Documente Academic
Documente Profesional
Documente Cultură
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
Contents
vii
viii
Contents
Contents
ix
Contributors
xi
xii
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,
University of Florida, Gainesville, FL, USA
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
Contributors
Contributors
xv
Part I
ObsessiveCompulsive Disorder
Among Adults
Introduction
Eric A. Storch and Adam B. Lewin
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,
University of South Florida, Tampa, FL, USA
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.
Treatment of Contamination
Obsessive-Compulsive
Disorder
Shannon M. Bennett
impairing, causing significant functional impairment and decreased quality of life (Albert etal.
2010; Fontenelle etal. 2010; Vorstenbosch etal.
2012; Jacoby etal. 2014).
S. M. Bennett
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
S. M. Bennett
10
S. M. Bennett
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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Treatment Course
Psychoeducation (Sessions 12) Following the
initial assessment, MRs treatment began with
11
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Fig. 2.2 Three-component model of emotions. (Adapted from Barlow etal. 2011)
12
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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14
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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
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
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
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
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
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
Psychiatry, 52, 987997.
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
Psychiatry, 162, 151161.
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.
21
Treatment of Sexual
Obsessive-Compulsive
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,
1600S Archer Rd, Gainesville, FL 32611, USA
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,
1600S Archer Rd, Gainesville, FL 32611, USA
e-mail: rahmanim@ufl.edu
23
24
A. M. Reid et al.
25
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.
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
28
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.
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)
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.
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
32
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
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A. M. Reid et al.
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.
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A. M. Reid et al.
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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
41
42
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:
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44
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
45
46
SUDS
10
10
10
9
8
7
7
6
6
5
5
4
3
2
1
47
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
49
50
Complicating Factors
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
52
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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
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and thoughts of this nature with relative ease. In
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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.
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
58
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.
Case Conceptualization
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
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
60
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
61
62
A. Golden et al.
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.
63
64
A. Golden et al.
Complicating Factors
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
65
66
A. Golden et al.
References
Abramowitz, J. S., Franklin, M. E., Schwartz, S. A., &
Furr, J. M. (2003a). Symptom presentation and outcome of cognitive-behavioral therapy for obsessivecompulsive disorder. Journal of Consulting and
Clinical Psychology, 71, 10491057.
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.
American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.).
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
Treatment of SymmetryObsessive-Compulsive
Disorder
Kiara R. Timpano, Julia Y. Carbonella,
Shelby E. Zuckerman and Demet ek
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
69
70
K. R. Timpano et al.
71
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
K. R. Timpano et al.
73
74
K. R. Timpano et al.
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
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
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
76
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K. R. Timpano et al.
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77
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Fig. 6.2 Functional analysis model of patients triggers, beliefs, emotional response, and behavioral responses
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
K. R. Timpano et al.
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
79
80
K. R. Timpano et al.
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
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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(6), 487495.
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.
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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.
Behaviour Research and Therapy, 35(9), 793802.
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
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743758.
Riccardi, C. J., Timpano, K. R., & Schmidt, N. B. (2010).
A case study perspective on the importance of motiva-
83
Treatment of Perfectionism-Related
Obsessive-Compulsive Disorder
Heather K. Hood and Martin M. Antony
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,
85
86
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-
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
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.
90
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
91
Avoidance (0100)
100
100
100
90
80
70
65
40
50
30
92
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
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94
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.
Complicating Factors
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
96
References
American Psychiatric Association. (2013). Diagnostic
and statistical manual of mental disorders (5th ed.).
Washington, DC: American Psychiatric Association.
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
97
Part II
Pediatric ObsessiveCompulsive
Disorder
Treatment of Contamination in
Childhood Obsessive-Compulsive
Disorder
Amy Przeworski, Jennifer Freeman, Abbe Garcia,
Martin Franklin and Jeffrey Sapyta
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
101
102
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.
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).
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
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
Behavioral Observations
Molly presented as quite shy and anxious. She
made poor eye contact and looked down for
A. Przeworski et al.
105
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
A. Przeworski et al.
107
108
A. Przeworski et al.
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
110
A. Przeworski et al.
111
112
Complicating Factors
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
A. Przeworski et al.
113
114
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115
Treatment of Sexual
Obsessions in Childhood
Obsessive-Compulsive
Disorder
Danielle Ung, Chelsea M. Ale
and Stephen P. H. Whiteside
Background
Phenomenology
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
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.
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
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.
D. Ung et al.
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
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
123
Rating
9
8.5
8
8
7.5
6
5
5
4
3
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.
125
126
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
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
Complicating Factors
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.
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
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Treatment of Scrupulosity
in Childhood ObsessiveCompulsive Disorder
10
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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-
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
133
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
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
135
136
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
138
139
140
141
142
143
144
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
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
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
and Therapy, 40, 825838.
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.
147
Treatment of Aggressive
Obsessions in Childhood
Obsessive-Compulsive
Disorder
11
149
150
E. L. Milliner-Oar et al.
151
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
E. L. Milliner-Oar et al.
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.
154
E. L. Milliner-Oar et al.
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
155
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E. L. Milliner-Oar et al.
157
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
E. L. Milliner-Oar et al.
159
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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
E. L. Milliner-Oar et al.
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
At home practice
Mum to say goodnight I love you, the family is safe 1x per night no note to check
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.
161
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Fig.11.4 Example exposure hierarchy for Daniels intrusive thoughts. SUDs subjective units of distress
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
162
E. L. Milliner-Oar et al.
163
164
E. L. Milliner-Oar et al.
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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165
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Fig. 11.5 Patient handout obsessive-compulsive disorder (OCD) busters program. (Farrell and Waters 2008)
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
166
Complicating Factors
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
E. L. Milliner-Oar et al.
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-
167
168
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,
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American Psychiatric Association. (2013). Diagnostic
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Baer, L. (1994). Factor analysis of symptom subtypes of
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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.
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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.
Freeston, M. H., Ladouceur, R., Gagnon, F., Thibodeau,
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.
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Geller, D. A., & March, J. S. (2012). Practice parameter for the assessment and treatment of children
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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
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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.
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Hasler, G., LaSalle-Ricci, V. H., Ronquillo, J. G., Crawley, S. A., Cochran, L. W., Kazuba, D., etal. (2005).
Obsessivecompulsive disorder symptom dimensions
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Kovacs, M. (1992). Childrens Depression Inventory
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Lee, H. J., & Kwon, S. M. (2003). Two different types
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March, J. S. (1997). Multidimensional anxiety scale for
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Mataix-Cols, D., Rosario-Campos, M. C., & Leckman,
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169
Treatment of Symmetry
in Childhood ObsessiveCompulsive Disorder
12
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
171
172
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.
173
Presenting Problem
Case Information
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
Case Conceptualization
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
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
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
178
179
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
2 (parent only)
3 (parent only)
10
11
12
Time-out required
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.
Complicating Factors
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
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
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Treatment of Perfectionism in
Childhood Obsessive-Compulsive Disorder
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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
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.
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
10
30
50
55
70
80
95
15
25
35
50
65
80
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
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
192
Complicating Factors
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-
30
55
80
70
75
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
194
References
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Approaches to common obstacles in the exposurebased treatment of obsessive-compulsive disorder.
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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.),
195
Treatment of Not-Just-Right
Experiences in Childhood
Obsessive-Compulsive
Disorder
14
197
198
J. Schubert et al.
199
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.
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.
201
202
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.
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
204
J. Schubert et al.
Sessions 6 Through 11
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
205
206
J. Schubert et al.
'LVFRPIRUW$Q[LHW\5DWLQJ
1-5(
H[SRVXUH
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Fig. 14.2 Anxiety/discomfort ratings across HA and NJRE exposures. HA harm avoidance, NJRE not-just-right experiences
Sessions 12 Through 14
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.
Complicating Factors
As with most patients, therapy presented
unexpected detours and roadblocks. Small
207
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.
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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B., & Smits, J. A. (2011). Specificity of disgust vulnerability in the distinction and treatment of OCD.
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Woods, D. W., Piacentini, J., Himle, M. B., & Chang,
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Initial psychometric results and examination of the
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Part III
ObsessiveCompulsive Spectrum
Disorders
Treatment of a Child
with Tourette Syndrome
15
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
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L. P. Hayes et al.
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
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216
L. P. Hayes et al.
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
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L. P. Hayes et al.
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
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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.
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,
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222
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.
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
Posttreatment Assessment
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.
Complicating Factors
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
L. P. Hayes et al.
References
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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
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Deckersbach, T., Sukhodolsky, D. G., etal. (2012).
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Managing Tourette syndrome: A behavioral intervention for children and adults, parent workbook. New
York: Oxford University Press.
Treatment of an Adult
with Trichotillomania
16
227
228
229
230
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
231
Case Conceptualization
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
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
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
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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
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.
Complicating Factors
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
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
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242
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
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.
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.
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
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
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
Hoarding Behaviors
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,
247
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
In bed
Emotions
Excited
Hopeless
Slight hope
A little relief
Behavior
Takes it home
249
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
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
251
252
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
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
254
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
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.
Complicating Factors
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
256
257
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).
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Furr, J. M. (2003). Symptom presentation and outcome of cognitive behavior therapy for obsessive
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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
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Frost, R. O., & Hartl, T. L. (1996). A cognitive-behavioral
model of compulsive hoarding. Behavior Research
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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),
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Frost, R. O., Steketee, G., Tolin, D. F., & Renaud, S.
(2008). Development and validation of the clutter
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Frost, R. O., Tolin, D. F., & Maltby, N. (2010). Insightrelated challenges in the treatment of hoarding. Cognitive and Behavioral Practice, 17, 404413.
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& 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
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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
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.
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.
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
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
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.
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
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,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.
Complicating Factors
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.
269
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
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suicidal behaviors. American Journal of Psychiatry,
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American Psychiatric Association. (2013). Diagnostic
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Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual
for the Beck Depression Inventory-II. San Antonio:
Psychological Corporation.
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.
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the American Academy of Dermatology, 63, 235243.
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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
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Koblenzer, C. S. (1985). The dysmorphic syndrome.
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Koran, L. M., Abujaoude, E., Large, M. D., & Serpe, R. T.
(2008). The prevalence of body dysmorphic disorder
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Body dysmorphic disorder in patients with cosmetic
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26, 478482. doi:10.1016/S1607-551X(10)70075-9.
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doi:10.1097/00005053-200003000-00007.
271
19
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
273
274
L. S. Hallion et al.
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
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
L. S. Hallion et al.
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.
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.
277
278
L. S. Hallion et al.
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
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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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
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
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
L. S. Hallion et al.
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
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
Complicating Factors
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
L. S. Hallion et al.
^W^
^W^
^W/^
^
^
^
^
^E
Fig. 19.3 Skin picking severity over treatment. SPS Skin-Picking Scale, SPIS Skin-Picking Impact Scale
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
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Part IV
Special Populations and
Considerations
20
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,
University of South Florida, Tampa, FL, USA
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
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
291
292
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
293
294
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
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
295
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
297
298
299
300
Complicating Factors
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
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
302
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comorbid attention deficit hyperactivity disorder. The
Treatment of a Youngster
with Tourettic ObsessiveCompulsive Disorder
21
305
306
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
308
Case Conceptualization
and Assessment
Prior to beginning treatment, Nick and his mother were administered the Yale Global Tic Severity Scale (YGTSS; Leckman etal. 1989) and the
Childrens YaleBrown Obsessive-Compulsive
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.
309
310
311
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)
Swiping
(9)
Repeating
(7)
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
314
SUDS
5
6
7
8
8
9
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
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.
Posttreatment Assessment
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).
Complicating Factors
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
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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
319
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
321
322
E. R. Lebowitz
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
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
326
E. R. Lebowitz
Case Conceptualization
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
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).
E. R. Lebowitz
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
330
E. R. Lebowitz
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
332
E. R. Lebowitz
333
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
Complicating Factors
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.
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
of Child and Adolescent Psychiatry, 50(7), 716725.
Gandhi. (1951). Satyagraha non-violent resistance (1st
ed.). Ahmedabad: Navajivan.
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(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
Treatment of Comorbid
Obsessive-Compulsive
Disorder in Youth with ASD:
The Case of Max
23
337
338
L. J. Farrell et al.
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
339
340
L. J. Farrell et al.
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.
23 Treatment of Comorbid Obsessive-Compulsive Disorder in Youth with ASD: The Case of Max
341
Case Conceptualization
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
L. J. Farrell et al.
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more details on the cognitive formulation and information processing biases associated with OCD, see Frost and
Steketee (2002)
23 Treatment of Comorbid Obsessive-Compulsive Disorder in Youth with ASD: The Case of Max
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
L. J. Farrell et al.
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
23 Treatment of Comorbid Obsessive-Compulsive Disorder in Youth with ASD: The Case of Max
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
L. J. Farrell et al.
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2&'0($17($07(//60(7+,60,*+7+$33(1
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
&+$1&(6BBBBBBBBBB
5,',1*7+(5$*(68'65DWLQJV
:KHQ,IHHOVWUHVVHG86(0<,4V %UHDWKH,&$1'27+,6
',6&29(57+(7587+:KDWUHDOO\KDSSHQHG5HDSSUDLVDO
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
23 Treatment of Comorbid Obsessive-Compulsive Disorder in Youth with ASD: The Case of Max
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
Removing spectacles and
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
Removing spectacles and
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
347
Post-SUDs
010
1
1
2
2
0
2
2
2
2
2
3
2
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
L. J. Farrell et al.
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
ERP exposure and response prevention, SUDs subjective units of distress
Post-SUDs
010
2
4
4
5
5
0
3
1
2
2
2
4
3
23 Treatment of Comorbid Obsessive-Compulsive Disorder in Youth with ASD: The Case of Max
349
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
No wet wipes and no hand
6
clean stuff (e.g. clothing)
washing
Step 3
Wash hands and use brothers towel
No wet wipes and no hand
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
No sanitizer, wipes, or towel 4
Step 3
Lying on the sand, sand in hair
No towel, no wipes
6
Step 4
Cartwheels in the sand
No sanitizer, wipes, or towel 0
ERP exposure and response prevention, SUDs subjective units of distress
Post-SUDs
010
1
0
0
1
2
0
3
2
0
0
350
L. J. Farrell et al.
23 Treatment of Comorbid Obsessive-Compulsive Disorder in Youth with ASD: The Case of Max
351
Complicating Factors
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
352
Fig. 23.3 Maxs self-rated
SUDs of his three most troubling target behaviours
L. J. Farrell et al.
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:LSLQJ5RXWLQH
7RLOHWLQJ5RXWLQH
23 Treatment of Comorbid Obsessive-Compulsive Disorder in Youth with ASD: The Case of Max
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
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.
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355
Treatment of Comorbid
Disruptive Behavior in a Youth
with Obsessive-Compulsive
Disorder
24
C.M.Ale() S.P.H.Whiteside
Department of Psychiatry & Psychology, Mayo Clinic,
Rochester, MN, USA
e-mail: ale.chelsea@mayo.edu
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).
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
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.
Case Conceptualization
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.
361
362
Exposure task
Compulsions to resist
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
364
Sat.
Sat.
Sat.
10 min.
10min
Attention
from sister.
Control of
the game
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
365
366
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.
Childrens YaleBrown Obsessive-Compulsive
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
Complicating Factors
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: OCD
Hierarchy development
3
Hierarchy development
4
Conduct ERP
5
Conduct ERP
commands)
6
Conduct ERP
814
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.
369
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.
Garcia, A. M., Freeman, J. B., Himle, M. B., Berman, N.
C., Ogata, A. K., Ng, J., etal. (2008). Phenomenology of early childhood obsessive compulsive disorder.
Journal of Psychopathology and Behavioral Assessment, 31, 104111.
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
& 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.
Treatment of Comorbid
Depression and ObsessiveCompulsive Disorder
25
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
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)
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
373
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
375
376
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.
378
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
379
380
Complicating Factors
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.
381
382
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.
383
Treatment of an Adult
with Obsessive-Compulsive Disorder with Limited
Treatment Motivation
26
385
386
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
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
388
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
M. G. Wheaton et al.
389
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
M. G. Wheaton et al.
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
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M. G. Wheaton et al.
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
394
Complicating Factors
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
M. G. Wheaton et al.
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.
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Treatment of Individuals
with Obsessive-Compulsive
Disorder Who Have Poor
Insight
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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
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.
Case Conceptualization
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-
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
62
58
65
62
58
47
49
52
404
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
405
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M. J. Larson et al.
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
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
409
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
Complicating Factors
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
412
M. J. Larson et al.
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Anthony Pinto
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416
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.
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
418
A. Pinto
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
Case Conceptualization
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
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
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
421
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.
422
Fig. 28.1 The cognitivebehavioral model of clinical
perfectionism. (Reproduced
from Shafran etal. 2010)
A. Pinto
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Fig. 28.3 The three channels of distress. (Reproduced from Cloitre etal. 2001; adapted for John)
424
A. Pinto
425
426
A. Pinto
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
Complicating Factors
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.
428
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Abbas, A., Sheldon, A., Gyra, J., & Kalpin, A. (2008).
Intensive short-term dynamic psychotherapy for
DSM-IV personality disorders: A randomized
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American Psychiatric Association. (2013). Diagnostic
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Chang, E. C., & Sanna, L. J. (2012). Evidence for the
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102108.
Cloitre, M., Hefferman, K., Cohen, L., & Alexander, L.
(2001). STAIR/MPE: A phase-based treatment for the
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(2002). Skills training in affective and interpersonal
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Diaconu, G., & Turecki, G. (2009). Obsessive-compulsive
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G., Sisto, A., & Semerari, A. (2011). Progressively
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Egan, S. J., & Hine, P. (2008). Cognitive behavioural
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Treatment of Suicide
Obsessions in ObsessiveCompulsive Disorder with
Comorbid Major Depressive
Disorder
29
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
431
432
C. T. Wetterneck et al.
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
C. T. Wetterneck et al.
435
Exposure
SUDS
40
60
65
70
70
70
80
8
9
10
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
C. T. Wetterneck et al.
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
C. T. Wetterneck et al.
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
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.
C. T. Wetterneck et al.
441
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
C. T. Wetterneck et al.
Fig. 29.1
Beck Depression Inventory-II (BDI-II) scores over 13
months
&KDQJHLQ%',,,6FRUH
%',,,7RWDO6FRUH
Complicating Factors
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
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.
444
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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
447
448
D
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
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
449
Therapist non-avoidance 36
Tics 171, 198, 213217
Tourette Syndrome 3
Tourettic OCD 306
W
Washing 6, 342
Y