()
OCD and Related Disorders Program, Massachusetts
General Hospital, 185 Cambridge St. Suite 2200, Boston,
MA 02114, USA
e-mail: nkeuthen@mgh.harvard.edu
L.S.Hallion J.M.Park
Massachusetts General Hospital/Harvard Medical
from 1.4 to 5.4% (Hayes etal. 2009; Keuthen

etal. 2010). The gender distribution of excoriation disorder is heavily skewed, with women
representing 75% or more of clinically significant skin pickers (Arnold etal. 1998; Odlaug and
Grant 2008; Wilhelm etal. 1999). However, no
gender differences have been observed in terms
of severity of distress or impairment among individuals with clinically significant picking (Tucker etal. 2011).
Excoriation appears to aggregate in families,
suggesting a possible genetic contribution to the
disorder (Monzani etal. 2012). Studies of individuals with skin-picking disorder have found a
28.343.0% prevalence of clinically significant
skin picking in first-degree relatives (Neziroglu
etal. 2008; Odlaug and Grant 2012). Skin-picking onset can occur in childhood, adolescence,
and adulthood (Bohne etal. 2002; Flessner and
Woods 2006; Keuthen etal. 2010). Skin picking
appears to be a chronic condition, with a mean
illness duration of 1920 years (Grant etal. 2007;
Keuthen etal. 2000).
Clinical Characteristics
Clinical characteristics and rates of skin picking
appear similar across cultures (Bohne etal. 2002;
Calikuu etal. 2012; Monzani etal. 2012). In a
large-scale (N
=
760), Internet-based study of
clinically significant skin picking, participants
reported picking from an average of 4.73 sites on
the body (Tucker etal. 2011). The most common

DOI 10.1007/978-3-319-17139-5_19
273
274
picking sites (endorsed by 40% of the sample)

included the face (the most common site; 74% of
the sample), scalp, arms, legs, and torso. Targets
of picking most commonly included pimples,
scabs, and pus or fluid beneath skin. The most
common picking behaviors were squeezing,
scratching, or digging at the skin. Across studies, fingernails are the most frequently reported
picking implements; however, tweezers, needles,
knives, and other objects are also used (Grant
etal. 2007; Neziroglu etal. 2008; Tucker etal.
2011).
Clinically significant skin picking is characterized in large part by a perceived lack of control
over picking behaviors (Arnold etal. 1998; Snorrason etal. 2011; Wilhelm etal. 1999). Similar
to trichotillomania (hairpulling disorder), picking
is often preceded by an urge or physical tension, with pleasure or gratification experienced
after the picking is complete (Tucker etal. 2011).
Skin picking is sometimes performed in response
to uncomfortable physical sensations or in an effort to correct perceived unattractiveness (Tucker
etal. 2011). However, more common triggers
are stress, boredom, distress, anger (Arnold etal.
2001; Neziroglu etal. 2008), and urges to pick
(Tucker etal. 2011).
Similar to trichotillomania, picking behaviors
occur both automatically (outside of awareness)
and consciously or intentionally (called focused picking; Grant etal. 2007; Keuthen etal.
2000). Often, picking episodes may begin automatically and become focused at a later point in
the picking episode (Grant etal. 2007; Keuthen
etal. 2000).
Excoriation disorder can be associated with
considerable interference and distress (Wilhelm
etal. 1999). Picking can result in considerable tissue damage and permanent disfigurement (Antony
etal. 1998; Wilhelm etal. 1999), as well as scars,
skin infections, and septicemia (Odlaug and Grant
2012; Keuthen etal. 2000; Neziroglu etal. 2008).
Skin picking is also time consuming: Tucker etal.
(2011) report that over 75% of participants spent
one or more hours per day in picking-related
thoughts and behaviors. Participants frequently reported moderate or greater damage to skin, as well
as mild-to-moderate interference in social life, re-
L. S. Hallion et al.
lationships, and work due to picking (Tucker etal.

2011). Other sources of impairment and distress
result from the guilt, shame, or frustration with
the perceived inability to control the behavior; in
one study, 85.9% of subjects reported anxiety and
66.3% reported depression due to picking (Flessner and Woods 2006).
Treatment
Dermatological treatment is most commonly
sought for skin picking; these treatments can include topical antibiotics, cleansers, and creams;
plastic surgery; dermabrasion; skin grafts; and
laser therapy (Arnold etal. 1998; Odlaug and
Grant 2008; Wilhelm etal. 1999). Conversely,
psychiatric treatment seeking for excoriation disorder is relatively uncommon; some studies estimate that less than 20% of individuals with clinically significant skin picking seek treatment for
the condition (Flessner and Woods 2006; Grant
etal. 2007). An exception is the Tucker etal.
(2011) study, which found that 49.3% of participants (n=367) had sought psychiatric treatment
for skin picking. This larger percentage may be
due to the studys recruitment methods: Participants were solicited from websites focused on
self-help and support for skin picking, related disorders (e.g., trichotillomania), and dermatological conditions (e.g., acne). Thus, this sample may
have been better informed about the psychiatric
basis ofand availability of psychiatric treatments forskin picking than the general population. In the Tucker etal. (2011) study, satisfaction with psychiatric treatment for skin picking
was low. Participants generally reported that their
providers were not knowledgeable about skin
picking. The most commonly provided treatment
was antidepressants (83.7% of the sample). The
majority of participants reported that their picking was unchanged or worse following treatment.
Few empirical studies have investigated psychiatric treatments for skin picking. Studies
examining the efficacy of selective serotonin
reuptake inhibitors (SSRIs) in the treatment of
skin picking have resulted in mixed findings. In
a 10-week double-blind trial of fluoxetine with
19 Treatment of an Adult with Excoriation (Skin-Picking) Disorder
17 participants (Simeon etal. 1997), those who

received fluoxetine had significant reductions
in symptoms relative to the control group. In an
open-label trial of 15 patients treated with fluoxetine, only eight patients experienced a 30% or
more reduction in symptoms (Bloch etal. 2001).
When these eight responders were randomly assigned to receive continued fluoxetine or placebo,
the patients who received continued fluoxetine retained their gains, while those assigned to placebo
experienced a return to baseline symptom levels.
In a 12-week open-label trial in 14 skin-picking patients (Arnold etal. 1999), fluvoxamine
produced a clinically significant reduction in
50% of participants. However, this study was
limited by its high attrition rate; only 50% of participants completed the study. More recently, in
an 18-week open-label trial of escitalopram with
29 patients, 44.8% of patients were full medication responders (defined as a 25% or greater decrease on the primary skin-picking outcome and
a global clinical severity of mild or less severe;
Keuthen etal. 2007). Lamotrigine, opioid antagonists, and glutaminergic agents have also been
used, with mixed success (Grant etal. 2012).
Cognitive-behavioral therapy (CBT) for excoriation disorder, which generally includes
HRT (habit reversal training; Azrin and Nunn
1973) and additional interventions, also appears
to be a promising treatment. In two randomized,
wait-list controlled pilot studies, those in the
CBT condition were found to have significant
reductions in skin picking at posttreatment and
23-month follow-up (Schuck etal. 2011; Teng
etal. 2006). In an open pilot study examining
acceptance-enhanced behavior therapy (AEBT),
all patients experienced significant reductions in
picking at posttreatment (Flessner etal. 2008).
Thus, although several promising interventions
have been identified, a lack of research precludes
strong conclusions about the efficacy of psychiatric treatments for skin picking.
Description of Presenting Problem

Emily was a 33-year-old, college-educated,
Caucasian woman who presented to our clinic
seeking treatment for self-injurious skin pick-
275
ing. Emily reported a 20-year history of selfinjurious skin picking, which began in the context of mild acne as a teenager. She reported a
waxing and waning course, which tended to increase in severity during times of stress. Emily
reported that her self-injurious skin picking was
the worst its ever been in the months leading up to her decision to seek treatment at our
specialty clinic for obsessive-compulsive and
related disorders.
Emily displayed moderately severe skin picking. She picked primarily from her face, neck,
chest, and pubic area. The most common targets
were pimples, bumps, scabs, and dried skin.
She also reported chewing the insides of her
cheeks and lips and biting her nails and cuticles,
often to the point of bleeding. Emilys skin picking occurred both automatically and intentionally. She reported spending up to three cumulative
hours each day looking in the mirror, which involved zooming in on her face, neck, and chest
in search of imperfections. Emily primarily used
her fingers and fingernails to pick at her skin,
but also occasionally used pins, tweezers, and a
metal extraction tool obtained from a beauty supply store.
Emilys skin picking resulted in moderate
damage, with visible lesions, scabs, and scars
covering approximately 15% of her face. There
were no significant infections at the time of treatment; however, she reported several superficial
infections in the past year, which she self-treated
with topical isopropyl alcohol and tea tree oil.
Emily reported no history of systemic infections
or medical treatment for injuries that resulted
from skin picking.
Emily completed two assessment sessions
and nine sessions of CBT, which included psychoeducation, self-monitoring and awareness
training, stimulus-control techniques, competing
response training, and relapse prevention as well
as elements of contingency management and
dialectical behavior therapy (DBT). Following
treatment, Emily experienced a clinically meaningful reduction in symptoms, as evidenced by a
5868% reduction on two measures of skin picking severity and impact (the Skin Picking Scale
(SPS; Keuthen etal. 2001b) and the Skin Picking
Impact Scale (SPIS; Keuthen etal. 2001a)).
276
Case Information
Demographic Information
Emily was the oldest child of her biological parents, with whom she resided until she began college. Emilys family of origin was middle-to-upper class; both parents were college educated and
employed. Emily was moderately overweight
(body mass index of 28). Her medical history
was unremarkable and no medical illnesses were
present at the time of treatment.
Emily endorsed a strong family history of impulse control and emotional disorders. Each of
her first-degree relatives was diagnosed with or
suspected to have psychiatric conditions including alcohol abuse or dependence (father, sibling),
trichotillomania (mother), and major depression
(mother, sibling). She also suspected bipolar disorder, alcohol abuse, and compulsive gambling
in one or more extended family members.
Upon assessment, Emily presented as high
functioning and accomplished. She had recently
completed a masters degree and was employed
full time as a professional at the time of assessment. She resided with her female partner of 3
years. Emily reported performing very well in
her current job and had received several promotions and raises during her career. Nevertheless,
she reported feeling overworked, unappreciated, and unhappy at work and was actively
seeking alternative employment at the time of
assessment.
Disorder Course
Emily reported a 20-year history of skin picking that began following the emergence of mild
acne during early adolescence. Emily reported
that she was unaware of her acne until her pediatrician prescribed an antibiotic during a regular
checkup. In the years following this encounter,
Emily experienced increasing concern and preoccupation with the appearance of her skin. She
pursued aggressive dermatological treatments
for acne, including over-the-counter face washes
and skin creams, prescription skin creams, and
several rounds of antibiotics, all of which she described as ineffective and several of which she
believes worsened her appearance. She subsequently persuaded her dermatologist to prescribe
Accutane, which she found moderately helpful.
Based on Emilys report, she may have met criteria for body dysmorphic disorder (BDD) as
an adolescent due to her preoccupation with her
skin. However, she never misperceived her acne
as severe or disfiguring. Rather, she acknowledged that her acne was relatively mild, but was
distressed by any blemishes and was strongly
motivated to achieve perfect skin.
Emily reported that she began picking at her
facial pores and pimples at age 13 in an attempt
to improve the appearance of her skin. Her skin
picking waxed and waned during adolescence
and early adulthood; she reported picking infrequently during periods of low stress (e.g., toward
the end of college) and immediately following
treatment with isotretinoin. However, after age
25, Emilys pick-free periods became infrequent
(lasting several days at most).
When Emily presented for treatment, her focused picking episodes occurred at least three
times daily (morning, late afternoon, and evening), with episodes often lasting for 30min or
longer. Emily also reported automatic picking,
but had difficulty articulating the frequency or
duration of these behaviors. Her primary picking
areas included the face, neck, and chest. Picking implements included fingernails, tweezers,
needles, and a metal extractor purchased from
a beauty supply company. Picking targets primarily included pimples or bumps on her face and
chest, dried skin, and scabs in any location on the
body. She generally disinfected open lesions with
undiluted isopropyl alcohol or tea tree oil, which
resulted in significant drying of the skin.
The intensity and frequency of Emilys focused skin picking occasionally caused her to
forgo social and leisure activities to attend to her
skin. Emilys relationship with her partner was
strained due to her picking; Emily reported that
she would get lost in her picking and would fail
to complete daily chores in the home. She often
avoided her partner after picking episodes due to
shame and embarrassment about her appearance.
At the time of assessment, Emily was spending

up to an hour each day applying heavy makeup to
conceal the skin damage caused by her picking.
Occasionally, she would wear scarves or hats to
cover lesions caused by her picking.
Previous Treatment
Emily reported first seeking psychiatric treatment for anxiety and depression when she was
19 years old, around the time she was publicly
coming out as a lesbian. She sought treatment
at her universitys student mental health service
and was subsequently referred to a psychiatrist.
She did not report her skin-picking behaviors to
her psychiatrist due to the belief that her picking
was not a big deal. She was prescribed 10mg
of fluoxetine for 2 years, then 30mg of escitalopram the following year following nonresponsiveness to the fluoxetine. She reports that both
medications were mildly helpful in reducing her
depression; however, she eventually discontinued her treatment because she did not want to be
dependent on medication.
In the months prior to presenting for treatment, Emily sought support for her skin picking
on anonymous self-help websites. Emily reported that, although she found the skills described
on the websites to be helpful for a brief period
of time (e.g., dimming bathroom lights; placing no picking reminders around her home),
she had difficulty sustaining behavioral changes
and lacked the motivation to continue to practice
behavioral skills on her own. No previous psychotherapy or psychiatric interventions for skin
picking were pursued.

Assessment
Emily presented to her initial psychiatric evaluation professionally dressed and carefully
groomed. Moderate tissue damage was visible
even through her heavy makeup. Assessment
was completed over two 50-min sessions and included an unstructured interview and two semi-
277
structured diagnostic interviews (the Structured

Clinical Interview for DSM-IV Axis I Disorders
(SCID); First etal. 1996) and relevant modules
of the Structured Clinical Interview for DSM-IV
Axis II Disorders (SCID-II; First etal. 1997). A
thorough risk assessment was also completed.
Emily denied any current or past suicidal ideation or intent and was not found to be at risk for
self-harm (other than secondary harm resulting
from picking) or harm to others. Emily completed several self-report measures, which included
the SPS (Keuthen etal. 2001b) and the SPIS
(Keuthen etal. 2001a), among others.
Emily was referred to a dermatologist for a
thorough assessment. The dermatological results
indicated that, although Emily had several open
wounds, no superficial or systemic infections
were present. The dermatologist instructed Emily
to discontinue her use of abrasive facial cleansers
and instead recommended a gentle, pH-balanced
cleanser and moisturizer. Emily was instructed
to use a 50% hydrogen peroxide solution and a
polysporin ointment to treat any new wounds.
The therapist also recommended that Emily
consult with a psychiatrist for adjunctive psychopharmacological treatment. However, Emily was
unwilling to consider psychoactive medication at
the time of assessment. Given the relatively low
risk in Emilys case, the therapist acquiesced to
Emilys preference, on the condition that a psychiatric evaluation remain on the table if the
therapist deemed it necessary during the course
of treatment.
Assessment Battery Results

SCIDAt the time of treatment, Emilys skin
picking was captured by a DSM-IV diagnosis of
impulse control disorder, not otherwise specified (ICD-NOS) (APA 1994). A review of her
case reveals that she also would have met criteria
for DSM-5 excoriation disorder. Emily also met
DSM-IV criteria for generalized anxiety disorder
(GAD) and moderate, recurrent major depressive
disorder (MDD).
Emily reported GAD onset around age 12.
Her worries had a chronic, persistent course.
Her most notable GAD symptoms included ex-
278
cessive and uncontrollable worries regarding

her work performance, interpersonal relationships, and community/world affairs. Emilys first
depressive episode occurred at age 16 and followed a waxing and waning course, with three
discrete episodes identified. The present episode
began approximately 1 year prior to Emilys presentation at our clinic. Her primary symptoms
included moderate anhedonia and chronic feelings of worthlessness and guilt. Emily attributed
these symptoms in part to shame regarding her
picking and dissatisfaction at work. She also
endorsed hyperphagia and occasional (twicemonthly) binge eating, which had resulted in a
15-lb weight gain within the past year. Emily denied a history of suicidal ideation or any previous
suicide attempts, although she endorsed some
mild non-suicidal self-injury (superficial cutting,
never requiring medical attention) during early
adolescence.
SCID-II Emily met diagnostic criteria for obsessive-compulsive personality disorder (OCPD).
Her primary symptoms included rigidity and perfectionism. These symptoms were particularly
notable at work, where she would focus excessively on minor details and work ceaselessly on
tasks until she felt satisfied with the end product.
Her excessive dedication to work occasionally
interfered with her personal life, as her partner
felt that Emily did not make enough time for her.
Emily also reported occasional arguments with
her partner regarding the right way to clean and
tidy the home.
Emily also displayed subthreshold traits of
borderline personality disorder (BPD). Emily
was prone to mild affective instability: Minor
situations (e.g., a gruff tone of voice from a supervisor) would cause Emily to experience brief
but intense anxiety, sadness, or anger. Emily reported that her current relationship was happier
and more stable than previous relationships, although some fears of abandonment were noted.
Emily also reported some impulsivity (e.g., purchasing unnecessary items, particularly when
experiencing intense emotions) and impaired
distress tolerance (e.g., drinking to self-soothe
following severe picking episodes).
Self-Report Measures The SPS (Keuthen etal.

2001b) is a well-validated, six-item self-report
measure that assesses frequency and intensity
of urges, time spent picking, interference due to
picking, and associated avoidance and distress.
These questions are on 5-point Likert scales,
which range from 0 (none) to 4 (extreme). Total
scores range from 0 to 24, with a cutoff of 7
corresponding to clinically significant picking
(Keuthen etal. 2001b). Emily scored a 19 at her
baseline assessment.
The SPIS (Keuthen etal. 2001a) is a 10-item
self-report measure of the psychosocial consequences of skin picking during the past week.
Items are rated on 6-point Likert scales ranging
from 0 (none) to 5 (severe) with a cutoff of 7, indicating clinically significant interference (Keuthen etal. 2001a). Emily scored a 31 at baseline.
The Beck Depression Inventory-2nd Edition
(BDI-II; Beck etal. 1996) is a widely used and
well-validated 21-item self-report questionnaire
that assesses the presence and severity of depressive symptoms during the past week. Emily
scored a 23 on this measure, indicating moderate
depression. The Penn State Worry Questionnaire
(PSWQ; Meyer etal. 1990) is a well-validated
16-item inventory that measures the presence and
severity of excessive and uncontrollable worry.
Emily scored a 62 on this measure, indicating
clinically significant worry.

Following the two-session assessment, it was determined that Emilys comorbid conditions (i.e.,
depression, GAD, OCPD) would not significantly interfere with treatment for skin picking.
Emily was therefore treated with nine 50-min
sessions of CBT for excoriation disorder over
11 weeks (sessions 79 were spaced 2 weeks
apart). Habit reversal training (HRT; Azrin and
Nunn 1973) was the primary cognitive-behavioral intervention. HRT is composed of three main
components: awareness training, competing response techniques, and social support. Awareness
training is designed to increase the individuals
awareness of cues that trigger skin picking. Com-
peting response techniques, which are behaviors

that are incompatible to skin picking (e.g., making a fist when having urges to pick), are utilized
to prevent the skin picking from occurring. Social support is implemented so that family members and friends may reinforce non-picking and
give gentle reminders and encouragement to the
individual to continue practicing the behavioral
skills. Other cognitive-behavioral interventions
included stimulus control (wherein the environment is adjusted so that picking becomes more
difficult), DBT-informed distress tolerance, emotion regulation and mindfulness skills (Linehan
1993a, b), contingency management (wherein the
patient is rewarded for resisting the urge to pick),
and cognitive restructuring (wherein maladaptive
thoughts are identified and challenged).
Session 1
During session 1, the therapist first reviewed the
results of her assessment with Emily. Emily was
informed that although treatment would focus
primarily on skin-picking symptoms, she might
wish to pursue additional CBT for any remaining
depression and anxiety symptoms after the conclusion of the skin-picking treatment.
The therapist then described the symptoms
and phenomenology of excoriation disorder and
elicited Emilys feedback about which symptoms
she felt applied to her case. Emily expressed relief at finding a psychologist who she felt understood her skin picking and agreed that many
common features of skin picking, including picking in response to stress, boredom, and urges,
applied to her case. She recognized that she often
engaged in automatic as well as focused picking.
The therapist completed psychoeducation regarding the biology and function of the skin, with
the goal of helping Emily understand the full impact of her skin picking. Emily was shown a diagram of the skin and was given educational materials to read at home. The therapist explained
that the skin consists of several delicate layers,
each consisting of thousands of cells. When the
skin is picked and squeezed, fluid (including
blood and bacteria) can leak into the surround-
279
ing layers, creating inflammation. The therapist

then reviewed the dermatologists recommendations with Emily. Emily was particularly encouraged to discontinue her use of abrasive cleaners
and exfoliants, which strip the outer layer of skin
and make it more vulnerable to infection. Emily
was concerned that a gentle cleanser would not
be sufficient to thoroughly cleanse her skin, but
agreed to a trial period.
Next, the therapist provided a brief overview
of the treatment. Emily was told that she would
be taught to identify triggers for picking and
develop strategies to reduce her urges to pick.
Emily expressed some doubt about her ability to
substitute alternative strategies for picking, but
agreed to try. Finally, Emily was provided with a
basic self-monitoring form and was instructed in
its completion (see Fig.19.1). The therapist told
Emily that tracking her picking episodes and the
sensations that preceded and followed each episode would be essential for reducing her picking.
The form included columns for date and time,
context (e.g., at home, watching TV), location
of picking, strength of urge to pick, sensations
or emotions that preceded the urge to pick, when
and why the picking stopped, and emotions that
followed the picking. A practice-monitoring log
was completed in the session.
Session 2
In session 2, the therapist reviewed the self-monitoring log with Emily and completed a functional analysis (see Fig.19.2). Emily noted that her
focused picking most often occurred when she
felt anxious, angry, or bored; in the morning before showering; and in the evening after getting
home from work and during her bedtime preparations. In these situations, Emily reported that
she would go to the bathroom and lean into the
mirror, looking for good spots to pick. Picking
targets most frequently included irregularities in
the skin, including clogged pores, bumps, dried
skin, and scars or scabs from previous picking
episodes. Following most picking episodes, the
therapist noted that Emily reported feeling not
only calmer and relieved but also sometimes
280
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Fig. 19.2 Sample functional analysis
ashamed or annoyed with herself. The therapist

drew a simple functional analysis diagram, showing that certain emotions (e.g., anxiety) and be-
haviors (e.g., leaning into the mirror) led to an

increased urge to pick, which was then reduced
by completing the picking. The therapist also
noted that scabs and open lesions from picking

episodes might increase Emilys touching behavior and mirror checking, while the shame that
resulted from picking increased her negative affect and might make her more vulnerable to future picking episodes.
To increase Emilys awareness of her picking behaviors, the therapist then assisted Emily
in completing a more detailed, step-by-step chain
analysis. Emily identified feeling stressed and
anxious after a difficult day at work as a strong
vulnerability factor. Contexts that increased the
likelihood of picking included being home alone,
feeling anxious or lonely, or noticing a bump on
her skin (usually after face touching or inspection
in the mirror). Other prompting events included
automatically touching or picking the skin on her
face, neck, arms, and chest. These contexts created a strong urge to pick. In response to this
urge, Emily would go to the bathroom and closely examine her face in the mirror. Sometimes, she
would disinfect the identified area with alcohol
prior to picking. She then squeezed and picked
her skin until she felt satisfied (often following
the dislodging of sebum or pus) or until she gave
up on an area, at which point she would search
for a new target. Immediate, short-term consequences of picking were a mixture of feelings
of relief, satisfaction, shame, and self-directed
anger. Emily was also able to identify long-term
negative consequences, including patches of dry
skin (from harsh disinfectants), shame, anxiety, and increased use of heavy makeup. Emily
agreed that these consequences likely perpetuated her picking. For homework, Emily was given
another copy of the monitoring form and a chain
analysis handout to complete at home.
Session 3
In session 3, the therapist first reviewed the selfmonitoring and chain analysis forms. In the remainder of the session, the therapist and Emily
jointly identified stimulus control and competing response techniques. Stimulus control techniques, which Emily was instructed to use whenever possible, included turning the bathroom
281
lights off during her bedtime routine and using

stall bathrooms rather than individual bathrooms
at work (Emily reported reluctance to pick in
public bathrooms due to the fear that a coworker
would see her). The therapist recommended that
Emily place a sticker on her mirror to remind her
not to zoom in. Emily was also encouraged to
wear gloves during sedentary activities to reduce
time spent touching her face; however, she did
not agree to this recommendation because she
was concerned it would make her look stupid.
Competing response techniques, which Emily
was instructed to use in response to picking
urges, included sitting on her hands, making a
fist, combing her cat, and preparing a meal. The
social support component of habit reversal training was also introduced: Emily was encouraged
to talk to her partner or post on the forum for an
online skin-picking support group when she had
an urge to pick.
For homework, Emily was instructed to practice her stimulus control and competing response
techniques. Emily was also given a self-monitoring form and a copy of the SPS and SPIS to complete and bring to the next session.
Session 4
In session 4, the therapist first reviewed Emilys
self-monitoring log and self-report measures.
Her SPS score was 14 and her SPIS score was
27, representing a decrease from baseline of 26
and 13%, respectively. Emily reported noticing
a decrease in focused picking, including picking
only two to three times most days, picking for
shorter durations, and one pick-free day (Emilys first pick-free day in several months). Emily
was surprised and pleased to discover that her efforts had been successful, although she was disappointed that she was not able to stop picking
completely. The therapist congratulated Emily on
her progress and on her hard work and normalized her struggle and frustration.
Emily reported that she found placing reminders on her mirror to be particularly helpful in
preventing picking episodes. However, she still
struggled to resist strong picking urges, particu-
282
larly with respect to scabs on her face (which

were visible from a distance), dried skin, and
urges that accompanied anger and anxiety. Therefore, the remainder of the session focused on relaxation training (e.g., diaphragmatic breathing,
which was practiced in session) and identifying
distress tolerance techniques. Emily had some
familiarity with mindfulness (i.e., intentionally
and nonjudgmentally shifting the focus of attention to what is happening in the present moment,
thereby increasing awareness of emotions, urges,
and behaviors) as a result of completing mindfulness-based yoga classes at the gym. The therapist
therefore suggested that Emily apply her mindfulness skills to other activities that would distract or soothe her in times of distress (e.g., mindfully savoring a special treat or taking a bath).
For homework, Emily was asked to brainstorm and introduce other competing responses
and ways to keep her hands busy. The self-monitoring log was expanded to include successful
attempts to resist picking, including which techniques Emily had successfully employed to combat the urge to pick.
Session 5
The session began with a review of the past
weeks self-monitoring log. Emily reported that
her focused and automatic skin picking continued to decrease. For the focused picking, Emily
noted that exercising was a helpful alternative to
managing her negative affect and urges to pick.
Emily noted that while she was able to decrease
the overall frequency of the skin picking, the
stronger urges remained difficult to control.
Emily expressed difficulty using competing
responses for automatic picking, given her lowered awareness at that time. Based on the monitoring log, Emilys high-risk situations for automatic picking included talking on the telephone
and driving. Emily was therefore encouraged
to implement stimulus-control strategies during
these times (e.g., driving with both hands on the
wheel). She was also encouraged to engage in
mindfulness in these high-risk situations. Contingency management was also introduced as a
strategy to help Emily further reduce her focused

picking. Emily was asked to identify treats that
she valued and use these as rewards for meeting
behavioral goals. Emilys behavioral goals included multiple consecutive pick-free days and
consistent use of stimulus control and competing
response techniques. Reward contingencies included purchasing a gentle luxury face cleanser that Emily enjoyed, a new sweater, a new computer game, and a ski trip with her partner.
For homework, the therapist instructed Emily
to complete the self-monitoring log, continue
stimulus control and competing response techniques, and practice mindfulness skills. She was
also asked to complete the SPS and SPIS.
Sessions 68
At the beginning of session 6, Emilys SPS and
SPIS scores were 8 and 20, representing decreases from baseline of 58 and 35%, respectively. The
therapist began sessions 68 by reviewing Emilys self-monitoring logs. During these reviews,
Emily was asked to identify particular situations
and coping strategies that led to increases or decreases in picking urges and behaviors. Emily
reported an overall decrease in picking over the
course of these sessions, as well as increases in
her number of total and consecutive days free
from picking. Emily also noted that her automatic picking at home reduced when she began
knitting again, an activity that she had enjoyed in
early adulthood but which she had discontinued
in recent years. Emily reported that knitting was
distracting and kept her hands busy; she was also
pleased to be able to gift the products to loved
ones. By session 8, she was pick-free more days
than not, with one period of five consecutive
pick-free days (her longest stretch in years).
However, some slips were observed, particularly during times of stress (following an argument with her partner or family and upon being
rejected from a job for which she interviewed).
Emily often became angry with herself following these slips. Cognitive interventions to reduce
black-and-white thinking (e.g., challenging Emilys belief that a single picking episode undid
her previous success) were particularly helpful

in reducing this anger. Although Emily wished
to be entirely pick-free, she was ultimately able
to acknowledge her considerable progress since
beginning treatment.
Additional interventions during these sessions included motivational interviewing (Miller
and Rollnick 2013), mindfulness exercises, and
distress tolerance coaching. Motivational interviewing techniques, including rolling with
resistance, eliciting change talk, and planning
behavioral changes, were used to sustain Emilys
commitment to treatment, particularly when she
became frustrated with her slips. Emily was
reminded to apply the mindfulness and distress
tolerance skills reviewed in session 5 during
high-risk situations (e.g., while driving; when
she noticed a bump or clogged pore; following arguments with her partner or family). Emily
agreed to continue practicing these skills, as she
found them moderately helpful.
At the beginning of session 8, Emily reported
an SPS score of 9 and SPIS score of 16, which
corresponded to a slight increase from session
6 (attributable in part to life stress during week
7) but a decrease from baseline of 53 and 48%,
respectively. The final session was scheduled
for 2 weeks later. Emily was given an additional
battery of self-report measures to complete and
bring to the final session.
Session 9
Session 9 occurred 2 weeks after session 8 and
was designed as a consolidation and relapse prevention session. Emily was asked to develop a
list of skills, techniques, and observations that
she had found particularly helpful in reducing
her picking. Emily noted that stimulus-control
techniques (especially dimming bathroom lights
and placing reminders around her home) had
been particularly helpful for her, as had distress
tolerance techniques (e.g., taking a walk, knitting, talking with her partner and friends). Emily
was also asked to list positive outcomes that she
had noticed from implementing these strategies.
These included healthier skin, reduced makeup
283
(which she reported that her partner found more

attractive), higher self-confidence, and reduced
guilt and shame. Emily was encouraged to review this list frequently (at least weekly and
whenever she had an urge to pick). Emily was
also encouraged to continue her involvement in
online support groups for skin picking.
Emilys self-report measures revealed a significant decrease in skin picking, with SPS
and SPIS scores of 6 and 13, corresponding to
a decrease of 68 and 58%, respectively (see
Fig.19.3). Emilys SPS score placed her below
the clinical cutoff (Keuthen etal. 2001b). Emily
also evidenced a significant decrease in depression symptoms (BDI-II=16) and some decrease
in worry (PSWQ=57). However, she still experienced interference and distress as a result of
these symptoms. Emily was therefore referred to
a therapist known to our clinic who specialized in
CBT for emotional disorders and emotional dysregulation. This therapist was also competent in
skin-picking treatment.
Emily reported that she was highly satisfied with her skin-picking treatment. Her selfreport measures and subjective ratings reflected
considerable improvement in her skin-picking
symptoms, and she scored below the clinical significance cutoff on one self-report skin-picking
measure. Emily was highly motivated to continue
improving her skin-picking symptoms and was
invited to recontact our clinic if she experienced
a relapse that she did not feel equipped to manage
independently.
Emilys case was characterized by several complicating factors. First, Emily met diagnostic criteria for OCPD. Correspondingly, she presented
with significant black-and-white thinking and
rigidity regarding several treatment recommendations. For example, she refused a consultation
with a psychiatrist. Had Emily presented with
more severe or treatment-resistant psychopathology, additional cognitive interventions may have
been necessary to increase her willingness to
consider psychoactive medication. Additionally,
284
^W^
^W^
^W/^
^
^
^
^
^E
Fig. 19.3 Skin picking severity over treatment. SPS Skin-Picking Scale, SPIS Skin-Picking Impact Scale
Emily initially refused several dermatological

recommendations (e.g., discontinuing her use of
heavy makeup). However, Emily was amenable
to other recommendations to reduce the likelihood of infection, including using more gentle
approaches to disinfecting her skin and switching to a gentle, pH-balanced cleanser and moisturizer. Finally, Emily refused several stimuluscontrol techniques (e.g., wearing gloves) for fear
that these would make her look unprofessional
or stupid. As such, Emily continued to engage
in some automatic picking until she and her
therapist ultimately developed a more acceptable
stimulus-control technique for her to use at home
(knitting).
Additional black-and-white thinking was observed in Emilys reaction to slips (usually focused picking episodes), particularly following a
streak of several pick-free days. Following these
slips, Emily became angry with herself for undoing her considerable progress. Cognitive interventions focused on identifying and challenging Emilys black-and-white distortions were
necessary to help Emily place her slips in the
context of her (much more significant) progress

in treatment.
Emilys case was also characterized by subthreshold features of BPD, including impulsivity,
emotion dysregulation, and fears of abandonment. These features occasionally impeded the
therapy dynamic, as Emily would sometimes
become irritable or impatient with the therapist or treatment. During treatment, Emily was
more likely to engage in severe focused picking episodes during periods of distress. Emily
also picked more following arguments with her
partner and family members, which may have
reflected her difficulty tolerating disruptions in
these relationships. The therapist worked with
Emily to help her realize the connections between arguments with loved ones and picking
behavior. DBT strategies, including breathing
exercises and distress tolerance skills (e.g., distraction, self-soothing) appeared moderately useful in helping Emily manage her emotions and
resist the urge to pick on these occasions. Emily
was also encouraged to use these skills following
severe picking episodes to regulate her emotions.
Emily also experienced some mild life disruptions during the course of treatment, including applying and interviewing for several new
jobs, which she was not offered. These disappointments exacerbated Emilys anxiety and
depression, which resulted in more severe and
damaging picking. Distress tolerance techniques
were only modestly helpful on these occasions.
Although Emilys depression and anxiety were
moderately reduced following her skin-picking
treatment, she and the therapist agreed that referral to another cognitive-behavioral therapist was
warranted to improve Emilys overall well-being
and improve her ability to tolerate and regulate
her distress.
Conclusions
Emily was a 33-year-old Caucasian woman with
excoriation (skin-picking) disorder who was successfully treated with nine sessions of CBT over
11 weeks. Treatment incorporated a combination
of several cognitive-behavioral interventions,
including psychoeducation, awareness training,
habit reversal training, stimulus control, cognitive restructuring, contingency management, and
DBT skills. Emily reported clinically significant
reductions in skin-picking frequency, intensity,
and impact, with reductions of 68 and 58% reported on the SPS and SPIS, respectively (see
Fig.19.1).
The heterogeneous and complex presentation
of this disorder is reflected in the present case. In
our clinical experience, oftentimes it is necessary
to combine traditional habit reversal training with
other cognitive-behavioral interventions (e.g.,
cognitive restructuring, distress tolerance skills)
to manage comorbid psychiatric symptoms that
may contribute to picking behaviors or interfere
with treatment. A thorough assessment at the outset of treatment is critical to accurately identify
the reinforcement contingencies that maintain the
picking, as well as any other factors (e.g., comorbid psychopathology) that may complicate treatment. Ongoing assessment throughout treatment
is also necessary to continually tailor the treatment
course for each patient. Given the present dearth
285
of treatment efficacy data, randomized controlled

trials of cognitive-behavioral therapy for excoriation (skin-picking) disorder are warranted.
Key Practice Points

Conduct a thorough assessment to provide an
accurate differential diagnosis and identify
potentially complicating comorbid psychopathologies.
Recommend the patient to consult with a
dermatologist to identify any infections or
skin damage that may require medical attention.
Provide detailed psychoeducation regarding
the nature of excoriation disorder, potential
tissue damage associated with picking, and a
rationale for treatment.
Develop a behaviorally oriented treatment
plan tailored to the individual needs of the
patient.
Continuously assess skin-picking symptoms
to tailor the treatment plan and establish
whether medical intervention (e.g., to treat
infections) is warranted.
References
American Psychiatric Association (APA). (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: American Psychiatric
Association.
American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th
ed.). Arlington: American Psychiatric Association.
Antony, M. M., Bieling, P. J., Cox, B. J., Enns, M. W., &
Swinson, R. P. (1998). Psychometric properties of the
42-item and 21-item versions of the depression anxiety stress scales in clinical groups and a community
sample. Psychological Assessment, 10, 176181.
Arnold, L. M., McElroy, S. L., Mutasim, D. F., Dwight,
M. M., Lamerson, C. L., & Morris, E. M. (1998).
Characteristics of 34 adults with psychogenic excoriation. Journal of Clinical Psychiatry, 59(10), 509514.
Arnold, L. M., Mutasim, D. F., Dwight, M. M., Lamerson, C. L., Morris, E. M., & McElroy, S. L. (1999). An
open clinical trial of fluvoxamine treatment of psychogenic excoriation. Journal of Clinical Psychopharmacology, 19, 1518.
286
Arnold, L. M., Auchenbach, M. B., & McElroy, S. L.
(2001). Psychogenic excoriation: Clinical features,
proposed diagnostic criteria, epidemiology and
approaches to treatment. CNS Drugs, 15(5), 351359.
Azrin, N. H., & Nunn, R. G. (1973). Habit-reversal: A
method of eliminating nervous habits and tics. Behaviour Research and Therapy, 11, 619628.
Beck, A. T., Steer, R. A., & Brown, O. K. (1996). Beck
depression inventory manual (2nd ed.). San Antonio:
Bloch, M. R., Elliott, M., Thompson, H., & Koran, L. M.
(2001). Fluoxetine in pathologic skin picking: Openlabel and double-blind results. Psychosomatics, 42(4),
314349.
Bohne, A., Wilhelm, S., Keuthen, N. J., Baer, L., & Jenike, M. A. (2002). Skin picking in German students.
Prevalence, phenomenology, and associated characteristics. Behavioral Modification, 26(3), 320339.
Calikuu, C., Kucukoncu, S., Tecer, O., & Bestepe, E.
(2012). Skin picking in Turkish students: Prevalence,
characteristics, and gender differences. Behavior
Modification, 36, 4966.
Deckersbach, T., Wilhelm, S., & Keuthen, N. J. (2003).
Self-injurious skin picking: Clinical characteristics,
assessment methods, and treatment modalities. Brief
Treatment and Crisis Intervention, 3, 249258.
First, M. B., Spitzer, R. L. Gibbon, M., & Williams, J. B.
W. (1996). Structured clinical interview for DSM-IV
axis I disorders, clinician version (SCID-CV). Washington: American Psychiatric Association.
First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W.,
& Benjamin, L. S. (1997). Structured clinical interview for DSM-IV axis II personality disorders, (SCIDII). Washington: American Psychiatric Association.
Flessner, C. A., & Woods, D. W. (2006). Phenomenological characteristics, social problems, and the economic
impact associated with chronic skin picking. Behavior
Modification, 30(6), 944963.
Flessner, C. A., Busch, A. M., Heideman, P. W., & Woods,
D. W. (2008). Acceptance-enhanced behavior therapy
(AEBT) for trichotillomania and chronic skin picking: Exploring the effects of component sequencing.
Fruensgaard, K., Hjortshoj, A., & Nielsen, H. (1978).
Neurotic excoriations. International Journal of Dermatology, 17, 761767.
Grant, J. E., Odlaug, B. E., & Kim, S. W. (2007).
Lamotrigine treatment of pathological skin picking:
An openlabel study. The Journal of Clinical Psychiatry, 68, 13841391.
Grant, J. E., Oldaug, B. L., Chamberlain, S. R., Keuthen,
N. J., Lochner, C., & Stein, D. J. (2012). Skin picking
disorder. The American Journal of Psychiatry, 169,
11431149.
Hayes, S. L., Storch, E. A., & Berlanga, L. (2009). Skin
picking behaviour: An examination of the prevalence
and severity in a community sample. Journal of Anxiety Disorders, 23, 314319.
Keuthen, N. J., Deckersbach, T., Wilhelm, S., Hale, E.,
Fraim, C., Baer, L., etal. (2000). Repetitive skin picking in a student population and comparison with a
sample of self-injurious skin-pickers. Psychosomatics,
41(3), 210215.
Keuthen, N. J., Deckersbach, T., Wilhelm, S., Engelhard,
I., Forker, A., OSullivan, R. L., etal. (2001a). The
skin picking impact scale (SPIS): Scale development
and psychometric analyses. Psychosomatics, 42,
397403.
Keuthen, N. J., Wilhelm, S., Deckersbach, T., Engelhard, I. M., Forker, A. E., Baer, L., & Jenike, M. A.,
(2001b). The skin picking scale: Scale construction
and psychometric analyses. Journal of Psychosomatic
Research, 50, 337341.
Keuthen, N. J., Jameson, M., Loh, R., Deckersbach, T.,
Wilhelm, S., & Dougherty, D. D. (2007). Open-label
escitalopram treatment for pathological skin picking. International Clinical Psychopharmacology, 22,
268274.
Keuthen, N. J., Koran, L. M., Aboujaoude, E., Large, M.
D., & Serpe, R. T. (2010). The prevalence of pathologic skin picking in US adults. Comprehensive Psychiatry, 51, 183186.
Linehan, M. (1993a). Cognitive-behavioral treatment of
borderline personality disorder. New York: Guilford.
Linehan, M. M. (1993b). Skills training manual for
treating borderline personality disorder. New York:
Guilford.
Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec,
T. D. (1990). Development and validation of the penn
state worry questionnaire. Behaviour Research Therapy, 28, 487495.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing, third edition: Helping people change. New
York: Guilford.
Monzani, B., Rijsdijk, F., Cherkas, L., Harris, J., Keuthen,
N., & Mataix-Cols, D. (2012). Prevalence and heritability of skin picking in an adult community sample:
a twin study. American Journal of Medical Genetics
Part B: Neuropsychiatric Genetics, 159(5), 605610.
Neziroglu, F., Rabinowitz, D., Breytman, A., & Jacofsky,
M. (2008). Skin picking phenomenology and severity
comparison. Primary Care Companion to the Journal
Odlaug, B. L., & Grant, J. E. (2008). Clinical characteristics and medical complications of pathologic skin
picking. General Hospital Psychiatry, 30(1), 6166.
Odlaug, B. L., & Grant, J. E. (2012). Pathologic skin picking. In J. E. Grant, N. J. Keuthen, D. W. Woods, & D.
J. Stein (Eds.), Clinical manual for the treatment of
trichotillomania, skin picking, and other stereotypic
movement disorders (pp.2142). Washington: American Psychiatric Association.
Schuck, K., Keijsers, G. P., & Rink, M. (2011). The effects
of brief cognitive behaviour therapy for pathological
skin picking: A randomized comparison to wait-list
control. Behaviour Research Therapy, 49, 1117.
Simeon, D., Stein, D. J., Gross, S., Islam, N., Schmeidler,
J., & Hollander, E. (1997). A double-blind trial of
fluoxetine in pathologic skin picking. Journal of Clinical Psychiatry, 58(8), 341347.
Snorrason, I., Smari, J., & Olafsson, R. P. (2011). Motor
inhibition, reflection, impulsivity, and trait impulsiv-

ity in pathological skin picking. Behavior Therapy, 42,
521532.
Teng, E. J., Woods, D. W., & Twohig, M. P. (2006). Habit
reversal as a treatment for chronic skin picking: A pilot
investigation. Behavior Modification, 30(4), 411422.
Tucker, B. T., Woods, D. W., Flessner, C. A., Franklin, S.
A., & Franklin, M. E. (2011). The skin picking impact
project: Phenomenology, interference, and treatment
287
utilization of pathological skin picking in a populationbased sample. Journal of Anxiety Disorders, 25, 8895.
Wilhelm, S., Keuthen, N. J., Deckersbach, T., Engelhard,
I. M., Forker, A. E., Baer, L., etal. (1999). Self-injurious skin picking: Clinical characteristics and comorbidity. Journal of Clinical Psychiatry, 60(7), 454459.
Part IV
Special Populations and
Considerations
Treatment of ObsessiveCompulsive Disorder in Very

Young Children
20
Carly J. Johnco and Adam B. Lewin
Treating Obsessive-Compulsive
Disorder in Very Young Children
The understanding and treatment of pediatric
obsessive-compulsive disorder (OCD) has tended
to focus on school-aged children and adolescents,
although there is an increasing recognition of that
some children experience the emergence of these
symptoms at very young ages. The classification
of young children in studies of OCD varies
greatly, with some studies capturing preschoolaged children aged between 3 and 6 years (Coskun
and Zoroglu 2009; Coskun etal. 2012) although
other studies include children up to the age of 8
(e.g., Freeman etal. 2008, 2014; Garcia etal. 2009;
Lewin etal. 2014b); however, most studies tend to
report a mean age of around 5 years. As a consequence of the time consumed with compulsive
behaviors and the extent of family accommodation of symptoms, the onset of OCD in childhood
can create significant barriers to the development
of appropriate social relationships and can impact
on academic functioning and functioning within
A.B.Lewin()
Departments of Pediatrics, Psychiatry and Psychology,
e-mail: alewin@health.usf.edu
C.J. Johnco
Department of Pediatrics, University of South Florida,
880 6th Street South, Suite 460, Box 7523, St Petersburg
FL 33701
the family (Piacentini etal. 2003; Sukhodolsky

etal. 2005). Cognitive behavioral therapy (CBT)
and selective serotonin reuptake inhibitor (SSRI)
treatments have established efficacy in the treatment of OCD in school-aged children and adolescents (Geller etal. 2012; Lewin and Piacentini
2009; Watson and Rees 2008); however, there has
been less research examining treatment efficacy in
younger children. Despite increasing work in this
area in recent years, there remains considerable
complexity in terms of assessment and treatment
of OCD in young children.
Phenomenology
While there is evidence of overlap in the symptomatology of OCD in older children, adolescents,
and adults (Selles etal. 2014), there is limited
understanding about the phenomenology of OCD
in young children. Although young children tend
to report similar compulsive phenotypes, there
tends to be lower levels of obsessions compared
with older children (Coskun etal. 2012). This
may be due to the stage of cognitive development of young children, or may highlight the
challenges in assessing obsessive symptoms in
young children with limited reflective function,
limited insight into their symptoms, and limited
verbal ability to articulate their experience. Studies of children with OCD onset prior to age 6
typically report preoccupations with cleanliness,
ordering and/or symmetry, size/shape/color of
clothes, smelling things, hoarding, and excessive

DOI 10.1007/978-3-319-17139-5_20
291
292
reassurance seeking (Coskun and Zoroglu 2009;

Coskun etal. 2012). However, young children
with OCD often present with atypical features,
including tics, sensory hyperresponsivity, disruptive behaviors, and emotional liability that can be
difficult to attribute to OCD or a comorbid condition (Lewin etal. 2015).
Comorbidity is high in young children
with OCD, with most children having at least
one comorbid diagnosis (Coskun etal. 2012),
highlighting the diffuse nature of symptom
presentation in young children, and challenges
with differential diagnosis. The most common
comorbid conditions are attention deficit/hyperactivity disorder (ADHD), separation anxiety,
oppositional defiant disorder, specific phobia,
and tic disorders (Coskun and Zoroglu 2009;
Coskun etal. 2012; Selles etal. 2014).
There is evidence of slightly different clinical and prognostic profiles in children with
early-onset OCD (younger than 10) compared
to those who first experience symptoms at an
older age (Garcia etal. 2009; Nakatani etal.
2011), including longer duration of symptoms
and increased risk of comorbid tics; however, there does not appear to be any difference
in treatment response (Nakatani etal. 2011).
Among preschoolers, OCD symptoms show high
heritability in twin studies (Eley etal. 2003), with
68100% of parents and first-degree relatives
reporting a current or lifetime history of OCD
(Coskun and Zoroglu 2009; Coskun etal. 2012).
Assessment
There are numerous barriers to effective treatment of OCD in young children, including parental identification of symptoms, issues with developmentally appropriate assessment, and barriers
to accessing evidence-based treatment. Parental
beliefs about psychopathology and parental attributions for their childs behavior can greatly
impact on whether they present for treatment. For
example, parents may mistakenly believe that
their child is being defiant when they refuse to
disengage from a compulsion, rather than understanding their fear response. Other attributional
C. Johnco and A. B. Lewin
errors can occur when parents believe that their

childs behavior is part simply of a developmental stage that they will grow out of it. This can
result in parents either seeking inappropriate
treatment options or failing to seek treatment at
all. Parental beliefs about the cause and solution
to their childs symptoms can also result in problematic family interactions, including dismissive
or punitive parenting. Among parents of children
with OCD, more than half of parents in one study
reported using physical punishment in an effort
to change their childs OCD-related behaviors
(Coskun etal. 2012), a reaction that is ineffectual in modifying OCD behaviors. If parents do
seek appropriate treatment, it can be difficult to
locate skilled and trained clinicians who are competent in an evidence-based treatment for OCD,
and who are willing to treat young children. In
addition, there is lower acceptability of medication treatment for OCD among parents of young
children, further limiting available treatment
options and providers (Lewin etal. 2014c).
If parents are able to access a suitably qualified
clinician, assessment of OCD in young children
presents a number of challenges, both practically
and diagnostically. Young children vary greatly in
their developmental capacities, especially verbal
ability and reflective functioning. This generally
requires clinicians to conduct the assessment
with parents, who may have varying levels of
psychological insight and awareness of their
childs symptoms. Given the diffuse symptom
presentations in young children, it can be difficult
for both parents and clinicians to compartmentalize childrens symptoms in ways consistent with
diagnostic nosology, adding to the complexity of
assessment and treatment planning.
Differential diagnosis is challenging with
young children. Very young children may present
with behavioral and cognitive rigidity, avoidance,
extreme routine adherence, drive for sameness,
excessive sensory sensitivity, reassurance-seeking, and challenging behaviors (Dar etal. 2012).
These types of symptoms can be challenging to
differentiate from behavioral problems, autism
spectrum disorders, and other anxiety disorders.
While older children can typically provide some
understanding of their underlying cognitions and
20 Treatment of Obsessive-Compulsive Disorder in Very Young Children
content of fears, this may be more difficult with

young children, further complicating differential
diagnosis. There are several clinical suggestions
for assisting with differential diagnosis in children (Lewin and Piacentini 2010). For example,
differential assessment from autism spectrum
disorders may be aided with careful assessment
for early delays in developmental milestones and
language development, difficulty establishing
and maintaining social relationships, stereotyped
movements, as well as understanding whether
repetitive behaviors are inherently rewarding
(vs. in response to feared outcome) or related to
topics of particular interest to the child. While
differential diagnosis usually remains complex,
clinicians must attempt to understand the context
in which symptoms occur and infer their nature
from this information.
History of streptococcal infection is another
important diagnostic consideration, with the
potential for children to present with pediatric
autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) or
pediatric acute-onset neuropsychiatric syndrome
(PANS), a condition that can emerge following
streptococcal infection in prepubertal children,
and it is characterized by OCD-like symptoms
with rapid onset and remission (Moretti etal.
2008). An expert medical review should be
sought for these clients.
Understanding appropriate developmental
stages and age-normative comparisons is especially relevant for assessing OCD in young children. For example, it is important to differentiate between normal and pathological ritualistic
behavior in young children. Many young children display some aspects of non-pathological
ritualized behavior, such as insisting on lining
their toys up, requiring a certain toy for sleep,
playing hopscotch with specified patterns of
jumping, and becoming fixated on being contaminated with cooties from the opposite gender
(Leonard etal. 1990). Similarly, a certain level of
magical thinking and some level of rigidity is normal in young children (Evans etal. 2002). While
some of these features begin to resemble OCD
obsessions and rituals, there is a need to distinguish between pathological and non-pathological
293
behavior based on developmental norms, and

functional impact. Young children with OCD
typically display poor insight into their symptoms and are unlikely to recognize the excessive
or inappropriate nature of their anxiety (Coskun
etal. 2012; Lewin etal. 2010; Selles etal. 2014);
thus, an assessment of functional impairment and
impact is important. This is especially important
in the context of family accommodation, whereby even parents may underreport the functional
impact of symptoms where excessive accommodation can minimize the obvious impairments.
Relevant areas to assess include the impact on
family functioning, social functioning, persistence and frequency of behaviors, and distress if
prevented from engaging in the behavior.
The specific measures used during assessment
are an important choice for clinicians. Structured
clinical interviews represent the gold standard of
assessment in that they facilitate the collection
of comprehensive information in order to inform
diagnostic decisions, are validated, and allow for
comparisons to research outcomes (Lewin and
Piacentini 2010). However, in routine clinical
practice, there are also limitations, most notably,
the length of time taken to administer comprehensive diagnostic interviews. There are a variety
of other challenges to administering standardized
assessments, including inadequate validation
with young children, underreporting symptoms
related to limited insight or embarrassment, and
the literacy skills needed to complete self-report
measures. While the constraints of the particular
clinical setting need to be taken into account, best
practice would suggest the use of semi-structured
clinical interviews, clinician-rated measures, as
well as parent-rated questionnaires during the assessment process. Measures are usually administered by the clinician or are completed with the
parent. The Childrens YaleBrown ObsessiveCompulsive Scale (CYBOCS; Scahill etal. 1997)
is the preferred clinical interview for assessing
OCD symptoms, and it has been validated in
58-year-olds (Freeman etal. 2011). This scale
shows good reliability and validity for the total
score and compulsions subscale, but poor reliability for the obsessions subscale in young children (Freeman etal. 2011)and, unsurprisingly,
294
limitations of child reporting and parental observation of obsessional symptoms in comparison

to compulsive behaviors. This study found that
the CYBOCS was sensitive to change, and this
measure showed good discriminant validity from
a measure of depression but poor discriminant
validity from ADHD measures (Freeman etal.
2008), consistent with the overlap of symptoms
and high comorbidity with ADHD in young children. The severity of OCD (as measured by CYBOCS total severity scores) among very young
children was commensurate with the severity of
older youth (Lewin etal. 2014a). The other clinical interview often used in conjunction with the
CYBOCS is the Anxiety Disorders Interview
ScheduleParent version (ADIS-P; Silverman
and Albano 1996), which is the gold standard
for diagnosing anxiety and related disorders, and
it has been used with parents of preschool-aged
children (e.g., Dodd etal. 2012; Fox etal. 2012;
Hudson and Dodd 2012; Kennedy etal. 2009).
Treatment
There are limited studies assessing the efficacy
of treatment for preschool OCD. Current recommendations would suggest family-based CBT
focusing on exposure and response prevention
(ERP) techniques and involving parents as a
first-line treatment for OCD in young children
(Gleason etal. 2007). Although there is preliminary evidence for the use of SSRI medication, the
early stage of neurological development in young
children and poor tolerability of SSRI medication
have resulted in the recommendation that medication should only be considered if symptoms
continue to cause impairment following CBT/
ERP treatment (Gleason etal. 2007).
Currently, the strongest evidence base for
treatment of OCD in young children is for the use
of family-based ERP. This treatment involves a
number of developmentally sensitive adaptations
to treatment protocols with older children, and it
principally involves psychoeducation about OCD
in children, parent-focused tools to facilitate ERP,
and adapted CBT skills to facilitate childrens
involvement in ERP. Psychoeducation for parents
usually focuses on the neurobiology of OCD,

correcting misattributions about OCD behaviors,
and differentiating OCD symptoms (ChoateSummers etal. 2008). Parents are taught basic
behavior management skills to facilitate ERP and
any family/parenting issues are addressed, including hostile or critical parenting practices and
family accommodation of symptoms (Freeman
etal. 2012). Parents are heavily involved in the
generation of exposure hierarchies with children
and the implementation of ERP to facilitate generalization and out-of-session practice (Freeman
etal. 2012; Lewin etal. 2014b). Studies vary in
their use of cognitive therapy components given
the cognitive capacities of young children, and
one study with very young children found strong
effect sizes focusing on ERP and reducing family accommodation, without cognitive therapy
components (Lewin etal. 2014b). To date, this
study utilizes the largest sample of very young
children (35 years) and would support an
exclusive focus on ERP procedures very early in
treatment (session 1 or 2). Family-based ERP has
been found to be superior to relaxation therapy in
young children (Freeman etal. 2008, 2014), and
treatment as usual (Lewin etal. 2014b), and contrary to common opinions, is not associated with
increased dropout due to clients finding the treatment aversive (Freeman etal. 2008, 2014). ERP
appears to be a highly tolerable and efficacious
treatment for OCD in young children, although
more randomized controlled trials among very
young children are clearly needed.
There is some evidence for the efficacy of
SSRI treatment for young children with OCD in
reducing symptoms (Coskun and Zoroglu 2009;
Ercan etal. 2012); however, the acceptability
and tolerability is problematic. Perhaps due to
the poor rate of acceptability of pharmacological treatment among parents of young children
(Lewin etal. 2014c), there are few clinical trials
in this age group. The few studies that are available have utilized small samples of children and
indicate high rates of adverse side effects. In a
study of SSRI use in children under the age of 7,
Zuckerman etal. (2007) found that 28% reported
at least moderate side effects. Similarly, Coskun
and Zoroglu (2009) found high rates of side
effects in young children, including behavioral

disinhibition (hyperactivity, irritability, and oppositional behaviors), decreased appetite, weight
loss, sleep disturbance, headache, and abdominal
pain. This study also reported one case of risky
behaviors (jumping from heights/onto road).
Given the high rates of adverse side effects of
pharmacological treatment of OCD in young
children, ERP is likely to be preferable to many
families.
Case Presentation
Presentation
The challenges involved with assessing and treating OCD in young children are illustrated in the
case of Murray, a 4-year-old Caucasian male,
who was referred by his pediatrician subsequent
to increasingly disruptive emotional and behavioral outbursts at preschool. Murrays mother,
Alice, reported that he had always been a very
neat child, although over the past 6 months he
had begun insisting on lining each of his toys up
along the wall in his room in a specific order, and
he would become very angry and upset if his parents or older sister (9 years) would touch or move
them. When this happened, Murray would scream
loudly and snatch the toy back, then proceed to
spend several minutes reorganizing his toys until
he felt they were lined up just right. As a result,
Murrays parents tried to keep his sister out of his
room, and Alice would only vacuum Murrays
room while he was at preschool so he did not
witness her moving the toys. Murray also lined
up the pencils and paints on the table at preschool
and would yell dont or get if another child
attempted to take one. Over the past 6 months,
Murrays reactions had begun to escalate, and he
had hit or pushed other children several times in
recent months when they had attempted to take
an item, leading to minor injuries and requiring
the preschool teacher to intervene.
Although Murray had always been a fussy
eater, his eating had become increasingly restrictive over the past year, refusing to eat slimy
foods, and insisting that his foods did not touch
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on his plate. Murray would push his plate away

or throw it on the ground when his mother or
preschool teacher presented him with foods that
he considered wrong, and he would begin to
cry inconsolably. He had also been known to spit
foods onto the table once they became slimy in
his mouth after chewing them. As a result, Alice
tried to only give Murray crunchy foods and
would make him another meal if he refused his
dinner, reporting concerns that he would be hungry or may lose weight if she did not provide
acceptable foods for him.
Alice also reported that Murray had always
been afraid of using public toilets, and he would
refuse to enter the bathroom even with his mother
accompanying him. Although he had been toilet
trained from the time he was two, he often wet
himself at preschool and while they were out
shopping as a result of his refusal to enter public bathrooms. Murray would use the toilet at
home, although refused to press the flush button.
It appeared that Murrays anxiety was related to
the unexpected sounds in the bathroom from the
automatic flush and electric hand dryer, and it
did not appear to be contamination related. Alice
also reported that Murray was fearful of the noise
made by the vacuum cleaner and blender.
Background
Murray had been conceived using in vitro fertilization (IVF) subsequent to Alice suffering two
miscarriages after the pregnancy with his older
sister. Alice described Murray as their miracle
baby. Alice reported an unremarkable pregnancy and delivery, but described him as a fussy
baby with early difficulties in feeding and
sleeping. She noted that as a toddler, Murray was
emotionally labile, and would have meltdowns
in crowds of people, especially loud situations,
and was inconsolable until Alice removed him
from the situation. As a result, the family had
chosen a small daycare center for him, and they
tended to avoid crowded shops and playgrounds,
preferring to go to a local park near their house
to play. Alice and her husband, Clarence, took
turns minding the children while the other parent
296
attended to necessary household tasks, such as

grocery shopping to avoid any meltdowns. Alice
reported that she was concerned about how Murray would cope when he transitioned to primary
school.
There was a strong family history of anxiety,
with Murrays father, Clarence, suffering social
anxiety in his adolescence and early adulthood
and Alice herself reporting being a worrier.
Alice reported suspicions that her mother suffered
from OCD and still had had a preoccupation with
contamination, although this was not discussed
openly in their family.
Alice reported that Murray had been under
the care of a pediatrician from a young age due
to his difficulties in feeding and sleeping. They
had attended occupational therapy sessions for
several months when he was 3 to help with his
emotional outbursts with little efficacy. Murrays
speech was slightly delayed and simple in content for his age, although the family had not
sought any speech therapy.
Murray had always been a shy child who took
a while to warm up in new situations; however,
he had made several friends at daycare. Over the
past 6 months, Murrays preschool teacher had
noted that the other children no longer wanted
to play with him as a result of his outbursts and
refusal to share the toys that he had arranged in
the playroom. While some of his friends would
sometimes try and play with him at the start of
the day, they often lost interest when Murray
began engaging in his ordering rituals.
of this assessment, it was determined that Murray

had a primary diagnosis of OCD and comorbid
specific phobiaother subtype (loud noises).
Murrays OCD and specific phobia present
in the context of significant family history of
anxiety. The difficulties surrounding Murrays
conception and his early temperament have influenced a parental perception that Murray is
precious and vulnerable, and, as a result, Alice
and Clarence try to protect him from getting upset.
In addition, Murray appears to have particular
sensory sensitivities (auditory and tactile) that
overlap with his fear-based symptoms. Given his
high levels of distress, and the difficulties Alice
and Clarence describe in terms of soothing him,
there are high levels of family accommodation of
his anxiety that are likely to be maintaining his
symptoms. Additionally, there is accommodation
of his symptoms at preschool where teachers try
to redirect the children to play with different toys
if there is an altercation with Murray, reinforcing his ritualized behavior. Murrays symptoms
are having an increasingly significant impact on
his social functioning at preschool, family functioning and relationship with his sister who now
complains that Murray gets preferential treatment in the family. Additionally, Murray will be
starting school next year where his symptoms are
likely to be more impairing, given the increased
structure of activities, toileting issues, and new
peer group.
Assessment and Case

Conceptualization
Despite the rationale for involving both parents

in treatment being provided, Clarence was unable to attend sessions regularly given his work
schedule. Alice attended 11 treatment sessions
with Murray, and Clarence attended 3 sessions
intermittently through the treatment. The initial session aimed at providing psychoeducation about OCD and anxiety. Psychoeducation
focused on providing information about adaptive
and dysfunctional anxiety, typical presentations
of OCD, the negative reinforcement of compulsive behaviors, and the role of accommodation
and avoidance in maintaining anxiety. Murrays
Given Murrays age, and the length of clinical

interviews, Alice and Clarence attended the first
session at the clinic without him and completed two semi-structured clinical interviews: the
CYBOCS to assess for the full range of OCD
symptoms and the ADIS to assess for comorbid disorders. Murrays level of functioning was
rated using the Childrens Global Assessment
Scale (CGAS) and the Clinical Global Impression-Severity Scale (CGI-S). Based on the results
emotional outbursts were explained in the context

of common anxiety reactions in young children.
Alice was able to understand and identify with
the vicious cycle of anxiety, whereby allowing
him to engage in his compulsions, and facilitating accommodation and avoidance of anxietyprovoking situations reduced his distress in the
short term, but led to an overall escalation in his
anxiety in the longer term. The efficacy of familybased CBT in the treatment of OCD and anxiety
in young children was reviewed along with the
treatment rationale, highlighting the importance
of reducing accommodation, avoidance, and compulsive behaviors. Psychoeducation was provided
in a developmentally sensitive way with Murray,
focusing on externalizing his OCD, identifying
how it makes him feel in his tummy, and what
behavior it makes him engage in. Examples were
provided to illustrate the link between feelings
and behaviors, asking questions such as sometimes OCD makes kids get mad with their mum or
dad, or with their friends. Does OCD ever make
you get mad? Maladaptive responses to anxiety were discussed using the language of OCD
being bossy and tricking kids into engaging in
certain behaviors, even though nothing bad was
going to happen. Murray engaged well with this,
and when asked is the OCD the boss of you, or
are you the boss of the OCD? he responses that
OCD was the boss of him, but he would prefer
to be the boss. Murray and Alice both laughed at
the idea of tricking OCD and bossing OCD back,
by not doing what it says. Murray suggested that
he could tell OCD no, that it was naughty or
that he was the boss to help reduce the intensity. While it was not anticipated that this would
be particularly potent in maintaining Murrays engagement in therapy or reducing his anxiety, this
was the first time that Alice had experienced any
level of motivation in Murray to resist his urges.
Session2 focused on behavior management
techniques and introduction to ERP. Murray and
his parents had a warm and loving relationship,
and he was generally a complaint child outside
of his anxiety-related outbursts. However, given
the severity of parental accommodation and difficulty tolerating his discomfort, some basic behavioral management principles were utilized in the
297
next sessions with Alice, who was encouraged to

review these with Clarence at home. Strategies focused mainly on selectively ignoring protests and
whining while using differential reinforcement of
alternative behaviors, including an introduction
to the use of rewards to increase brave behaviors in preparation for exposure sessions.
Parenting skills were practiced in session
with the therapist during a child-led play period,
including unstructured play and play involving the need to complete a slightly challenging
puzzle. This allowed the therapist to highlight
the need for clear and focused communication
with Murray, rather than lengthy bargaining or
explanations to encourage behaviors, or providing excessive reassurance. The therapist provided coaching to Alice during the interaction
rather than engaging directly with Murray. Alice
engaged quickly with the use of labeled praise
and reflective statements about appropriate play
behaviors after noticing a change in Murrays behavior and his ability to persevere with the puzzle
despite some frustration.
Given that most of Murrays inappropriate and
aggressive behaviors occurred in the context of
his compulsions being interrupted, basic behavior management strategies were conceptualized
to be important in assisting Alice and Clarence
to feel more confident in reducing their level of
parental accommodation. Some basic emotioncoaching skills were addressed, where Alice was
encouraged to label Murrays feelings and experience and provide suggestions on more appropriate behaviors if necessary (e.g., I can see that
you are really angry that your sister moved your
truck, because the OCD tells you they have to be
in a special way on the wall. You can tell her that
you want her to stay out of your room using your
words, but we do not hit each other in our family). Logical consequences were also reinforced,
such as requiring Murray to clean up the mess
if he spits food on the table. Practice using the
parent management skills was set for homework
both to demonstrate the skills for Clarence and
to build Alices confidence. Murray enjoyed the
play task, and was eager to play with his parents
at home during the week, requesting that his sister was not allowed to join in.
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The remainder of the second session focused

on introducing ERP. Rationale for exposure was
reviewed with Murray and Alice in the context
of OCD tricking kids to get them to engage in
certain behaviors, and that when kids engage in
those behaviors, OCD gets stronger, while OCD
gets weaker when they do not. In an effort to
boss back, part of the sessions would involve
doing things to annoy OCD, like not doing what
it told him to do. Murray was uncertain initially,
although was pleased to know that his mother
and therapist would be helping him, and that
they would start by practicing easy steps to help
Murray get stronger. Murray and his mother
generated an initial exposure hierarchy with the
help of the therapist. Given that young children
often fund the use of subjective units of distress (SUDs) ratings difficult to understand and
use, steps were categorized into steps in terms
of increasing difficulty using descriptors like
a little, medium, or big. The hierarchy
focused on the domain that Alice considered to
be the most impairing currently, his ordering (see
Table20.1). Murray was able to rate which step
would be more or less difficult when presented
with two options and the order of steps was approximated with the assistance of Alices impressions. The importance of reducing family accommodation of Murrays OCD was discussed with
Alice, and it was incorporated throughout the
exposure tasks with assistance from the therapist
to reduce her participation in Murrays rituals
(e.g., delaying leaving from home to allow him
to complete his ordering ritual, avoiding vacuuming while Murray was home, discussing/reassuring him that he had arranged his toys once they
had left the house).
Exposure sessions initially started with
therapist-led exposure to model the exposure
procedure for Murrays parents. The therapist
would identify the step being targeted, and Murrays distress ratings (little, medium, or big).
Young children are highly motivated by extrinsic
rewards, and Murray selected a sheet of stickers that he found appealing and was instructed
that he would receive one sticker for each step
he completed to take home and show his father.
Murray was very excited by this idea. During the

Table 20.1 Exposure hierarchy for ordering
Expected anxiety/
Step
difficulty
Big/very hard to do
Leave toys out messy
overnight
Choose one toy to play with.
Do not move other toys
Murray to put toys away in
box
Allow mum to move toys in
different order
Medium/hard to do
Drop pencils on table
and leave wherever they
land10mins
Murray to move two toys out
of lineleave for 15min
Drop pencils on table
and leave wherever they
land2mins
A little/a little bit hard
to do
Murray to move one toy out
of line
(Home/preschool practice
only) Let another child take
one pencil/paint
Allow teacher/therapist take
one pencil or paint out of line
initial session, Murray was reluctant to engage in

exposure, and on the first two tasks, he snatched
the pencil back from the therapist. The therapist
reoriented Murray to the task, and Murray preselected the sticker that he would like to work
towards. The step was attempted a second time,
during which Murray was able to complete the
task where he was praised by his mother and
therapist, and received his sticker. Once Murray
began to earn stickers, he became more engaged
in the session. Alice stuck the hierarchy on the
fridge and Murray was allowed to draw a red line
through the step once he and Alice felt that he was
confident with completing that step. Alice spoke
with Murrays preschool teacher about facilitating exposure tasks involving other children, and
after completing this step once in the presence of
his mother, the preschool teacher facilitated addition practice allowing other children to share the
toys he was playing with.
After two sessions of therapist-led exposures,

sessions focused on parent-led exposure with
support, skill correction, and support from the
therapist. In particular, Alice benefitted from
setting limits around the amount of instruction
and reassurance she would provide before
completing an exposure task. Murray became
resistant to progressing to the more challenging
tasks, especially the final task of moving his toys
into a box rather than lined up on the wall. Alice
was prompted to break this task into several steps
of increasing difficulty, such as putting only
three toys in the box and subsequently increasing
the number placed in the box, with the aim of
building back up to the original target behavior.
Play was also used during the steps to make
that task more enjoyable for Murray, such as
racing two toy cars with his mother to see which
car could get into the box the fastest. Selective
ignoring of Murrays protests and persistence
in completing the step was modeled in session
if Murray hesitated to complete the step, as it
became apparent that if Murray showed initial
signs of distress, Alice was quick to intervene
or reduce the difficulty of the tasks (e.g., Alice
would suggest they try again later, or place the
toy in the box herself). A token system was also
employed whereby once Murray obtained ten
stickers he was rewarded with a small Lego set.
Prompting from his mother about the number of
stickers he had obtained towards the Lego, along
with the alterations in parenting strategies, was
sufficient to motivate Murray to persist with
these more challenging steps.
Once there was some progress in addressing
the ordering behaviors (around session 6), two
more hierarchies were sequentially developed to
increase Murrays ability to tolerate loud noises
(including going inside and using public toilets)
and then to progressively eat a greater variety
foods (including soft foods) and allow his foods
to touch or mix together.
Posttreatment Assessment Results

By session, the end of session 11, Alice reported
that she felt that Murrays symptoms were well
299
managed and she wanted to terminate the weekly

sessions. She reported feeling more confident
about supporting his continued progress and
wanted to trial a break from therapy. Although
Murray still displayed some compulsive behaviors, these had minimal impact on his functioning and Alice reported that she felt better able to
continue this work independently.
The final session involved relapse prevention,
review of the gains Murray and his parents had
made during treatment, and the familys plans
to continue their progress. Murray was able to
choose one toy to play with at preschool and
could take that toy to another area to play without
the need to line up the remaining toys. He still
had some difficulty allowing toys to be messy
but was able to walk away and engage in another
task on most occasions. Murray had begun to
play more regularly with other children, although
he was most successful with make-believe games
and running/chasing games as opposed to games
involving drawing where he still insisted that
all the pencils were inside the pencil box, or all
emptied onto the table. His toys at home were kept
in a toy box and Murray was diligent in packing
his toys away at the end of the day, although
did not require this to be in any specific order
within the toy box. Murray was able to use the
public toilets in several local shopping centers,
although was still apprehensive when entering
an unfamiliar bathroom. His tolerance for loud
noises had improved and he no longer cried
when Alice used household appliances, although
he still preferred to be in an adjacent room while
his mother was vacuuming. Murray was eating
a greater variety of foods although would still
refuse custard and some fruits. On reassessment,
Murrays CGI-I score was a 2 (much improved)
and his CGAS score was 75 (previously 53)
indicating a substantial improvement in his
functioning, with some remaining symptoms. His
CYBOCS score had come down from 30 (severe
symptoms) to 7 (subclinical range).
There was a notable decline in family
accommodation surrounding Murrays anxiety.
The family now visited several playgrounds in
the area, including an indoor play center that
tended to be quite loud at times. He had also
300
accompanied his mother to the supermarket

twice. Murrays parents made a conscious effort
to borrow pencils from him while he was drawing to reinforce the unstructured nature of play as
well as sharing, and they no longer delayed their
departure from home to allow him to arrange/
pack away his toys. On one occasion, Alice
had started to drive down the driveway without
Murray, prompting him to abandon packing away
his toys to get in the car.
Murray showed notable improvements in
mixing his foods, and Alice had been able to
incorporate cooking meals such as fried rice
for dinner. Despite having eaten custard (an
especially difficult food on Murrays slimy food
hierarchy) twice during treatment sessions, Alice
still found it difficult to insist on Murray eating
the meal that was prepared for him, and her meal
choices were often made to accommodate his
preference for crunchy food. In addition, Alice
tended to prompt Murray to go to the bathroom
before they went out to avoid his needing to go
to the toilet while they were out, although was
usually able to encourage him to use the toilet if
the need arose.
A follow-up booster session was attended 1
month following the completion of treatment
with Alice, Clarence, and Murray to monitor his
progress. At this stage, Murrays progress had
improved slightly, and he was able to leave some
toys around his room in random places while he
slept. There was little change in his aversion to
loud noises or foods; however, Alice did not feel
that this was interfering significantly in his life.
Alice and Clarence agreed that it would be important to continue to work on any residual symptoms in a less formal way, as well as continuing
to reduce the accommodation of symptoms.
Clarence attended two exposure sessions; however, he tended to get easily frustrated with Murray
and give up on the task, deferring to the therapist
or Alice to respond. His inconsistent attendance
appeared to influence his level of confidence
implementing skills and resulted in Alice being
primarily responsible for completing additional

exposure practice out of session. She reported
becoming fatigued by the amount of effort this
required on her behalf. Despite her discussing
this with Clarence, he insisted that he was unable
to take the time off work to attend the sessions,
and his involvement continued to be minimal in
practice at home despite repeated promises of increased effort. Unfortunately, he did not attend
any further sessions, and the therapist suspected
that Clarences ambivalence about committing to
treatment and his difficulty tolerating the initial
increase in Murrays immediate distress as they
discontinued parental accommodation of his
rituals may have influenced his disengagement.
Clarences limited involvement also increased
the parental burden on Alice to be primarily responsible for implementing treatment changes
and was likely to have played a role in the familys early termination from treatment.
The therapist faced ongoing challenges
throughout therapy relating to family accommodation. While both parents understood the
rationale behind the exposure tasks, there was an
underlying dialectic where they feared that his
experience of emotional distress would become
overwhelming, or that it may damage his brain
in some way in the long term. Despite corrective information from the therapist, this remained
an underlying parental concern that maintained
a certain tendency towards accommodation and
avoidance. In session, exposure tasks allowed a
more direct observation of these behaviors and
Alice was often asked to reflect on her experience of facilitating the task as well as on Murrays
behavior to assist with her insight.
Murrays developmental stage was another
therapeutic challenge, and he would often forget
what happened during exposure tasks in previous weeks, requiring either prompting from his
mother about the outcome or repeating the same
task to generalize learning. Murray was sick for
1 week during the treatment with a viral infection, and, upon return, there was evidence of an
increase in his OCD severity. The therapist used
this naturally occurring event to review relapse
prevention psychoeducation with Alice, and upon
reengaging with previously accomplished tasks,
Murray quickly returned to his pre-sickness level

of exposure. The ability to make particular tasks
interesting and engaging for Murray was a constant consideration for Alice and the therapist, as
Murray quickly lost motivation to become the
boss of the OCD. Engaging Murray in early sessions appeared to be important for Alice, as she
reported some ambivalence about seeking treatment given his young age and her perception that
she was being a mean parent; however, time
spend naming/drawing/discussing OCD with
young children is unnecessary in many cases, and
the initial enthusiasm elicited by these activities
tends to dissipate early in treatment. The primary
method of increasing motivation to engage young
children to complete exposure tasks is rewards
and behavioral management principles, while the
focus with parents is on implementing behavioral
management, reducing accommodation, and facilitating exposure. As illustrated in this case,
Murray motivation was maintained through the
use of material rewards, and this was utilized to
facilitate continued progress.
It was unclear whether Murrays aversion to
slimy food was fear based or more related to sensory over-responsivity. While his tolerance of
loud noises improved, his aversion to particular
textures remained potent and did not appear to
habituate easily. There was a meaningful shift in
the variety of foods he would eat, and his willingness to attempt to eat foods was improved during
the treatment.
Conclusions
OCD in young children can present with a diffuse set of symptoms, some of which can resemble stereotypical OCD nosology, while others
can be more difficult to diagnose or understand.
There is an increasing awareness that very young
children can, and do, present with mental health
difficulties, and that early intervention with these
children can be effective in preventing a negative trajectory. Left untreated, OCD can lead to a
chronic course of impairing symptoms, and significantly impact on the quality of life and functional ability of a child. Early intervention may
301
limit the negative impact of OCD on academic

and social functioning as children transition to
school, and may be easier to treat given that the
behaviors are less engrained than chronic OCD.
Additionally, young children are highly motivated by external incentives and are likely to be
more responsive to parental directions than older
youth, which may increase the chances of remission. There is promising evidence for the efficacy
of family-based ERP and CBT in the treatment
of OCD in young children, although this type of
treatment is dependent on high levels of parental
motivation and engagement.
This case study highlights some of the complexities involved with assessment, diagnosis,
and treatment with young children and suggests
a number of key treatment considerations for
clinicians. As summarized in Table20.2, there
are a number of important considerations for
clinical practice during assessment and treatment of OCD in young children. While clinicians
working therapeutically with young children
often focus heavily on engaging the young
person, for example, through play therapy or
drawing, this case example highlights the need
to engage parents as a critical component of
treatment, given they will be the facilitators of
change. Young children have very limited capacity to make meaningful and enduring changes
independently, and parents should be involved
in all treatment sessions to ensure that parents
learn how to implement skills and support generalization of skills to other contexts. This raises
a number of challenges, including the level of
Table 20.2 Key practice points for the treatment of

obsessive-compulsive disorder in young children
Key practice points
Engage parents in treatment throughout sessions
Focus mainly on exposure and response prevention
with young children, including reducing parental
accommodation of OCD
Behavior plan for building new repertoire of behavior
Minimize focus on cognitive therapy due to developmental capacities
Be aware of normative developmental stages versus
pathological symptoms. Consider differential diagnosis
issues throughout assessment and treatment
302
parental motivation, parental beliefs about the

cause and solution for OCD symptoms, and
problematic family dynamics that may interfere
with the therapeutic process. However, one of the
advantages of working so closely with parents
during the treatment of OCD in young children
is that broader parenting issues can be identified
and addressed during the sessions, affecting more
systemic change within the family. The impact of
family accommodation and parenting behaviors
is also important to address.
Older children and adolescents are often able
to complete certain aspects of therapy independently, while parental involvement is critical with
younger children. Cognitive therapy treatment
components are often utilized somewhat independently with older children, although the cognitive
developmental stage of young children tends to
limit the utility of strategies that rely more heavily on abstract thinking and cognitive reasoning.
Additionally, young children typically lack the
literacy skills necessary to engage in traditional
pencil-and-paper thought challenging forms.
Adapted forms of cognitive therapy may be possible in some cases, however, it is the exposure
elements of therapy are critical for treatment.
When working with young children, it is important to provide concrete forms of motivation,
as young children rarely find exposure therapy
intrinsically motivating, and are unlikely to be
able to tolerate their immediate distress in the
context of longer-term relief. Young children are
especially motived by external rewards, such as
the attention and support of a parent, or tangible
rewards, and this is a facilitator of change during
therapy to motivate necessary behaviors.
Given the diffuse symptom presentations
among young children, and the challenges involved with accurate diagnosis, clinicians should
continue to consider differential diagnostic issues
throughout the treatment process, rather than exclusively during assessment. This may result in
changes to the formulation and treatment plan
as new information or contextual understanding
about particular behaviors become available during treatment.
References
Choate-Summers, M. L., Freeman, J. B., Garcia, A.
M., Coyne, L., Przeworski, A., & Leonard, H. L.
(2008). Clinical considerations when tailoring
cognitive behavioral treatment for young children
with obsessive compulsive disorder. Education and
Treatment of Children, 31(3), 395416. doi:http://
dx.doi.org/10.1353/etc.0.0004.
Coskun, M., & Zoroglu, S. (2009). Efficacy and safety
of fluoxetine in preschool children with obsessivecompulsive disorder. Journal of Child and Adolescent
Psychopharmacology, 19(3), 297300. doi:http://
dx.doi.org/10.1089/cap.2008.055.
Coskun, M., Zoroglu, S., & Ozturk, M. (2012).
Phenomenology, psychiatric comorbidity and
family history in referred preschool children with
obsessive-compulsive disorder. Child and Adolescent
Psychiatry and Mental Health, 6, 36. doi:http://dx.doi.
org/10.1186/1753-2000-6-36.
Dar, R., Kahn, D. T., & Carmeli, R. (2012). The
relationship between sensory processing, childhood
rituals and obsessive-compulsive symptoms. Journal
43(1),
679684.
doi:http://dx.doi.org/10.1016/j.
jbtep.2011.09.008.
Dodd, H. F., Hudson, J. L., Morris, T. M., & Wise, C. K.
(2012). Interpretation bias in preschool children at risk
for anxiety: A prospective study. Journal of Abnormal
Psychology, 121(1), 2838. doi:10.1037/a0024589.
Eley, T. C., Bolton, D., OConnor, T. G., Perrin, S., Smith,
P., & Plomin, R. (2003). A twin study of anxietyrelated behaviours in pre-school children. Journal of
Child Psychology and Psychiatry, 44(7), 945960.
doi:10.1111/1469-7610.00179.
Ercan, E. S., Kandulu, R., & Akyol Ardic, U. (2012).
Preschool children with obsessivecompulsive
disorder and fluoxetine treatment. European Child and
Adolescent Psychiatry, 21(3), 169172. doi:10.1007/
s00787-012-0244-2.
Evans, D. W., Milanak, M. E., Medeiros, B., & Ross, J. L.
(2002). Magical beliefs and rituals in young children.
Child Psychiatry and Human Development, 33(1),
4358.
Fox, J. K., Warner, C. M., Lerner, A. B., Ludwig, K.,
Ryan, J. L., Colognori, D., etal. (2012). Preventive
intervention for anxious preschoolers and their
parents: Strengthening early emotional development.
Child Psychiatry and Human Development, 43(4),
544559. doi:10.1007/s10578-012-0283-4.
Freeman, J., Garcia, A. M., Coyne, L., Ale, C., Przeworski,
A., Himle, M., etal. (2008). Early childhood OCD:
Preliminary findings from a family-based cognitivebehavioral approach. Journal of the American
Academy of Child and Adolescent Psychiatry,
47(5),
593602.
doi:http://dx.doi.org/10.1097/
CHI.0b013e31816765f9.

Freeman, J., Flessner, C. A., & Garcia, A. (2011). The
childrens yale-brown obsessive compulsive scale:
Reliability and validity for use among 5 to 8 year
olds with obsessive-compulsive disorder. Journal
of Abnormal Child Psychology, 39(6), 877883.
doi:10.1007/s10802-011-9494-6.
Freeman, J., Garcia, A., Benito, K., Conelea, C., Sapyta,
J., Khanna, M., etal. (2012). The pediatric obsessive
compulsive disorder treatment study for young
children (POTS jr): Developmental considerations
in the rationale, design, and methods. Journal of
Obsessive-Compulsive and Related Disorders, 1(4),
294300. doi:10.1016/j.jocrd.2012.07.010.
Freeman, J., Sapyta, J., Garcia, A., Compton, S., Khanna,
M., Flessner, C., etal. (2014). Family-based treatment
of early childhood obsessive-compulsive disorder:
The pediatric obsessive-compulsive disorder treatment
study for young children (POTS Jr)a randomized
clinical trial. Journal of the American Medical
Association Psychiatry, 71(6), 689698. doi:10.1001/
jamapsychiatry.2014.170.
C., Ogata, A. K., Ng, J., etal. (2009). Phenomenology
of early childhood onset obsessive compulsive
disorder. Journal of Psychopathology and Behavioral
Assessment, 31(2), 104111. doi:http://dx.doi.
org/10.1007/s10862-008-9094-0.
Geller, D. A., March, J., & The AACAP Committee on
Quality Issues. (2012). Practice parameter for the
assessment and treatment of children and adolescents
with obsessive-compulsive disorder. Journal of
the American Academy of Child and Adolescent
Gleason, M. M., Egger, H. L., Emslie, G. J., Greenhill,
L. L., Kowatch, R. A., Lieberman, A. F., etal. (2007).
Psychopharmacological treatment for very young
children: Contexts and guidelines. Journal of American
15321572. doi:10.1097/chi.0b013e3181570d9e.
Hudson, J. L., & Dodd, H. F. (2012). Informing early
intervention: Preschool predictors of anxiety disorders
in middle childhood. PLoS ONE, 7(8), e42359.
doi:10.1371/journal.pone.0042359.
Kennedy, S. J., Rapee, R. M., & Edwards, S. L. (2009).
A selective intervention program for inhibited
preschool-aged children of parents with an anxiety
disorder: Effects on current anxiety disorders and
temperament. Journal of the American Academy of
Child and Adolescent Psychiatry, 48(6), 602609.
doi:10.1097/CHI.0b013e31819f6fa9.
Leonard, H. L., Goldberger, E. L., Rapoport, J. L.,
Cheslow, D. L., & Swedo, S. E. (1990). Childhood
rituals: Normal development or obsessive-compulsive
symptoms? Journal of the American Academy of Child
and Adolescent Psychiatry, 29(1), 1723. doi:http://
dx.doi.org/10.1097/00004583-199001000-00004.
Lewin, A. B., & Piacentini, J. (2009). Obsessivecompulsive disorder in children Kaplan & Sadocks
comprehensive textbook of psychiatry (9th ed.,
303
pp.36713678). Philadelphia: Lippincott, Williams &

Wilkins.
research. Child Youth Care Forum, 39(2), 7389.
doi:10.1007/s10566-009-9092-8.
Lewin, A. B., Bergman, R. L., Peris, T. S., Chang,
S., McCracken, J. T., & Piacentini, J. (2010).
Correlates of insight among youth with
obsessive-compulsive disorder. Journal of Child
Psychology and Psychiatry, 51(5), 603611.
doi:10.1111/j.1469-7610.2009.02181.x.
Lewin, A. B., Piacentini, J., De Nadai, A. S., Jones, A. M.,
Peris, T. S., Geffken, G. R., etal. (2014a). Defining
clinical severity in pediatric obsessive-compulsive
disorder. Psychological Assessment, 26(2), 679684.
doi:10.1037/a0035174.
Lewin, A. B., Park, J. M., Jones, A. M., Crawford,
E. A., De Nadai, A. S., Menzel, J., etal. (2014b).
Family-based exposure and response prevention
therapy for preschool-aged children with obsessivecompulsive disorder: A pilot randomized controlled
trial. Behaviour Research and Therapy, 56, 3038.
doi:http://dx.doi.org/10.1016/j.brat.2014.02.001.
Lewin, A. B., McGuire, J. F., Murphy, T. K., & Storch,
E. A. (2014c). The importance of considering parents
preferences when planning treatment for their
childrenthe case of childhood obsessive-compulsive
disorder. Journal of Child Psychology and Psychiatry,
55(12), 1314-1316. doi: 10.1111/jcpp.12344.
Lewin, A. B., Wu, M. S., Murphy, T. K., & Storch,
E. A. (2015). Sensory over-responsivity in
pediatric obsessive compulsive disorder. Journal
of Psychopathology and Behavioral Assessment,
37(1), 134-143. doi: 10.1007/s10862-014-9442-1.
doi:10.1007/s10862-014-9442-1.
Moretti, G., Pasquini, M., Mandarelli, G., Tarsitani,
L., & Biondi, M. (2008). What every psychiatrist
should know about PANDAS: A review. Clinical
Practice and Epidemiology in Mental Health, 4, 13.
doi:10.1186/1745-0179-4-13.
Nakatani, E., Krebs, G., Micali, N., Turner, C., Heyman,
I., & Mataix-Cols, D. (2011). Children with very early
onset obsessive-compulsive disorder: Clinical features
and treatment outcome. Journal of Child Psychology
and Psychiatry, 52(12), 12611268. doi:http://dx.doi.
org/10.1111/j.1469-7610.2011.02434.x.
Piacentini, J., Bergman, R., Keller, M., & McCracken,
J. (2003). Functional impairment in children and
adolescents with obsessive-compulsive disorder.
Journal of Child and Adolescent Psychopharmacology,
13(2
Suppl),
S61S69.
doi:http://dx.doi.
org/10.1089/104454603322126359.
Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort,
S. I., King, R. A., Goodman, W. K., etal. (1997). Childrens yale-brown obsessive compulsive scale: Reliability and validity. Journal of the American Academy
304
of Child and Adolescent Psychiatry, 36(6), 844852.
doi:10.1097/00004583-199706000-00023.
Selles, R. R., Storch, E. A., & Lewin, A. B. (2014).
Variations in symptom prevalence and clinical
correlates in younger versus older youth with
obsessive-compulsive disorder. Child Psychiatry
and Human Development Feb(Pagination), No
Pagination Specified. doi:http://dx.doi.org/10.1007/
s10578-014-0435-9.
disorders interview schedule for DSM-IV-child and
Sukhodolsky, D. G., do Rosario-Campos, M. C., Scahill,
L., Katsovich, L., Pauls, D. L., Peterson, B. S., etal.
(2005). Adaptive, emotional, and family functioning
of children with obsessive-compulsive disorder and
comorbid attention deficit hyperactivity disorder. The

American Journal of Psychiatry, 162(6), 11251132.
doi:http://dx.doi.org/10.1176/appi.ajp.162.6.1125.
Watson, H. J., & Rees, C. S. (2008). Meta-analysis
of randomized, controlled treatment trials for
pediatric obsessive-compulsive disorder. Journal of
Child Psychology and Psychiatry, 49(5), 489498.
doi:10.1111/j.1469-7610.2007.01875.x.
Zuckerman, M. L., Vaughan, B. L., Whitney, J., Dodds,
A., Yakhkind, A., MacMillan, C., etal. (2007).
Tolerability of selective serotonin reuptake inhibitors
in thirty-nine children under age seven: A retrospective
chart review. Journal of Child and Adolescent
Psychopharmacology, 17(2), 165174. doi:http://
dx.doi.org/10.1089/cap.2007.0086.
Treatment of a Youngster
with Tourettic ObsessiveCompulsive Disorder
21
Krishnapriya Ramanujam and Michael B. Himle

Obsessive-compulsive disorder (OCD) and tic
disorders (TD) are relatively common neuropsychiatric disorders of childhood. They are also
known to be highly comorbid with up to 50% of
individuals with TD having a lifetime history of
OCD and up to 30% of individuals with OCD
reporting a lifetime history of tics (Gomes de Alvarenga etal. 2012). As described in other chapters within this volume, OCD is characterized by
intrusive, recurrent, and persistent thoughts; images; or urges that cause anxiety or distress (i.e.,
obsessions) accompanied by overt or covert goaldirected repetitive behaviors that the individual
feels compelled to perform, according to rigid
rules, that are aimed at reducing anxiety or preventing some feared outcome (i.e., compulsions,
American Psychiatric Association 2013). In contrast, TD is characterized by rapid, repetitive,
nonrhythmic motor, and vocal tics (American
Psychiatric Association 2013). Many individuals
with TD also report generalized or focal sensory
phenomena (i.e., premonitory urges) that precede
some of their tics and are alleviated when the tic
is performed (Kwak etal. 2003). Although TD
and OCD are separate and distinct conditions,
complex tics and compulsions sometimes share
features that make them difficult to distinguish.
M.B.Himle() K.Ramanujam
Department of Psychology, University of Utah, 380S.
1530 E., BehS #502, Salt Lake City, UT 84112, USA
e-mail: michael.himle@utah.edu
Simple tics, which are typically the first

symptoms to emerge in TD, involve the production of rapid, meaningless, discrete movements,
or sounds that tend to occur erratically and unpredictably without regard to context. Although simple tics can usually be distinguished from compulsions by their brevity, lack of purpose, and
involuntary appearance, many individuals with
TD also display complex, orchestrated repetitive
behaviors that appear more purposeful and that
share features with compulsions. Examples include patterned touching, tapping, rubbing, saying things in a certain way or a certain number
of times, performing actions (e.g., blinking or
staring) or uttering words in a specific manner
or sequence, evening out or straightening objects,
repeating gestures or sentences (echophenomenon), rereading and rewriting, and orchestrated
or sequential patterns of simple tics (Grados and
Mathews 2009). These behaviors, which are
often referred to as impulsions1 (Cath etal.
2001), are usually elicited by specific visual, auditory, tactile, or sensory stimuli (e.g., seeing a
specific object or hearing a specific sound). Although impulsions can occur in TD alone, they
1
The repetitive behaviors associated with TOCD have
been described using a variety of terms including Tourette-related rituals, complex tics, tic-like compulsions,
and impulsions. In agreement with Cath etal. (2001), we
find each of these terms to be unsatisfying for a variety of
reasons. However, in this chapter we use the term impulsion to refer to these behaviors to highlight that they differ from the classic definitions of tics and compulsions
in important ways.

DOI 10.1007/978-3-319-17139-5_21
305
306
are particularly common when TD and OCD are

comorbid. This presentation, commonly referred
to as Tourettic OCD (or tic-related OCD, TOCD),
has been shown to have a specific symptom profile that differs from tic-free OCD. In particular,
individuals with TOCD are less likely than those
with tic-free OCD to report obsessions and compulsions related to contamination, cleaning, and
checking and are more likely to report the aforementioned tic-like impulsions, such as touching, tapping, and rubbing behaviors related to
thoughts or feelings of symmetry and exactness
(Holzer etal. 1994; Leckman etal. 1994; Storch
etal. 2008).
Although impulsions are one of the hallmark
features of TOCD, whether to classify and conceptualize these behaviors as tics, compulsions,
or as distinct symptoms all together continues
to be a source of uncertainty and inconsistency
within the OCD and TD literatures. While impulsions share topographical and functional features
with both tics and obsessions/compulsions, they
also differ from classic symptoms of TD and
OCD in important ways. In contrast to simple tics,
which tend to occur erratically and unpredictably,
impulsions tend to be stimulus bound; that is,
they are elicited by specific internal or external
stimuli. Also in contrast to simple tics which are
experienced as involuntary, impulsions are often
experienced by the patient as semi-volitional
or unvolitional because their performance alleviates an urge, neutralizes a feeling of something
being not just right or incomplete, or achieves
a sense of exactness or symmetry (Leckman etal.
1993). While this feature of impulsions shares
some overlap with obsessions (intrusive, recurrent, and persistent thoughts; images; or urges
that are often elicited by specific stimuli) and
compulsions (repetitive behaviors that the individual feels compelled to perform), impulsions
are rarely performed to alleviate anxious arousal and lack the goal-directedness and cognitive
content typical of tic-free OCD (e.g., to prevent
or neutralize feared outcomes; Cath etal. 2001).
Others have noted that obsession-based compulsions tend to be elaborate, are ego-dystonic, and
are directed at changing the external environment
(e.g., cleaning or checking), whereas impulsions
K. Ramanujam and M. B. Himle
tend to be brief, ego-syntonic, impulsive, and

directed toward the self (George etal. 1993).
However, as noted by OConnor etal. (2005)
and consistent with our clinical impression, attempting to distinguish between impulsions and
OC and TD behaviors is complicated by the fact
that some individuals with OCD have limited
insight and awareness regarding their symptoms
and many individuals with TD generate post hoc
rationalizations or explanations for why they are
performing complex tics.
There is currently no definitive answer regarding whether impulsions should be conceptualized
as complex tics or OCD-related rituals. However,
while this can pose challenges to clinical assessment (described later in this chapter), there are
efficacious non-pharmacological interventions,
described in detail in other chapters within this
volume, for treating the symptoms of both TD
(habit reversal training, HRT) and OCD (exposure and response prevention, ERP), and these
protocols can be adapted to successfully treat
the unique symptoms of TOCD (Leckman etal.
1994; Mansueto and Keuler 2005). Below, we
describe how we adapted and combined HRT
and ERP to successfully treat Nick (pseudonym),
a 12-year-old youngster presenting with several
TOCD-related impulsions.

in Case
Nick was a 12-year-old Caucasian male with a
history of comorbid TD and OCD. At the time
of treatment, he reported typical symptoms of
both disorders, including simple facial, head, and
shoulder tics as well as obsessions and compulsions related to harming others or being responsible for harm befalling his mother. However,
his most noticeable and impairing symptoms included several stimulus-bound repetitive behaviors (i.e., impulsions) that involved touching and
tapping objects and performing and repeating
specific actions. He denied typical feelings associated with anxious arousal or any obsessional or
catastrophic fears associated with performing (or
not performing) these behaviors, but did report
21 Treatment of a Youngster with Tourettic Obsessive-Compulsive Disorder
that the behaviors were preceded by unpleasant

sensory and not just right feelings that were
alleviated when the behaviors were performed.
Although there were some fairly reliable external
triggers for Nicks impulsions, they were not elicited every time he encountered a particular trigger and almost anything he touched could trigger
his internal discomfort and resulting repetitive
behavior. He also noted that while he was generally aware of when he performed the behaviors,
they were not precontemplated, and he described
them as neither voluntary nor involuntary. At the
time he presented to our clinic, Nick was being
treated with a selective serotonin reuptake inhibitor (SSRI), which had reduced his overall level of
anxiety and traditional OCD symptoms, but had
little effect on his repetitive behaviors. Although
his neurologist had recommended a trial of ticsuppressing medication, his parents opted to try
a behavioral approach first due to concerns about
potential medication side effects.
Case Information
Nick was a physically healthy child who reached
all major developmental milestones within normal limits. As an infant, he had difficulties with
transitions and often became overwhelmed by
new situations and activities, and he had always
been more shy and inhibited than his three younger siblings. As a child, Nick was hypersensitive to
clothing tags and refused to wear underwear or
socks. This improved as he aged, but he still preferred loose fitting clothing. He had always been
(and continued to be) a picky eater, refusing to
eat foods of certain textures, such as yogurt and
mashed potatoes. He also displayed occasional
anger outbursts from the ages of 47 but was otherwise appropriately compliant and happy. Family psychiatric history revealed that Nicks father
had simple tics (eye blinking, shoulder shrugging, sniffing, throat clearing) and was obsessive about things, but had never been formally
diagnosed with TD or OCD. His mother reported
that she had been diagnosed with an unspecified
anxiety disorder and depression and had been
on antidepressant medications most of her adult
307
life. One of his younger brothers (age 8) also had

simple facial tics (eye blinking, nose twitching).
Nicks tics began with simple facial movements (eye blinking, facial stretching) that were
first noticed at age 4. As is common in TD, these
movements took a waxing and waning course
and would disappear for days or weeks at a
time. Because Nicks father had similar tics and
because the tics were not problematic, the family was not overly concerned and did not seek
medical attention. At age 6, Nick began to show
symptoms of anxiety and OCD. When in the
first grade, Nick would get overly upset when
his mother dropped him off at school and would
cry and plead for her not to leave. Several times
per week he would spend much of the morning
in the school nurses office complaining of stomachaches and would frequently call his mother
to seek reassurance that she was okay. He also
refused to participate in soccer or baseball unless his mother was standing on the sideline, and
he worried about adult things such as whether
the family had enough money to buy groceries.
Nicks mother also reported that he had always
been perfectionistic and overly hard on himself
when he made mistakes on schoolwork or playing sports. Even in elementary school, he would
recheck his homework answers several times and
would get upset if prevented from doing so. He
would also get upset and perseverate when his
xeroxed homework assignments were not perfectly symmetrical on the page. At age 8, Nick
was evaluated by a psychologist, diagnosed with
an unspecified anxiety disorder, and was referred
to a child therapist. The therapist diagnosed
him with OCD, and Nick attended five sessions
of talk therapy across several months with little
benefit.
By age 9, Nicks facial tics had progressed to
involve simple head and shoulder jerks as well as
a grunting tic, at which time he was evaluated by
a neurologist who diagnosed Nick with TD (and
confirmed a diagnosis of OCD). He was prescribed a low dose of an SSRI (sertraline) by a
child psychiatrist, which helped a quite a bit for
his anxiety, but did nothing for his tics. Nicks
touching, tapping, and repetitive behaviors started when he was 10 years old. Whenever he saw
308
or came in contact with a book, he would have

to tap each page with each index finger several
times before reading it. In addition, he would
occasionally tap his right shoulder and then tap
his left shoulder immediately after to make them
even. Nicks mother said that these behaviors
lasted for a few months and then morphed into
other repetitive behaviors such as having to write
his homework with a particular amount of force
(which he could tell by the pressure in his hands).
If his writing did not feel right, he would erase
and rewrite it up to 1015 times, occasionally
causing tears in the paper. His mother reported
that his repetitive behaviors frequently changed,
stating that they seemed to come and go out of
nowhere and there seemed to be something
new every week. Nick was subsequently reevaluated by his psychiatrist who gradually increased his sertraline, which did not improve
his symptoms. Nicks neurologist had recently
recommended a trial of tic-suppressing medication (she could not remember the name of the
medication), but fearing adverse side effects, the
family opted to first try a behavioral approach to
symptom management.
and Assessment
Prior to beginning treatment, Nick and his mother were administered the Yale Global Tic Severity Scale (YGTSS; Leckman etal. 1989) and the
Scale (CYBOCS; Scahill etal. 1997) to establish a baseline measure of Nicks overall tic and
OCD severity. Although not described here due
to space limitations, we also recommend that clinicians conduct a thorough evaluation to assess
for additional psychological and behavioral conditions that are known to be comorbid with both
TD and OCD, including depression, co-occurring
anxiety disorders, attention-deficit hyperactivity disorder, and oppositional defiant disorder,
among others. When present, these conditions
often contribute to functional impairment and
can complicate treatment delivery.
Brief Description of the YGTSS and CYBOCS The

YGTSS is a clinician-completed interview and
rating scale designed to assess tic severity and
impairment. After completing a detailed tic
checklist to assess for the presence/absence of
common motor and vocal tics, the rater assigns
anchored 05 point ratings along five dimensions of tic severity: number of tics present,
frequency of tics, tic complexity, tic intensity,
and interference resulting directly from the tics.
Each of these dimensions is scored separately for
motor and vocal tics to produce separate motor
and vocal tic severity scores, each ranging from
0 to 25. The motor and vocal tic severity scores
are then combined to produce a total tic severity
score ranging from 0 to 50, with higher numbers
indicating more severe tics. The scale also contains a single-item overall impairment dimension
with scores ranging from 0 to 50.
Like the YGTSS, the CYBOCS is a semi-structured clinician administered interview and rating scale designed to assess for the presence of
common obsessions and compulsions, as well
as severity along several dimensions. There
are two primary sections on the CYBOCS: the
symptom checklist and the severity rating scales.
The examiner first interviews the child and his/
her caregiver to assess for the presence of common obsessions and compulsions. Obsessions
and compulsions are then rated separately (04
point scale) on several severity items including time spent, interference, distress, resistance,
and degree of control over obsessions and compulsions. Individual items are then summed to
derive separate obsession and compulsion severity scores ranging from 0 to 20 and a total severity score ranging from 0 to 40.
Caveats for Assessing TOCD Using the YGTSS
and CYBOCSAs noted earlier, the lack of
conceptual clarity regarding whether impulsions should be classified as complex tics or
compulsions can create challenges for clinical
assessment. Both the YGTSS and the CYBOCS
include these symptoms on their respective
symptom checklists (however, the CYBOCS
does acknowledge in a footnote that these symp-
toms may or may not be OCD related), so these

symptoms are likely to influence severity ratings
on both measures. While this poses particular
challenges for research, we find clinical value in
administering both measures because, in addition
to impulsions, most individuals with TOCD have
classic symptoms of both TD and OCD. In addition, although the YGTSS and CYBOCS severity ratings share some overlap, they also capture
unique and important dimensions of symptom
severity. For example, both measures contain
interference ratings, yet the nature of interference captured by each instrument is quite different. Interference on the YGTSS measures direct
interference due to tics (e.g., directly interrupts
the flow of behavior and/or prevents intended
actions), whereas the CYBOCS measures more
global interference (e.g., causes interference with
social or school performance). In addition, the
YGTSS captures dimensions of number, intensity (noticeability), and complexity of symptoms,
whereas the CYBOCS captures dimensions of
time spent performing the behavior as well as
distress, resistance, and control over the symptoms. We find that these two measures provide
unique and useful clinical information and prefer
to administer both if time permits.
Baseline Assessment of Nicks TD, OCD, and
TOCD Symptoms Results of the clinical assessment revealed that Nicks simple motor tics (eye
blinking, nose movements, head and shoulder
jerks) were present virtually all the time and
tic-free intervals never lasted more than a few
minutes. However, they rarely drew attention to
him and never interfered with ongoing behavior
or speech. During the CYBOCS interview, Nick
also reported symptoms that were consistent with
traditional OCD. He would occasionally become
overwhelmed that he might impulsively harm
someone else (e.g., by punching them in the
face) even though there was no reason to do so
and he had never hit or hurt anyone. To neutralize these thoughts/impulses, he would instead hit
himself on the shoulder repeatedly (510 times)
until the thought went away. He also worried that
something bad might happen to his mother when
they were separated (e.g., he stated that she could
309
get in a car accident, but this was vague) unless

he told her that he loved her, and this was the
last thing he thought and said before she left the
house. Although bothersome to Nick, the OCD
symptoms had decreased since increasing his
medication and were causing minimal disruption
or impairment on a day-to-day basis. At the time
of the interview, he was spending less than 1h
per day engaged in these symptoms, and although
they occurred daily, long symptom-free intervals
were common. He reported that he occasionally
tried to resist them and was usually able to do so
if he tried. He did, however, report that attempts
to resist these rituals resulted in substantial anxiety, and he would often break down and cry.
Nicks most noticeable and impairing symptoms included several impulsions. He reported
that he would repeatedly swipe his finger across
certain objects (e.g., newspapers, computer
screens), repeatedly open and close doors, turn
faucet handles on/off several times, and forcefully tap his index finger on particular (e.g., shiny)
surfaces. Nick denied any physiological arousal
or obsessional or catastrophic fears associated
with performing these behaviors. He did experience an uncomfortable pressure in his hands
and fingers that was relieved if he performed
these behaviors a certain number of times (the
number varied across each performance) and/
or with a certain amount of force until it felt or
sounded just right. He also reported that when
he touched an object with one side of his body
(e.g., placed his right elbow on top of his desk,
shook someones hand, or closed a door), he felt
he needed to repeat the action with the other side
of his body and with the same amount of force
(e.g., touch his left elbow on the desk, shake
hands with his left hand, close the door with this
left hand) until things (felt) even in that part of
(his) body. When asked what would happen if
he resisted performing the behaviors, Nick said
that the associated feelings would build up and
make it impossible for him to concentrate on anything else. He described that he would get frustrated and annoyed but would not become emotionally upset. On the rare occasion where he was
able to resist the behavior (e.g., if he was forced
to leave the room), he did not feel compelled to
310
later return and complete the behavior, stating

that it was out of sight, out of mind. Nick also
noted that although there were some reliable triggers for each of these behaviors, they were not
performed every time he encountered a particular
trigger and that almost anything he touched could
trigger the accompanying sensations.
In addition to being personally distressing,
Nicks repetitive behaviors were causing significant disruption at home, school, and in his
extracurricular activities. At school, Nick was
spending considerable time tapping on his desk
and having to retouch objects in the classroom,
which was interfering with timely completion
of his schoolwork. He performed the behaviors
many times per day throughout the day, and
symptom-free intervals never lasted more than
an hour. Though the actual movements were usually brief (taking a few seconds to complete), he
would occasionally get stuck performing the
same behavior repeatedly for several minutes.
They also interfered with homework and with
morning/bedtime routines, causing him to be
tardy for school on a regular basis. Nick had also
stopped playing soccer (he was a goalie) because
he would constantly retouch the soccer ball and
goal posts, which interrupted play.
Based on these symptoms, Nick was given a
baseline YGTSS total motor tic severity score of
19/25 (he did not have vocal tics) and an overall
impairment score of 35/50. On the CYBOCS, he
obtained a score of 13/20 on the obsession subscale and a 16/20 on the compulsion subscale, for
a total CYBOCS severity score of 29/40.
Case Conceptualization Nicks symptoms fit the
typical profile of TOCD. Although he met diagnostic criteria for both TD and OCD, his most
prominent and impairing symptoms involved
repetitive behaviors that did not fit neatly within
the definition of tics or compulsions. In contrast
to his simple tics, which occurred unpredictably
and largely outside of his awareness, his touching, tapping, and symmetry behaviors were elicited by specific internal and external stimuli.
In addition, although he was usually aware of
when (though not necessarily how many times)
he performed these behaviors, he denied that
they were precontemplated, and he often failed

to recognize their performance until the action
was underway or complete. Further, most of his
repetitive behaviors were performed to reduce
uncomfortable sensory urges rather than anxious
arousal. While his description of these urges did
share some overlap with the common definition
of an obsession (intrusive, recurrent, and persistent thoughts, images, or urges that are elicited
by specific stimuli), they lacked the cognitive
and goal-directed elements typical of obsessions
and compulsions (i.e., goal-directed repetitive
behaviors that the individual feels compelled to
perform, according to rigid rules, that are aimed
at preventing a feared outcome).

Overview and Rational for Treatment
To treat Nicks TOCD symptoms, we used an
adapted version of ERP. The rationale for ERP
for OCD is based on a behavioral model that posits that compulsions are strengthened, through
negative reinforcement, because they serve to
reduce anxiety or distress associated with an obsessional thought (Franklin and Foa 2011). The
goal of ERP is to teach the individual to gradually
confront stimuli that elicit obsessions and associated anxiety/distress (in a least-to-most hierarchical fashion) while refraining from performing the
compulsion. Within this context, ERP teaches the
individual to inhibit the compulsion in the presence of obsession-triggering stimuli (i.e., inhibitory learning), allows anxiety habituation, and
extinguishes the negative reinforcement cycle.
A similar model can be applied to TOCD. Like
compulsions, impulsions are strengthened (i.e.,
are negatively reinforced) because they serve to
reduce an aversive sensory urge, discomfort, or
sense of asymmetry or unevenness. Similar to
its application in OCD, ERP for TOCD involves
exposing the individual to urge-triggering stimuli
and the associated sensory distress while inhibiting the impulsion. While this approach has been
shown to be successful for treating both simple
and complex tics and associated premonitory
urges (Verdellen etal. 2004), we found that in

Nicks case, several modifications were needed
to address his symptoms. Most importantly, as is
often the case in TOCD, Nicks repetitive behaviors were impulsive; although he was sometimes
aware of when he performed them, they were not
precontemplated, and he often failed to recognize
their performance until the action was underway
or had already been completed, making it extremely difficult for him to inhibit them as part of
response prevention. To address this issue, we
incorporated elements of HRT into ERP. HRT,
which is an effective intervention for simple
and complex motor and vocal tics (Himle etal.
2006), includes three main components: awareness training (AT), competing response training (CRT), and social support. In AT, Nick was
taught to recognize the early warning signs for
his impulsions. This included teaching him to
recognize external triggers, internal sensations,
and the early movements involved in his repetitive actions so that he could catch them early in
the action sequence. After sufficient awareness
was achieved, Nick was taught to engage in a
behavior directly incompatible with the targeted impulsion (i.e., a competing response, CR)
whenever he recognized a warning sign so that
he could better prevent himself from performing
the behavior during ERP.
As noted earlier, in addition to his primary
TOCD symptoms, Nick also displayed simple
motor and vocal tics. Because these tics were
relatively mild and not causing interference
or impairment, they were not targeted in treatment. Had they warranted intervention, treatment would likely have involved straightforward
HRT for those tics. In addition, he also displayed
symptoms typical of classic OCD, including
obsessions and compulsions (and associated
anxiety) related to fears of harming someone and
harm befalling his mother. Although these were
addressed in Nicks treatment, we do not describe
the treatment of these symptoms in this chapter.
Rather, we refer the reader to other chapters within this volume that outline the typical course of
treatment for these types of obsessions and compulsions.
311
Course and Format of Treatment Nick and his

mother jointly attended ten weekly treatment sessions and two biweekly follow-up sessions. Each
session lasted 6090min. Structured homework
assignments were assigned between each session. In general, each session involved a review
of the previous week, updating treatment progress, therapist-assisted practice with HRT/ERP
(targeting one impulsion at a time), and assigning
homework for the coming week.
Session 1
Session 1 began with a review of Nicks symptoms and what he hoped to achieve from treatment as well as a discussion of the rationale for a
behavioral approach to treating TOCD. We then
provided psychoeducation about TD and OCD.
The purpose of psychoeducation was to decrease
blame, stigma, and negative feelings related to his
symptoms, to help him better understand TD and
OCD, and to address any misperceptions about
these disorders and/or their treatment. The topics
covered in psychoeducation included diagnostic
criteria, phenomenology, prevalence, and course
of OCD and TD, and what is known about their
causes. In Nicks case, it was particularly important to discuss the similarities and differences
between TD and OCD, to introduce the concept
of TOCD, and to come to agreement on how we
would refer to his symptoms (did he identify them
as tics or compulsions?). Nick stated that because
he experienced them differently from his simple
tics, he had not really thought about what to call
them, so the therapist introduced the concept of
impulsions and further discussed the grey area
between involuntary and compulsive behavior,
defining, and discussing each term as they related
to his impulsions. This psychoeducation was also
helpful for Nicks mother. Although she understood that Nicks behaviors were symptoms of
TD/OCD, because they appeared more voluntary
than his simple tics, she would occasionally ask
him to stop, blame him for not wanting to resist
his behaviors, and respond as if Nick was being
oppositional or stubborn.
312
Table 21.1 Symptom list (session 1)
Impulsion
Behavior(s)
(SUDS 010)
Evening out Touching object with
(10)
one hand, then other
hand
Urge
Trigger(s)
Pressure in hand, general sense of

frustration (cognitive have to),
vestibular sense of body leaning
to the side
Shaking hands; touching desks, tables,

etc.; turning doorknobs; bumping into
someone or something; opening or
turning pages of books; opening/closing doors
Computer screens, TV screen, newspapers, book pages, phone screen
The sound the door makes closing,
proprioceptive feedback (force) of door
closing, sound and force of doorknob,
or faucet handle stopping
Shiny or reflective objects, windows/
glass
Swiping
(9)
Repeating
(7)
Swiping his index

Pressure in fingertip
finger across objects
Pressure in whole hand
Opening and closing
doors, turning doorknobs, turning faucet
handles
Tapping
Tapping or pressing all Spark feeling in fingertips
(5)
five fingers on objects
(simultaneously, like a
claw)
SUDS subjective units of distress scale
Although Nick was generally motivated to

get treatment, he made statements of ambivalence, noting that he gets considerable attention
for his symptoms. At one point, he stated that if
his symptoms were reduced, he and his parents
would not have anything to talk about. He also
stated that he had earned a plaque (in jest) at
the end of the last school year for breaking the
school record for being tardy and thought (somewhat jokingly) that he could break his own record in the upcoming year. In order to increase
motivation, the therapist helped Nick to create a
list of the pros and cons of learning behavioral
management strategies with particular emphasis
on how things would be improved if his symptoms were less severe (e.g., it would be easier
to concentrate on schoolwork and get it done in
a timely manner, he could resume soccer, etc.).
Second, the therapist, Nick, and his mother developed and implemented a reward program in
which Nick would earn points for coming to sessions, for working hard during sessions (attending, actively practicing skills, etc.), and completing his homework between sessions. His points
were exchanged for a preferred item at the end
of treatment. Finally, the therapist worked with
Nicks parents to decrease the attention they were
giving his symptoms as well as to reduce parental
accommodation of his symptoms.
Using the pretreatment YGTSS and CYBOCS
as a guide, the therapist and Nick then gener-
ated a list of his most bothersome impulsions,

created operational definitions of each, and outlined associated internal feelings (referred to as
urges for convenience) and known triggers (see
Table 21.1). Nick was then asked to rate how
bothersome each of his symptoms was, on a 010
scale, using subjective units of distress scale
(SUDS) in order to prioritize the order in which
his impulsions would be addressed in treatment
and to monitor treatment progress.
Nick rated his evening-out impulsion as the
most bothersome, so that was the first symptom targeted for treatment. The final activity in
session 1 was to teach Nick to self-monitor his
evening-out impulsion. The purpose of self-monitoring was to begin to increase Nicks awareness
of each time that impulsion occurred, to provide
the therapist with an estimate of how many times
per day the impulsion was occurring, and to identify additional triggers. During self-monitoring,
Nick was asked to carry a small notebook and to
record each time he performed his evening-out
impulsion throughout the day. He was also asked
to record how many times he repeated the behavior, what triggered the impulsion, and to rate the
associated urge on a 010 SUDS. Finally, he was
also asked to record any successful attempts to
resist performing the impulsion. Nicks mother
was instructed to also monitor for this impulsion
and prompt Nick to record his behavior in his
notebook.

Table 21.2 Self-monitoring homework: evening out (session 1)
Number of repeats
Trigger
SUDS
9
Doorknob
6
3
Pet/touch dog
4
5
Light switch
3
4
Light switch
3
12
Doorknob
8
Session 2
When Nick returned for his second session, the
therapist first reviewed his self-monitoring homework. Nick had diligently recorded his eveningout impulsion. In addition, he was able to identify
several additional triggers (light switches, petting
his dog), which were added to his symptom list.
He noted that he had performed his evening-out
impulsion much more than he had previously
thought. He also noted that he had tried to resist his impulsion several times, but was largely
unsuccessful, stating, Once I get going, I cant
stop. A sample of Nicks self-monitoring homework is provided in Table21.2. It was clear from
his homework that some triggers were associated with stronger SUDS ratings than others and
that stronger triggers tended to elicit a greater
number of repetitions of the impulsion. It is noteworthy that Nicks mother also reported that he
needed frequent prompts throughout the week, as
she often observed him performing evening-out
impulsions that Nick claimed he did not notice.
Based on his self-monitoring homework, Nick
and the therapist created a trigger hierarchy based
on the degree to which they elicited the urge to
perform the evening-out impulsion. Again, Nick
was asked to indicate, using a 010 SUDS rating
scale, the degree to which each trigger elicits the
feeling associated with his evening-out impulsion.
After creating a trigger hierarchy, HRT was
then conducted for Nicks evening-out impulsion
and consisted of two primary activities: AT and
CRT. The purpose of AT was to teach Nick to become more aware of each time his impulsion occurred. The first step in AT involved developing
a detailed description of the discrete, sequential
movements involved in the impulsion, beginning with the first movement. To begin AT, Nick
313
Resist (yes/no)
No
No
No
No
No
was asked to simulate his impulsion and describe

each of the movements involved. Nick quickly
came to realize that his impulsion almost always
started by touching something with his right hand
(he was right-handed) followed by his left hand.
He also described that his left hand was usually
at his side, requiring him to raise his left forearm
and rotate his left elbow. He also described that
the pressure feeling in his right hand preceded
initiation of the movements of his left arm. So
the sequence of his impulsion included: touch
object with right hand feeling in right hand
raise left forearm rotate left elbow touch
object with left hand repeat until feeling was
assuaged.
After generating a detailed definition of Nicks
evening-out impulsion, the therapist initiated the
second component of AT, response detection.
The purpose of response detection was to teach
Nick to recognize each instance of his impulsion
(or the associated feeling) and catch it as early as
possible in the sequence. To do so, the therapist
presented Nick with several of the low-SUDS
triggers from his symptom list and asked him to
say a brief code word as soon as he recognized
the urge or beginning actions of the evening-out
behavior (Nick chose to say the word yup).
The triggers were then introduced repeatedly,
and Nick was asked to touch them with his right
hand, keeping in mind that not every presentation
of the trigger elicited the impulsion to touch the
item with his left hand. Initially, Nick was able to
say yup only after he actually touched the triggering object with his left hand. When this happened, the therapist prompted Nick by stating the
code word (yup) as soon as he saw Nicks left
forearm rise and his left elbow rotate. After several minutes of repeated feedback and practice,
Nick was able to catch the impulsion earlier in
314
Table 21.3 Nicks trigger hierarchy for his evening-out impulsion

Trigger
SUDS
Trigger
Light switch
3
Bump into someone with right arm
Pet dog
3
Bump into object with right arm
Open book
4
Turn doorknob
Touch desk
4
Open and close door
Shake hands with stranger
4
Turn kitchen faucet handle
Shake hands with someone familiar 5
Turn bathroom faucet handle
the sequence, saying yup when he recognized

the urge and before his left arm began to move
(which the therapist praised each time). When
Nick was able to catch 80% of his impulsions
early in the sequence, the therapist introduced
CRT.
The purpose of CRT was to teach Nick to
perform a behavior that was incompatible with
his impulsion (i.e., a competing response) each
time he felt the associated urge, caught the impulsion midstream, and/or immediately after he
performed an impulsion. Nick and the therapist
worked together to come up with a CR according
to five general rules: (1) the CR should be something that would make his impulsion impossible
or difficult to perform, (2) the CR should interrupt the earliest movement in the sequence, (3)
the CR should be something that is less noticeable than the impulsion itself, (4) the CR should
(ideally) be a behavior that he can perform anytime and anywhere, and (5) the CR should be a
behavior that he can sustain for an extended period of time, until his urge to perform the impulsion subsides. For Nicks evening-out impulsion,
the CR involved pinning his left elbow to his hip
(elbow bone to hipbone) while making a fist with
his left hand. The therapist then prompted Nick
SUDS
5
6
7
8
8
9
to simulate and practice the CR several times to

assure mastery.
When it was clear that Nick understood and
had mastered the CR, ERP was introduced. Nick
was exposed to triggers from his hierarchy, beginning with those that had the lowest SUDS ratings, and was asked to use the CR to refrain from
performing the impulsion (see Table21.3). During these exposure tasks, Nick was also asked to
provide periodic SUDS ratings, which the therapist recorded on worksheet (see Table21.4). To
begin, the therapist asked Nick to repeatedly turn
the light switch on/off and to use the CR if he felt
the urge to touch it with his left hand. Initially,
Nick used the CR continuously while doing the
exposure task, regardless of whether he felt the
urge. Because the purpose of HRT and ERP was
to teach Nick to inhibit the impulsion when it was
triggered, the therapist prompted him to relax
(not perform the CR) until he felt the urge. When
he recognized the urge to perform the impulsion,
Nick quickly initiated the CR and focused on the
triggering stimulus for at least a minute or until
his urge ratings reduced to zero (or a near-zero
manageable level) for three consecutive ratings.
Another trial of the exposure exercise was then
initiated. If Nick performed the impulsion during
Table 21.4 Exposure record for Nicks evening-out impulsion

Trigger
Assignment
Light
Flip light switch on/off with your right hand, use your CR to stop yourself from evening out with your
switch
left hand
Trial
SUDS (010): Rate every 30s
1
3
4
5
6
5
4
3
1
1
1
2
3
5
4
3
4
2
3
1
1
0
3
3
2
1
1
2
1
0
0
10
2
1
0
0
0
CR competing response, SUDS subjective units of distress scale
exposure tasks, the therapist prompted him to use

his CR, and the next practice trial began.
By the end of the second session, Nick was
able to recognize and interrupt most instances of
his evening-out impulsion using the CR. In addition, he learned that although his urges increased
initially while using his CR, they declined to a
manageable level after a few minutes. To conclude the second session, Nicks mother was
taught how to appropriately prompt and praise
use of the CR (i.e., social support), and Nick and
his mother were asked to conduct daily 4060min practice sessions each day of the upcoming week. During practice sessions, Nick was
assigned to repeatedly approach several of the
least-provoking triggers (light switches, petting the dog, shaking strangers hands, touching
books) and practice using his CR while recording his SUDS ratings on exposure record forms
(see Table21.4). In addition, Nicks mother was
asked to prompt him to use his CR throughout
the week when she observed the evening-out impulsion. Finally, Nick was asked to use the CR
as many times as possible throughout the week
and to continue to self-monitor his evening-out
impulsion as described in session 1, paying particular attention to any new triggers as well as
whether he was able to resist his impulsions. He
was also asked to begin to self-monitor his swiping impulsion, which was the second impulsion
on his symptom list (see Table21.1).
Session 3
When Nick and his mother returned for the third
session, the therapist first reviewed the selfmonitoring and exposure homework. His selfmonitoring homework revealed that Nick had
been able to resist his evening-out impulsion
about 70% of the time during the past week. His
homework also showed that both his initial and
peak urge ratings reported during his exposure
homework had decreased over the course of the
week. The light switch was very rarely triggering the evening-out impulsion, and when it did,
the urge was tolerable (peak SUDS rating of 12)
and easy for Nick to resist, even without using
315
the CR. Similar improvement was noted with

several other low SUDS items on the trigger hierarchy. As a general rule, items were considered
mastered when they were triggering a tolerable
urge that could be easily resisted, and Nick demonstrated that he was able to resist the impulsion
in the presence of the trigger several times across
multiple days. In Nicks case, the mastery criteria
were set at (a) the peak SUDS ratings during exposure trials were reduced by at least 50% from
baseline and had a peak SUDS rating <2 and (b)
Nick was able to resist the impulsion in the presence of the trigger at least ten consecutive times
across three consecutive days. When these criteria were met for an item on Nicks hierarchy, the
exposure exercise was considered mastered, and
the next item on the hierarchy was introduced
(e.g., bumping into something with his right arm,
turning doorknobs).
After assigning and practicing several new exposure tasks for his evening-out impulsion, Nick
and the therapist began working on his swiping
impulsion (see Table21.1). Based on his selfmonitoring information from the previous week,
it was clear that this impulsion was occurring during two different situations. On some occasions,
the urge to swipe his finger was triggered simply
by seeing a particular object, such as a TV or computer screen. In these instances, he recognized the
urge well before he performed the behavior but
said that he felt a pressure feeling in his fingers
that compelled him to approach the stimulus and
repeatedly swipe his finger across the surface
until the feeling went away. Self-monitoring data
showed that he was able to resist swiping under
these circumstances about 50% of the time. On
other occasions, however, Nick was already interacting with the stimulus, and the swiping was
experienced as automatic. For example, he
demonstrated that when swiping through pictures
on his mobile phones touch screen, he would
swipe his right index finger on the screen one time
(with intention) for the purpose of advancing to
the next picture. However, periodically, he would
swipe his finger across the screen several times
in rapid succession (and with greater force) until
the pressure feeling in his fingertip was alleviated.
He was rarely, if ever, able to resist the impulsion
316
under these circumstances. After creating a trigger hierarchy for his swiping impulsion, HRT was
introduced as described above. First, Nick and the
therapist came up with a detailed response description. The therapist then asked Nick to scroll
through pictures on his mobile phone (at a rate of
one picture every 2s) and to respond by saying
yup each time he felt the pressure feeling and/or
performed the swiping impulsion (i.e., response
detection). This continued until he was able to
catch 80% of his swiping impulsions. A CR was
then introduced, which involved having Nick fold
his index finger into his palm and placing the pad
of his thumb over the top of the middle phalanx
on his index finger. Nick then practiced using the
CR to refrain from swiping while confronting
the first items on his trigger hierarchy. Exposure
homework for his evening-out and swiping impulsions was then assigned, and Nick was asked
to begin self-monitoring the next impulsion on his
symptom list.
Sessions 410
Sessions 410 generally followed the same format as sessions 2 and 3. Each week, the therapist began by reviewing Nicks self-monitoring
homework. When new triggers were identified
for a particular impulsion, they were given a
SUDS rating and added to the respective trigger
hierarchy. Self-monitoring was also valuable for
identifying new exposure homework tasks. For
example, when working on Nicks swiping impulsion, he noted that the impulsion was much
more likely to be triggered (and more difficult to
resist) when the screen was dull versus when it
was bright. The urge also varied depending upon
the amount of pressure he placed on the screen
(it was worst when he lightly brushed the screen
with his fingertip). Based on this information,
exposure tasks with varying levels of screen
brightness and fingertip pressure were included
on his hierarchy for that impulsion. In addition
to reviewing his self-monitoring homework, the
therapist reviewed Nicks exposure homework
each week, crossing off mastered items and adding new, more difficult, exposure assignments.
HRT and ERP were introduced for Nicks repeating and tapping impulsions (see Table21.1)
in sessions 4 and 6, respectively. A variety of
sights, sounds, and proprioceptive cues triggered
the repeating impulsion. The tapping impulsion
was triggered almost exclusively by the sight of
shiny or translucent surfaces. His awareness of
when he performed both of these impulsions was
very good, so he required only brief AT in subsequent sessions. The CR for his repeating impulsion was to fold his hands together and place
them in his lap. While this was an effective CR,
initially the urge to repeat an action (even for the
easiest items on his hierarchy) would increase to
the point of becoming unbearable, so he would
give in and perform the impulsion. Unable to
find easier triggers, the therapist challenged Nick
to resist the impulsion (using the CR) for successively increasing time intervals. Initially, Nick
was able to resist for only 2min (which corresponded to an SUDS rating of 10), so for the next
assignment he was encouraged to try to resist for
as long as he could or for at least 30s longer than
the previous attempt. After several practice sessions, he was able to resist the impulsion for most
triggers completely (the urge reduced after about
10min). The CR for his tapping impulsion was
introduced in session 5 and involved folding his
fingers into his palm and making a fist. Nick mastered this CR quickly. Sessions 6 through 9 were
focused on progressing through Nicks trigger hierarchies for all of his impulsions. At the seventh
session, Nick reported that he had a rough week
and let things slide which resulted in a slight
increase in the frequency of his symptoms so the
therapist reviewed with Nick the progress he was
making and revisited his motivational materials
to help get him back on track.
By the tenth session, it was clear that Nick had
mastered the HRT and ERP skills and had made
substantial progress in treatment. He was able
to resist each of his impulsions except for rare
occasions in which he came into contact with a
particularly strong trigger. Although Nick continued to identify a few new triggers (or variations
of triggers) between each session, he had worked
through approximately 80% of each of his trigger hierarchies.
Sessions 1112
Based on his progress, Nick was scheduled for
two additional therapy sessions each scheduled
2 weeks apart. Prior to session 11, in addition to
working on newly assigned exposure homework,
Nick was challenged to actively seek out new
triggers and/or past triggers that he may not have
come into contact with over the course of treatment. For example, even though he had worked
on touching a soccer ball as part of his exposure
homework, he had not played in a soccer game,
so this was assigned as homework. Likewise, although he had worked on touching books, desks,
and other school-related materials, treatment was
administered over the summer when he was not
in school, so Nick and his mother were assigned
to go to his old (and new) classroom in order to
find possible triggers and to practice using his
CRs. In addition, Nick was encouraged to test
himself with each of his mastered triggers and
to record final SUDS ratings for each of them.
Two weeks later, Nick returned for his 12th
and final session. During this session, Nick and
the therapist updated his symptom hierarchy and
discussed his progress in treatment. They then reviewed all of Nicks impulsions, their definitions,
associated CRs, and generated a detailed weekly
plan for completing remaining exposure homework. In order to assess how well he was able
to generalize what he learned over the course of
treatment, Nick was asked to play the role of the
therapist and to outline how he might address a
new symptom using HRT and ERP. This allowed
Nick to demonstrate that he had mastered the
skills he would need to address any symptoms
that might arise in the future.
and Summary of Outcomes
At the final treatment session, Nick and his
mother were re-administered the YGTSS and the
CYBOCS. Consistent with clinical impression,
the YGTSS revealed that Nicks simple tics had
not changed in severity (they were not targeted
in treatment); however, his complex tics/impul-
317
sions were greatly diminished in frequency, intensity, complexity, and interference. His swiping and tapping symptoms had been absent for
more than a week. Although he continued to have
repeating impulsions on a daily basis, prolonged
symptom-free intervals were common. When
impulsions did occur, they were brief and short
in duration. For example, prior to treatment, he
would often get stuck repeating actions for
several minutes, such as opening and closing the
door. After treatment, they were limited to one or
two repetitions of the action. Consistent with his
self-monitoring data, Nick reported that he was
much better at recognizing his symptoms and attempted to resist them most of the time, usually
with success. Overall, Nick and his mother reported the symptoms had reduced to the extent
that they were no longer interfering with Nicks
day-to-day activities. At posttreatment, Nick was
given a YGTSS total motor tic severity score of
10/25 (a 48% decrease); however, his residual
score was driven primarily by his simple tics. On
the CYBOCS, he obtained a score of 4/20 on the
obsession subscale (9 point change) and a 6/20
(10 point change) on the compulsion subscale,
for a total CYBOCS severity score of 10/40 (19
point change).
Although Nicks case was relatively straight forward, several potential complicating factors need
to be considered when treating TOCD. First, comorbidity is common in children with OCD+TD.
In addition to contributing to functional impairment, comorbid conditions (e.g., ADHD, depression) can interfere with motivation and treatment
compliance. Second, most children with TOCD
present with a complex combination of tics, obsessions and compulsions, and impulsions. In
Nicks case, the impulsions were the most distressing and caused the most functional impairment. Prioritizing which symptoms to treat first
can be a challenge when treating TOCD. However, we find that once children master HRT (for
tics) and/or ERP (for obsessions and compul-
318
sions), extending the treatment to include related

symptoms is usually intuitive.
In terms of treatment delivery, the most commonly encountered problems include compliance
and motivation. Behavioral interventions require
considerable effort between sessions, which
can be challenging for both children and their
parents. In cases like Nick, it is not uncommon
for parents to expect the child to do the therapy
homework on their own, which is not ideal as
parents play an active role as support personnel. Parents may also struggle when children are
asked to endure distress as they progress through
treatment, which can lead to parental accommodation of symptoms, such as avoiding contact
with TOCD triggers, comforting or distracting
the child during an exposure exercise, and/or
modifying the childs daily routine (i.e., reducing chores, homework, etc.) to alleviate overall
distress. When this occurs, it can interfere with
treatment progress and should be addressed. We
find that parents are usually well intentioned in
their accommodation and do not realize that it
could be potentially problematic. Parents usually
welcome more healthy and adaptive ways to respond to their childs symptoms.
In general, we have found that most complicating factors can be adequately addressed by
adopting a flexible approach to treatment while
maintaining the fidelity of HRT and ERP procedures. For example, some children will easily recognize their impulsions and require very little AT,
whereas others may require considerable practice
and even multiple sessions to achieve sufficient
awareness. Likewise, some children will experience substantial urge reduction very quickly,
whereas for others the urge can be quite stubborn, staying quite high throughout multiple exposure trials and/or reducing to low levels but not
subsiding completely. However, it is our clinical
experience that between-session urge reduction
does not require within-session urge reduction,
so we encourage children to practice using their
CR repeatedly in the presence of triggers even if
their urge is stubborn. Finally, some children
will have very few triggers for their impulsions,
whereas others will experience the impulsion
seemingly randomly. In the former case, we tend
to emphasize the ERP component of treatment,

whereas in the latter case, we tend to place more
emphasis on HRT.

TOCD is a unique variant of OCD, representing a blend of tics and obsessive-compulsive
symptoms that can pose challenges to assessment, conceptualization, and treatment.
Impulsions differ from simple tics and classic obsessions and compulsions in important
ways.
ERP has been shown to be effective for treating TOCD; however, incorporating elements
of HRT can optimize outcomes.
References
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders: DSM-5. Washington, D.C.: American Psychiatric Association.
Cath, D. C., Spinhoven, P., Hoogduin, C. A., Landman, A.
D., van Woerkom, T. C., van de Wetering, B. J., etal.
(2001). Repetitive behaviors in tourettes syndrome
and OCD with and without tics: What are the differences? Psychiatry Research, 101, 171185.
Franklin, M. E., & Foa, E. B. (2011). Treatment of
obsessive compulsive disorder. Annual Review
of Clinical Psychology, 7, 229243. doi:10.1146/
annurev-clinpsy-032210-104533.
George, M. S., Trimble, M. R., Ring, H. A., Sallee, F. R.,
& Robertson, M. M. (1993). Obsessions in obsessivecompulsive disorder with and without Gilles de la
tourettes syndrome. American Journal of Psychiatry,
150, 9397.
Gomes de Alvarenga, P., de Mathis, M. A., Dominguez Alves, A. C., do Rosario, M. C., Fossaluza, V.,
Hounie, A. G., etal. (2012). Clinical features of ticrelated obsessive-compulsive disorder: Results from
a large multicenter study. CNS Spectrums, 17, 8793.
doi:10.1017/s1092852912000491.
Grados, M. A., & Mathews, C. A. (2009). Clinical phenomenology and phenotype variability in tourette
syndrome. Journal of Psychosomatic Research, 67,
491496. doi:10.1016/j.jpsychores.2009.07.011.
Himle, M. B., Woods, D. W., Piacentini, J. C., & Walkup,
J. T. (2006). Brief review of habit reversal training for
tourette syndrome. Journal of Child Neurology, 21,
719725.
Holzer, J. C., Goodman, W. K., McDougle, C. J., Baer, L.,
Boyarsky, B. K., Leckman, J. F., & Price, L. H. (1994).
Obsessive-compulsive disorder with and without a

chronic tic disorder. A comparison of symptoms in 70
patients. British Journal of Psychiatry, 164, 469473.
Kwak, C., Dat Vuong, K., & Jankovic, J. (2003). Premonitory sensory phenomenon in tourettes syndrome.
Movement Disorders, 18, 15301533.
Leckman, J. F., Riddle, M. A., Hardin, M. T., Ort, S. I.,
Swartz, K. L., Stevenson, J., & Cohen, D. J. (1989).
The Yale global tic severity scale: Initial testing of
a clinician-rated scale of tic severity. Journal of the
American Academy of Child and Adolescent Psychiatry, 28, 566573.
Leckman, J. F., Walker, D. E., & Cohen, D. J. (1993).
Premonitory urges in tourettes syndrome. American
Leckman, J. F., Grice, D. E., Barr, L. C., de Vries, A. L.,
Martin, C., Cohen, D. J., etal. (1994). Tic-related vs.
non-tic-related obsessive compulsive disorder. Anxiety, 1, 208215.
Mansueto, C. S., & Keuler, D. J. (2005). Tic or compulsion?: Its tourettic OCD. Behavior Modification, 29,
784799. doi:10.1177/0145445505279261.
319
OConnor, K., Aardema, F., & Pelissier, M. (2005).

Beyond reasonable doubt: Reasoning processes in
obsessive-compulsive disorder and related disorders.
England: Wiley.
Scahill, L., Riddle, M. A., McSwiggan-Hardin, M., Ort,
S. I., King, R. A., Goodman, W. K., etal. (1997). Childrens yale-brown obsessive-compulsive scale: Reliability and validity. Journal of the American Academy
of Child and Adolescent Psychiatry, 36, 844852.
Storch, E. A., Stigge-Kaufman, D., Marien, W. E., Sajid,
M., Jacob, M. L., Geffken, G. R., etal. (2008). Obsessive-compulsive disorder in youth with and without a
chronic tic disorder. Depression & Anxiety, 25, 761
767. doi:10.1002/da.20304.
Verdellen, C. W., Keijsers, G. P., Cath, D. C., & Hoogduin, C. A. (2004). Exposure with response prevention versus habit reversal in tourettess syndrome: A
controlled study. Behavior Research and Therapy, 42,
501511. doi:10.1016/s0005-7967(03)00154-2.
Treatment of Extreme Family

Accommodation in a Youth
Disorder
22
Eli R. Lebowitz
Nature of the Problem and Associated date are centered on obsessive-compulsive disorder (OCD).
Research Basis
That a childs emotional disorder is likely to involve others within the same family unit is rather
self-evident. Less obvious are the answers to
questions such as How (i.e., in what form) will
a childs disorder involve family members?;
What kinds of involvement are helpful and
should be encouraged?; Which are unhelpful
and should be resisted?; How can family members modify unhelpful forms of involvement?
These are difficult questions, but they are faced
by almost all families coping with a childs emotional or behavioral disorder.
The term family accommodation refers to all
the ways in which family members change their
own behavior to help a relative avoid or alleviate
distress caused by an emotional disorder. In the
context of childhood disorders, family accommodation usually refers primarily to accommodation
by parents, but siblings (and even other relatives)
can, and frequently do, engage in accommodation. Systematic empirical research into family accommodation has a brief history. Not by
chance, the start and the bulk of this history to
Dr. Lebowitz receives royalties from John Wiley and
Sons.
E.R.Lebowitz()
Child Study Center, Yale University, 230S. Frontage
Road, 06520 New Haven, CT, USA
e-mail: eli.lebowitz@yale.edu
The first attempt to systematically quantify

and measure family accommodation was by
Calvocoressi etal. (1995). They interviewed the
caretaker relatives of 34 adult OCD patients and
found that the large majority (88%) reported
engaging in family accommodation. The degree
of accommodation ranged quite broadly, from
minor changes in behavior to multiple daily accommodations. They also found that the degree
of reported accommodation correlated with poorer overall family functioning and higher family
stress.
An enduring result of this early foray into
measuring family accommodation has been the
clustering of accommodation behaviors into two
main categories. One category includes family
members active participation in symptom-driven behaviors. In the context of OCD, examples of
participation include performing rituals, providing verbal reassurances, providing items needed
for the completion of rituals (e.g., soap or Purell),
or avoiding places or activities that could trigger
OCD-related distress. The second category includes modification of family functioning. In the
context of OCD, this might include changes to
work or leisure schedules, taking over responsibilities that would normally belong to the disordered relative or other changes to family routines.
Modification and participation are not strictly
separate, and many forms of accommodation can
plausibly be described as both participation and
modification (e.g., mother drives roundabout

DOI 10.1007/978-3-319-17139-5_22
321
322
route, taking child to school to avoid driving past

a hospital). Nevertheless, factor analytic studies
have supported this broad division into modification and participation in OCD, as well as other
anxiety disorders (Albert etal. 2010; Lebowitz
etal. 2013a).
Since the initial Calvocoressi etal. (1995)
study, there have been numerous efforts to study
family accommodation in relatives of both adults
and children using interviews and self-report
instruments (Flessner etal. 2011a, b; Lebowitz etal. 2012a; Merlo etal. 2009; Storch etal.
2007a). These studies have consistently reported
high frequency of accommodation among parents of youth with OCD. Family accommodation
has also been convincingly tied to the severity
of youths OCD, with greater accommodation
predicting more severe symptoms and greater
impairment. No less importantly, family accommodation is a predictor of poor response to treatment. Youth in the largest randomized controlled
trial for pediatric OCD to date, were less likely
to respond to either cognitive-behavioral therapy
(CBT) or medication, or both, when greater family accommodation was reported prior to treatment (Garcia etal. 2010). Conversely, a number
of smaller clinical trials have reported that improvement in OCD symptoms over treatment is
associated with reduced family accommodation
(Barrett etal. 2004; Merlo etal. 2009; Storch
etal. 2007b). The unfortunate irony of these data
is that as parents invest more and more in attempting to prevent their childs distress, the actual impact of the disorder seems to get larger and
larger, and the probability of successful treatment
gets smaller and smaller.
Why would family accommodation predict
more severe OCD and poorer treatment response? A number of plausible hypotheses exist.
One possibility is that family accommodation is
essentially at odds with the goals of treatment for
OCD. Treatment for OCD typically focuses on
encouraging coping, self-regulation, not giving
in to OCD (e.g., through exposure and response
prevention, ERP) and minimizing the impact of
the disorder on daily life. Family accommodation, on the other hand, lowers the need for selfregulation (as the child relies on the parent to pre-
E. R. Lebowitz
vent distress), actively encourages avoidance and

the performance of rituals (by providing items,
participating in the rituals, etc.), and magnifies
the impact of the disorder on the whole familys
life (by modifying routines and schedules in accordance with the OCD).
Another related possibility is that children
who are highly accommodated face an unfortunate choice. They must either work hard in a challenging treatment that explicitly and deliberately
triggers their distress, or they may continue to
rely on parents and siblings to create an environment that allows them to escape the distress (or at
least they believe it will allow them to do so). For
many children, the answer might be something
of a no brainer. They may be considerably less
motivated to apply themselves in treatment than
youth whose choice is between working hard at
treatment and dealing with the OCD without the
help of parents accommodation.
A logical conclusion appears to be that working with parents to reduce their accommodation,
instead of prior to or during child treatment, has
the potential to improve the childs OCD symptoms and may increase the likelihood of the child
benefitting from treatment directly. However, reducing accommodation presents parents with significant challenges of its own. A growing body of
research is demonstrating that many youth with
OCD will respond negatively in the short term to
parents attempts not to accommodate. Studies of
coercive-disruptive behavior, or forceful attempts
to impose accommodation, have found that many
youth will resort to either verbal or physical aggression, dramatic exhibits of distress, emotional
blackmail (e.g., You dont love me enough to
do this for me), or any combination of these in
their attempts to ensure the adherence of family
members to the strict rules driven by their OCD
(Lebowitz etal. 2011a, b, c).
In an international survey of expert clinicians
and researchers, the vast majority indicated that
coercive-disruptive behaviors were common
among the OCD youth they encountered (Lebowitz etal. 2011c). More rigorous studies since
have confirmed this belief, finding coercivedisruptive behaviors to be prevalent (Lebowitz
etal. 2011a). Importantly, there is some indica-
22 Treatment of Extreme Family Accommodation in a Youth with Obsessive-Compulsive Disorder
tion that these behaviors may not be easily identified using standard screening measures that are
intended to assess the presence of more typical
externalizing symptoms. Use of more specialized measures is recommended in evaluating disruptive behavior in youth with OCD (Lebowitz
etal. 2011a). These findings reaffirm the need for
parent-based interventions that include concrete
steps for reducing family accommodation, while
providing parents with practical tools for coping
with childrens resistance or coercive-disruptive
behaviors.
One such parent-based intervention is the
Supportive Parenting for Anxious Childhood
Emotions (SPACE) Program (Lebowitz and
Omer 2013). In SPACE, parents are first educated about family accommodation and about
the importance of adopting a supportive, rather
than protective, stance toward the child. Support
is defined as any parental verbal or nonverbal
communication to the child that successfully
integrates both of the following elements: acknowledgment and acceptance of the difficulty
and distress experienced by the child and a confidence in the childs ability to cope and to tolerate
at least some degree of distress. The therapist and
parents then methodically chart the various ways
in which parents have been accommodating the
childs symptoms and a target accommodation is
selected as the first focus of treatment. Parents
are instructed to inform the child in a supportive manner that although they recognize the difficulty for the child they are confident that the
child can cope better and that the current accommodations are actually not helpful. Subsequently,
a detailed plan is formulated with the therapist,
describing the concrete changes that the parents
will make to their behavior. The child is informed
of the plan, and over the coming weeks parents
work to systematically reduce the accommodation. During treatment session, their progress is
monitored, and difficulties are addressed. SPACE
includes modules for troubleshooting some of
the common difficulties that can arise during the
treatment process. One module includes tools for
dealing with aggressive or destructive behavior
from the child. Another module focuses on increasing parents ability to work cooperatively
323
with each other. Often two parents will have divergent views of the childs difficulties and the
best ways to handle them, and the therapist will
work to facilitate a collaborative process. Another module provides parents with tools for responding to children who express threats toward
themselves as a result of the steps taken by the
parents. Parents learn to provide the child with
maximum protection, while not abandoning the
goal of reducing the accommodation. Another
module focuses on recruiting support from outside the home to support both parents and child
during the difficult process.
SPACE is markedly different from other family-based interventions for childhood OCD or
anxiety. It is the only program that makes reducing family accommodation the main treatment
goal and includes a detailed and practical set of
steps for achieving this goal; it is exclusively
parent-based (not an add-on to child therapy)
allowing for treatment of youth who do not participate in treatment themselves; and it provides
tools for coping effectively with coercive-disruptive behaviors that are commonly associated
with parental attempts to reduce accommodation.
Clinical trials have supported the usefulness of
SPACE in working with very difficult cases that
are unlikely to respond to CBT, including youth
who have explicitly refused to engage in any kind
of therapy themselves (Lebowitz 2013; Lebowitz
etal. 2014).
How does SPACE work when children refuse
to participate or collaborate? All psychotherapy
relies on a working alliance between therapist
and client. Traditionally, the client is identified
as the person with the disorder, and as a result
a working alliance between that individual and
the therapist is crucial to successful intervention. However, exceptions exist to this rule. One
kind of exception is the family therapy approach.
Family therapy has generally redefined the person with the disorder as the family with the
disorder and therefore necessitates an alliance
between therapist and family. Another kind of
exception is parent work. Parent training for coping with childrens oppositional defiant disorder
and related externalizing symptoms is among the
most evidence-based treatments of all. In treat-
324
ments like parent management therapy, parents

learn to modify their own behavior leading to
changes in the childs behavior. Direct treatment
or alliance with the child is not required or expected. In OCD and related anxiety disorders,
the focus has usually been on the individual with
the OCD, but the same principle can apply. What
is needed is a conceptual framework, other than
CBT, to guide the parent work and inform the
specific therapeutic steps.
One conceptual framework that is particularly
suited to informing parent work without relying
on child collaboration is nonviolent resistance
(NVR). NVR is most frequently recognized from
its applications in the broader social context such
as the revolutionary work of Gandhi (1951) and
Martin Luther King Jr. (King 2003). But the fundamental principles of NVR are applicable to
any situation in which one person (or entity) is
attempting to bring about change while neither
engaging in confrontation with another side nor
requiring the collaboration of that other side. Applications of NVR to parent training have already
been demonstrated (Lebowitz etal. 2012b; Weinblatt and Omer 2008). In SPACE, parents learn
to accept that they cannot directly change their
childs behavior and begin to focus instead on
changing their own behavior. They modify their
actions to better reflect a belief in the childs ability, rather than requiring the child to believe they
can cope. By shifting attention away from child
change and focusing on parent change, parents
success is no longer contingent on the child
complying. This rapidly decreases the potential
for escalation in the relationship, which is common when parents try to directly shape a childs
behavior against the childs will.

in the Particular Case that Will Be
Presented
Alyssa was a 14-year-old, English-speaking
Asian girl living with biological parents (Hana
and Ken), a 16-year-old brother (Fred), and a
9-year-old sister (Emi). Alyssa presented with
numerous obsessive and compulsive symptoms,
E. R. Lebowitz
as well as severe family accommodation. Alyssas obsessions included near constant concern
about contamination from people, surfaces, or
germs in the air. Ever since her sister Emi had the
flu (1 year before evaluation), Alyssa had been
particularly concerned about being contaminated
by her. Alyssa also had frequent obsessions about
her underwear not being clean (not necessarily
related to becoming sick), superstitious thoughts
involving unlucky numbers, and frequent somatic obsessions related to the possibility that she
was sick or was becoming sick (e.g., some diseases have incubation periods so not feeling sick
doesnt prove anything). Alyssas compulsions
included ritualized hand washing and showering
totaling upwards of 2.5h per day, avoiding certain individuals (e.g., her sister) and certain parts
of the house (e.g., kitchen), and extensive checking of her underwear with very prolonged cleaning after using the bathroom.
Alyssas parents reported engaging in numerous forms of family accommodation. All Alyssas food was prepared and served separately
using dishes no one else used, including being
cooked separately in her pots and pans. Alyssas dishes were washed in separate cycles of the
dishwasher and were kept in a separate cabinet.
The parents brought Alyssa her food to the dining room even if the family ate in the kitchen.
Both parents always changed clothes immediately after coming home and showered for at least
15min. Alyssas parents also reported checking
their own temperature each day (often more than
once) and showing Alyssa the result. Alyssas
sister no longer slept in their shared bedroom and
had moved to a mattress on the living room floor.
Likewise, her sister was not allowed to use the
kids bathroom and used the parents instead.
Both parents avoided parking near ambulances
or near disabled persons parking spots, and they
promised Alyssa that they had not done so in
her absence (not always factually correct). When
Alyssas grandmother was sick and was hospitalized for 1 week, Alyssas mother did not visit her
because of Alyssas symptoms. Finally, the entire
family was careful not to touch any of Alyssas
things, enter her room, or sit on her couch in
the living room.
Case Information
Alyssa was a gifted student in the eighth grade.
She was described as a smart, creative, and resourceful child, who excelled at art and loved
animals. Her early development was unremarkable apart from severe separation anxiety when
she entered preschool at the age of three. Hana
reported that she had one aunt who had been hospitalized in a psychiatric hospital, but she did not
know the specific diagnosis or symptoms. Neither parent had ever made use of mental health
services, but Ken described having panic attacks
in college and being a little OCD about things
like checking to make sure the car is locked. He
did not feel his habits interfered with his functioning in any way.
Alyssa was reluctant to communicate during
most of her evaluation and the bulk of information was gathered from her parents. They reported that Alyssa had become highly preoccupied
after experiencing a brief, acute gastrointestinal
illness during a family vacation 2 years prior.
Alyssa had been particularly upset at having had
an accidentnot reaching a bathroom in time
during a bout of diarrhea.
Following that illness, Alyssa became extremely concerned about the possibility of becoming sick. Her fears related to the unpleasant
symptoms she would experience if she developed
even a minor illness and to the possibility of serious or life-threatening disease. Another recurring
concern was that her underwear would not be
clean after a visit to the bathroom.
Hanna and Ken described a very rapid escalation in the severity of Alyssas symptoms. For
the first month after they returned from their vacation, they had assumed that Alyssas concerns
would fade as she settled back into her normal
routine. The parents first began to suspect that
the issue was more serious when they noticed
Alyssa repeatedly washing hands for many minutes at a time. They also realized that Alyssa was
using an inordinate amount of toilet paper and
taking an excessive amount of time to exit the
bathroom after bowel movements. The parents
consulted with their pediatrician who suggested
Alyssa might have OCD but did not feel qualified
325
to make a diagnosis and referred them to a child

psychologist.
Alyssa and her parents met with the psychologist who agreed that Alyssa had OCD. However,
she felt that the symptoms were best understood
as part of Alyssas psychological reaction to puberty. Alyssa had had her first period at the age of
12, not long before the trip on which she became
sick. The therapist suggested to the parents that
Alyssa was ambivalent about her transition to
womanhood and suggested that becoming sick
and unclean underwear were symbolic representations of menstruation. She recommended
that Alyssa begin therapy to work on her feelings about womanhood and sexuality and that
the parents not attend to the symptoms as these
would likely resolve as she learned to feel comfortable with her maturing body.
Alyssa initially liked the therapist and willingly attended weekly psychotherapy sessions.
During these sessions, the therapist chose not to
focus on the OCD symptoms. Instead, she employed various methods including conversation,
art, play, and projective psychological tests to encourage Alyssa to reflect upon and communicate
her feelings. Occasionally, she would introduce a
relaxation method, such as deep breathing or visualization, to help Alyssa cope with her anxious
preoccupation.
Throughout the course of this treatment, which
lasted approximately 8 months, Alyssas OCD
symptoms grew steadily worse. One precipitating factor was her younger sister, Emi, having the
flu. Alyssa reacted to this development with what
her parents described as a shocking level of
anxiety. She absolutely forbade Emi from coming near her or touching any of her things. Alyssa
became so agitated at Emis presence that Hana
and Ken told Emi to sleep in the living room on a
mattress rather than in the girls shared bedroom.
Emis flu lasted less than a week, but Alyssa
continued to be extremely avoidant of her even
after she got well. She began to ask her parents
for plastic dishes rather than using ones that Emi
might have contaminated and ultimately used
only a separate set of dishes for all her needs.
Alyssas symptoms seemed to multiply daily.
She started checking her temperature every day
326
and soon demanded that her parents do the same.

She became hysterical when Ken told her he had
visited a friend in the hospital and refused to go
near him for over a week. Following that episode,
she insisted that both her parents shower and
change their clothes immediately upon entering
the house, even after very brief exits. Her parents were dismayed and confused, unsure how to
respond to all these seemingly bizarre demands.
Any attempts on their part to resist the demands
were met with extreme distress and hostility.
Alyssa would become highly distraught, yelling
and crying, hitting them, and throwing objects
around the house. She would call them names and
accuse them of not caring about her. And after
they ultimately gave in and complied, she would
be tearful and apologetic, saying I know Im a
freak, I wish I was dead. Then you wouldnt have
to deal with me.
After 8 months of therapy, it was clear to Hana
and Ken that treatment was not successful, and
Alyssa became less willing to attend her sessions.
She told her parents it was not helping and that
she was tired of the therapist because she treats
me like a baby. The parents met with another
psychologist who told them that the recommended treatments for OCD were CBT and medication. He suggested they consult immediately
with a psychiatrist and offered to begin CBT with
Alyssa. Alyssa attended only one more session,
before flatly refusing to return. She told her parents that the therapist wanted to make her sick,
that he had told her she would have to stand up
to OCD, and that therefore she would never go
back. She did however begin taking a selective
serotonin reuptake inhibitor (SSRI) medication.
Alyssa and her parents met with two additional
CBT experts, but the parents had to bribe Alyssa
to get her to the meetings, and in both cases she
refused to return. Hana and Ken described feeling very helpless. They realized their daughter
was quite ill and worried about her ability to
function throughout life. They were also increasingly frustrated by the impositions that Alyssas
OCD was placing on their lives, and they worried
about the effect it was having on their other children, particularly Emi. For a brief period of time,
the medication seemed to be helping, and Alyssa
E. R. Lebowitz
seemed slightly less concerned. But this affect

did not last, and soon things were as bad as ever.
Alyssas symptoms were markedly worse at
home compared to outside the house. At school,
despite telling her parents that the OCD was
just as bad, she was able to function quite well.
Most of her teachers were unaware of the problem, and although she did excessively wash her
hands and attempt to refrain from visiting the
student restroom, she maintained a high level of
both academic and social functioning. The most
significant change socially was that she stopped
inviting friends to visit her at home and subsequently also stopped visiting the homes of others. However, she frequently communicated with
her friends over telephone and social networks
and sometimes spent time with them after school,
outside of the house.
and Assessment
The interview with Alyssa and her parents, along
with structured interviews and questionnaires,
supported a clear diagnosis of OCD. Alyssa and
her parents completed a structured interview
for assessing the presence and severity of OCD
symptoms, the Childrens YaleBrown Obsessive-Compulsive Scale (CYBOCS) (Scahill etal.
1997). The CYBOCS includes questions that assess the frequency, severity, and interference of
obsessions and compulsions. The maximum total
score on CYBOCS is 40, and a score above 16 is
often considered an indicator of clinically significant symptoms. Alyssas total score on the parent-rated CYBOCS was 31, indicative of severe
OCD symptoms. Table22.1 shows the parents
responses to the ten severity items (all scored
04). Alyssa did not respond to all items on the
CYBOCS. She answered only the obsessions
items, and her total score from that half alone was
11, indicative of moderately severe obsessions.
Alyssas parents also completed the Interviewer-Rated Family Accommodation Scale
(FAS-IR; Calvocoressi etal. 1999). The FAS-IR
includes 12 questions that assess accommodation to the OCD symptoms. The total maximal
327
Table 22.1 Alyssas pretreatment scores on the childrens YaleBrown obsessive-compulsive scale (CYBOCS)
Obsessions
Compulsions
Item
Score
Description
Item
Score
Description
Time spent on
2
Between 1 and
Time occupied by
3
Between 3 and 8h a
day
compulsions
3h a day
obsessions
Interference
2
Definite interference,
Interference
3
Substantial
but manageable
impairment
Distress associated with 3
Very frequent and
Distress associated
4
Incapacitatobsessions
disturbing
with compulsions
ing anxiety/
frustration
Resistance
4
Yields willingly to all Resistance
4
Yields willingly to all
thoughts
compulsions
Control over thoughts
3
Rarely can stop
Control over
3
No control
thoughts
compulsions
Total
15
Total
16
Total
31
score on FAS-IR is 48. Alyssas parents score

was 39, indicative of extreme family accommodation. The highest rated items on the FASIR were Facilitating Avoidance, Facilitating
Compulsions, Refraining from Saying/Doing
Things, Tolerating Odd Behavior/Household
Disruption, and Participating in Compulsions.
Parents also indicated frequently Providing Reassurance, Taking on Patients Responsibilities, and Modifying their Personal and Family
Routines.
Ken and Hana completed the coercive-disruptive behavior checklist for pediatric OCD (CDPOC; Lebowitz etal. 2011a) which assesses the
presence, form, and severity of coercive-disruptive behaviors or youths attempts to forcefully
impose accommodation and demand compliance
with OCD-driven rules. The parents total score
on the 18-item checklist was 55 of a possible 72,
indicative of frequent coercive-disruptive behaviors of multiple kinds. Among the items scored,
the highest were Impose strict rules of cleanliness or order on other family members, Forbid the performance of normal actions or react
with violence or rage if they are performed, and
Forbids the use of objects in his/her vicinity because of feelings of fear or disgust.
Alyssas assessment also included an evaluation of non-OCD symptoms. A structured interview (Anxiety Disorders Interview Schedule
(ADIS) for DSM IV; Silverman and Albano 1996)
was used to assess the presence of other anxiety
diagnoses or additional psychopathology. Alyssa

met diagnostic criteria for generalized anxiety
disorder and reported subclinical symptoms of
separation anxiety disorder. Although she did
not meet criteria for a mood disorder, Alyssas
self-reported symptoms of depression were quite
high. Her normalized score on the Child Depression Inventory (CDI; Kovacs 1985), adjusted for
age and gender, was 66, significantly above the
average. The most elevated subscales were Negative Mood and Negative Self-Esteem.
Based on all the material gathered through
Alyssas evaluation the case was conceptualized
as one of severe OCD with extreme family accommodation. The accommodation was seen as
likely contributing to the severity and maintenance of the disorder, and as reducing Alyssas
motivation for treatment, posing a possible barrier to CBT. In discussion with Alyssa and her parents, it was clear that Alyssa was determined not
to participate in therapy. Her parents were offered
a parent-based treatment (SPACE). The rationale
for a parent intervention was that while Alyssa
was declining treatment, the parents were actually motivated to change the current situation.
Because the extreme family accommodation XE
"Accommodation:family" was conceptualized as
likely contributing to the severity and chronicity
of Alyssas symptoms as well as lowering her
motivation for individual therapy, the goals of the
parent treatment included:
328
1. Reduce family accommodation and the negative impact of OCD on the family.
2. Improve Alyssas OCD symptoms.
3. Increase Alyssas motivation to participate in
therapy herself (if needed).

Part 1: Setting the Stage During the first part
of treatment (sessions 12), the therapist focused
on introducing Ken and Hana to the rationale and
goals of the SPACE treatment. She clarified that
although they would be attending the meetings,
the objective was to treat Alyssas OCD, and
she discussed the need for them to implement at
home the steps they planned together in the sessions. She also explained that working with parents does not mean that the parents are to blame
for the childs disorder.
The therapist asked Hana and Ken about any
concerns they had in regard to treatment. Both
parents and Ken, in particular, voiced the concern
that Alyssa would not agree to any plans or steps
they planned in treatment. The therapist took this
opportunity to emphasize that treatment would
not require Alyssas consent or collaboration.
She explained that they would only make plans
that Hana and Ken could implement regardless
of Alyssas will.
The therapist explained to Ken and Hana that
when a child feels anxious or distressed, their
normal reaction is to look to parents to help them
to avoid whatever is making them uncomfortable
and to help them to see better. She emphasized
that this is a healthy and normal part of childrens
behavior, and that parents normal response is
to try to help children feel better and to remove
anything that is causing them distress. She also
explained that this normal reaction, although it
is good in many cases, can be unhelpful when a
child has a disorder like OCD.
Part 2: Charting Accommodation The second
stage of treatment included a detailed mapping of
the various forms of accommodation to Alyssas
symptoms. The therapist explained to Hana and
Ken that accommodation refers to all the changes
E. R. Lebowitz
they make to their own behavior because of the

Alyssas OCD. Accommodation can include both
behaviors they do because of the OCD or behaviors they refrain from doing due to the disorder.
Then, the therapist asked the parents to describe
all the accommodations they had noticed, and
she used a daily chart to help the parents identify additional accommodations. The therapist
asked about the frequency and regularity of each
accommodation and about the distress relating to
it. See Table22.2 for Hana and Kens accommodation chart.
The therapist asked the parents to use a similar chart to record their accommodation over the
course of the week, noting differences and any accommodations that might have been overlooked.
Part 3: Choosing a Target and Informing the
Child The therapist worked with Hana and Ken
to choose an accommodating behavior on which
to focus in the coming weeks. The goal would
be to supportively reduce the accommodation
in a systematic manner. Reviewing the various
accommodations that had been reported by the
parents, they decided the first target would be to
stop showering and changing clothes after every
return home. This target was selected for the following reasons:
1. It was a frequently and regularly recurring
accommodationhappening at least twice a
day and involving both parents.
2. It was clearly a parent behavior that the parents controlled and could choose to change
(not a behavior that directly involved Alyssa).
3. It caused both parents significant distress. The
therapist preferred an accommodation that
caused the parents distress because she believed Ken and Hana would be more likely to
persist in the face of difficulty.
The next step was for Ken and Hana to let Alyssa
know that they planned to make changes in their
accommodation of showering when they enter
the home. The therapist explained:
This may be a difficult process for Alyssa because
she is very used to you going along with the
OCD rules. It is important that we let her know in
advance that you are making changes in order to
help her. But it is also important to convey that you
will do this even if she does not agree.

Table 22.2 Hana and Kens accommodation chart from early in treatment
Hana
Morning
Getting up
Getting dressed
Breakfast
Lunch
Other
Evening
Supper
Family time
Bedtime
Other
Ken
Must wake Alyssa from the
hallnot enter room
Assures Alyssa that her clothes were not washed with Emis
Tells sister not to use Alyssas bathroom
Uses special dishes
Brings food into dining room
Going to school
Afternoon
Pick up from school
329
Drives her separately from

Emi
Cannot drive by hospital
Drives her separately from Emi
Showers and changes clothes on return home
Separate dishes
Serves her in dining room
Mother checks own temperature multiple times
Separate dishes
Serves her in dining room
Tells sister not to use Alyssas bathroom
Does not use Alyssas couch in the living room
Tells Emi not to sleep in Alyssas bed

Does not enter Alyssas room
Washes clothes separately
Ken and Hana were very apprehensive about

Alyssas reaction. They feared she would become
angry or even violent. And that she would ask
them a lot of questions which they would not
know how to answer. The therapist decided to
suggest that they use a written message, which
they would read to Alyssa, to help them say just
what they meant. Together they worded the following message:
Alyssa, you are a wonderful girl and we love you
so very much. We know how afraid OCD can make
you feel and how important it is to you that we
dont trigger the OCD. But we also know that
you are a strong girl who can cope with feeling
afraid. We believe that by trying to help you, and
not trigger OCD, we have actually made things
worse for you. We have decided that we will
make changes in how we behave. One thing that
we have decided to change is the showering when
we come home. We know this is important to you
but we believe it is not helping. We are going to
think about how to change this and we will tell you
before we make the changes. But we are absolutely
Does not use Alyssas

couch in the living room
Showers and changes clothes
on return home
Father checks own temperature multiple times
Does not enter Alyssas room
sure we need to make changes. We are not trying

to hurt or to punish you. We love you and we are
doing it because we are your parents and its our
job to take care of you. Love, Mom and Dad.
The therapist role-played with the parents how

they would approach Alyssa and quietly say that
they wanted to tell her something and that it was
so important to them that they wrote it down in a
letter. Ken and Hana were concerned that Alyssa
would not listen to them or that she would want to
know the details of the changes they were planning. The therapist asked the parents to role-play
how they would say We are going to think about
that, and we will tell you before we do anything,
and then would stand up and leave the room even
if Alyssa was still upset or angry.
Part 4: Formulating a Plan The therapist considered that for the parents to successfully reduce
their accommodation, they would need a detailed
330
plan describing precisely how their behavior

would change. She understood that without a
concrete plan the parents would have difficulty
improvising under the stress of Alyssas coercive-disruptive behaviors. Therefore, the therapist worked with Hana and Ken on a specific plan
of reduced accommodation.
Accommodation in SPACE can be reduced either gradually or abruptly. In this case, the therapist agreed with Ken and Hana that continuing to
shower in some cases when they returned home,
but not in others, would likely be more difficult
for them as well as for Alyssa. Therefore, they
developed the following plan:
Parents will not shower when returning home.
Parents will not change their clothes when
returning home.
Parents will not answer more than one question per day (each) about their showering or
changing clothes.
The therapist planned and role-played with the
parents the communication of this plan to Alyssa. In the first announcement, the previous
week, Alyssa had become highly agitated and
had stormed out of the room after Hana and Ken
refused to answer her questions. Therefore, the
therapist instructed them that if Alyssa chose to
leave the room during the announcement, they
would leave a printed copy of the message on her
bed, which she could review later if she chose.
Like the first one, this announcement included a
statement expressing their understanding of the
difficulty Alyssa experienced and a belief that
she could cope with the anxiety as well as the
details of the changes they planned to make.
Part 5: Reducing AccommodationThe next
session was a tense one. The therapist asked the
parents about the preceding week and Ken and
Hana were both visibly upset. Ken described
Alyssas reaction to the announcement of their
plan as surprisingly indifferent. She did not
ask many questions, and the parents ascribed
her nonchalant behavior to a disbelief that they
would actually implement the changes.
This hypothesis seemed to be confirmed the
first time that the reduced accommodation was
actually implemented. Ken and Hana had chosen
E. R. Lebowitz
Saturday morning as the first day for reducing the

accommodation because they hoped that it would
be easier if both parents were there, and Alyssa
was usually in a good mood on the weekends.
Hana left the house to run some errands on Saturday morning, and Ken noticed that Alyssa was
repeatedly checking the window to see when her
mother returned. When she spotted Hana parking the car, she immediately interrupted the game
she was playing to go stand near the front door.
Hana entered the house and began to walk toward
her room, at which point Alyssa stood in front of
her and said You need to shower. Hana replied
that they were no longer doing that, and Alyssa
became increasingly agitated, first trailing after
her yelling that she had to shower and ultimately
becoming physically aggressive: She threw a
cup at her mothers head and broke a second cup
on the floor. Hana retreated to her room where
she waited until Ken told her Alyssa was calmer
again before coming out.
Ken was extremely disturbed by Alyssas reaction and questioned whether they had gone too
far. He told Hana that he was not confident the
plan was a good one and she suggested that they
call the therapist, but Ken said he would rather
wait until their appointment. As a consequence,
Ken did not implement the reduced accommodation, and Hana, who felt that her effort had been
wasted, also resumed showering as usual.
Hana felt disappointed and angry at Ken for
not following through on the plan and causing
her to back off as well. She told the therapist that
her trust in Kens ability to engage in treatment
was shaken and added that he was always prone
to giving in to the children too easily. Ken was
offended by this accusation and said that he had
legitimate concerns for Alyssa.
Session ModulesThe therapist identified the
need to reengage Hana and Ken with the treatment process and to reestablish the alliance
between them. She also understood that the parents needed a plan for coping with Alyssas outbursts. Therefore, she chose to implement parts
of the modules on improving collaboration and
coping with disruptive behaviors.
The therapist reminded both parents that a
successful process involves integrating acknowl-
edgement of the childs difficulty with a confidence in the childs ability to cope. In this light,
both Kens concern for Alyssas wellbeing and
Hanas determination to reduce the accommodation are both crucial elements of a shared goal.
The therapist discussed Kens concerns and discovered that they were actually centered on the
possibility that Alyssa would lose control over
herself and would do something actually dangerous to Hana. Hana had not realized this and was
mollified when she understood that Ken was trying to protect both Alyssa and herself.
The therapist suggested that in order to succeed, both parents would have to work together
and formulate a plan that would allow them to
change their behavior while also protecting everyone from Alyssas extreme reactions. To this
end, she suggested that the parents make use of
supporters from outside the family. The therapist
explained that the level of aggression Alyssa displayed was likely to be much lower if there were
other people around, and she suggested that for
the first week they make an effort to have someone else there. Together with the therapist, Ken
and Hana came up with a list of friends, relatives,
and neighbors from whom they could request assistance. They also agreed that when either parent was being confronted by Alyssa about the
accommodation, both parents would act together.
Either distancing themselves from Alyssa for a
little while or otherwise addressing the problem,
so that neither parent would have to cope on their
own.
Finally, the therapist suggested that both parents speak with Alyssa again and tell her that they
were mistaken to stop the plan but that they had
concerns, which they have now addressed. The
parents would state that they intend to continue
the plan (which they would spell out again).
Part 5: Reducing Accommodation: Continued At the next session, Ken and Hana were
significantly more encouraged. They had told
Alyssa of their plan to continue and had successfully arranged for outside supporters to be in
the home for the first few days of its implementation. This time, it was Ken who was the first
to return home without showering, while Hanas
331
sister was there visiting. When Ken entered

the house, Alyssa was visibly upset and tried to
motion to him and glare at him, but he chose not
to respond and went to his room. Alyssas aunt
was able to distract Alyssa with a new book she
had brought with her, and after approximately
10min Alyssa seemed to be calm again. When the
aunt left a little while later, Alyssa stormed into
her parents room and demanded that they never
do that to her again. Ken and Hana reminded
her that they knew it was difficult but that they
believed she could handle it and then refused to
speak about it. Alyssa again broke a cup, but both
parents ignored it.
Over the following days, Alyssa seemed to
become gradually accustomed to the parents not
showering. On one occasion, when she returned
home from school with her mother she refused to
enter the house unless Hana promised to shower.
Hana entered the house and half an hour later
Alyssa followed. On another occasion, she yelled
Ill make you shower and threw water from a
pitcher on her father, but he ignored her and she
did not repeat that behavior.
Overall, Ken and Hana reported that they had
successfully not performed the accommodation
for five consecutive days, and they were confident they could continue to do so. They no longer
relied on the presence of external support, and
they felt more trusting of each other.
The therapist asked them to continue implementing the same plan for an additional week
and to express to Alyssa that they were proud of
her growing ability to cope without the accommodation. Hana remarked that she had said that
to Alyssa at bedtime and that Alyssa had seemed
pleased by the compliment.
Part 6: Additional TargetsAfter Hana and
Ken had successfully eliminated one important
accommodation for two consecutive weeks, the
therapist suggested they take on another target
problem. Ken wanted to stop checking their temperature for Alyssa, and Hana said she would like
to see Alyssas sister, Emi, able to resume sleeping in her room. They also said they would like
Alyssa to be able to enter the kitchen.
The therapist suggested that they not focus
on Alyssas behavior as it was not directly under
332
their control (though they could choose not to

bring her food into the dining room) and that they
target the temperature checks. The therapist acknowledged that enabling Emi to sleep in her bed
was of great importance. But she explained that
focusing on other goals first may be better since
Emi might feel distress if she was instructed to
sleep in her own bed while Alyssa rejected her
presence. The parents took more initiative this
time in formulating the plan and decided they
would initially limit the temperature checks to
once per day at most. They also wrote down how
they would communicate this to Alyssa.
At the next session, Ken and Hana reported
that they had informed Alyssa about the temperature checks and that Alyssa had actually seemed
relieved when she realized they were not stopping altogether. Over the week, they had limited
the checks to one time per day. Although Alyssa
did request additional checks, she had accepted it
when they refused to cooperate.
Hana and Ken also noted some other encouraging changes in Alyssas behavior. Alyssas
hand washing seemed to be reduced in frequency
and she had stopped asking Ken whether he had
parked near an ambulance or disabled persons
parking spot. Neither parent had commented to
Alyssa on this, but both had noticed the changes.
Before the meeting with the therapist, Ken and
Hana had informed Alyssa that they would now
be stopping the temperature checks altogether
and Alyssa had not seemed overly concerned.
Hana and Ken were eager to make additional changes. In particular, they were now eager
to stop using separate dishes for all of Alyssas
needs and to stop washing her dishes separately.
The therapist concurred, but she warned the parents that Alyssas progress did not mean that this
change would be easy for her to accept. Together
they formulated the following plan:
All the food for the family would be cooked
together in the same pots and pans.
Alyssas food would still be served in her
dishes (for now).
All dishes would be washed together in the
dishwasher and stored together.
If Alyssa chose not to eat and prepared her
own food instead, the parents would not interfere (as long as she was eating adequately).
E. R. Lebowitz
Alyssa responded with tremendous distress to this

plan. She accused her parents of not going slowly
enough, of not recognizing her illness, and not
understanding what they were doing to her. She
threatened not to eat anything and run away from
home, and she told her parents that they would
be sorry when she was dead because of them.
She also said they would undo all the progress
she had already made. Ken and Hana were deeply
concerned but decided to follow through and observe how she handled the changes in actual fact.
On the first day, Ken took Alyssa out for some
errands so she would not be home when Hana
was preparing dinner. When they returned home,
Hana served dinner and Alyssa asked her if she
had used her pots. Hana reminded her of their
decision and told her she had not. Alyssa was furious. She vowed not to eat and not to let anyone in the house eat either. She pushed dishes off
the table onto the floor, hit both her parents, and
ultimately went to her room without eating. Her
mother left a plate with food for her in the dining room, but she did not eat it. The next day,
Alyssa again asked her mother if she had used
the separate dishes and again became upset when
she was told no. She was not as explosive but she
refused to eat any cooked food and ate only cold
vegetables and some crackers.
Part 7: Additional Targets: continued At their
meeting with the therapist, Ken and Hana were
concerned that if Alyssa did not start to eat they
would need to change their plan. The therapist
suggested they wait and see, bearing in mind
that Alyssa was at least eating a little and was
still getting breakfast and lunch. The therapist
also pointed out that if Alyssa truly did not eat
to the point of endangering her health then they
would definitely need to address that, but not by
resuming the unhealthy accommodation.
Over the next week, Alyssa very gradually
began to eat food her mother prepared. She asked
Hana if she would agree to cook for everyone in
the dishes that had previously been Alyssas, and
Hana agreed. Gradually, Alyssa stopped asking
about the dishes and began to eat normally. To
her parents surprise, she also announced that
she could now eat and enter the kitchen, and she
began to join the rest of the family when they ate
there. Her parents praised her for this initiative

and she replied that she discovered it wasnt so
bad.
Alyssa also showed other advances. The time
she spent in the bathroom and the amount of toilet paper she used were reduced significantly,
and when Emi fell down and hurt herself Alyssa
(seemingly without thinking about it) helped her
up and hugged her. Emi was shocked and was so
moved that she continued to hug Alyssa who allowed her to do so. Hana decided to capitalize
on this event by telling Alyssa that they had been
planning to insist that Emi be allowed back in
her room but that it would be beautiful if Alyssa
told her she did not object to her coming back.
Alyssa promised to think about it, and the next
day she independently brought Emis things back
into the girls room.
Part 8: Summary and TerminationDuring
the final sessions of the treatment, the therapist
worked with Hana and Ken on reducing the
remaining accommodations and on planning for
coping with similar challenges in the future. The
therapist reviewed the changes in the parents
attitudes and opinions:
How capable they think Alyssa is of coping
with discomfort.
How they define their own role in helping
Alyssa overcome OCD.
333
How much they rely on each other and trust

each other to follow through.
How concerned they are about Alyssas future
and her ability to function independently.
Both parents felt they had significantly revised
the way they thought about the OCD and their
own goals in relation to the disorder. Ken said
I thought my job was to help her feel better and
that her job was to beat OCD. Now I know I can
actually help her beat OCD. Hana said I spent
so much energy, so much time, trying to make an
OCD free home for her. Now I know she needs to
be able to live in the real world, and that we can
help her to that.
The therapist and parents also noted Alyssas
remaining OCD symptoms and discussed the
possibility of treatment for Alyssa. Alyssa had
become less resistant to the idea of participating in CBT but indicated that she was not ready
yet. Ken and Hana were encouraged that she
was no longer ruling it out altogether and decided
to raise the issue again 1 month later.
At her posttreatment evaluation, Alyssa was
more willing to cooperate with the evaluator. Her
OCD score based on both parent- and child-rated
CYBOCS was 15, greater than 50% improvement compared to before treatment and indicative
of mild-to-moderate symptoms. See Table22.3
for the details of the posttreatment CYBOCS.
Ken and Hanas family accommodation score
Table 22.3 Alyssas posttreatment scores on the Childrens YaleBrown Obsessive-Compulsive Scale (CYBOCS)
Obsessions
Compulsions
Item
Score
Description
Item
Score
Description
Time occupied by
2
Between 1 and 3h
Time spent on
1
Less than 1h a day
obsessions
a day
compulsions
Interference
0
None
Interference
1
Slight interference,
performance not
impaired
Distress associated
1
Mild
Distress associated with 2
Moderate
with obsessions
compulsions
Resistance
2
Makes some effort to Resistance
2
Makes some effort
resist
to resist
Control over thoughts 2
Sometimes able to
Control over
2
Can control with
stop/divert obsessions compulsions
difficulty
Total
7
Total
8
Total
15
334
on FAS-IR was greatly reduced from 39 before

treatment to 12 after treatment, and their rating
of Alyssas coercive-disruptive behavior on CDPOC was similarly reduced from 55 before treatment to 13 after treatment with SPACE.
Three complicating factors, none of which is unusual in treatment with SPACE, required special
consideration by the therapist in this case.
Parent CooperationThe parents ability to
work collaboratively and to present a unified
front was challenged when Hana began implementing a plan to modify their accommodation
and Ken was not prepared to follow through. This
event had the potential to significantly derail the
treatment process. Kens choice not to implement
the agreed-upon plan angered Hana and evoked
similar frustrations she had harbored from previous occasions. The therapist managed this challenge by:
Framing both parents perspectives as necessary ingredients in the common objective of
creating a supportive stance toward Alyssa
Facilitating communication so that Hana
understood Kens motivations and identified
with them
Acknowledging the validity of Kens safetyrelated concerns and planning around them
Planning better cooperation in the future, having both parents respond to aggressive outbursts
Youth Threats to Others and SelfA second
complicating factor was Alyssas explosive outbursts which included aggressive statements and
behaviors toward her parents as well as herself.
The therapist handled this common complication
by:
Preparing the parents in advance through discussion, planning, and role-playing
Framing the outbursts as signals of distress
rather than misbehaivor, reducing the need
to discipline Alyssa for her outbursts
E. R. Lebowitz
Involving supporters from outside the immediate family, whose presence had an inhibiing
effect on her Alyssa and reduced the level of
explosiveness
Instructing the parents not to engage with the
outbursts and to distance themselves when
necessary
The therapist chose not to directly address
Alyssas threatening statements toward herself
(youll be sorry when Im dead) as these were
assessed to be angry statements, not indicative
of actual threat of self-injury. However, SPACE
includes a set of tools for dealing with threats
toward the self as well as additional tools for
dealing with aggressive externalized behavior.
Involvement of SiblingsThe third complication in the case was the involvement of a younger
sister, Emi, who was involuntarily also accommodating Alyssas symptoms (by not entering her
room and not sleeping in it). The therapist chose to
delay targeting this accommodation, recognizing
that making it a focus would put substantial pressure on Emi from her parents as well as her sister.
While this worked out well in this case, in other
cases, it can become necessary to directly modify
a behavior involving a sibling. When that happens, parents are encouraged to maintain the focus
on their own behavior, while being careful not to
place responsibility of the shoulders of a sibling.

OCD in youth can be treated with parent-based
interventions aimed at reducing family accommodation. SPACE is one such treatment. Therapists who work with parents to reduce family
accommodation need to be prepared for strong
resistance from youth to the parental changes.
Parents need effective and concrete strategies,
such as those in SPACE, to cope with youths
resistance. Promoting cooperation and collaboration between parents is key to successful parentbased treatment. Parent-based treatments like
SPACE may be particularly helpful when youth
decline individual treatment or have not responded to it sufficiently.
References
Albert, U., Bogetto, F., Maina, G., Saracco, P., Brunatto,
C., & Mataix-Cols, D. (2010). Family accommodation
in obsessive-compulsive disorder: Relation to symptom dimensions, clinical and family characteristics.
Psychiatry Research, 179(2), 204211.
Barrett, P. M., Healy-Farrell, L., & March, J. S. (2004).
Cognitive-behavioral family treatment of childhood
obsessive-compulsive disorder: A controlled trial.
Journal of the American Academy of Child and Adolescent Psychiatry, 43(1), 4662.
Calvocoressi, L., Lewis, B., Harris, M., Trufan, S. J.,
Goodman, W. K., McDougle, C. J., & Price, L. H.
(1995). Family accommodation in obsessive-compulsive disorder. American Journal of Psychiatry, 152(3),
441443.
Calvocoressi, L., Mazure, C. M., Kasl, S. V., Skolnick,
J., Fisk, D., Vegso, S. J., etal. (1999). Family accommodation of obsessive-compulsive symptoms: Instrument development and assessment of family behavior.
Journal of Nervous and Mental Disease, 187(10),
636642.
Flessner, C. A., Sapyta, J., Garcia, A., Freeman, J. B., Franklin, M. E., Foa, E., & March, J. (2011a). Examining the
psychometric properties of the Family Accommodation
Scale-Parent-Report (FAS-PR). Journal of Psychopathology and Behavioral Assessment, 33(1), 3846.
Flessner, C. A., Freeman, J. B., Sapyta, J., Garcia, A.,
Franklin, M. E., March, J. S., & Foa, E. (2011b).
Predictors of parental accommodation in pediatric
obsessive-compulsive disorder: Findings from the
pediatric obsessive-compulsive disorder treatment
study (POTS) trial. Journal of the American Academy
Gandhi. (1951). Satyagraha non-violent resistance (1st
ed.). Ahmedabad: Navajivan.
the pediatric obsessive compulsive treatment study
and Adolescent Psychiatry, 49(10), 10241033.
King, M. L., Jr. (2003). Martin Luther King explains nonviolent resistance understanding prejudice and discrimination (pp.500506). New York: McGraw-Hill.
Kovacs, M. (1985). The childrens depression, inventory (CDI). Psychopharmacology Bulletin, 21(4),
995998.
Lebowitz, E. R. (2013). Parent-based treatment for childhood and adolescent OCD. Journal of ObsessiveCompulsive and Related Disorders, 2(4), 425431.
Lebowitz, E. R., & Omer, H. (2013). Treating childhood
and adolescent anxiety: A guide for caregivers. New
Jersey: Wiley.
Lebowitz, E. R., Omer, H., & Leckman, J. F. (2011a).
Coercive and disruptive behaviors in pediatric obses-
335
sivecompulsive disorder. Depression and Anxiety,

28(10), 899905.
Lebowitz, E. R., Vitulano, L. A., & Omer, H. (2011b).
Coercive and disruptive behaviors in pediatric obsessive compulsive disorder: A qualitative analysis. Psychiatry, 74(4), 362371.
Lebowitz, E. R., Vitulano, L. A., Mataix-Cols, D., &
Leckman, J. (2011c). Editorial perspective: When
OCD takes overthe family! Coercive and disruptive
behaviours in paediatric obsessive compulsive disorder. Journal of Child Psychology and Psychiatry and
Allied Disciplines, 52(12), 12491250.
Lebowitz, E. R., Panza, K. E., Su, J., & Bloch, M. H.
(2012a). Family accommodation in obsessivecompulsive disorder. Expert Review of Neurotherapeutics,
12(2), 229238.
Lebowitz, E. R., Dolberger, D., Nortov, E., & Omer, H.
(2012b). Parent training in non violent resistance for
adult entitled dependence. Family Process, 51(1),
117.
Lebowitz, E. R., Woolston, J., Bar-Haim, Y., Calvocoressi, L., Dauser, C., Warnick, E., etal. (2013a). Family accommodation in pediatric anxiety disorders.
Lebowitz, E. R., Omer, H., Hermes, H., & Scahill, L.
(2014). Parent training for childhood anxiety disorders: The SPACE program. Cognitive and Behavioral
Practice, 21(4), 456469.
Merlo, L., Lehmkuhl, H., Geffken, G., & Storch, E.
(2009). Decreased family accommodation associated
with improved therapy outcome in pediatric obsessive-compulsive disorder. Journal of Consulting and
I., King, R. A., Goodman, W. K., etal. (1997). Childrens Yale-Brown obsessive compulsive scale: Reliability and validity. Journal of the American Academy
Silverman, W. K., & Albano, A. M. (1996). Anxiety Disorders Interview Schedule (ADIS-IV) parent interview
schedule. New York: Oxford University Press.
Storch, E. A., Geffken, G. R., Merlo, L. J., Jacob, M. L.,
Murphy, T. K., Goodman, W. K., etal. (2007a). Family accommodation in pediatric obsessive-compulsive
disorder. Journal of Clinical Child and Adolescent
Psychology, 36(2), 207216.
Storch, E., Geffken, G., Merlo, L., Mann, G., Duke, D.,
Munson, M., etal. (2007b). Family-based cognitivebehavioral therapy for pediatric obsessive-compulsive disorder: Comparison of intensive and weekly
approaches. Journal of the American Academy of
Child and Adolescent Psychiatry, 46(4), 469478.
Weinblatt, U., & Omer, H. (2008). Non-violent resistance:
A treatment for parents of children with acute behavior
parents. Journal of Marital and Family Therapy, 34,
7592.
Treatment of Comorbid
Disorder in Youth with ASD:
The Case of Max
23
Lara J. Farrell, Sophie C. James, Brenna B. Maddox,

Donna Griffiths and Susan White
Autism spectrum disorder (ASD) is a chronic

neurodevelopmental disorder characterized by
social communication and social interaction deficits, in addition to restricted, repetitive patterns
of behaviour or interests (American Psychiatric
Association, APA 2013). This restricted, repetitive domain includes a wide variety of manifestations, such as motor stereotypies, repetitive
speech, circumscribed interests, fascination with
odd objects or parts of objects, and excessive
adherence to routines. The number of individuals diagnosed with ASD has increased dramatically in the past 20 years, with current prevalence estimates of 1.7% of children (Russell
etal. 2014). Psychiatric comorbidity is common
amongst people diagnosed with high-functioning
ASD, and obsessive-compulsive disorder (OCD)
is especially prevalent (Leyfer etal. 2006; van
Steensel etal. 2011). It is estimated that up to
80% of youth with ASD have clinically significant anxiety (Nadeau etal. 2011), with OCD
being one of the most frequent comorbid condiL. J. Farrell()
School of Applied Psychology and Behavioural Basis
of Health, Griffith University, and Menzies Health Institute Queensland, Gold Coast Campus,
QLD, Australia
S.C.James D.Griffiths
School of Applied Psychology, Griffith University, Gold
S. White B. B. Maddox
Child Study Centre, Virginia Tech University,
Blacksburg, VA, USA
e-mail: sww@vt.edu
tions found in 37% of these youth (Leyfer etal.

2006). Conversely, between 3 and 7% of people with OCD also meet diagnostic criteria for
ASD (Chasson etal. 2011), and an even greater
percentage exhibit ASD traits. Indeed, in OCD
samples, ASD occurs ten times more than in the
general population (Ivarsson and Melin 2008).
Despite the relatively common co-occurrence,
there are many unanswered questions about the
clinical presentation and treatment of OCD symptoms in children with ASD. Limited research suggests that children with comorbid high-functioning ASD and OCD rate their OCD symptoms as
equally distressing, time consuming, and interfering as do children without ASD (Lewin etal.
2011). Using the Childrens YaleBrown Obsessive Compulsive Scale (CY-BOCS; Scahill etal.
1997), Mack etal. (2010) found similar types of
symptoms across the ASD+OCD group (n=12)
and OCD-alone group (n=12). Lewin etal. (2011)
also found largely similar CY-BOCS symptom
profiles between youth with ASD and co-occurring
OCD (n=35) and youth with OCD alone (n=35),
although several group differences were identified. The children with ASD and OCD were significantly less likely to endorse sexual obsessions
and checking, washing, or repeating compulsions,
compared to the children with OCD alone.
The high degree of phenotypic overlap between OCD and ASD can make differential or
dual diagnosis difficult. A particular challenge is
teasing apart the restrictive, repetitive behaviour
and interest domain of ASD from the presence
of clear obsessions and compulsions. A thorough

DOI 10.1007/978-3-319-17139-5_23
337
338
d iagnostic evaluation must examine the role of

antecedents and consequences in the maintenance of a persons repetitive thoughts and behaviours (Abramowitz and Houts 2002), in addition to the quality (e.g. enjoyable vs undesirable)
or emotional valence of the thoughts and behaviours (Spiker etal. 2012). In the context of OCD,
obsessions are experienced as intrusive and unwanted, and they typically cause marked anxiety or distress. In the context of ASD, however,
perseverative thoughts do not regularly cause
anxiety or distress, but rather relate to an idiosyncratic circumscribed interest or intense preoccupation, often with unusual objects (South etal.
2005). Thus, a childs emotional reaction to his
or her repetitive thoughts may be informative for
differential or dual diagnosis of OCD and ASD.
In the context of OCD, compulsions are egodystonic, unwanted, difficult to resist, and aimed
at relieving anxiety or distress. Children with
ASD are more likely to willingly engage in their
restricted, repetitive behaviours, which are usually experienced as rewarding and pleasurable.
In contrast to OCD compulsions, many repetitive behaviours within ASD are not performed
in response to a specific distressing thought or
feeling, although some routines and rituals can
serve an anxiety-reducing function for people
with ASD. An example of repetitive behaviour
(RB), whereby belongings are organized and arranged in a particular way, and the nature of this
behaviour when relating to ASD versus OCD, are
L. J. Farrell et al.
presented in Table23.1. This example illustrates

the similarities in the repetitive nature of the behaviour associated with ASD and OCD as well
as highlights the distinct differences in emotional
valence and antecedents of RB.
Given that OCD can lead to significant functional impairment in youth with ASD, empirically supported treatment approaches are greatly
needed. In the last few years, several randomized
controlled trials have demonstrated that cognitive-behavioural therapy (CBT), modified for
ASD, may effectively reduce anxiety in youth
with ASD (e.g. Reaven etal. 2012; Wood etal.
2009), but these studies have lacked a specific
focus on OCD. It is promising that youth with
ASD have demonstrated that they possess many
of the requisite cognitive skills for CBT, such as
discrimination between thoughts, feelings, and
behaviours (Lickel etal. 2012). In fact, the rulebound, analytical style of thinking that is characteristic of individuals with high-functioning
ASD may be particularly well suited to a CBT
approach. In addition, case reports of OCD treatment in children with high-functioning ASD suggest that CBT, with appropriate modifications,
can effectively target OC symptoms, as reviewed
below.
Reaven and Hepburn (2003) completed 14
sessions of CBT with a 7-year-old girl with superior intellectual abilities and comorbid ASD with
OCD. The intervention plan was primarily based
on the treatment protocol of March and Mulle
Table 23.1 Clinical example illustrating key factors for differentiation of ASD-related RB and OCD
Behaviour
Insistence on excessive organizing/arranging belongings
Factor
More likely ASD-related RB
More likely OCD-related compulsion
Timeline (onset)
Behaviour onset early (e.g. <age 5) or this Later onset, after recognition or apparparticular behaviour is new, but is preceded ent presence (in hindsight) of ASD core
difficulties
by other, similar behaviours
Emotional valence
Curiosity, appetitive, can sometimes be
Ego-dystonic behaviour is unwanted or felt as
seen as driven to perform the activity
onerous by the child, fear/discomfort driven,
difficult to disengage from
Antecedents
Overarousal, boredom, social stimulation
Intrusive image or thought, intense discomfort, urge or impulse, feeling not just right
Response to interrup- Resistance, oppositionality, tantrum
Resistance, distress, fear, anxiety, anger
tion or request to stop
Context
Not context dependent, though there may
May appear in certain situation, may be hidbe triggers that exacerbate behaviour
den in others, and not occur in some contexts,
such as school
ASD autism spectrum disorder, RB repetitive behaviour, OCD obsessive-compulsive disorder
23 Treatment of Comorbid Obsessive-Compulsive Disorder in Youth with ASD: The Case of Max
(1998), using exposure and response prevention

(ERP) techniques. Reaven and Hepburn emphasized that the treatment targeted the clients OCD
symptoms and not her special or circumscribed
interests that are characteristic of ASD. ASDrelated modifications included active involvement from parents, infrequent use of metaphors
or abstract concepts due to the clients literal
thinking style, liberal use of visual aids, direct
and explicit directions for exposure exercises,
integration of the clients circumscribed interests
or idiosyncratic descriptions into treatment, and
reliance on social stories (Gray 1998) to improve
social understanding and highlight the impact of
the childs OCD symptoms on others. The client
showed clear improvements in OCD symptoms,
from a CY-BOCS intake score of 23 (moderate
severity) to a final score of 8 (mild severity).
Treatment gains were also maintained at a series
of follow-up sessions.
Lehmkuhl etal. (2008) reported on a similarly
modified CBT approach for a 12-year-old male
with ASD, OCD, and average cognitive ability.
The client presented with contamination concerns, rituals involving hand washing and hand
sanitizer, and repetitive checking behaviours.
Additional treatment modifications included a
reduced focus on cognitive restructuring and an
earlier introduction of ERP, due to the clients
difficulty in identifying specific obsessions. During exposures, the clients physiological signs of
distress (e.g. sweating) were closely monitored,
given the challenges of emotion recognition associated with ASD. A behaviour reward system
was also implemented to improve adherence to
ERP practice at home and at school. Over the
course of ten 50-min sessions, the clients CYBOCS score decreased from 18 (moderate severity) to 3 (subclinical severity), with gains maintained at a 3-month follow-up.
Rooney etal. (2011) provided another case
example of CBT effectively reducing OCD
symptoms in the context of ASD in a 7-year-old
female with a diagnosis of pervasive developmental disorder not otherwise specified. While
repeated ERP sessions improved her OCD symptoms, Rooney etal. augmented the treatment
with problem-solving skill building to increase
339
the clients flexibility and decrease rigid patterns

of thinking. Additional treatment modifications
included the avoidance of hypothetical descriptions of exposure tasks, simplification of the subjective units of distress (SUDs) self-report rating
scale to only three points, and active parental
participation.
In summary, these single-subject studies provide preliminary evidence that CBT, with modifications, can be an effective treatment for OCD
symptoms in youth with high-functioning ASD.
Promising results have also been reported from
the treatment of adults with ASD and OCD (Russell etal. 2009, 2013). Given this relatively common comorbidity, the lack of treatment research
in this area is surprising. The following case example describes a young man with ASD (level
1) who presented for treatment of severe, comorbid OCD, and describes his response to intensive
CBT for OCD.
Presenting Problem: The Case of Max

Max, a 16-year-old Caucasian Australian male,
was referred by his general practitioner to participate in an intensive treatment trial for OCD
at a university psychology department. Max had
a relatively homogeneous OCD symptom presentation, with obsessions and compulsions focused almost exclusively on contamination fears,
and associated excessive washing and cleaning
rituals. He also had repeating rituals related
to these contamination obsessions, whereby he
felt compelled to conduct his rituals (i.e. wiping,
washing, cleaning) precisely three-times each.
As is common with paediatric OCD, Max also
had several diagnosed comorbid conditions, specifically, attention-deficit hyperactivity disorder
(ADHD), and ASD (level 1). Level 1 specifier for
ASD indicates that with non-substantial external
appropriate supports, Max can function reasonably well. Max, accompanied by his parents, presented for treatment due to the severe impact his
OCD was having on the family.
School was a major trigger for Maxs contamination fears. For Max, the ground and floor were
highly contaminated; therefore, he would go to
340
great lengths to avoid touching anything that had

touched the floor. If Max were to drop anything
on the ground while at school, for example, he
refused to touch it again, and the item (e.g. a
pencil) needed to be replaced. While at school or
outside of the home, Max would avoid rubbish
bins, bathrooms, particular classrooms and certain teachers he perceived as unhygienic, for fear
of contamination. Max was unable to touch his
schoolbooks upon his return home from school,
because of his fear of cross-contamination from
the school environment, which made homework
difficult to complete and a constant source of frustration for the family. He had stopped reading his
own books for fear of germs, and he insisted that
these were stored separately from his familys
books. Upon returning home from school, Max
would engage in time-consuming rituals in order
to cleanse himself and neutralize his heightened
anxiety. Max would routinely shower as soon as
he stepped into the house, which involved washing his body and shampooing his hair three times
before he deemed himself clean, a process which
resulted in protracted showers, taking approximately an hour to complete. After completing his
elaborate shower routine, Max could not tolerate
to be touched by his family.
The intensity of his fear of contamination led
to symptoms where he felt contaminated, even
in the absence of contact with a contaminant. For
example, if Max were to watch television and
see pictures of germs (i.e. a person using a public bathroom), he would have the notion that the
germs were transferred through the TV and onto
surfaces nearby (e.g. remotes, tiles, furniture and
his glasses). For Max, his symptoms were not
only exacerbated by contact with germs or objects he perceived as germy, but, rather, he was
crippled by the fear that the germs were spreading and multiplying. He experienced extreme
dread and a sense of loss of control over containing the spread of contamination, therefore, feeling unable to neutralize his fear and anxiety.
Maxs family was profoundly impacted by
his OCD, and they would regularly assist Max
with ritualizing, comply with his OCD demands,
provide reassurance, and assist with or complete
tasks for him in order to reduce his distress or
need to ritualize. This process is known as family
accommodation (Storch etal. 2007a) and is particularly common amongst families with a child
or youth with OCD. Max required assistance with
his shower routine, so he could avoid touching
doors or handles that he or other family members
may have touched after using the toilet. Max also
required assistance with personal grooming such
as teeth, nose, hair, and toileting. At the completion of toileting, Max would call for his mother
to wipe all surfaces of the toilet area to ensure
any bodily fluids were removed. This process involved wiping Maxs feet, followed by the tiled
area where he stood, and when Max left the toilet, his mother would wipe the toilet and walls.
Maxs mother (or his father if his mother were
unavailable) would be required to turn on the taps
for Max to wash his hands. To assist Max with his
washing routine, the bathroom taps were changed
so that he could turn these off with his forearm to
avoid touching them.
The extent of accommodation behaviours performed for Max was far reaching. Max was very
dependent on his family for much of his daily
living activities as a result of his OCD fears and
rituals. Moreover, as a consequence of his ASD,
Max had particularly poor emotional regulation
skills, as well as very low tolerance for frustration. These emotional deficits, combined with
severe OCD, resulted in regular fits of intense
anger or rage, usually the result of his family
not adequately accommodating to his demands.
In these instances, which occurred almost daily,
Max would scream, cry, kick, and punch furniture or walls until someone complied/accommodated to his OCD demands.
Family History and History

of the Presenting Problem
Max was born and grew up in middle class suburbia in Queensland, Australia. Max lived with
his biological parents and a brother, 3 years his
senior. Maxs father was the breadwinner of the
family and worked full time. While there was
no known paternal family history of mental illness, his maternal family history of mental illness
was extensive. His mother was a fulltime homemaker, prevented from working due to prolonged
depression and severe anxiety for much of her

life. There was a strong maternal family history
of mental health problems, including substance
abuse, mood disorder, and multiple suicide attempts in numerous relatives. Max had previously suffered depression, but had not attempted
suicide in the past, and had no depressive symptoms or suicidal ideation at the time of treatment.
Growing up, Max was a pleasant and happy
young boy, according to his parents. He was affectionate, shy, and sensitive. Max had always
experienced difficulties in social situations and
making friends. Max reported having no friends
at school, and his mother described him as being
difficult and controlling with other young
people his age. Max suffered rejection from
his peers and had been bullied at school in the
past, so had a preference for solitary activities.
His teachers described his classroom behaviour
as excellent; however, Max experienced trouble
with his handwriting, and he required extra time
to complete tasks at school as a result of his poor
attention/concentration.
Max was first diagnosed with ASD at 9 years
of age by his paediatrician. As is typically seen
with teens who have ASD, Max had reduced
eye contact, deficits in social reciprocity, and
little interest in social interaction. He had a keen
interest in motor vehicles and was an avid carracing fan. At 16 years of age, Max was unable
to do simple household tasks such as unstacking
the dishwasher, making a cup of tea, or hanging
out laundry. Maxs every need was pandered to,
including fetching a drink or snack to eat. Max
was unaware of where to find breakfast cereal or
a bowl in the family kitchen, having never prepared his own breakfast before. Maxs parents
explained that while Max is 16, they perceived
his competence and capabilities to be that of a
12-year-old, despite having at least average cognitive abilities. Maxs lack of basic living skills
highlighted the extent to which his parents, particularly his mother, accommodated his every
need and demand.
Max had been diagnosed with OCD 3 years
prior, following sudden onset of symptoms when
he was aged 13 years, but had not undergone any
previous behavioural interventions for either his
ASD or OCD. The antecedent of his contamina-
341
tion fears was a science class where Max learned

about microorganisms. His most severe symptoms had been in the initial 6 months of his sudden onset OCD. At the time Max presented for
treatment, he had been under the care of a psychiatrist and was prescribed medication including a
selective serotonin reuptake inhibitor (SSRI) and
an antipsychotic and selective norepinephrine
reuptake inhibitor (SNRI) for the treatment of his
previously diagnosed OCD, ASD, and ADHD.
Prior to treatment commencing, Max had been on
stable doses of these medications for 6 months.
We can attempt to understand the development
and current presentation of symptoms using a
cognitive-behavioural model, as well as incorporating the unique social and emotional deficits
characteristic of ASD (see Fig.23.1). Max likely
had a biological vulnerability for OCD, given
the very strong familial history of mental health
problems. Adverse early childhood experiences,
including poor attachment with his mother who
was emotionally unavailable due to her chronic
and lifelong battle with depression, coupled with
stressful social experiences (i.e. bullying, social
isolation) may have heightened Maxs predisposition to psychopathology. The onset of OCD in
childhood can be either abrupt or insidious, occurring over a long period of time. For Max, he
experienced an acute onset of OCD following
what was a largely benign school event (microorganism science class) for most teenagers; however, for a child with ASD and vulnerabilities such
as Max, this resulted in the activation of threat
processing and rigid and inflexible dysfunctional
beliefs (i.e. Micro-organisms are dangerous;
they are everywhere; they are disgusting; I cant
cope with the possibility of contamination),
leading to exacerbation in fear, avoidance, and
neutralizing.
Maxs daily distress was triggered by his obsessive thoughts about germs. Moreover, his appraisals of germs were interpreted through a filter
of heightened disgust sensitivity, and therefore
the experience of feeling contaminated. He believed that if he came into contact with germs,
342
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Fig. 23.1 A cognitive-behavioural formulation of Maxs

OCD, incorporating core social and emotional deficits
of ASD. --- denotes deficits associated with ASD; for
more details on the cognitive formulation and information processing biases associated with OCD, see Frost and
Steketee (2002)
unless he washed immediately, then he could not

touch anything for fear of spreading the contamination. He also believed that if he did not clean
things excessively, in particular three times, the
stimuli were not clean and were therefore intoler-
able to him. In an effort to reduce his anxiety and

disgust, Max would wipe or wash his hands three
times or engage in his excessive shower routine,
giving him temporary relief from his distress.
Washing and wiping compulsions would give
only short-term respite, however, with Maxs

worries recurring after a short time, perpetuating
the obsessive-compulsive cycle.
Interpersonal and interfamilial relational distress also played both contributing and maintaining roles in Maxs OCD. His negative social history at school as well as the ongoing peer rejection
and bullying likely impacted his vulnerability to
experience threat and feelings of being violated at schoolit is therefore not surprising that
school was a major source of ongoing contamination. The burden placed on Maxs family to accommodate both his ASD deficits (i.e. in self-care
and daily living skills) and OCD behaviours was
also a source of ongoing stress and resulted in extreme family discord. Max would react to stress
in the family unit with increased anxiety and poor
emotional regulation, resulting in fits of rage and
subsequent increase in his OCD symptoms and
demands placed upon his family. This became
a perpetuating cycle of poor family functioning,
escalating distress and OCD symptoms, and subsequent family accommodation, which served as
a short-term solution, but fed the ongoing pathological cycle of symptom exacerbation and dysfunctional family accommodation and discord.
Despite Maxs family being in a state of crisis at the time of treatment, his parents love, affection, and concern for him was evident, which
served as a protective factor and predicted a positive prognosis for Max. His parents affectionately described him as an intelligent, kind, caring,
funny, and good-natured young man. Max and his
family were committed and motivated to undergo
treatment for his OCD, with Maxs father arranging to take time from his work commitments to ensure he was available to attend all assessment and
treatment appointments with Max and his mother.
Max demonstrated adequate insight into his condition, but had lingering doubts and uncertainty
about his fears. He was able to articulate the irrational nature of his OCD with comments such as
My brain thinks that there are germs everywhere,
even though no one else seems concerned, and he
indicated a degree of motivation with comments
such as I think I can overcome this.
343
Assessment
As part of his participation in a research study of
intensive treatment for paediatric OCD, a number
of assessments were carried out pre- and posttreatment. Interviews were carried out including
the anxiety disorders interview schedule for children for DSM-IVparent report (ADIS-P; Silverman and Albano 1996) to identify childhood
anxiety, mood, and externalizing disorders based
on DSM-IV-text revision (TR) criteria. The autism diagnostic interview-revised (ADI-R; Lord
etal. 1994) was delivered to Maxs parents to
confirm a diagnosis for ASD, and the CY-BOCS
(Scahill etal. 1997) was used to assess for the
presence of obsessions, compulsions, and the
overall severity of OCD.
A number of self-report measures were also
completed to assess general symptoms and functioning, including the Child Depression Inventory (CDI; Kovacs 1992), Multidimensional
Anxiety Scale for Children (MASC; March
etal. 1997), and the Pediatric Quality of Life
(PedsQL) 4.0 Child Report (Varni etal. 1999).
Parent-rated measures included the Social Responsiveness Scale (SRS; Constantino and Gruber 2005), and the Family Accommodation Scale
(FAS; Calvocoressi etal. 1995). A therapist rated
Maxs functioning on the Childrens Global Assessment Scale (CGAS; Schaffer etal. 1983). In
addition to these measures, close monitoring of
Maxs three most troubling compulsions was carried out throughout his treatment. This involved
Max rating his distress on a scale of 0 (no distress) to 8 (very, very distressed) for each of his
three target repetitive behaviours during a 2-week
baseline, at pretreatment, each treatment session,
post treatment, and 3-months post treatment. The
three target behaviours were:
1. Shower routinewashing himself three times
2. Wiping routineincluding wiping spectacles,
the remote control, surfaces
3. Toileting routineusing three wipes, mother
cleaning toilet and his feet
344
Table 23.2 Pretreatment assessment summary

Measure
Score
Description
OCD (CSR)
7
Clinical
ADHD (CSR)
4
Clinical
CY-BOCS obsessions
16
Severe to extreme
CY-BOCS compulsions
16
Severe to extreme
CY-BOCS total
32
Extreme
CDI T-score
79
Very elevated
MASC T-score
82
Very elevated
PedsQL
64
Physical, emotional, social and school impairments
SRS T-score
63
Mild to moderate ASD high functioning
FAS
51
Extreme family accommodation
OCD obsessive-compulsive disorder, CSR clinician severity rating, ADHD attention-deficit hyperactivity disorder,
CY-BOCS Childrens YaleBrown Obsessive Compulsive Scale, CDI Child Depression Inventory, MASC Multidimensional Anxiety Scale for Children, SRS Social Responsiveness Scale, FAS Family Accommodation Scale, PedsQL
Pediatric Quality of Life
Pretreatment Assessment Results

Max participated in a multiple baseline trial of
three sessions of intensive CBT, combined with
threeweekly maintenance sessions conducted via
videoconference. At pretreatment, Max received
a principal diagnosis of OCD (clinician severity
rating (CSR)=7, range 18) and comorbid diagnosis of ADHD (CSR=4) on the ADIS-P. The
ADI-R confirmed Maxs diagnosis of ASD level
1, meeting the cut-off scores across the communication and language, social and restricted and
repetitive behaviour domains. Maxs scores for
the other interview and self-report baseline measures are presented in Table23.2.
Treatment
Empirically supported treatment approaches for
OCD include CBT, which incorporates ERP,
either alone or in combination with serotonergic reuptake inhibitor (SRI) medication (Barrett
etal. 2008). Current psychosocial treatments for
OCD are generally effective for most youthbut
not all, and as such there is a need for innovation in current approaches. Moreover, typical
treatments tend to be both lengthy and costly, requiring substantial commitment from parents and
children, and are often only provided in specialist clinics. To date, there is preliminary evidence
for the efficacy of more intensive approaches to

CBT (Storch etal. 2007b, 2010; Whiteside and
Jacobsen 2010). The clinical trial Max entered
into was exploring the effectiveness of a brief
model, utilizing fewer but longer duration exposure sessions, combined with weekly e-therapy
to support generalization of ERP at home following treatment. This approach draws heavily on
the work of the one-session treatment approach
for specific phobias, whereby exposure to phobia
stimuli occurs during one prolonged 3-h session
(see Ollendick etal. 2009).
In order to cultivate motivation and readiness
for therapy, as well as provide a rationale for the
intensive approach, and establish appropriate and
realistic expectations, a family education session
was conducted prior to intensive ERP.
Family Psychoeducation Session This session
focused on (a) education about obsessions and
compulsions, and the cycle of OCD; (b) education on the maintaining role of family accommodation; (c) education on the nature of exposure
therapy and the rationale for intensive treatment
(i.e. to provide rapid relief from OCD); (d) establishing fear hierarchies; and (e) parental contingency management via rewards for fighting
OCD.
Given the crippling nature of the family accommodation in this case of comorbid OCD and
ASD, it was deemed appropriate for the family to
be involved in every treatment session. The rationale for this family approach was (1) to provide
Maxs parents with education and training on
how to manage OCD demands and (2) to allow
Max to learn alternative ways of managing his
OCD, despite his parents being available to him
in session. At the beginning of the treatment, everyone in the family was on edge in regards to
Maxs OCD demands. From the outset of treatment, a new framework was established, whereby the family and Max were united as a team with
the goal to work together, against the demands of
OCD. The therapist used Maxs keen interest in
car-racing to help cultivate detachment towards
OCD and ally Max and his parents together,
much like a racing team (i.e. DriverMax; and
the pit teamMum and Dad and Therapist). This
worked well for Maxindeed he named the family Allies Xtreme Race Team, and he named
OCD the OCD Mean Team.
Intensive ERP Session 1The first session
of intensive treatment involved (1) reviewing
Maxs progress over the past week, (2) reviewing the psychoeducation information presented in
the previous session, and (3) planning and conducting numerous ERP tasks across the remaining session. The nature of ERP in this treatment
approach is graduated, spaced, therapist assisted,
and under the control of the child. To overcome
any difficulties with ASD language and communication deficits, the therapist ensured the use
of clear, precise language in terms of instructions for therapy goals, in particular ERP exercises. Furthermore, the therapist would check
for Maxs understanding by asking him to repeat
back to her the agreed ERP goal.
The first hour of session 1 with Max and his
parents was conducted in the psychology clinic
and involved a review of the previous sessions
psychoeducation material on the development
and maintenance of OCD. Anxiety management
strategies were also introduced and practiced
in order to help Max feel strong against OCD,
including using slow, controlled breathing, half
smile, and strong thoughts to fight back against
OCD (e.g. its not realits just OCD trick-
345
ing me; I am safe and strong). These strategies were taught at the outset given Maxs ASD
deficits in emotional regulation and his tendency
to rage when he felt particularly threatened or
stressed. The nature of ERP was reviewed with
Max, and the goal for Max during ERP was
clearly described as having two essential objectives: (1) to ride out the rage (achieve habituation) and (2) discover the truthsee what really
happens (violate threat expectancies via behavioural experiments). These two objectives were
written on a large laminated card and placed on
the wall during each session to remind Max of
his goals. Given his seemingly high intelligence
(untested) and his ASD-driven desire for facts
and knowledge, Maxs motivation to fight OCD
was harnessed by focussing on using his IQs
to discover the truth during ERP tasks, which
were setup as a series of OCD behavioural experiments. See Fig.23.2 for the ERP worksheet
used in session.
The car-racing analogy was continued throughout Maxs treatment. The goal of treatment was
therefore to win races against OCD. Wins were
described to Max as resulting from accumulating
laps against OCD (i.e. successful ERP/resistance
against OCD/talking back to OCD/staying calm
in the face of OCD). Each intensive session was
then conducted within the concept of a particular
race track. Max would design and draw a track
for each session, and the therapist would design
a number of challenges or ERP tasks spaced
around the track. Successful completion of ERP
tasks resulted in scoring laps against OCD. Rewards were built into the program, whereby for
each race win (session completion), Max would
be awarded points to use towards a new model
car kit. Max would earn points for how many laps
he achieved during the session, as well as during
the following week of home-based ERP practice.
The remaining 2h of session 1 therefore involved
ERP therapy via a graduated approach, using
therapist modelling to complete the tasks. SUDs
ratings (0=no fear or distress to 10=highest fear
or distress) were used to measure Maxs distress
prior to the task, throughout ERP and at the completion of the task. A 10-min break was taken at
346
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Fig. 23.2 Customized exposure and response prevention (ERP) worksheet used to measure subjective units of distress
(SUDs) over a period of time for each exposure task
the completion of each hour to allow Max time

to take a rest and have a snack. Table23.3 shows
examples from Maxs ERP hierarchy for hour 2
and 3 of the first session.
There were some difficulties during the intensive session whereby Max would resist engaging
in certain tasks, which he argued were not logical. This resistance was likely driven by his ASD
rigidity in thinking, and also served the function
to avoid certain tasks that Max felt were too challenging for him. For example, when asked if he
could tolerate a thumbprint on one of the lenses
of his spectacles, he became irritated and stated
that this was not logical and refused to touch
his lenses. When challenged about his resistance,
he became increasingly distressed and stormed
off for a brief period. Elopement amongst youngsters with ASD, either during therapy or as a general behaviour, is not uncommon. Indeed, in a
recent study (Interactive Autism Network 2011),
children aged 410 years with ASD were found

to engage in elopement at rates four times higher
than their unaffected siblings. The functional
nature of elopement differs across individuals,
highlighting the need for a functional assessment
of the behaviour in terms of defining appropriate interventions. In this session, Max returned
on his own accord, after taking a short walk
around the campus, allowing Max the opportunity to regulate his emotion and behaviour. In this
case, it seemed that Max resorted to elopement
when he became increasingly frustrated by the
situation (e.g. not being understood) and overwhelmed by the exposure demands. A discussion
followed about Maxs need to take time out for a
walk around campus, as this strategy was commended as being more appropriate and adaptive
than raging, which typically occurred under the
same conditions within the home context. It was
therefore contracted with Max that if he felt over-
Table 23.3 Example exposure hierarchy for intensive ERP session 1 (not all ERP steps listed)
ERP steps Exposure task
Response prevented
Pre-SUDs
010
Clinic
Hour 2
Step 1
View pictures of germscartoon
Removing spectacles and
6
representations
cleaning lenses
Steps 24 View pictures of germsrealistic
7
representations, increase intensity
cleaning lenses
Step 5
View pictures of polluted environRemoving spectacles and
8
mentsrealistic representations
cleaning lenses
9
Step 6
View YouTube video of germs
realistic representation
cleaning lenses or wiping
surfaces
Step 7
Touch door handle to entry door in
No hand washing
4
clinic room
No hand washing or wiping 7
Step 8
Walked outside of the clinic and
8
other areas of the university campus, surfaces
Have break, afternoon tea, no
opening doors and touching doors
hand washing
(e.g. lecture theatre)
Clinic
Hour 3
Step 1
Walk into the unisex toilet with dad No hand washing
8
Step 2
Touch bottom of shoe
No hand washing
7
Step 3
Touch the floor inside bathroom
No hand washing
8
Step 4
Touch moneycoins and notes
No hand washing
9
Step 5
Shake hands with therapist and dad No hand washing
8
ERP exposure and response prevention, SUDs subjective units of distress
whelmed and needed time out, he would indicate

this by raising his hand in a stop sign, and taking
5min to walk. He was given a map of the campus with clear boundaries highlighted, which he
agreed to not walk beyond, as a matter of safety.
Upon returning to the session, Max explained
why he was upset, and that his optometrist had
specifically told him not to touch the lenses. Max
was unable to tolerate any departure from these
instructions or any suggestion that this might
sometimes happen accidently in the process of
removing his glasses. Max was praised for being
able to use his IQs and for thinking through
why he felt so distressed. A discussion on problem solving and the strengths in using this approach to understand his anxiety followed. Max
was set the homework task of calling his optometrist during the week to talk through what would
happen if he did get a smudge on his glasses.
Following the intensive exposure session, a
review of the session was provided, highlighting
the sessions key learning points. Maxs achievements in therapy were reviewed and photos taken
of Max during each ERP task were provided to
347
Post-SUDs
010
1
1
2
2
0
2
2
2
2
2
3
2
the family in order to compile a photo-book of

Maxs race against OCD. Plans for homework
ERP tasks were set and written down for Max,
allowing for practice of the gains made during
the session.
Intensive ERP Session 2Session 2 involved
further ERP tasks, which were conducted in
Maxs home. ERP within the home environment
presents a particularly useful approach when
OCD is largely restricted to the home context,
and/or when family accommodation and family discord are particularly high, as was the case
for Max and his family. The session began with
Max taking the therapist on a tour of his home
and showcasing his model car collection. The
therapist reviewed Maxs home ERP tasks and
discussed any difficulties encountered with his
homework. Self-reports by Max and his parents
indicated that Max had completed most of the
tasks agreed to during the preceding week. While
Max had reduced the time spent in the shower, he
was still requiring some assistance, in particular,
with opening doors.
348
During the intensive session, Max was assisted in ERP through therapist modelling, in
order to present the ERP tasks in a controlled
manner and provide Max with social learning opportunities to challenge his OCD beliefs. During
the first hour of session, Max conveyed a good
understanding of OCD and applied his skills of
using his IQs to reframe negative/intrusive
thoughts, and he demonstrated his ability to tolerate his anxiety during ERP by way of riding
out the rage. During the second hour, Max was
able to continue his contamination challenges,
which incrementally became more demanding on
him, while resisting ritualizing or demanding his
parents assist him. The final hour of the session
was conducted at the beach, where Max was able
to face a number of major hurdles, including
contact with sand, walking barefoot in the park,
and visiting a public bathroom. Table23.4 shows
Maxs exposure steps and pre- and post-SUDs

ratings for session 2.
There were some difficulties during this session whereby Max became highly agitated and
argumentative about touching the bathroom
taps with his hands. He argued again that this
was not logical because his parents had spent
money changing the taps in order for him to be
able to turn them on and off using his forearms.
He became very upset, screaming and yelling at
his parents, and refused to engage further. He
also demanded that his parents wipe and clean
the taps and sink following the therapist touching
these during modelling of the ERP task. De-escalation techniques, specifically going outside with
the therapist, deep breathing, redirecting Maxs
focus through grounding techniques, such as engaging the senses (e.g. name five things you can
see, hear), were used to assist Max to regulate
Table 23.4 Example exposure hierarchy for intensive ERP session 2 (not all ERP steps included)
ERP steps
Exposure task
Response prevented
Pre-SUDs
010
Hour 1
Home
Step 1
Open bathroom door
No hand washing
4
Step 2
Touch TV remote
No wet wipes or washing
8
Step 3
Change the channel to one where
No removing spectacles, wip- 7
germs commercials often played
ing lenses or surfaces
No hand washing
10
Step 4
Sit on driveway with therapistdrawing chalk race track on
driveway
Hour 2
Home
Step 1
Touch the bathroom taps
No hand washing, or wiping
10
No removing spectacles, wip- 2
Step 2
Touch remotes, change channels,
looking for germ commercials
ing lenses or surfaces
Step 3
Use the toilet, barefoot
No washing or wiping
10
Step 4
Sit on toilet floor and play UNO with No washing or wiping floor/
10
therapist
feet
Beach and park
Hour 3
Step 1
Standing barefoot in public park
No hand/foot washing or use 10
area, accompanied by Maxs pet dog of hand sanitizer or wipes
Step 2
Standing barefoot on the sand
No use of hand sanitizer or
8
wipes, no towel use
9
Step 3
Return to parksitting directly on
No hand or feet washing,
the park bench, preparing home tasks no use of wipes, sanitizer or
towel
Step 4
Walk inside public bathroom
No washing or wiping
9
Step 5
Stand barefoot in public bathroom
No washing/wiping
10
Post-SUDs
010
2
4
4
5
5
0
3
1
2
2
2
4
3
his intense emotional response. Once Max had

calmed down he was willing to re-engage.
At this point in Maxs treatment, the therapist implemented formal training in emotional
regulation techniques in order to augment Maxs
treatment of OCD. An analogy of an emotional
frustration beaker was introduced, whereby the
therapist demonstrated to Max the accumulation
of frustration (using water) in a glass beaker (e.g.
McKinlay etal. 2006). The therapist drew a picture of Maxs body on the front of the beaker to
assist his understanding of this abstract concept.
Max would pour water into the beaker to demonstrate his frustration increasing as the therapist
described daily triggers to him, such as: a kid
at school calls you a name, mum is late to collect you from school, you are running late for
an appointment, you see someone at school spit
on the ground. As Maxs beaker overflowed with
water, the therapist likened this to Maxs fits of
rage when he became full of frustration. Further
discussion followed in regards to understanding
beaker fillers, that is, the unique triggers that increase frustration and anxiety. Max drew pictures
of frustration beakers for him and his parents, and
they continued to monitor and record additional
349
frustration beakers over the following weeks. This

module concluded with a discussion on methods
to empty frustration beakers, which Max enjoyed
and was able to engage in. He identified activities
including relaxation, playing with the dog, building model cars, and listening to music. The family
made a weekly timetable whereby they scheduled
time to engage in activities that emptied their beakers. It was suggested that this was important both
before and after ERP exercises in order for Max to
win laps against OCD.
Intensive ERP session 3The session focused
on continuing the ERP gains achieved in session
2, and it was therefore conducted again at Maxs
home, with the final hour held at a different beach
and park. A review of the home tasks indicated
that Max had completed most of the assigned
tasks, he had reduced the number of wipes being
used, he was tolerating touching the TV remotes
without using wipes, handling his school books
without concern, and he reported that he was
no longer bothered by watching TV commercials that showed germs. Intensive session 3 followed the same format as the previous sessions.
Table23.5 displays examples from Maxs expo-
Table 23.5 Sample steps from Maxs exposure hierarchy for intensive ERP session 3
ERP steps
ERP task
Response prevented
Pre-SUDs
010
Hour 1
Home
Step 1
Use school books in various rooms
No wet wipes and no hand
4
washing
Step 2
After touching school books, touch
6
clean stuff (e.g. clothing)
washing
Step 3
Wash hands and use brothers towel
7
washing
Hour 2
Home
Step 1
Wash hands and use fathers towel
No hand washing after towel 8
drying
Step 2
Leave spectacles outside on lawn
No wiping
7
No washing/wiping
2
Step 3
Stand in bathroom barefoot after
father uses toilet
Hour 3
Beach and park
Step 1
Walking barefoot on the beach
No sanitizer, wipes, or towel 4
accompanied by Maxs pet dog
Step 2
Hands in the water, splashing
Step 3
Lying on the sand, sand in hair
No towel, no wipes
6
Step 4
Cartwheels in the sand
Post-SUDs
010
1
0
0
1
2
0
3
2
0
0
350
sure hierarchy and pre- and post-SUDs ratings

for session 3.
Overall, Max approached intensive session
3 with confidence, and he was willing to engage and meet each lap challenge that was
set for him. During this session, however, there
was one explosion of rage by Max, whereby
he became extremely irritated during an argument with Mum. An argument broke out on the
beach, whereby Max and his mother clashed over
throwing a stick to their pet dog. Unclear about
what was Maxs concern, his mother continued
to throw the stick, refusing to give into Maxs demands, at which point Max screamed, yelled and
ran off down the beach for a short period of time.
Upon his return, while still extremely frustrated,
he explained his fear that the stick was too small
and the dog was at risk of choking. The therapist
used this opportunity to introduce another modification to CBT aimed at addressing Maxs poor
problem-solving skills and explosive behaviour.
Collaborative problem solving (CPS) strategies were introduced whereby Max and his parents were taught steps in resolving problems in
a mutually satisfactory manner (Greene 2010).
The model conceptualizes aggressive or explosive behaviour as the by-product of deficits in the
development of cognitive skills, specifically in
the domains of flexibility, frustration tolerance,
and problem solving. These skill deficits are
characteristic of youth with ASD, and they were
certainly hypothesized to contribute to Maxs
inability to regulate his emotions and problemsolve conflicts with his parents. The CPS approach aims to achieve three primary goals. The
first goal is to help parents understand the lagging cognitive skills model, thereby enhancing
parental empathy for the child at times of disagreement and stress. The second goal is to help
parents and youth become cognizant of three
common options for handling problems or unmet
expectationsimposition of adult will (plan A),
CPS (plan B), and removal of the parents expectation (plan C)and the impact of each of these
three strategies on adultchild interactions. The
third goal is to help adults and children become
proficient at solving problems collaboratively, so
as to resolve potential conflict in a manner that

reduces the likelihood of aggressive outbursts.
For Max and his parents, the therapist used
the current conflict as an example to demonstrate
(using a stick in the sand) the three alternate
outcomesplan A (do what mum says), plan B
(work it out together), or plan C (give in to Max,
and the OCD mean team wins). Using this framework, the various options were discussed, that is,
when plan A (adult) and plan C (child) solutions
are used, one party either surrenders to the other
or does not have an opportunity to contribute to
the solution (i.e. win/lose scenario). When plan B
(both) is used, both parties express their concerns
and generate solutions to the problem (i.e. win/
win). Using the current difficulty as an example,
Max and his parents expressed their concerns or
point of view, and then they generated solutions
to the problem. They agreed on a solution to seek
a larger, more solid stick for the dog to chase.
Maxs ability to stay calm, use his IQs to work
out why he was feeling so upset, and problem
solve with his parents was praised. At the completion of the session, Maxs therapist developed
a form for the family to use at home, to practice
CPS throughout the week. Maxs achievements
were reviewed, photos provided to the family
of lap wins, and reward points allocated. His increase in confidence and ability to manage his
OCD symptoms were becoming evident to all.
Three
E-Therapy Maintenance of Gains
weekly 1-h follow-up e-therapy sessions followed Maxs intensive treatment, allowing for
generalization of ERP to continue at home and
school, to practice further ERP tasks during session, and to provide ongoing support to his family in reducing their accommodation to Maxs
OCD demands. It was at this stage of therapy that
withdrawal of family accommodation practices
began to occur in a systematic way. Given the
extent and chronicity of the family accommodation, together with Maxs poor emotional regulation and deficits in problem solving skills, it was
deemed important to time the reduction of family
accommodation when Max was better equipped
to understand his intense emotions and manage
these more effectively, and his parents were more

confident in understanding OCD and how to
assist Max in managing his symptoms, without
engaging in maladaptive accommodation. Steps
to achieve his parents gradual withdrawal of
accommodation were decided by Max, and steps
were developed to address this systematically,
week by week.
Post Assessment Summary

A full review of Maxs progress was conducted
at the completion of his therapy and again at a
3-month follow-up. An overview of his therapeutic outcomes is presented in Table23.6. On the
basis of parent diagnostic interviews, Max maintained a diagnosis of OCD (CSR=4) and comorbid diagnosis of ADHD (CSR=4) at post treatment, indicating a significant improvement in
his OCD despite still meeting clinical range. At a
3-month follow-up, however, Max no longer met
diagnostic status for OCD, with a subthreshold
CSR rating of 2. The three most distressing target behaviours were rated by Max throughout the
treatment process. As can be seen in Fig.23.3,
there was systematic reduction of distress across
these symptoms, from pretreatment to 3 months
post treatment.
351
Maxs comorbid presentation of OCD and ASD
presented a number of complicating issues that
required modifications to the standard delivery
of CBT for paediatric OCD. Deficits in Maxs
emotion regulation, poor frustration tolerance,
and lags in his problem solving skills meant
Max experienced explosive emotional outbursts.
Indeed, during treatment Max experienced moments of rage, which were seized by his highly
attuned therapist as opportunities to teach Max
and the family additional strategies for (a) emotional regulation and (b) CPS. These approaches
not only addressed Maxs poor emotion regulation and problem solving deficits but also presented a vehicle for bringing the family together
to work collaboratively towards the same goals,
which appeared to improve the general emotional
functioning of Maxs parents and went some way
towards improved parentchild interactions.
The degree to which the family was over involved in OCD and modified their expectations
of Max within the home was another major complicating factor in Maxs treatment. The family
accommodation in this case served to exacerbate
Maxs symptoms and reinforce his diminished
sense of self-efficacy. This pathological degree
of accommodation led to dysfunctional family
Table 23.6 Posttreatment and 3-month follow-up assessment summary

Measure
Post-score
Description
3-month score
Description
OCD CSR
4
Clinical
2
Subclinical
ADHD CSR
4
Clinical
4
Clinical
CY-BOCS obsessions
10
Moderate
4
Mild
CY-BOCS compulsions 10
Moderate
3
Mild
CY-BOCS total
20
Moderate
7
Subclinical
CDI T-score
67
Elevated
64
High average
MASC T-score
69
Elevated
61
Slightly elevated
40
Reduced physical, emoPedsQL
48
Reduced physical, emotional, social, and school
tional, social, and school
impairments
impairments
FAS
48
Extreme family
4
Very low family
accommodation
accommodation
OCD obsessive-compulsive disorder, CSR clinician severity rating, ADHD attention-deficit hyperactivity disorder,
CY-BOCS Childrens YaleBrown Obsessive-Compulsive Scale, CDI Child Depression Inventory, MASC Multidimensional Anxiety Scale for Children, FAS Family Accommodation Scale, PedsQL Pediatric Quality of Life
352
Fig. 23.3 Maxs self-rated
SUDs of his three most troubling target behaviours

relationships, and it was crippling Maxs parents.

Psychoeducation about family accommodation
and its impact was central to Maxs treatment and
recovery. In order to effectively deliver ERP, as
well as transfer control back to Maxs parents, it
was essential that his parents were involved in
every step of treatment. This allowed the therapist opportunities for modelling of appropriate responses to OCD, as well as addressing unacceptable behaviour by Max; training his parents in effective ways to support ERP at home; cultivating
an alliance amongst the family against OCD; and
the development of adaptive stress management
and conflict management within the family.

This case has demonstrated that CBT with ERP
can be effective in treating comorbid OCD in
a young person with ASD. While the treatment
approach used in this case was intensive, the
therapeutic process and outcomes would be very
similar if given in standard weekly sessions. This
treatment produced a clinically significant reduction in OCD, anxiety and depression symptoms,
while improvements were also seen in Maxs
quality of life and overall functioning. Maxs parents were also to benefit, being able to enjoy leisurely activities together once more. With Maxs
distress and demands for accommodation greatly
reduced, the family unit was functioning much
better at conclusion of therapy.
The present case highlights the importance
of psychoeducation concerning family accom-
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modation in the treatment process of paediatric

OCD, particular when accommodation practices
are extreme, which might be a correlate of ASD
comorbidity. As family accommodation is of
significant clinical relevance, and accommodation may worsen manifestations of the illness
and interfere with treatment approaches, determining contributory familial factors in childhood OCD and involving the family in therapy
are vital to the management of this illness. For
clinicians, assessing family accommodation is
an important process in order to develop a functional assessment and formulation of the disorder
and develop individualized treatment plans. Addressing family accommodation behaviours with
parents may serve to not only improve outcomes
for their child but also reduce guilt and blame for
past behaviours and redirect attention to focus on
more adaptive strategies in supporting change in
a child with OCD.
An important consideration when treating comorbid OCD and ASD is parental involvement
in the treatment process. Certainly in this case,
Maxs parents were motivated and took an enthusiastic approach to participating in the treatment
and supporting their son. Efforts to improve existing interventions increasingly have focused on
aspects of the family environment that may influence treatment adherence and the maintenance of
therapeutic gains, and the inclusion of families
has routinely been recommended as an adjunct to
individual child interventions. While it is generally agreed that CBT should include parents, to
date there have been no systematic trials providing empirical evidence for the benefits of family
353
Table 23.7 Modifications to CBT for comorbid OCD and ASDkey practice points
Barriers to treatment
Modification of CBT required
Language and/or communication deficits Use of clear language, instructions, and visual aids
Engagement in therapy
Utilize special interest to motivate and engage with therapeutic goals
Elopement
Plan for elopement prior to therapy with verbal contract highlighting
boundaries and safety practices
Family accommodation
Involving family in therapy and giving strategies to gradually reduce
accommodating behaviours
Emotional regulation deficits
Emotion regulation training incorporated into therapy
Problem solving deficits
Collaborative problem solving between child and parents for mutual
resolution
CBT cognitive-behavioural therapy
augmented CBT in comparison to child focussed

CBT. This is an area for future research, given
that parents are perfectly placed to ensure the
longevity of therapeutic gains by having an increased ability to expose their children to feared
situations.
In this case, modification to CBT was essential to address some of the unique complications
associated with comorbid ASD and OCD, and
it included (1) use of clear, precise language,
instructions, and visual aids; (2) utilizing the
childs area of restricted interest to cultivate motivation and compliance with therapeutic goals;
(3) dealing with elopement during session; (4)
involving a high degree of family involvement
to adequately address family accommodation
and maladaptive parentchild interactions; (5)
emotion regulation training to address explosive
behaviour and poor emotional functioning of the
child and family; and (6) CPS to address parentchild conflict and deficits in childs problem
solving, frustration tolerance, and chronic inflexibility. Table23.7 outlines the key practice points
in a case of comorbid OCD and ASD.
In clinical practice, a clear understanding of
the distinctions between ASD and OCD may
prevent diagnostic overshadowing, which occurs when impairing obsessions and compulsions are attributed to the diagnosis of ASD and
not recognized as OCD symptoms (Simonoff
etal. 2008). Diagnostic overshadowing is problematic because it detracts from learning how
ASD and OCD may intersect and possibly complicate treatment. A thorough clinical evaluation
should include a functional assessment of the
RB. It is currently unknown how the accurate
differentiation of ASD-specific RBs versus cooccurring OCD with ASD informs the treatment
approach. Although ERP has growing support as
a treatment for OCD in high-functioning ASD,
preliminary findings suggest that modified ERP
may also be effective in reducing RBs within the
context of ASD and co-occurring intellectual disability (Boyd etal. 2013). To determine the optimal treatment approach for youth with comorbid
ASD and OCD, future research is needed with
larger sample sizes, standardized outcome measures, control groups, and follow-up assessments.
References
Abramowitz, J. S., & Houts, A. C. (2002). What is OCD
and what is not? Problems with the OCD spectrum
concept. Scientific Review of Mental Health Practice,
1, 139156.
Barrett, P. M., Farrell, L., Pina, A. A., Peris, T. S., & Piacentini, J. (2008). Evidence-based psychosocial treatments
for child and adolescent obsessive-compulsive disorder. Journal of Clinical Child and Adolescent Psychology, 37, 131155. doi:10.1080/15374410701817956.
Boyd, B. A., Woodard, C. R., & Bodfish, J. W. (2013).
Feasibility of exposure response prevention to treat
repetitive behaviors of children with autism and an
intellectual disability: A brief report. Autism, 17, 196
204. doi:10.1177/1362361311414066.
Calvocoressi, L., Lewis, B., Harris, M., Trufan, B. S.,
Goodman, W. K., McDougle, C. J., & Price, L. H.
(1995). Family accommodation in obsessive compulsive disorder. American Journal of Psychiatry, 152,
441443.
Chasson, G. S., Timpano, K. R., Greenberg, J. L., Shaw,
A., Singer, T., & Wilhelm, S. (2011). Shared social
competence impairment: Another link between the
354
obsessive-compulsive and autism spectrums? Clinical Psychology Review, 31, 653662. doi:10.1016/
j.cpr.2011.02.006.
Constantino, J. N., & Gruber, C. P. (2005). Social responsiveness scale (SRS). Los Angeles: Western Psychological Services.
Frost, R. O., & Steketee, G. (Eds.). (2002). Cognitive
approaches to obsessions and compulsions: Theory,
assessment and treatment. Amsterdam: Pergamon.
Gray, C. A. (1998). Social stories and comic strip conversations with students with Asperger syndrome
and high-functioning autism. In E. Schopler, G. B.
Mesibov, & L. J. Kunce (Eds.), Asperger syndrome or
high-functioning autism? (pp.167198). New York:
Plenum.
Greene, R. W. (2010). The explosive child. New York:
Harper.
Interactive Autism Network (IAN). (2011). IAN research
report: Elopement and wandering. Interactive Autism
Network: Kennedy Krieger Institute (producer).
www.iancommunity.org/cs/ian_research_reports/
ian_research_report_elopement#? viewType=print.
Accessed 2 April 2011.
Ivarsson, T., & Melin, K. (2008). Autism spectrum traits
in children and adolescents with obsessive-compulsive disorder (OCD). Journal of Anxiety Disorders,
22, 969978. doi:10.1016/j.janxdis.2007.10.003.
Kovacs, M. (1992). Childrens depression inventory
(CDI). Tonawanda: Multi-Health Systems.
Lehmkuhl, H. D., Storch, E. A., Bodfish, J. W., & Geffken,
G. R. (2008). Brief report: Exposure and response
prevention for obsessive compulsive disorder in
a 12-year-old with autism. Journal of Autism and
Developmental Disorders, 38, 977981. doi:10.1007/
s10803-007-0457-2.
Lewin, A. B., Wood, J. J., Gunderson, S., Murphy, T. K.,
& Storch, E. A. (2011). Phenomenology of comorbid autism spectrum and obsessive-compulsive disorders among children. Journal of Developmental
and Physical Disabilities, 23, 543553. doi:10.1007/
s10882-011-9247-z.
Leyfer, O. T., Folstein, S. E., Bacalman, S., Davis, N. O.,
Dinh, E., Morgan, J., & Lainhart, J. E. (2006). Comorbid psychiatric disorders in children with autism:
Interview development and rates of disorders. Journal
of Autism and Developmental Disorders, 36, 849861.
doi:10.1007/s10803-006-0123-0.
Lickel, A., MacLean, W. E., Blakeley-Smith, A., & Hepburn, S. (2012). Assessment of the prerequisite skills
for cognitive behavioral therapy in children with
and without autism spectrum disorders. Journal of
Autism and Developmental Disorders, 42, 9921000.
doi:10.1007/s10803-011-1330-x.
Lord, C., Rutter, M., & Le Couteur, A. (1994). Autism
diagnostic interview-revised: A revised version of a
diagnostic interview for caregivers of individuals with
possible pervasive developmental disorders. Journal
of Autism and Developmental Disorders, 24, 659685.
doi:10.1007/BF02172145.
Mack, H., Fullana, M. A., Russell, A. J., Mataix-Cols, D.,
Nakatani, E., & Heyman, I. (2010). Obsessions and
compulsions in children with Aspergers syndrome or
high-functioning autism: A case-control study. Australian and New Zealand Journal of Psychiatry, 44,
10821088. doi:10.3109/00048674.2010.515561.
March, J., & Mulle, K. (1998). OCD in children and adolescents: A cognitive-behavioral treatment manual.
New York: Guilford.
March, J., Parker, J., Sullivan, K., Stallings, P., & Conners, C. (1997). The multidimensional anxiety scale
for children (MASC): Factor structure, reliability and
validity. Journal of the American Academy of Child
and Adolescent Psychiatry, 36, 554565.
McKinlay, B. D., Stewart, S. L., & Cullion, C. (2006). The
Brake Shop: Intervention for Co-Morbid Tourette
Syndrome and Intermittent Explosive Disorder. Poster
presented at the Tourette Syndrome Foundation of
Canada International Symposium on Neurodevelopmental Disorders, Edmonton, AB.
Nadeau, J., Sulkowski, M. L., Ung, D., Wood, J. J.,
Lewin, A. B., Murphy, T. K., etal. (2011). Treatment
of comorbid anxiety and autism spectrum disorders.
Neuropsychiatry, 1, 567578.
Ollendick, T. H., st, L.-G., Reuterskild, L., Costa, N.,
Cederlund, R., Sirbu, C., Davis, T. E., III., & Jarrett,
M. A. (2009). One-session treatment of specific phobias in youth: A randomized clinical trial in the United
States and Sweden. Journal of Consulting and Clinical Psychology, 77, 504516. doi:10.1037/a0015158.
Reaven, J., & Hepburn, S. (2003). Cognitive-behavioral
treatment of obsessive-compulsive disorder in a child
with Asperger syndrome: A case report. Autism, 7,
145164. doi:10.1177/1362361303007002003.
Reaven, J., Blakeley-Smith, A., Culhane-Shelburne, K., &
Hepburn, S. (2012). Group cognitive behavior therapy
for children with high-functioning autism spectrum
disorders and anxiety: A randomized trial. Journal
of Child Psychology and Psychiatry, 53, 410419.
doi:10.1111/j.1469-7610.2011.02486.x.
Rooney, M., Alfano, C. A., Walsh, K. S., & Parr, A. F.
(2011). Differential Diagnosis and Treatment of
Obsessive-Compulsive, Inattentive, and Sleep Symptoms in a 7-Year-Old With PDD-NOS. Clinical Case
Studies, 10(2), 133146.
Russell, A. J., Jassi, A., Fullana, M. A., Mack, H., Johnston, K., Heyman, I., etal. (2013). Cognitive behavior
therapy for comorbid obsessive-compulsive disorder
in high-functioning autism spectrum disorders: A randomized controlled trial. Depression and Anxiety, 30,
697708. doi:10.1002/da.22053.
Russell, A. J., Mataix-Cols, D., Anson, M. A., & Murphy,
D. G. (2009). Psychological treatment for obsessive
compulsive disorder in people with autism spectrum
disordersa pilot study. Psychotherapy and Psychosomatics, 78, 5961.
Russell, G., Rodgers, L. R., Ukoumunne, O. C., & Ford, T.
(2014). Prevalence of parent-reported ASD and ADHD
in the UK: Findings from the millennium cohort study.
Journal of Autism and Developmental Disorders, 44,
3140. doi:10.1007/s10803-013-1849-0.
Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort,
S. I., King, R. A., Goodman, W. K., etal. (1997).
Childrens Yale Brown obsessive compulsive scale:
Reliability and validity. Journal of American Academy of Child and Adolescent Psychiatry, 36, 844852.
doi:10.1097/00004583-199706000-00023.
Schaffer, D., Gould, M. S., Brasic, J., Ambrosini, P.,
Fisher, P., Bird, H. R., & Aluwahlia, S. A. (1983). A
childrens global assessment scale (CGAS). Archives
of General Psychiatry, 40, 12281231.
disorders interview schedule for DSM-IVchild and
Simonoff, E., Pickles, A., Charman, T., Chandler, S., Loucas, T., & Baird, G. (2008). Psychiatric disorders in
children with autism spectrum disorders: Prevalence,
comorbidity, and associated factors in a populationderived sample. Journal of the American Academy
doi:10.1097/CHI.0b013e318179964f.
Spiker, M. A., Lin, C. E., van Dyke, M., & Wood,
J. J. (2012). Restricted interests and anxiety
in children with autism. Autism, 16, 306320.
doi:10.1177/1362361311401763.
Storch, E. A., Geffken, G. R., Merlo, L. J., Jacob,
M. L., Murphy, T. K., Goodman, W. K., etal.
(2007a). Family accommodation in pediatric obsessivecompulsive disorder. Journal of Clinical
Child and Adolescent Psychology, 36, 207216.
doi:10.1080/15374410701277929.
Duke, D., Munson, M., etal. (2007b). Family-based
cognitive-behavioral therapy for pediatric obsessivecompulsive disorder: Comparison of intensive and
weekly approaches. Journal of the American Academy
355

doi:http://dx.doi.org/10.1097/chi.0b013e31803062e7.
Storch, E. A., Lehmkuhl, H. D., Ricketts, E., Geffken, G.
R., Marien, W., & Murphy, T. K. (2010). An open trial
of intensive family based cognitive-behavioral therapy in youth with obsessive-compulsive disorder who
are medication partial responders or nonresponders.
Journal of Clinical Child and Adolescent Psychology,
39, 260268. doi:10.1080/15374410903532676.
South, M., Ozonoff, S., & McMahon, W. M. (2005).
Repetitive behavior profiles in Asperger syndrome
and high-functioning autism. Journal of Autism and
Developmental Disorders, 35, 145158.
van Steensel, F. J. A., Bgels, S. M., & Perrin, S. (2011).
Anxiety disorders in children and adolescents with
autistic spectrum disorders: A meta-analysis. Clinical
Child and Family Psychology Review, 14, 302317.
doi:10.1007/s10567-011-0097-0.
Varni, J. W., Seid, M., & Rode, C. A. (1999). The PedsQL: Measurement model for the pediatric quality of life inventory. Medical Care, 37(2), 126139.
doi:10.2307/3767218.
White, S. W., Oswald, D., Ollendick, T., & Scahill, L.
(2009). Anxiety in children and adolescents with
autism spectrum disorders. Clinical Psychology
Review, 29, 216229. doi:10.1016/j.cpr.2009.01.003.
Whiteside, S. P., & Jacobsen, A. B. (2010). An uncontrolled examination of a 5-day intensive treatment for
pediatric OCD. Behavior Therapy, 41(3), 414422.
doi:http://dx.doi.org/10.1016/j.beth.2009.11.003.
Wood, J. J., Drahota, A., Sze, K., Har, K., Chiu, A., &
Langer, D. A. (2009). Cognitive behavioral therapy
for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of
Child Psychology and Psychiatry, 50, 224234.
doi:10.1111/j.1469-7610.2008.01948.x.
Disruptive Behavior in a Youth
Disorder
24
Chelsea M. Ale and Stephen P. H. Whiteside

Research Basis
Obsessive-compulsive disorder (OCD) is an impairing, but treatable, disorder that is often complicated by disruptive behavior (noncompliance,
anger outbursts, aggression; Masi etal. 2005;
Storch etal. 2012). When youth with OCD experience distress from contact with feared stimuli
or unsatisfactory completion of rituals, it is not
uncommon for them to throw a temper tantrum
or go into a rage (i.e., episodes of explosive
anger or aggression triggered by minor provocations; Storch etal. 2012). In a subset of youth
with OCD, anger outbursts and noncompliance
predate the onset of OCD or generalize to situations unrelated to obsessions and compulsions
warranting a diagnosis of a disruptive behavior
disorder (DBD), including oppositional defiant
disorder, conduct disorder, or attention deficit/
hyperactivity disorder. Whether clinical or subclinical in severity, disruptive behavior is often
associated with increased OCD severity and
poorer treatment outcome (Garcia etal. 2010;
Masi etal. 2005; Lebowitz etal. 2011; Storch
etal. 2008, 2010). As such, it is essential for the
clinician to identify disruptive behaviors and directly address them in treatment.
C.M.Ale() S.P.H.Whiteside
Department of Psychiatry & Psychology, Mayo Clinic,
Rochester, MN, USA
e-mail: ale.chelsea@mayo.edu
As in Pattersons (Patterson 1982; Patterson

etal. 1992) coercive cycle of parentchild interactions, disruptive behavior in pediatric OCD
is thought to be maintained and to generalize
through both negative and positive reinforcement. In the first coercive pattern, the child
makes a demand (e.g., wash your hands before
handing me my plate) which the parent denies;
the child persists in the demand and increases
the severity of disruptive behavior (e.g., hitting,
kicking, screaming); the parent gives into the request (positively reinforcing the childs tantrum),
and the child quiets down (negatively reinforcing the parents giving-in). In the second coercive
pattern, the parent repeatedly makes a request or
yells at the child (e.g., use the plate I gave you),
the child yells back ignoring the request (punishing the parents command), the parent gives in
and removes the demand (negatively reinforcing
the childs noncompliance), and the child stops
arguing (negatively reinforcing the parents giving-in).
Through these maladaptive interactions, anger
outburst and noncompliance are negatively reinforced through avoidance of or escape from
exposure to feared stimuli. Over time, this pattern can lead to increasingly quick and intense
reactions from youth when confronted with obsession-provoking situations. Moreover, Storch
etal. (2012) found that 77% of parent-reported
rage episodes by children with OCD were triggered by limit setting, suggesting that disruptive
behavior may have generalized to noncompliance for some families. Not surprisingly, if a

DOI 10.1007/978-3-319-17139-5_24
357
358
child responds to requests with anger and defiance, even when unrelated to OCD, it will likely
be difficult to enlist the childs cooperation with
exposure and response prevention (ERP).
Phenomenology Estimates for the frequency
of disruptive behavior in pediatric OCD vary
widely. Reports of diagnosable disorders range
from 9 to 57% (Garcia etal. 2008; Geller etal.
1996; Ivarsson etal. 2008). However, individual
behaviors are more common with parents reporting an average of 1.85 rage outbursts per week
from their children with OCD (Storch etal.
2012). Of those families reporting intense behavioral outbursts, 61% reported verbal aggression, and 60% reported physical aggression. It
is important to note, however, that youth who
display disruptive behavior only in the context
of OCD symptoms would not meet criteria for a
comorbid DBD. Although the presence of disruptive behaviors in OCD appears to be unrelated to
gender (Krebs etal. 2013; Lebowitz etal. 2011),
OCD-related temper outbursts appear to be more
common in younger children (Krebs etal. 2013).
However, the presence of diagnosable DBDs
appears to be unrelated to age (Lebowitz etal.
2011; Storch etal. 2010).
Impact The presence of comorbid oppositional
defiant disorder appears to be related to more
severe OCD symptoms (Lebowitz etal. 2011;
Storch etal. 2010). Children who have both OCD
and disruptive behaviors experience significantly
greater OCD severity, worse functional impairment, more family accommodation (FA), and
less success at resisting compulsive behaviors
when compared to children with uncomplicated
OCD or other comorbid diagnoses (Nadeau etal.
2013; Storch etal. 2010). The mechanism by
which disruptive behaviors affect severity may
involve the childs interactions with family members. For instance, families of children with cooccurring disruptive behavior disorders experience more FA of OCD symptoms (Storch etal.
2010). In fact, FA may account for as much as
97% of the total effect of disruptive behaviors on
OCD severity (Lebowitz etal. 2014).
C. M. Ale and S. P. H. Whiteside
Treatment As with uncomplicated OCD, ERP

is the recommended treatment for children with
comorbid disruptive behavior. This treatment
involves helping the child confront obsessionprovoking stimuli for a prolonged time, while
refraining from rituals. As would be expected,
given the nature of the symptoms, children with
OCD and DBD tend to respond worse to ERP,
as well as medication treatments, compared
to children with sole OCD (Storch etal. 2008;
Garcia etal. 2010; Masi etal. 2005). Perhaps as
a result of the poor response to first-line treatments, children with OCD and DBD are approximately three times more likely to be taking an
atypical antipsychotic (e.g., risperidone, aripiprazole) than those with OCD alone (Storch etal.
2010). As such, these children are at heightened
risk for adverse side effects, as well as continued
symptoms.
Another approach to adjunctive treatment
involves adding behavioral interventions for disruptive behavior to ERP. A large body of literature supports the efficacy of parent management
training (PMT) for DBDs (Chorpita etal. 2011).
PMT for DBDs involves breaking the coercive
cycle by instructing parents in the use of differential attention, tangible reinforcement of good
behavior, and consistent consequences for misbehavior. The effectiveness of implementing PMT
sequentially or concurrently with ERP for pediatric OCD with disruptive behavior is supported
by a handful of case studies (Ale and Krackow
2011; Lehmkuhl etal. 2009; Owens and Piacentini 1998). More generally, the feasibility of integrating parents into the delivery of ERP for pediatric OCD has been demonstrated (Freeman etal.
2008; Storch etal. 2007, Whiteside etal. 2014)
and can reduce disruptive behavior (Krebs etal.
2013). Taken together, this developing literature
suggests that parent training can be modified to
provide effective treatment of children with comorbid OCD and disruptive behavior disorders.
The following section describes a challenging, but representative, presentation of OCD
and ODD in a school-aged child. To protect the
patients privacy, the childs name and key details about the family have been changed, but the
24 Treatment of Comorbid Disruptive Behavior in a Youth with Obsessive-Compulsive Disorder
diagnostic and treatment details are accurate to

the patients presentation.
Case Information
At the time of assessment, Jamie was a 9-year,
10-month-old female in the first semester of the
fourth grade. Jamies parents sought assessment
and treatment through an OCD specialty clinic
due to Jamies persistent obsessive thoughts about
harm coming to her parents and herself, excessive checking behaviors, and excessive questioning. Jamie frequently asked reassurance-seeking
questions about information that parents knew
Jamie was aware of (e.g., did I just brush my
teeth?) and had inconsolable worries that serious
harm might come of small injuries (e.g., getting
a small scrape on her knee and then needing parents to check it repetitively and assure her she did
not need stitches for days at a time). Jamie also
had difficulty with her schoolwork because she
had to write her mathematics problems exactly
correctly or else she was compelled to erase and
rewrite. This also interfered with Jamies reading, as she would have to start the paragraph over
again if she read a word wrong or doubted that
she understood what she read. If she could not get
it right, Jamie feared that something bad would
happen to her parents and had to check on them
to make sure they were safe. Jamies parents were
at a loss for how to help Jamie and spent a lot of
time and energy attempting to appease her fears.
Although Jamies parents described her as a
bright and loving child, they said that over the
past year, she had become a tyrant and a bully
in their home. They noted that if they did not answer Jamies questions in exactly the right way,
she would scream and go into a rageoften hitting them or breaking anything around her. During several rage episodes, Jamie had broken two
handheld video games that she cared a lot about.
Jamie also displayed these aggressive episodes at
school. When she was not allowed to go to her
mothers classroom in the middle of the school
day, Jamie screamed and slammed the door. She
had been sent to the principals office several
times; once for kicking a teachers aide who was
359
trying to help Jamie with a mathematics assignment, but was not explaining it right. Jamies
parents also described situations when Jamies
aggressive behaviors did not seem directly associated with OCD behaviors. When they set limits
on video game time or asked Jamie to complete
chores, she would refuse and then scream and
throw things if parents did not back down. The
parents often negotiated with Jamie and tried to
avoid these types of conflicts because it created a
lot of chaos in the home and was upsetting to their
younger children. Jamie also frequently swore at
her sister and her parents when she was told to
do something that she did not want to do. For example, she called her mother a profane name and
hung up the phone on her mother when she was
told that she would not be allowed to stay for dinner at her grandmothers house. Parents reported
that they did not think that Jamie could not control her behavior because of OCD, and they did
not know if hitting was a compulsion at times.
They were very concerned about Jamies irritability, anxiety, and anger flare-ups. Her mother
noted that Jamie frequently made statements like,
I want to kill myself or Im going to kill you,
when she was having a tantrum, but had never
made any suicidal attempt or serious homicidal
attempts.
Jamie lived with her married mother and father, her three younger sisters (ages 18 months
to 8 years) and her 3-year-old cousin. Her father
was employed as an accountant, and her mother
was a teacher at the same school as Jamie attended. Her maternal grandmother also lived nearby,
and Jamie often spent time with her grandmother
after school. Jamie did not get along well with
her sisters or her cousin. Although they tried to
play together, Jamie bossed them around and
would become very upset if they did not play
the game the way Jamie wanted to play. Jamies
mother described her as always having been a
strong-willed child and also not wanting to try
new things unless she was sure she would be successful at it. She attributed this to Jamie being the
first-born child, but retrospectively wondered if it
had been an early sign of anxiety.
At the time of assessment, Jamie was a few
months into her fourth-grade year. She reported
360
that she liked school and her teacher. Jamie

earned mostly As and Bs and stated that school
was very important to her. Jamie had an Individualized Education Plan (IEP) for Other
Health Impairment (i.e., OCD) in place for the
past 2 years. With her IEP, she received support
for reading, writing, and mathematics, which included extra time on tests and extra time to complete homework. Jamie also was able to leave
the classroom whenever she became anxious, to
go to the resource room. She would just have to
tell her teacher and then was allowed to walk by
herself to the quiet room. Many times, however,
Jamie went to her mothers classroom down the
hallway instead. She would try to talk with her
mother and often sought reassurance for worries related to her mothers safety and Jamies
own behaviors. At other times, when Jamie was
in a raging tantrum, Jamies mother would be
pulled from her classroom to try to help calm
Jamie down. This was a big problem for Jamies
mother, as it interfered with her ability to teach
her own class. She also reported embarrassment
about not being able to help her daughter in front
of her colleagues. She felt that she knew how to
manage disruptive behavior in her students, but
found it more challenging to apply the same principles with her daughter.
Jamie had become less popular with classmates over the past year because of her bossiness
and the tantrums she had had in front of peers.
She primarily spent time outside of school with
a female cousin of her same age. Jamie did not
display many disruptive behaviors around her
cousin and displayed better play and sharing
skills with her.
Jamie had relevant medical history which may
have influenced her OCD at the time of assessment. About a year prior to the current treatment,
Jamie had suffered from a treatment-resistant urinary tract infection, which had been very painful
for her. Jamies parents had recalled that Jamies
irritability was the primary symptom that had
caused them to investigate her illness. For the
months following treatment of the acute infection, a parent took Jamie to her primary care physician whenever she complained of pain, asked to
go to the doctor, or was more irritable.
Jamie had not ever received cognitive behavioral therapy or psychotherapy/counseling of any
type. She had initially been prescribed stimulant
medication by her pediatrician when she was 5
years old, but was referred for an evaluation by
a board-certified child and adolescent psychiatrist about 3 months prior to seeking behavioral
treatment. When she began behavioral treatment,
Jamie was taking fluoxetine, guanfacine, and aripiprazole. She also took melatonin before bed.
Jamies aggressive and disruptive behaviors
appeared to be a mixture of OCD-driven behavior-avoidant behaviors and disruptive behaviors
independent of anxiety and were conceptualized
through a behavior theory framework. As in typical cases of OCD, compulsive behaviors alleviate anxiety in the short term, but negatively reinforce obsessions and subsequent anxiety over
time. Parental accommodation, like compulsive
behaviors, increases anxiety through negative
reinforcement and made Jamies obsessive and
compulsive behaviors become more impairing at
home and school. For example, when she would
leave the classroom to seek reassurance from her
mother, it did not make her less anxious next time
she had an obsessive thought in class, but made
it even harder to tolerate anxiety without gaining
reassurance from her mother.
When Jamie was escaping from many
demands as parents accommodated OCD symptoms, she learned that she could also gain attention and access to preferred things with these
same disruptive behaviors. Jamies disruptive
and aggressive behaviors generalized to coercive disruptive behaviors that were not directly
related to alleviating anxiety. As in the coercive
process, Jamies parents inconsistent responding and giving in were also negatively reinforced
because it calmed down Jamie or averted disruption. With three other young children in the
home, and high levels of parental stress, parents
were just trying to survive and keep the family
functioning in the short term.
The following assessments were collected

from Jamies mother by a non-treating clinician about 2 weeks prior to beginning treatment.
Jamie was asked to complete self-report assessment measures, but quickly became frustrated
when she circled the wrong answer and then
crumpled them up. When she was later asked to
try again and offered help, Jamie appeared to respond in a rushed and haphazard manner that was
deemed invalid. Therefore, no self-report data
were available.
Symptom Checklist and Childrens YaleBrown
Obsessive-Compulsive Scale (CY-BOCS; Scahill
etal. 1997) The CY-BOCS symptom checklist
is a clinician-administered survey of commonly
endorsed obsessive and compulsive symptoms.
The CY-BOCS severity scale is a ten-item
semi-structured clinician-administered measure
of obsession and compulsion severity over the
previous week. Prior to treatment, Jamie and
her mother were administered the CY-BOCS.
Although Jamie was not compliant with the
interview and screamed much of the session, her
mother was able to provide adequate information
for the rater. She endorsed that Jamie has particularly lucky and unlucky numbers and a related
compulsion of having to complete tasks in sets of
five, repetitive questions and a related obsession
that she would forget things (e.g., Is my birthday
in October? Is my hairbrush in my backpack?),
repetitive writing of mathematics problems and
a related obsession that she might have done it
wrong, lining toys up the right way, not being
able to get rid of toys that she no longer plays
for fear that she might need them, and reassurance seeking that nothing terrible will happen.
Jamies total CY-BOCS score of 29 falls in the
severe range.
Items of Family Accommodation (FA items; Calvocoressi etal. 1999) The FA items are 13 clinician-administered questions that assess the degree
to which family members accommodated the
childs participation in obsessions and compulsions during the previous month. Items endorsed
as occurring daily included reassurance, avoid-
361
ing things that would make Jamie more anxious,

and avoiding going places. Severe disruptions in
the familys routine and extreme distress when
not accommodated were also endorsed. Prior to
beginning treatment, Jamies FA items totaled 34.
Rage Outbursts and Anger Rating Scale
(ROARS; Budman etal. 2008) The ROARS is
a clinician-rated measure of frequency, intensity,
and duration of rage and anger based on all available information. Prior to treatment, Jamies rage
was rated as 7 out of 9, placing her in the severe
range.

Treatment was structured in four phases: (1) parent psychoeducation (sessions 12), (2) skills
acquisition and practice (sessions 37), and (3)
problem-solving parenting skills and conducting
progressively challenging ERP (sessions 814),
and (4) exposure skills generalization and relapse prevention (session 15) conducted over the
course of 8 weeks. Due to the level of impairment
Jamies disruptive behaviors were causing for her
and her family, the first eight sessions were conducted biweekly in order to expedite skills acquisition. The first two sessions were conducted
with Jamies mother alone so that she could be
oriented to the parenting skills and the treatment
goals without having to attend to Jamies needs
in session. All sessions thereafter were conducted
with both Jamie and her mother. While her father
was encouraged to attend all sessions, he was not
able to make it due to his work schedule and their
child care needs. Since both parents could not attend, Jamies mother was encouraged to attend
consistently over the course of treatment and
to relay information and skills to her husband.
Treatment began after Jamie and her mother had
completed assessments and consented to behavioral treatment of OCD and disruptive behavior.
Sessions 1 and 2 (parent only, 90min) During
the first session, the goal was to provide psychoeducation to Jamies mother about the maintaining variables of disruptive behaviors and
362
Table 24.1 Examples of progressively challenging exposures

Difficulty
level
Low
Exposure task
Compulsions to resist
Getting a grade from school

Uncertain if homework is right
Getting a scrape (without blood)
Packing a bag to go to cousins house
Having sister come into room
Asking mom if it is a good grade

Rewriting. Asking mom to check repeatedly
Asking for a Band-Aid. Not asking questions about it
Rechecking. Asking parents to recheck the bag
Checking toys are in the right place. Asking if toys
might have been moved
Asking mom if she might have needed them. Taking
them out of the trash
Rearranging repeatedly. Checking
Checking with mom. Getting reassurance that she is
safe
Talking about injury. Looking up on the computer.
Going to the doctor
Checking. Reassurance seeking/questioning
Throwing away unneeded papers

Having toys in the wrong place in the room
Having an image of getting kidnapped
Thinking that she could be hurt
High
Going to an unfamiliar place with crowds

(mall, theme park)
obsessive/compulsive behaviors in order to provide an underpinning for the various treatment

components. Specifically, it was discussed that
all behaviors generally aim to get something or
to get away from something as a foundation for
differentiating coercive behaviors and anxietydriven behaviors. Jamies mother was provided
with a worksheet on which she would record
Jamie problem behaviors and would begin to
identify the triggers and consequences (i.e.,
antecedents, behaviors, and consequences). This
monitoring worksheet is provided in Table24.1
with examples of behaviors that Jamies mother
recorded over the first several weeks of treatment. The monitoring worksheet would become
a way for Jamies parents to decipher the function of her behaviors and also would help them to
report more accurately on behaviors that occurred
between sessions.
As part of psychoeducation for OCD, negative reinforcement was highlighted as the ways
that compulsive behaviors serve to make obsessions stronger. Later that week in the second session, the role of parental accommodation was
discussed. While parents aim to help their children to escape from or avoid anxiety, parental
accommodation works similarly to a compulsion
to maintain OCD through negative reinforcement. Jamies mother noted that it had been difficult to know when Jamie was having a tantrum
to get something and when she was really scared

or distressed because of OCD. It had not seemed
fair to Jamies parents to punish her if her behaviors were because she was scared and so like most
parents of children with OCD, accommodated Jamies behaviors to avoid Jamies distress and disruption in the family. Jamies mother discussed
an understanding of the exposure principles, but
noted that she was nervous for the aggressive
behavior that Jamie might show if not accommodated. We discussed that exposure would be
introduced gradually with that hope that Jamie
would be able to manage her disruptive behavior and could be rewarded for her successes.
Jamies mother was then asked to brainstorm a
preliminary list of the Jamies obsessions and
compulsions (see Table24.1, e.g., fear hierarchy)
in session to help both demonstrate what exposures would look like and prepare the therapist
for starting exposures with Jamie.
The use of differential attention to shape Jamies behaviors was also introduced in the second session (i.e., positive attention to increase
desirable behaviors and removal of attention to
decrease her undesirable/attention-seeking behaviors). She discussed that she and Jamies father had tried to ignore many of the behaviors, but
worried that they were giving her permission to
act that way by not punishing her, so sometimes
she was sent to her room, and sometimes they
ignored her behavior. The critical role of consistency between parents and over time was emphasized. The therapist then worked with Jamies
mother to determine which behaviors would be
ignored and which would be consequated with
time-out. All annoying, non-dangerous behaviors
(e.g., screeching, arguing with siblings, stomping
her feet) would be completely ignored, as they
were likely attention seeking or attention maintained.
Session 3 (Child and Parent, 60min) The goals
of the third session were to build rapport with
Jamie, to provide Jamie with education about
OCD, to work with Jamie and her mother to complete the hierarchy of fears, and to coach Jamies
mother in practicing the use of positive attention
and planned ignoring. After the therapist introduced herself to Jamie, she discussed the session
rules (i.e., listen, answer questions, and use hands
and feet safelyno hitting, kicking, throwing,
biting). Jamie was pleased to learn that she would
earn a small reward at the end of the session if she
complied with all of the rules. Jamie was briefly
engaged in a discussion about Webkinz toys and
things she likes to do at home. As soon the discussion shifted toward OCD and behaviors that
get her in trouble at home, Jamies affect became
very negative and she disengaged from conversation. When Jamie was introduced to the idea
of facing her fears through exposure and earning
rewards for being brave, she became aggressive,
throwing her shoe at the wall and screaming. This
became a good opportunity to review differential
attention with Jamies mother and to encourage
in-session practice. Jamies mother and the therapist sat silently for about 10minutes until Jamie
stopped screeching. Jamies mother was asked
to complete the monitoring form (Table 24.2)
between sessions and to help Jamie brainstorm
a list of rewards that she could earn at home for
completing ERP tasks.
Session 4 (child and parent, 60min) The goals
of the next session were to problem-solve the use
of positive attention and planned ignoring and to
conduct the first exposure task with a low-level
fear. Jamies mother came into the session con-
363
cerned that Jamie would not be able to handle an

exposure task today because she was already feeling very anxious. Jamie was very upset that she
had earned a C on a reading assignment. Given
that Jamie had not contacted reinforcement (i.e.,
earned a reward) in the last session, and the therapist wanted to reward Jamies engagement in the
session, it was decided with Jamies mother that
they would defer starting exposures until session
5. Jamie was not told this, but was given a lot
of praise and attention for discussing her frustration with her teacher and her disappointment in
earning a C. She was also asked to discuss the
therapy homework that she and her mother had
worked on to create a list of rewards for engaging in exposures at home. This was an important
part of the session because the therapist was able
to discuss exposure concepts with Jamie without
her being aggressive or avoidant. The therapist
encouraged Jamies mother to praise Jamie for
her age-appropriate behaviors (e.g., talking with
the doctor, sharing her ideas about rewards, and
using a soft-speaking voice). Jamie did earn a
nominal reward at the end of the session for complying with all of the session rules.
of session 5 were to provide education to Jamies
mother about giving effective commands and to
conduct the first in-session exposure task with
Jamie. Jamies mother reported that Jamie was
very anxious over the weekend because she
had a school choir performance. When Jamie
was praised for being brave over the weekend
and was asked to discuss how anxious she was
feeling, she refused to speak with the therapist,
and her behavior quickly escalated. She hit her
mother and began screaming No! The therapist
discussed with her mother that this aggressive
behavior appeared to be escape driven, as it effectively diverted all conversation away from talking about anxiety. They would need to develop
alternative methods for assessing anxiety in the
session, as Jamie refused to use a 010 fear thermometer, and this appeared to be a trigger for
disruptive behavior. Jamies mother discussed
that she can tell when Jamie becomes anxious by
364
Table 24.2 Behavior tracking chart example

Setting (A)
The behavior (B)
What did she do?
Day of What was hap(Describe as if paintweek
pening before the
behavior occurred? ing a picture)
Fri.
Jamie stayed after She yelled, Im not
school for a party, hungry! then yelled
and she didnt want that she was hungry,
to get dinner on the but I didnt get her
the right dinner with
way home
the family, and she
didnt want to be
with the family
Arguing, teasing, and
Fri.
Playing with her
upsetting her sister
sister and then
arguing and teasing
her sister
Sat.
Cut her lip on a box Crying, saying it hurt,
asking if it looked
bad and if it would
be okay even after I
looked at it.
Mon.
Getting ready for
Asking if her lip
school
was okay repeatedly.
Tried to show me the
box she cut it on
Mon.
Getting ready to go Screaming and yellto the grocery store ing that she didnt
with kids (dad not want to go
home yet)
Tues.
Sat.
Sat.
Sat.
Consequences of the behavior (C)

How did you
Gained?
respond?
Attention?
Tangible?
Ignored screaming. Attention?
Reminded her of her
reward chart
Pulled sister away

and got them
engaged in another
activity
Gave her an ice
pack. Told her it was
fine. Then ignored
Got out of?

Demands?
Feelings?
10 min.
10min
Attention
from sister.
Control of
the game
Ignored and continued getting ready for

school
Attention
Continued getting
kids in the car. Jamie
followed out to the
car, screamed the
whole way there, but
we just ignored
Ignored her and later
Playing with toys. She threw all the
when she wanted to
I asked her to help clothes down and
play the Wii, I told
me carry her folded knocked over other
her she had to put
laundry to her room folded clothes.
away her clothes
Started yelling
first. She grumbled,
but did it
Ignored her and told
Setting up the
Kept opening the
Christmas tree
branches in a specific sister to ignore her.
Worked on the other
way and yelling at
her sister that she was side of the tree
not opening them
right. Going back
and fixing sisters
branches
Gave wet washcloth Reassurance
Playing with sister Said stomach hurt
and she was going to and ignored
throw up
Already in bed
Came downstairs and Didnt say anything. Reassurance
Handed her a pillow
said she was going
and blanket and said
to throw up and I
good night
needed to take her
to the doctor. Went
and laid on bathroom
floor
Duration
How long
did it last?
20min
Anxiety
about being
hurt
5min
Anxiety
about being
hurt
Avoid
chores
12min
Avoid
chores
10min
Anxiety
25min
30min
Anxiety
about being
sick
Anxiety
about being
sick
her rigid posture and when she is very anxious

the skin on her neck became red. These would be
good behavioral observations to use as an alternative gauge of Jamies anxiety level. The therapist and Jamies mother ignored Jamies screaming. When Jamie threatened to leave the building,
she was calmly told that security would be called
if she left the area. This became a good opportunity to model responding neutrally for Jamies
mother. The therapist also discussed the selective use of commands and picking your battles.
No formalized exposure was conducted during
the session. Jamie did not earn a small prize due
to her aggressive and disruptive behaviors. For
homework, Jamies mother was to continue using
positive reinforcement of desired behaviors,
ignoring non-dangerous behaviors, and using
commands selectively. She and Jamies father
were also focusing on decreasing their involvement in Jamies rituals by responding neutrally
to her distress and praising any attempts at facing
her fears.
Session 6 (Parent, 30min; Parent and Child,
30min) The goals of session 6 were to discuss
the use of a time-out from positive reinforcement
procedure with Jamies mother and to conduct
the first in-session exposure task with Jamie.
Jamies mother noted that Jamie had taken a trip
with her father and her sister over the weekend
and had done many brave things. One example
they relayed was an incident when Jamie ran
ahead and got into an elevator without her father
and the doors closed. Jamie got off at the correct
floor and her father soon followed, but she was
very upset. Jamies father simply told her she did
a good job getting off at the correct floor even
though it must have been scary and then ignored
further reassurance-seeking questions and crying. Jamies mother reported that Jamie has been
responding well to their neutrality, and they
noticed that she was recovering more quickly
from anxiety-provoking situations.
For the first half of the session, Jamies mother
and the therapist met alone while Jamie was in
the waiting room with her grandmother and siblings. The therapist reviewed the concept of time-
365
out from positive reinforcement as removal of

anything interesting or possibly entertaining, as
well as any positive or negative attention. Jamies
mother was able to delineate major rule violations (i.e., biting, hitting, scratching, kicking,
throwing, pushing, pinching, shoving, punching,
or breaking household items). Although the therapist noted the transportability of time-out from
positive reinforcement, they discussed a specific
plan for where and how it would be carried out
in the home. Jamie would sit in the laundry room
and her mother would set the microwave timer to
5min. If Jamie violated any major rules while in
time-out, she would have to start the timer over
again. Jamies mother was in agreement with this
plan and would relay it to Jamies father.
Jamie joined the session for the second half.
She was angry and made threats toward her
mother immediately upon entering the room. At
the prompting of the therapist, Jamies mother
reviewed the household rules and discussed the
general time-out from positive reinforcement
procedure. Shortly after this discussion, Jamie
kicked her mother in the leg and was told that this
was a major rule violation, and she would have
to serve a time-out. Due to the confines of the
therapy setting, there was not an available timeout space, and so Jamies mother left the room as
a time-out. Jamie was supervised neutrally by the
therapist and told that her mother would rejoin
the session when Jamie displayed safe behavior
and had served her time-out without further violations. After about 20min, Jamie showed calm
behavior and her mother was able to rejoin the
session. No formalized exposure was conducted
during this session. For homework, the family
would continue positive reinforcement, planned
ignoring, selective use of commands, and neutral disengagement from OCD. They would also
implement time-out from positive reinforcement
procedures for any major rule violations.
of session 7 were to practice behavior management skills and to conduct an initial in-session
exposure. Parents had been conducting exposures outside of session when they identified the
function of Jamies behavior to be escaping anxi-
366
ety. They responded neutrally when Jamie sought

reassurance which did not allow her to complete
compulsions, and so she had experienced exposure with response prevention. For example,
Jamie had screamed at her parents to check her
backpack to make sure she had her homework in
it, even though she had just put her homework
in her backpack. Jamies mother simply told her
that they were leaving for school and she would
not check her backpack. In typical cases, parents
would be directed to tell children that they would
not help provide reassurance because that would
make OCD stronger. In this case, parents and the
therapist had discovered that mentioning OCD or
anxiety ratings triggered Jamies defiant behaviors, so parents were told to pick their battles and
not to reference OCD directly when disengaging
from rituals.
During the session, Jamies behavior did not
warrant the use of time-out, and parents reported
that they had not used time-out at home because
Jamie had not violated any of the major rules. For
the initial in-session exposure, Jamies mother
suggested that doing tasks not in 5s would
likely be mildly difficult for Jamie and was
something that the family had not been working
on at home. Jamie was asked to try this as a bravery task and would be rewarded with 15minutes
to play on the computer during the second half of
the session while Jamies mother and the therapist
discussed parenting skills. Jamie wrote her name
four times on a piece of paper, took six steps
around the office, and tapped her leg three times.
She was praised for resisting completing rituals.
Jamie stated that this was no big deal and asked if
she could then have computer time. She was told
that she would need to continue not doing things
in 5s in order to keep playing on the computer,
and she agreed to this plan. Jamie appeared to
be embarrassed by the exposure task and wanted
to get through it as quickly as possible without
indicating that it was difficult. Jamies mother
confirmed that this was how she had been while
conducting exposure tasks at home. The family was encouraged to continue exposure with
response prevention at home, providing praise
for Jamie not completing rituals even when she
was dismissive of her efforts.
Session 814 (child and parent, 60min)Once

exposure tasks had begun, and all primary parenting skills were being utilized regularly, the sessions
were able to follow a more consistent pattern. During the first 30minutes of the session, Jamie and
her mother briefly reported on successful exposures since the last session and then engaged in
an exposure with response prevention task (see
Table24.1 for exposures conducted). Jamie was not
questioned about her anxiety level throughout the
exposure, as is typically done in manualized ERP,
but instead Jamies mother gauged when the exposure would be over based on Jamies level of resistance, Jamies attempts to avoid, and her observations of Jamies postural rigidity. If Jamie was able
to engage in the exposure task without any major
rule violations, she was immediately rewarded by
getting to use the computer in the room to play an
online game for the next 15minutes of the session.
If she was not successful, Jamie would leave the
second half of the session to sit in the waiting room
with her grandmother. Jamie enjoyed playing the
video game, and this was a highly motivating
reward for her.
In the second half of the session, Jamies
mother and the therapist discussed any situations
that had arisen since the last session when she
and Jamies father were unsure of how to react
or had trouble using the parent behavior management skills. They then discussed the situation,
and how to respond in the future. Jamies parents
continued completing the behavior-monitoring
form with increasing ability to differentiate the
function of Jamies behaviors and to respond accordingly more consistently.
Session 15 (Child and Parent, 60min)During
the 15th session, after 8 weeks of therapy, Jamie
and her mother met together to review Jamies
progress. Jamie engaged in the session with ageappropriate behaviors and recalled how difficult
it had been when she first came to therapy. They
discussed ways that Jamie has faced her fears
and resisted doing compulsive behaviors and
ways that parents have changed their behavior to
help Jamie. With a focus on relapse prevention,
Jamie was encouraged to brainstorm areas where
she may still feel nervous and ways to face those
367

W
D

zK^
'/^
&
ZKZ^
Fig. 24.1 Pre-, mid-, and posttreatment assessment results. CY-BOCS Childrens YaleBrown Obsessive-Compulsive
Scale, CGI Clinical Global Impression, FA family accommodation, ROARS Rage Outbursts and Anger Rating Scale
fears. They discussed the importance of continued exposure with response prevention in their
day-to-day lives to continue to have success and
maintain treatment gains.
Posttreatment AssessmentVisual comparison
of pretreatment and posttreatment assessment
results are displayed in Fig.24.1. Jamies mother
met with a non-treating clinician for posttreatment assessment within a week of session 15.
Scale (CY-BOCS; Scahill etal. 1997) Based on
Jamies mothers report, Jamies posttreatment
CY-BOCS total score was rated as 13. This falls
below a commonly used clinical cutoff of 16,
placing Jamies OCD in the subclinical range
post treatment. This is a clinically significant
reduction from her pretreatment rating of 29, in
the severe range.
Items of Family Accommodation (Calvocoressi
etal. 1999) Jamies mother also reported a clinically significant reduction in accommodation of
OCD symptoms with a total posttreatment score
of 18, down from 39 pretreatment. She indicated
that in the past month, she has never avoided
doing things, going places, or being with people
because of Jamies OCD. The family no longer

modified their routines based on Jamies OCD.
She reported that Jamie still became moderately anxious and moderately angry/abusive
when her mother did not accommodate OCD
symptoms.
Rage Outbursts and Anger Rating Scale (ROARS;
Budman etal. 2008) Based on the report of
Jamies mother, Jamies ROARS total score was
rated as 4 out of 9 (in the moderate range) post
-treatment, a significant reduction from 7 (in the
severe range) pretreatment.
When working with children with disruptive behavior and OCD, there often is a difference between the a priori session goals and what is actually accomplished in the session (see Table24.3).
The diligently evidence-based therapists may
worry that they are veering off-track if they do
not complete an exposure task in session when
treating a child with OCD. This case illustrates
the need for therapist flexibility for in-the-moment decision making. In Jamies treatment,
exposures were intended to begin in the second
368
Table 24.3 Session goals targeting disruptive behavior disorder (DBD) and obsessive-compulsive disorder (OCD)
and goal attainment
Session
Targeting DBD
Targeting OCD
1
Education: disruptive behavior
Education: OCD
Education: functional assessment
Education: exposure with response prevention

(ERP)
2
Education: differential attention
Education: parental accommodation
Hierarchy development
3
Modeling differential attention
Child education: ERP
Child education: fear thermometer
Hierarchy development
4
Parent practice differential attention
Conduct ERP
5
Education: antecedent control (i.e., effective
Conduct ERP
commands)
6
Education: time-out from positive reinforcement

Conduct ERP
+Modeling time-out in session
7
Parent practice time-out in session
Conduct ERP
814
Problem solve implementation of parenting skills

Progressively more challenging ERP
15
Review and discuss generalization
Review and discuss generalization
Indicates that the goal was attained in session
Indicates that the goal was not attained

+Indicates an unplanned, but attained session component
child session (i.e., fourth session overall), but due

to her disruptive behaviors in session, exposures
did not start until the fifth child session (i.e., seventh session overall). The therapist had intended
to treat OCD and disruptive behavior concurrently, but this case called for the incorporation of
PMT strategies before Jamie was able to engage
successfully in ERP. By maintaining focus on
the case conceptualization of disruptive behavior
as being related to, but sometime above-and-beyond OCD symptoms, the therapist was able to
utilize evidence-based principles to move toward
therapeutic goals.
Implementing evidence-based treatment was
further complicated by Jamies noncompliance
with assessment techniques prior to, during, and
following treatment. Child self-report assessment
measures were attempted before starting treatment, mid-treatment, and following treatment,
but Jamie refused to discuss her anxiety or would
become disruptive and aggressive when her
mother discussed her OCD around her. Jamie was
noncompliant completing these forms, and thus
psychometric self-report data were not collected.
When it came to treatment, her noncompliance
with assessment and avoidance of OCD discus-
sion continued to be a challenge. For the first several sessions, Jamie became aggressive when the
therapist attempted to have her rate her anxiety
or discuss a fear thermometer. The therapist had
to judge whether changing assessment modalities would be accommodating OCD and therefore
worsen it over time, or if this was an example of a
specific behavior to accommodate for the greater
good of allowing treatment to progress. The therapist was able to use hierarchy information gained
from Jamies mother to begin exposures and used
observations of Jamies behavior to guide when
the exposure could be finished.

The present case demonstrates the integration of
parent management strategies into ERP for a child
with comorbid OCD and disruptive behavior.
Given the association between disruptive behavior,
more severe OCD and poorer outcome, it is essential that therapists identify and treat these symptoms. Identification begins with separating disruptive behavior from OCD. Parents and clinicians
will often be more tolerant of anger outbursts and
369

Recognize that disruptive behaviors often interfere with treatment and need to be addressed directly
Extinguishing disruptive behavior primarily involves working directly with the parents to implement behavioral
principles (differential attention, reinforcement, aversive consequences)
Disruptive behavior that interferes with the familys ability to engage in ERP in session or at home needs to be
addressed first with parent management strategies
ERP should be implemented as soon as the child will cooperate enough to earn attention/reinforcement or avoid
consequences
The ordering and balancing of ERP and behavior modification requires flexibility by the therapist
ERP exposure and response prevention
defiance in response to fear-provoking situations

than they would be to more standard misbehavior,
such as tantrums when told to turn off the television. This is especially true with children who
have been generally compliant prior to the onset
of OCD. Unfortunately, this well-intentioned accommodation can maintain, if not worsen, OCD
and disruptive behavior. The therapist must often
begin by educating the parent and then the child
that, while it is understandable to feel angry and
frustrated by OCD fears, it is not acceptable to
express those feelings through yelling, swearing,
hitting, or kicking. These types of behaviors are
dangerous and will not be tolerated by society in
the long term, regardless of their function.
Once the therapist and parent have decided
that disruptive behaviors need to be addressed
(children rarely agree at this stage), it is important
for the therapist to recognize that this intervention
primarily involves working with the parent(s).
Attempts to work individually with the child to
develop insight into his reactions, develop anger
management skills, or to release frustration in the
session are unlikely to be as effective as PMT.
The degree to which the child is involved during
this stage depends on the parents level of comfort
and the childs degree of cooperation during the
session. Specifically, if the parent is unsure about
the appropriateness of behavioral measures, such
as removing attention, the therapist will need the
freedom to explore and address these concerns
outside of the childs presence. However, once
the parent and therapist are in agreement, and if
the child is reasonably cooperative during sessions, the therapist can work with them conjointly
to implement and revise the behavioral plans, as
was demonstrated in the current case.
Balancing and ordering parent management

strategies and ERP can also be a challenge. Milder tantrums and emotional outbursts can often be
ignored if parents are able to manage the behavior and the symptoms do not interfere with treatment. In these cases, ERP can be implemented
immediately with the assumption that the outbursts will improve with relief from obsessions
and compulsions (as in Ale and Krackow 2011).
When disruptive behavior prevents implementation of ERP at home or in session these symptoms
must be managed first (as in Lehmkuhl etal.
2009). Because ERP will most likely be needed
to reduce the OCD symptoms, the goal should
be to implement this intervention as soon as possible. As such, in the case example, the therapist
intended to begin ERP in session, but decided to
delay exposure until the patient displayed a basic
level of cooperation (Table 24.4).
In conclusion, it is important for clinicians to
recognize disruptive behavior as symptoms separate from OCD that need to be addressed directly.
Moreover, whereas ERP involves direct work
with the patients, increasing cooperation and
decreasing anger outburst necessitates working
primarily with parents. Recognizing these factors will help therapists have more success with a
challenging population.
References
Ale, C. M., & Krackow, E. (2011). Concurrent treatment
of early childhood OCD and ODD: A case illustration.
Clinical Case Studies, 10, 312323.
Budman, C., Coffey B. J., Shechter, R., Schrock, M.,
Wieland, N., Spirgel, A., & Simon, E. (2008). Aripiprazole in children and adolescents with tourette disorder
with and without explosive outbursts. Journal of Child
& Adolescent Psychopharmacology, 18, 509515.
370
Calvocoressi, L., Mazure, C. M., Kasl, S. V., Skolnick, J.,
Risk, D., Vegso, S. J., etal. (1999). Family accommodation of obsessive-compulsive symptoms: Instrument
development and assessment of family behavior. The
Journal of Nervous & Mental Disease, 187, 636642.
Chorpita, B. F., Daleiden, E. L., Ebesutani, C., Young,
J., Becker, K. D., Nakamura, B. J., etal. (2011). Evidence-based treatments for children and adolescents:
An updated review of indicators of efficacy and effectiveness. Clinical Psychology Science and Practice,
18, 154172.
Freeman, J. B., Garcia, A. M., Coyne, L., Ale, C. M.,
Przeworski, A., etal. (2008). Early childhood OCD:
Preliminary findings from a family-based cognitivebehavioral approach. Journal of the American Academy of Child & Adolescent Psychiatry, 47, 593602.
C., Ogata, A. K., Ng, J., etal. (2008). Phenomenology of early childhood obsessive compulsive disorder.
Journal of Psychopathology and Behavioral Assessment, 31, 104111.
the pediatric obsessive compulsive treatment study
& Adolescent Psychiatry, 49, 10241033.
Geller, D. A., Biederman, J., Griffin, S., Jones, J., &
Lefkowitz, T. R. (1996). Comorbidity of juvenile
obsessive-compulsive disorder with disruptive behavior disorders. Journal of the American Academy of
Child and Adolescent Psychiatry, 35, 16371646.
Ivarsson, T., Melin, K., & Wallin, L. (2008). Categorical
and dimensional aspects of co-morbidity in obsessivecompulsive disorder (OCD). European Child & Adolescent Psychiatry, 17, 2031.
Krebs, G., Bolhuis, K., Heyman, I., Mataix-Cols, D.,
Turner, C., & Stringaris, A. (2013). Temper outbursts
in paediatric obsessive-compulsie disorder and their
association with depressed mood and treatment outcome. Journal of Child Psychology and Psychiatry,
54, 313322.
Lebowitz, E. R., Omer, H., & Leckman, J. F. (2011).
Coercive and disruptive behaviors in pediatric obsessive-compulsive disorder. Depression and Anxiety, 28,
899905.
Lebowitz, E. R., Storch, E. A., MacLeod, J., & Leckman,
J. F. (2014). Clinical and family correlates of coercivedisruptive behavior in children and adolescents with
obsessive-compulsive disorder. Journal of Child and
Family Studies. doi:10.107/s10826-014-0061-y.
Lehmkuhl, H. D., Storch, E. A., Rahman, O., Freeman,
J. B., Geffken, G. R., & Murphy, T. K. (2009). Just
say no: Sequential parent management training and
cognitive-behavioral therapy for a child with comorbid disruptive behavior and obsessive compulsive disorder. Clinical Case Studies, 8, 4858.

Masi, G., Millepiedi, S., Mucci, M., Bertini, N., Milantoni,
L., & Arcangeli, F. (2005). A natuaralistic study of
referred children and adolescents with obsessive-compulsive disorder. Journal of the American Academy of
Child & Adolescent Psychiatry, 44, 673681.
Nadeau, J. M., Lewin, A. B., Arnold, E. B., Crawford,
E. A., Murphy, T. K., & Storch, E. A. (2013). Clinical correlates of functional impairment in children
and adolescents with obsessive-compulsive disorder.
Journal of Obsessive Compulsive and Related Disorders, 2, 432436.
Owens, E. B., & Piacentini, J. (1998). Case study: Behavioral treatment of obsessive compulsive disorder in
a boy with comorbid disruptive behavior problems.
Journal of the American Academy of Child & Adolescent Psychiatry, 37, 443446.
Patterson, G. R. (1982). Coercive family process. Eugene:
Castalia.
Patterson, G. R., Reid, J. B., & Dishion, T. J. (1992). Antisocial boys. Eugene: Castalia.
Scahill, L., Riddle, M. A., McSwiggan-Hardin, M., Ort,
S. I., King, R. A., Goodman, W. K., etal. (1997). Childrens Yale-Brown obsessivecompulsive scale: Reliability and validity. Journal of the American Academy
Duke, D., Munson, M., etal. (2007). Family-based
cogntive-behavioral therapy for pediatric obsessivecompulsive disorder: Comparison of intensive and
weekly appraoches. Journal of the American Academy
Storch, E. A., Merlo, L. J., Larson, M. J., Geffken, G. R.,
Lehmkuhl, H. D., Jacob, M. L., etal. (2008). Impact of
comorbidity on cognitive-behavioral therapy response
in pediatric obsessive-compulsive disorder. Journal of
the American Academy of Child and Adolescent Psychiatry, 47, 583592.
Storch, E. A., Lewin, A. B., Geffken, G. R., Morgan,
J. R., & Murphy, T. K. (2010). The role of comorbid disruptive behavior in the clinical expression of
pediatric obsessive-compulsive disorder. Behaviour
Storch, E. A., Jones, A., Lack, C., Ale, C. M., Sulkowski,
M., Lewin, A. B., & Murphy, T. K. (2012). Rage
attacks in pediatric obsessive-compulsive disorder:
Phenomenology and clinical correlates. Journal of the
51, 582592.
Whiteside, S. P. H., McKay, D., De Nadai, A. S., Tiede,
M. S., Ale, C. M., Storch, E. A. (2014). A baseline controlled examination of a 5-day intensive treatment for
pediatric obsessive-compulsive disorder. Psychiatry
Research, 220, 441446..
Depression and ObsessiveCompulsive Disorder
25
Ryan J. Jacoby and Jonathan S. Abramowitz

Depression is a psychological state characterized
by a chronically sad mood (e.g., feeling empty
or hopeless) that is often associated with anhedoniathe diminished capacity to experience
pleasure or interest in activities that are typically
enjoyed. The following signs and symptoms may
also be present: reduced or increased appetite
leading to weight loss or weight gain, insomnia
or hypersomnia, psychomotor agitation or retardation, fatigue, feelings of guilt, crying, diminished concentration, and recurrent thoughts of
death. Although depression is observed within
the context of many psychological syndromes, as
well as in nonclinical individuals, a person meets
criteria for a major depressive episode if the
aforementioned symptoms persist for at least a
2-week period and interfere with daily functioning (American Psychiatric Association (APA)
2013). Major depressive disorder (MDD) is defined by the occurrence of one or more major depressive episodes at any point during the lifetime
(APA 2013). Dysthymia, a similarly chronic form
of depression, involves a generally depressed
mood and reduced interest for 2 years or more,
but does not grossly disable the persons daily
functioning (APA 2013).
J.S.Abramowitz() R.J.Jacoby
Department of Psychology, UNC-Chapel Hill, Campus
Box 3270 (Davie Hall), Chapel Hill, NC 27599, USA
e-mail: jabramowitz@unc.edu
Depressive symptoms are often observed in

individuals with obsessive-compulsive disorder
(OCD), which is not surprising given that a
main symptom of OCD is obsessional anxiety,
and anxiety is the single best predictor of the
development of clinically severe depressive
symptoms (Hranov 2007). Depression also ranks
as the most commonly co-occurring problem
among anxiety diagnoses (Kessler et al. 1998),
affecting up to 90% of people with anxiety
disorders (Gorman 1996). Table 25.1 lists the
rates of MDD among adult OCD samples in extant
studies. Across seven countries, the lifetime
prevalence ranged from 12.4 to 60.3%. In the
USA, researchers found a lifetime comorbidity
rate of 54.1% and a concurrent comorbidity
rate of 36% (e.g., Nestadt etal. 2001). Clinical
observations, and studies on the temporal nature
of this comorbidity pattern, suggest that in most
(but not all) instances, OCD symptoms predate
the depressive symptoms (Bellodi etal. 1992;
Demal etal. 1993). This suggests that the mood
disturbance often occurs as a response to the
distress and functional impairment associated
with obsessions and compulsions.
Individuals with OCD and depression also
show an earlier age of OCD onset and more
severe symptoms as compared to nondepressed
OCD sufferers (e.g., Abramowitz etal. 2007).
Depressive symptoms are also more strongly
associated with the severity of obsessions than
with compulsions (Ricciardi and McNally 1995)
and may be specifically associated with sexual
and religious obsessions (Hasler etal. 2005).

DOI 10.1007/978-3-319-17139-5_25
371
372
Table 25.1 Rates of lifetime major depressive disorder
in samples of adult OCD patients
Study
DSM
% comorbidity
N
IV
87
24
Antony etal.
(1998)
Yaryura-Tobias III-R
391
29
etal. (1996)
Crino and
III-R
108
50
Andrews (1996)
Ricciardi and
III-R
125
21
McNally (1995)
Andrews etal.
IV
641
17
(2002)
IV
80
54
Nestadt etal.
(2001)
12
33
Sanderson etal. III-R
(1990)
Finally, relative to nondepressed OCD patients,

those with depression tend to believe more
strongly that their intrusive obsessional thoughts
are significant and meaningful (Abramowitz
etal. 2007).
Treatment Outcome
The most effective psychological treatment for
OCD is cognitive-behavioral therapy (CBT)
incorporating psychoeducation, exposure and
response prevention (ERP), and cognitive techniques (e.g., Abramowitz 2006; Abramowitz
etal. 2011). On average, CBT results in a 5070%
reduction in OCD symptoms. The most effective
pharmacological treatments for OCD are the
serotonin reuptake inhibitor (SRI) medications
(e.g., fluvoxamine), which also happen to be antidepressants (Abramowitz 2006). These medications, on average, result in a 2040% OCD
symptom reduction. Cognitive-behavioral treatment, in particular, requires considerable effort
on the part of the patient, including deliberately
confronting ones fears without attempting
to control or reduce the distress using rituals
or avoidance behaviors. Individuals suffering
with depression, however, might lack the willpower to complete such challenging work and
fall prey to dysfunctional self-defeating beliefs
(e.g., I dont deserve to get better). Indeed,
the cognitive, physiological, behavioral, and
R. J. Jacoby and J. S. Abramowitz
affective symptoms of depression can interfere

with the effects of this treatment.
In addition to reducing OCD symptoms,
CBT and SRIs are associated with improvement in depressive symptoms, yielding large
pre- to posttreatment effects (e.g., Eddy etal.
2004). Two studies with OCD patients receiving CBT (primarily involving ERP) have examined the effects of comorbid MDD on treatment
response (Abramowitz and Foa 2000; Steketee
etal. 2001). In both studies, OCD symptoms
improved, yet the presence of MDD predicted
poorer outcome. Although clinical observations
suggest that depressed OCD patients require
higher doses of SRIs than do nondepressed OCD
patients, empirical findings demonstrating an
attenuated response to pharmacotherapy among
comorbid patients are lacking (e.g., Fineberg and
Craig 2010).
A number of factors might contribute to
the attenuating effects of depression on OCD
treatment (for a review, see Keeley etal. 2008).
For example, depressed individuals can show
decreased compliance with ERP instructions
if they perceive themselves as more helpless
(Seligman 1975) and less deserving of a
happy life, or if they hold low expectations of
improvement (Bandura 1977). Psychomotor
retardation can also attenuate their ability to do
the work required to improve with ERP. With
respect to medication, depressed patients have
reduced hope and optimism, thereby depleting
medications of their nonspecific (i.e., placebo)
effects. They might also attribute any treatment
gains to external or circumstantial sources, and
therefore evidence less improvement and more
relapses than nondepressed patients.
A Case Example: Jennifer

Jennifer, a 32-year-old married woman, experienced an exacerbation of OCD and depressive
symptoms during the 6 months following the birth
of her first child, Jordan. During the later stages
of pregnancy, she began experiencing frequent
worries about whether Jordan would be born
healthy. Although her doctors had absolutely no
25 Treatment of Comorbid Depression and Obsessive-Compulsive Disorder
concerns about the pregnancy, Jennifer remained

concerned that the baby would be born with
complicationsalthough she could not articulate
exactly about what she was particularly worried.
Shortly after giving birth to Jordan (a routine and
healthy labor and delivery), however, Jennifer
began having unwanted thoughts that her newborn would succumb to sudden infant death syndrome (SIDS). As a result, she began routinely
checking his crib and insisting that her husband,
Jack, do the same. These thoughts and checking
behaviors intensified for Jennifer over the next
few weeks. When Jordan was 2 months old, she
decided that the baby monitor she had been using
was not safe enough, and so she began sleeping in Jordans room just in case there was an
emergency. Jennifer and Jack disagreed about
this arrangement, and Jennifers concerns for
Jordans safety in general; Jack felt that Jennifer
was going too far. This led to frequent arguments
and relationship distress. Nevertheless, at other
times, Jack provided Jennifer with reassurance
that her fears were unfounded. He did not think
it was good for Jennifer to feel so anxious all the
time, and he did what he could to keep her calm.
At 4 months postpartum, Jennifer began to
experience other sorts of distressing thoughts,
such as images of deliberately harming Jordan
by throwing him down the steps and smothering
him with a pillow. Jack would reassure Jennifer
that she would never act on those thoughts, but
after weeks of having to give frequent reassurance, he began to lose patience and spent more
and more time away from home. Jennifer, on the
other hand, took these thoughts seriously and
began wondering whether she was fit to be a
mother. This led her to the use of distraction and
thought suppression attempts in order to control
the unwanted thoughts. She also began avoiding Jordan as much as possible, which resulted
in frequent conflicts over childcare. Jennifer was
experiencing periods of depressed mood and reduced appetite. By 6 months postpartum, Jennifer was engaging in frequent checking of parenting books, the Internet, and with friends who also
have babies in order to get assurance that she was
not the kind of person who would harm her
child. The thoughts about harm befalling Jordan
373
were almost constant, and Jennifers mood was

typically low. She worried whether she was developing schizophrenia (thinking that these unwanted thoughts might be signs of a psychotic
break and that she was delusional), and now
she spent more and more time sleeping. She also
derived less and less enjoyment from activities
and people she typically liked. At this point, and
following discussions with Jack and other family members and friends, Jennifer agreed to come
to our anxiety disorders clinic for an evaluation.
Although she realized that she needed help, she
had been afraid to tell any professionals about
her thoughts of harming Jordan until now because she was afraid that doctors would have her
committed for these obsessional infanticidal
thoughts.
Case Formulation
An initial unstructured interview in our clinic revealed that Jennifer had grown up in a small suburb in the southeast with her two brothers (Paul
and Greg who were 2 and 4 years older than Jennifer, respectively) and her parents (who were
married and both still living at the time she came
to treatment). Although she experienced some
sibling conflict growing up (as the youngest,
Jennifers older brothers used to tease her), overall her family was relatively close and enjoyed
family dinners, attending church on Sunday as
a family, and the occasional family vacation.
Since her middle brother, Paul, was frequently
getting in trouble at school, Jennifer tended to
follow the rules, was a fairly conscientious student and daughter, and was rarely reprimanded
as a child. Although she saw her family members
less frequently in adulthood, Jennifer spoke with
her mother frequently by phone, and the family
continued to see one another for holidays a few
times a year. Other than an uncle who had struggled with alcohol use problems (her mothers
brother), there was no history of mental health
problems in Jennifers family that she was aware
of. Her mother was diagnosed with breast cancer when Jennifer was 18, which she described
as a difficult time, but one that united the family
374
together in support of her mother (whose cancer

had been in full remission for 3 years).
Jennifer excelled academically, graduating
from a small liberal arts college with honors,
receiving her masters in education, and then
teaching for 6 years at an elite private high school
(before taking a leave of absence from her job
in order to raise Jordan). She had never had difficulties making or maintaining friendships and
had several close female friends from both high
school and college whom she kept in touch with
regularly. She had few romantic relationships before she met Jack in college and described their
connection as being immediate and intense.
They dated for 6 months before Jack proposed,
and Jennifer described the first few years of their
relationship and marriage as being the happiest
of her life. Although Jennifer had always been
concerned about safety (e.g., checking the lock
on the door three or four times before leaving
the house for fear that she would be responsible
for a break-in), Jack found this cautious aspect
of Jennifer endearing and saw it as a sign of her
strong morals and that she cared about others.
Every now and then, these behaviors would interfere with their plans (e.g., making them late to
meet friends for dinner so that they could return
home to check that the stove was turned off), but
these times were relatively infrequent and only
led to minor disagreements. Once or twice, Jack
questioned Jennifer about her anxiety; she simply
said that she felt she had to go back and check
otherwise the doubts left her feeling very anxious
and unable to proceed.
Jennifer had some difficulties sleeping (waking up in the middle of the night and having trouble falling back to sleep) and took nonsteroidal
anti-inflammatory agents approximately once
every 3 months for migraines. She denied use of
any tobacco products, caffeine, or recreational
drugs and reported drinking approximately 12
glasses of wine per week. In her freshman year
of college, Jennifer attended five supportive psychotherapy sessions through her campus health
services for difficulties adjusting to college. She
described that during this time, she felt guilty for
no reason, was crying all the time, and felt worthless. She also worried that the friends she was
making in college were not really her friends and

were just tolerating her. The psychologist at
campus health referred Jennifer to a psychiatrist
in the practice who prescribed an SRI to treat her
depressive symptoms, but Jennifer experienced
intolerable adverse effects (e.g., hypersomnia,
weight gain) and discontinued this medication
after a few weeks. After two additional failed trials of SRIs, Jennifer decided not to try any more
medications. Although she had found the supportive therapy sessions with the counselor helpful, she also ended up discontinuing these after a
few sessions when her mood improved. Jennifer
denied any history of physical or sexual abuse
and any suicidal ideation.
Assessment and Case

Conceptualization
Jennifers therapist at our clinic recognized her
symptoms as OCD and administered the Yale
Brown Obsessive-Compulsive Scale (YBOCS;
Goodman etal. 1989a, b) symptom checklist to
thoroughly assess the breadth of her symptoms.
Jennifer endorsed unwanted aggressive thoughts
as her primary obsessional theme. Her thoughts
of impulsively harming Jordan and of accidents
befalling him were the main obsessions. Compulsive rituals included checking, reassurance
seeking, and mental neutralizing in the form of
thought suppression attempts. These symptoms
were then rated on the YBOCS severity scale;
Jennifers score was 27, indicating fairly severe
symptoms. These results were consistent with
Jennifers responses on the Dimensional Obsessive-Compulsive Scale (DOCS; Abramowitz
etal. 2010), a self-report measure of the main
domains of OCD symptoms. Jennifer showed elevated scores on the unacceptable thoughts and
responsibility for harm, but not the contamination or symmetry, subscales. The Brown Assessment of Beliefs Scale (BABS; Eisen etal. 1998)
was also administered to assess Jennifers recognition of the senselessness of her obsessional
fears. Her score was 12, indicating fair insight.
Finally, Jennifer completed the Beck Depression
Inventory (BDI; Beck etal. 1996) with a score of
28, confirming the presence of clinically severe

depressive symptoms as Jennifer had also indicated during the initial interview.
The interview confirmed that Jennifers depression was triggered in part by the obsessional
thoughts themselves. Specifically, she believed
her thoughts indicated a deep seated, perhaps
unconscious, intent to harm her child. When her
thought suppression attempts failed, she mistook
this to suggest that she was really losing her
mind. During a period in life that she had expected to be joyous and exciting, here she was
experiencing uncontrollable thoughts about the
worst possible things. Jennifer also felt depressed
over the problems with her marriage and family. She and Jack argued often, and Jennifer felt
hopeless about things getting better.
This information collected, Jennifers therapist conceptualized Jennifers OCD symptoms as
the primary problem, with depression as secondary yet as contributing to the maintenance of the
obsessions. The standard cognitive-behavioral
models of OCD and depression were used to
understand these symptoms. According to this
model (e.g., Rachman 1998), Jennifers obsessions began as normally occurring personally
relevant unpleasant thoughts and images (e.g.,
about harm befalling her infant) that she erroneously interpreted as threatening based on beliefs
about the importance of thoughts and need for
certainty (e.g., Thinking about being violent will
lead to violence). Jennifers misinterpretations
led to anxiety and fear, which she attempts to reduce or control by avoiding obsessional triggers
(e.g., Jordan) and engaging in compulsive rituals
(e.g., checking and reassurance-seeking). Such
rituals are negatively reinforced by the reduction
in distress they engender and thus develop into
strong habits. Yet, rituals and avoidance also call
additional attention to the obsessions they are
performed in response to, and thus, along with
attempts to suppress intrusions, invariably increase the frequency and salience of obsessional
thoughts for Jennifer.
According to Becks (1976) cognitive model
of depression, low mood arises from overly negative beliefs about oneself, the world, and the future. Jennifers depression was conceptualized as
375
resulting from her negative self-relevant beliefs

about her obsessive thoughts (e.g., Only bad
people have bad thoughts) as well as the hopelessness that resulted from her thought suppression failures (e.g., Even when I try to stop the
thoughts, they keep coming back; therefore, I
must really be an awful person). Jennifers relationship distress and the realization that she was
not able to care for her baby in a healthy way also
contributed to her depressive symptoms. As research indicates that negative mood states trigger
negative intrusive thoughts, Jennifers depressive
symptoms were conceptualized as contributing to
her obsessional symptoms, thus completing another vicious cycle.
Relationship stress and conflict also play
an important role in the maintenance of OCD.
Couples in which one partner suffers with anxiety-related problems such as OCD often report
interdependency, unassertiveness, and avoidant
communication patterns that foster stress and
conflict (Marcaurelle etal. 2005; McCarthy and
Shean 1996). In all likelihood, OCD symptoms
and relationship distress influence each other,
rather than one exclusively leading to the other.
For example, Jennifers avoidance behavior, excessive checking, and reassurance seeking lead
to frequent disagreements and relationship conflict with Jack; this conflict and distress likely
contribute to anxiety and uncertainty that exacerbate Jennifers obsessional thinking. Particular aspects of a distressed relationship that
might contribute to OCD maintenance include
poor problem-solving skills, hostility, and criticism (Marcaurelle etal. 2005). Moreover, such
communication patterns are associated with premature treatment discontinuation and symptom
relapse (Chambless and Steketee 1999; Craske
etal. 1989; Steketee 1993).
Treatment Rationale and Course

of Treatment
Despite the well-established effectiveness of
exposure-based CBT for OCD as described earlier in this chapter and elsewhere in this volume,
treatment manuals have not routinely addressed
376
the comorbid depressive symptoms with which

Jennifer presented (and which are present in
many patients seeking treatment for OCD), despite the fact that depression can attenuate the effects of CBT. Thus, in deciding on an approach
that was likely to be helpful, Jennifers therapist
considered the following possibilities, as well as
their empirical support.
Combining Antidepressant Medication

with CBT
Antidepressant medications, such as the SRIs,
are the most widely used treatments for both
depression and OCD-related disorders (e.g.,
Schatzberg and Nemeroff 2009). Thus, the use
of these agents was one consideration for Jennifer. Very few studies, however, have addressed
whether antidepressants offer an advantage over
CBT, specifically for comorbid samples; the existing studies have numerous methodological
difficulties that limit the conclusions that can be
drawn. In one study, Marks etal. (1980) found
that clomipramine (CMI) helped severe depression and OCD symptoms more than did placebo.
However, the comparison included only five patients on CMI and five on placebo, and analyses
were conducted at the 4-week point in treatment,
which may not have been enough time for CMI to
yield full benefit in all patients. Foa etal. (1992)
examined whether using imipramine (IMI) prior
to CBT would facilitate improvement in OCD
symptoms once CBT began. They gave depressed OCD patients either pill placebo or IMI
for 6 weeks prior to CBT, finding that although
IMI improved depressive symptoms, it did not
potentiate the effects of CBT on OCD symptoms.
Abramowitz etal. (2000) compared severely depressed OCD patients who either were or were
not using SRI medications during CBT and found
no differences between groups, although the
sample size of the severely depressed group in
that study (n=11) was small. Thus, there is little
compelling evidence that medication would potentiate the effects of CBT for Jennifer. Another
concern the therapist considered was that, like

many patients with OCD, Jennifer has previously
tried multiple SRIs and had experienced side effects and little clinical benefit. Thus, the therapist
decided not to refer Jennifer for medication in an
attempt to augment CBT and discussed this decision with Jennifer.
Adding Cognitive Therapy

for Depression
Research suggests that cognitive therapy (CT)
could be a useful intervention for Jennifer since
it can be effective for both OCD (Wilhelm and
Steketee 2006) and depression (Beck and Beck
2011). In addressing Jennifers depressive symptoms, CT would involve learning to identify and
challenge cognitive distortions (e.g., I am a terrible mother) and overly negative and biased
interpretations of events (e.g., I will never get
better) that give rise to depressed mood, hopelessness, and helplessness. It would also include
behavioral activation in which Jennifer would be
helped to increase her engagement with people
and activities she typically enjoys.
Another reason Jennifers therapist considered
CT was that the conceptual approach and procedures of CT for depression and OCD are largely
similar (e.g., identifying and challenging maladaptive cognitions)although the content of
the dysfunctional beliefs that are targeted is different. For example, to address OCD symptoms,
Jennifer would use CT to modify dysfunctional
beliefs about the threatening effects of intrusive
thoughts. Thus, she could learn to make use of
the same general skills to reduce both OCD and
depressive symptoms.
Accordingly, Jennifers therapist decided
to use CT to address Jennifers depressive
symptoms prior to beginning exposure techniques for OCD. It was hoped that this approach
would help increase Jennifers mood and compliance with the more challenging exposure therapy
assignments.
Addressing Interpersonal Aspects

of OCD
Given the interpersonal nature of Jennifers difficulties with OCDshe and Jack often argued,
yet at other times, Jack provided reassurance and
helped Jennifer to avoid obsessional triggersit
was decided to include Jack in parts of treatment.
Abramowitz etal. (2013) have outlined a couplebased CBT program for OCD that addresses both
interpersonal conflict and symptom accommodation in the context of exposure-based treatment of
OCD. Specifically, it would be important for Jack
to understand the general conceptual model of
OCD and rationale for CBT to reduce his resentment and criticism of his wifes symptoms, and
increase his hopefulness for treatment responsiveness. This would also help Jack understand
that it is important for Jennifer to learn how to
tolerate obsessional thoughts and anxiety, rather
than escape from it. The therapist could also help
Jennifer and Jack to change interaction patterns
that maintain OCD (and depressive) symptoms,
for example, by learning healthier ways of communicating about OCD and depression and by
building CBT interventions into their everyday
life and functioning as a couple.
During the initial interview, the therapist
briefly explained what the treatment program
would entail, answered questions that Jennifer
had, and scheduled 16 weekly sessions (a subset
of which Jack was scheduled to attend). The content of these sessions is described in the remainder of this section.
Course of Treatment
Behavioral Assessment During the first therapy
session, Jennifers therapist assessed Jennifers
intrusive thoughts, inquiring about (a) the content
of the thoughts and stimuli that trigger them, (b)
her interpretations of the unwanted thoughts, and
(c) her responses to them. Jennifer worried that
the presence of her obsessional thoughts (as described above, e.g., accidental or deliberate harm
befalling Jordan) meant that unconsciously she
wanted horrible things to happen to Jordan. She
377
was also afraid that merely thinking about committing heinous acts made it more likely that she
would actually commit them; thus, she worked
hard to avoid or suppress such thoughts. Jennifer
had come to view herself as unfit to be a parent
and perhaps evil at heart. Although at times she
was able to recognize the senselessness of her
fears, Jennifer had trouble with the possibility
that, if left alone with her infant she could, act on
these thoughts. She believed she had to take precautions, such as having others nearby to stop her
if she lost control. When the obsessional thoughts
came to mind, Jennifer would let Jack know what
was going through her mind and ask him to reassure her that she was not going crazy, developing
schizophrenia, or that she was not going to do
anything terrible. Sometimes she would have to
leave the house to try to clear her mind, leaving
Jack to care for Jordan. At other times, Jennifer
would check medical references for information
about schizophrenia to reassure herself that she
did not have this condition.
Psychoeducation and Discussion of Treatment
Goals Jack was invited to attend the second session, which began with the therapist normalizing
the experience of intrusive negative thoughts by
teaching the couple that practically everyone
from time to time experiences ideas, images, or
impulses that are upsetting or inconsistent with
their personality. The therapist even gave examples of her own unwanted thoughts. Jennifer had
never considered that others had similar experiences and was somewhat relieved to receive this
education. She also learned that it was her mistaken appraisals of these thoughts as personally
significant, dangerous, and as needing to be controlled that were the real problem. Jennifer and
Jack understood that trying to control or suppress
obsessional thoughts, uncertainty, and anxiety
was actually contributing to Jennifers preoccupation and was giving the obsessions a life of
their own.
The therapist used a demonstration to help

Jennifer recognize that she was very unlikely to act
on her unwanted thoughts. Jennifer and Jack were
asked to hold paperweights from the therapists
desk. The therapist turned her back and asked the
378
couple to vividly imagine throwing these objects at

her. Of course, neither threw the paperweight, even
after visualizing doing this for a few minutes. The
results of this experiment (i.e., thoughts themselves
do not lead to actions) were discussed in terms of the
probability that Jennifer would act on thoughts to
harm Jordan. Although the probability was not zero,
Jennifer was easily able to tolerate the thoughts and
uncertainty about throwing the paperweight. Thus,
the couple learned that the overall goal of treatment for OCD would be to learn to treat obsessional
thoughts in the same manner as the paperweight
thoughts. Both Jennifer and Jack agreed that they
would work toward this goal.
CT for Depression At sessions 3, 4, and 5, treatment focused on CT for depression (Jennifer came
by herself to these sessions). Although more hopeful, she described feeling guilty and worthless on
a daily basis, and considering herself a failure as
a parent because of her obsessional thoughts and
her inability to be a good, loving mother. CT for
depression was introduced during session 3 with
the therapist using handouts describing cognitive
errors to teach Jennifer to recognize maladaptive
beliefs, including overgeneralizing, catastrophizing, and discounting the positive. Jennifer
was then asked to self-monitor these thinking patterns during the week between sessions 3 and 4,
and then, in sessions 4 and 5, she was taught to
generate more realistic appraisals of herself and
her future based on logic and previous experience (evidence). For example, her idea that I am
a failure was modified to I have trouble with
anxiety and depression because of OCD, but I
succeed at other thingssuch as teaching. I am
not a failure, but a person with personal strengths
and limitations, just like everyone else. Jennifer
was shown how to use daily thought diaries to
practice identifying and modifying dysfunctional
thoughts. She also worked with the therapist to
develop a routine of activities that she enjoyed
(behavioral activation), such as renting her favorite movies and going hiking with a group of her
close friends.
CT for OCD Sessions 6 and 7 involved continuing to apply CT techniques for depression and
also learning to apply it for OCD as described in

Wilhelm and Steketee (2006). In particular, Jennifer was taught how to identify dysfunctional
beliefs about the importance of obsessional
thoughts, the need to control such thoughts, and
intolerance of uncertainty. Jennifer challenged
these beliefs using rational disputes, examining
her own previous experiences and other sorts of
real-life evidence, and using behavioral experiments to test out the logic of her thoughts. For
example, she was asked to think about anything
in the world except a pink elephant, but to let
the therapist know if any pink elephant thoughts
came to mind. Within a few seconds, Jennifer
was thinking of the pink elephant, which led to
a discussion about the inevitable failure of trying
to suppress thoughts. Jennifer began to understand that rather than trying to control or avoid
obsessional thoughts, it would be more beneficial
to develop the skills for managing them, as well
as the resulting anxiety and uncertainty that such
thoughts provoked. Jennifer reported feeling
more optimistic about treatment and her future
in general than she had felt in a long time. She
agreed that she was ready to move on to practicing ERP.
ERP Consistent with the inhibitory learning
approach (e.g., Abramowitz and Arch 2014;
Craske etal. 2008), ERP techniques were introduced (during session 8) as methods to help
Jennifer weaken the fear and urge to perform
rituals that had become associated with situational triggers (e.g., holding Jordan on a flight
of stairs) and obsessional thoughts (e.g., about
harming Jordan). Jennifer would be helped to
directly confront a list of situations and thoughts
under the therapists supervision and then practice similar exposures on her own in different
contexts or environments (e.g., with her husband,
alone, at home, out at a shopping center, etc.).
The main aim of exposure would be to provoke
anxiety, uncertainty, and obsessions and allow
Jennifer to practice managing the associated distress until it abated naturally with time, although
habituation of anxiety was not used as an explicit
indicator of success within or between sessions.
After this rationale was reviewed, Jennifer and

Table 25.2 Jennifers exposure item list
Situation/thought
Think about Jordan dying from accidents (e.g., SIDS,
chocking)
Think of smothering Jordan with a pillow
Think of throwing Jordan down the stairs
Hold Jordan while walking staircases
Hold a pillow over Jordan while he is sleeping
SIDS sudden infant death syndrome
her therapist constructed a list of situations and

thoughts for exposure (see Table25.2). Jennifer
agreed to practice confronting these situations
and thoughts without performing checking or
reassurance-seeing rituals and without trying to
resist intrusive thoughts or uncertainty.
During the first exposure session, Jennifer and
the therapist collaboratively wrote the following
scenario about Jordan choking to death:
Youre on the floor with Jordan. He is sitting there
playing happily with one of his toys and youre
eating popcorn from a small bowl. The phone
rings and you get up to find where you left your
phone, leaving Jordan on the floor. While youre
up, Jordan becomes curious and he reaches into
the bowl of popcorn and grabs a piece. He puts it
into his mouth, just as he had seen you do, but he
cannot chew it and it gets caught in the back of his
throat. Jordan starts coughing, but the popcorn is
really stuck and its not coming out. Meanwhile,
you return with your phone to see him struggling,
unable to breathe. You screamyour worst nightmare is coming true! You pick him up and start
hitting his back to try to dislodge the piece of
popcorn, but its not working. Jordan is not able to
breathe. He is turning a bluish gray color because
he cant get any oxygen, and you see his eyes
close. Youre in a panic now heart racing, sweating, feeling dizzy. Whats happening!? Can this
be it? Is Jordan going to die? Why did you leave
him there with the popcorn? No one else is home
and youre completely overwhelmed with panic.
All sorts of things race through your head as you
try desperately to save your son. Youre holding
Jordans lifeless body as you dial 911 and explain
whats happening. But the voice on the other end is
saying it will take 15minutes to get an ambulance
to your house. You know that it will be too late.
Jordan will be gone by then.
Jennifer read this scene into her smart phone and

practiced listening to the recording for the remainder of the session. Rather than keeping track
of subjective anxiety levels, the therapist kept
track of Jennifers expectations of being able to
379
tolerate thinking about this scene as well as the

anxiety and the distress that it provoked. As the
exposure began, Jennifer believed that she would
only be able to handle thinking about this scene
for a few minutes. But after a few minutes, she
realized that she could manage it, despite the distress it provoked. After about 30min of listening
to the scene, Jennifer was able to articulate that
although the thought was very distressing, she
could think about it and recognized that the probability of such an event was acceptably lowalthough not zero. After about 40min, the therapist
left the office and allowed Jennifer to practice
confronting the thought on her own. Again, Jennifer exceeded her expectations for tolerating the
thought on her own. At the end of the session,
Jennifer felt very good about completing the exercise and was instructed to practice the same
task once each day between sessions. At the end
of each treatment session, Jennifer chose an item
from the exposure list to practice confronting
during the next session (some of which included
bringing Jordan to the session).
Jacks Involvement in Treatment
Jack
attended several exposure sessions in which
the therapist taught him how to play the role of
coach and offer emotional support to Jennifer
as she completed exposure practices within and
outside the sessions. Jack was also taught how to
provide gentle, but firm reminders to Jennifer not
to engage in avoidance or rituals. The emphasis
was placed on helping Jennifer tolerate and get
through the obsessional anxiety, as opposed to
trying to immediately alleviate this distress. The
therapist also helped Jennifer and Jack to use two
types of communication skills when dealing with
OCD-related matters between sessions. The first
skill involved sharing thoughts and feelings or
emotional expressiveness training (EET) in which
the couple was taught to discuss with one another
how they feel (as opposed to offering solutions)
during exposure, while also listening effectively
to each other. The second skill involved learning
how to make decisions as a couple around choosing and implementing exposure tasks, and resisting rituals (Abramowitz etal. 2013; Epstein and
Baucom 2002).
380
Because Jennifer had a history of occasionally

manipulating Jack into providing reassurance, the
therapist explained the deleterious effects of such
accommodation, noting that while well intended,
helping Jennifer alleviate her anxiety by providing assurances served to maintain obsessional fear.
Next, the therapist helped the couple develop a list
of activities which had become hampered by OCD
and then use the decision-making skills learned earlier to choose how to handle these situations by promoting the idea of exposure, rather than relying on
avoidance and compulsive rituals. In other words,
the couple was instructed in how to build ERP techniques into their everyday life and functioning as
a couple. For example, Jennifer and Jack resumed
sleeping in their own bedroom, and Jack stopped
checking on Jordan whenever Jennifer had obsessional fears that he might not be safe in his crib.
The therapists aim was to help Jennifer and Jack to
work toward a life in which they confront the situations and stimuli that Jennifer had been avoiding in
order to teach Jennifer how to tolerate anxiety and
uncertainty.
Sessions 1216Over the course of the next

month, Jennifer practiced CT and ERP. She
quickly recognized how effective it was to confront her fears, rather than avoid, and diligently
completed all in-session and homework assignments. She and Jack worked extremely well
together and were able to reclaim the life they
had before Jennifers anxiety had taken over.
After 4 months of treatment, Jennifer reported
that her depressive symptoms had improved
greatly and her BDI score at session 16 was only
5 (an 82% reduction in depressive symptoms).
Moreover, she had resumed sharing with Jack the
caretaking responsibilities for Jordan. She was no
longer avoiding being alone with Jordan, and the
couple was no longer arguing about OCD-related
matters. Checking and reassurance-seeking
behavior had almost disappeared, and although
Jennifer occasionally experienced negative
thoughts about Jordan, she was able to tolerate
these and recognize that the risks of catastrophic
consequences were acceptably low. Her YBOCS
severity score at session 16 was 9 (a 67% reduction in OCD symptoms). With input from both
Jennifer and Jack, it was decided that for the next

3 months, Jennifer would see the therapist on a
monthly basis for follow-up sessions. Jennifer
continued to remain improved through this time,
and treatment was therefore terminated.
Religious Scrupulosity and Fear of Sin
In session 6, when Jennifer and her therapist first
began applying CT techniques to her unwanted
thoughts, Jennifer described that while these
techniques made sense for challenging depressive thoughts, she was hesitant to apply what she
had learned to her OCD symptoms. Specifically,
she told her therapist that her Christian background had taught her that thoughts are morally
equivalent to actions and that therefore thinking
of something immoral was the same as committing an immoral act (i.e., moral thoughtaction
fusion; Shafran etal. 1996). She could recall
several biblical passages that exemplified the
importance of control over thoughts in order to
avoid sin and punishment.
Jennifer and her therapist discussed the definition of sinful behavior. Jennifer said she had
learned that a sin is something a person does
that he or she (a) does deliberately, (b) knows is
wrong, and (c) does not feel remorseful about.
When Jennifer was asked to evaluate her intrusive thoughts against this definition, she recognized differences, but said that she could not be
sure whether God was upset with her for having
the thoughts she had. Thus, for Jennifer, the mere
possibility that her obsessions meant that she
is an immoral person and may do something to
hurt her child, provoked high levels of anxiety
and distress. They discussed how no one, including other practicing Christians, really knows for
sure whether God is upset with them and therefore must accept such things on faith. It was
explained that OCD had led Jennifer to essentially lose her faith in faith. Thus, the therapist
framed the purpose of cognitive restructuring and
exposure as helping Jennifer to become a more
faithful Christian. This would involve exposure
to external (actual stimuli and situations) and internal (i.e., thoughts) triggers of religious obsessions to give her opportunities to confront such
stimuli and learn healthier and more productive
responses to them. Jennifer said that this explanation made sense to her and that she was willing
to give cognitive restructuring and exposure a try.
Intolerance of a Partners Distress

While Jack seemed to understand the rationale for
exposure and was able to adhere to the guidelines
during in-session exposure practice, he described
that it was difficult for him to resist providing reassurance when obsessional triggers would provoke Jennifers anxiety in their daily life. Jack
said that in those moments (e.g., when Jennifer
would call him at work asking him to calm her
fears that she was developing schizophrenia),
he knew that reassuring her was contrary to the
treatment model, but that it felt wrong to withhold comfort from Jennifer when he knew what
he needed to say in order for her to feel better. He
also said he hated to see Jennifer feeling so distressed all the time and was even concerned that
too much anxiety could harm Jennifer. The therapist reemphasized that although providing reassurance seemed like the right thing to do when
Jennifer was very anxious, that this would only
relieve Jennifers anxiety in the moment, and in
the long-term it would fuel her OCD and keep
her from learning to tolerate her obsessions and
learn skills for managing these situations on her
own. Furthermore, because accommodation had
become the primary means by which Jack would
express care and concern for Jennifer, the therapist helped the couple redefine the ways in which
they showed affection and love for one another
so that they continue to feel emotionally close
while reducing accommodation. For example,
Jack and Jennifer decided to have a weekly date
night on Thursdays, now that Jennifer was feeling more and more capable of being away from
Jordan, in order to focus on the two of them as
a couple (outside of OCD). Jack said that these
types of activities gave him the strength to resist
accommodating Jennifers OCD because he felt
like overall he was becoming a better partner.
381

Jennifers case illustrates the use of CBT for OCD
with comorbid depression. Table 25.3 highlights
several key practice points we feel were important in the success of Jennifers course of therapy
and are important to consider in the treatment of
this comorbidity pattern. In particular, CT methods for depression and OCD symptoms were
used to augment traditional ERP procedures.
Given Jennifers helplessness and hopelessness
at baseline, it is likely that she would have had
difficulty with adherence (if not discontinued
therapy altogether) if ERP had been begun immediately. Consequently, ERP was delayed to a
point in treatment that is significantly later than
in typical implementation. Instead, by the introduction of CT first, she had the opportunity (a) to
establish rapport with her therapist, (b) to see that
the therapist understood her OCD symptoms, (c)
to understand her own symptoms better, and (d)
to develop cognitive coping strategies to reduce
her depressive symptoms and prepare for ERP
exercises. It is interesting to speculate whether
these factors contributed to her engagement in
the more difficult aspects of the therapy. Indeed,
some have advocated that CT strategies be used
routinely to help patients confront feared situations during exposure (e.g., Kozak 1999).
Another important practice point was the inclusion of Jennifers husband, Jack, in treatment.
The reestablishment of healthy ways of relating
was viewed as important for (a) the reduction of
accommodation behavior that maintained Jennifers OCD symptoms and (b) reducing Jennifers
depression symptoms by alleviating the distress
in her relationship with Jack.
Table 25.3 Key practice points in the treatment of
comorbid OCD and depression
Assess for the temporal nature of the relationship
between OCD and depression
Consider adding cognitive therapy for depression
and OCD before starting with exposure and response
prevention
Consider involving a spouse, partner, or other support
person in treatment
Use an inhibitory learning approach to exposure and
help the patient to learn fear tolerance, as opposed to
relying on habituation of anxiety as an indicator of
success
382
Jennifers depression was quite straightforward

and clearly secondary to her OCD. That is, she
was primarily depressed about having obsessional
thoughts about the very subject that was most
important to herher newborn baby. Very likely,
the reduction in her OCD symptoms in the middle
and later stages of treatment resulted in further
improvements in her depression. It is likely that
many patients with postpartum depression also
experience obsessional thoughts and indeed
OCD, but present with depressive complaints
because postpartum OCD is less recognizable
than postpartum depression (e.g., Fairbrother and
Abramowitz 2007). In some instances, however,
patients depressive symptoms represent primary
disorders, which transcend the distress associated
with OCD. For example, one patient we evaluated
had experienced depression for several years before
the onset of her OCD. An important question is
whether patients whose depressive symptoms are
related to the distress or functional impairment
associated with OCD would fare better in CBT for
OCD when compared to patients for whom OCD
and depression represent truly unrelated diagnoses.
In summary, although research demonstrates
that ERP is the best available treatment for OCD,
the presence of comorbid disorders may interfere with its strong effects. In particular, severely
depressed OCD patients tend not to fare as well
with ERP as do nondepressed patients. The introduction of CT techniques is one strategy that
might improve depressed OCD patients response
to exposure therapy. Given that SRI medications
are effective in the treatment of OCD, pharmacotherapy might also be suggested in such cases.
References
Abramowitz, J. S. (2006). Understanding obsessivecompulsive
disorder: A cognitive-behavioral
approach. Mahwah: Lawrence Erlbaum Associates.
Abramowitz, J. S., & Arch, J. J. (2014). Strategies
for improving long-term outcomes in cognitivebehavioral therapy for obsessive-compulsive
disorder: Insights from learning theory. Cognitive and
Behavioral Practice, 21, 2031.
Abramowitz, J. S., & Foa, E. B. (2000). Does comorbid
major depressive disorder influence outcome or
exposure and response prevention for OCD? Behavior
Therapy, 31, 795800.

Abramowitz, J. S., Franklin, M. E., Street, G., Kozak, M.,
& Foa. E. B. (2000). Effects of comorbid depression
on response to treatment for obsessive-compulsive
disorder. Behavior Therapy, 31, 517528.
Abramowitz, J. S., Storch, E. A., Keely, M., & Cordell, E.
(2007). Obsessive-compulsive disorder with comorbid
major depression: What is the role of cognitive factors?
Behavior Research and Therapy, 45, 22572267.
Abramowitz, J. S., Deacon, B., Olatunji, B., Wheaton, M.
G., Berman, N., Losardo, D., Timpano, K., McGrath,
P., Riemann, B., Adams, T., Bjorgvinsson, T., Storch,
E. A., & Hale, L. (2010). Assessment of obsessivecompulsive symptom dimensions: Development and
evaluation of the dimensional obsessive-compulsive
scale. Psychological Assessment, 22, 180198.
Abramowitz, J. S., Deacon, B. J., & Whiteside, S. P.
(2011). Exposure therapy for anxiety: Principles and
practice. New York: Guilford.
Abramowitz, J. S., Baucom, D. H., Wheaton, M. G.,
Boeding, S., Fabricant, L. E., Paprocki, C., & Fischer,
M. S. (2013). Enhancing exposure and response
prevention for OCD: A couple-based approach.
Washington, DC: Author.
Andrews, G., Slade, T. I. M., & Issakidis, C. (2002).
Deconstructing current comorbidity: Data from the
Australian national survey of mental health and wellbeing. The British Journal of Psychiatry, 181(4),
306314.
Antony, M. M., Downie, F., & Swinson, R. P. (1998).
Diagnostic issues and epidemiology in obsessivecompulsive disorder. Obsessive-compulsive disorder:
Theory, research, and treatment, 332.
Bandura, A. (1977). Self-efficacy: Toward a unifying
theory of behavioral change. Psychological Review,
84, 191215.
Beck, A. T. (1976). Cognitive therapy and emotional
disorders. New York: International Universities press.
Beck, J. S., & Beck, A. T. (2011). Cognitive behavior
therapy: Basics and beyond. New York: Guilford.
for the Beck depression inventory-II. San Antonio:
Bellodi, L., Scioto, G., Diaferia, G., Ronchi, P., &
Smiraldi, E. (1992). Psychiatric disorders in families
of patients with obsessive-compulsive disorder.
Chambless, D. L., & Steketee, G. (1999). Expressed
emotion and the prediction of outcome of behavior
therapy: A prospective study with agoraphobic
and obsessive-compulsive outpatients. Journal of
Consulting and Clinical Psychology, 67, 658665.
Craske, M. G., Burton, T., & Barlow, D. H. (1989).
Relationships among measures of communication,
marital satisfaction and exposure during couples
treatment of agoraphobia. Behaviour Research and
Therapy, 27(2), 131140.
Craske, M. G., Kircanski, K., Zelikowsky, M.,
Mystkowski, J., Chowdhury, N., & Baker, A. (2008).

Optimizing inhibitory learning during exposure
therapy. Behaviour Research and Therapy, 46, 527.
Crino, R. D., & Andrews, G. (1996). Obsessivecompulsive disorder and axis I comorbidity. Journal
of Anxiety Disorders, 10(1), 3746.
Demal, U., Lenz, G., Mayrhofer, A., Zapotoczky, H-G.,
& Zitterl, W. (1993). Obsessive-compulsive disorder
and depression: A retrospective study on course and
interaction. Psychopathology, 26, 145150.
Eddy, K., Dutra, L., Bradley, R., & Westen, D. (2004). A
multidimensional meta-analysis of psychotherapy and
pharmacotherapy for obsessive-compulsive disorder.
Clinical Psychology Review, 24, 10111030.
Eisen, J. L., Phillips, K. A., Baer, L., Beer, D. A., Atala, K.
D., & Rasmussen, S. A. (1998). The Brown assessment
of beliefs scale: Reliability and validity. The American
Journal of Psychiatry, 155(1), 102108.
Epstein, N., & Baucom, D. H. (2002). Enhanced
cognitive-behavioral therapy for couples: A contextual
approach. Washington, DC: American Psychological
Association.
Fairbrother, N., & Abramowitz, J. S. (2007). New
parenthood as a risk factor for the development of
obsessional problems. Behaviour Research and
Therapy, 45, 21552163.
Fineberg, N., & Craig, K. J. (2010). Pharmacotherapy
for obsessive-compulsive disorder. In D. Stein, E.
Hollander, & B. Rothbaum (Eds.), Textbook of anxiety
disorders (2nd ed.). (pp.311338). Washington, DC:
American Psychiatric
Foa, E. B., Kozak, M. J., Steketee, G., & McCarthy, P.
R. (1992). Treatment of depressive and obsessivecompulsive symptoms in OCD by imipramine
and behavior therapy. British Journal of Clinical
Goodman, W. K., Price, L. H., Rasmussen, S. A., &
Mazure, C. (1989a). The Yale-Brown Obsessive
Compulsive Scale: I. Development, use, and reliability.
Archives of General Psychiatry, 46(11), 10061011.
Goodman, W. K., Price, L. H., Rasmussen, S. A., &
Mazure, C. (1989b). The Yale-Brown Obsessive
Compulsive Scale: II. Validity. Archives of General
Psychiatry, 46(11), 10121016.
Gorman, J. M. (1996). Comorbid depression and anxiety
spectrum disorders. Depression and Anxiety, 4,
160168.
Hasler, G., LaSalle-Ricci, V., & Ronquillo, J. (2005).
Obsessive-compulsive symptom dimensions show
specific relationships to psychiatric comorbiditiy.
Hranov, L. G. (2007). Comorbid anxiety and depression:
Illumination of a controversy. International Journal of
Psychiatry in Clinical Practice, 11(3), 171189.
Keeley, M. L., Storch, E. A., Merlo, L. J., & Geffken, G.
R. (2008). Clinical predictors of response to cognitivebehavioral therapy for obsessive-compulsive disorder.
Clinical Psychology Review, 28, 118130.
Kessler, R. C., Stang, P. E., & Wittchen, H. U. (1998).
Lifetime panic-depression comorbidity in the National
383
Comorbidity Survey. Archives of General Psychiatry,

55, 801808.
Kozak, M. J. (1999). Evaluating treatment efficacy for
obsessivecompulsive disorder: Caveat practitioner.
Marcaurelle, R., Belanger, C., Marchand, A., Katerelos,
T. E., & Mainguy, N. (2005). Marital predictors of
symptom severity in panic disorder with agoraphobia.
Journal of Anxiety Disorders, 19(2), 211232.
Marks, I. M., Stern, R., Mawson, D., Cobb, J., &
McDonald, R. (1980). Clomipramine and exposure
for obsessive-compulsive rituals I. British Journal of
McCarthy, L., & Shean, G. (1996). Agoraphobia and
interpersonal relationships. Journal of Anxiety
Disorders, 10(6), 477487.
Nestadt, G., Samuels, J., Riddle, M., Liang, K-Y.,
Bienvenu, O., Hoehn-Saric, R., Grados, M., & Cullen,
B. (2001). The relationship between obsessivecompulsive disorder and anxiety and affective
disorders: Results from the Johns Hopkins OCD
Family Study. Psychological Medicine, 31, 481487.
Rachman, S. (1998). A cognitive theory of obsessions:
Elaborations. Behaviour Research and Therapy, 36,
385401.
Ricciardi, J. N., & McNally, R. J. (1995). Depressed
mood is related to obsessions but not compulsions
in obsessive-compulsive disorder. Journal of Anxiety
Disorders, 9, 249256.
Sanderson, W. C., DiNardo, P. A., Rapee, R. M., &
Barlow, D. H. (1990). Syndrome comorbidity in
patients diagnosed with a DSM-IIIR anxiety
disorder. Journal of Abnormal Psychology, 99(3), 308.
Schatzberg, A. F., & Nemeroff, C. B. (Eds.). (2009).
Textbook of psychopharmacology, fourth edition.
Seligman, M. E. P. (1975). Helplessness. San Francisco:
Freeman.
Shafran, R., Thordarson, D. S., & Rachman, S.
(1996). Thought-action fusion in obsessive
compulsivedisorder. Journal of Anxiety Disorders, 10,
379391.
Steketee, G. (1993). Treatment of obsessive-compulsive
disorder. New York: Guilford.
Steketee, G., Chambless, D. L., & Tran, G. Q. (2001).
Effects of Axis I and II comorbidity on behavior
therapy outcome for obsessive-compulsive disorder
and agoraphobia. Comprehensive Psychiatry, 42,
7686.
Wilhelm, S., & Steketee, G. (2006). Cognitive therapy
for obsessive-compulsive disorder: A guide for
practitioners. Oakland: New Harbinger.
Yaryura-Tobias, J. A. T. J., Todaro, J., Grunes, M. S.,
McKay, D., Stockman, R., & Neziroglu, F. (1996).
Comorbidity versus continuum of Axis I disorders in
OCD. In meeting of the association for advancement
of behavior therapy. New York, NY.
Treatment of an Adult
with Obsessive-Compulsive Disorder with Limited
Treatment Motivation
26
Michael G. Wheaton, Anthony C. Puliafico, Allan

Zuckoff and H. Blair Simpson
Nature of the Problem and Research

Base
Obsessive-compulsive disorder (OCD) results
in impairing symptoms and is a leading cause
of illness-related disability across the world
(Murray and Lopez 1996). Fortunately, effective treatments exist for OCD, including pharmacotherapy with serotonin reuptake inhibitors
(SRIs; Koran and Simpson 2010) and cognitivebehavioral therapy (CBT) consisting of exposure
and ritual prevention (E/RP; Abramowitz etal.
2009). Though effective, these treatments also
have some limitations. For example, medications
sometimes cause significant side effects, including sleep disturbance, weight gain, and sexual
dysfunction. Undergoing E/RP can be stressful,
and some patients drop out of treatment prematurely or do not adhere to the prescribed procedures. Therefore, in order to maximally benefit
from E/RP, individuals must have sufficient moH.B.Simpson() M.G.Wheaton
Anxiety Disorders Clinic and the Center for OCD and
Related Disorders, New York State Psychiatric Institute,
1051 Riverside Drive, Unit 69, 10032 New York,
USA
e-mail: simpson@nyspi.colubmia.edu
A.C.Puliafico H.B.Simpson
Department of Psychiatry, Columbia University Medical
Center, Columbia University, New York, NY, USA
A.Zuckoff
Departments of Psychology and Psychiatry, University of
Pittsburgh, Pittsburgh, PA, USA
tivation to tolerate the associated anxiety and distress to participate in treatment.

Motivation has been defined as the probability
that a person will enter into, continue, and adhere
to a specific change strategy (Miller and Rollnick
2013). Limited motivation for treatment is a potential obstacle for patients to maximally benefit
from therapy. Level of motivation has been predictive of treatment response to CBT for OCD
(Haan etal. 1997; Hoogduin and Duivenvoorden
1988; Keijsers etal. 1994). Foa and colleagues
(1983) reported their clinical observations on
why nearly 100 OCD patients refused or dropped
out of E/RP treatment, noting that a lack of
motivation was a key factor. In addition, they
note that sometimes a patients stated reasons for
rejecting treatment (e.g., lack of time) masked
an underlying problem of low motivation (Foa
etal. 1983).
Although the exact mechanism through which
low motivation leads to poorer treatment outcome
has not been empirically confirmed, one possibility is that individuals with poor motivation do not
adhere to the treatment. Indeed, patient adherence
appears to be one of the most powerful predictors of outcome with E/RP (Simpson etal. 2011).
Two elements of E/RP suggest that motivation is
critical to adherence: (1) the difficult nature of
exposures and (2) time commitment. In E/RP, patients are taught in-session to confront what they
fear (exposure) and to refrain from performing
compulsions (ritual prevention), both of which
can be highly distressing to patients. Time burden
for this therapy can also be substantial; a typical

DOI 10.1007/978-3-319-17139-5_26
385
386
E/RP course includes up to 25 sessions (ideally

delivered twice weekly), and patients are expected to continue exposures and eliminate rituals
outside of session. Therefore, the intensive and
potentially stressful nature of E/RP requires substantial commitment from patients.
Given the importance of motivation in E/RP,
several strategies have been used to enhance
motivation for treatment. Standard E/RP (Foa
etal. 2012) includes strategies to help promote
motivation, including building a strong treatment
alliance and providing psychoeducation about
OCD and a clear rationale for conducting exposures while refraining from rituals. Standard E/
RP can also be modified to enhance motivation,
such as by engaging significant others in treatment and matching the frequency of therapy sessions to the patients need. In addition, delivering
E/RP in a residential format may help promote
motivation due to the structure of the residential
program and the 24/7 aspect of the care. Some
residential treatments include motivation group
sessions in order to promote a productive attitude
and enhance personal commitment to treatment
(Osgood-Hynes etal. 2003).
Cognitive therapy also includes techniques
to enhance motivation. These techniques have
been used as an adjunct to E/RP (McKay etal.
2010). For example, Sookman and colleagues
developed a schema-based treatment approach
in part to improve patients ability to participate
in E/RP (see Sookman and Steketee 2007). This
approach utilizes cognitive therapy techniques
to target dysfunctional schemas and maladaptive beliefs that could interfere with E/RP (e.g.,
core beliefs such as, Im a dangerous person
and I can never change). Preliminary data suggest that this intervention can help OCD patients
who have failed prior E/RP (Sookman and Pinard
1999). However, this approach is complex and
has not been systematically dismantled to investigate which ingredients best improve problems
with low motivation.
Incorporating both behavioral and cognitive approaches, Pollard and colleagues (Pollard
2006; Van Dyke and Pollard 2005) developed a
readiness therapy for OCD patients who demonstrated treatment-interfering behaviors (TIBs)
M. G. Wheaton et al.
that obstructed their ability to participate in previous OCD treatment. Many of these TIBs (e.g.,
missing appointments, nonadherence to the treatment plan, and homework assignments) relate to
problems with motivation. In readiness therapy,
which can be delivered either individually or in
a group format, TIBs are first identified and then
targeted with cognitive and behavioral interventions (e.g., contingency management, evaluating
evidence for faulty beliefs, skills training). The
goal is to reduce barriers and enhance commitment to subsequent E/RP.
Finally, we and others have examined whether motivational interviewing (MI) can increase
treatment motivation in conjunction with E/RP
(Zuckoff etal. 2015). Motivational interviewing is a collaborative, goal-oriented counseling
style for strengthening a persons own motivation
and commitment to change through particular
attention to the language of change (Miller and
Rollnick 2013). Initially developed for patients
with alcohol problems, MI has since been found
to improve treatment entry, retention, adherence,
and outcome in a variety of disorders and contexts (Hettema etal. 2005; Zuckoff and Hettema
2007; Lundahl etal. 2010). An MI approach considers difficulty with motivation for treatment as
a function of patient ambivalence about change
and involves strategies to increase patients
perceived importance of change and confidence
in their ability to change. MI involves a general
approach that is patient centered and in which
open-ended and nonconfrontational questions
and reflective listening are used to invite patients
to talk about why and how they might change. In
an MI approach, the goal is to help the patient, not
the therapist, become the advocate for change.
Several studies have attempted to combine
MI and CBT including E/RP. Three small studies
used MI strategies as a prelude to CBT. Maltby
and Tolin (2005) developed a four-session readiness intervention to be delivered prior to E/RP
entry in order to enhance motivation for starting E/RP. In this intervention, two sessions involved MI procedures, while the others included
a combination of psychoeducation and planning
for treatment. Twelve patients who previously
refused E/RP were randomized to either receive
26 Treatment of an Adult with Obsessive-Compulsive Disorder with Limited Treatment Motivation
the intervention (n=7) or remain on a waiting list (n=5). One month later, 86% of those
who received the readiness intervention agreed
to begin E/RP, a significantly higher percentage
than the waitlist group (20%). Notably however,
more than half of the patients who initiated E/
RP after the readiness intervention discontinued
before completing treatment, a rate higher than
the typical EX/RP dropout rate. In a pediatric
sample (aged 617 years, n=16) undergoing
intensive family-based CBT (that consisted of
psychoeducation, cognitive training, and E/RP
exercises), Merlo and colleagues (2010) compared adding three sessions of MI to three sessions of extra psychoeducation. Individuals who
received CBT+MI had faster gains and finished
treatment three sessions earlier than those who
received CBT+ psychoeducation, though OCD
symptoms did not differ posttreatment (Merlo
etal. 2010). Finally, Meyer etal. (2010) tested
a strategy to enhance cognitive behavioral group
therapy (CBGT), which involves E/RP as well
as cognitive restructuring, for adults with OCD
by including two individual therapy sessions that
included MI (as well as thought mapping) delivered weekly prior to entering a 12-week course
of CBGT. Forty patients were assigned to receive
either an information-only control treatment or
the MI+ thought mapping enhancement, and a
completer analysis found patients who received
the enhancement sessions evidenced statistically
significantly greater improvement after treatment, though in this case MI was combined with
another intervention.
Simpson etal. (2008) developed a protocol to
integrate MI with standard E/RP, with the goal
of increasing patient motivation for E/RP treatment. This included redesigning the introductory
sessions (which involve information gathering
and forming a treatment plan) to be consistent
with an MI approach. This protocol also included
a short (1530min) MI module to be used in
subsequent sessions when patients were unwilling to engage in exposures or did not complete
agreed-upon homework. In an open pilot trial in
five individuals, this approach appeared to enhance treatment participation and led to reduced
symptoms and increased quality of life (Simpson
387
etal. 2008). However, a subsequent randomized

trial comparing E/RP+MI (n=15) to E/RP alone
(n=15) did not prove more effective than E/RP
alone (Simpson etal. 2010a). One interpretation
of these findings is that an MI approach is not
necessary for every patient. At the same time, an
MI approach may still be helpful in individual
cases where the patient expresses ambivalence or
reluctance about treatment-related change.
In summary, problems with limited motivation can interfere with the ability of patients to
maximally benefit from E/RP, which is the psychotherapy with the strongest evidence base for
the treatment of OCD. Although several strategies have been developed to address motivation
problems, this chapter focuses on strategies to
enhance motivation that are compatible with an
MI approach. We detail a case history and treatment course for an individual who presented for
treatment at our center with limited motivation
for treatment and some of the specific strategies
used by the therapist. Finally, we conclude the
chapter with practice points.

Jason (pseudonym), a 28-year-old Caucasian
male, presented for treatment at a specialty OCD
treatment center in the New York metropolitan
area. Jason self-identified as having OCD at intake, and reported a long history of a range of
obsessive-compulsive symptoms. He reported
that he had two primary domains of symptoms:
(1) contamination concerns centered on the fear
of becoming ill with the flu and (2) fear of making a mistake, particularly at work, coupled with
compulsive checking. Jason reported that his
contamination fears were quite distressing, but
defended some of his compulsive symptoms,
saying that he felt like it was reasonable to take
all possible precautions to avoid getting sick. In
terms of his checking behaviors, Jason reported
being bothered by needing to recheck things that
he already knew to be correct, while at the same
time believing that his checking and attention
to detail helped him to be a model employee. In
fact, he reported that his checking rituals had on
388
occasion actually prevented him from making

clerical mistakes, and expressed some reluctance
to reduce his checking.
Jason reported a past history of largely unsuccessful treatment for his OCD, as detailed
below. When asked why he was presenting for
treatment at the present moment, Jason reported
that he had been considering treatment for some
time, but was deterred by the cost and time commitment. Our site offered E/RP at no cost to
participants who completed neuropsychological tasks as part of a research study; this made
E/RP seem more appealing. As he explained, If
it is free treatment, I thought it would be worth
a shot. When Jason learned that the treatment
would require twice-weekly therapy sessions he
hesitated, saying he would need to think it over to
determine whether treatment was worth the time
he would miss at his job. Ultimately, he decided
to try E/RP. Thus, even within the intake session,
the treating clinician identified that low motivation might be a complicating factor for Jasons
treatment, as evidenced by some ambivalence
about the need to change and hesitation about
committing to treatment.
Case Information
Jason grew up with both parents and a younger sister in a suburban town in the southeastern
USA. Jason described his upbringing as typical
and reported close relationships with his immediate family. Jason described his mother as a worrywart and said that she was currently taking
medication to help manage her anxiety, though
he was unclear about her diagnosis. Jason noticed his own excessive anxiety in middle school,
which manifested as intense worries about grades
and the fear that he might turn in assignments with
mistakes. However, he stated that this concern
actually helped him achieve high grades and earn
admission to a competitive college. In college,
his academic anxiety worsened to the point that it
significantly bothered him and interfered with his
studies. Often he was so concerned about making
a mistake on an assignment that he spent hours
rereading and rewriting it. He was also frequently
beset by doubts that he might have forgotten to

turn an assignment in or that it might have gotten
lost after submitting it. To relieve this anxiety, he
frequently checked the websites associated with
his classes to make sure he had not missed an assignment and emailed his professors to ask for
reassurance that they had received his submitted
assignments.
In Jasons sophomore year, an outbreak of
H5N1 avian influenza (bird flu) was reported
in many countries across the world. Jason was
transfixed by the media reaction to the pandemic, particularly reports that even healthy young
adults could be susceptible to this particular
strain of flu. Even though no cases of H5NI were
reported in his area, Jason became obsessed with
the idea that he might become infected by it. He
began taking special precautions around eating,
such as always using hand sanitizer and avoiding
food that was not in a wrapped package or that he
had not seen prepared. In addition, seeing stray
hairs or bits of lint on his floor or clothing triggered a sense of contamination and thoughts that
he might become ill. To alleviate these concerns,
he began compulsively picking hairs and pieces
of lint off of his carpet and inspecting his clothing
for bits of debris before putting it into his laundry hamper. At times, this ritualistic cleaning and
checking clothes for hair and lint went for hours,
though he tried to limit these behaviors around
his roommates.
Jasons parents suggested that he visit his universitys counseling center. He met with a school
counselor who provided supportive psychotherapy for four sessions, but he stopped because he
found it relatively unhelpful. He also met with a
school psychiatrist, who prescribed a low dose of
a selective serotonin reuptake inhibitor (SSRI).
Jason found the medication somewhat helpful at
managing his anxiety and he continued taking
the SSRI (at the same dose) for the next several
years.
After graduating, Jason moved to New York
to pursue a career in the business world. He
found a clerical job working in the human resources department of a large corporation. This
job involved reviewing personnel files and
maintaining multiple databases. Many aspects
of the job triggered obsessive thoughts that he

might have made a mistake. For example, Jasons duties included inputting employees bank
account information into a database for direct
deposit payments, and he frequently found himself doubting whether he had put the numbers in
correctly, prompting him to check multiple times
and taking much more time to complete these
tasks than other employees. He also continued to
be bothered by obsessive thoughts that he might
contract the flu or another virus due to perceived
unsanitary conditions (both in his workplace and
at home), especially as indicated by dirt, stray
hairs, and pieces of lint. Although he was living
in a studio apartment, he regularly spent many
hours picking hairs and lint off of the floor.
One year before presenting in our clinic,
Jason sought treatment from another provider
trained to do E/RP therapy. Jason attended only
three sessions before dropping out of treatment.
It frightened him to hear that treatment would
involve facing situations that he was afraid
of during exposure practices, and made him
reconsider whether his issues with OCD were
serious enough to warrant such a stressful
treatment. In addition, he cited the high cost of
treatment and the long commute from his home
as additional reasons for discontinuing treatment. However, he continued to take his SSRI
medication, which was now being prescribed by
his general practitioner.

Assessment
At intake to the clinic, Jason was assessed by
an independent evaluator, who administered the
Structured Clinical Interview for Diagnostic and
Statistical Manual of Mental Disorders (DSMIV; SCID; First etal. 1996). Jason met criteria
for OCD, but no other Axis I disorders. Jason
did describe worrying about minor matters (e.g.,
letters getting lost in the mail), but did not meet
full criteria for generalized anxiety disorder. In
addition, a personality disorder screening tool
was administered, and Jason endorsed symptoms
of perfectionism, rigidity, and hypermorality,
389
qualifying for a comorbid diagnosis of obsessivecompulsive personality disorder (OCPD).

The YaleBrown Obsessive-Compulsive
Scale (YBOCS; Goodman etal. 1989a, b) was
used to measure OCD symptom severity. On the
symptom checklist, Jasons target obsessions
were: (1) concern with dirt/germs and contamination, (2) concern that he will make a mistake
because of not being careful enough, and (3) the
need to know or remember information. Target
compulsions included: (1) checking related to
contamination, (2) checking for mistakes, and (3)
rereading/rewriting. Jason reported that 34h of
his day were occupied by obsessions and compulsions, which he reported to be moderately distressing and very difficult to resist, resulting in a
significant interference both socially and at work.
On the YBOCS severity scale, Jason was rated
with a total score of 27, indicating severe OCD.
On the Clinician Global Impressions (CGI) Scale
(Guy 1976), the evaluator rated Jason as markedly ill based on the distress and interference
caused by his OCD.
Jason was also administered the Brown Assessment of Beliefs Scale (BABS; Eisen etal.
1998), a well-validated measure of patients insight into the senselessness of their symptoms.
On this measure, the rater and patient identify the
dominant belief underlying his/her obsessions
and then the clinician asks specific questions to
quantify how convinced the patient is that the belief is accurate. Jason endorsed a belief that If
I am not careful enough, a calamity will befall
me (either contracting the flu or making a terrible
mistake at work). Jasons BABS score was rated
at 8, indicating fair insight, suggesting he was
somewhat reluctant in acknowledging the excessive and unreasonable nature of his symptoms
(Eisen etal. 1998).
Despite the degree of impairment Jason was
experiencing, the independent evaluator also
noted ambivalence for change in Jasons presentation. In line with concept of readiness rulers
(Rollnick etal. 1992), the evaluating clinician
asked the patient to rate on a 10-point scale (with
anchors of 1not ready to 10already trying)
his readiness to (1) stop his compulsions and (2)
stop avoiding actions that trigger obsessions.
390
To both questions, Jason answered 6, indicating moderate readiness: With further probing,
he expressed uneasiness at the idea of stopping
all of his rituals and maintaining that there are
some situations he is avoiding for good reason
and would never want to approach.
Treatment Course
E/RP treatment proceeded according to a standardized protocol (Foa etal. 2012). In this protocol, the first two sessions are introductory and
include gathering specific information about
the patients OCD symptom and their triggers,
providing psychoeducation about OCD and the
rationale for E/RP, developing an exposure hierarchy and agreeing to a treatment plan. Jason
reported a range of triggers for contamination
obsessions, including seeing hairs/lint on his carpet or clothing, eating in public restaurants, and
touching poles on the subway. Fears about making a mistake were usually triggered by sending
emails to colleagues, submitting paperwork, and
collating files.
In gathering information about these specific
OCD triggers, the clinician used reflective
listening, a key MI skill, to help the patient
articulate clear reasons for change. In addition to
simple reflections (repeating what the patient has
said to convey understanding), the therapist also
targeted statements indicating potential ambivalence about change using amplified reflections
(in which the therapist slightly exaggerates the
patients sustain talk, or statements in favor of
maintaining the status quo, to the point that the
patient may feel the need to disagree with it), as
illustrated below:
Jason: Auditing files at work definitely triggers me to check and re-check to make sure I
havent made a mistake, but that might actually help me catch any potential errors.
Therapist: Oh, I see. So in that sense
having OCD is actually making you a better
employee.
Jason: Well, I wouldnt say that. Actually
sometimes I end up taking much longer to do
the audits than my coworkers because of how
much time I spend triple checking. My boss

has even commented to me that I should be
getting through the files faster.
When Jason seemed to articulate contradictory
opinions, the therapist sometimes employed double-sided reflections (reflecting both the sustain
talk as well as a previously made statement in
favor of change), as illustrated in the exchange
below:
Jason: I miss out going out to eat with my
friends, but I dont think I want to start eating at those sorts of dirty restaurants, even if
all my friends go there, because then I think I
really could get sick.
Therapist: In some ways your avoidance and
rituals feel like a good thing, and at the same
time they are stopping you from having the
social life you want to have.
Jason: Yeah, I guess I have mixed feelings
about it. But on some level I realize it would
be much easier if I could just get over my
obsession about getting the flu because I know
rationally that even if I did get the flu Id probably be okay.
After using these strategies to facilitate change
talk, the therapist utilized key questions to elicit
a clear verbal commitment from Jason to proceed
with E/RP treatment. The therapist then worked
collaboratively with Jason to design an exposure
hierarchy to target situations and objects that provoked his contamination fears. At the lower end
of this hierarchy, Jason identified activities such
as reading about the flu and watching movies that
involved illness epidemics (e.g., Outbreak, Contagion). In the moderate range of this hierarchy,
Jason identified activities that involved reducing
his washing-related compulsions, such as leaving
bits of hair and lint on his carpet at home and
touching subway poles with bare hands. Finally,
at the top of this hierarchy, Jason selected eatingrelated exposures (e.g., eating without washing
his hands first, eating food from dirty restaurants). During this treatment planning, Jason
expressed clear reasons for change in relation to
his contamination symptoms and reported being
committed to conduct those exposures, despite
how difficult they seemed.
On the other hand, Jason expressed clear reluctance to conduct exposures targeting obsessions
about making a mistake at work by stopping his
excessive checking. Jasons reluctance was due
to fears that he would actually make a mistake at
work, resulting in being fired. In standard E/RP,
the therapist might have used psychoeducation in
an attempt to convince the patient that these exposures were necessary. Cognitive therapy techniques could also have been used to help Jason
evaluate the likelihood and severity of the types
of work mistakes he feared. However, noting the
patients past history of discontinuing E/RP and
hearing the patients ambivalence about change
in this domain, therapist took an MI approach to
avoid arguments by instead defusing discord.
The therapist utilized the specific MI strategy of
shifting focus, wherein the therapist suggested
that they gather information about situations
that trigger checking for mistakes, while starting
treatment on the contamination hierarchy, reevaluating together how to address the checking domain as treatment progressed. This strategy succeeded at reducing discord and supported Jasons
autonomy inside the treatment. At the conclusion
of the second introductory session, the therapist
offered Jason an affirmation (Its hard even to
think about confronting some of these situations
we reviewed and at the same time you are taking
an important first step by coming today. You are
brave and courageous to start treatment and I
value your commitment. I am confident you can
help yourself using E/RP), aimed to strengthen
rapport and promote openness to treatment.
Beginning in session 3, Jason began practicing exposures. The first exposures involved confronting flu-related stimuli in the form of newspaper articles, movies, and even words associated the flu. For example, Jason wrote H1N1,
swine flu, bird flu, and influenza on notecards which he hung around his apartment. As
he progressed in treatment, he also worked to reduce his rituals, for example, purposefully leaving pieces of hair and lint on his carpet and in his
backpack.
The therapist utilized the Patient E/RP Adherence Scale (PEAS; Simpson etal. 2010b) at every
session. This measure includes clinician ratings
391
of patient effort in exposure practices and overall ritual prevention success, both in-session and
between-session. Jasons ratings on the PEAS indicated good adherence to in-session exposures,
which he was able to conduct with minimal compulsions or safety aids like asking for therapist
reassurance. However, the therapist noticed that
Jasons between-session PEAS scores were significantly worse, as he frequently failed to complete assigned exposures and was successful at
preventing only a portion (30%) of his rituals.
The therapist identified this nonadherence as
having the potential to reduce the effectiveness
of the treatment and devoted session time to try
to address the issue. Jason reported that he was
having trouble scheduling time for hour-long exposures due to his busy work schedule. The therapist utilized the MI strategy coming alongside
(It is difficult to prioritize homework exposures
with your busy schedule) and elicited comments
to highlight a discrepancy between this behavior
and the patients personal goals (And I also hear
you say how important it is to you to try your
hardest to get over OCD). Once the patient reiterated his commitment to treatment, the therapist
expanded the discussion of the potential hurdle
presented by homework adherence using the
MI-congruent strategy of elicitprovideelicit.
First, the therapist asked for the patients ideas
(What do you think would help you overcome
this obstacle?) and then asked for permission to
provide information to supplement the patients
solutions (Would you like to hear some strategies of how other people have overcome this
same issue?) before finally eliciting the patients
reaction (How do you think this could be applicable to you?). In this discussion, Jason planned
specific times during the day in which he would
practice exposures and decided that it would be
helpful if the therapist utilized between-session
phone calls to promote homework adherence.
After eight sessions, Jason was reassessed by
the independent evaluator in a mid-treatment assessment. Jason was rated as having a YBOCS
score of 21, a 6-point reduction from baseline,
which was rated as minimal improvement on the
CGI change scale. The therapist reviewed the
results of this evaluation with Jason, who agreed
392
with the assessment, saying that he felt he had

made some improvement, but many of his most
troubling symptoms persisted. The therapist elicited Jasons thoughts about this using doublesided reflections and open-ended questions (e.g.,
You see change with the treatment and at the
same time some of your symptoms still remain
and this is troubling to you. What do you think
we need to do differently?). Jason identified his
reluctance to take on bigger items on his exposure hierarchy as an impediment to progress in
treatment. Specifically, he reported that exposures involving eating felt too difficult to try because they felt like they could actually cause him
to become ill. In response, the therapist used the
MI strategies of looking forward and bolstering
confidence, as illustrated below:
Therapist: Eating exposures feel risky to you.
What will your life be like if nothing changes
in this area? [looking forward]
Jason: Well, I guess if I never practice these
exposures Im always going to have a hard
time going out to eat at restaurants. My friends
always make fun of me, and sometimes I have
to turn down their invitations because I dont
trust the food. I dont want that to keep happening, but the idea of doing these exposures
just seems too hard.
Therapist: This feels insurmountable right
now. Can you think of another situation in
which you came up against something that felt
impossible and yet you somehow found a way
to do it? [bolstering confidence]
Jason: Well to be honest, I guess the first
exposures we practiced werent all that easy
to start.
Therapist: Thats true, youve already faced
some situations that were really anxiety-provoking. You demonstrated real courage in
each of those exposures, and in each instance
your anxiety gradually reduced and you were
able to manage. Given those experiences and
the momentum youve developed through
your hard work thus far, how can we proceed?
This discussion helped elicit a commitment to
change and move forward with treatment and
bolstered Jasons confidence in his ability to do
so effectively. Collaboratively, Jason and the
therapist agreed that his first eating-related exposure would be to consume a handful of peanuts
in the office without having washed his hands
after commuting to therapy on the subway. On
the planned day, the patient arrived late for his
appointment and stated resolutely that he had
changed his mind and would not be able to complete the planned exposure. Compatible with an
MI approach that respects the patients autonomy, the therapist stopped the exposure and emphasized personal choice and control:
Therapist: Youre having trouble with this
exposure. I want you to know that its completely your choice whether to proceed or
not. I will not push you to do something that
doesnt feel right for you.
Jason: Im just not sure Im ready to do this.
Eating without washing my hands feels really
scary to me. Almost anything would be easier.
Therapist: What do you feel ready to do right
now?
Jason: I guess I could try starting with door
handles here in the clinic.
By working with Jason to titrate the exposure so
that Jason felt it was doable, the therapist was
able to guide Jason to eventually work his way
up to the top of his contamination hierarchy.
Jason became much more able to limit his rituals and avoidance related to contamination, to the
point where he was spontaneously approaching
situations that he had avoided in the past. Sensing that substantial gains had been made in the
contamination domain, the therapist then brought
up exposures targeting obsessions about making mistakes at work. Jason still exhibited great
reluctance to work on this domain, saying, Im
honestly not sure I want to change this. I like the
fact that Im the type of person who hates making
mistakes, and Im afraid if I change Ill become
sloppy, and maybe even stop caring about errors
and then Ill lose my job.
To enhance motivation, the therapist employed
a running head start (also referred to as a decisional balance discussion). The therapist asked
questions to explore the potential benefits of not
changing (Maybe there are advantages to not
doing anything about your OCD symptoms?),
in order to convey acceptance and understanding
of the patients ambivalence and defuse the potential for discord, before moving on to ask about
the potential reasons for change (What about the
other side? What disadvantages of continuing to
have OCD really stand out as important?). Jason
identified both positive (i.e., greater confidence
that he will not make a mistake) and negative (i.e.,
time lost, perception of coworkers that he is a
slow worker) aspects of maintaining his checking
compulsions. He also identified pros of changing (i.e., greater work efficiency), in addition to
potential cons (i.e., might make a mistake, exposures would be stressful). Through questions,
reflections, and selective emphasis, the therapist
highlighted the pros of making a change as well
as the cons of maintaining the status quo. In this
discussion, the therapist also highlighted the discrepancy between continuing excessive checking
and some of Jasons important goals and values.
Specifically, Jason was able to identify three important values that were impacted by his checking behaviors: (1) having a sense of mastery at
work, (2) being perceived as reliable and conscientious by coworkers, and (3) being a dependable
and available friend. Jason was able to articulate
clear instances in which his excessive checking
was not in line with these values. For example,
Jason recalled how he had been late in turning in
some assignments due to his desire to recheck, as
well as times when he let friends down by canceling plans because he was unable to leave work).
By developing and highlighting this discrepancy
between maintaining the checking behavior and
these important values, the therapist was able to
draw out greater commitment to change.
This approach succeeded at enhancing Jasons
motivation to work on his fears of making mistakes at work. Jason began with relatively easy
exposures, such as replying to an email from a
coworker without checking his sent mail folder
to confirm that it was sent and to ensure that he
had not included any mistakes (e.g., typos). Exposure practices included having Jason complete
additional elements of his job without any compulsive checking, such as collating paperwork.
By this point, 17 sessions had elapsed, constituting a standard dose of E/RP.
393
Following his 17th session, Jason was again

administered the YBOCS and scored a 16, reflecting a substantial reduction in time spent with
obsessions and compulsions (12h per day), as
well as greater ability to control his symptoms.
However, Jasons YBOCS score indicated that
significant residual symptoms remained. Indeed,
Jason felt that he could do better and reported
to the therapist that he desired to keep working,
especially as he had not yet completed the exposures at the top of his fear-of-making-mistakes
hierarchy. Therefore, Jason accepted the offer to
keep working together for an additional four E/
RP sessions.
Early on in these additional sessions, Jason
made statements indicating that he had hesitations about taking on more exposures, expressing
that part of him felt he may have actually made
enough progress in therapy. The therapist listened for and sought to amplify this sustain talk
in order to elicit further change talk. In particular, the therapist aimed to develop discrepancy
between maintaining the status quo and Jasons
important life values, as illustrated below.
Jason: In thinking about it, Im actually not
sure I need to take on todays exposure. I feel
like Im functioning better at work already,
and I can manage at this level.
Therapist: So you feel that you have accomplished everything that you came here for.
Jason: I know Ive made definite progress.
Therapist: There really wouldnt be any benefit to continuing.
Jason: Well Im not sure about that. I mean
part of me really thinks I could still improve.
Therapist: How would leaving your OCD
symptoms exactly where they are get in the
way of living a life that you value?
Jason: I know Id like to get my work done
faster so I wouldnt feel like such a laggard.
Therapist: Theres a part of you that doesnt
want to do todays exposure, and at the same
time, another part of you has the courage and
determination to get as much out of the therapy as possible so that you can become the
worker you want to becomedependable and
efficient. So where does that leave you now?
How do you want to proceed?
394
With conversations such as these, the therapist

was able to tap into Jasons underlying values to
elicit change talk to help Jason face exposures
that pushed him well beyond his usual comfort
zone. For example, Jason practiced an exposure
in which he wrote down a series of expletives
on paper immediately before quickly typing and
sending an email to a coworker without checking to be sure he had not accidentally included an
expletive. These exposures provoked a great deal
of anxiety and strong urges to check, but as with
all previously practiced exposures, Jason found
that his anxiety gradually decreased and he became more comfortable even without checking.
In the final sessions, the therapist addressed
relapse prevention and guided Jason through a
discussion of how motivation to continue practicing E/RP often wanes with time, particularly
once intensive treatment has concluded. As part
of Jasons relapse prevention plan, he and the
therapist had another decisional balance discussion, this time evaluating the pros and cons of
continuing to approach anxiety provoking situations while refraining from rituals. In a posttreatment evaluation, Jason was rated as having
a YBOCS=10, indicating minimal symptoms
(Farris etal. 2013). Jason reported spending less
than an hour a day on obsessions and compulsions and said he was able to control 90% of his
compulsive urges. The symptoms that remained
were some minimal picking of hair and lint off of
his carpet and clothes, and he was rated as much
improved on the CGI.
As described, Jason reported a pattern of maladaptive perfectionism and rigidity, which met
DSM-IV criteria for OCPD. Jasons OCPD complicated his treatment, contributed to his fair
insight, and was a factor in his few remaining
symptoms at termination. OCPD is relatively
common in OCD patient populations, with prevalence estimates of comorbid OCPD ranging from
23 to 35% (Albert etal. 2004; Pinto etal. 2006,
2011; Samuels etal. 2000). Compared to OCD
patients without OCPD, individuals with both
conditions tend to have poorer insight into the

senselessness of their symptoms (Lochner etal.
2011), and OCPD has also been linked to worse
treatment outcomes. For example, Pinto etal.
(2011) found that OCD patients with comorbid
OCPD benefited less from E/RP. Importantly,
compared to other OCPD traits, maladaptive perfectionism was especially predictive of poor E/
RP outcome (Pinto etal. 2011).
Jasons excessive cleaning behaviors (hand
washing, picking hairs, and lint off the carpet)
were mainly motivated by fears of becoming ill
with the flu, but they also related to perfectionistic tendencies with regard to standards for tidiness and neatness. The therapist had much greater
difficulty eliciting change talk for some of these
behaviors. For example, though Jason recognized
that his hand washing was excessive and problematic, he reported that picking crumbs, hair,
and lint off of his carpet was the right thing to
do. These symptoms were congruent with Jasons underlying desire for orderliness and would
be considered ego-syntonic. Through treatment, Jason was able to gradually reduce these
behaviors, but they were not entirely eliminated.
This case highlights the importance of investigating OCPD traits as complicating factors in E/RP
treatment, especially in terms of treatment motivation (Pinto etal. 2008).
Conclusions and Practice Points

Psychotherapy involving E/RP has the potential
to substantially improve the lives of individuals
with OCD, though problems with motivation
can result in a failure to maximally benefit from
this treatment. Limited motivation can manifest
as reluctance, not only to starting E/RP but also
to progressing through increasingly anxietyprovoking exposures. Among several techniques
that show promise to enhance motivation for
E/RP, MI offers practitioners one approach to
enhance motivation and facilitate treatment.
Consistent with the view that reluctance
for change and treatment stems from underlying ambivalence, MI suggests that therapists
avoid confrontation and argumentation during
treatment, instead suggesting that they defuse

discord by supporting patient autonomy and expressing understanding and acceptance of the
patients conflicting feelings about treatment and
change. A central component of MI is the notion
that people learn what they think in part by hearing themselves speak. MI encourages patients to
talk about the importance of change by highlighting the discrepancy between current behaviors
and the patients important life goals and values.
MI practitioners also attempt to elicit talk of confidence in the ability to change by highlighting
and fostering patient self-efficacy.
In the case of Jason, problems with limited
motivation became evident through nonadherence to homework and reluctance to take on
some exposures. MI-congruent strategies, particularly reflective listening, articulating values,
highlighting discrepancy, and decisional balance
discussions proved helpful at enhancing Jasons
willingness to fully participate in treatment,
while also bolstering his sense of self-efficacy.
Once Jason committed to change, treatment progressed rapidly and his symptoms were significantly reduced.
The case history presented here illustrates how
limited motivation can be targeted in adults with
OCD, highlighting MI, one of several strategies
that have been used to enhance motivation. Other
strategies include cognitive techniques and readiness therapy, in addition to modifications that can
be made within the E/RP protocol itself. Optimal
treatment should be tailored to each individuals
presenting concerns and could include a combination of these motivational enhancement techniques for patients with limited motivation for
treatment.
Importantly, though some empirical research
has been done on the topic of motivation for
treatment in OCD, substantial questions remain.
In particular, no studies have directly compared
different motivational-enhancement techniques,
or systematically evaluated how best to integrate
such efforts with E/RP (i.e., as a stand-alone
treatment before E/RP entry or interwoven within
standard E/RP). Future research is also necessary
to determine which interventions are most effective at improving patient adherence to E/RP treat-
395
ment and whether this improved patient adherence then causally leads to improved treatment
outcome. Finally, the case reviewed here was
relatively straightforward. In other instances, E/
RP treatment can be complicated by factors such
as poor insight and other forms of comorbidity
(e.g., severe depression). It is not clear if MI is effective in these cases, again highlighting the need
for greater research on motivational enhancement in conjunction with OCD treatment.
Key Practice Points

Limited motivation may interfere with the
ability of some OCD patients to adhere to E/
RP treatment, limiting their ability to fully
benefit from this treatment.
MI aims to increase motivation for change and
willingness to fully participate in treatment.
An MI approach aims to resolve ambivalence
in favor of patients intrinsic motivation for
change.
Specific MI strategies including eliciting
change talk, defusing discord, and highlighting discrepancy between the patients current
behaviors and important goals and values.
Strategies derived from an MI approach can
be used alongside E/RP procedures and may
help enhance adherence to this treatment for
some individuals.
References
Abramowitz, J. S., Taylor, S., & McKay, D. (2009).
Obsessive-compulsive disorder. The Lancet, 374,
491499.
Albert, U., Maina, G., Forner, F., & Bogetto, F. (2004).
DSM-IV obsessive-compulsive personality disorder:
Prevalence in patients with anxiety disorders and in
healthy comparison subjects. Comprehensive Psychiatry, 45, 325332.
Eisen, J. L., Phillips, K. A., Baer, L., Beer, D. A., Atala,
K. D., & Rasmussen, S. A. (1998). The Brown
assessment of beliefs scale: Reliability and validity.
Farris, S. G., McLean, C. P., Van Meter, P. E., Simpson, H.
B., & Foa, E. B. (2013). Treatment response, symptom
remission, and wellness in obsessive-compulsive disorder. The Journal of clinical psychiatry, 74, 685690.
396
(1996). Structured clinical interview for DSM-IV Axis
I disorders, patient edition (SCID-P), version 2. New
York: Biometrics Research Department, New York
State Psychiatric Institute.
Foa, E. B., Steketee, G., Grayson, J. B., & Doppelt, H.
G. (1983). Treatment of obsessive-compulsives: When
do we fail? In E. B. Foa & P. M. G. Emmelkamp
(Eds.), Failures in behavior therapy (pp.1034). New
York: Wiley.
and response (ritual) prevention for obsessive compulsive disorder: Therapist guide. New York: Oxford
University Press.
C., Fleischmann, R. L., Hill, C. L., etal. (1989a). The
Yale-Brown obsessive compulsive scale: I. Development, use, and reliability. Archives of General Psychiatry, 46(11), 10061011.
C., Delgado, P., Heninger, G. R., & Charney, D. S.
(1989b). The Yale-Brown obsessive compulsive
scale: II. Validity. Archives of General Psychiatry, 46,
10121016.
Guy, W. (1976). Clinical Global Impressions. In W. Guy
(Ed.), ECDEU assessment manual for psychopharmacology, revised (DHEW Publ No ADM 76-338)
(pp.218222). Rockville: National Institute of Mental
Health.
Haan, E. D., Oppen, P. V., Balkom, A. J. L. M., Spinhoven, P., Hoogduin, K. A. L., & Dyck, R. V. (1997).
Prediction of outcome and early vs. late improvement
in OCD patients treated with cognitive behaviour therapy and pharmacotherapy. Acta Psychiatrica Scandinavica, 96, 354361.
Hettema, J., Steele, J., & Miller, W. R. (2005). Motivational interviewing. Annual Review of Clinical Psychology, 1, 91111.
Hoogduin, C. A., & Duivenvoorden, H. J. (1988). A decision model in the treatment of obsessive-compulsive
neuroses. British Journal of Psychiatry, 152, 516521.
Keijsers, G. P., Hoogduin, C. A., & Schaap, C. P. (1994).
Predictors of treatment outcome in the behavioural
treatment of obsessive-compulsive disorder. British
Koran, L., & Simpson, H. (2010). Guideline watch
(March 2013): Practice guideline for the treatment of
patients with obsessive-compulsive disorder. In APA
practice guidelines. Arlington: American Psychiatric.
Lochner, C., Serebro, P., der Merwe, L. V., Hemmings,
S., Kinnear, C., Seedat, S., & Stein, D. J. (2011).
Comorbid obsessivecompulsive personality disorder
in obsessivecompulsive disorder (OCD): A marker of
severity. Progress in Neuro-Psychopharmacology and
Biological Psychiatry, 35(4), 10871092.
Lundahl, B. W., Kunz, C., Brownell, C., Tollefson, D., &
Burke, B. L. (2010). A meta-analysis of motivational
interviewing: Twenty-five years of empirical studies.
Research on Social Work Practice, 20, 137160.
Maltby, N., & Tolin, D. F. (2005). A brief motivational
intervention for treatmentrefusing OCD patients.
Cognitive Behaviour Therapy, 34, 176184.
McKay, D. E., Abramowitz, J. S., & Taylor, S. E. (2010).
Cognitive-behavioral therapy for refractory cases:
Turning failure into success. Washington, DC: American Psychological Association.
Merlo, L. J., Storch, E. A., Lehmkuhl, H. D., Jacob, M.
L., Murphy, T. K., Goodman, W. K., & Geffken, G.
R. (2010). Cognitive behavioral therapy plus motivational interviewing improves outcome for pediatric
obsessivecompulsive disorder: A preliminary study.
Cognitive Behaviour Therapy, 39, 2427.
Meyer, E., Souza, F., Heldt, E., Knapp, P., Cordioli, A.,
Shavitt, R. G., & Leukefeld, C. (2010). A randomized clinical trial to examine enhancing cognitivebehavioral group therapy for obsessive-compulsive
disorder with motivational interviewing and thought
mapping. Behavioural and Cognitive Psychotherapy,
38, 319336.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York:
Guilford.
Murray, C. J. L., & Lopez, A. D. (1996). The global burden of disease: A comprehensive assessment of mortality and disability from diseases, injuries and risk
factors in 1990 and projected to 2020. Cambridge:
Harvard University Press.
Osgood-Hynes, D., Riemann, B., & Bjorgvinsson, T.
(2003). Short-term residential treatment for obsessivecompulsive disorder. Brief Treatment and Crisis Intervention, 3, 413.
Pinto, A., Mancebo, M. C., Eisen, J. L., Pagano, M. E.,
& Rasmussen, S. A. (2006). The brown longitudinal
obsessive compulsive study: Clinical features and
symptoms of the sample at intake. Journal of Clinical
Pinto, A., Eisen, J. L., Mancebo, M. C., & Rasmussen, S.
A. (2008). Obsessive compulsive personality disorder.
In J. S. Abramowitz, D. McKay, & S. Taylor (Eds.),
Obsessive-compulsive disorder: Subtypes and spectrum conditions. New York: Elsevier.
Pinto, A., Liebowitz, M. R., Foa, E. B., & Simpson, H.
B. (2011). Obsessive compulsive personality disorder
as a predictor of exposure and ritual prevention outcome for obsessive compulsive disorder. Behaviour
Pollard, C. A. (2006). Treatment readiness, ambivalence,
and resistance. In M. M. Antony., C. Purdon, & L.
J. Summerfeldt (Eds.), Psychological treatment of
obsessive compulsive disorder: Fundamentals and
beyond (pp.6178). Washington, DC: APA Books.
Rollnick, S., Heather, N., Gold, R., & Hall, W.
(1992). Development of a short readiness to
changequestionnaire for use in brief, opportunistic
interventions among excessive drinkers. British Journal of Addiction, 87, 743754.
Samuels, J., Nestadt, G., Bienvenu, O. J., Costa, P. T., Jr.,
Riddle, M. A., Liang, K. Y., Hoehn-Saric, R., Grados,
M. A., & Cullen, B. A. (2000). Personality disorders

and normal personality dimensions in obsessive-compulsive disorder. British Journal of Psychiatry, 177,
457462.
Simpson, H. B., Zuckoff, A., Page, J. R., Franklin, M. E.,
& Foa, E. B. (2008). Adding motivational interviewing to exposure and ritual prevention for obsessive
compulsive disorder: An open pilot trial. Cognitive
Behaviour Therapy, 37, 3849.
Simpson, H. B., Zuckoff, A. M., Maher, M. J., Page, J.
R., Franklin, M. E., Foa, E. B., etal. (2010a). Challenges using motivational interviewing as an adjunct
to exposure therapy for obsessive-compulsive disorder. Behaviour Research and Therapy, 48, 941948.
Simpson, H. B., Maher, M., Page, J. R., Gibbons, C. J.,
Franklin, M. E., & Foa, E. B. (2010b). Development
of a patient adherence scale for exposure and response
prevention therapy. Behavior Therapy, 41, 3037.
Simpson, H. B., Maher, M. J., Wang, Y., Bao, Y., Foa, E.
B., & Franklin, M. (2011). Patient adherence predicts
outcome from cognitive behavioral therapy in obsessive-compulsive disorder. Journal of Consulting and
Sookman, D., & Pinard, G. (1999). Integrative cognitive
therapy for obsessive-compulsive disorder: A focus on
multiple schemas. Cognitive and Behavioral Practice,
6, 351362.
397
Sookman, D., & Steketee, G. (2007). Directions in specialized cognitive behavior therapy for resistant obsessive-compulsive disorder: Theory and practice of two
approaches. Cognitive and Behavioral Practice, 14,
117.
van Dyke, M. M., & Pollard, C. A. (2005). Treatment
of refractory obsessive-compulsive disorder: The StLouis model. Cognitive and Behavioral Practice, 12,
3039.
Zuckoff, A., & Hettema, J.E. (2007, November). Motivational interviewing to enhance engagement and adherence to treatment: A conceptual and empirical review.
In H. B. Simpson (chair), Using motivational interviewing to enhance CBT adherence. Paper presented
at the 41st annual convention of the Association for
Behavioral and Cognitive Therapies, Philadelphia,
PA.
Zuckoff, A., Balan, I. C, & Simpson, H. B. (2015).
Enhancing the effectiveness of exposure and response
prevention in the treatment of obsessive compulsive
disorder: Exploring a role for motivational interviewing. In H. Arkowitz, W. R. Miller, and S. Rollnick
(Eds.), Motivational interviewing in the treatment of
psychological disorders (2nd ed). New York: Guilford.
Treatment of Individuals
Disorder Who Have Poor
Insight
27
Michael J. Larson, Kaitlyn Whitcomb, Isaac J. Hunt

and Daniel Bjornn
Nature of Insight and Research Basis

Insight in obsessive-compulsive disorder
(OCD)refers to an individuals recognition that
his/her symptoms are present, excessive, and unreasonable (Foa and Kozak 1995). A large proportion of individuals with OCD have limited
awareness of the presence and impact of their
obsessions and compulsions. Poor insight can be
found in 930% of adults diagnosed with OCD
(Catapano etal. 2010; Cherian etal. 2012; Foa
and Kozak 1995; Jakubovski etal. 2011; Ravi
Kishore etal. 2004). Storch etal. (2008) demonstrated that pediatric cases of OCD are associated with even lower rates of insight than adults
(poor insight found in 35 of 78 children or 45%).
Despite the high rates of poor insight, the fourth
edition of the Diagnostic and Statistical Manual
of Mental Disorders (DSM-IV) was the first edition of the DSM to include a specifier for poor
insight in OCD (American Psychiatric Association 1994). The more recent DSM-5 was further
revised to include more diagnostic specifiers for
insight (American Psychiatric Association 2013).
Specifically, when making a diagnosis of OCD,
M.J.Larson()
Department of Psychology and Neuroscience Center,
Brigham Young University, 244 TLRB, Provo,
UT 84602, USA
e-mail: michael_larson@byu.edu
K.Whitcomb I.J.Hunt D.Bjornn
Department of Psychology, Brigham Young University,
Provo, UT, USA
a clinician may indicate whether the client has

good or fair insight, poor insight, or absent insight/delusional symptoms. These classifiers
have led to a renewed interest in the role of insight in OCD-related functioning and treatment.
Research on insight suggests poorer treatment
outcomes and increased functional impairment
in those with low insight relative to high insight.
In this chapter, we outline the research on the
problem of insight in OCD and OCD treatment
and then present an illustrative case of how poor
insight can influence OCD diagnosis and treatment, as well as provide suggestions for tailoring
treatment to individuals with poor insight.
Clinical Impact of Poor Insight

Individuals with poor insight into their obsessive-compulsive symptoms generally experience
a more severe form of the disorder (Catapano
etal. 2010; Cherian etal. 2012; Jacob etal. 2014;
Jakubovski etal. 2011; Ravi Kishore etal. 2004).
An earlier age of OCD onset is correlated with
poor insight (Catapano etal. 2010; Ravi Kishore
etal. 2004) and longer duration of illness (Ravi
Kishore etal. 2004). Poor insight is also associated with greater severity of obsessive-compulsive
symptoms (Catapano etal. 2010; Cherian etal.
2012; Jacob etal. in press; Jakubovski etal. 2011;
Ravi Kishore etal. 2004) and an increased likelihood for comorbid depressive symptoms (Catapano etal. 2010; Ravi Kishore etal. 2004). The
increased severity of symptoms may be linked

DOI 10.1007/978-3-319-17139-5_27
399
400
to the decreased ability to resist obsessions and

compulsions (Catapano etal. 2010; Jacob etal.
in press). Research on the relationship between
poor insight and specific subtypes of OCD demonstrates that poor insight may be associated
with the contamination (Cherian etal. 2012) and
hoarding (Jakubovski etal. 2011) dimensions of
the disorder.
Treatment Relationships with Insight

In addition to the increased severity of OCD
symptoms, poor insight creates several barriers to
treatment. For example, Tolin etal. (2004) found
that OCD patients with poor insight put forth less
effort in psychotherapy. Additionally, individuals
with poor insight into their OCD symptoms are
only half as likely as their peers with good insight
to seek treatment in the first place (Demet etal.
2010). Although some studies have found no significant treatment outcome differences between
individuals with poor insight and good insight
(Alonso etal. 2008; Eisen etal. 2001), a growing body of evidence indicates that poor insight is
associated with decreased effectiveness of pharmacological treatments and cognitive-behavioral
therapies (CBTs; Catapano etal. 2010; Erzegovesi etal. 2001; Shetti etal. 2005; Tolin etal. 2004;
Raffin etal. 2009). It is therefore an important
step in the clinical treatment of people with OCD
to assess the clients level of insight into his or
her symptoms as part of the initial evaluation. In
cases with poor insight, a starting point may be
to help the client understand the full impact of
her or his obsessive-compulsive symptoms with
increased psychoeducation and focus on insight
before proceeding with treatment.
Insight in OCD increases as obsessive-compulsive symptoms decrease in treatment (Alonso
etal. 2008; Eisen etal. 2001). Although insight
and symptom severity covary as a function of
treatment, a causal relationship between the two
has not been established. To date, no research has
been conducted to demonstrate whether deliberate attempts to improve insight before beginning
treatment result in greater treatment compliance
and improved outcomes. Below, we present a
M. J. Larson et al.
case of an individual with severe and debilitating

OCD symptoms who had been unemployed for
more than 33 years due to OCD-related anxiety
and was fully unaware of the obsessive-compulsive nature of her symptoms. We highlight difficulties and procedures during both the assessment and treatment process and conclude that
increased psychoeducation and focus on insight
can benefit individuals with poor insight presenting for OCD treatment.

Ruth (name changed to protect confidentiality;
however, the case report is completed with her
permission) is a 55-year-old Caucasian female
who was referred by a relative in the medical
field for a psychological evaluation to get more
information about why she struggled to initiate
and complete tasks. At the initial interview, Ruth
simply stated that she wanted to know why she
could not function like a normal person. She
said that she was hoping to find an explanation
for her experiences, saying, I just want to know
whats wrong with me and find out if theres anything I can do about it. She reported frequently
feeling nervous, uncomfortable in social situations, and unable to maintain occupational positions.
Though she had very poor insight at the time
of the evaluation, Ruth learned through assessment and subsequent cognitive-behavioral
treatment that the experiences she was describing were symptoms of OCD. Specifically, she
endorsed obsessions about contamination and
cleanliness, organization, and perfection as well
as compulsions of washing and changing clothes
after being exposed to contaminating situations, checking, organizing, and avoiding. During the assessment, however, she described her
experiences in different terms. She explained that
she consistently felt too restless and distractible
to start or complete tasks, noting particular difficulty with jobs she considered to be too daunting
(e.g., cleaning her room), resulting in a seemingly
paradoxical situation in which she wanted things
to be clean, but felt she could not bring herself
27 Treatment of Individuals with Obsessive-Compulsive Disorder Who Have Poor Insight
to do the cleaning. In social situations, such as

family gatherings, she reported feeling that she
had to escape as fast as possible, saying she felt
like a smothered, sweaty, nervous wreck, when
all those people came into her world, and she
knew she would have to clean up after them. She
also noted significant distress centered around
her inability to work outside the home. Specifically, she indicated that she felt suffocated, restless, and like she was on pins and needles any
time she did work. Lastly, she reported feeling
extremely uncomfortable around places or people she felt were dirty, stating that she had to go
home and change all her clothes and shower or
wash her hands after being in those situations (we
expound on these symptoms below). Ruth had
very poor insight regarding her obsessions and
compulsions and made no connection between
the distressing experiences she described and a
possible diagnosis of OCD. In fact, she indicated
that she was unaware that she had any obsessions
or compulsions, or that all of these experiences
were related and could be explained by and treated as OCD.
Case Information
When asked about the onset of her symptoms,
Ruth explained that she had noticed her symptoms of OCD throughout her life, but was unclear
of a precise time of onset. She was raised on a
farm in a small city by her biological parents with
her two brothers. She has lived and worked on the
farm most of her life and currently resides there
with her aging mother. She reported a number
of habits she developed in living on the family
farm that she later (i.e., during treatment) came
to recognize as compulsive behaviors employed
to decrease anxiety caused by obsessions. For example, she would wash her hands frequently during farm work, avoid certain areas of the farm she
considered to be contaminated, and wear gloves
while handling even nontoxic cleaning agents
to avoid being poisoned or contaminated. She
also reported that she often feels so antsy that
she has difficulty even getting anything done
around the house or farm. She reported that she
401
had a good relationship with her family, but noted

that her parents were often critical of her growing
up, and she did not feel like she could be open
about her day-to-day struggles. Even now, Ruth
states that her mother criticizes Ruths nearly
constant struggle to stay organized and clean and
does not seem to understand her.
Ruth also noticed her OCD symptoms while
attending school, although she did not recognize them as such. She stated that she was smart
enough to get good grades by simply floating
through school, even though she often avoided
doing her homework. After finishing high school,
Ruth started attending a local university while
continuing to live at home and work on the farm.
She said that it proved too difficult to work and
attend school simultaneously, so she transferred
to a different school and moved away from home;
however, while she was away at school, she felt
constantly nervous and had difficulty completing
assignments. After a year of school, she decided she just could not do it, and moved home.
What she did not realize was that her struggle to
complete her homework and other tasks could be
related to an obsessive need for perfection that
created anxiety about trying and failing. She even
mentioned that when she moved back to the family farm, she could not bring herself to unpack
her boxes, so they remained in stacks in her bedroom through treatment, over 20 years later.
Aside from working on the farm with her family, Ruth only briefly held two other jobs in the
community. She said she worked for 2 months
as a grocery store bookkeeper, but could not
work there any longer than that because she frequently felt anxious and could not stay in that
small room where she worked, even though she
enjoyed the work she did. She also worked for
two and a half months at a veterinarians office,
which she said was tolerable because she was
able to move around more, but she had to stop
working due to sickness. She stopped working
there at the age of 22 years, and she had not had
a job outside the home since that time (approximately 33 years). Again, she made no connection
between obsessions of perfection and her struggle to work.
402
Ruth denied previous history of mental illness in her family. She reported that her father
died of pancreatic cancer and that her mother
has an autoimmune disease called sarcoidosis.
When asked if she had experienced any serious
illnesses, Ruth reported that as a young adult she
had her appendix removed. While she was recovering from the surgery, a family friend came to
visit who reportedly had hepatitis at the time and
transmitted the disease to Ruth while they were
playing cards together. She reported that at the
time, she and her family thought pesticides from
the farm had poisoned her. She noted that it was
at this point that she noticed her preoccupation
with contaminants and poisons began; however,
her insight into her experience was such that neither she nor her physician ever considered OCD
in relation to her incorrect assumption that her
hepatitis symptoms were caused by poison. It
was not until she had been sick for about a year
that she was diagnosed with hepatitis.
Another significant medical issue that Ruth
reported is a long history of anorexia nervosa.
She has struggled with anorexia for most of her
adult life, reporting that she binges and purges
512 times per day, with typical binges including
sandwiches, nuts, cookies, and ice cream. Other
than her daily breakfast of chicken broth and
Brewers yeast, she reported that she purges everything she eats by vomiting immediately after
eating. Ruth said she was first diagnosed with
bulimia in her 20s by her psychiatrist, but that
it later developed into anorexia. She reports
that she has worked with a few therapists on her
eating disorder over a couple of years, but never
considered OCD as an explanation or comorbid
condition associated with her experiences and
never received treatment for it. The treatment she
did get she reported she did not like or consider
helpful, and thus has not sought treatment in over
20 years.
While explaining her experiences with anorexia and her struggle to function as she would
like to, Ruth commented that she has felt hopeless for years. She reported that the struggle to
hold a job distresses her most because she cannot
take care of herself financially or contribute to
M. J. Larson et al.
the well-being of her family. In fact, she reported

that because of her symptoms and being unable to
feel like a productive contributor, she has given
up on having a happy life and feels worthless on
a regular basis.
Prior to conducting our assessment with Ruth, we
formulated potential explanations for the struggles she described in her initial intake interview,
which included a simple description of her concern about her inability to finish tasks, as well
as her anorexia. As possible explanations for her
struggle to be productive, we sought to rule in or
rule out attention-deficit/hyperactivity disorder
(ADHD) which could cause significant distractibility, major depressive disorder (MDD) which
could blunt motivation and focus, OCD which is
highly comorbid with anorexia and could cause
anxiety in task completion, malnutrition due to
her eating disorder that could limit her cognitive
functioning, and low intellectual ability or poor
executive functioning that could inhibit her ability to plan and organize.
After conducting a thorough assessment, we
were able to rule in or out each of our potential
explanations for her symptoms (see Table27.1
for tests administered and results). We confirmed
Ruths previous diagnosis of anorexia nervosa,
binge eating/purging type, as evidenced by her
refusal to maintain a normal body weight, fear
of weight gain, influence of body shape on selfevaluation, and regular binging and purging.
Symptoms of OCD were assessed using a clinical interview, the YaleBrown Obsessive-Compulsive Scale (Y-BOCS) and scales on the Minnesota Multiphasic Personality InventorySecond
Edition (MMPI-II). Results of the assessment
measures given are provided in Table27.1. Ruth
endorsed clinically significant symptoms of OCD
with limited insight into her symptoms and a total
Y-BOCS score of 28, which falls in the severe
range. She endorsed recurrent obsessions about
contamination, cleanliness, and organization that
were more significant than worries about real-

Table 27.1 Psychometric tests and measures and corresponding results
Y-BOCS
WAIS-IV
CAARS-L
Self
Obs.
Obsessions
13
FSIQ
117
Inattention
74
77
Compulsions 15
VCI
96
Hyperactivity
62
52
Total
28
PRI
125
Impulsivity
59
68
WMI
114
Self-concept
69
72
PSI
127
DSM Inatten.
70
63
DSM Hyper.
56
57
DSM Comb.
65
61
ADHD index
71
75
MMPI-2
VRIN
TRIN
F
Fb
Fp
L
K
S
403
1
84
2
107
3
94
4
53
5
57
6
59
7
83
8
78
9
43
0
69
Y-BOCS YaleBrown Obsessive-Compulsive Scale, DSM Diagnostic and Statistical Manual, WAIS-IV Wechsler Adult
Intelligence ScaleFourth Edition, FSIQ full-scale intelligence quotient, VCI Verbal Comprehension Index, PRI
Perceptual Reasoning Index, WMI Working Memory Index, PSI Processing Speed Index, CAARS-L Conners Adult
ADHD Rating Scalelong version (self and observer report), ADHD attention-deficit/hyperactivity disorder, DSM
Inatten. DSM-IV inattention, DSM Hyper. DSM-IV hyperactivity, DSM Comb. DSM-IV combined type, MMPI-2
Minnesota Multiphasic Personality InventorySecond Edition, VRIN Variable Response Inconsistency Scale, TRIN
True Response Inconsistency Scale
life problems, were unsuccessfully ignored, and

were recognized as a product of her own mind.
She also reported repetitive compulsive behaviors performed in response to her obsessions that
were intended to reduce distress. Though Ruth
acknowledged that most people do not experience
these things, she did not believe them to be excessive. These obsessions and compulsions were
reported to cause significant distress, particularly
when Ruth felt she was not in control of a situation, took more than 4h a day, and interfered with
her work and social life. The symptoms reported
were not due to substance use and were not exclusively related to her eating disorder, though she
did have many additional compulsions surrounding eating. Ruth also showed elevated levels of
anxiety and depressive symptoms on the MMPIII. Taken together, we determined that Ruth met
criteria for a diagnosis of obsessive-compulsive
disorder, with poor insight. We noted that these
symptoms likely accounted for much of the distress Ruth described, making it difficult for her
to concentrate, initiate and complete tasks, and
participate in social and occupational endeavors
without experiencing significant distress.
Another comorbid condition we assessed for
that could account for a portion of Ruths distress and trouble concentrating was depression.
She reported clinically significant symptoms of
62
58
65
62
58
47
49
52
depression, such as depressed mood, anhedonia,

decreased energy, sleep disturbance, and feelings
of worthlessness, which indicate that at the time
of the assessment, Ruth met criteria for MDD.
We also assessed suicide risk, but Ruth reported
that she was not having suicidal thoughts and had
no plan to attempt suicide.
In contrast, some of our other potential explanations for her symptoms seemed less likely after
our initial assessment. For example, cognitive
ability was not likely to be the source of Ruths
occupational concern, as she reported performing well in the jobs she had, and she performed
above average when compared to her same-age
peers on the Wechsler Adult Intelligence ScaleFourth Edition (WAIS-IV). On measures of inattention, namely the Conners Adult ADHD Rating ScaleSelf-Report: Long Version (CAARSS:L) and Observer Report: Long Version
(CAARS-O:L), Ruth and her brother reported
that she struggles significantly with inattention
and memory. However, she did not endorse diagnosable symptoms of ADHD in our clinical interview. Lastly, she reported some symptoms of
anxiety, such as feelings of restlessness, muscle
tension, difficulty concentrating, and irritability,
but did not report worrying about several routine things or exclusively social fears. As such,
we determined that these symptoms were likely
404
better explained by her OCD than by generalized

or social anxiety.
In reporting the results of the assessment to
Ruth, we made sure to adapt our feedback to
her poor level of insight. We explained that her
symptoms could be understood as a pattern of
behavior in which she worries or obsesses about
things like cleanliness and contamination and
then feels compelled to use behaviors (i.e., washing, avoiding, etc.) to decrease the anxiety caused
by those obsessions. She expressed that she was
relieved to know there was an explanation for her
experience, and that there was a way to treat it.
She decided to pursue therapy at our clinic as the
first step in her treatment.

Ruths 20-session treatment course generally
followed the manual utilized by Abramowitz
etal. (2003) in their study of intensive versus
twice-weekly CBT for OCD, but was adapted
to address Ruths poor insight. Broad changes
we made include additional psychoeducation to
enhance insight, a focus on insight throughout
treatment and particularly during cognitive restructuring, four additional sessions, and the use
of once-weekly sessions instead of twice-weekly
sessions. We used this manual because it is an
empirically supported method that employs CBT
with exposure and ritual prevention (ERP), the
gold standard in OCD treatment (Ponniah etal.
2013). It uses a set of interventions that are additive steps (explained below), which we believed
would lead to increased insight and concomitant
reduction of obsessive thoughts, compulsive behaviors, and improved emotion regulation skills.
In determining how best to treat Ruth, we also
had to consider whether or not to incorporate
treatment for her anorexia. Because of liability
issues associated with the training status of our
clinic, the seriousness and chronicity of her anorexia, as well as a lack of clinical expertise in
eating disorder treatment, we decided it would
be best to refer that portion of her treatment to
another clinician. We discussed this decision
with Ruth and gave her contact information for
M. J. Larson et al.
potential resources to pursue. Recent studies suggest that OCD-related difficulties can be treated
simultaneously with eating disorders (Simpson
etal. 2013); however, our clinic was not equipped
with the eating disorder resources needed to treat
anorexia of Ruths severity. Thus, Ruth accepted
a referral to address her eating disorder at an alternate facility with expertise in eating disorders.
The Abramowitz etal. manual we selected
starts by describing how to educate clients about
the cycle of OCD. Specifically, it explains that
certain internal or external cues spark discomfort
or anxiety, which the client attempts to reduce by
using rituals or avoiding those cues altogether.
Using rituals to decrease anxiety is reinforced because they provide initial relief, but do not function as a long-term solution to the anxiety because they do not address the obsessions, or the
root of the anxiety. The treatment elaborates on
this topic, explaining that the goal is to interrupt
this cycle by breaking the connection between
the cues or triggers and anxiety and the connection between anxiety and the automatic reaction
to engage in rituals.
Explaining this cycle of OCD symptoms was
especially important for Ruth because her poor
insight led to poor recognition that she had compulsive behaviors, let alone that she was using
those rituals to decrease anxiety from obsessions. In fact, in our first session, we described
this cycle in detail, and when asked if she understood, she replied, I guess; but I cannot grab
onto what Im doing in terms of behaviors that
fit the aforementioned cycle. In order to illustrate
the cycle, we spent extra time relative to typical
OCD treatment cases going through specific examples of how the cycle played out in her life.
For example, we suggested that when she goes
to a house that she considers to be dirty, the accompanying thoughts she might have include,
Its dirty and Ill get contaminated, noting that
those thoughts probably do not go away. We then
asked her how that experience and those thoughts
affected her anxiety, and she endorsed that they
were associated with increased anxiety. We asked
her what she does after leaving the dirty house,
and she reported that she changes all her clothes
and takes a shower. When asked how the shower
affects her anxiety, she reported that it decreases

it. After going through a few more examples of
her patterns of behavior, she said she could see
how the cycle played out in her life more. We
continued to review the concept of the OCD
cycle for the first four sessions to make sure she
understood it well.
Homework assignments for the initial sessions focused on awareness and insight into
OCD-related behaviors. Specifically, in the first
session, we asked Ruth to read a handout from
the manual explaining OCD-related facts and
self-monitor her triggers, thoughts, and compulsions. She reported that she would read the handout, but struggled to self-monitor, so we made
our instructions for self-monitoring more specific
for her next homework assignment and practiced
in session. We asked that she pay attention to any
time she felt anxious throughout the week between sessions and then try to identify the triggers associated with that anxiety as she experienced them in the present moment, and also to
sit and reflect on triggers that she had historically
dealt with. After attempting the homework with
these new instructions adapted to her poor level
of insight, she reported that she was able to come
up with a short list of triggers. However, she still
reported that it was still difficult to identify triggers because she had to use [her] brain in a way
that [she was] not used to.
After discussing the OCD cycle, we drew a diagram to help illustrate the cycle in another way
to continue to try and help improve her insight
(see Fig.27.1 for diagram). We used this type
Fig. 27.1 The OCD cycle diagram used to educate Ruth.

It shows that an internal or external cue 1 triggers an
increase in anxiety 2. Performing a compulsive ritual 3
serves to decrease the anxiety. The next time a cue triggers anxiety 4, the same ritual is performed to decrease
the anxiety again, and the cycle continues 5
405
of diagram throughout treatment to demonstrate

how the OCD cycle applied to her specific obsessions and compulsions, how ERP could interrupt
the cycle, and to demonstrate progress. In this
way, we added additional psychoeducation techniques not included in the manual. Although Ruth
lacked insight into her symptoms, based on our
assessment of her cognitive abilities, we knew
that she had the intelligence to understand our
psychoeducation. As such, we believed including
additional psychoeducation would improve her
insight into her symptoms and positively affect
her response to treatment.
In addition to psychoeducation, there are four
main treatment procedures outlined in the treatment manual: self-monitoring of rituals, ERP,
cognitive restructuring, and relapse prevention.
Self-monitoring was introduced in the first session and was emphasized throughout treatment.
We used two forms to help Ruth monitor her triggers, thoughts, and compulsions, and later her
ERP practice. First, we used a form with columns
in which to record trigger events, accompanying
automatic thoughts, the realistic probability that
the automatic thought is true, and alternative outcomes and coping strategies. Second, we used an
ERP tracking form that included spaces to report
the date and time of each exposure practice, the
type of exposure, and her subjective unit of distress (SUDS) ratings over the course of the exposure practice.
Initially, Ruth struggled to self-monitor and
track her own symptoms, at least partly due to her
lack of insight. For example, as noted above, one
of her homework assignments in her first session
was to monitor her triggers that sparked anxiety
and the compulsions or rituals she engaged in to
decrease that anxiety. However, Ruth reported
that she had trouble noticing specific triggers
because she did not go out much during the
week between our sessions. Although she was
correct in noticing she engaged in less compulsive behaviors inside her home than outside, she
failed to realize at the time that she engaged in
many compulsive behaviors without ever leaving
her house. For example, she endorsed re-rinsing
dishes after they were washed in the dishwasher,
avoiding certain areas of the farm she considered
406
contaminated, washing her shoes after working

outside, etc.
To aid her in her efforts to identify triggers
and monitor her own behavior, we talked through
multiple different scenarios as we began to develop a hierarchy of feared or potentially contaminating situations. We started by introducing the idea of SUDS ratings, identifying triggers she had mentioned in our assessment, and
determining what she thought her SUDS rating
would be if she confronted those triggers without performing a ritual afterward. Due to her
lack of insight, this process required the majority of two sessions to complete. An abbreviated
version of the hierarchy we initially developed
over the course of approximately two sessions is
shown in Table27.2. While Ruth required direction and encouragement in her self-monitoring,
developing this hierarchy created a starting point
for her progression through treatment. Over the
course of treatment and with frequent education
about obsessions and compulsions, she eventually gained the insight needed to identify her own
triggers in other areas of her life.
The therapeutic procedure that occupied the
most time in session was ERP. Once Ruths initial OCD hierarchy was established, we started
in-session ERP and continued with that as our
M. J. Larson et al.
dominating intervention in the majority of the

subsequent sessions. Initially, we spent a significant amount of time explaining the rationale
for ERP. We introduced the concept by acknowledging that though ERP can be unpleasant and
distressing at first, after multiple exposures to
the same trigger, eventually the trigger will no
longer cause anxiety, and the cycle between that
trigger and increased anxiety will be broken. We
explained that the response prevention is needed to dispel the idea that in order for anxiety to
come down, the compulsion must be performed,
thus breaking the cycle between peaked anxiety
and automatic performance of rituals. After I described this process, Ruth said Youve got my
heart beatingIm a nervous wreck already. Ill
do it, but Im scared.
The way we used ERP was by conducting insession exposures and then assigning exposure
practice for homework as outlined in the treatment manual. We tracked in-session exposures
and homework exposures using the same ERP
tracking form described above. Initially, Ruth
expressed that she felt she could never do most
of the exposure practices on her hierarchy, so
we felt it would be important to highlight the
effects of ERP and her progress throughout
treatment. To do this, we drew a graph of each
Table 27.2 Examples from the initial hierarchy developed for Ruths treatment
SUDS
Hierarchy item
SUDS Hierarchy item
0
Eating ice cream from cone
60
Crumpling one page of a new book
10
Touching the therapy room door
65
Thinking about putting a tool back in the
wrong spot
10
Folding one item of clothing differently
70
Touching Moms dirty laundry
20
Thinking about seeing someone dirty
80
Thinking about germ warfare
25
Smelling bug spray on someone else
80
Everything out of order in a shopping cart
30
Thinking about touching brothers laundry
85
Putting a tool back just to the left of where it is
supposed to go
40
Leaving one item out of place in a shopping
90
Bug spray applied on skin
cart
40
Setting clothes unfolded in drawers
90
Watching shows about new diseases or outbreaks on TV
50
Touching syrup
90
Watching someone else crumple one page of a
new book
50
Playing a game with nieces and nephews
90
Touching the bathroom doorknob
50
Smelling Clorox, Pine-Sol, and Lysol
100
Drinking out of unexamined water fountain
60
Seeing or writing the word Leprosy
100
Having to throw the clean clothes on the closet
(or cancer or hepatitis) on a piece of paper
floor and leave them
SUDS subjective unit of distress
407
Table 27.3 Examples from the extended (additional) hierarchy developed for Ruths treatment
SUDS
Hierarchy item
SUDS
Hierarchy item
30
Talking to family about how you are doing
90
Asking for help to learn how to do something
30
Touching the mirror in the bathroom
90
Going out to a restaurant alone
50
Asking a grocery store clerk for help finding 100
Touching the handle on the toilet in a public
something
bathroom
70
Forcing yourself to work on five things
100
Asking a friend to go out to ice cream with you
when you feel like you cannot start
75
Sitting down with people you do not know
100
Striking up a conversation with someone you
and visit
do not know very well
80
Touching the sink handle in the bathroom
100
Doing a puzzle in a cluttered room
80
Working on a public computer
100
Refraining from washing hands throughout an
entire outdoor task
90
Sitting down with people and teaching them 100
Eating something off of the floor
something
in-session exposure on the white board (see Fig.

27.2 for an example). At first, Ruth struggled
to regularly complete her assigned exposure
homework, explaining that she did not have the
energy, could not focus, or did not have time.
Additional psychoeducation about the benefits
of ERP and how they changed the severity of
obsessive thoughts and compulsive behaviors
were employed to address this, and she eventually became more committed to the ERP homework. Specifically, we emphasized in-session
ERP experiences in which she experienced a
decrease in anxiety and felt positive emotions
in response. We also explained that the time we
spend in session every week is limited, and thus
exposure practice outside of session is essential
to the treatment plan.
Cognitive restructuring was the final major
procedure utilized in treatment and was used primarily in the context of ERP practice. To simplify
the way we first explained the cognitive aspect
of treatment, we first introduced the idea of automatic thoughts and then added only one or two
cognitive restructuring techniques per session.
We also introduced the cognitive restructuring
techniques using concrete acronym to improve
the clients ability to remember some key points
and techniques. The acronym was ELVES,
used to remind her to search for Evidence for
and against the truthfulness of her automatic
thoughts, consider the Likelihood that her automatic thoughts were accurate, be aware of oVergeneralization and Extreme thinking, and consider her unrealistic Standards. Initially, applying
these techniques to Ruths specific triggers took

a lot of direction. After initiating an exposure, we
would ask her how she could apply each individual technique. However, she eventually learned
to use each cognitive restructuring technique effectively and identified the techniques she found
to be most helpful (Extreme thinking and Unrealistic standards).
By our ninth session, Ruth had been introduced
to all of the cognitive restructuring techniques
and had mastered the majority of the items on her
original hierarchy. As such, we decided to add additional triggers to the hierarchy (see Table27.3),
though some of the triggers she could not come up
with a guess as to what her SUDS rating would be.
Similarly, as we added items to her hierarchy, it
became more difficult and required more processing and psychoeducation to understand what automatic thoughts accompanied certain obsessions
and compulsions. Entirely new discoveries were
made that explained some of the functional impairment Ruth originally described in her assessment.
For example, in her assessment, one of her main
concerns had been that she would approach her
bedroom to clean it, felt she did not know where
to start, and could never bring herself to clean it.
This seemed somewhat paradoxical, considering
her obsessions about cleanliness and organization.
Thus, it was difficult to identify what the automatic
thought was that accompanied her feelings of anxiety surrounding task initiation, especially because
she had no guesses as to what could explain the situation. Our first conceptualization of the problem
was that perhaps Ruth simply felt overwhelmed by
408
M. J. Larson et al.
the size of the task, and therefore she felt too much
anxiety to be able to work on it. Therefore, we determined it might help her if she assigned herself
small portions of the needed cleaning as exposure
homework, hypothesizing that she would experience a decrease in anxiety as she realized the task
was not insurmountable. However, after she tried
this, we discovered through much discussion that
the reason her anxiety around task initiation was
so high was because she wanted everything to be
organized just perfect. When asked why she
needed it to be organized and perfect, she said she
did not know, it just does. We realized in that
moment that it seemed her cleaning functioned as
a compulsion employed to decrease the anxiety
caused by the trigger of disorganization or imperfection. Yeah thats exactly what Im doing with
this. I start to clean up one thing, and the anxiety
will come down because Im cleaning it, and then
the anxiety comes back up so I clean, and Im yoyoing in that areathats exactly why that anxiety
is always there. Oh, I see! Ive been totally focusing on the perfect. I see, I see! I couldnt find out
why the anxiety was so high, but I was using cleaning as a compulsion! That really helps me now.
Boy this is neat; I wish Id got this help years and
years ago.
Next, we discussed and uncovered the accompanying automatic thought. She realized that she
feels, If youre not perfect, then youre a bad
person. I havent connected with that before, but
I know thats whats going onit amazes me how
my brain has been working. Wow, this is good. I
was hoping we could penetrate some of these areas.
So I need to start telling myself, Im an okay person, because Ive been telling myself Im a rotten
person because I cant do this and I cant do that.
In order to establish this cognitive distortion, we
had to stray from the manuals direction to spend
the majority of session time working on exposures
in order to address Ruths lack of insight and find
new symptomatic areas. In fact, throughout our
treatment of individuals with poor insight, we have
found that increased time spent on identifying and
restructuring maladaptive cognitions increases insight and improves understanding as to the rationale behind each step of treatment.
Understanding Ruths obsessions about perfection explained several other compulsions we
had not fully understood beforehand. For example, her struggle to play games with her nieces
and nephews seemed to stem more from an obsession about the organization and perfection of
the game, rather than fears of contamination or
a lack of desire to enjoy the game. She felt anxious while playing because she was consistently
worried that one of her nieces or nephews would
damage a part of the game. Similarly, her constant
struggle to maintain organization of her grocery
cart was another manifestation of this same obsession. The exposure practice depicted in Fig.27.2
is another example. Ruth expressed that she had
not been able to really read since high school
because any time she sat down to read she was
too anxious worrying about keeping the book in
perfect condition, so she could not pay attention
to or enjoy what she was reading. An exposure we
came up with to address this was to write in, tear

Fig. 27.2 The decrease in anxiety during the exposure to wrinkle pages in a book. SUDS subjective unit of distress,
ERP exposure and ritual prevention
pages, crease pages, and crumple pages in one of

her perfect books. After doing that exposure in
session, she said, I didnt think Id ever be able to
mark my books like I wished I could; but I think
Im going to be able to now. Whereas before Id
nevereven in grade school I wouldnt write in
a book. However, we discovered that an even
more anxiety-provoking exposure practice for
Ruth was writing in, tearing, and crumpling one
of the pages in the therapists book. Her SUDS
rating went up to 80, and she became visibly anxious. In discussing this reaction, she reported that
she was taught that you return things in the same
condition you received them. She said she would
always think this way and felt if you did not return
things perfectly, you were a bad person.
A final discovery we made through discussion
was in the area of social interactions. She originally described feeling restless and uncomfortable in social situations, and we had thought this
was because she felt the individuals she interacted
with were either contaminated or disorganizing
and messing up her space. However, through the
process of in-session social exposures and discussing their effects, Ruth identified that she felt
extremely anxious and antsy after opening up and
talking with another person. She said she felt she
could not concentrate and felt on edge, and she
noted that she believed this was because she was
409
afraid that because she had spoken with someone

and opened up, something bad would happen.
In discussing why she felt something bad would
happen after talking to someone, she noted that
as a child, she once had a friend come to play and
had a very enjoyable time. She said she had told
her father about what a great time she had had.
She reported He said You really had fun with
her didnt youyou played with her better than
you do your brothers. And he just took his belt
off and just whipped the socks right off of me. I
thought I was going to die. So I never invited anybody down ever again. She said that after that
experience, she always felt that if she enjoyed a
social interaction, something bad would happen.
She also expressed that either others were contaminated and she did not want to talk to them,
or she was not good enough to talk to them anyway. We processed these beliefs and automatic
thoughts, and how they related to her obsessions
and avoidant compulsions and opened a door for
her to make progress in an entirely new area.
Lastly, we used regular assessments throughout treatment to help monitor progress. First, we
used the Y-BOCS periodically to monitor her
OCD symptoms. From session1 to session8, we
noted a significant drop in both obsessive and
compulsive symptoms, from the severe range
to the moderate range (see Fig.27.3). However,

Fig. 27.3 The decrease in YaleBrown Obsessive-Compulsive Scale (Y-BOCS) scores during treatment and after an
11-week follow-up session
410
M. J. Larson et al.
between session 8 and 15, we noted that her obsessive symptom score remained the same, and
her compulsive symptom score increased by 1.
In discussing this with Ruth, she reported that
she was not surprised or bothered by this, because she had opened so many new doors to new
areas of symptoms that she had not been aware
of, where before she had been responding to the
questions in regard to a more restricted range of
obsessions and compulsions. Lastly, from session
15 to 19, we noted another decrease in scores,
from the moderate to the mild range. This decrease in scores is consistent with our treatment
goal of significant reduction of OCD-related
thoughts and time on compulsive behaviors by
more than half.
The other outcome measure we used throughout treatment was the Outcome Questionnaire
(OQ-45; Lambert etal. 1996), a brief, self-report,
general symptom distress assessment designed
to track client progress through treatment. It is
a scale that ranges from 0 to 180, with higher
scores indicating greater distress. A score of 63 or
more indicates clinically significant symptoms.
The community sample average score is 45, managed behavior health outpatient settings average
is 77, and the inpatient average is 94. Figure27.4
illustrates Ruths progression through treatment

using the OQ-45, showing a general decrease in
symptom distress over time.
Following 11 weeks of treatment, Ruth returned for a relapse prevention and follow-up
session. At the time of the follow-up session,
Ruths Y-BOCS score rose just slightly, from a
10 at the end of treatment to a 13 at follow-up;
however, her overall distress as measured by the
OQ-45 continued to decrease, with a follow-up
score of 73 down from a 79 at the end of treatment. The client reported some difficulties due to
a fall and subsequent shoulder injury, but noted
that she continues to practice her exposure exercises and that she feels a considerable increase in
her daily functioning.
The most significant complicating factor of treatment was Ruths poor insight into her symptoms.
As illustrated above, because of her poor insight,
treatment ran four sessions longer than the manual calls for, required additional psychoeducation,
and called for significant time spent identifying
automatic thoughts, obsessions, and compulsions

Fig. 27.4 The decrease in Outcome Questionnaire (OQ) 45 scores during treatment and after an 11-week follow-up
session
411
Table 27.4 Specific protocol modifications to work with poor insight

Changes made to the protocol to accommodate poor
Example of change
insight
Additional psychoeducation
We added diagrams to illustrate the OCD cycle and how
it applied to her life, and drew out graphs of exposure
practice to visually represent her experience and progress
Focus on insight
Additional time on tracking homework assignments to
help her identify her own triggers
Additional time identifying automatic thoughts
During exposure practice, we spent extra time identifying and understanding the source of automatic thoughts
behind anxiety (which often took more than one session
to identify)
Additional sessions
We added four additional sessions to accommodate lack
of insight, basing this decision to continue treatment on
the additional areas of OCD (i.e., ensuring possessions
are kept in perfect condition) that we identified later on
in treatment and wanted to work on
Once-weekly sessions
We decided to hold 2-h once-weekly sessions instead
of twice-weekly sessions to allow Ruth enough time
between sessions to practice exposures and work on
developing insight on her own
(see Table27.4 for a summary). However, Ruths

progression from no insight into her symptoms
to her current, curious, and self-aware state is
part of what makes the case such a success in our
eyes. Of course, she reported that she still has a
lot of work to do, but the growth is remarkable.
Another significant complicating factor was
Ruths anorexia. Initially, this caused some confusion for Ruth as she was unsure what she was
allowed to talk about in session. Even after she
had been assured that she was free to talk about
anything she wished in session, but that we would
not focus on treating her eating disorder because
of liability and expertise issues, it complicated
sessions at times. Firstly, we spent a significant
portion of several sessions discussing treatment
resources, encouraging her to pursue them; however, she felt she would be overwhelmed trying
to attack both at once. Secondly, there were several times when Ruth made connections between
our treatment and her eating disorder (i.e., using
cognitive restructuring skills to address thoughts
associated with her eating disorder), and it would
have been nice to be able to spend more time fostering those connections (though we of course encouraged that type of generalization). In the end,
Ruth reported that she thought it was best that she
received treatment separately, because she stated
that she thought she would not have been able to

stick with it if she had had to face everything
at once, and that now that shes seen the progress
in her OCD, she thinks she can tackle the more
challenging anorexia.
Lastly, elements in Ruths personal life created complicating factors for treatment. She lived
with her mother, who had been diagnosed with
sarcoidosis, and needed the house to be constantly clean so that no outside source would compromise her fragile immune system. This proved
problematic for Ruth when we were trying to
encourage her to let go of some of her clean
habits and engage in contamination exposure
exercises. For example, one exposure we suggested was to take the trash out without washing
her hands afterward. She reported that she would
like to, but could not because her mothers doctor had specifically asked Ruth to always wash
her hands and make sure that she was clean so
she did not infect her mother. Ruth also was
in the middle of a disability case, initiated by her
family members, to help her bring in some income since she had been unable to work due to
her anorexia and OCD; however, the case caused
Ruth significant stress. We discussed the conflict
and what it meant for her to be going to court
to be either deemed disabled, and ultimately
412
imperfect legally, and be awarded money for it

or found not disabled and technically lose the
case. She also was not to change her work status
throughout the course of the case, so encouraging her to face her fears of the workforce was an
inaccessible exposure.

OCD in individuals with poor insight can be
challenging due to perceptions that some treatment may not be needed, decreased effort in
psychotherapy, and increased symptom severity.
Notably, no studies that we are aware of have
systematically treated insight in addition to traditional therapy techniques. Thus, what is done in
clinical practice, including what we report with
the current case, is done anecdotally and based
on practitioner intuition as to what will be helpful
for the client. Research systematically examining
and treating insight in individuals with OCD is a
clear future direction needed for the field.
Despite the absence of systematic research, we
have used OCD-specific evidence-based treatment protocols to treat individuals with OCD,
making minor modifications to address poor
insight. Based on our clinical observations of
Ruths experience with these modifications, treatment of individuals with OCD and poor insight
seems to be enhanced when alterations to traditional CBT protocols include additional psychoeducation, a strong focus on insight and symptom
identification, consistent treatment frequency (we
typically choose one session per week rather than
two per week or one every other week in order to
give the client enough time to practice and focus
on the current symptoms), and additional sessions
focusing on symptom insight (see Table27.4). In
Ruths case, implementing these changes led to
a good treatment response that was maintained
posttreatment, though the specific differential effect of our alterations is unknown. Thus, whereas
the crux of treatment remains the evidence-based
OCD protocols, simple changes and making treatment more concrete may be a good way to treat
individuals with poor insight.
M. J. Larson et al.
References
Abramowitz, J. S., Foa, E. B., & Franklin, M. E. (2003).
Exposure and ritual prevention for obsessive-compulsive disorder: Effects of intensive versus twice-weekly
sessions. Journal of Consulting and Clinical Psychology, 71, 394398.
Alonso, P., Menchn, J., Segals, C., Jaurrieta, N., Jimnez-Murcia, S., Cardoner, N., etal. (2008). Clinical
implications of insight assessment in obsessive-compulsive disorder. Comprehensive Psychiatry, 49,
305312.
Catapano, F., Perris, F., Fabrazzo, M., Cioffi, V., Giacco,
D., De Santis, V., & Maj, M. (2010). Obsessivecompulsive disorder with poor insight: A three-year
prospective study. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 34, 323330.
Cherian, A. V., Narayanaswamy, J. C., Srinivasraju, R.,
Viswanath, B., Math, S. B., Kandavel, T., & Reddy,
Y. C. J. (2012). Does insight have specific correlation
with symptom dimensions in OCD? Journal of Affective Disorders, 138, 352359.
Demet, M., Deveci, A., Takin, E., Erbay Dndar, P.,
Trel Ermertcan, A., Mizrak Demet, S., etal. (2010).
Risk factors for delaying treatment seeking in obsessive-compulsive disorder. Comprehensive Psychiatry,
51, 480485.
Eisen, J., Rasmussen, S., Phillips, K., Price, L., Davidson,
J., Lydiard, R., etal. (2001). Insight and treatment outcome in obsessive-compulsive disorder. Comprehensive Psychiatry, 42, 494497.
Erzegovesi, S., Cavallini, M., Cavedini, P., Diaferia, G.,
Locatelli, M., & Bellodi, L. (2001). Clinical predictors of drug response in obsessive-compulsive disorder. Journal of Clinical Psychopharmacology, 21,
488492.
Jacob, M. L., Larson, M. J., & Storch, E. A. (2014).
Insight in adults with obsessive-compulsive disorder.
Comprehensive Psychiatry, 55, 896903.
Jakubovski, E., Pittenger, C., Torres, A. R., Fontenelle,
L. F., do Rosario, M. C., Ferro, Y. A., etal. (2011).
Dimensional correlates of poor insight in obsessivecompulsive disorder. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 35, 16771681.
Lambert, M. J., Burlingame, G. M., Umphress, V., Hansen, N. B., Vermeersch, D. A., Clouse, G. C., &
Yanchar, S. C. (1996). The reliability and validity of
the outcome questionnaire. Clinical Psychology and

Ponniah, K., Magiati, I., & Hollon, S. D. (2013). An
update on the efficacy of psychological therapies in
the treatment of obsessive-compulsive disorder in
adults. Journal of Obsessive-Compulsive Related Disorders, 2, 207218.
Raffin, A., Guimares Fachel, J., Ferro, Y., Pasquoto
de Souza, F., & Cordioli, A. (2009). Predictors of
response to group cognitive-behavioral therapy in the
treatment of obsessive-compulsive disorder. European
Ravi Kishore, V., Samar, R., Janardhan Reddy, Y. C.,
Chandrasekhar, C. R., & Thennarasu, K. (2004). Clinical characteristics and treatment responde in poor and
good insight obsessive-compulsive disorder. European Psychiatry, 19, 202208.
Shetti, C., Reddy, Y., Kandavel, T., Kashyap, K., Singisetti, S., Hiremath, A., etal. (2005). Clinical predictors
413
of drug nonresponse in obsessive-compulsive disorder.

The Journal of Clinical Psychiatry, 66, 15171523.
Storch, E. A., Milsom, V. A., Merlo, L. J., Larson, M.,
Geffken, G. R., Jacob, M. L., etal. (2008). Insight in
pediatric obsessive-compulsive disorder: Associations
with clinical presentation. Psychiatry Research, 160,
212220.
Simpson, H. B., Wetterneck, C. T., Cahill, S. P., Steinglass, J. E., Franklin, M. E., Leonard, R., Weltzin, T.
E., & Riemann, B. C. (2013). Treatment of obsessivecompulsive disorder complicated by comorbid eating
disorders. Cognitive Behaviour Therapy, 42, 6476.
Tolin, D., Maltby, N., Diefenbach, G., Hannan, S., & Worhunsky, P. (2004). Cognitive-behavioral therapy for
medication nonresponders with obsessive-compulsive
disorder: A wait-list-controlled open trial. The Journal
Treatment of ObsessiveCompulsive Personality

Disorder
28
Anthony Pinto

Research Base
Obsessive-compulsive personality disorder
(OCPD) is a chronic condition that involves a
maladaptive pattern of excessive perfectionism,
preoccupation with orderliness and details, and
the need for control over ones environment. The
Diagnostic and Statistical ManualFifth Edition (DSM-5) defines OCPD as an enduring pattern that leads to clinically significant distress or
functional impairment due to four or more of the
following: preoccupation with details and order,
self-limiting perfectionism, excessive devotion
to work and productivity, inflexibility about morality and ethics, inability to discard worn-out
or worthless items, reluctance to delegate tasks,
miserliness toward self and others, and rigidity
and stubbornness (American Psychiatric Association 2013). The DSM-5 reports that OCPD
is one of the most common personality disorders in the general population, with an estimated
prevalence ranging from 2.1 to 7.9% (American
Psychiatric Association 2013). Individuals with
this condition present frequently for treatment in
mental health (Bender etal. 2001) and primary
care (Sansone etal. 2003) settings. Yet OCPD
A.Pinto()
Department of Psychiatry, Hofstra North Shore-LIJ
School of Medicine, The Zucker Hillside Hospital,
Ambulatory Psychiatry Center, 75-59 263rd Street,
Glen Oaks, NY, USA 11004
e-mail: apinto1@nshs.edu
remains an understudied phenomenon, and there

is no definitive empirically supported treatment
for OCPD.
OCPD traits are associated with significant
functional impairment. The pursuit of perfection ends up being problematic (i.e., spending
inordinate amounts of time on relatively trivial
tasks, missing deadlines to write and rewrite assignments). Individuals with OCPD are typically
seen as overly rigid and controlling since they
often expect their coworkers, friends, and family
to conform to their right way of doing things.
They may also be inflexible about matters of morality and ethics and may attempt to impose their
views on others. Consequently, individuals with
OCPD often suffer from impaired interpersonal
functioning as well as high levels of internal
distress (Cain etal. 2015). A recent study using
well-validated measures of quality of life and
psychosocial functioning found equivalent levels
of impairment in psychosocial functioning and
quality of life in patients with OCPD compared
to those with OCD (Pinto etal. 2014). Further, a
study of treatment-seeking patients with personality disorders found OCPD, along with borderline personality disorder, to be associated with
the highest economic burden of all personality
disorders in direct medical costs and productivity
losses (Soeteman etal. 2008).
As with other personality disorders, impaired
interpersonal functioning is a hallmark feature of OCPD. Clinical descriptions note that
interpersonal conflicts frequently occur among
individuals with OCPD, often triggered by their

DOI 10.1007/978-3-319-17139-5_28
415
416
impossibly high standards for the behavior of

others, difficulty acknowledging differing viewpoints, and rigidity (Pollak 1987). Millon (1981)
also notes that individuals with OCPD may be
uncompromising and demanding, and OCPD has
been linked with outbursts of anger and hostility,
both at home and at work (Villemarette-Pittman
etal. 2004). In a recent study investigating
interpersonal functioning in OCPD, Cain etal.
(2015) found that individuals with OCPD reported hostile-dominant interpersonal problems
and sensitivities with warm-dominant behavior
by others, as well as less empathic perspective
taking relative to healthy controls, which may
underlie some of the interpersonal problems
described above.
Of the core features of OCPD, research and
clinical reports have highlighted the importance
of perfectionism as a major contributing factor
to life impairment. The belief that anything less
than perfect performance is unacceptable (termed
maladaptive perfectionism) has been linked to
the development of depression (Rice and Aldea
2006). Socially prescribed perfectionism (the
belief that one will be judged against unrealistic standards by others) has been linked to poorer
relationship adjustment (Haring etal. 2003) as
well as suicidal ideation (Hewitt etal. 1997). In
fact, a diagnosis of OCPD may be a risk factor
for suicidality, as Diaconu and Turecki (2009)
found that among depressed patients, individuals
with OCPD reported increased current and lifetime suicidal ideation as well as a greater number
of lifetime suicide attempts. Of special clinical
concern, depressed patients with OCPD reported
fewer reasons for living and less anxiety on the
fear of death questionnaire, both prognostic indicators of suicide.
Although there is no empirically validated
gold-standard treatment for OCPD, psychotherapy is recommended as the treatment of choice
(Sperry 2003). Below is a review of the limited
treatment research in OCPD.
Psychodynamic PsychotherapyPsychodynamic
treatment for OCPD involves an insight-oriented
approach that attempts to reveal how the OCPD
symptoms function to defend the individual
A. Pinto
against internal feelings of insecurity and uncertainty. With this insight, patients then work to
change their inflexible patterns of behavior and
give up their rigid demands for perfection in
favor of a more reasonable outlook. One uncontrolled study suggests that supportive-expressive
psychodynamic therapy is effective for treating
patients with personality disorders, including
OCPD (Barber etal. 1997). This study included
14 OCPD patients and found significant improvement after 52 sessions, but did not include a
control group. Two subsequent trials found that
mixed groups of personality disorder patients
(including some patients with OCPD) treated
with brief psychodynamic treatments improved
in terms of general functioning relative to waitlist control groups (Abbass etal. 2008; Winston
etal. 1994). However, neither of these two studies specifically investigated improvement among
those with OCPD, and the study outcomes did
not assess for changes in OCPD symptoms
specifically. Further research is needed to determine the effectiveness of psychodynamic treatments for OCPD.
Cognitive TherapyThe cognitive approach to
treating OCPD involves identifying and restructuring the dysfunctional thoughts underlying
maladaptive behaviors (Bailey 1998; Beck
and Freeman 1990; Beck 1997). For example,
patients would be taught to challenge all-ornothing thinking by considering the range of
possibilities that might be acceptable. Similarly,
therapists might teach patients to recognize
instances in which they overestimate the consequences of mistakes (catastrophizing) by examining the realistic significance of minor errors.
Some approaches also incorporate behavioral
elements, such as behavioral experiments (e.g.,
purposefully making small mistakes in order to
observe the actual consequences; Sperry 2003).
Establishing rapport can be difficult with some
OCPD patients, due to rigid thinking styles and
difficulty with emotional expression. In light of
this difficulty, Youngs (1999) schema-focused
therapy aims to identify and restructure patients
maladaptive schemas as they are expressed in the
therapy process.
28 Treatment of Obsessive-Compulsive Personality Disorder
Although several cognitive and behavioral approaches to OCPD have been described (Kyrios
1998), very little empirical research has been conducted to test these treatments. In an uncontrolled
trial conducted in Hong Kong Chinese patients,
Ng (2005) recruited individuals with treatment
refractory depression who also met Statistical
Manual of Mental DisordersFourth Edition
(DSM-IV) criteria for OCPD and offered cognitive therapy focusing on OCPD. Ten patients
were treated, and after a mean of 22.4 sessions,
all showed reductions in depression and anxiety
symptoms, and nine no longer met diagnostic
criteria for OCPD. However, this study did not
include a control group and the sample size was
small (N=10). Strauss etal. (2006) conducted an
open trial of cognitive therapy among outpatients
with avoidant PD (n=24) and OCPD (n=16),
who received up to 52 weekly sessions. Of the
OCPD patients, results indicated that 83% had
clinically significant reductions in OCPD symptom severity and 53% had clinically significant
improvement in depression severity. However,
this open trial did not include a comparison condition, such as a waitlist control group or an alternative treatment, precluding a firm conclusion about
the efficacy of cognitive therapy for OCPD.
Very little data exist to compare the effectiveness of cognitive therapy with psychodynamic
treatment. In one study, Svartberg etal. (2004)
randomized Cluster C patients to receive 40
treatment sessions of either cognitive therapy
(N=25) or short-term psychodynamic treatment
(N=25). Avoidant PD was the most frequent diagnosis in the sample, though OCPD was also
represented, with eight individuals in the cognitive therapy group (32%) and nine in the psychodynamic group (36%) meeting DSM-III criteria.
The results revealed that both patient groups
showed significant improvements on measures
of symptom distress, interpersonal problems, and
core personality pathology after treatment and at
2-year follow-up. Both treatments were equally
effective. However, this study did not specifically report on the improvements seen in the patients with OCPD. More research is needed to determine which treatment is maximally effective
for treating individuals with OCPD.
417
Alternative PsychotherapiesOther treatments

for OCPD have been explored in single-case studies. For example, two case studies have reported
on adapting metacognitive therapy for individuals with OCPD (Dimaggio etal. 2011; Fiore etal.
2008). Metacognitive therapy aims to improve
the individuals ability to understand mental
states, enhancing awareness of their own emotions, while also improving empathy and interpersonal functioning. This form of psychotherapy would seem well suited to the interpersonal
problems frequently observed in individuals with
OCPD, but more testing is needed. Lynch and
Cheavens (2008) describe an adaption of dialectical behavioral therapy (DBT) designed to target
cognitive rigidity and emotional constriction and
report on its successful implementation with one
individual with OCPD. DBT and other so-called
third wave cognitive behavioral treatments, such
as acceptance and commitment therapy (ACT),
have shown promise for the treatment of personality disorders (Ost 2008). However, systematic
evaluation of these treatments for patients with
OCPD is needed.
My clinical experience, observations, and review of the literature point to the need to design
novel treatments that challenge maladaptive perfectionism/rigidity and promote skills in healthy
emotion regulation strategies and interpersonal
functioning. As a result, for this case study, I
piloted a novel therapeutic intervention which
consists of two established cognitive-behavioral
therapy (CBT) modules: CBT for clinical perfectionism/rigidity preceded by skills training in
emotion regulation and relationship flexibility.
Skills Training in Affective and Interpersonal
Regulation (STAIR; Cloitre etal. 2001, 2002) is
a manualized form of CBT with two goals, the
first to learn how to experience feelings without
becoming overwhelmed. This involves becoming more aware of feelings and what triggers
them, learning how to manage certain emotions
that can at times interfere with or overshadow
relationship goals. A second goal is to improve
interpersonal skills and use these skills flexibly
and effectively in relationships. STAIR was administered with the intention of improving the
participants current emotional/interpersonal
418
functioning as well as preparing them to fully

utilize the subsequent intervention. CBT for
clinical perfectionism/rigidity (Egan and Hine
2008; Riley etal. 2007; Shafran etal. 2010) is
a manualized cognitive-behavioral approach that
consists of four aims developed originally by
Fairburn etal. (2003): (1) identifying perfectionism as a problem and understanding maintaining
mechanisms, including rigidity, overworking or
overtraining, behavioral avoidance, dichotomous
thinking, and cognitive biases; (2) conducting
behavioral experiments to learn more about the
nature of perfectionism and alternative ways
of living; (3) psychoeducation and cognitive
restructuring (in combination with behavioral
experiments) to modify personal standards, selfcriticism, rigid rules and cognitive biases (such
as selective attention to perceived failures); and
(4) broadening the individuals scheme for selfevaluation, by examining existing methods of
evaluating the self, and identifying and adopting
alternative cognitions and behaviors.
Case Study: Presenting Problem

and Background
John is a 26-year-old Caucasian male, never married, currently in graduate school and working at
an internship. He lives with two roommates and
has been in a romantic relationship for the past
9 months. His presenting problem is preoccupation with lists, order, and perfectionism, resulting
in interpersonal problems and compromising his
productivity. He presented with a neat appearance, full range of affect, euthymic mood, with
normal rate, tone, and volume of speech, linear
thought process, appropriate thought content, and
denying suicidal ideation. John is not currently
receiving any psychiatric or psychological treatment. He reports no psychiatric hospitalizations
and has never had psychotherapy. His only prior
treatment was the use of a psychostimulant for
about 1 year starting at age 25 (he stopped the
medication 2 months prior to this evaluation).
The medication was prescribed by a psychiatrist after John described trouble with focusing
and completing tasks. John denies any chronic
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medical conditions, and his only medical hospitalization was for a tonsillectomy as a child.
When asked to recount the various ways that
OCPD gets in the way of his life, here is what
John told me (in his own words, edited for clarity):
I guess as far back as I can remember, perhaps
when I was 6 years old, I was preoccupied with
order, how my room was organized, and how I had
my toys set up. Thats the way I liked it, and I would
have a problem if my brothers or other people came
into my room, and placed things out of my order,
the way I liked them. At that point, it was just with
my things and that didnt get in the way of my life.
However, as I grew up and went to school, I definitely started to notice that I had a really big problem with procrastination on writing assignments.
My high standards were getting in the way of completing assignments. So, procrastination definitely
started to show itself as I went through school.
The most pervasive part of OCPD for me is the
perfectionism, and getting bogged down in the
details of any assignment that Im doing. If I feel
like I am missing one minor detail, it gets in the way
of completing the particular writing or research
assignment. I really feel like I have to find that one
thing before I can move on. With any paper Im
writing, I find myself stuck on page 1. I am often
trying to get it just perfect, before I can move on to
the rest of the paper. I notice that with readings at
school, it always takes me a lot longer to complete
things than other people. I think I get obsessed
with the details of the assignment or trying to
understand every particular thing that I was dealing with. One really good example, is that I spend
anywhere from a half hour to an hour writing an
email that would take most people 5min to write. I
make sure that all of my grammar and punctuation
are perfect, that it says exactly what I wanted to say,
and that it comes off just right. Especially in school,
when working in groups, this has always been a
huge problem for me. I never feel comfortable delegating anything to others, and always think that
my idea of how we should do the project is the way
that it should be done. So naturally, there have been
conflicts with that. Also, procrastination has been
a huge problem for me. With every assignment, I
say, Ok, this is not going to happen. Im going to
spend a lot of time on it, but Im going to get this
done in time. However, the very last day before the
deadline arrives, Ill be scrambling and doing it all
at once. My goal is to try to make it great by spending a lot of time on it, and doing it just the way I
want. But instead, I end up pushing it off, and then
it would be nowhere near what I want it to be.
I have a lot of extremely high standards and
I often hold my significant other to those high

standards as well. I would be very argumentative
with them. I would find anything that I thought we
werent seeing eye to eye on and really harp on that.
If I noticed a flaw in them, I tended to focus on the
flaws and ignore anything else that was good about
them. Emotionally, it became very hard to express
affection towards them. Even if I had negative
emotions towards them, I was fearful of expressing
those emotions as well.
Even in my free time, when Im doing something
where Im trying to enjoy myself, I feel like I have
a really hard time being spontaneous. I feel like
everything has to be planned out, or I wont have a
good time. I would be frustrated if a friend came up
to me and said, Hey, do you want to go grab drinks
right now or go do something?, if it was something
I hadnt planned on. If I didnt think things were set
up to go right, I wouldnt have a good time.
Doing any sort of chore is really a chore. It can be
very frustrating, because with every little thing that
I do, theres a right way to it. If its not done in that
right way, then I get really upset. The best example
might be the dishwasher. I always had this idea that
the dishwasher had to be loaded in one particular
way, and if it didnt get loaded in that way, then we
were going to have horribly dirty dishes. I could
not understand why any of my roommates didnt
get that. So, anytime I would open the dishwasher
and theyd put something in there, Id freak out and
have to reorganize it. With shirts, I always had to
have a perfectly ironed shirt before I could go into
work. Thats just the way it had to be. With a lot of
things around my house, if I dont have control over
it, it makes me very uneasy.
and Assessment
At the evaluation visit, psychiatric and personality disorder diagnoses were confirmed by the
Structured Clinical Interview for DSM-IV Axis I
Disorderspatient version (SCID-I/P; First etal.
1996) and the Structured Clinical Interview for
DSM-IV Axis II Personality Disorders (SCID-II;
First etal. 1997), respectively. John did not meet
criteria for any affective, anxiety, psychotic, substance, somatic, or eating disorders. There was
no evidence of attentional problems. Besides
OCPD, John met criteria for avoidant personality disorder (see section on Complicating Factors). John met the clinical threshold for six of
the DSM-5 OCPD criteria:
419
1. Preoccupation with details/order: He

devotes inordinate amounts of time to
methodically compiling to do lists that are
counterproductive; must organize his work or
home office space so that it is just so (e.g.,
computer charger lays correctly and coffee
mug is in the correct spot) before he can be
productive; constantly looks for the best or the
most efficient way to do things (to the point
of inefficiency). At work, he has been given
feedback that he is excessively attentive to
superfluous details and late to turn in writing
assignments because he insists on spending
the bulk of time researching the topic, leaving
little time to do the writing itself.
2. Self-limiting perfectionism: John has very
high standards for the quality of his work
(including emails, writing, reading assignments)everything must be done the perfect
way, excessive revising when writing (he
estimates that writing assignments take him
three to six times longer to complete than
his graduate school peers) and excessive time
spent rereading assignments (he estimates that
reading assignments take him twice as long to
complete than his graduate school peers). This
difficulty completing tasks has significantly
compromised his productivity at school and
work.
3. Inflexibility about morality/ethics: John follows rules to the letter of the law, is angered
and frustrated by those who do not adhere to
rules (e.g., distressed when he sees litter and
upset when someone at work leaves the door
to the file room open since it contains confidential data). His girlfriend is turned off by his
judgmental points of view; others often tell
him that the things that upset him are not a
big deal.
4. Inability to discard: John has difficulty discarding items (e.g., clothing, textbooks, magazines, receipts, school papers) which has resulted in a clutter that interferes in his living
space.
5. Reluctance to delegate: John has difficulty
delegating work because of concerns and
frustrations that it will not be done the right
420
way. At school, he resists group projects because of his tendency to butt heads with group
members over the quality of the joint product.
At home, he takes on most of the chores (e.g.,
cleaning, loading dishwasher, caring for the
dog) because he knows his roommates would
not do them the way he wants. He often redoes
others work which results in confrontations.
6. Rigidity and stubbornness: Johns need to
be methodical makes him resistant to change.
He finds comfort in routines (e.g., usually eats
the same foods every day). He often insists on
being right even in areas in which there is no
right answer. He frequently argues with others about being right (especially in romantic
relationships, and this has contributed to the
demise of most previous dating relationships).
At school, he gets angry/resentful towards
classmates and professors with differing opinions.
John completed questionnaires about his OCPD
symptoms, quality of life, and interpersonal
functioning at the orientation visit (week 0), after
phase I (week 7), after phase II (week 14), and
2 months after acute treatment (week 22; see
Table28.1). The following measures were used:
The Quality of Life Enjoyment and Satisfaction QuestionnaireShort Form (Q-LES-Q-SF;
A. Pinto
Endicott etal. 1993) is a self-report instrument

that assesses quality of life in social, leisure,
household, work, emotional well-being, physical,
and school domains. The total score is expressed
as a percentage of the maximum possible score
of 70. Lower scores on the Q-LES-Q-SF indicate
poorer quality of life.
The Clinical Perfectionism Questionnaire
(CPQ; Chang and Sanna 2012; Fairburn etal.
2003) is a self-report measure designed to assess the current level of clinically dysfunctional
perfectionism. The items assess the cognitive,
behavioral, and affective components of setting
personally demanding standards of performance
and striving to meet them and the consequences
on the individuals self-evaluation when these
standards are met or not met. Higher scores on
the CPQ are indicative of higher clinically significant perfectionism.
The Inventory of Interpersonal ProblemsShort Circumplex (IIP-SC; Hopwood etal. 2008)
is a self-report measure of interpersonal problems (subscales: domineering, vindictive, cold,
introverted, submissive, exploitable, overly nurturing, and intrusive). The total score represents
an index of interpersonal distress across all types
of interpersonal problems, with higher scores
indicating greater distress.
Table 28.1 Clinical measures completed by John and percent change by time point
% Change
% Change
Assessment
Baseline
After phase I
After phase II Two month
week 014
week 022
measure
(week 0)
(week 7)
(week 14)
follow-up
(week 22)
Q-LES-Q
38.6
71.4
77.1
80.0
99.7
107.2
CPQ
38
27
27
17
28.9
55.3
IIP-SC total
97
64
50
29
48.4
70.1
DERS total
123
91
67
68
45.5
44.7
POPS total
264
221
144
136
45.4
48.4
Difficulty with 47
39
22
24
53.2
48.9
change
Emotional
36
34
20
19
44.4
47.2
overcontrol
Rigidity
76
60
46
39
39.5
48.7
71
57
34
32
52.1
54.9
Maladaptive
perfectionism
Reluctance to 45
38
21
19
53.3
57.8
delegate
Q-LES-Q quality of life enjoyment and satisfaction questionnaire, CPQ clinical perfectionism questionnaire, IIP-SC
inventory of interpersonal problems-short circumplex, DERS difficulties in emotion regulation scale, POPS pathological obsessive-compulsive personality scale
The Difficulties in Emotion Regulation Scale

(DERS; Gratz and Roemer 2004) assesses emotion regulation via a total score and six subscales: nonacceptance of emotional responses,
difficulties engaging in goal-directed behavior
when experiencing negative emotions, difficulties remaining in control of behavior when experiencing negative emotions, lack of emotional
awareness, limited access to emotion regulation
strategies, and lack of emotional clarity. Higher
scores indicate more difficulties with emotion
regulation.
The Pathological Obsessive-Compulsive Personality Scale (POPS; Pinto 2011) is a 49-item
self-report measure of maladaptive obsessivecompulsive personality traits and severity. A bifactor structure has been identified for this scale,
consisting of five specific trait factors (rigidity,
emotional overcontrol, maladaptive perfectionism, reluctance to delegate, and difficulty with
change) and an overall factor (based on all items)
that represents obsessive-compulsive personality
pathology on a continuum of increasing severity
and dysfunction. The POPS has demonstrated
excellent internal consistency reliability as well
as convergent and discriminant validity. The individual factors and the overall score are strongly
associated with greater psychosocial impairment
and poorer quality of life in both community
samples and patient samples with a principal diagnosis of OCPD.
Initial impressions of John are that he is an
intelligent, conscientious, yet highly self-critical
man whose quality of life (Q-LES-Q) and interpersonal relationships (IIP-SC) are being majorly
impacted by clinically significant perfectionism
and rigidity (POPS, CPQ) as well as his difficulties modulating negative emotions (DERS).
Shafran etal. (2002) define clinical perfectionism as the overdependence of self-evaluation
on the determined pursuit of personally demanding, self-imposed standards in at least one highly
salient domain, despite adverse consequences
(p.778). The cycle of clinical perfectionism is
maintained by cognitive biases (e.g., all-or-nothing thinking) and performance-related behaviors,
including checking, being overly thorough, and
avoidance/procrastination (see Fig.28.1 for illus-
421
tration of model and Fig.28.2 for its application

to John). In order to bolster Johns response to a
targeted perfectionism intervention and strengthen his social supports, I decided to precede this
intervention with a cognitive-behavioral skills
building module (STAIR) that emphasizes increasing emotional awareness and instilling
greater relationship flexibility.
Treatment Course
The 14-week treatment protocol consists of 15
sessions: an orientation visit, STAIR (phase I;
six weekly sessions), and CBT for perfectionism/
rigidity (phase II; eight weekly sessions). Below
is the session-by-session protocol, including
the agenda for each session and notes on Johns
progress in treatment.
Orientation Session (Week 0)Treatment rationale and targets for phase I and II were reviewed
as well as psychoeducation about OCPD and
related functional impairment.
Phase I: STAIR TreatmentSix Sessions

(Weeks 16)
The first phase of the treatment consisted of six
sessions of STAIR (each 50min long). STAIR
sessions each have essentially the same format:
(1) psychoeducation about relationships and interpersonal skills deficits, (2) identification of
strengths and weaknesses related to a given skill,
(3) illustration of new skill, and (4) practice of
new skill. John was given a session outline handout at the end of each STAIR session so he could
review the psychoeducation and skills training
from each session at home. Between-session
work was assigned at the end of each session
and consisted of exercises directly related to the
content of the given session. Between-session
work from the previous week was reviewed at
the beginning of each session, and difficulties in
implementing new coping skills were addressed.
The six STAIR sessions follow a conceptual progression from a focus on basic identification and
422
Fig. 28.1 The cognitivebehavioral model of clinical
perfectionism. (Reproduced
from Shafran etal. 2010)
A. Pinto
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/
W

d
&
Z
Fig. 28.2 The cognitivebehavioral model of

perfectionism adapted for
John

^
/
^
t
D
K

t
^

Z
^
>/
^

W
labeling of emotions to a review of the importance of emotions in interpersonal relationships

to a focus on interpersonal flexibility.
Session 1 Focus: Introduction

to Treatment Rationale
During this session, psychoeducation about emotion regulation was presented. In addition, John
practiced self-monitoring of feelings and labeling
emotions. A self-monitoring form was introduced
and demonstrated by asking John to identify a
time in the past week where strong feelings were

triggered. John rated the intensity of the feeling
and identified the situation or trigger. The importance of self-monitoring throughout phase I of
this treatment was emphasized. John was given
a list of feelings words to aid in identifying his
emotions. Breathing retraining (with emphasis on slow, rhythmic diaphragmatic breathing)
was demonstrated and practiced. Homework 1:
Breathing retraining practice for 5minutes twice
daily and self-monitoring of feelings.
423
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Fig. 28.3 The three channels of distress. (Reproduced from Cloitre etal. 2001; adapted for John)
Session 2 Focus: Emotion Regulation

In session 2, we began by reviewing the selfmonitoring form that John completed between
sessions and checked with regard to the breathing
exercise he completed. This sessions psychoeducation covered negative mood regulation,
the connection between feelings, thoughts, and
behaviors, and a discussion of Johns current
coping skills. John also learned about identifying
the three channels of distress: physiological, cognitive, and behavioral (see Fig.28.3) as well as
new coping skills for intervening at each channel.
Homework 2: Breathing retraining; self-monitoring; practice new coping skills for cognitive
channel (e.g., positive images/self-statements
and shifting attention during stressful events).
Session 3 Focus: Distress Tolerance
During this session, we reviewed the feelings
self-monitoring form and alternative coping
methods. This weeks psychoeducation explored
acceptance of feelings/distress tolerance, and to
illustrate this we completed an exercise on assessing pros/cons of an identified goal and coping
with the associated distress (using a decisional
balance form). John focused on the pros/cons of

making contact with a former supervisor that he
worried would be disappointed with him for not
meeting a deadline. John concluded that making
the contact would be beneficial for his career,
despite the distress/shame he would endure. We
also identified pleasurable activities (from a list
of suggestions), including riding his bicycle and
making plans with friends. Homework 3: Breathing retraining; self-monitoring; assess pros and
cons of entering one difficult situation and tolerating distress; use new skills to manage distress;
engage in pleasurable activities.
Session 4 Focus: Relationship Between

Affect and Interpersonal Problems
We reviewed the feelings self-monitoring form,
emphasizing and reinforcing John for trying
alternative means of coping with distress, and
discussed positive activities that he had explored
in the past week. John noted that his former supervisor was very happy to hear from him and that
she was highly complementary of his work and
expressed interest in working with him again. She
made no mention of the missed deadline and may
424
not have even been aware of it. Psychoeducation

for session 4 focused on interpersonal schemas
(organizing templates/expectations/beliefs about
relationships and how they work) and included
an exercise on identifying interpersonal schemas,
using an interpersonal schema worksheet. One
of the primary goals of STAIR is helping individuals identify the interpersonal schemas that
are coming into play in current relationships and
causing problems in their interpersonal functioning. John discussed his insistence on doing all
aspects of a job himself (at his internship and at
home) and how this view may affect how others
perceive him. Homework 4: Breathing retraining; self-monitoring; interpersonal schema worksheet once daily.
Session 5 Focus: Alternative Interpersonal

Schemas
John and I reviewed feelings monitoring and alternative coping, and he was given feedback on
attempts to complete the interpersonal schema
worksheet. Role play was presented as a powerful therapy tool. We identified a relevant interpersonal situation (a perceived conflict with a peer
in his graduate program) and conducted three
iterations of the role play: first, with John as himself and me as the other person, then me as John
and John playing the other person, and finally
switching back to John as himself and me as the
other person. This approach allowed me to give
John immediate feedback on his interpersonal
skills and ways to make his communication more
effective which he was then able to practice. We
discussed generating alternative schemas to interpersonal situations and applied the role plays
to the interpersonal schema worksheet. John also
learned how to use covert modeling (imagining
yourself in the interaction) as another tool for
coming up with alternative responses when role
play is not possible. Homework 5: Breathing retraining; self-monitoring; initiate at least one interpersonal situation so that he can practice using
an alternative approach.
Session 6 Focus: Interpersonal Flexibility
During this session, we reviewed feelings monitoring and alternative coping as well as attempts
A. Pinto
to complete interpersonal schema worksheet.

This sessions psychoeducation was about various types of power balances in relationships
(equal power relationships, relationships where
you have more power than the other, and relationships where you have less power than the other)
and the importance of flexibility and adaptability in interpersonal situations. To demonstrate
this, we conducted role plays for different power
balances in Johns life. Lastly, we discussed the
transition to Phase II of treatment: CBT for perfectionism/rigidity. Homework 6: Self-monitoring; interpersonal schema worksheet once daily;
practice using interpersonal flexibility with different power differentials; make list of questions/
concerns regarding transition to phase II.
Phase II: CBT for Clinical Perfectionism/

RigidityEight Sessions (Weeks 714)
The second phase of the treatment consisted of
eight sessions of CBT for perfectionism/rigidity
(each 50min long). Throughout phase II, John
was assigned to read sections from the book
Overcoming Perfectionism (Shafran etal. 2010).
Between-session work was assigned at the end
of each session and consisted of exercises directly related to the content of the given session.
Between-session work from the previous week
was reviewed at the beginning of each session,
and difficulties in implementing exercises were
addressed.
Session 1 Focus: Cognitive-Behavioral

Formulation and Psychoeducation
We began by reviewing the highlights of phase
I. John noted that he benefitted from learning to
better verbalize his emotions, knowing how and
when to apply assertiveness to interactions, identifying interpersonal goals, being flexible with
regard to different power differentials in interactions, and challenging assumptions that arise
from interpersonal schemas. Phase II of treatment
was introduced. John and I reviewed the main
domain(s) of Johns psychosocial functioning
impacted by perfectionism and discussed examples. We also reviewed the cognitive-behavioral
model of perfectionism and how it is maintained

from a case example, and then we drew the
model based on Johns own life (see Fig.28.2).
We also discussed the pros/cons of perfectionism
and making changes and assigned readings for
homework.
Session 2 Focus: Self-Monitoring

and Myths Regarding Perfectionism
We discussed any questions about reading assignments and then reviewed key points about
self-monitoring. We generated a list of behaviors
that are contributing to Johns clinical perfectionism (e.g., list making, checking/going over work
mentally, avoidance/procrastination, not deviating from routines). John was assigned to monitor
specified behaviors for homework. Next, John
identified areas of his life that have been affected by his perfectionism, and we practiced selfmonitoring of perfectionism-related thoughts/
standards, emotions, and behaviors. Finally, we
reviewed a list of myths relevant to perfectionism
(e.g., Successful people work harder than less
successful people; To get ahead you have to be
single-minded and give up all outside interests.)
Besides his reading assignment and self-monitoring, John was asked to complete a questionnaire
about the frequency of various perfectionismrelated behaviors (e.g., How often do you check
your work for mistakes?)
Session 3 Focus: Surveys and Behavioral
Experiments
The assigned questionnaire and self-monitoring
forms were reviewed, followed by a discussion
of the rationale for using surveys in this treatment
as a means of learning how others cope with
some of the standards John has been struggling
with. For example, writing research papers is a
particular challenge for John. Due to his need to
make sure he has done an exhaustive review of
the academic literature, he would spend so much
time researching the topic that he would leave
little time for the actual writing. We decided to
create a survey that he would give to graduate
school peers so that he could better understand
how much time and effort his colleagues were
putting in to their research papers (e.g., how long
425
would they spend looking for articles/references

vs. writing). Afterwards, we discussed the rationale for behavioral experiments and discussed a
case example. We then set up a behavioral experiment (going to work without ironing his shirt
to see if anyone will notice) which John will conduct for homework. Setting up the experiment included specifying the belief/standard to be tested,
the prediction, and the approach. John agreed to
note the results and reflect on how they relate to
his prediction.
Session 4 Focus: Dichotomous Thinking:

Challenging via Behavioral Experiments
The session began by reviewing the outcomes
of the survey and behavioral experiment. John
was fascinated to hear his graduate school peers
methods for doing research papers. He noted that
learning the methods of his most respected peers
gave him further insight on the inefficiency of
his approach to writing papers. John also completed the behavioral experiment, and, contrary
to his prediction, there were no reactions to his
wrinkled work shirt, and the outcome of his day
did not appear to be affected by the shirt. Next,
I provided psychoeducation about dichotomous
(all-or-nothing) thinking. To explore this further,
we set up a behavioral experiment for all or
nothing thinking: John agreed to test his belief
that if he cannot outline all of the assigned chapters for a class, he might as well wait until the
exam to do it. In this experiment, he agreed to
outline one chapter. I also introduced continuums
to emphasize flexible thinking.
Session 5 Focus: Challenging Cognitive
Biases
This session focused on cognitive biases such
as selective attention to the negative, discounting positive aspects of performance, double
standards and accompanying self-criticism, and
overgeneralization. These cognitive maintenance
factors of clinical perfectionism and rigidity were
addressed using behavioral experiments in addition to cognitive restructuring (using thought
diaries). John reported on a self-initiated behavioral experiment. On three nights over the last
week, he made a point of going to sleep before
426
A. Pinto
his roommates to test whether they would lock

up and shut the lights (tasks he usually takes on
himself due to concern that the others will not).
Contrary to his prediction, he reported that his
roommates did take on these tasks when he went
to sleep. Upon reflection, John was relieved that
he would no longer have to be the last to bed.
who is more compassionate. We discussed which

coach in the analogy would yield better performance from athletes. Afterwards, we practiced
thought records for self-critical and compassionate thoughts, and I explained the concept of treating yourself as you would treat a friend. Related
worksheets were assigned.
Session 6 Focus: Procrastination, Time

Management, and Pleasant Events
We began with psychoeducation about procrastination, its relationship to perfectionism, and the
benefits/costs associated with it. We then identified areas of procrastination in Johns life, particularly with his school work and preparing for
exams/research papers. We discussed problemsolving approaches to procrastination, including
the technique of breaking tasks into manageable
chunks, and applied this to an upcoming group
project for one of his classes. We discussed time
management, activity scheduling, and balancing
achievement and fun. We reviewed a possible
time management schedule, blocking out study
time versus leisure. John agreed to do a behavioral experiment to test his belief that activities
that are not planned out are a waste of time. He
agreed to ride his bike around his city without a
planned destination.
Session 8 Focus: Self-Evaluation

and Relapse Prevention
We reviewed Johns final homework assignments
and then discussed the final psychoeducation
topic, self-evaluation and how to broaden it to be
based on various life areas rather than just based
on achievement. We reflected on Johns strong
progress in treatment and changes that he wants
to continue to develop in line with his goals/
values, and discussed relapse prevention and preparing for potential setbacks.
John showed clinically significant improvement over the 14 weeks of treatment and no
longer met diagnostic criteria for OCPD at the
end of phase II. His improvement was further
demonstrated by the robust change in his scores
on the symptom and functioning measures (see
Table 28.1). This improvement was maintained
at the 2-month follow-up assessment. John was
asked to comment on his progress and what components were helpful. Here is his response:
Session 7 Focus: Self-Criticism

and Self-Compassion
John reported completing the experiment and
enjoying his bike ride. He concluded that even
spontaneous/unplanned activities can be worthwhile. I checked in regarding his group project and his attempt at breaking the assignment
down into manageable chunks. We discussed
the problem of self-criticism and how it stems
from trying to adhere to rigid and demanding
rules as well as extreme personal standards for
performance. An overarching goal of this phase
includes encouraging the patient to relax rules
for performance (i.e., do things well enough),
replace rules with guidelines (i.e., do things flexibly), and avoid generalizing poor performance
on a task to negative judgments about self-worth.
A story was presented about two coaches, one
who is highly critical and hostile and another
The first thing thats been very helpful is with regulating my emotions. I guess its funny, because
until treatment began, I would often find that when
asked how Im feeling, or what my emotions were
like, I wouldnt know. I would just say, Im not
sure what Im feeling. I always had a hard time
expressing them. But now, I think the treatment
has greatly helped me to become more emotionally aware, and aware of what Im feeling, and to
be able to write out what Im feeling at a particular
time. It has been very helpful to connect the feelings Im having with the thoughts Im having. For
example, why I am feeling a particular way, and
why the thought that Im having in my head is leading to that feeling. So, the emotional part has been
very helpful. Also, it has been really helpful to test
these high standards I have and to do these experiments with myself. For example, if I think that
whatever Im doing has to be done in a particular
way, or has to meet a standard, I can test that and
discover that its OK not to. It has been great. For
instance, with my leisure time, I always thought
that everything had to be specifically planned, or

I wasnt going to enjoy myself. But I did experiments where I went out without a plan, and I
had a wonderful time enjoying myself. Another
example is with ironing my shirtsI thought that
if I went to work with a wrinkled shirt, everyone
would think I was a fool, Id be embarrassed, and
it would just be horrible. However, I went to work
with a wrinkled shirt one day, and the world didnt
explode. Everything was great, I had a great day at
work, and nobody seemed to notice. So those are
the biggest things that have been really helpful in
overcoming a lot of this. Im really grateful for this
opportunity. Ive seen a huge improvement.
A potential complicating factor in Johns treatment was a comorbid diagnosis of avoidant personality disorder, though John readily
acknowledged (and I would concur) that OCPD
was the condition that was having the biggest
impact on his functioning. This comorbidity is
not surprising as avoidant was the most common
co-occurring personality disorder (present in
more than a quarter (27.5%) of individuals with
OCPD) in a large longitudinal study of personality disorders (McGlashan etal. 2000). During the
baseline assessment, John noted that he avoids
opportunities in which people may critique him,
tends to be inhibited in new interpersonal situations due to feelings of inadequacy (afraid to
say something wrong or stupid; does not want to
disappoint), generally views himself as socially
inferior, and avoids new activities due to fear of
embarrassment, noting that he avoids scenarios
where I dont know the procedures. While the
presence of these avoidant traits may have contributed to Johns clinical presentation being less
hostile-dominant relative to others with a primary OCPD diagnosis, these traits did not have
a noticeable impact on his adherence as he had
excellent attendance to sessions and regularly
completed his assignments, even initiating his
own behavioral experiments in phase II.
Another potential complication in Johns
treatment was the fact that he broke up with his
girlfriend of 9 months early in treatment. While
this could have negatively impacted his ability to
engage in treatment, John did not report adverse
emotional consequences following the break up.
427
In fact, he expressed relief after exiting the relationship as he had intended to leave for some
time but was avoiding the uncomfortable conversation. This behavior of persisting in relationships beyond the point of his intended exit was a
pattern for him in his previous romantic relationships.

OCPD is marked by the core features of self-limiting perfectionism and rigidity. Despite the prevalence of OCPD in the general population and
its significant associated functional impairment,
there is no definitive empirically-supported treatment for the condition. This chapter outlines a
novel pilot psychotherapy that addresses not only
the core symptoms of OCPD but also problems
with emotion regulation and interpersonal functioning. The 14-week treatment consists of two
established manualized CBT components: (1) the
skills building module (STAIR) that emphasizes
increasing emotional awareness and instilling
greater relationship flexibility; and (2) CBT for
perfectionism/rigidity which targets the maintaining mechanisms in the clinical perfectionism
model, namely cognitive biases, counterproductive behaviors, rigid rules/standards, and punishing self-criticism.
John, a 26-year old graduate student, presented for treatment because his quality of life and
interpersonal relationships were being majorly
impacted by his intense perfectionism and rigidity as well as his difficulties modulating negative
emotions. John was clearly motivated and open
to change. He embraced the treatment and followed through on between-session practice. His
response to treatment was clinically significant
as evidenced by his diagnostic remission at the
conclusion of treatment as well as at least 45%
improvement in scores on all symptom and functioning measures, both of which were maintained
2months post-treatment. This is notable considering OCPD has at times been dismissed as an
unchangeable personality condition. While this
pilot offers a promising lead for further study,
much more systematic research is needed to further develop treatment of this disorder.
428
Key Practice Points

OCPD remains an under-recognized phenomenon in the community. For example, a recent
community survey found very low recognition rates for OCPD, with participants much
more likely to correctly identify depression,
schizophrenia, and OCD (Koutoufa and Furnham 2014). Clinicians should be aware of its
core features and symptomatic behaviors so
that they can assess for them. In the case of
John, his trouble with focusing and completing tasks had been previously mislabeled and
treated as an attentional problem.
Skills training in modulating negative emotions and applying flexibility to relationships
may be key components in treating OCPD
because they may allow these individuals to
better access support from others, including
family, friends, and even the therapist. Future
research should examine whether training in
these skills will decrease alliance ruptures
with the therapist and potentially facilitate
changes in OCPD symptoms.
When treating a patient with OCPD, it is
important for the clinician to convey that the
objective of CBT targeting the clinical perfectionism model is not to remove the individuals standards for performance but rather to
relax these internalized rules (i.e., do things
well enough) and replace them with guidelines which allow for greater flexibility and
are less likely to trigger harsh self-criticism.
Behavioral experiments can be an effective
way to test perfectionism standards since they
allow the individual to objectively collect
his/her own data (in the real world) as to the
validity of the standard.
References
Abbas, A., Sheldon, A., Gyra, J., & Kalpin, A. (2008).
Intensive short-term dynamic psychotherapy for
DSM-IV personality disorders: A randomized
controlled trial. Journal of Nervous and Mental
Disease, 196(3), 211216.
and statistical manual of mental disorders (5th ed.,
DSM-5). Washington, DC: American Psychiatric.
A. Pinto
Bailey, G. R., Jr. (1998). Cognitive-behavioral treatment
of obsessive-compulsive personality disorder. Journal
of Psychological Practice, 4(1), 5159.
Barber, J. P., Morse, J. Q., Krakeuer, I., Chittams, J., &
Crist-Christoph, K. (1997). Change in obsessivecompulsive and avoidant personality disorders
following time-limited supportive-expressive therapy.
Beck, J. S. (1997). Cognitive approaches to personality
disorders. In J. H. Wright & M. E. Thase (Eds.),
Cognitive therapy review of psychotherapy.
Beck, A. T., & Freeman, A. (1990). Cognitive therapy of
personality disorders. New York: Guilford.
Bender, D. S., Dolan, R. T., Skodol, A. E., Sanislow, C. A.,
Dyck, I. R., McGlashan, T. H., etal. (2001). Treatment
utilization by patients with personality disorders.
American Journal of Psychiatry, 158(2), 295302.
Cain, N. M., Ansell, E. B., Simpson, H. B., & Pinto,
A. (2015). Interpersonal functioning in obsessivecompulsive personality disorder. Journal of
Personality Assessment, 97(1), 9099.
Chang, E. C., & Sanna, L. J. (2012). Evidence for the
validity of the clinical perfectionism questionnaire
in a nonclinical population: More than just negative
affectivity. Journal of Personality Assessment, 94(1),
102108.
Cloitre, M., Hefferman, K., Cohen, L., & Alexander, L.
(2001). STAIR/MPE: A phase-based treatment for the
multiply traumatized. Unpublished manual.
Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H.
(2002). Skills training in affective and interpersonal
regulation followed by exposure: A phase-based
treatment for PTSD related to childhood abuse.
Journal of Consulting and Clinical Psychology, 70(5),
10671074.
Diaconu, G., & Turecki, G. (2009). Obsessive-compulsive
personality disorder and suicidal behavior: Evidence
for a positive association in a sample of depressed
patients. Journal of Clinical Psychiatry, 70(11),
15511556.
Dimaggio, G., Carcione, A., Salvatore, G., Nicolo,
G., Sisto, A., & Semerari, A. (2011). Progressively
promoting metacognition in a case of obsessivecompulsive personality disorder treated with
metacognitive interpersonal therapy. Psychology and
Psychotherapy, 84(1), 7083; 98110.
Egan, S. J., & Hine, P. (2008). Cognitive behavioural
treatment of perfectionism: A single case experimental
design series. Behaviour Change, 25(4), 245258.
Endicott, J., Nee, J., Harrison, W., & Blumenthal, R.
(1993). Quality of life enjoyment and satisfaction
questionnaire: A new measure. Psychopharmacology
Bulletin, 29(2), 321326.
Fairburn, C. G., Cooper, Z., & Shafran, R. (2003).
Cognitive behaviour therapy for eating disorders: A
transdiagnostic theory and treatment. Behaviour
Fiore, D., Dimaggio, G., Nicolo, G., Semerari, A., &
Carcione, A. (2008). Metacognitive interpersonal
therapy in a case of obsessive-compulsive and

avoidant personality disorders. Journal of Clinical
Psychology, 64(2), 168180.
W. (1996). Structured clinical interview for DSM-IV
Axis I disordersPatient edition (SCID-I/P, version
2.0). New York: Biometrics Research Department,
New York State Psychiatric Institute.
First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B.
W., & Benjamin, L. S. (1997). Structured clinical
interview for DSM-IV Axis II personality disorders
(SCID-II). Washington, DC: American Psychiatric.
Gratz, K. L., & Roemer, L. (2004). Multidimensional
assessment of emotion regulation and dysregulation:
Development, factor structure, and initial validation
of the difficulties in emotion regulation scale. Journal
of Psychopathology and Behavioral Assessment, 26,
4154.
Haring, M., Hewitt, P. L., & Flett, G. L. (2003).
Perfectionism, coping, and quality of intimate
relationships. Journal of Marriage and Family, 65,
143158.
Hewitt, P. L., Newton, J., Flett, G. L., & Callander,
L. (1997). Perfectionism and suicide ideation in
adolescent psychiatric patients. Journal of Abnormal
Child Psychology, 25(2), 95101.
Hopwood, C. J., Pincus, A. L., DeMoor, R. M., & Koonce,
E. A. (2008). Psychometric characteristics of the
inventory of interpersonal problems-short circumplex
(IIP-SC) with college students. Journal of Personality
Assessment, 90(6), 615618.
Koutoufa, I., & Furnham, A. (2014). Mental health
literacy and obsessive-compulsive personality
disorder. Psychiatry Research, 215(1), 223228.
Kyrios, M. (1998). A cognitive-behavioural approach
to the understanding and management of obsessivecompulsive personality disorder. In C. P. Perris &
P. D. McGorry (Eds.), Cognitive psychotherapy of
psychotic and personality disorders: Handbook of
theory and practice (pp.351378). New York: Wiley.
Lynch, T. R., & Cheavens, J. S. (2008). Dialectical
behavior therapy for comorbid personality disorders.
Journal of Clinical Psychology, 64(2), 154167.
McGlashan, T. H., Grilo, C. M., Skodol, A. E., Gunderson,
J. G., Shea, M. T., Morey, L. C., etal. (2000). The
collaborative longitudinal personality disorders study:
Baseline Axis I/II and II/II diagnostic co-occurrence.
Acta Psychiatrica Scandinavica, 102(4), 256264.
Millon, T. (1981). Disorders of personality: DSM-III, Axis
II. New York: Wiley.
Ng, R. M. (2005). Cognitive therapy for obsessivecompulsive personality disorderA pilot study in
Hong Kong Chinese patients. Hong Kong Journal of
Ost, L. G. (2008). Efficacy of the third wave of behavioral
therapies: A systematic review and meta-analysis.
Pinto, A. (2011). Introducing the POPS (pathological
obsessive-compulsive personality scale): Derivation
and exploratory factor analysis. Paper presented
at the annual meeting of the Society for Personality
Assessment, Cambridge, MA.
429
Pinto, A., Steinglass, J. E., Greene, A. L., Weber, E. U.,

& Simpson, H. B. (2014). Capacity to delay reward
differentiates obsessive-compulsive disorder and
obsessive-compulsive personality disorder. Biological
Psychiatry, 75(8), 653659.
Pollak, J. M. (1987). Obsessive-compulsive personality:
Theoretical and clinical perspectives and recent
research findings. Journal of Personality Disorders,
1(3), 248262.
Rice, K. G., & Aldea, M. A. (2006). State dependence
and trait stability of perfectionism: A short-term
longitudinal study. Journal of Counseling Psychology,
53, 205212.
Riley, C., Lee, M., Cooper, Z., Fairburn, C. G., & Shafran,
R. (2007). A randomised controlled trial of cognitivebehaviour therapy for clinical perfectionism: A
preliminary study. Behaviour Research and Therapy,
45(9), 22212231.
Sansone, R. A., Hendricks, C. M., Sellbom, M., &
Reddington, A. (2003). Anxiety symptoms and
healthcare utilization among a sample of outpatients
in an internal medicine clinic. International Journal of
Psychiatry in Medicine, 33(2), 133139.
Shafran, R., Cooper, Z., & Fairburn, C. G. (2002). Clinical
perfectionism: A cognitive-behavioural analysis.
Shafran, R., Egan, S., & Wade, T. (2010). Overcoming
perfectionism: A self-help guide using cognitive
behavioral techniques. London: Robinson.
Soeteman, D. I., Hakkaart-van Roijen, L., Verheul, R.,
& Busschbach, J. J. (2008). The economic burden of
personality disorders in mental health care. Journal of
Clinical Psychiatry, 69(2), 259265.
Sperry, L. (2003). Handbook of diagnosis and treatment
of DSM-IV-TR personality disorders (2nd ed.). New
York: Brunner-Routledge.
Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman,
C. F., Brown, G. K., Barber, J. P., etal. (2006). Early
alliance, alliance ruptures, and symptom change in a
nonrandomized trial of cognitive therapy for avoidant
and obsessive-compulsive personality disorders.
Journal of Consulting and Clinical Psychology, 74(2),
337345.
Svartberg, M., Stiles, T. C., & Seltzer, M. H. (2004).
Randomized, controlled trial of the effectiveness of
short-term dynamic psychotherapy and cognitive
therapy for cluster C personality disorders. American
Villemarette-Pittman, N. R., Standford, M. S., Greve,
K. W., Houston, R. J., & Mathias, C. W. (2004).
Obsessive-compulsive personality disorder and
behavioral disinhibition. Journal of Psychology,
138(1), 522.
Winston, A., Laikin, M., Pollack, J., Samstag, L. W.,
McCullough, L., & Muran, J. C. (1994). Short-term
psychotherapy of personality disorders. American
Young, J. E. (1999). Cognitive therapy for personality
disorders: A schema-focused approach (3rd ed.).
Sarasota: Professional Resource.
Treatment of Suicide
Obsessions in ObsessiveCompulsive Disorder with
Comorbid Major Depressive
Disorder
29
Chad T. Wetterneck, Monnica T. Williams,

Ghazel Tellawi and Simone Leavell Bruce

Research Basis
Obsessive-compulsive disorder (OCD) is characterized by obsessions and/or compulsions. Obsessions are recurrent and unwanted thoughts that
are distressing to the individual. Compulsions are
repetitive behaviors performed in response to obsessions to reduce distress (American Psychiatric
Association 2013). OCD has lifetime and 12month prevalence rates estimated to be 2.3 and
1.2%, respectively (Ruscio etal. 2010). Roughly,
two thirds of individuals with OCD report that
they are severely impaired in various life roles,
such as home management and work. For example, Ruscio etal. found that about half of those
with OCD experienced obsessions for an average of 5.9h a day and engaged in compulsions
for 4.6h a day. For those with clinically severe
OCD, great impairment occurs in relationships
C.T.Wetterneck()
Rogers Memorial Hospital, 34700 Valley Road,
Oconomowoc, WI 53066, USA
e-mail: cwetterneck@rogershospital.org
C.T.Wetterneck M.T.Williams G.Tellawi
S.L.Bruce
Department of Psychological & Brain Sciences, Center
for Mental Health Disparities, University of Louisville,
Louisville, KY 40292, USA
and social functioning. Ninety percent of those

with OCD meet criteria for another disorder at
some point in their lives (Ruscio etal. 2010).
There are high rates of comorbidity with major
depressive disorder (MDD; 40.7% comorbidity
rate) and mood disorders in general (63.3%), but
other anxiety disorders are most common (75.8%
comorbidity rate; Ruscio etal. 2010).
Obsessions and compulsions are expressed
in various ways, and the most common symptom dimensions are contamination, doubt/
checking, symmetry, and unacceptable thoughts
(Abramowitz etal. 2003). Individuals with unacceptable thoughts experience more shame and
fear and less social acceptance than those with
contamination or doubt/checking obsessions (Simonds and Thorpe 2003). Unacceptable thoughts
may include themes that are religious, violent, or
sexual (Williams etal. 2013). Violent obsessions
can include fears of harming others or of committing suicide (Gordon 2002).
With the variety of symptom presentations,
OCD is often misdiagnosed, with certain presentations more often misdiagnosed than others (Sussman 2003). One study found that misidentification rates were nearly 40% across all
symptom dimensions and significantly higher for
vignettes that involved taboo thoughts in OCD
versus contamination obsessions (Glazier etal.
2013). Misdiagnosis can cause a delay in appro-

DOI 10.1007/978-3-319-17139-5_29
431
432
priate treatment, which delays improvement in

the individual, ineffectively utilizes health-care
resources, and may result in worsened symptoms
or drop out from treatment (Glazier etal. 2013).
Additionally, a misdiagnosis (e.g., labeling
someone with sexual obsessions about children
as a pedophile) can lead to significant societal
backlash and internal shame for the individual
receiving the diagnosis.
Numerous studies have supported cognitivebehavioral therapy (CBT), specifically exposure
and ritual/response prevention (ERP, as the treatment of choice for adults and children with OCD
(Abramowitz etal. 2005; NICE 2006; Rosa-Alcazar etal. 2008). The treatment consists of psychoeducation, imaginal and in vivo exposures,
and ritual/response prevention. Psychoeducation
is designed to teach the individual about OCD
and provide a rationale for treatment. Exposures
allow the individual to contact feared triggers,
either directly or through vividly imagining coming into contact with the stimulus. During exposures, the individual engages in response prevention, which is refraining from avoidance or neutralizing behaviors.
In terms of medicinal treatments for OCD,
only serotonin reuptake inhibitors (SRIs) have
been approved by the Food and Drug Administration. However, many patients fail to reach
minimal levels of symptoms through the use of
SRIs alone (Simpson etal. 2013a). Therefore,
it is often recommended that SRIs are complemented by CBT or another medication in treating OCD. Despite treatment being effective for
many, 3846% of participants who completed
ERP combined with SRIs achieved minimal
symptoms, indicating that many people fail to
respond fully or at all to this treatment (Simpson
etal. 2013a).
Functional analytic psychotherapy (FAP)
is an interpersonally focused treatment that attempts to ameliorate problems that are rooted in
relationships among people. FAP utilizes basic
behavioral techniques, including shaping and
reinforcement, during the therapy session in
order to foster awareness, courage, and intimacy
(Tsai etal. 2009). A few studies have examined
the treatment of OCD through the use of FAP.
C. T. Wetterneck et al.
Kohlenberg and Vandenberghe (2007) used FAP

to target a patients avoidance and fear of being
dependent on others, as well as her lack of trust.
In addition, Vandenberghe (2007) described how
FAP can be used to aid in treatment of OCD in
conjunction with ERP. It has also been suggested
that FAP may help target altering reactions to difficult emotions and problems with intimacy in
OCD and related spectrum conditions (Wetterneck and Hart 2012).

Paul is a Cuban-American high school teacher in
his mid-40s, who has a young child with his wife.
All three live together in a small Midwestern
town. Paul presented to treatment due to intense,
intrusive obsessive thoughts about committing
suicide, with his main fear regarding the lasting
effect that his suicide would have on his child and
wife. While Paul denied suicidal intent and had
no desire to kill himself, he feared that he would
suddenly lose control and on impulse kill himself. Paul also feared that he would be unable to
maintain his employment while battling his disturbing thoughts. He believed that his symptoms
would become so bad that he would be forced
to receive electroconvulsive therapy. In response
to his obsessions, Paul spent several hours a day
finding reassurance online and frequently from
his wife that he would not harm himself. Paul
also engaged in contingency planning on his own
and with his wife, considering what actions his
family would need to take if he were to become
incapacitated due to a mental breakdown. He also
reported difficulty focusing on his work and paying attention in class. He had difficulty enjoying
things in his life, like time with his family, because of his obsessions and the excessive amount
of time spent performing compulsions. He frequently ruminated for hours about the shame he
would bring upon his family once friends, family
members, and coworkers discovered that he had
committed suicide. In addition, he likened his depressed mood to a dark cloud over all aspects
of his life. Paul had previously received brief
treatment (CBT with ERP) for OCD surround-
29 Treatment of Suicide Obsessions in Obsessive-Compulsive Disorder with Comorbid Major
ing violent obsessions and was now receiving

treatment for depression at a university center for
mood disorders. He had no prior suicide attempts
or psychiatric hospitalizations.
Case Information
Pauls obsessions about suicide did not appear to
be completely unprovoked. When Paul was in his
mid-20s, his youngest brother committed suicide
by hanging himself. Although his brother was
never diagnosed with a psychological disorder,
Paul believed his brother suffered from bipolar
disorder. In addition, Paul also had an uncle and
two other relatives who had committed suicide.
The fact that suicide seemed to run in his family intensified the fear that he might become so
depressed one day that he would kill himself on
impulse. These thoughts were unwanted, distressing, and ego-dystonic for Paul.
During his college years, Paul experienced
a traumatic drug event with psilocybin mushrooms, which troubled him for the rest of his
college years. Psilocybin mushrooms, otherwise
known as magic mushrooms, can cause distortions in audio and visual senses. Even after 20
years, Paul cringed when he recalled this in session. He remembered seeing distorted faces and
hearing unearthly sounds, which terrified him at
the time. Shortly after that experience, Paul recalled listening to the radio and hearing a famous
rock star talk about the damaging effects that
drug use had on his brain. Paul then began experiencing intrusive thoughts about possible brain
damage through the use of the mushrooms. He
believed that his thoughts were triggered directly
by hearing that radio show. These thoughts appeared to be his first bouts of OCD, but, at the
time, he was not aware of this condition. Paul
began reading and collecting information about
the effects of hallucinogenic drugs on the brain.
If Paul was exposed to any conversation or trigger that reminded him of hallucinogenic drugs or
brain damage, he would experience heightened
anxiety, which sent him into further investigation and rumination about whether or not he had
caused irreparable damage to his brain.
433
Later in life, Paul sought treatment due to obsessions that he may harm others, which was diagnosed as OCD. His treatment lasted about six
to eight sessions, and he received CBT with ERP.
His aggressive obsessions reduced substantially;
however, his fears about brain damage and suicide obsessions were not recognized or treated
during this time.
When Paul initially presented for treatment,
he was experiencing obsessions that he may
harm himself, and that this would traumatize
his young child and leave a huge burden on his
wife. These obsessions led to constant feelings
of depression that negatively affected his quality of life. Paul sought constant reassurance from
his wife who was his only source of support and
the only person who knew about his obsessions.
Paul frequently required her to tell him that he
was not really going to commit suicide and was
not capable of that act. His fear was exacerbated
by the intense feelings of depression that seemed
to run parallel to his feelings of anxiety. He did
not have an organized plan about how he might
commit suicide, but he consistently avoided triggers to decrease the possibility of killing himself
on impulse, despite these thoughts being distressing and ego-dystonic. He avoided dealing with
sharp objects, and the idea of holding or making
a noose caused a spike of anxiety. Pauls fear
led to time-consuming mental rituals, including latching onto news stories or movies about
people who committed suicide. If a story about
suicide flashed across a website, Paul would read
the story searching for as many details as possible. If he deemed his life was dissimilar to the
victim, he gained brief reassurance that he would
not harm himself.
Paul reported that as a child he was raised in
an environment in which there was no discussion
of emotions and psychological issues. Despite his
mother having many emotional outbursts and attempting suicide in front of Paul and his family
members, these incidents were never discussed.
Paul received only minimal explanations as to
why these things were occurring. He even once
witnessed his mother intentionally crash a car
into a tree. Paul was always told your mother is
emotional as a way to explain her actions. This
434
led to Paul feeling as though his emotions were

to be feared, a burden on others, and that they
should be suppressed.

Assessment
Paul wondered if his worries were actually a result of OCD rather than depressive ruminations,
and thus he sought consultation with an OCD
specialist. He was assessed with the YaleBrown
Obsessive-Compulsive Scale (YBOCS; Goodman etal. 1989), Mini-International Neuropsychiatric Interview (MINI; Sheehan etal. 1998),
Beck Anxiety Inventory (BAI; Beck 1990), Beck
Depression Inventory-II (BDI-II; Beck etal.
1996), Penn State Worry Questionnaire (PSWQ;
Meyer etal. 1990), Quality of Life Enjoyment
and Satisfaction Questionnaire (Q-LES-Q; Endicott etal. 1993), and the Beck Scale for Suicide
Ideation (BSSI; Beck etal. 1979). The results
from the MINI indicated a diagnosis of OCD and
MDD. At baseline, Paul scored 22 on the BDI-II
(moderate depression), 30 on the YBOCS (severe
OCD), 27 on the BAI (severe anxiety), 53 on the
PSWQ (moderate worry), 46 on the Q-LES-Q,
and 15 on the BSSI. Pauls Q-LES-Q score indicates that his quality of life and enjoyment was
average, with poor scores in the areas of mood,
social relationships, overall sense of well-being,
and medication.
Later into his treatment, Paul completed the
Young Schema Questionnaire (YSQ; Young and
Brown 1994) and the Functional Idiographic Assessment Template (FIAT; Callaghan 2006). The
YSQ assesses for long-standing schemas that
likely develop in childhood and adolescence and
may interfere with treatment for Axis I conditions. The schemas are assessed based on the endorsement of maladaptive thoughts or behaviors
that may have been functional earlier in life (e.g.,
avoidance of an emotion or situation one does
not understand), but they are dysfunctional when
applied and generalized to situations as an adult
(e.g., avoidance of all emotion in general). It is
not commonly used for OCD treatment, but it has
been shown to relate to treatment outcome for
OCD (Haaland etal. 2011). His results revealed

themes of inconsistent relationships, not having
relationships in which his needs are met, a general mistrust for others and his own feelings, and
lacking someone he can depend on. The FIAT is
designed to explore interpersonal strengths and
weaknesses; Paul endorsed that he valued close
relationships but has difficulties recognizing,
expressing, and being receptive to his emotions
within these contexts.
Pauls symptoms are best understood with a
cognitive-behavioral conceptualization of OCD.
As suicide was prominent in his family, it is natural that he would have concerns about this, but it
was Pauls response to these thoughts that created difficulty for him. These frequent thoughts
were significantly distressing, and he made efforts to reassure himself that he would not commit suicide. His intrusive thoughts about suicide
led to him ruminating about contingency plans
and always seeking his wifes reassurance, which
decreased his anxiety short term but led to more
distress over time. Despite his attempts at reassurance, Paul was unable to completely avoid his
intrusive thoughts of suicide, and their continued
presence led to more distress. However, Pauls
suicidal thoughts were only associated with his
OCD, and he indicated no intent or desire to commit suicide. This was key in terms of differential
diagnosis; separating suicidal obsessions from
true suicidal ideation or intent, which he did
not experience. Pauls BSSI score was elevated,
which would normally indicate suicidal ideation. However, through the use of interviewing
and self-report measures, it was concluded that
Pauls BSSI score was indicative of thoughts that
were unwanted and obsessional rather than actual suicidal ideation. His responses on items on
the BSSI reinforced this, as he endorsed I would
try to save my life if I found myself in a lifethreatening situation, I do not accept the idea
of killing myself, and I do not expect to make
a suicide attempt.
Engaging in rituals (e.g., devising contingency plans) resulted in distance from social
and family activities, and this isolation contributed to his symptoms of depression. Avoiding
his thoughts, seeking reassurance, and making
contingency plans reinforced the notion that his

thoughts were actually threatening, by proving to
him that his methods were helping him avoid suicide. Due to the temporary reduction in anxiety,
Paul saw his rituals as necessary strategies. Thus,
he maintained the cycle of experiencing an intrusive thought, engaging in rituals, and experiencing brief relief from his anxiety.

Assessment and Treatment Planning
When Paul presented to treatment, he was taking fluoxetine 80mg and lorazepam (0.51mg)
occasionally, as needed to help him sleep. The
initial consultation included an assessment of
symptoms and gaining background information.
Paul had written some of his own imaginal exposure scripts, a technique he had learned during his previous OCD treatment, as an attempt
to treat himself, but he was discouraged that the
scripts were not helping him.
The first session with Paul consisted of a family meeting with his wife to review Pauls OCD
symptoms and their impact at home. This meeting
consisted of a discussion of symptoms, treatment
history, progress to date, and psychoeducation
about the OCD cycle. The OCD cycle is a way
of conceptualizing OCD, in which an obsession
leads to anxiety, which makes the person want
to perform a compulsion. The compulsion then
provides relief, but it is only temporary and short
lasting, and it then strengthens the obsession and
435
continues the cycle (Heyman etal. 2006). The

therapist also explained how reassurance was
part of the OCD cycle, which only worsened
symptoms. Pauls wife agreed that she would
no longer provide reassurance in response to his
obsessions. Additionally, Paul was instructed to
not engage in contingency planning, as this was a
common compulsion for him.
The second session consisted of more assessment and information gathering. He was assessed
using the MINI and YBOCS. Although a twiceweekly therapy schedule was recommended,
Paul was unable to come that often due to distance and his work commitments. He agreed to
increase sessions from once to twice a week after
school was out. Upon ending the school year,
Paul briefly attended therapy twice a week.
Exposure and Ritual/Response

Prevention
After the assessment was complete, a hierarchy
of his distressing situations was created, with
each assigned a Subjective Units of Distress
Scale rating (SUDS; Wolpe 1969; Table29.1).
Situations listed are ranked from least to greatest
as measured by the clients reported SUDS, 0 (no
anxiety, calm) to 100 (very severe anxiety, worse
ever experienced). The hierarchy was created as
a guide for treatment to help choose exposure exercises to be conducted in and out of session. In
addition, Paul and the therapist worked together
to complete a list of his rituals, and he was asked
to refrain from these.
Table 29.1 Exposure hierarchy

Number
Exposure
SUDS
Saying I really want to die at home alone
40
Listening to psychedelic music (Pink Floyd)
60
Watching a documentary about hallucinogens
65
Hearing only part of a news story on suicide
70
Standing on a high bridge
70
Imaginal exposure story about killing self
70
Make and hold a noose or other instrument of suicide
80
8
9
10
Watch a documentary about suicide (Kurt Cobain)

Watching a suicide-themed movie about a real person
Holding a knife to chest
80
80
80
436
A main theme that arose during the early sessions was the suicide of Pauls younger brother.
This experience was important because of the
sadness that Paul still carried and because of its
relationship to his current fears of committing
suicide. Also, it was important to discuss this
story to help rule out a diagnosis of posttraumatic
stress disorder (PTSD). Discussing his brothers
suicide also functioned as an exposure exercise
because the story was suicide themed and anxiety provoking for Paul. Because this was Pauls
first encounter with an exposure exercise in his
current treatment, it was recommended that he
work on spoiling his compulsions in some
way. Spoiling meant that if he performed a
ritual after being exposed to an obsession or
anxiety-provoking stimulus, he would reexpose
himself without performing the ritual again. The
function of spoiling a ritual is to increase his
anxiety again, thus counteracting the temporary
anxiety-reducing effects of a ritual. Another way
to spoil his obsessions was to agree with them;
for example, saying, Yes, I do want to kill myself in response to a suicidal obsession.
Another main theme that was discussed during
the early sessions was Pauls fear that he would
lose control and be forced into a psychiatric facility. Based on these themes, Pauls homework
centered on writing about his brothers suicide
to further confront his feelings related to the suicide. Additionally, he was to write about his traumatic drug experience so that exposures could be
designed around that story. Paul was also told to
complete self-monitoring of his rituals to aid in
ritual prevention, and he was reminded of the importance of completing these work sheets many
times in treatment.
After these early sessions, Paul remained discouraged and expressed difficulty resisting his
compulsions, including contingency planning.
Even though psychoeducation was provided in
the first two sessions, it was clear that it was necessary to add more to the psychoeducation conversation. He was given additional information
about why it is so important to resist contingency
planning, in order to not perpetuate his OCD
cycle. Because he was feeling discouraged and
his mood was suffering, activities that he could
engage in to help improve his mood were also

discussed, including taking his child to church
and going to yoga with his wife.
Based on his exposure hierarchy, Pauls first
exposure was to repeatedly say, I want to kill
myself. This was conducted in several sessions
and daily for homework. He was instructed to
repeat this imaginal exposure often in order to
begin habituating to such thoughts. His first experience with this exposure resulted in a peak
SUDS of 40 and a drop to 15. His SUDS during
his second experience with this exposure started
at 30, peaked at 70, and dropped to 50. By the
end this exposure, his SUDS started, peaked, and
ended at 10. This low SUDS indicated that he had
habituated to this exposure, and that it was time
to begin a new exercise.
Despite his progress with the exposure, Paul
reported that his mood was dysphoric, and that
he was feeling anxious. As a result, additional
psychoeducation was provided consisting of explaining the nature of OCD as a what if disorder. Paul was told that the what if should be
considered the voice of OCD, and that he should
resist subsequent urges to ritualize, including refraining from seeking information on the Internet to reassure himself that he would not commit
suicide. In order to help keep Paul encouraged,
provide him with support, and help him remain
focused on not ritualizing or contingency planning, two check-in reminder phone calls were
used to aid in his ritual prevention.
While still working on his first exposure, he
was instructed to write about his traumatic drug
experience, which related to future exposure exercises. Recounting this distressing drug memory
was then used as an exposure in session, as his
second and third exposures on his hierarchy related to this experience. While reading this story,
his SUDS started at 35. In order to make this story
more anxiety provoking, Paul was instructed to
rewrite the story by adding more feared consequences. When he brought this revised story into
session, it included his fear that he had caused
permanent brain damage by taking drugs.
After engaging in this exposure exercise, Paul
discussed his difficulty with ritual prevention
outside of session. He was still making contin-
gency plans and engaging in negative self-talk.

Self-compassion was discussed in the session,
which was important because research has shown
that OCD severity has a negative relationship
with self-compassion (Wetterneck etal. 2013).
It was hoped that increasing his self-compassion
might alleviate some of the emotions (i.e., guilt
and shame) in response to his obsessions. He reported that his main worry was letting his family
down. In order to provide him with more support,
Paul was instructed to attend an OCD support
group held in the same location as his individual
sessions. His experiences in this group were discussed throughout his individual treatment. Paul
found the group to be a positive experience.
To tackle these fears more directly, with the
intention of decreasing Pauls perceived setbacks,
he was instructed to draft a preliminary imaginal
exposure at home about killing himself, leaving
his wife behind, and his suicides effect on his
family. Upon reading this exposure, his SUDS
only decreased from a 70 to 45 after completing
the reading. In session, as is commonly done in
OCD treatment (i.e., Freeston etal. 1997), Paul
recorded his suicide narrative on a small, handheld digital recorder and listened to it, experiencing a peak of 50 in his SUDS, before it decreased.
He was instructed to listen to his suicide narrative
daily. Paul consistently listened to his imaginal
exposure most days of the week and eventually
experienced only mild anxiety. This indicated
that he had habituated to this specific narrative,
and that it was time to create a new, more difficult
exposure.
In order to specifically target his ritual of contingency planning, he was asked to write a story
detailing a feared outcome based on his failure
to make contingency plans. The story ended with
Paul becoming hospitalized and permanently
disabled due to his failure to plan in the face of
his declining mental health. It appeared this was
helpful, as, a session later, Paul reported cutting
down on contingency planning.
Pauls previous suicide story was reviewed
to remove parts that were not anxiety provoking
and add more anxiety-provoking details. These
details included suicide attempts, becoming incapacitated, being forced to undergo electroconvul-
437
sive therapy, and brain surgery in a mental hospital. This exposure was assigned as homework,
and he was instructed to listen to it for 4560min
a day.
After ten sessions, Paul reported that his mood
was somewhat better, and that he had been agreeing with his OCD fears as a way of spoiling
them, rather than mentally ritualizing and contingency planning. Agreeing with his OCD (e.g.,
saying statements such as Yes, I am going to
commit suicide and traumatize my daughter)
was important to disrupt the OCD cycle. He had
also resisted the temptation to read about OCD
online.
To further progress up his hierarchy, a documentary about depression and mental illness was
found (Running from Crazy; Kopple 2013) to
expose Paul to his core fear of harming his family
by becoming suicidal. Potential movie scenes that
could be used for exposure exercises were brainstormed including themes of suicidal ideation,
suicide attempts, and aftereffects of suicide on
the family. Paul found a documentary on assisted
suicide, which he watched in session. The most
anxiety-provoking moments were discussed, and
his SUDS peaked at 50. Paul also watched the
movie The Hours, which has prominent suicide themes throughout. His SUDS began at 30,
peaked at 50, and ended at 35.
Around the time that Paul was exposed to a
documentary about depression and mental illness, he reported hearing on the news that the
suicide rate was increasing in the state in which
he lived. This made Paul fearful, so the discussion centered on the utility of agreeing with his
OCD statements and using such experiences as
an exposure. Although Paul was habituating to
the anxiety of the documentary, his mood was
becoming more dysphoric, and he reported difficulty consistently engaging in his exposure
homework. He reported listening to his suicide
narrative some days of the week, with his highest
SUDS reaching 5060. Also, because his teaching year was due to begin in 2 months, Paul reported engaging in some compulsions surrounding contingency planning for what to do if he
became depressed in the fall. Again, it was important to revisit psychoeducation on ritualizing
438
to help improve Pauls mood and encourage him

to not engage in compulsions. The voice of OCD
was again discussed as a what if that leads to
doubt and contingency planning, and these behaviors were identified as compulsions. Also, because his OCD appeared to be entering into other
areas of his life, an analogy was used to illustrate
this, in which OCD was said to call in from different phone numbers. He was able to recognize
that OCD occurs in various incarnations.
Once Paul had habituated to his suicide narrative, he advanced to exposures using tangible
props. He was listening to his narrative while
holding a knife and looking at pictures of his
child. This was also assigned for homework,
and he was able to listen to it consistently. These
props were chosen because his biggest fear was
that he would kill himself and ruin his childs
life. After repeatedly listening to this narrative,
Paul began habituating to the recording, with his
peak SUDS reaching 30 and dropping to a 10. In
session, he experienced a higher level of distress
when listening to his suicide note, with his SUDS
starting at 30, peaking at 50, and ending at 25. To
augment the exposure, he rewrote his imaginal
exposure with additional negative outcomes. The
next time Paul listened to this exposure in session, he held a knife to his neck, and his SUDS
began at 20, reached 45, and eventually dropped
to 35. This exposure was done twice as homework after his 21st session, with beginning, peak,
and ending SUDS of 20, 65, 40 and 25, 45, 30,
respectively, across 2 days.
Around this time, Paul began experiencing
stressors at home and argued frequently with his
wife. To encourage Paul to resolve his at-home
stressors, the role of stress in OCD was discussed. Paul understood that stress could worsen
symptoms (Rasmussen and Eisen 1991), and he
agreed that his exposures were more difficult
when he was feeling anxious in general. He was
also encouraged to practice being optimistic, and
he was told that optimism does not equal reassurance. Positive thinking was framed as something
different than reassurance and metacognitions in
which he evaluates his thoughts as positive or
negative. Despite his stressors, Paul was spending less time focusing on his OCD symptoms, but
still had the desire to check the Internet for information on OCD and make contingency plans. He
reported feeling better than at the start of treatment and noticed that he was less avoidant of
triggers. Paul was able to recognize that OCD is a
chronic yet treatable condition that requires management. He was encouraged not to try to differentiate between thoughts that were occurring in
the context of his OCD versus those that were
related to his depression. He was also encouraged
to continue agreeing with his OCD thoughts and
identify unrealistic thoughts.
By this time, Paul had been attending treatment once per week on a relatively consistent
basis. However, around his 22nd session, Paul
was due to go on a 1-month vacation, so a weekly check-in phone call was held. Pauls anxiety
about going away on vacation and not receiving
treatment interfered with his homework completion and contributed to a setback in terms of his
OCD symptoms. He began having obsessions
about his anxiety not getting better and the treatment not working. He created contingency plans
of what would happen if ERP were to fail. He
was also concerned about his quality of life and
his feelings of depression. To alleviate these
fears, Paul was encouraged to change his attitude
toward his OCD and take an offensive stance toward the disorder. The importance of metacognitions was also discussed, encouraging him to be
aware of how he was thinking about his thoughts
and how much importance he was giving to them.
He was reminded that the more attention he gives
to his thoughts, the more they become important
and influential. This was discussed in terms of his
suicide obsessions, and how his constant rumination about them was giving them more meaning
than they should have in his life. Additionally, he
was reminded about the importance of breaking
the OCD cycle.
After his vacation, Paul returned for his 23rd
session. The focus returned to his last exposure,
in which he listened to the suicide narrative with
props (i.e., holding a knife to his neck, looking at
a picture of his family). Despite traveling, he had
found time to do his imaginal exposure homework but was not able to use props. He no longer
found it difficult to listen to the recording with
his SUDS starting at 20, peaking at 25, and ending at 20. Paul had habituated and was ready for
a new creative exposure.
The next session took place on a high bridge,
and he was instructed to stand by the edge of the
bridge (which had a guardrail for safety) and listen to his suicide note recording. The note was
written to his daughter and was an explanation
and apology for taking his own life and detailed
how he thought she would react to this news. His
SUDS did not reach a high peak due to the novelty of the bridge experience and because he was
habituating to the recording of the suicide narrative.
Paul had reached a point where his exposures
were not resulting in significant distress. Further
reinforcing the notion that he was habituating to
his exposures, his peak SUDS when watching the
suicide-themed film The Hours was down to
15. However, during a difficult week for Paul,
in which his poor relationship with his parents
greatly impacted his mood, and he was afraid of
unraveling at the upcoming school year, he experienced a large rise in his anxiety upon watching The Hours. His SUDS during this exposure
peaked at a 55.
Pauls additional current stressors, including significant construction on his home and the
beginning of school, were affecting his OCD
symptoms. Focus shifted away from his exposure exercises and more toward psychoeducation
and discussion of problems in his life. Paul was
able to discuss the feelings of abandonment he
felt as a result of his mother not being able to
discuss his psychological issues with him. After
Pauls brothers suicide, his mother was no longer emotionally available to help him through
his struggles, and this was a major obstacle for
him.
To help Paul cope with the problems in his
life, several strategies were employed. Through
cognitive strategies, Paul recognized that his fear
of committing suicide was unrealistic because
he was not actually suicidal, and individuals
with OCD very rarely act on their fears
(Veale etal. 2009). He was told to stop responding
to the false alarm created by his OCD and chal-
439
lenge his defeatist attitude. In order to prepare for

the new school year, the OCD cycle was again
discussed, as was the harm in ruminating. The
importance of social support was discussed, as
were the potential cultural barriers that he felt
were leading to difficulty making friends. Mindfulness, which can be helpful for OCD (Patel
etal. 2007), was also a focus, as Paul noticed
he was distracted by mundane things and wanted
help experiencing the present moment. He was
encouraged to decrease ruminations about future
difficulties and urged to instead stay in the present. A discussion also involved learning to be
okay without being 100% recovered, because he
had a tendency to want to be fully better before
engaging in pleasurable activities. He acknowledged being less impaired than he thought and
was also encouraged to accept his parents distance regarding mental health issues. After this
session, he reported no compulsions in the 5 days
prior to the school starting.
Despite all of these stressors, Paul was making an effort to not ruminate about mental illness, and he had less of an urge to do so. Paul
experienced many other gains toward the end of
the ERP, including becoming able to recognize
that his contingency planning was a compulsion,
and attempting to have more of an outward focus
on valued activities instead of spending his days
wrapped up in his own thoughts. Paul had fewer
intrusive thoughts, and compulsions, and was experiencing improvement in his mood. He reached
a time where he could not remember his most recent suicidal thought and had become able to create his own imaginal exposures.
After reviewing Pauls progress, the focus
returned to completing exposure exercises. Paul
had a much easier time watching The Hours
and reported fewer attempts at seeking reassurance. Pauls last exposure consisted of watching The Hours, with a focus on the scenes that
made him most anxious to make the exposure
most effective. By this point, his SUDS associated with the film peaked at a 10. After successfully habituating to the film exposure, the focus
of therapy shifted to focus on how to maintain the
gains from ERP.
440
Because Paul had made significant improvements, the topic of relapse prevention and maintenance of gains was addressed. To demonstrate
that he would be able to maintain his gains, it was
necessary to ensure that he was able to come up
with his own imaginal exposures and use exposure statements to combat his obsessions. Whenever he felt OCD-related anxiety, he was encouraged to use that as an opportunity to combat the
OCD by conducting a short self-directed exposure. He was also encouraged to find a story or
movie in which the character unravels the way he
was afraid might happen to him at school and use
that as his own exposure.
After about 30 sessions, winter approached,
and Pauls mood took a downturn. He had been
doing generally well with his OCD symptoms
but was ruminating about his relationship with
his parents and worried that he was starting to
become depressed. Paul was attempting to not
ruminate on his ability to tackle the whole academic year and rather focus on the present, but
because Paul associated the winter season with
depression, he found himself ruminating about
how winter would affect his mental health. He
was concerned about differentiating between
compulsions and depressive ruminations, and
he was advised that rumination about his mental state or the formation of contingency plans
would lead to a relapse of his OCD. He was instructed to increase his social interactions and to
exercise to counter his depressed state (George
etal. 1989; Tsang etal. 2008). These components
were important because despite making major
gains in terms of his OCD, Paul still had clinically significant OCD symptoms, and his depression did not resolve. During this time, Pauls social support came from his wife who had recently
been diagnosed with a chronic thyroid condition.
Due to her illness, she was no longer able to
provide basic attention and caring. This left him
feeling more isolated than before. In addition,
his parents were not helpful or emotionally supportive, exacerbating his feelings of depression
and isolation. It was recommended that the focus
of treatment shift toward specifically targeting
Pauls depression.
Functional Analytic Psychotherapy

Although Paul had now habituated to his exposure exercises, it was clear that he was still in
need of treatment to further reduce his OCD and
address his depression. Despite his BDI-II score
only being 13 at the start of the FAP treatment,
it was clear that his experience of his depression was greater than what was captured by the
BDI-II, and he was not where he wanted to be
in terms of his mood. There were many barriers
to continuing his care, including financial concerns, time constraints, maladaptive cognitions
about his ability to lift his depression, and a pessimistic attribution style. Despite these barriers,
at session 34, he began treatment for his depression using FAP, an interpersonally oriented behavioral therapy that targets the behaviors and
attitudes maintaining his isolation. FAP results
in the formation of a more personal and genuine relationship between the therapist and the
client than traditional ERP. Twelve sessions of
FAP were utilized to augment his interpersonal
skills, increase his receptiveness to his emotions,
and increase his social support. He was administered the YSQ and the FIAT at this time. The
themes from these questionnaires helped guide
decision making regarding the interpersonal processes that would benefit Paul if he were able to
take relational risks in these areas. Paul was also
encouraged to take one interpersonal risk daily to
increase his connectedness with others.
FAP began with a discussion of his elevated
schemas based on the YSQ and the way in which
he had learned to relate to and communicate his
needs to others. His refusal to ask for emotional
support was a pattern established early on by his
parents not addressing his emotional needs and
Paul witnessing emotions as dangerous. As a
result of these experiences, Paul learned to expect for people in his life to be emotionally unavailable and block himself from feeling or sharing emotions. The therapist explained the connection between his experience with his parents
and his current lack of behavioral repertoire to
form lasting and meaningful relationships. This
type of explanation is common in FAP as it helps
to reduce shame and validate why a pattern began
and may have been functional at first, and why

a person may continue to use the strategy even
after it is no longer effective.
In FAP, Paul would be practicing interpersonal exposures during session where he would be
asked to take interpersonal risks with his therapist
in order to be able to then generalize these new
behaviors outside of session with others. FAP relies on working with outside-of-session problematic behaviors in the session, evoking them if necessary, and shaping dysfunctional behavior to be
more functional and providing immediate natural
reinforcement for improvements. The goal for
therapy was to increase his ability to tolerate, acknowledge, and share his emotions in session and
generalize these gains outside of session, thereby
increasing social interaction and support to alleviate his depressed mood. The therapist routinely
offered self-disclosing information with Paul in
order to model the types of behaviors he would
need to develop to connect with others.
Pauls ongoing difficulties with the feelings of
parental emotional neglect as well as some marital discord allowed the therapist to encourage
Paul to express the feelings and emotions that he
would normally have felt pressured to conceal.
After each session, he was asked to complete
and send in a bridging form between sessions, in
which he answered a set of questions about interpersonal processes in the therapeutic relationship
that occurred in session (Holman etal. 2012). His
homework included expanding his social network by scheduling outings with colleagues from
work and expressing his emotions to his brother
about parental issues and marital concerns. Paul
identified these types of conversations and actions as risks he normally would have avoided.
Prior to engaging in FAP, Pauls natural inclination was to rule out connecting with those
who he deemed as different from him or who
he thought would not have shared his interests.
For example, although he worked around many
other academics, the suggestion of initiating
conversations or initially after hours activities
with these people was not favorable to Paul.
The math teacher would only want to talk about
math, which would be boring to Paul so therefore
the math teacher would not be a good fit. These
441
types of disqualifying thoughts were keeping

him isolated. As the treatment progressed, Paul
initiated conversations and outings with two colleagues as well as his brother. He mentioned how,
especially with his brother, he began to appreciate that connection. Paul was also able to take
risks with his brother and asked to discuss his
hurt feelings regarding their parents. Even when
his brother did not respond to this request, Paul
was able to reach out again and assert his need
for his brother to be present with him in regard to
these feelings.
By the end of treatment, Paul was working on
how to connect with his wife by changing some
patterns of behavior that may have contributed to
the disconnect they were experiencing. Through
this treatment, he came to realize that the issues
he faced with his wife may be associated with
how consumed he had been with the OCD obsessions. He stated that conversations with his
wife revolved around what he needed from her
as opposed to her emotional needs and wants. He
began working to rebuild trust between them by
becoming more attentive to her emotional needs.
Treatment Outcome
At the end of his treatment, Pauls relevant symptom scores had decreased, and he reported significant relief from the suicidal obsessions. He
was able to recognize dysfunctional thinking
more quickly. His quality of life improved, and
he had fewer intrusive thoughts. Paul also was
becoming more assertive of his needs. By the end
of his ERP for OCD treatment, Pauls YBOCS
score had reached 20 (from 30 at baseline) and
his BDI-II score was 13 (22 at baseline). At the
end of the FAP treatment, Pauls BDI-II score
was 11, indicating minimal levels of depression,
and his YBOCS was 8. Pauls Q-LES-Q score
increased to 54 from 46 (with no areas rated as
poor) and his PSWQ score decreased to 31 from
53, indicating low levels of worry. Paul experienced significant relief from the suicidal obsessions, became more able to recognize pessimistic
thinking and evidenced an improved quality of
life and fewer intrusive thoughts (Fig.29.1).
442
Fig. 29.1
Beck Depression Inventory-II (BDI-II) scores over 13
months
&KDQJHLQ%',,,6FRUH
%',,,7RWDO6FRUH

Paul experienced a number of complicating factors during treatment. His financial situation almost prevented him from receiving treatment, so
he was offered therapy at a reduced cost. This led
to him thinking that he was taking advantage of
his therapists by not paying the full price. The
reduced-cost sessions were rationalized as a part
of the FAP approach, basically offered as a way
to show that his therapists cared for him, and that
he would be able to improve if he was able to
accept the caring. To alleviate this feeling, Paul
alternated weekly receiving one full session and
one half-hour session. However, he maintained
this feeling, which contributed to missed sessions, and this issue was discussed on several occasions.
Additionally, because Paul lived in a small
town, he had to commute 1h each direction for
his treatment. Many sessions were also cancelled
or postponed due to bad weather in the area. Because of Pauls schedule as a high school teacher,
there was also difficulty coordinating a time to
meet with his therapist. All of these factors resulted in gaps in treatment.
Along with all of these difficulties, Pauls
OCD was quite persistent. He had previously
received treatment for OCD, but relapsed, with
his obsessions taking on a form different than
his previous presentation for treatment. Also,

6HVVLRQ1XPEHU

although Paul had been taking medication for

his OCD, his symptoms were not substantially improved, which is a common outcome
(Pigott and Seay 1999). Furthermore, Paul was
in treatment for his OCD twice as long as is
typical when following Foa et al.s (2012) protocol, 34 sessions compared to 17. Even with
the additional sessions, he did not achieve minimal symptoms at the end of the ERP (Simpson
etal. 2008).
Finally, Paul found it hard to accept that OCD
should be the primary focus of treatment, instead
of his morbid ruminations, which he felt were
proof that his therapy should focus on his depression. Upon completion of ERP, Paul still maintained a modest level of depression. He believed
that he would always be mildly depressed, as that
was how he had lived his entire life. This often
prevented him from being proactive in combating the disorder.
Finally, Paul experienced a few significant
stressors in his home life, which exacerbated
his tendency toward negative thinking. Paul
was distressed from feeling emotionally cutoff from his parents, who did not provide him
with the level of care that he felt he needed.
His social support was limited almost exclusively to his wife, contributing to his feelings
of isolation. Paul did not believe he would be
able to increase his limited social support in the
small town where he resided and was resistant
to the therapists attempts to assist him in this

area. During Pauls treatment for depression,
his wife began experiencing significant medical
issues that impacted their marriage. They were
involved in many arguments, which negatively
affected his mood.

Thoughts of suicide differ greatly when they are
occurring in the context of either depression or
OCD. While those with MDD may view suicide
as a means to escape and relief, for an individual
with suicide obsessions in OCD, the thought of
committing suicide is quite distressing. This can
be assessed by asking the patient how the idea
of suicide makes him/her feel. Because the suicidal thoughts play such a different role, treatment for suicidal ideation in depression and
suicidal obsessions in OCD differs. Therefore,
it is important that suicidal obsessions in OCD
be differentiated from actual suicidal ideation
and intent. See Table29.2 for other key practice
points.
Virtually, no research has been conducted
regarding obsessions of suicide in OCD, and
this obsession is distressing for the individual
and can be easily misunderstood. Based on the
results found in this case study and limited previous research (Wetzler etal. 2007), CBT approaches, such as ERP, are effective treatments
443
for this type of OCD presentation, which is consistent with previous studies that have shown that
ERP can be effective for reducing OCD symptom severity within the unacceptable thoughts
subtype (e.g., Abramowitz etal. 2003; Williams
etal. 2013).
While ERP is effective in the treatment of
OCD, it is sometimes necessary to augment this
with other approaches. In Pauls case, additional
targets included depression and social isolation.
In such cases, adjunctive treatments such as
FAP and mindfulness-based treatments may be
beneficial.
For Paul, FAP helped greatly reduce his symptoms of depression and contributed to positive
changes in his marriage and other relationships.
Previously, Paul was very cautious about overstepping boundaries and asking questions that
may have seemed too personal. Paul became less
concerned about offending someone with bolder
questions, which may be why he felt more comfortable giving friends marriage advice or reprimanding someone for bad behavior. He also was
more aware of and interested in his wifes needs.
Furthermore, Paul connected further with his
brother and reached out to other friends. These
are some examples of out-of-session behaviors
he normally would have neglected or avoided in
the past. The things he learned and behaviors he
practiced continue to slowly generalize into his
normal life outside of session as Paul continues
to improve.

Differential diagnosis
Benefits of ERP
OCD is a very heterogeneous disorder. Atypical presentations must be carefully assessed

ERP is the gold standard for the treatment of OCD, including treatment-resistant OCD and
OCD with unusual presentations
Limitations of ERP
Although most improve with ERP, many do not achieve minimal symptoms. ERP may not
be sufficient to address all factors that maintain symptoms
When to augment
ERP should be augmented when OCD symptoms remain clinically significant after an
adequate treatment course
Benefits of FAP
FAP can be useful in increasing interpersonal connectedness, which can in turn reduce OC
and depressive symptoms
ERP exposure and ritual/response prevention, OCD obsessive-compulsive disorder, FAP functional analytic
psychotherapy
444
References
Furr, J. M. (2003). Symptom presentation and outcome of cognitive behavioral therapy for obsessivecompulsive disorder. Journal of Consulting and
Abramowitz, J. S., Whiteside, S. P., & Deacon, B. J.
(2005). The effectiveness of treatment for pediatric obsessive-compulsive disorder: A meta-analysis.
Behavior Therapy, 36, 5563.
and statistical manual of mental disorders (5th ed.,
Text Revision, DSM-5). Washington, DC: American
Psychiatric Association.
Beck, A. T. (1990). Beck anxiety inventory. San Antonio:
The Psychological Corporation.
Beck, A. T., Kovacs, M., & Weissman, A. (1979). Assessment of suicidal ideation: The scale for suicide ideation. Journal of Consulting and Clinical Psychology,
47, 343352.
for the beck depression inventory-II. San Antonio:
Butwicka, A., & Gmitrowicz, A. (2010). Symptom clusters in obsessive-compulsive disorder (OCD): Influence of age and age of onset. European Child and
Adolescent Psychiatry, 19, 365370.
Callaghan, G. M. (2006). The functional idiographic
assessment template system. The Behavior Analyst
Today, 7, 357398.
Endicott, J., Nee, J., Harrison, W., & Blumenthal, R.
(1993). Quality of life enjoyment and satisfaction
questionnaire: A new measure. Psychopharmacology
Bulletin, 29, 321326.
Fairfax, H. (2008). The use of mindfulness in obsessive
compulsive disorder: Suggestions for its application
and integration in existing treatment. Clinical Psychology and Psychotherapy, 15, 5359.
and response (ritual) prevention for obsessive-compulsive disorder (2nd ed.). New York: Oxford University Press.
N., Rheaume, J., Letarte, H., & Bujold, A. (1997).
Cognitive-behavioral treatment of obsessive thoughts:
A controlled study. Journal of Consulting and Clinical
George, L. K., Blazer, D. G., Hughes, D. C., & Fowler,
N. (1989). Social support and the outcome of major
depression. British Journal of Psychiatry, 15,
44784485.
Glazier, K., Calixte, R., Rothschild, R., & Pinto, A.
(2013). High rates of OCD symptom misidentification by mental health professionals. Annals of Clinical
C., Fleischmann, R. L., Hill, C. L., & Charney, D. S.
(1989). The Yale-Brown Obsessive Compulsive Scale.
Part I. Development, use and reliability. Archives of
General Psychiatry, 46, 10061011.
Gordon, W. M. (2002). Sexual obsessions and OCD. Sexual and Relationship Therapy, 17, 343354.
Haaland, A. T., Vogel, P. A., Launes, G., Haaland, V. O.,
Hansen, B., Solem, S., & Himle, J. A. (2011). The role
of early maladaptive schemas in predicting exposure
and response prevention outcome for obsessive-compulsive disorder. Behavior Research and Therapy, 49,
781788.
Hannan, S. E., & Tolin, D. F. (2005). Acceptance and
mindfulness-based behavior therapy for obsessivecompulsive disorder. In S. M. Orsillo & L. Roemer
(Eds.), Acceptance and mindfulness-based approaches
to anxiety: Conceptualization and treatment (pp.271
299). New York: Springer Science + Business Media.
Hanstede, M., Gidron, Y., & Nyklicek, I. (2008). The
effects of a mindfulness intervention on obsessivecompulsive symptoms in a non-clinical student population. The Journal of Nervous and Mental Disease,
196, 776779.
Hasler, G., Pinto, A., Greenberg, B. D., Samuels, J., Fyer,
A. J., Pauls, D., Knowles, J. A., McCracken, J. T.,
Piacentini, J., & Riddle, M. A., etal. (2007). Familiality of factor analysis-derived YBOCS dimensions
in OCD-affected sibling pairs from the OCD collaborative genetics study. Biological Psychiatry, 61,
617625.
Heyman, I., Mataix-Cols, D., & Fineberg, N. A. (2006).
Obsessive-compulsive disorder. British Medical Journal, 333, 424429.
Holman, G., Kohlenberg, R. J., Tsai, M., Haworth, K.,
Jacobson, E., & Liu, S. (2012). Functional analytic
psychotherapy is a framework for implementing
evidence-based practices: The example of integrated
smoking cessation and depression treatment. Journal
of Behavioral Consultation and Therapy, 7, 5862.
Jenike, M., Baer, L., Minichiello, W., Rauch, S., & Buttolph, M. (1997). Placebo-controlled trial of fluoxetine and phenelzine for obsessive-control disorder.
Kohlenberg, R. J., & Tsai, M. (1994). Improving cognitive therapy for depression with functional analytic
psychotherapy: Theory and case study. The Behavior
Analyst, 17, 205319.
Kohlenberg, R. J., & Vandenberghe, L. (2007). Treatment-resistant OCD, inflated responsibility, and the
therapeutic relationship: Two case examples. Psychology and Psychotherapy: Theory, Research and Practice, 80, 455465.
Kopple, B. (2013). Running from crazy [Motion Picture].
Meyer, T. J., Miller, M. L., Metzger, R. L., & Borkovec,
T. D. (1990). Development and validation of the Penn
State Worry Questionnaire. Behaviour Research and
Therapy, 28, 487495.
NICE. (2006). Obsessive-compulsive disorder: Core
interventions in the treatment of obsessive-compulsive disorder and body dysmorphic disorder. The British Psychological Society & The Royal College of
Psychiatrists (National clinic practice guideline, No.
31). www.nice.org.uk. Accessed 01 Oct 2014.
Patel, S. R., Carmody, J., & Simpson, H. B. (2007). Adapting mindfulness-based stress reduction for the treat-

ment of obsessive-compulsive disorder: A case report.
Pigott, T. A., & Seay, S. M. (1999). A review of the efficacy of selective serotonin reuptake inhibitors in
obsessive-compulsive disorder. Journal of Clinical
Psychiatry, 60, 101106
Rasmussen, S. A., & Eisen, J. L. (1991). Phenomenology
of OCD: Clinical subtypes, heterogeneity and coexistence. In J. Zohar, T. R. Insel, & S. Rasmussen (Eds.),
The psychobiology of obsessive-compulsive disorder.
New York: Springer.
Rosa-Alczar, A. I., Snchez-Meca, J., Gmez-Conesa,
A., & Marn-Martnez, F. (2008). Psychological treatment of obsessive-compulsive disorder: A meta-analysis. Clinical Psychology Review, 28, 13101325.
Ruscio, A. M., Stein, D. J., Chiu, W. T., & Kessler, R. C.
(2010). The epidemiology of obsessive- compulsive
disorder in the National Comorbidity Survey Replication. Molecular Psychiatry, 15, 5363.
P., Janavas, J., Weiller, E., Hergueta, T., Baker, R., &
Dunbar, G. C. (1998). The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development
and validation of a structured diagnostic psychiatric
interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry, 59, 2233.
Simonds, L. M., & Thorpe, S. J. (2003). Attitudes toward
obsessive-compulsive disorders: An experimental
investigation. Social Psychiatry and Psychiatric Epidemiology, 38, 331336.
R., Huppert, J. D., Cahill, S., Vermes, D., Schmidt, A.
B., Hembree, E., Franklin, M., Campeas, R., Hahn, C.
G., & Petkova, E. (2008). A randomized, controlled
trial of cognitive-behavioral therapy for augmenting
pharmacotherapy in obsessive-compulsive disorder.
Simpson, H. B., Foa, E. B., Liebowitz, M. R., Huppert, J.
D., Cahill, S., Maher, M. J., McLean, C., Bender, J.,
Marcus, S., Williams, M. T., Weaver, J., Vermes, D.,
Van Meter, P. E., Rodriguez, C., Powers, M., Pinto,
A., Imms, P., Hahn, C-G., & Campeas, R. (2013a). A
randomized controlled trial of cognitive-behavioral
therapy vs. Risperidone for augmenting serotonin
reuptake inhibitors in obsessive-compulsive disorder.
Journal of the American Medical AssociationPsychiatry, 70, 11901199.
R., Huppert, J. D., Cahill, S., Vermes, D., Schmidt,
A. B., Hembree, E., Campeas, R., Hahn, C. G., &
Petkova, E. (2013b). Randomized, controlled trial of
445
cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. American Journal of Psychiatry, 165, 621630.
Sussman, N. (2003). Obsessive-compulsive disorder: A
commonly missed diagnosis in primary care. Primary
Psychiatry, 10, 14.
Taberner, J., Fullana, M., Caseras, X., Pertusa, A., Bados,
A., van den Bree, M., & Mataix-Cols, D. (2009). Are
obsessive-compulsive symptom dimensions familial
in non-clinical individuals? Depression and Anxiety,
26, 902908.
Tsai, M., Kohlenberg, R. J., Kanter, J. W., Kohlenberg, B.,
Follette, W. C., & Callaghan, G. M. (2009). A guide
to functional analytic psychotherapy. New York:
Springer.
Tsang, H. W. H., Chan, E. P., & Cheung, W. M. (2008).
Effects of mindful and non-mindful exercises on
people with depression: A systematic review. British
Vandenberghe, L. (2007). Functional analytic psychotherapy and the treatment of obsessive compulsive disorder. Counseling Psychology Quarterly, 20, 105114.
Veale, D., Freeston, M., Krebs, G., Heyman, I., &
Salkovskis, P. (2009). Risk assessment and management in obsessive-compulsive disorder. Advances in
Psychiatric Treatment, 15, 332343.
Wetterneck, C. T., & Hart, J. M. (2012). Intimacy is a
transdiagnostic problem for CBT: Functional analytic
psychotherapy is a solution. International Journal for
Behavior Consultation and Therapy, 7, 167176.
Wetterneck, C. T., Lee, E. B., Smith, A. H., & Hart, J.
M. (2013). Courage, self-compassion, and values in
obsessive-compulsive disorder. Journal of Contextual
Behavioral Science, 2, 6873.
Wetzler, A. J., Elias, R., Fostick, L., & Zohar, J. (2007).
Suicidal ideation versus suicidal obsession: A case
report. CNS Spectrum, 12, 553556.
Williams, M. T., Mugno, B., Franklin, M. E., & Faber,
S. (2013). Symptom dimensions in obsessive-compulsive disorder: Phenomenology and treatment with
exposure and ritual prevention. Psychopathology:
International Journal of Descriptive and Experimental Psychopathology, Phenomenology and Psychiatric
Diagnosis, 46, 365376.
Wolpe, J. (1969). The practice of behavior therapy. New
York: Pergamon.
Young, J. E., & Brown, G. (1994). Young schema-questionnaire. In J. E. Young (Ed.), Cognitive therapy for
personality disorders: A schema-focused approach
(2nd ed., Rev. ed., pp.6376). Sarasota: Professional
Resource.
Index
Accommodation
charting328
family 28, 35, 65, 129, 157, 175, 296, 321,
322, 340, 351, 361, 367
parental 192, 207
hierarchy of 192
role of 137
primary208
reducing 330, 331
Adult
CBT treatment for 25
OCD
perfectionism 85, 86
treatment outcome for 28
TTM228
Adults
OCD symptoms 6
OCRDs, treatment for 4
Aggressive obsessions 150
case information 57, 58
nature and treatment of 55, 56
presenting problem, description of 56, 57
treatment history 58
treatment of 167, 168
Autism Spectrum Disorder (ASD) 337
children with 337, 338
level 1 339
B
Body dysmorphic disorder (BDD) 259, 263

CBT269
DSM-IV diagnosis of 262
risk factors 259
treatment of 260
Body image 264
Clutter 242, 256

Coercive-disruptive behavior 322, 323, 327, 330
Cognitive behavioural therapy (CBT) 150, 186
adult, treatment for 25
BDD269
clinical perfectionism/rigidity
challenging cognitive biases 425
challenging via behavioral experiments 425
cognitive behavioral formulation and
psychoeducation424
pleasant events 426
procrastination426
self-criticism and self-compassion 426
self-evaluation and relapse prevention 426
self-monitoring and myths regarding
perfectionism425
surveys and behavioral experiments 425
time management 426
components427
for OCD 88
HD, treatment for 242
Comorbidity
assessment of 216
OCD, young children 292
Comprehensive Behavioral Intervention for Tics
(CBIT) 214, 217, 223225
Compulsions
cognitive/behavioral56
mental151
perfectionism95
sexual 23, 24, 26
Contamination
fear of 340
OCD
phenomenology 5, 6
treatment 6, 7

DOI 10.1007/978-3-319-17139-5
447
448
D
Delusionality 259, 260, 263, 268, 269

Depression 255, 278, 371, 375
cognitive therapy for 376, 378
Developmental, OCD 200
Dialectical Behavior Therapy (DBT) 417
Discarding 246, 251
Discomfort 11, 89, 124, 206
Disgust 6, 33, 102
Disruptive behavior 176, 357, 358, 368
E
Early intervention 229, 301

Emotion regulation 16, 102, 279, 351, 404, 417,
421, 423
Excoriation disorder 273
CBT275
Excoriation disorder See also Skin picking
disorder273
Exposure and response prevention 306
Exposure and response prevention (ERP) 10,
12, 16, 9193, 158, 161, 162, 378
application of 52
CBT118
contamination, fear of 103
goal of 56
intensive
session 1 345347
session 2 34749
session 3 349, 350
mistakes in 160
motivation for 95
OCD56
EXRP
goal of 310
TOCD310
Extreme accommodation 327
F
Family
accommodation 28, 33, 35, 65, 129, 143, 157,
175, 182, 294, 296, 321, 322, 324, 327,
350, 351, 361, 367
functioning, modification 321
history244
Family-based treatment 167
Functional Analytic Psychotherapy (FAP) 432,
440, 441
Index
H
Habit reversal training (HRT) 217, 237, 278,

311, 313
Hair-pulling227
Harm
avoidance symptoms 201, 203
fear of 158
Hoarding disorder (HD) 241, 242
advantages and disadvantages of 249
assessment255
CBT treatment 242
prevalence of 241
treatment barriers 255
I
Intolerance uncertainty 85, 86, 193

M
Motivational interviewing (MI) 283, 386, 387,

394
N
Not just right experiences (NJREs) 198

O
Obsessions50
non-sexual23
sexual 23, 33, 117, 118, 129
suicidal441
Obsessive-compulsive disorder (OCD) 25, 357
children, perfectionism in 186
incompleteness, distressing feelings of 198
motivation, lack of 385
NJREs
case conceptualization and assessment 201
case information 200
presenting problem, description of 199, 200
problem, nature of 197, 198, 199
treatment course 202
obsessions and compulsions 431
paediatric, treatment participation for 343
poor insight 5, 399, 403
preschool, treatment for 294
scrupulosity131
treatment barriers 292
Obsessive-compulsive personality disorder
(OCPD) 85, 415
core features of 416
Index
diagnosis of 416
DSM-IV criteria for 394
interpersonal functioning in 416
psychodynamic treatment for 416
OC spectrum disorders 241, 259
ODD358
Oppositional defiant disorder (ODD) See
ODD292
Ordering, exposure hierarchy for 298
P
Parent training 181, 323

Pediatrics
OCD118
ERP358
evidence-based treatments for 171, 172
prevalence132
psychoeducation136
Psychoeducation 11, 12, 34, 157, 344, 345
OCD
behavioral model of 90
maintenance of 122
treatment goals 377
449
Sexual symptoms 27, 29, 30, 33, 35

Skin-picking273
clinical characteristics and rates of 273
features of 279
psychiatric treatment for 274
self-injurious275
SPACE 323, 328, 330, 334
Suicidality 259, 416
Suicide
assessment of 66
obsessions438
risk of 157, 269
Symptomology 154, 156, 181
T
Therapist non-avoidance 36
Tics 171, 198, 213217
Tourette Syndrome 3
Tourettic OCD 306
W
Washing 6, 342
Y
Relationship flexibility 417, 421, 427

Religious obsessions 39, 134, 381
Religious rituals 39, 41, 43
S
Saving Cognition Inventory (SCI) 246, 247

Scrupulosity131
ERP, modifications of 40
OCD 39, 131
religious 380, 381
treatment, youth 145
Young children 292, 298, 301, 302

OCD293

Clinical Handbook of Obsessive-Compulsive and Related Disorders

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Clinical Handbook of Obsessive-Compulsive and Related Disorders

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Clinical Handbook of Obsessive

Compulsive and Related Disorders

Eric A. Storch Adam B. Lewin

ISBN 978-3-319-17138-8ISBN 978-3-319-17139-5 (eBook)

Dedicated with much love to Jill, Maya, Noah,

Part I ObsessiveCompulsive Disorder Among Adults

Part II Pediatric ObsessiveCompulsive Disorder

Part IV Special Populations and Considerations

Jonathan S. Abramowitz Department of Psychology, UNC-Chapel Hill,

Martin E. Franklin University of Pennsylvania School of Medicine, Philadelphia, PA, USA

Andrew C. RakhshaniDivision of Medical Psychology, Department of

Melanie M. VanDykeSaint Louis Behavioral Medicine Institute, Saint

Obsessive-compulsive disorder (OCD) and

to access care (Blanco etal. 2006; U.S.D.H.H.S.

Springer International Publishing Switzerland 2016

body dysmorphic disorder, and excoriation

E. A. Storch and A. B. Lewin

Cleaning Out the Anxiety:

Phenomenology of Contamination OCD

Springer International Publishing Switzerland 2016

with poor insight), contamination-related OCD

important aspect of the treatment (Adams etal.

Treatment of Contamination OCD

2 Treatment of Contamination Obsessive-Compulsive Disorder

fear of contracting the flu, and a strong disgust

Background Information Having been anxious

to-day life, though he remained more attentive to

2 Treatment of Contamination Obsessive-Compulsive Disorder

reported that he had been nervous to move to a

get rid of any contaminants from his day and so

Assessment and Case Conceptualization

severe range on this scale. MR endorsed that the

  

  

   

   

Fig. 2.1 MRs exposure hierarchy

2 Treatment of Contamination Obsessive-Compulsive Disorder

However, while he could articulate that he knew

psychoeducation in session 1 about the nature

your intrusive thoughts in a more helpful way by

2 Treatment of Contamination Obsessive-Compulsive Disorder

as well as the triggers and consequences related

toring form he had completed during the week,

Fig. 2.4 Symptom-monitoring forms

magical thinking, or believing that two things are

2 Treatment of Contamination Obsessive-Compulsive Disorder

his symptoms. For example, he learned that he

the week. He agreed to monitor these exposure

2 Treatment of Contamination Obsessive-Compulsive Disorder

He was able to resist rinsing off the shower in

2 Treatment of Contamination Obsessive-Compulsive Disorder

sessions 11 and 12, to give MR more time to

For MR, it was useful to expand his exposure

2 Treatment of Contamination Obsessive-Compulsive Disorder

treatment outcome for pediatric obsessive-compulsive

Sexual obsessions occur in approximately

Springer International Publishing Switzerland 2016

thoughts. When compulsions are present, they

they may experience sexual pleasure and arousal

3 Treatment of Sexual Obsessive-Compulsive Symptoms During Exposure and Response Prevention

report an urge or desire to engage in homosexual

Description of the Presenting Problem