Cognitive Behavior Therapy for Obsessions and Compulsions: New Applications and Emerging Trends

This paper describes recent developments in the cognitive behavioral treatment (CBT) of obsessive compulsive disorder (OCD). Although behavioral treatment of OCD consisting of exposure and response prevention (ERP) has been shown to be clinically effective, certain limitations with ERP have led clinical researchers to propose that treatment should be augmented with direct cognitive interventions. Modification of dysfunctional beliefs and faulty appraisals or interpretations of the obsession are now considered a crucial component of CBT for obsessions and compulsions. This paper discusses the conceptual basis of the new CBT for OCD and reviews its limited empirical status. A case example is provided in which CBT is used to treat obsessional ruminations of becoming sick. The article concludes with a discussion of the challenges and pitfalls involved in offering CBT for obsessions and compulsions.     

Integrating Religion and Spirituality Into Treatment for Late-Life Anxiety: Three Case Studies

Generalized anxiety disorder (GAD) is common in older adults and, although cognitive behavioral therapy (CBT) is an efficacious treatment for late-life GAD, effect sizes are only moderate and attrition rates are high. One way to increase treatment acceptability and enhance current cognitive behavioral treatments for GAD in older adults might be to incorporate religion/spirituality (R/S). The cases presented here illustrate the use of a 12-week modular CBT intervention for late-life anxiety, designed to allow incorporation of R/S elements in accordance with patient preferences. The three women treated using this protocol chose different levels and methods of R/S integration into therapy. All three women showed substantial improvement in worry symptoms, as well as a variety of secondary outcomes following treatment; these gains were maintained at 6-month follow-up. These preliminary results suggest that the incorporation of R/S into CBT might be beneficial for older adults with GAD. Strengths, limitations, and future directions are discussed.     

What Drives OCD Symptom Change During CBT Treatment? Temporal Relationships Among Obsessions and Compulsions

Cognitive behavior therapy (CBT) is an effective treatment for obsessive-compulsive disorder (OCD). However, less is known about how obsessions and compulsions change during treatment, either in tandem, sequentially, or independently. The current study used latent difference score analysis to show path-analytic dynamic modeling of OCD symptom change during CBT. Four competing models of the temporal relationship between obsessions and compulsions were examined: no coupling (obsessions and compulsions are not dynamically related), goal directed (obsessions lead to subsequent changes in compulsions), habit driven (compulsions lead to subsequent changes in obsessions), and reciprocal. Treatment seeking participants (N = 84) with a principal diagnosis of OCD completed 12 weeks of CBT group therapy and completed measures assessing obsession and compulsion severity at pretreatment, Sessions 4 and 8, and end of treatment. Bivariate results supported the goal directed traditional CBT model, where obsession scores are temporally associated with subsequent changes in compulsion scores. These results have implications for theoretical and treatment modelling of obsessions and compulsions in OCD treatment.     

Anxiety Disorders in Late Life: Considerations for Assessment and Cognitive-Behavioral Treatment

Anxiety disorders are among the most frequently diagnosed mental disorders in late life. As older adults comprise a growing segment of the population, evidence-based treatments for anxiety disorders in late life have come into sharper focus. Cognitive-behavioral therapy (CBT) for anxiety disorders in late life has received less empirical attention and widespread dissemination relative to other age groups. Increasing older adults’ access to timely assessment and effective treatment can help reduce the personal and societal costs of anxiety disorders. The purpose of this review paper is to discuss important considerations for the assessment of anxiety disorders in older adults and offer adaptations to CBT treatment for this population. As part of assessment considerations, we discuss how physical health conditions, cognitive impairment, and functional limitations can impact anxiety disorder diagnoses with older adults. We also outline validated self-report measures of anxiety disorder symptoms for older adults and highlight the importance of assessing older adults’ suitability for CBT. Several recommendations for adapting CBT protocols for older adults with anxiety disorders are described, such as extending psychoeducation, altered treatment pacing, use of content aids, and medical contraindications for interoceptive exposure. A case study is included that illustrates helpful assessment and treatment adaptions for an older woman with panic disorder. We highlight the pressing need to increase research and dissemination of CBT for anxiety disorders for older adults to meet the needs of an increasing segment of the population worldwide.     

The Treatment of Mental Contamination: A Case Series

The recommended treatment for obsessive-compulsive disorder (OCD) is cognitive behavior therapy (CBT) incorporating exposure and response prevention (ERP), which is effective for approximately 50% of patients. However, there has been little advance in treatment outcomes since the introduction of ERP in 1979. It has been suggested that some progress can be made in treating contamination obsessions and washing compulsions by addressing feelings of dirtiness and contamination that arise without physical contact with a tangible contaminant. To date, the treatment of these “mental contamination” fears in OCD has not been systematically explored. This paper reports on a case series of 12 participants with OCD who received 10 to 20 sessions of a CBT-based treatment for mental contamination. At the end of treatment, 7 participants no longer met the diagnostic criteria for OCD and mental contamination and these gains were maintained at 6-month follow-up. The clinical implications of these findings are discussed.     

Successful and Unsuccessful Treatment of Obsessive-Compulsive Disorder in Older Adults

Obsessive compulsive disorder (OCD) is a condition that was once thought to rarely occur in older adults. Subsequently, treatment of OCD in the elderly has received very limited attention. However, recent epidemiological studies have highlighted the prevalence of this disorder in late life and, thus, focus has turned to comprehensive treatment for this population. This article describes two older adults who received intensive, cognitive behavioral treatment in an inpatient setting. Treatment modifications incorporating age-specific concerns are discussed, as are potential factors influencing treatment success versus symptom relapse.     

Patient utilization of cognitive-behavioral therapy for OCD

The current study examined utilization of cognitive-behavioral therapy (CBT) by individuals receiving treatment for obsessive-compulsive disorder (OCD). Participants were 202 adults with primary DSM-IV OCD who enrolled in a longitudinal, observational study of the course of OCD and completed 2 years of annual follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. One hundred twenty participants reported that a mental health professional recommended CBT for their OCD symptoms at some point during the 2-year follow-up period. One quarter (n = 31) of these participants did not initiate CBT despite receiving a treatment recommendation. Thirty-one percent of the 89 participants who entered CBT endorsed dropping out of CBT prematurely and less than one third received an adequate “dose” of CBT sessions. Self-reported CBT drop-out rates were significantly greater than attrition rates reported in clinical trials using intensive schedules of exposure and ritual prevention (EX/RP). Perceived environmental barriers and fears regarding treatment participation were the most frequently endorsed reasons for not participating or dropping out of CBT. Despite its efficacy for OCD, many individuals with clinically significant symptoms fail to initiate CBT when recommended by a mental health professional, receive treatments that are less intensive than those used in clinical trials, or drop out of treatment prematurely. Financial costs of CBT, difficulty attending sessions, and fears regarding treatment are significant barriers to initiating and completing therapy.     

Predicting Treatment Response in Older Adults with Insomnia

This study examined potential predictors of treatment outcome in late-life insomnia. Fifty-four older adults with chronic insomnia were treated with cognitive–behavior therapy (CBT), pharmacotherapy (PCT), or combined CBT plus PCT. Pretreatment characteristics such as demographic, clinical, psychometric, and sleep variables were examined as correlates or potential predictors of treatment response. Treatment response was defined by posttreatment sleep efficiency as measured subjectively by daily sleep diary and objectively by polysomnography. The results indicate that age, insomnia duration, medical illness, and previous use of sleep medications can moderate subjective or objective treatment outcome or both of these in late-life insomnia. However, there are no reliable predictors of outcome across all treatment and assessment modalities. The implications of these findings for the treatment of insomnia in older adults seen in primary care settings are discussed.     

The role of executive functioning in CBT: a pilot study with anxious older adults

Cognitive behavior therapy (CBT) is an effective treatment for late life anxiety and depression. The successful use of CBT is assumed to rely on cognitive skills known as executive functions (EF; e.g., hypothesis generation, allocation of attention, self-monitoring) governed by the prefrontal cortex. Because older adults sometimes have executive deficits as a consequence of normal aging, EF may be a mediator of CBT outcome in older samples. The current pilot study tested the hypothesis that older adults with executive deficits (as measured by neuropsychological tests) would show decreased therapeutic benefit from CBT for generalized anxiety disorder, as compared to a group with intact EF. Results indicated differential response to CBT within the dysfunction group depending on the stability (and possibly, the etiology) of executive deficits from pre- to posttreatment. Those whose EF scores remained low from pre- to posttreatment did not respond to CBT, while those whose scores improved responded quite well, similar to an Intact EF group. Results indicate that some, but not all, older adults with executive dysfunction show decreased benefit from CBT, and are consistent with the assumption that executive skills are important for the successful use of CBT. However, some participants may show improvement on both mood and cognitive skills during treatment, which is discussed further.     

Associations between miscellaneous symptoms and symptom dimensions: an examination of pediatric obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) in children and adults is a heterogeneous disorder associated with significant psychosocial impairment. Although factor analytic studies have identified symptom dimensions, these analyses do not capture the varied miscellaneous symptoms that fail to load on a specific dimension despite being functionally related. The present study sought to extend the findings of previous research in adults to a sample of youth with OCD (n=131). Logistic regression analyses were used to examine the predictive value of each of the four symptom factors (contamination symptoms, obsessions and checking, symmetry and ordering, and hoarding) to the miscellaneous OCD symptoms. The vast majority of miscellaneous symptoms (17 of the 18 symptoms) were associated with one or more symptoms factors (i.e., contamination symptoms, obsessions and checking, symmetry, and ordering). Hoarding was not related to any miscellaneous symptom. In addition to improving our understanding about the clinical presentation of pediatric OCD, findings also have important assessment (e.g., understanding which miscellaneous symptoms relate to certain dimensions) and treatment implications (e.g., hierarchy development).     

Evidence-based psychological treatments for late-life anxiety

This project identified evidence-based psychotherapy treatments for anxiety disorders in older adults. The authors conducted a review of the geriatric anxiety treatment outcome literature by using specific coding criteria and identified 17 studies that met criteria for evidence-based treatments (EBTs). These studies reflected samples of adults with generalized anxiety disorder (GAD) or samples with mixed anxiety disorders or symptoms. Evidence was found for efficacy for 4 types of EBTs. Relaxation training, cognitive-behavioral therapy (CBT), and, to a lesser extent, supportive therapy and cognitive therapy have support for treating subjective anxiety symptoms and disorders. CBT for late-life GAD has garnered the most consistent support, and relaxation training represents an efficacious, relatively low-cost intervention. The authors provide a review of the strengths and limitations of this research literature, including a discussion of common assessment instruments. Continued investigation of EBTs is needed in clinical geriatric anxiety samples, given the small number of available studies. Future research should examine other therapy models and investigate the effects of psychotherapy on other anxiety disorders, such as phobias and posttraumatic stress disorder in older adults.     

Translating Research for Professional Development and Effective Clinical Practice With Older Adults

This paper offers a commentary on the articles in the special series on cognitive behavior therapy with older adults (Carmin, 2012-this issue), noting the commonalities found across discussions of diagnostic interviewing and cognitive-behavioral assessment and treatment for late-life insomnia, depression and suicide risk, PTSD, and OCD. These case studies demonstrate best practices in the application of cognitive-behavioral strategies for assessment and intervention with a diverse range of older adults. Clinicians can improve the effectiveness of their work with aging clients by expanding their skills in assessment and managing interprofessional relationships in integrated health-care settings. Reflected by the papers in this series, ongoing professional development and research attention are both essential as clinicians from the mental health disciplines increase provision of CBT with older adults. Treatments for specific disorders and problems will also benefit from the growing literature on successful aging, and the application of positive psychology in our future collaborations with older adults and their care partners.     

Videoconferencing-based cognitive-behavioral therapy for obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a prevalent, chronic and disabling anxiety disorder. Despite the efficacy and strength of pharmacologic interventions for OCD, medications are not always well accepted or effective, making an efficacious psychosocial alternative especially attractive. Cognitive-behavioral therapy (CBT) has been established as an effective treatment for adult OCD, yet access to such treatment is limited, especially in rural areas. Technological advances allow for therapy to be provided in a real-time format over a videoconferencing network. This method allows therapists to provide state-of-the-art treatment to patients who would not otherwise have access to it. This paper presents three cases of OCD successfully treated via videoconferencing CBT. The presence of OCD was established via structured clinical interview and clinician-rated outcome measures were completed by evaluators blinded to the method of treatment. A multiple baseline across individuals design was used to support the internal validity of the CBT outcome data. Patient ratings of therapeutic alliance were high across all three cases. Information gathered from qualitative interviews post-treatment confirmed quantitative measures finding high levels of patient satisfaction. This pilot study suggests that videoconferencing-based CBT is a promising method to bring appropriate treatment to thousands who live far distances from well-trained therapists.     

Content difference between normal and abnormal obsessions

Although it has long been thought that experiencing an obsession is a psychiatric symptom, more recent literature, has seen the normalisation of obsessions and other presumably clinical phenomena. That is, not only people suffering from psychiatric disorders experience obsessions but non-clinical individuals also do so. Furthermore, it has been argued that such normal obsessions are very similar to abnormal ones, in terms of content. However, in the present study, evidence was obtained indicating that normal and abnormal obsessions do differ in content. A sample of 133 healthy undergraduates was given a list of 70 obsessions, with some originating from obsessive-compulsive disorder (OCD) patients, and others stemming from healthy volunteers. Participants were asked to indicate whether they had ever experienced these obsessions. Participants endorsed significantly more normal than abnormal obsessions, suggesting that the two kinds of obsessions do differ from each other. In addition, the experience of clinical obsessions was more strongly associated with scores on a measure of OCD symptoms, than was the experience of normal obsessions.     

Changes in quality of life following cognitive-behavioral therapy for obsessive-compulsive disorder

Cognitive-behavioral therapy (CBT) incorporating exposure and response prevention is a first line treatment for obsessive-compulsive disorder (OCD). Although, the efficacy of CBT in reducing OCD symptoms is well documented, less is known about its effects on quality of life (QOL). In the current study, functional impairment aspects of QOL (as measured by the Sheehan Disability Scale) were assessed among 70 adult outpatients with OCD before and after CBT. Statistically significant improvements in QOL and large pre- to post-treatment effect sizes were observed for work, social, and family functioning. Improvements in social and family functioning were predicted by improvements in OCD symptom severity even after controlling for improvements in depressive symptoms. In addition, clinically significant change in OCD symptoms and QOL were highly related, although there was a subset of participants whose symptoms improved without corresponding improvements in QOL. These results suggest that the effects of CBT may extend beyond OCD symptom reduction to QOL.     

Cognitive-behavioral psychotherapy for pediatric obsessive-compulsive disorder

Discusses the cognitive-behavioral psychotherapy for pediatric obsessive-compulsive disorder (OCD). Over the past 15 years, cognitive-behavioral psychotherapy has emerged as the psychosocial treatment of choice for OCD across lifespan. Unlike other psychotherapies that have been applied usually unsuccessfully to OCD, cognitive-behavioral treatment (CBT) presents a logically consistent and compelling relationship between the disorder, the treatment, and the specified outcome. Nevertheless, despite a consensus that CBT is usually helpful, clinicians routinely complain that patients will not comply with behavioral treatments and parents routinely complain that clinicians are poorly trained in CBT, with the result that many if not most children and adolescents are denied access to effective psychosocial treatment. This unfortunate situation may be avoidable, given an increased understanding regarding the implementation of CBT in children and adolescents with OCD. To this end, we review the principles and the practical aspects of the cognitive-behavioral treatment of OCD in youth, move on to discuss empirical studies supporting the use of CBT in the pediatric age group, and conclude by discussing directions for future research.     

A cross-sectional investigation of autogenous and reactive obsessions and associated cognitive and symptom correlates in China

Categorizing clinical obsessions as either autogenous or reactive, a model that has been supported by several studies, may represent a parsimonious approach to characterizing individuals with obsessive-compulsive disorder (OCD). However, most published studies on autogenous and reactive obsessions have been carried out with participants in highly developed nations (e.g., United States, Australia). No studies have been carried out in less developed countries, such as China. It was hypothesized that the nature of autogenous and reactive obsessions and their correlates would generalize to China. This cross-sectional study incorporated three groups from China: a college student sample (N = 1,701), a clinical sample of patients with OCD (N = 158), and a clinical control group of patients with anxiety disorder other than OCD (N = 88). Confirmatory factor analysis provided support for the autogenous and reactive model of obsessions in a Chinese sample. The results also showed that autogenous and reactive obsessions demonstrated a pattern of associations with cognitive and symptom correlates (e.g., obsessive beliefs, traditional OCD subtype themes) that were comparable to those found in previous research. The current study supports the autogenous and reactive obsessions model of OCD and its correlates in China, providing additional evidence for the cultural invariance of the model.     

Pastoral theory and practice in the team approach to treatment of scrupulosity as a component of obsessive compulsive disorder

The statistical estimates of the prevalence of Obsessive Compulsive Disorder (OCD) in the general population have increased dramatically in recent years. "Blasphemous" obsessions and religious compulsions dominate the clinical picture of many sufferers of OCD. Freud proposed that religion might be a contributing factor for many patients with mental illness. He hedged, however, that observation--something that many of his followers have not done. Others have noted the pathoplasticity of strict religious upbringing and images of God as vindictive or otherwise harsh. Only recently--since the 1970s--has much clinical attention been focused on this disorder by the other disciplines within the mental health community. The church, however, is ahead of the curve in diagnosis and treatment of scrupulosity. It has long been a concern for pastoral counselors--particularly pre-Vatican II Roman Catholic priests. Pathological religion influences OCD and pastoral counseling, the author proposes, can contributes to recovery.     

Sex-specific clinical correlates of hoarding in obsessive-compulsive disorder

Little is known about whether the clinical correlates of hoarding behavior are different in men and women with obsessive-compulsive disorder (OCD). In the current study, we evaluated the association of hoarding with categories of obsessions and compulsions, psychiatric disorders, personality dimensions, and other clinical characteristics separately in 151 men and 358 women with OCD who were examined during the OCD Collaborative Genetics Study. We found that, among men but not women, hoarding was associated with aggressive, sexual, and religious obsessions and checking compulsions. In men, hoarding was associated with generalized anxiety disorder and tics whereas, among women, hoarding was associated with social phobia, post-traumatic stress disorder, body dysmorphic disorder, nail biting, and skin picking. In women but not men, hoarding was associated with schizotypal and dependent personality disorder dimensions, and with low conscientiousness. These findings indicate that specific clinical correlates of hoarding in OCD are different in men and women and may reflect sex-specific differences in the course, expression, and/or etiology of hoarding behavior in OCD.     

First-Line Treatment for Pediatric Obsessive–Compulsive Disorder

Pediatric obsessive–compulsive disorder (OCD) is a common psychiatric disorder that impairs children’s functioning in home, school, and community settings. Once thought to be an untreatable or treatment refractory disorder, evidence-based treatments now exist for pediatric OCD. Various psychological treatment approaches for pediatric OCD have been investigated and research supports the use of cognitive-behavioral therapy (CBT) with exposure and response prevention (E/RP) and combined CBT/E/RP with serotonin reuptake inhibitor pharmacotherapy. This paper reviews these approaches and highlights the prominent role of CBT/E/RP as a first-line treatment for pediatric OCD.