Obsessive-Compulsive Disorder

Effectiveness of Pharmacological and Therapeutic Interventions in the Alleviation of the Severity of Obsessive-Compulsive Disorder Symptoms James F. Whittenberg, M.Ed., CSC, LPC-Intern Stillman Middle School, Brownsville, TX Ph.D. Candidate, Capella University, Minneapolis, MN

Abstract The purpose of this literature review is to discover the degree of significance effective interventions have on alleviating the severity of obsessive-compulsive disorder (OCD) symptoms. Effective treatments include pharmacotherapy, behavior therapy, cognitive-behavioral therapy (CBT), group therapy, family therapy, play therapy and a multi-therapeutic treatment. Recommendations will be made concerning the most effective treatment of OCD symptoms. Other treatments such as yogic meditation and relaxation techniques will be addressed and recognized for their success in alleviating the severity of OCD symptoms. 2

Symptom Presentation  Severe, disruptive, unwanted obsessions  Ritualistic compulsions used to counteract anxiety  Fear of harm to self or others that disrupts life  Symptoms appear unnecessary to others  Condition is often hidden and remain untreated (Cooper, 1996) 3

Obsessions Defined  Obsessions are recurrent & persistent thoughts, impulses, or images that are experienced as intrusive & inappropriate & that cause marked anxiety or distress  The obsessions are not simply excessive worries about real life problems  The person attempts to ignore or suppress such obsessions or neutralize them with some other thought or action  The person recognizes that the obsessions are a product of his/her own mind & are excessive or unreasonable (DSM-IV-TR; APA, 2000) 4

Compulsions Defined  Compulsions are repetitive behaviors (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) that the person feels driven to perform in response to an obsession according to rules that must be applied rigidly  The behaviors or mental acts are aimed at preventing or reducing distress or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive (DSM-IV-TR; APA, 2000) 5

Checking and Washing 6

Diagnostic Criteria  The obsessions or compulsions cause marked distress, are time consuming (take more than 1 hour a day), or significantly interfere with the person’s normal routine, occupational (or academic) functioning, or usual social activities or relationships  If another Axis I disorder is present, the content of the obsessions or compulsions is not restricted to it (e.g. eating disorder, Trichotillomania, Body Dysmorphic Disorder, Substance Abuse, Paraphillia, Hypochondriasis, Major Depressive Disorder, etc.)  The disturbance is not due to the physiological effects of a substance or a medical condition (DSM-IV-TR; APA, 2000) 7

Assessment  Obsessive-Compulsive Inventory (OCI; Foa et al., 1998)  Obsessive-Compulsive Inventory – Revised (OCI-R; Foa et al., 2002)  Yale-Brown Obsessive-Compulsive Inventory (Y-BOCS; Clark et al., 2005) 8

Biological Factors  Genetic predisposition to developing OCD (Turner et al., 1985)  Possible dominant frontal lobe dysfunction (Christensen et al., 1987)  High levels of serotonin & norepinephrine (Ruchsow, Grön, & Reuter, 2005) 9

Psychosocial Factors  Mowrer’s theory of avoidance learning & Skinner’s theory of classical conditioning (Christensen et al., 1987)  Thought-action fusion (inflated sense of responsibility) (Lewin et al., 2005)  Patient’s attempts to suppress symptoms (Moritz & Pohl, 2006) 10

Comorbidity  anorexia nervosa, body dysmorphic disorder, social phobia, panic disorder, generalized anxiety disorder, and post-traumatic stress disorder, major depression, schizophrenia, & Tourette's Syndrome (Turner et al., 1985)  Tourette’s Syndrome (Taylor et al., 2005)  Major Depression (Hiss et al., 1994; Clark et al., 2005; Woody et al., 2005; Lawrence et al., 2006) 11

Childhood OCD  Shame, self-doubt, isolation, & secrecy interfere with appropriate peer relationships and social development (Hafner et al., 1981)  Fear that their peers will view them as bad or weird (Swedo et al., 1989)  Identifying and exploring feelings can enable children to discharge anxiety, anger, sadness, or other emotions (Gold-Steinberg & Logan, 1999) 12

Celebrity Sufferers Jessica Alba Kathy Lee Gifford Drew Barrymore Howard Hughes Penelope Cruz John Laroquette Cameron Diaz Howie Mandel Leonardo DiCaprio Michaelangelo Harrison Ford Wolfgang Mozart Kathie Lee Gifford Donny Osmond John Laroquette Howard Stern Charles Darwin Marc Summers Albert Einstein Billy Bob Thornton Harrison Ford Donald Trump 13

Prescription Medication 14

Pharmacotherapy  SSRIs (Celexa, Prozac, Luvox, Paxil, Zoloft) (Freeston et al., 1997)  Clomipramine (Anafranil) (Abramowitz,1997)  Risperidone (Risperdal) with Clomipramine (O’Connor, 2007)  St. John’s Wort (NCCAM, 2007) 15

Behavior Therapy  Exposure & Response Prevention (ERP)  Rank-ordered list of the patient’s obsessions and compulsions & situations in which they occur  Gradual exposure to situations with instructions not to engage in compulsions  Feared consequences of not performing rituals fail to occur, resulting in reduction of anxiety (Christensen et al., 1987; Abramowitz et al., 2003) 16

Cognitive Therapy  Targeting dysfunctional cognitions provides a more comprehensive treatment than ERP or medication (Franklin et al., 2000)  Relaxation, breathing skills, guided imagery, & cognitive restructuring are used in treatment (Franklin et al., 2002)  Patients receiving CBT with medication are less likely to relapse after withdrawing medication (McLean et al., 2001) 17

Cognitive vs. Behavior Therapy  ERP alone is more effective than CBT alone, but ERP alone had a much higher dropout rate (Mclean et al., 2001)  REBT was proven equally effective as ERP (Emmelkamp et al., 1988; Van Oppen et al., 1995)  It is difficult to ascertain superiority of either intervention, however, a combination of ERP & CBT appears to be the most effective therapy (Abramowitz, 1997; Franklin et al., 2002) 18

Yogic Meditation and Relaxation Techniques  Unilateral forced nostril breathing (UFNB) (Werntz et al., 1983)  Progressive muscle relaxation is done in graduated steps during which targeted muscle groups are tensed and relaxed (Abramowitz, 1997)  There is no scientific evidence to support the value of these approaches to recovery from anxiety disorders (NIMH, 2007) 19

Group Therapy  Enright (1991) used nine weekly 90-minute group sessions. However, only 17% made clinically significant improvement after six months.  Krone et al. (1991) used a 7-week group program of ERP & CBT. 43% improved after six months.  Fals-Stewart et al. (1993) used ERP, imagery, & relaxation. The control group (BT) only improved depressive symptoms. The experimental group improved in OCD and anxiety symptoms as well. 20

Family Therapy  OCD patients showed more improvement when spouses participated (Hafner, 1982)  Patients in FT showed more improvement compared to individually treated patients (Mehta, 1990)  OCD patients in FT showed a 45% decrease in symptoms (Thornicroft et al., 1991)  Family members need the skills to cope with emotions & stress of dealing with OCD behavior (Cooper, 1996) 21

Play Therapy  Play therapy can facilitate self-expression in children (Hafner et al., 1981)  Through play therapy, children can develop an increased tolerance for perceived imperfections (Gold-Steinberg & Logan, 1999)  Play therapy offers a format for understanding children's concerns about their anxiety and provides opportunities for mastery of ERP techniques (Lewin et al., 2005) 22

Support Groups  OCD support groups can be a vehicle for decreasing social isolation caused by OCD (OCF, 2007)  Sessions focus on a particular topics, such as perfectionism, taking risks, managing the side- effects of medications, and the role of family members in supporting recovery (OCA, 2007)  Internet support group and annual conferences also play a significant role in the alleviation of symptoms and recovery from OCD symptoms (OCF, 2007) 23

As Good As It Gets 24

Conclusions  Relapse rates for patients with OCD can be as high as 90% with medication alone (Christensen et al., 1987)  Combining medication with ERP can reduce OCD symptoms by 50% (Franklin et al., 2000)  The rate increases to 69% when the OCD patient receives CBT and family therapy (Franklin et al., 2002)  Research shows that participants of support groups display as much as 90% improvement (OCF, 2007) 25

Recommendations After reviewing the current literature, it is recommended that a multi-therapeutic treatment including pharmacotherapy, individual cognitive- behavior therapy, group behavioral therapy, family therapy (including play therapy for patients that are young children), and participation in OCD support groups all be utilized to maximize the opportunity for recovery from severe OCD symptoms. Other treatments such as yogic meditation and relaxation techniques are also recognized for their success in alleviating the severity of OCD symptoms. 26

Internet Resources  http://www.childdevelopmentinfo.com/disorders/child_OCD.htm  http://www.surgeongeneral.gov/library/mentalhealth/home.html  http://www3.who.int/icd/vol1htm2003/fr-icd.htm  http://clinicaltrials.gov/ct/gui/c/a2b/show/NCT00035412?order=86&JServS  http://www.nimh.nih.gov/healthinformation/ocdmenu.cfm  http://ocdamembers.aol.com/west24th  http://www.ocdla.com/  http://www.ocdhotline.com/_wsn/page2.html  http://www.ocfoundation.org/  http://www.ocdhope.com/  http://www.ocd-world.org.uk/  http://www.socialanxietyassist.com.au/famous_people.shtml  http://en.wikipedia.org/wiki/Obsessive-compulsive_disorder 27

Obsessive-Compulsive Disorder

by James Whittenberg II on Jul 18, 2009

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Obsessive-Compulsive Disorder — Presentation Transcript