Overview of Treatments for Obsessive- Compulsive Disorder and Spectrum Conditions: Conceptualization,

Overview of Treatments for Obsessive- Compulsive Disorder and Spectrum Conditions: Conceptualization,

Overview of Treatments for ObsessiveCompulsive Disorder and Spectrum
Conditions: Conceptualization,
Theory, and Practice
Nicholas Maltby, PhD
David F. Tolin, PhD
This paper presents an overview of obsessive-compulsive disorder (OCD) and the
obsessive-compulsive spectrum disorders (OCSDs) by outlining the major arguments
for and against the spectrum construct. Cognitive, behavioral, and biological models
are reviewed, as are assessment strategies for adults and children. Treatment options for
OCD are critically evaluated, and it is argued that exposure and ritual prevention (ERP)
has the best support as the first-line psychological treatment. Suggestions for
overcoming the most common obstacles faced during treatment are provided. In
addition, strategies for dealing with partial or nonresponse or treatment refusal are
discussed. Stepped-care models are presented as a potential method of addressing the
problems caused by the expense and time commitment of existing treatments. [Brief
Treatment and Crisis Intervention 3:127–144 (2003)]
KEY WORDS: obsessive-compulsive disorder, obsessive-compulsive spectrum, reviews,
cognitive-behavioral therapy, pharmacotherapy.
Obsessive-compulsive disorder (OCD) is a chronic anxiety disorder, marked by recurrent, intrusive, and distressing thoughts (obsessions)
and/or repetitive behaviors (compulsions). Epidemiological data suggest a 6-month prevalence
of 1–2% (Myers et al., 1984) and a lifetime
prevalence of 2–3% (Robins et al., 1984), making OCD the world’s fourth most common mental disorder (exceeded only by phobias, depresFrom the Anxiety Disorders Center at The Institute of Living
in Hartford, CT.
Contact author: Nicholas Maltby, PhD, Anxiety Disorders
Center, The Institute of Living, 200 Retreat Avenue, Hartford, CT 06106. Phone: (860) 545-7685. Fax: (860) 5457156. E-mail: [email protected].
© 2003 Oxford University Press
sion, and alcohol abuse). OCD often severely disrupts social and vocational functioning (Leon,
Portera, & Weissman, 1995), and it is associated
with a fourfold risk of unemployment (Koran,
Thienemann, & Davenport, 1996). Family functioning is usually impaired, due in part to the
large burden assumed by spouses and parents
(Amir, Freshman, & Foa, 2000; Calvocoressi et
al., 1995). Age of onset is typically early, between 10 and 23 years (Rasmussen & Tsuang,
1986), and the disorder is usually chronic. Because of OCD’s high prevalence and because of
the chronic, debilitating nature of its symptoms,
the World Health Organization named OCD
among the top 10 causes of years lived with
illness-related disability (Murray & Lopez, 1996).
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The symptoms of OCD tend to cluster into recognizable subtypes. Checking and washing are
the most common and together account for over
50% of OCD cases (Foa et al., 1995; Mataix-Cols,
Baer, Rauch, & Jenike, 2000). Other common
subtypes include doubting, mental ritualizing,
ordering, hoarding, and scrupulosity (Foa, Kozak, Salkovskis, Coles, & Amir, 1998). A number of studies have attempted to empirically derive OCD subtypes by applying factor analysis
to the Yale-Brown Obsessive-Compulsive Scale
(Y-BOCS) symptom checklist (Goodman, Price,
Rasmussen, Mazure, Delgado, et al., 1989;
Goodman, Price, Rasmussen, Mazure, Fleischmann, et al., 1989). These studies yield from
three to five factors with a high degree of consensus across studies. All studies identified a
contamination/cleaning factor, and all studies
with four or more factors identified obsessions/
checking, symmetry/ordering, and hoarding as
factors (Leckman et al., 1997; Mataix-Cols,
Rauch, Manzo, Jenike, & Baer, 1999; Summerfeldt, Richter, Antony, & Swinson, 1999).
Mataix-Cols and colleagues (1999) added an additional factor, sexual/religious obsessions, in
their five-factor solution, while Baer’s (1994)
three-factor solution combined symmetry and
hoarding into one factor and added another factor, “pure obsessions,” that may be consistent
with the obsessions/checking factor in other
studies. Thus, factor-analytic studies are generally consistent in identifying at least four core
subtypes of OCD: washing, checking, ordering,
and hoarding.
A common misconception in OCD concerns
the prevalence of patients classified as being
“purely” obsessional, without any compulsions. This notion may be an artifact of early definitions of OCD, which maintained that obsessions were mental events and that compulsions
were overt behaviors. However, current theories
recognize that compulsions can be either actions
or thoughts. Mental compulsions (e.g., mental
review, counting, praying) are differentiated
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from obsessions by their function. Obsessions
elicit anxiety, while compulsions either reduce
anxiety or are completed to stave off a perceived
consequence. It is very rare for an OCD patient
not to engage in ritualizing; 99.8% of OCD patients describe either mixed behavioral and
mental compulsions, or behavioral compulsions
only (Foa et al., 1995). Thus, the presence of
covert rituals should be routinely assessed, especially in the absence of overt compulsions.
OCD Spectrum Disorders
Although obsessions and compulsions are the
defining criteria for OCD, these symptoms are
also present in a number of other disorders. For
example, body dysmorphic disorder, Tourette’s
syndrome, and trichotillomania all involve intrusive or repetitive thoughts or behaviors. Because of the phenomenological overlap of these
disorders with OCD, as well as their apparent preferential response to serotonergic medications,
researchers have proposed grouping these disorders together into a category called obsessivecompulsive spectrum disorders (OCSDs). It has
been argued that the OCSDs affect as many as
10% of the U.S. population and cause significant
economic burden, as well as disruptions in quality of life (Hollander et al., 1996).
One conceptualization places OCSDs along a
continuum from “compulsive” to “impulsive”
(Hollander et al., 1996). The “compulsive” end
of the spectrum is characterized by harm–
avoidant rituals and includes OCD, hypochondriasis, restrictive anorexia, and body dysmorphic disorder (McElroy, Phillips, & Keck, 1994).
The “impulsive” end of the spectrum is characterized by self-damaging behaviors and includes trichotillomania, compulsive gambling,
Tourette’s syndrome, bulimia nervosa, kleptomania, and impulsive personality disorders
(McElroy et al., 1994). Another conceptualization
places disorders along a motoric/obsessional di-
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Overview of OCD
mension. Motoric disorders involve repetitive
behaviors without obsessions (e.g., Tourette’s
disorder). Obsessional disorders reflect the inverse pattern of obsessions without repetitive
behaviors (Hollander & Wong, 2000).
OCD and the OCSDs share a common controversy over the degree to which they reflect either a more unified disorder or many distinct
disorders. Patients with OCD frequently present
with symptoms of more than one subtype (Rasmussen & Eisen, 1988), suggesting a more unified solution. However, that some subtypes of
OCD appear to respond differentially to different
treatments (Buchanan, Meng, & Marks, 1996;
Jenike, Baer, Minichiello, Rauch, & Buttolph,
1997; Lelliott, Noshirvani, Basoglu, Marks, &
Monteiro, 1988; Rachman, 1980) suggests that
they may be distinct disorders. Similarly, critics
argue that the concept of the OCD spectrum is
predicated mainly on superficial similarities in
surface topography, selective interpretation of
medication response data, and misinterpretation of relatively sparse and inconsistent neuroimaging data. Behaviors that resemble each
other, they argue, may not represent the same
illness, and impulsive behaviors do not serve the
same neutralizing function as do compulsions
(Abramowitz & Houts, in press; Tolin & Foa,
2001). In addition, the spectrum concept could
become overinclusive. For example, the same
similarities used to relate Tourette’s syndrome to
OCD have also been used to relate Tourette’s syndrome to autistic spectrum disorders (Barnhill &
Horrigan, 2002; Bejerot, Nylander, & Lindstrom, 2001). On the other hand, some of the
spectrum disorders tend to respond to similar
pharmacological and psychosocial treatments,
and some demonstrate a functional relationship
between mental and behavioral events that parallels that of OCD; it is therefore suggested that
at least some OCSDs may be related to OCD. Articles by Steketee and Neziroglu, Stemberger,
Stein, and Mansueto, and Deckersbach, Keuthen, and Wilhelm in this special issue will elab-
orate on specific OCSDs and their relationship
to OCD.
Models of OCD
Behavioral
Behavioral models of OCD (e.g., Kozak & Foa,
1997) posit that compulsive behaviors are a form
of avoidance that maintain obsessive fears via
negative reinforcement (anxiety reduction) and
by blocking opportunities for habituation to
feared objects and situations. Indeed, laboratory studies show that exposure to feared stimuli increased patients’ anxiety, whereas performing compulsions led to decreased anxiety
(Hodgson & Rachman, 1972). Some individuals
with OCD, generally checkers, do report increased fear after performing compulsions
(Roper, Rachman, & Hodgson, 1973); however,
mildly anxiety-evoking behaviors might be considered as avoidance behaviors if they serve to
prevent the occurrence of strong anxiety (Herrnstein, 1969). Thus, while checking the stove may
elicit anxiety in some patients, refraining from
checking the stove is perceived as an even more
anxiety-producing event because of the increased risk of an aversive event (e.g., the house
burning down). In summary, the specific function of compulsions may vary, but the general
function appears to be one of anxiety reduction
and/or prevention.
Cognitive
Traditional cognitive models of psychopathology have been “top-down”; that is, they emphasize the role of dysfunctional cognitions in the
etiology and maintenance of disorders (Beck,
Emery, & Greenberg, 1985). According to such
models, OCD is characterized by dysfunctional
assumptions, such as overestimation of threat,
intolerance of uncertainty, importance of
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thoughts, need to control thoughts, responsibility, and perfectionism (Obsessive Compulsive
Cognitions Working Group, 1997). Thus, OCD
develops and is maintained as normal unpleasant thoughts as being perceived as harmful, immoral, or dangerous. Such beliefs are strengthened when neutralizing strategies lead to decreased anxiety, a factor that overlaps with the
behavioral model (Rachman, 1998; Salkovskis,
1985). More recent models of psychopathology
have been “bottom-up,” reflecting an emphasis
not on beliefs but rather on the processes of
mental activity (Williams, Watts, MacLeod, &
Mathews, 1997). Information-processing studies of OCD have shown that OCD is characterized
by an attentional bias toward threat cues (Foa,
Ilai, McCarthy, Shoyer, & Murdock, 1993; Lavy,
van Oppen, & van den Hout, 1994); increased
memory for, and impaired forgetting of, threatrelated stimuli (Constans, Foa, Franklin, &
Mathews, 1995; Radomsky & Rachman, 1999;
Tolin, Hamlin, & Foa, 2002; Wilhelm, McNally,
Baer, & Florin, 1996); decreased memory confidence (Constans et al., 1995; Tolin, Abramowitz,
Brigidi, et al., 2001); and difficulty inhibiting
the processing of irrelevant information (Enright & Beech, 1990, 1993; Tolin, Abramowitz,
Przeworski, & Foa, 2002). Bottom-up and topdown models of OCD should not be considered
mutually exclusive; indeed, we propose that an
integrated cognitive-behavioral model of OCD
must take into account both dysfunctional beliefs and biases as well as deficits in information
processing.
Biological
Biological models of OCD have focused on the
role of abnormal serotonin metabolism and hyperactive frontal-striatal circuits in creating the
symptoms of OCD. The serotonin hypothesis
is predicated on the observation that patients
with OCD respond preferentially to serotonin
reuptake inhibitors (SRIs) as opposed to non-
130
serotonergic medications or a placebo. However,
more direct tests of the serotonin hypothesis,
such as biological challenge studies, have been
inconclusive (Barr, Goodman, & Price, 1993;
Barr, Goodman, Price, McDougle, & Charney,
1992). Neuroimaging and neurosurgical evidence
suggests that OCD is associated with hyperactivity in frontal-striatal curcuits of the brain,
which includes the orbitofrontal cortex, anterior cingulate cortex (ACC), caudate nucleus,
and thalamus (Baxter, 1992; Breiter et al., 1996;
Saxena & Rauch, 2000). The biological models of
OCD are not wholly separate from cognitivebehavioral models. Neurotransmitter activity,
regional metabolic actvity, behavioral reinforcement, maladaptive beliefs, and informationprocessing biases may be conceptualized as different ways of understanding OCD symptoms.
Similarly, each of these systems might be thought
to influence the others, rather than rely on a singular direction of causality (e.g., biological irregularities cause dysfunctional behaviors). As
an example of these complex interrelationships,
both SRI medications and behavior therapy appear to produce comparable changes in brain
metabolic activity (Schwartz, Stoessel, Baxter,
Martin, & Phelps, 1996).
Assessment of OCD
Steketee and Neziroglu in this volume discuss
assessment strategies for OCD. In our clinic, assessment of OCD includes a comprehensive evaluation of current and past OCD symptoms, associated functional impairments, the patient’s degree of insight into the senselessness of OCD
symptoms, and structured interviews for comorbid Axis I and Axis II psychopathology.
In addition, we examine the patient’s understanding of OCD and its treatment, and we
provide education as needed. The Yale-Brown
Obsessive-Compulsive Scale (Y-BOCS) (Goodman, Price, Rasmussen, Mazure, Delgado, et al.,
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Overview of OCD
1989; Goodman, Price, Rasmussen, Mazure,
Fleischmann, et al., 1989) is considered the
“gold standard” of OCD assessment. This semistructured interview contains a symptom checklist and a severity scale. The symptom checklist
includes a list of obsessions and compulsions,
categorized according to content. The severity
scale of the Y-BOCS assesses symptom severity
using five questions for obsessions and five
for compulsions. A variation of the Y-BOCS, the
Child Yale-Brown Obsessive-Compulsive Scale
(CY-BOCS; Scahill et al., 1997), is used for children and adolescents.
A number of standardized self-report measures have been developed for the assessment of
OCD. Because of their ease of use and relatively
quick completion time, these measures may
provide greater utility in monitoring treatment
progress than do structured interviews. A number of sources (e.g., Antony, Orsillo, & Roemer,
2001) provide detailed examination of individual measures, but a brief listing of the most commonly used inventories includes a self-report
version of the Y-BOCS (Warren, Zgourides, &
Monto, 1993); the Obsessive Compulsive Inventory (Foa et al., 1998; a recently published,
abbreviated version of which appears in Foa et
al., in press); the Maudsley Obsessional Compulsive Inventory (Hodgson & Rachman, 1977);
and the Padua Inventory (Sanavio, 1988). In addition to these diagnostic measures, several
other measures have been published that assess
cognitive features thought to underlie OCD; we
routinely include these measures as part of a
comprehensive OCD assessment. These measures include the Obsessive Beliefs Questionnaire (Obsessive Compulsive Cognitions Working Group, 2001), the Thought-Action Fusion
Scale (Shafran, Thordarson, & Rachman, 1996),
and the Thought Control Questionnaire (Wells
& Davies, 1994).
Behavioral assessment of OCD symptoms is
not commonly reported in the literature, but it
can be very useful for evaluating the severity of
fear, for facilitating treatment planning, for
monitoring progress, and for measuring treatment outcome (Mavissakalian & Barlow, 1981).
Behavioral-avoidance tests (BATs) represent one
form of behavioral assessment that can be tailored to the patient’s symptom profile. For example, patients with contamination concerns
may be asked to touch “dirty” objects like doorknobs, garbage cans, or toilets; checkers may be
asked to leave doors unlocked, to drive over potholes, or to leave objects in a manner that might
cause someone harm (e.g., placing sticks on a
pathway); hoarders can bring objects into the
office to be discarded; and patients with ordering compulsions can be asked to misarrange objects in their house or car. Because of the idiosyncratic nature of many compulsions, behavioral assessment often requires creativity and
the willingness to travel with the patient. As
will be discussed later, such BATs tie in nicely
with exposure and ritual-prevention exercises
that are used to reduce the patient’s fear of these
activities.
Treatment of OCD
Exposure and Ritual Prevention
Exposure and ritual prevention (ERP), also
called exposure and response prevention, consists of gradual, prolonged exposure to feareliciting stimuli or situations, combined with
strict abstinence from compulsive behavior. In
practice, this treatment would mean that a patient with contamination concerns, for example,
would be encouraged to touch progressively
“germier” objects while simultaneously refraining from washing or cleaning. Similarly, a patient
with obsessive concerns about harming other
people while driving might be encouraged to
drive in increasingly congested areas without
looking in the rearview mirror. The purpose of
these exercises is to allow patients to experience
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a reduction of their fear response, to recognize
that these situations are not excessively dangerous, and to accept their fear will not last forever.
Thus, although ERP is a “behavioral” intervention, its mechanism of action may well be cognitive (Foa & Kozak, 1986).
One of the more difficult aspects of ERP is that
patients must eventually be willing to perform
exposures to their highest fears—and these exposures often feel very risky to the patient. For
instance, the highest exposure for the contamination patient just mentioned might be touching a toilet in a public restroom. To help patients
make judgments about the appropriateness of an
exposure, we often use the principle of acceptable risk in defining the range of possible exposures with the patient. No exposure is risk free;
however, the risk of the exposure may be similar to risks commonly taken every day and thus
be acceptable. For instance, the patient who
balks at touching a toilet without hand washing
may be asked to compare the risk of this exposure to that of a camping trip where cleanliness
is often delayed for days or weeks. We also find
it helpful to encourage patients to assume that a
situation is safe unless there is clear evidence to
the contrary; typically, OCD patients tend to assume a situation is dangerous unless they can
find clear evidence of safety (which is often difficult to obtain). Therapists can influence the
patient’s willingness to engage in more difficult
exposures by preparing the patient for these at
an early stage, by maintaining an expectation
that they will be doing so, and by collaboratively engaging in exposures along with the patient. With this in mind, it is also important to
pace the level of anxiety elicited during exposures. Exposures should elicit anxiety, but not
so much that the patient feels overwhelmed.
Regular subjective units of distress (SUDS) ratings can help gauge levels of anxiety. As can be
seen, ERP demands flexibility of the patient and
clinician. Therapists must be able to design creative exposures that address the patient’s OCD
132
symptoms, and they must be willing to leave the
office because many exposures can only be done
in the patient’s home or at another fear-relevant
location.
Numerous studies attest to the efficacy of ERP
in adult outpatients with OCD (e.g., Cottraux,
Mollard, Bouvard, & Marks, 1993; Fals-Stewart,
Marks, & Schafer, 1993; Kozak, Liebowitz, &
Foa, 2000; Lindsay, Crino, & Andrews, 1997;
van Balkom et al., 1998). Approximately 75% of
patients treated with ERP improve significantly,
usually defined as 30 to 50% improvement, and
they remain so at follow-up (Franklin & Foa,
1998). Despite this fact, ERP is not widely used
by mental health practitioners, as shown by a recent survey of nine Boston-area hospitals and
clinics, many of which are known for their expertise in treating anxiety disorders (Goisman et
al., 1993). One possible explanation for this discrepancy is that while ERP is efficacious, it may
not be cost effective. ERP is time consuming and
expensive; thus, many patients and third-party
payers are unable or unwilling to pay for treatment. Approximately 25% of OCD patients
also refuse ERP (Franklin & Foa, 1998), presumably because of apprehension about the difficulty and intensity of the treatment. To address
this obstacle, we (Maltby, Tolin, & Diefenbach,
2002) have developed a brief, four-session readiness intervention consisting of psychoeducation, a videotape example of an ERP session, motivational interviewing techniques, and a phone
conversation with a former ERP patient. Initial
results are encouraging: to date, 60% of patients
receiving the readiness intervention chose to
begin ERP, whereas only 20% of patients in a
wait-list condition entered ERP.
Cognitive Therapy
We believe that the distinction between “behavioral” and “cognitive” therapy is somewhat
arbitrary. During ERP, we routinely assist patients in changing inaccurate beliefs about
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Overview of OCD
feared situations, such as pointing out that
feared consequences did not occur or that the
patient’s fear did not remain forever. Similarly,
cognitive therapy (CT) often involves direct behavioral suggestions to reduce avoidant behavior. In OCD, the specific goal of CT is to teach patients to identify and correct their dysfunctional beliefs about feared situations (e.g.,
Freeston et al., 1997). Wilhelm (this issue) elaborates on the use of CT, so we will describe it
here only briefly. To date, CT strategies have emphasized the top-down (beliefs and appraisals),
rather than the bottom-up (information processing), cognitive models of OCD. In most
cases, this strategy has involved either rationalemotive therapy (RET), in which irrational
thoughts are identified and targeted via rational
debate, or CT along the lines of Beck and colleagues (1985), in which Socratic questioning
and behavioral experiments are used to challenge the validity of distorted thoughts. In either case, the patients are asked to elaborate
on their “automatic” appraisals of feared situations, and they are then taught to identify the
inaccuracies or logical inconsistencies in those
thoughts. For example, a patient with contamination concerns may identify the belief that all
germs are dangerous. The therapist helps the patient to identify and label the irrational features
of this belief (e.g., “overgeneralization”). The
patients are then instructed to monitor the occurrence of this thought in their daily life, and
they are given specific instructions for challenging the thought. In this case, the patient might
be instructed either to recall that many germs
are benign or even beneficial or to acknowledge
that deaths from germs are more rare than would
be expected if this thought were true. The patient may be encouraged to conduct behavioral
experiments, in which they come into contact
with certain germs in order to see that they are
not harmed. The overlap of these strategies with
ERP should be clear; we suggest that the difference is largely one of emphasis.
The specific efficacy of CT for OCD has not
been firmly established. In two studies, RET was
found to yield results that did not differ from
those of ERP (Emmelkamp, Visser, & Hoekstra,
1988), and the addition of RET to ERP did not
appear to enhance treatment results (Emmelkamp & Beens, 1991). In comparative efficacy
studies of adults with OCD, Beck-style CT produced moderately strong results that did not
differ significantly from those of ERP (Cottraux
et al., 2001; van Balkom et al., 1998; van Oppen
et al., 1995); in a comparison study of group treatment, CT yielded moderate results that were not
as strong as those obtained using group ERP
(McLean et al., 2001). It should be noted, however, that in each of these CT comparison studies, ERP sessions were briefer and more widely
spaced than were those used in ERP studies
(Kozak et al., 2000), and they did not emphasize
intense, therapist-assisted exposures. Our preference, based on these data, is to use ERP whenever possible. However, cognitive therapy may
play a useful, adjunctive role when ERP has not
produced optimal results. In an open trial with
five adult OCD patients who had failed to respond to pharmacotherapy and ERP, an intensive CT program was associated with decreases
in self-reported OCD symptoms (Krochmalik,
Jones, & Menzies, 2001).
Anxiety Management Training
Some clinicians have argued for the use of anxiety management training (AMT) in the treatment of patients with OCD, particularly with
children (March & Mulle, 1998). AMT strategies
include training in slow, diaphragmatic breathing; progressive muscle relaxation; and coping
imagery. AMT strategies such as relaxation have
not been shown to be an effective component of
treatment for OCD (Marks, 1987). Because AMT
strategies are designed to reduce exposure to
anxiety, they may interfere with the core process of ERP—that is, evoking anxiety to allow
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for habituation and cognitive change to occur.
In general, patients are able to tolerate the distress of ERP, and they therefore do not require
AMT (Franklin, Tolin, March, & Foa, 2001).
However, some patients may be so anxious at
baseline that they are unable to tolerate even
mild exposure; thus, AMT may be a useful adjunct to ERP in such cases.
Pharmacotherapy
Serotonin reuptake inhibitors (SRIs) are the
first-line pharmacological treatment of choice
for OCD (Rasmussen & Eisen, 1997). These are
also reviewed by Pato and colleagues in this issue. SRIs commonly used in OCD treatment include the selective SRIs (SSRIs) fluoxetine, sertraline, fluvoxamine, paroxetine, and citalopram;
the serotonin-norepinephrine reuptake inhibitor (SNRI) venlafaxine; and the tricyclic antidepressant clomipramine. Although 30–60% of
patients respond to treatment utilizing SRIs,
relapse rates are high (65–90%) when acute treatment is discontinued. Longer-term pharmacotherapy may therefore be required. Most researchers recommend at least one year of continued treatment following successful treatment
(March, Frances, Carpenter, & Kahn, 1997); however, few studies of maintenance treatment have
been conducted. In one discontinuation study
(Koran, Hackett, Rubin, Wolkow, & Robinson,
2002), patients randomly assigned to receive placebo following one year of sertraline were more
likely to experience an acute exacerbation in
their OCD symptoms as measured by the Y-BOCS
and CGI than were patients who continued to receive sertraline. In a discontinuation study of
CBT versus clomipramine (O’Sullivan, Noshirvani, Marks, Monteiro, & Lelliott, 1991), patients
who received CBT fared better at 6-year followup than did clomipramine patients, who did not
differ from patients who had received placebo.
Meta-analytic studies suggest that clomipramine yields higher rates of responding than
134
do SSRIs but that no SSRI is superior to any
other (Greist, Jefferson, Kobak, Katzelnick, &
Serlin, 1995; Stein, Spadaccini, & Hollander,
1995). However, clomipramine’s side-effect profile prevents it from being widely accepted as a
first-line intervention; prescribers typically prefer to begin pharmacotherapy with the more
easily tolerated SSRIs. In a large randomized
controlled trial, clomipramine was superior to
placebo. However, ERP was superior to clomipramine (85% responder rate vs. 50%, respectively). Interestingly, and contrary to common
clinical practice, the combination of clomipramine and ERP yielded a 71% responder rate,
which was superior to clomipramine alone but
not to ERP alone (Kozak et al., 2000). Another
randomized controlled trial found that fluvoxamine yielded similar treatment outcomes as
ERP and CT did, and all were superior to placebo (van Balkom et al., 1998).
Predictors of Treatment Response
No reliable markers of treatment response have
been identified for cognitive-behavioral or pharmacological treatments. Some studies have
found that higher initial severity of OCD symptoms was associated with poorer outcomes (de
Haan et al., 1997; Keijsers, Hoogduin, & Schaap,
1994) while others have not (Cottraux, Messy,
Marks, Mollard, & Bouvard, 1993; Steketee &
Shapiro, 1995). Research on the effects of comorbid personality disorders is similarly mixed,
with some studies that found attenuated treatment response and with other studies that did
not (Fals-Stewart & Lucente, 1993; Fals-Stewart
& Schafer, 1993; Mavissakalian, Hamann, &
Jones, 1990; Steketee, 1990). Type of OCD may
also be related to outcome. Hoarding in particular has been associated with poor response to
ERP (Abramowitz, Franklin, Schwartz, & Furr,
2002; Black et al., 1998; Mataix-Cols, Marks,
Greist, Kobak, & Baer, 2002), SRI medications
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Overview of OCD
(Black et al., 1998; Mataix-Cols et al., 1999) or
their combination (Saxena et al., 2002). Likewise, sexual and religious concerns have also
been associated with poor response to ERP
(Mataix-Cols et al., 2002); this factor may be
due to poorer insight among patients in these
subgroups (Tolin, Abramowitz, Kozak, & Foa,
2001). Duration of OCD was unrelated to outcome in two studies of CBT (Cottraux, Messy, et
al., 1993; Steketee & Shapiro, 1995), but later
age of onset was associated with positive outcome in one study of clomipramine (Ackerman,
Greenland, Bystritsky, Morgenstern, & Katz,
1994). Early reports suggested that pretreatment
depression predicted poorer outcome of ERP
(Foa, 1979); however, later research indicated
that highly and mildly depressed patients responded similarly to treatment (Foa, Kozak, Steketee, & McCarthy, 1992). In a large sample of
OCD patients, only severe depression was associated with attenuated outcome of ERP, although even those patients showed significant
clinical improvement (Abramowitz, Franklin,
Street, Kozak, & Foa, 2000). Lower initial motivation appears to be associated with poorer outcome of cognitive-behavioral therapy (de Haan
et al., 1997; Keijsers et al., 1994); this result may
be mediated by reduced follow-through with
exposure exercises (Araujo, Ito, & Marks, 1996;
O’Sullivan et al., 1991). Insight into the irrationality of obsessive fears has been associated
with poorer outcome in some studies of pharmacotherapy and CBT (Catapano, Sperandeo, Perris, Lanzaro, & Maj, 2001; Erzegovesi et al.,
2001; Foa, 1979; Neziroglu, Stevens, & YaryuraTobias, 1999), but not in others (Eisen et al.,
2001; Foa et al., 1983; Hoogduin & Duivenvoorden, 1988). Ideally, further research on predictors of outcome will lead to the development of
treatment algorithms in which patients can be
matched a priori to specific treatments; however, the available body of research does not yet
support such decisions with the possible exception of hoarding, which may require specific
interventions tailored to the idiosyncratic nature of hoarding-related symptoms (Hartl &
Frost, 1999).
Treatment Augmentations
Partial or nonresponse is common among cognitive-behavioral and pharmacological interventions for OCD. In general, the recommendation is
to augment or change to an alternative treatment when a patient reports an insufficient response to a treatment of adequate dose and duration (March et al., 1997; McDonough & Kennedy, 2002). Thus, an inadequate response to
an SRI could be followed by CBT with a different SRI, or it could be augmented with a different class of medications. Inadequate responses
to CBT may be addressed by using an alternate
form of CBT or by adding SRI augmentation.
Medications typically used to augment SRI
treatment include clonazepam, buspirone, l-tryptophan, lithium, olanzapine, and risperidone
(McDonough & Kennedy, 2002). Empirical studies of these recommendations, however, have
been lacking. A recent study indicated that seven
of nine patients who had failed to respond to fluoxetine showed at least a 25% Y-BOCS reduction when treated with weekly ERP. We are currently examining the efficacy of ERP for patients who have failed to respond to multiple
SRI trials; preliminary results suggest that OCD
symptoms decrease with ERP augmentation, but
to a lesser extent than has been found with treatment-naïve patients (Tolin, Diefenbach, Maltby,
Woodhams, & Worhunsky, 2002). Similarly, a
highly focused cognitive therapy has been associated with significant improvements for some
patients who had previously failed ERP or multiple trials of SRI medications (Jones & Menzies,
1997; Krochmalik et al., 2001).
Because of OCD’s substantial impact on family
functioning as well as the risk of family members’ accommodating (and inadvertently rein-
Brief Treatment and Crisis Intervention / 3:2 Summer 2003
135
MALTBY AND TOLIN
forcing) patients’ compulsions (Amir et al.,
2000; Calvocoressi et al., 1995), family intervention may also be indicated as a supplement to
traditional CBT and pharmacological interventions. In individual and group settings, inclusion of family members resulted in superior outcomes than did CBT alone (Grunes, Neziroglu, &
McKay, 2001; Van Noppen, Steketee, McCorkle,
& Pato, 1997). Family intervention is particularly helpful in the treatment of children with
OCD, by training parents to utilize ERP methods
(Knox, Albano, & Barlow, 1996). In some cases,
family intervention alone may be sufficient to
elicit reductions in compulsive behaviors, such
as instructing parents not to respond to excessive reassurance-seeking (Francis, 1988; Tolin,
2001).
For patients with severe, intractable, and debilitating OCD that has failed to respond to
CBT and pharmacological interventions, neurosurgery may be an option. Current neurosurgical approaches include subcaudate tractomy
(Bridges et al., 1994), anterior cingulotomy (Baer
et al., 1995; Dougherty et al., 2002), anterior
capsulotomy (Mindus & Nyman, 1991), and
combined orbitomedial/cingulate lesions (Hay
et al., 1993). To date, no controlled studies of
these procedures have been conducted; however, the available evidence suggest that 20–
40% of patients receive significant benefits from
these procedures, though many patients require
more than one operation (Baer et al., 1995;
Bridges et al., 1994; Dougherty et al., 2002; Hay
et al., 1993; Rauch et al., 2001). Newer techniques that minimize or avoid destruction of
brain tissue such as transcranial magnetic stimulation and deep brain stimulation are being developed but their efficacy has yet to be established (Greenberg et al., 2000; Malhi & Sachdev,
2002; Nuttin, Cosyns, Demeulemeester, Gybels,
& Meyerson, 1999; Sachdev et al., 2001).
136
Future Directions
Given that OCD is heterogeneous and that many
OCD subtypes and OCSDs may respond differentially to existing behavioral and pharmacological treatments, one potential goal of future
research is to construct treatment algorithms
based on predictors of outcome. As described
previously, this line of research is in its infancy.
However, early research has indicated that
unique variations of CBT can be developed for
OCD and OCSD subtypes such as hoarding
(Hartl & Frost, 1999), contamination fears (Krochmalik et al., 2001), trichotillomania (Lerner,
Franklin, Meadows, Hembree, & Foa, 1998; Ninan, Rothbaum, Marsteller, Knight, & Eccard,
2000; Tolin, Franklin, Diefenbach, & Gross,
2002), hypochondriasis (Clark et al., 1998; Visser & Bouman, 2001; Warwick, Clark, Cobb, &
Salkovskis, 1996), and body dysmorphic disorder (McKay et al., 1997; Wilhelm, Otto, Lohr, &
Deckersbach, 1999).
Nonetheless, the lack of a comprehensive biopsychosocial model of OCD and OCSDs likely
impedes progress in understanding and treating these conditions. In other disorders (such
as panic disorder), the development of such
models has led to significant advances in conceptualization and treatment (e.g., Clark, 1986).
Indeed, Foa and Kozak (1997) suggest that behavior therapy in general may have reached an
“efficacy ceiling” that will only be broken by
improved models based on psychopathology
research. In addition to potentially advancing
the treatment of OCD, biopsychosocial models
may provide testable hypotheses that help resolve the current controversies in OCD research, such as the heterogeneity problem and
the relative placement of spectrum disorders.
We suggest that a comprehensive biopsychosocial model must explain and predict not only
obsessions and compulsions, but also the attributional and information-processing biases
Brief Treatment and Crisis Intervention / 3:2 Summer 2003
Overview of OCD
noted in OCD, findings from neuroimaging studies, and genetic and familial factors.
Also, since the expense and time commitment of CBT have been identified as barriers to
treatment, there is a need to develop alternative treatment algorithms that are acceptable
to patients, that contain costs, and that deliver
the most effective treatment components. Group
therapy represents one promising area of treatment development; preliminary results indicate that CBT can be delivered effectively in a
brief group format, with good results (Himle
et al., 2001; McLean et al., 2001; Van Noppen,
Pato, Marsland, & Rasmussen, 1998). Other researchers have explored the use of self-help
manuals (Fritzler, Hecker, & Losee, 1997) and
computer-assisted therapy (Baer & Greist, 1997;
Baer, Minichiello, Jenike, & Holland, 1988;
Nakagawa et al., 2000) as ways of reducing
health care costs. The utility of these approaches,
however, is limited by the inability to selfcorrect by providing patients with their optimal level of treatment and no more. A preferable approach might be the use of stepped-care
algorithms, in which patients initially receive
the least expensive, intrusive, and difficult treatment (e.g., self-help) and then step up through
more intensive treatment modalities if previous steps fail or yield only a partial response. We
have been piloting stepped-care models of delivering ERP for OCD, though it is still too early
to determine if this model of delivering treatment adequately addresses the cost, effectiveness, and patient acceptance concerns for which
it was developed.
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