Obsessive-Compulsive Disorder

Transcription

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2 Obsessive-Compulsive Disorder

3 About the Author Jonathan S. Abramowitz, PhD, is Associate Professor and director of the OCD/Anxiety Disorders Program at the Mayo Clinic. He has written or edited four books and over 75 research articles and book chapters on OCD and other anxiety disorders. For his contributions to the field, Dr. Abramowitz has received awards from the American Psychological Association and the Mayo Clinic. Advances in Psychotherapy Evidence-Based Practice Danny Wedding; PhD, MPH, Prof., St. Louis, MO (Series Editor) Larry Beutler; PhD, Prof., Palo Alto, CA Kenneth E. Freedland; PhD, Prof., St. Louis, MO Linda C. Sobell; PhD, ABPP, Prof., Ft. Lauderdale, FL David A. Wolfe; PhD, Prof., Toronto (Associate Editors) The basic objective of this new series is to provide therapists with practical, evidence-based treatment guidance for the most common disorders seen in clinical practice and to do so in a reader-friendly manner. Each book in the series is both a compact how-to-do reference on a particular disorder for use by professional clinicians in their daily work, as well as an ideal educational resource for students and for practice-oriented continuing education. The most important feature of the books is that they are practical and reader-friendly : All are structured similarly and all provide a compact and easy-to-follow guide to all aspects that are relevant in real-life practice. Tables, boxed clinical pearls, marginal notes, and summary boxes assist orientation, while checklists provide tools for use in daily practice.

4 Obsessive- Compulsive Disorder Jonathan S. Abramowitz Mayo Clinic, OCD/Anxiety Disorders Program, Rochester, MN

5 Library of Congress Cataloging in Publication is available via the Library of Congress Marc Database under the LC Control Number Library and Archives Canada Cataloguing in Publication Abramowitz, Jonathan S Obsessive compulsive disorder / Jonathan S. Abramowitz. (Advances in psychotherapy--evidence-based practice) Includes bibliographical references. ISBN Obsessive-compulsive disorder. 2. Obsessive-compulsive disorder Treatment. I. Title. II. Series. RC533.A a C X 2006 by Mayo Foundation for Medical Education and Research PUBLISHING OFFICES USA: Hogrefe & Huber Publishers, 875 Massachusetts Avenue, 7th Floor, Cambridge, MA Phone (866) , Fax (617) ; info@hhpub.com EUROPE: Hogrefe & Huber Publishers, Rohnsweg 25, Göttingen, Germany Phone , Fax , hh@hhpub.com SALES & DISTRIBUTION USA: Hogrefe & Huber Publishers, Customer Services Department, 30 Amberwood Parkway, Ashland, OH Phone (800) , Fax (419) , custserv@hhpub.com EUROPE: Hogrefe & Huber Publishers, Rohnsweg 25, Göttingen, Germany Phone , Fax , hh@hhpub.com OTHER OFFICES CANADA: Hogrefe & Huber Publishers, 1543 Bayview Avenue, Toronto, Ontario M4G 3B5 SWITZERLAND: Hogrefe & Huber Publishers, Länggass-Strasse 76, CH-3000 Bern 9 Hogrefe & Huber Publishers Incorporated and registered in the State of Washington, USA, and in Göttingen, Lower Saxony, Germany No part of this book may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from the publisher. Printed and bound in the USA ISBN

6 Preface This book describes the conceptualization, assessment, and psychological treatment of obsessive-compulsive disorder (OCD) using the empirically supported cognitive-behavioral therapy procedures of exposure, response prevention, and cognitive therapy. The development of effective problemfocused treatments for psychological disorders such as OCD has created an enormous need for the dissemination of treatment programs, such as this one, to mental health professionals who want to know how to use such techniques with their patients. This book builds upon psychological principles of behavior change. As such, it assumes basic knowledge and some training in psychotherapeutic intervention. It is written for psychologists, psychiatrists, social workers, students and trainees, and other mental health care practitioners. It is intended not only for those specializing in OCD or other anxiety disorders, but for those clinicians who wish to learn how to manage OCD effectively in their day-to-day practice. The book is divided into five chapters. The first chapter describes the clinical phenomenon of OCD, differentiating it from other disorders with similar characteristics and outlining empirically supported diagnostic and assessment procedures. Chapter 2 reviews what is known about the leading theoretical models of the development and maintenance of OCD, and their treatment implications. In Chapter 3, I present a framework for conducting an initial assessment and for deciding whether a particular patient is a candidate for the psychological treatment program outlined in Chapter 4. Methods for explaining the diagnosis of OCD and introducing the treatment program are incorporated. Chapter 4 presents in detailed fashion the nuts and bolts of effective psychological treatment techniques for OCD. There are numerous case examples and transcripts of in-session dialogs to illustrate the treatment procedures. The chapter also reviews scientific evidence for the efficacy of this program, and describes a number of common obstacles to successful treatment. Finally, Chapter 5 includes a series of case examples describing the treatment of various sorts of OCD symptoms (contamination, fears of responsibility for harm, etc.). A variety of forms and patient handouts for use in treatment appear in the book s Appendix. OCD is a highly heterogeneous disorder. For example, some patients experience fears of germs and contamination, while others have recurring unwanted anxiety-evoking ideas of committing heinous acts that they are unlikely to commit (e.g., running into pedestrians while driving, murdering loved ones). It is rare to see two sufferers with completely overlapping symptoms. Although a systematic and multicomponent treatment approach is advocated in this book, this manual is not intended as a cookbook. Instead, the clinician is guided in tailoring specific treatment components to individual patients needs. This manual provides a practical and structured approach with supporting didactic materials for both clinicians and patients.

7 vi Advances in Psychotherapy: Obsessive-Compulsive Disorder Acknowledgments I am indebted to a large group of people, including series editor Danny Wedding and Robert Dimbleby of Hogrefe and Huber, for their invaluable guidance and suggestions. The pages of this book echo with clinical wisdom I acquired during my pre- and postdoctoral training at the Center for Treatment and Study of Anxiety in Philadelphia, where I spent many hours learning about OCD and its treatment from master clinicians such as Martin Franklin and Michael Kozak, who also took a genuine interest in my professional development. In addition, I wish to thank my undergraduate and graduate academic mentors Kathleen Harring, T. Joel Wade, and Art Houts for impressing upon me the importance of science in psychology and psychological practice. I am also grateful for the support of my wonderful colleagues at Mayo Clinic, including Stephen Whiteside, Sarah Kalsy, Brett Deacon (now at the University of Wyoming), Katherine Moore, Stefanie Schwartz (now in private practice in Florida), Kristi Dahlman, and Jill Snuggerud. I owe a great deal to my remarkably competent secretary, Marcia Redalen, who oversees my daily schedule and frequently communicates with patients. This book is dedicated to all of the patients and research participants who have come to our clinic seeking help and, not knowing what to expect of treatment, found the courage to confront their fears and defeat their anxiety. They believed in us, confided in us, challenged us, and educated us. Most of all, this book would not be possible without the enduring love, support, and patience of my wife Stacy, and our children, Emily and Miriam. Their affection inspires me to do my very best every day. With their help, I have gained a clearer sense of who I am as a person, a father, a husband, and a psychologist. Dedication To my parents, Ferne and Les Abramowitz my only creators

8 Table of Contents Preface v Acknowledgments vi Dedication vi 1 Description Terminology Definition Insight Epidemiology Course and Prognosis Differential Diagnoses Generalized Anxiety Disorder (GAD) Depression Tics and Tourette s Syndrome (TS) Delusional Disorders (e.g., Schizophrenia) Impulse Control Disorders Obsessive Compulsive Personality Disorder (OCPD) Hypochondriasis Body Dysmorphic Disorder (BDD) Comorbidities Diagnostic Procedures and Documentation Structured Diagnostic Interviews Semi-Structured Symptom Interviews Self-Report Inventories Documenting Changes in Symptom Levels Theories and Models Neuropsychiatric Theories Neurochemical Theories Neuroanatomical Theories Psychological Theories Learning Theory Cognitive Deficit Models Contemporary Cognitive-Behavioral Models Diagnosis and Treatment Indications Form Versus Function The Diagnostic Assessment Identifying the Appropriate Treatment Empirically Supported Treatments for OCD Factors that Influence Treatment Decisions Age Gender Race

9 viii Advances in Psychotherapy: Obsessive-Compulsive Disorder Educational Level Patient Preference Social Support Clinical Presentation OCD Symptom Theme Insight Comorbidity Treatment History Presenting the Recommendation for CBT Treatment Methods of Treatment Functional Assessment Self-Monitoring Psychoeducation Using Cognitive Therapy Techniques Planning for Exposure and Response Prevention Implementing Exposure and Response Prevention Ending Treatment Mechanisms of Action Efficacy and Prognosis Variations and Combinations of Methods Variants of CBT Treatment Procedures Combining Medication and CBT Problems in Carrying out the Treatment Negative Reactions to the CBT Model Nonadherence Arguments Therapist s Inclination to Challenge the Obsession When Cognitive Interventions Become Rituals Unbearable Anxiety Levels During Exposure Absence of Anxiety During Exposure Therapist Discomfort with Conducting Exposure Exercises Case Vignettes Further Reading References Appendix: Tools and Resources

10 1 Description 1.1 Terminology Obsessive-compulsive disorder (OCD) (300.3) was previously known as obsessive-compulsive neurosis. It is sometimes considered part of a spectrum of conditions characterized by more or less similar features (see Section 1.5). 1.2 Definition OCD is classified in the DSM-IV-TR (American Psychiatric Association, 2000) as an anxiety disorder (300.3) defined by the presence of obsessions or compulsions (see Table 1). Obsessions are persistent intrusive thoughts, ideas, images, impulses, or doubts that are experienced as unacceptable, senseless, or bizarre and that evoke subjective distress in the form of anxiety or doubt. Definition of obsessions and compulsions Table 1 DSM-IV Diagnostic Criteria for OCD A. Either obsessions or compulsions. Obsessions are defined by (1), (2), (3), and (4): (1) repetitive and persistent thoughts, images, or impulses that are experienced, at some point, as intrusive and inappropriate and that cause marked anxiety or distress (2) the thoughts, images, or impulses are not worries about real-life problems (3) the person tries to ignore or suppress the thoughts, images, or impulses, or neutralize them with some other thought or action (4) the thoughts, images, or impulses are recognized as a product of one s own mind and not imposed from without Compulsions are defined as (1) and (2): (1) repetitive behaviors or mental acts that one feels driven to perform in response to an obsession or according to certain rules (2) the behaviors or mental acts are aimed at preventing or reducing distress or preventing feared consequences; however the behaviors or mental acts are clearly excessive or are not connected in a realistic way with what they are designed to neutralize or prevent B. At some point during the disorder the person has recognized that the obsessions or compulsions are excessive or unreasonable.