Obsessive Compulsive Contamination Fears and Anorexia Nervosa: The Application of the New Psycho- Educational Treatment of Danger Ideation Reduction Therapy (DIRT) Lynne M. Drummond University of London, United Kingdom Peter Kolb Springfield University Hospital, London, United Kingdom The case history of a woman with severe and enduring anorexia nervosa and obsessive compulsive disorder (OCD) with contamination fears is presented. These contamination fears centred on her fear of contamination by fat and fatty substances as she worried about gaining weight. Previous treatment with graded exposure had shown no clinically significant benefits. She was admitted to a specialist unit for the treatment of OCD as an inpatient. Due to the previous failure of the recognised psychological treatments for OCD it was decided to use the new psychoeducational approach of danger ideation reduction therapy (DIRT). This treatment resulted in an improvement in her OCD symptoms despite the fact that the emphasis of the treatment was on the risk of bacteria and dirt. It is believed that this is the first documented case of DIRT being used for a patient with anorexia nervosa and OCD. 44 The link between anorexia nervosa and obsessive compulsive disorder (OCD) has been recognised for over 50 years (Dubois, 1949; Palmer & Jones, 1939). This comorbidity of OCD and eating disorders has also been more recently reported (Fahy, Osacar, & Marks, 1993; Kaye, Bulik, Thornton, Barbarich, & Masters, 2004). A study examining OCD sufferers found a high lifetime prevalence of anorexia nervosa and bulimia nervosa (Thiel, Broocks, Ohlmeier, Jacoby, & Schussler, 1995). Additionally, using standardised rating instruments, these workers showed that 37% of a cohort of 93 anorexic or bulimic females concurrently fulfilled the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for OCD (Thiel et al., 1995). Comorbidity correlated positively with the severity of the eating disorder. Studies such as these have led to the suggestion that both OCD and anorexia nervosa may have a common psychopathology (Hsu, Kaye, & Weltzin, 1993). OCD can be treated by drugs acting on the serotinergic system, to which 40% to 60% of patients respond (Fineberg & Gale, 2005; McDougle & Goodman, 1991). Address for correspondence: Dr Lynne M. Drummond, Consultant Psychiatrist and Senior Lecturer, St George s, University of London, Cranmer Terrace, London SW17 ORE, United Kingdom. E-mail: l.drummond@sgul.ac.uk Volume 25 Number 1 2008 pp. 44 50
Application of DIRT Alternatively, psychological treatment involving graduated exposure and selfimposed response prevention (ERP) results in 75% to 80% of patients improving by at least 50% on standardised measures (Cottraux et al., 2001; Foa & Goldstein, 1978; James & Blackburn, 1995; Marks, Hodgson, & Rachman, 1975; McLean et al., 2001; review by Drummond & Fineberg, 2007). Trials of cognitive therapy have failed to show any additional benefit to ERP (Cottraux et al., 2001; James & Blackburn, 1995; McLean et al., 2001; review by Drummond & Fineberg, 2007). A new treatment called danger ideation reduction therapy or DIRT, based on a psychoeducational model, has been pioneered for patients with contamination fears who refuse to undertake or who fail in exposure therapy (Govender, Drummond, & Menzies, 2006; Jones & Menzies, 1998). This treatment is fundamentally different from previous exposure and cognitive treatments because it does not encourage the patient to confront the feared contaminant. Indeed, in many of the trial DIRT studies, anti-exposure instructions were given. The treatment consists of the following components: 1. Cognitive restructuring. This is based on the techniques of rational emotive therapy (Ellis, 1962). Unrealistic thoughts about contamination are evaluated and re-evaluated in conjunction with factual information. More appropriate thoughts about the feared contaminants are developed and then recorded. The patient is then asked to rote learn the responses and to repeat them at least daily. 2. Filmed interviews. These consist of a number of filmed interviews with people who work in situations commonly feared by obsessive compulsive patients with contamination fears. 3. Corrective information. The patient is asked to view a list of facts about their feared contaminant and also to read information about the deleterious effects of overzealous hand washing and other decontaminating behaviours. 4. Microbiological experiments. Results of microbiological experiments that were undertaken at the University of Sydney are discussed with the patient. In these experiments subjects were asked to touch frequently feared contaminants such as money or toilet door handles with one hand while keeping the other hand clean. Both hands were then imprinted on blood agar plates. In both conditions normal commensal flora and no pathogens were found. 5. Probability of catastrophe. Patients are asked to estimate the probability of catastrophe occurring in different situations. They are then asked to break down this scenario into its component parts and estimate the likelihood of the feared consequence at each stage. This is then computed and compared with the original probability estimate. 6. Attentional focusing. This is a form of meditation. Patients are taught to focus the mind away from the danger-related intrusive thoughts and onto benign, nonthreatening stimuli. In a controlled study of 21 obsessive compulsive washers, the 10 patients treated by DIRT demonstrated reduction in obsessive compulsive scores with a mean 4-point reduction on the Maudsley Obsessive-Compulsive Inventory (MOCI; Jones & Menzies, 1998). Importantly, Krochmalik, Jones, and Menzies (2001) have shown that DIRT may return intractable cases to normal functioning in as few as 14 weeks, even when poor insight is present. 45
Lynne M. Drummond and Peter Kolb Clinical experience has led the authors to believe that patients with fragile and chronic anorexia nervosa often find the stress of ERP too much and therefore they may lose weight during the OCD treatment. For this reason it was decided to try DIRT to treat a patient with particularly severe and chronic anorexia nervosa. 46 Case Report A 31-year-old woman was referred to the Behavioural Cognitive Psychotherapy Unit (BCPU) at South West London and St George s Hospital for inpatient treatment of her OCD. The BCPU specialises in treating patients with severe, chronic, resistant OCD, many of whom have complicating comorbid diagnoses (Drummond, 1993; Drummond, Pillay, Rani, & Kolb, 2007). The patient had a history of restrictive anorexia nervosa since the age of 12 years. This diagnosis was compatible with both the fourth edition Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) and ICD-10 criteria for anorexia nervosa. Her Body Mass Index (BMI) over these last 19 years had varied from 11 to 19. She had had amenorrhoea since age 19, although she had menstruated for 2 months at 29 years. She had been hospitalised on 3 occasions for this problem with good immediate outcome. At the time of admission to the BCPU, she was receiving ongoing maintenance treatment for her eating disorder. OCD had also started 19 years ago when the patient was 12 years old. She felt the OCD preceded the onset of anorexia nervosa by a few months and felt both had been precipitated by menstruation. Initially her worries had been fear that she may not perform perfectly at school and fear she may not be able to do well in life. At age 23 the worries also changed to include fear of contamination. At the time of admission to the BCPU, her main obsessive worry was that she may become contaminated by dirt or germs or by fatty substances. Although she realised that it was irrational, she became concerned that if she ingested germs they may cause her to put on weight due to their bulk. She thus had extensive cleaning compulsions comprising hand washing over 100 times a day and extensive cleaning rituals in the kitchen where she would only use her own cooking utensils, crockery and cutlery. Despite severe traumatic dermatitis of the hands, she was unable to use hand cream for fear of absorbing the fat. Previous treatment for her OCD had included three trials of graded exposure as an inpatient whilst being treated for her anorexia nervosa in a private psychiatric hospital. None of these attempts had improved her OCD symptoms substantially and the major focus of work had been to control her low weight. In addition, she had received full doses of fluoxetine and paroxetine and at admission was receiving 200 mg of sertraline and 5 mg of olanzapine daily. This drug regime had been unchanged for 2 years. On admission her Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman et al., 1989) score was 30 (Obsession subscale score 15; Compulsion subscale score 15), which indicates the most severe OCD. Her score on the Padua Inventory (Sanavio, 1988) was 92, which indicates substantial impairment due to OCD. The Beck Depression Inventory (Beck, 1978) showed significant depression with a score of 27 out of a maximum of 63. She had been advised prior to admission that she must achieve a BMI of at least 19 before being admitted for OCD treatment, and that if her weight dropped by more than 2 kg during the admission she would be discharged. Her medication remained unchanged throughout her inpatient stay.
Application of DIRT Treatment started by focusing on the DIRT program. These sessions took place at weekly intervals with the therapist and with self-directed homework between sessions. Each treatment session with the therapist lasted approximately 1 hour. She was given no instructions about exposure to feared situations throughout the DIRT program. She was sceptical about DIRT as it focuses on possible illness from dirt and germs and did not seem to directly address her specific fears. Her medication remained unchanged throughout her inpatient stay. Despite this, over 12 weeks of treatment she showed significant improvements. Her Y-BOCS score fell to 20 (moderately severe OCD) and her subscale scores showed that her score for obsession was now 9 out of 20 (Obsession subscale score 9; Compulsion subscale score 11). As she had completed the components of the DIRT program, she was then offered treatment with ERP. After a further 12 weeks of therapy her Y-BOCS score was 19 and her BDI score 28. The subscale scores of the Y-BOCS showed that overall her score for obsession was 9 and her score for compulsions was 10. This meant that the intensive ERP treatment failed to produce any recordable increased benefit. At discharge from hospital, however, she had reduced her Y-BOCS score from severe to moderate, and this enabled her to live a fuller life. Her BDI score at 6-weeks follow-up was 21 (which indicates mild moderate depressive symptoms). The gains in obsessive compulsive symptoms and her weight were maintained to 1-year follow-up as shown in Figure 1. 30 25 20 15 10 5 BMI Y-BOCS BDI 0 0 12 24 6 FU 1yr FU 47 FIGURE 1 Body Mass Index; Yale-Brown Obsessive Compulsive Scale Score and Beck Depression Inventory Score Throughout Admission and at 6-Weeks and 1-Year Follow-Up Note: 0 = admission; 12 = 12-week review; 24 = discharge from hospital at 24 weeks; 6 FU = 6-weeks post-discharge follow-up; 1yr FU = 1-year post-discharge follow-up
Lynne M. Drummond and Peter Kolb Discussion The case history demonstrates that DIRT was useful in initially reducing the fear associated with the obsessive thoughts. It is believed that this reduction in anxiety allowed the patient to embark on a program of graded exposure to beneficial result. Previous trials of graded exposure had not resulted in sustained benefit due to a lack of continued adherence to the program. The DIRT program focuses on the risk of spreading various types of infection by engaging in different activities. It involves examining the body s defences against infection and information and provides information about risk. DIRT worked for this patient despite the fact that her obsessive thoughts did not concern conventional fear of dirt and germs for their own sake, but were concerning possible deleterious effects they may have on her weight. The patient clearly recognised these thoughts as illogical, but this did not alter her fear. This finding is consistent with the theory that at a subconscious and emotional level patients have a number of beliefs about the danger of their obsession even when they intellectually recognise these as erroneous (Jones & Menzies, 1997). DIRT may be particularly useful for the fragile patient with restrictive anorexia nervosa and OCD. Although treatment involving ERP has been demonstrated to be effective in patients suffering from OCD (Cottreaux et al., 2001; Foa & Goldstein, 1978; James & Blackburn, 1995; Marks et al., 1975; McLean et al., 2001), this treatment is stressful in nature as it involves asking the patient to face the feared situation. Although the addition of cognitive techniques should theoretically reduce some of the anxiety, the patient is still being asked to engage in exposure tasks (Salkovskis, 1999). Personal clinical experience led the authors to believe that particular care is needed with patients who have comorbid anorexia nervosa and OCD as aggressive treatment of the OCD seemed to render some patients liable to an exacerbation of weight loss and symptoms of the eating disorder. It is believed that the stress of exposure treatment may be a factor in this. DIRT seems to have the advantage with these vulnerable patients as it is a psychoeducational treatment without a direct exposure component. By providing the patient with evidence refuting the OCD beliefs about dirt and bacteria, it is expected that the patient may spontaneously engage in exposure with minimal, or much reduced, anxiety. In the current case, the patient had both anorexia nervosa and OCD for many years, and had been treated for both conditions many times. DIRT seemed to offer her sufficient improvement to allow her to engage in graded exposure without detrimental weight loss or overwhelming anxiety. More studies examining the outcome of comorbid OCD and anorexia nervosa are needed. This report, however, suggests that using less confrontational and more psychoeducational methods with these fragile patients may offer a way forward. 48 Acknowledgment We would like to thank Professor J.H. Lacey, St George s, University of London, for his extremely helpful comments and advice. References American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Beck, A.T. (1978). The Depression Inventory. San Antonio, Texas: Psychological Corporation.
Application of DIRT Cottraux, J., Note, I., Yao, S.N., Lafont, S., Note, B., Mollard, E., et al. (2001). A randomized controlled trial of cognitive therapy versus intensive behaviour therapy in obsessive-compulsive disorder. Psychotherapy and Psychosomatics, 70, 288 297. Drummond, L.M. (1993). The treatment of severe, chronic, resistant obsessive-compulsive disorder: An evaluation of an inpatient programme using behavioural psychotherapy in combination with other treatments. British Journal of Psychiatry, 163, 223 229. Drummond, L.M., & Fineberg, N.A. (2007). Obsessive-compulsive disorders. In G. Stein (Ed.), College seminars in adult psychiatry (pp. 270 286). London: Gaskell. Drummond, L.M., Pillay, A., Rani, R.S., & Kolb, P.J. (2007). Specialised inpatient treatment for severe, chronic resistant obsessive-compulsive disorder (OCD); A naturalistic study of clinical outcomes. Psychiatric Bulletin, 31, 49 52. Dubois, F.S. (1949). Compulsion neurosis with cachexia. American Journal of Psychiatry, 106, 107 115. Ellis, A. (1962). Reason and emotion in psychotherapy. New York: Lyle Stuart. Fahy, T.A., Osacar, A., & Marks, I. (1993). History of eating disorders in female patients with obsessive-compulsive disorder. International Journal of Eating Disorders, 14(4), 439 443. Fineberg, N.A., & Gale, T. (2005). Evidence-based pharmacological treatments for obsessive compulsive disorder. International Journal of Neuropsychopharmacology, 8, 107 129. Foa, E.B., & Goldstein, A. (1978). Continuous exposure and complete response prevention in the treatment of obsessive-compulsive neurosis. Behavior Therapy, 9, 821 829. Goodman, W.K., Price, L.H., Rasmussen, S.A., Mazure, C., Fleischmann, R.L., Hill, C.L., et al. (1989). The Yale-Brown Obsessive Compulsive Scale, I: Development, use, and reliability. Archives of General Psychiatry, 46, 1006 1011. Govender, S., Drummond, L.M., & Menzies, R.G. (2006). The use of danger ideation reduction therapy in the treatment of severe chronic resistant obsessive-compulsive disorder. Behavioural and Cognitive Psychotherapy, 34, 1 4. Hsu, L.K., Kaye, W.H., & Weltzin, T. (1993). Are the eating disorders related to obsessive compulsive disorder? International Journal of Eating Disorders, 14(3), 305 318. James, I.A., & Blackburn, I.M. (1995). Cognitive therapy with obsessive-compulsive disorder. British Journal of Psychiatry, 166, 444 450. Jones, M.K., & Menzies, R.G. (1997). The cognitive mediation of obsessive-compulsive handwashing. Behaviour Research and Therapy, 35, 843 850. Jones, M.K., & Menzies, R.G. (1998). Danger ideation reduction therapy (DIRT) for obsessive-compulsive washers. A controlled trial. Behaviour Research and Therapy, 36, 121 125. Kaye, W.H, Bulik, C.M., Thornton, L., Barbarich, N., & Masters, K. (2004). Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry, 161(12), 2215 2221. Krochmalik, A., Jones, M.K., & Menzies, R.G. (2001). Danger ideation reduction therapy (DIRT) for treatment resistant compulsive washing. Behaviour Research and Therapy, 39, 897 912. Marks, I.M., Hodgson, R., & Rachman, S. (1975). Treatment of chronic obsessive-compulsive disorder by in vivo exposure. British Journal of Psychiatry, 12, 349 364. McDougle, C.J., & Goodman, W.K. (1991). Obsessive-compulsive disorder: Pharmacotherapy and pathophysiology. Current Opinion in Psychiatry, 4, 267 272. McLean, P.D., Whittal, M.L., Thordarson, D.S., Taylor, S., Sochting, K.O., Koch, W.J., Paterson, R., & Anderson, K.W. (2001). Cognitive versus behaviour therapy in group treatment to obsessive-compulsive disorder. Consulting and Clinical Psychology, 69, 205 214. Palmer, H.D., & Jones, M.S. (1939). Anorexia nervosa as a manifestation of compulsion neurosis. Archives of Neurology and Psychiatry, 41, 856 858. Salkovskis, P.M. (1999). Understanding and treating obsessive-compulsive disorder. Behaviour Research and Therapy, 37(suppl. 1), 29 52. Sanavio, E. (1988). Obsessions and compulsions: The Padua Inventory. Behaviour Research and Therapy, 26,169 177. 49
Lynne M. Drummond and Peter Kolb Thiel, A., Broocks, A., Ohlmeier, M., Jacoby, G.E., & Schussler, G. (1995). Obsessive-compulsive disorder among patients with anorexia nervosa and bulimia nervosa. American Journal of Psychiatry, 152(1), 72 75. 50