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Behavior therapy for the treatment of Obsessive-Compulsive Disorder: Theory and practice
Behavior Therapy for the Treatment of Obsessive-Compulsive Disorder: Theory and Practice William E. Minichiello, Lee Baer, and Michael A. Jenike Behavior therapy techniques for Obsessive Compulsive Disorder (OCD) have been effective in treating this difficult anxiety disorder. This review explores the theory and underlying behavioral strategies, rebuts common misconceptions about behavior therapy, and outlines the clinical management of obsessions, cleaning rituals, checking rituals, and obsessional slowness. Predictors of treatment failure and outcome research for OCD are reviewed. o 1988 by Grune & Stratton, Inc.
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F THE NEUROTIC DISORDERS, Obsessive Compulsive Disorder (OCD) must rank high on the list of the most difficult to treat. Over the years various psychological and somatic treatments have yielded results of 20% to 40% “much improved.“‘,* Behavior therapy techniques on the other hand, have yielded 60% to 70% of patients “much improved” after treatment, and improvement has been maintained at 2 to 3 years follow-up.3,4 Behavior therapy techniques produce the most significant changes in compulsive rituals of washing and checking, whereas the changes in obsessions are less predictable.3 Before proceeding to discuss the theory and the various behavioral strategies used to treat OCD patients let us first clarify some common misconceptions about behavior therapy. MISCONCEPTIONS
Substitute Symptoms
ABOUT
BEHAVIOR
THERAPY
Will Result From Behavioral Change
A frequently-heard criticism of behavior therapy is that although the target behavior may be modified, other insidious substitute symptoms may arise. This idea is a result of the Freudian hydraulic theory which predicts that an unconscious conflict must be resolved or it will express itself in other symptoms. In fact, research on behavior therapy in general, and on behavior therapy for OCD in particular, has found no evidence for substitute symptoms.4 When anxiety, depression, or adjustment in job, martial, or family relationships is examined, the results of follow-up studies show improvements in these areas. It is true, however, that unless a careful behavioral analysis is performed at the outset of treatment, one can overlook an important controlling variable, such as excessive guilt, which might result in a large number of apparently shifting checking rituals.
From the Obsessive-Compulsive Disorders Clinic, Massachusetts General Hospital, Boston. Address reprint requests to William E. Minichiello, M.D., Obsessive Compulsive Disorders Clinic and Research Unit. Psychosomatic Unit, Ambulatory Care Center, Massachusetts General Hospital, Fruit St, Boston, MA 02114. 0 1988 by Grune & Stratton, Inc. 0010-440X/88/2902/0005$03.00/0
Comprehensive
Psychiatry,
Vol. 29, No. 2 (March/April),
1gBB: pp 123-137
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It Is Dangerous to Interrupt Rituals
It has been stated that it is dangerous to interrupt a person who is actively engaged in ritualistic behavior.4 This caveat may be due to the notion that the ritual serves as a defense against the breakthrough into consciousness of an unconscious impulse with its associated anxiety. Thus, it is argued, ritual interruption may produce overwhelming anxiety, which may reach psychotic proportions. In fact, the interruption of rituals in OCD patients does not result in any increase in self-report of anxiety, in psychophysiological measure of anxiety, or in subjective report of discomfort.* Furthermore, follow-up studies after 7 years with over 150 OCD patients have revealed no lasting problems caused by the response prevention procedure.’ Thoughts Are Ignored in Behavior Therapy
Behavior therapy is sometimes accused of being overly simplistic by not dealing with the patient’s thoughts or unconscious motivations. In fact, however, a thorough behavioral analysis examines all variables which can be empirically demonstrated to have an effect on behavior.6 The trend in behavioral analysis is to evaluate the motoric, affective, physiological, and cognitive spheres of behavior. Along these lines, Rachman’ and Lang’ have proposed the three-system approach to fear. In brief, this theory states that instead of the traditional concept of fear as a unitary or “lumped” concept, there are in fact three components involved in the experience and expression of “fear”: motoric, physiological, and verbal responses, which are at best loosely correlated. The lump model of fear implicitly assumes a perfect correlation among these systems, an assumption proven untenable by much behavioral research which has indicated the often low correlation among these systems.’ This low correlation is termed “desynchrony” by Hodgson and Rachman,’ and when it persists after treatment it may predict treatment failure. Behavior Therapy Assumes That all Maladaptive Behavior Is Learned Through Simple Processes
As behavior therapy has moved from the laboratory to clincial populations, it has been forced to take into account factors other than major learning principles of operant and respondent conditioning. Among these additional factors have been individual differences in personality, genetic factors preparing individuals for ease of learning certain associations,” and the concomitant presence of psychiatric diseases such as bipolar disorder and schizophrenia, which require pharmacologic treatment. In addition, behaviors are often seen to fluctuate with the patient’s mood, as when checking rituals increase and decrease with the level of depression.” This phenomenon is consistent with Hull’s mathematical equation for learning in which a prominent term is “drive state,” thought to be a multiplicative factor in determining the strength of a given behavior at a given time.” The Use of Drugs Is Incompatible
With Behavior Therapy
Although behavior therapy first attempts to modify maladaptive behavior through the application of learning principles, without somatic intervention, there are many occasions where psychopharmacology and behavior therapy complement one another. For example, the presence of concomitant depression poses several
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problems for behavioral treatment. For one, agitated depressives do not habituate based on normally to anxiety-provoking stimuli.‘3*‘4 Thus, behavioral treatments habituation, such as exposure therapy, are not effective until the mood disorder is treated. In addition, a mood disorder can make it almost impossible for patients to comply with behavioral programs such as response prevention. In these cases adjunctive psychopharmacologic intervention is often critical for compliance with the treatment protocol, as shown by Marks et al.” with clomipramine, and Baer et al.” with lithium. The decision to treat a patient with behavior therapy or medication should not be an “either-or” decision. In our OCD clinic, patients may be treated with medications alone, behavior therapy alone, or a combination of the two as warranted by the clinical situation. All Patients Respond Equally Well to Behavior Therapy The presence of (1) schizotypal personality disorder,16 (2) overvalued ideationI (3) severe depression or mania,” (4) poor compliance,3 or (5) severe family problems3 are all poor predictors for success with behavioral treatments in OCD. Behavior therapy techniques no matter how powerful or how skillfully employed are ineffective when the above factors are present. THEORETICAL Some of the theoretical discussed below.
underpinnings
CONSIDERATIONS for the behavioral
treatment
of OCD are
Learning and Maintenance of Compulsions Marks3 has cogently argued that it is not necessary to assume that compulsive rituals are learned or conditioned, since this is ultimately an untestable hypothesis. Instead he suggests that we call the environmental event that precedes the ritual not a “conditioned stimulus,” but rather call it an “evoking stimulus.” Further, he suggests that instead of referring to the ritual as the “conditioned response,” we instead operationally identify it as the “evoked response.” As Marks points out, these definitions are not only parsimonious, but they further suggest the effective treatment procedure: break the connection between the evoking stimulus and the evoked response. Nevertheless, a general anxiety-reduction theory of the maintenance of OCD behaviors has developed, and it has implicitly or explicitly influenced most behavioral treatments. The following discussion includes only those theoretical considerations which have clear clinical applications. A complete review of theories of obsessions and compulsions can be found elsewhere.5 The predominant behavioral explanation of the maintenance of obsessive and compulsive behavior has been the two-stage learning theory of Mowrer.” According to this theory, anxiety is classically conditioned to a specific environmental event (stage l-classical conditioning). The person then engages in compulsive or ritualistic behavior in order to decrease anxiety. If the compulsion succeeds in reducing the anxiety, the compulsive behavior is reinforced and is more likely to occur again in the future (stage 2---operant conditioning). Ritualistic behavior preserves the fear response, since the person does not remain in contact with the eliciting stimulus long enough for the conditioned anxiety to habituate. In turn, the
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anxiety reduction following the ritual strengthens the compulsive behavior, producing a cycle which is difficult to break. Wolpe” proposed a modification of the anxiety-reduction hypothesis, suggesting instead that there are two classes of obsessive compulsive behavior: one anxietyincreasing, and another anxiety-decreasing. Anxiety-increasing obsessions occur automatically in response to anxiety-provoking stimulation. Anxiety-reducing compulsion occur as a reaction to the anxiety, and their performance temporarily decreases anxiety. Although the anxiety-reduction theory has been the most accepted behavioral theory of obsessive and compulsive behavior, others have been presented,” based partly on the clincial experience that some rituals actually increase anxiety. However, these are a small minority of all rituals.5 In addition, compulsive behaviors have been conceptualized as stereotyped behaviors.” However, most compulsions appear to be purposeful behaviors, rather than analogs of purposeless stereotyped behaviors as seen in animals or brain-damaged humans. The anxiety-reduction theory was tested in an experimental study of OCD patients by Rachman and Hodgson.’ Subjective measures of anxiety and physiologic measures of autonomic arousal were recorded while subjects were exposed to situations which evoked their compulsive rituals. As predicted by the two-stage theory, exposure to the stimulus resulted in an increase in both physiologic and subjective measures of anxiety. In accord with this theory, when patients were allowed to engage in ritualistic behavior, there were decreases in both measures of anxiety. However, interruption of the compulsive ritual by the experimenters did not result in the predicted increase in anxiety. These patterns hold strongest for patients with washing or cleaning rituals. On the other hand, patients with checking rituals showed smaller increase in anxiety when presented with the evoking situation. Furthermore, engaging in the compulsive rituals produced less reduction in the elicited anxiety of the checkers, and in seven of 36 trials, it was found that engaging in the checking rituals actually increased anxiety, a phenomenon not seen in any of the cleaners. In checkers, changes in anxiety were reflected only on subjective reports, but no significant changes were noted in pulse rate variability, a measure of autonomic arousal.5 Rachman and Hodgson’ summarized their revised theory of obsessions and compulsions and their respective effects on anxiety. “Obsessions and compulsions can (1) reduce anxiety/discomfort or (2) increase anxiety/discomfort or (3) leave anxiety/discomfort unchanged. Compulsive cleaning rituals most often follow the type 1 pattern (ie they reduce discomfort), and checking rituals follow either the first or the second pattern” (p. 166).*
Patients suffering with obsessions but with no compulsive behaviors have been largely ignored both in behavioral theory and practice. It is typically assumed that the obsessive thoughts, images, and urges are subject to operant and classical conditioning just as motoric compulsions, and so are treated in similar ways. AS we will see, the literature is unclear concerning the usefulness of behavioral techniques for such patients. OUTCOME
RESEARCH
Early applications of behavior therapy techniques to OCD were no more effective than other psychotherapies. This was due to the early reliance on imaginal
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techniques for desensitization.’ When these techniques were modified in the early 1970s to emphasize desensitization in real life (in vivo), the success rates of the treatments surpassed those of other psychological or somatic treatments. Exposure and Response Prevention
There have now been more than ten controlled and uncontrolled outcome studies of behavior therapy for OCD over the past 15 years, involving more than 200 patients in various countires.2’3’5The treatment protocol is almost without exception comprised of exposure to the feared situation and response prevention, a procedure in which the patient is prevented from carrying out the ritualistic behavior. These studies have examined only OCD patients exhibiting ritualistic behavior, almost always of the checking or cleaning variety. Patients with only obsessive thoughts, without ritualistic activity, have been studied separately and results have been unpredictable.3 In general, these studies have found that 60% to 70% of patients with compulsive rituals were much improved after behavioral treatment. Approximately 20% to 30% of the patients were found to be treatment resistant, while the dropout rate averaged 20%~~Treatment was carried out over a relatively short period, averaging 3 to 7 weeks, with a ten-session treatment program most common. At follow-ups of 2 years or more, improvements in rituals were maintained in almost all of the patients.3 Early studies were done with hospitalized patients” whereas more recent studies have looked at outpatients. Outpatient studies frequently involved home treatment which appears to be necessary for adequate generalization of treatment gains.5 Although obsessive and compulsive symptoms are usually greatly reduced with behavioral treatment, and interference with occupational and social functioning is reduced, the ritualistic behavior is rarely totally eliminated.3 Outcome studies have differed in their relative emphasis on the various components of the treatment. Meyer et al.” have stressed the importance of strictly enforced response prevention while Rachman et al.’ have emphasized exposure, and the addition of participant modeling (ie, the therapist modeling the desired behavior for the patient). In general, results indicate that the effects of the treatment combination of exposure and response prevention are quite robust across studies, producing comparable results despite various modifications in the procedures. Commenting on the many studies comparing the importance of various components of the treatment package, Rachman and Hodgson’ have summarized the current situation: “The most striking outcome of these comparison studies is that so few significant differences have emerged” (p. 34 1). Several early studies by Rachman et a1.20controlled for the effects of exposure therapy by also including a relaxation-training group as a control for therapist exposure and nonspecific factors. Results indicated that relaxation reduced the anxiety and depression ratings of the OCD patients but did nothing to reduce rituals, thus providing evidence of the specific effects of exposure therapy. Foa, Steketee, and Milby2’ have shed some light on the relative contributions of the components of the treatment package. They found that the exposure and response prevention components produced differential effects in the treatment of compulsive washers. Exposure therapy was found to help mainly in reducing the anxiety component, while response prevention had its greatest effect in reducing the ritualistic washing. Further, it was found that the combined treatment was more
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effective than either component in isolation. They also provide evidence that in the treatment of checking rituals, a combination of imaginal exposure (i.e., having the patient vividly imagine the most feared consequences of not ritualizing) plus response prevention is superior to response prevention alone. This may occur because the catastrophic consequences many checkers fear will never actually occur in real life, so that habituation must be carried out in imagination.” Cognitive Treatments
The use of cognitive techniques in the treatment of obsessions and compulsions has been less predictable than exposure plus response prevention.3 Although the technique of Thought-Stopping is widely used to treat obsessive thoughts, clear empirical support for its usefulness remains lacking. A controlled trial of taperecorded Thought-Stopping in obsessives yielded negative results.” Two other uncontrolled trials of Thought-Stopping on less severely disturbed populations have produced positive results,23~24while several other uncontrolled trials have yielded variable results.3 Because OCD patients commit obvious cognitive errors in inference and in assessing the probability of danger, the application of cognitive therapy techniques to directly change these cognitive processes has been attempted. Emmelkamp et a1.25compared the effects of a congnitive-therapy technique of self-instructions or self-statements added to exposure in vivo v in vivo exposure alone. Both groups improved equally. Thus, cognitive therapy technique did not add significantly to the therapeutic effects of exposure in vivo. The negative finding of Emmelkamp et al.” is consistent with studies of other disorders treated with cognitive therapy and other behavioral techniques: cognitive techniques do not add significantly to the results obtained with behavioral techniques alone.6 Treatment Failures
Outcome studies have shown that poor compliance with the treatment program is the most common reason for treatment failure with behavior therapy for OCD.3 Also, patients who are severely depressed appear not to habituate to the feared situation despite prolonged in vivo exposure.14 Patients who strongly hold the belief that their compulsive rituals are necessary to forestall future catastrophies (i.e., “overvalued ideas”) also have a poorer outcome.i4 Recently, Minichiello et a1.16 have found that patients meeting criteria for Schizotypal Personality Disorder (SPD) do not respond well to behavioral treatment of OCD. The literature on behavioral treatment of Checking versus cleaning rituals. OCD indicates that another factor related to success/failure seems to be whether patients have rituals of the checking or cleaning type. Rachman and Hodgson have hypothesized that the presence of checking compulsions may in some instances be a poor prognostic indicator.’ Although few reports of behavioral treatment of OCD specify the acutal number of checkers v washers who were treated, a review of this literature indicates that in at least some studies, a disproportionate number of treatment failures were compulsive checkers. For example, in discussing treatment failures, Rachman et a1.20reported that five of the seven had checking compulsions. In addition, Foa and Goldstein26 found that checkers appeared to respond to treatment more slowly than
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do cleaners. Rachman and Hodgson’ later noted that many checkers are unable to engage in the prescribed response prevention, especially those who engage in excessive checking when alone at home. Foa et al.,*’ in a study solely of checkers treated with exposure and response prevention, found that many of them relapsed between the end of treatment and 6 month follow-up. Patients with checking rituals required an additional form of treatment, “imaginal flooding” or “imaginal exposure,” in which the patients were helped to imagine the catastrophic results they feared would occur if they did not engage in the ritualistic checking. As an example, a patient with a fear of dropping his baby on concrete was asked to imagine throwing the baby down on concrete and being arrested and tried for murder. Strictly speaking, imaginal flooding is often not a simple habituation procedure like exposure in vivo, since the situations imagined are frequently catastrophies which will never occur in real life. As a result, this procedure may have more in common with paradoxical procedures as used in other forms of therapy, where patients are asked to imagine a situation which is greatlty exaggerated. Schizotypal personality disorder. Over the past two years, the authors have evaluated for behavior therapy 29 patients with OCD. After treating these patients with standard behavior therapy techniques and some with concomitant antidepressant medication, we independently noticed that a certain proportion of our patients were not responding to the standard behavioral treatment. It did not appear that they were merely resistant to treatment, but some seemed to “defy the laws of learning.” We noticed that ten of these 29 OCD patients (35%) met DSM-III criteria for SPD in addition to criteria for OCD. They did not meet criteria for schizophrenia, although many of them had been diagnosed as such in the past, and had been treated ineffectively with neuroleptics.” We retrospecitvely reviewed the treatment outcome of the OCD patients treated with behavior threrapy either alone or in combination with medication, and also determined which of them met DSM-III criteria for SPD. We found that 84% of OCD patients, without SPD, and only 10% of those with SPD achieved at least moderate improvement in their OCD symptoms with combined behavioral and pharmacologic treatment.16 Patients with concomitant SPD and OCD had a distribution of obsessions and compulsions statistically indistinguishable from non-SPD OCD patients: In the concomitant SPD and OCD patients, 30% were pure obsessionals, 25% had checking rituals predominating, 25% had washing rituals predominating, and 20% had mixed checking and washing rituals, a distribution not significantly different from our non-SPD patients. The concept of the schizotypal personality as a poor prognostic indicator in OCD appears to have validity in light of the literature on treatment failure. This personality disorder encompasses several of the poor predictive factors reviewed earlier. Most noticeably, these patients strongly believe their rituals are necessary or some terrible event will occur. They frequently have difficulty complying with prescribed treatment and with assigned record-keeping tasks. Rachman and Hodgson’ have similarly found that the presence of an “abnormal personality” is a negative outcome predictor of behavior therapy for OCD. Our clinical impression is that the poor outcome of these patients is not solely the result of resistance to the treatment. Instead it appears that the overvalued ideas of
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these patients make it difficult for them to comply with treatment. In addition, support and involvement in treatment by family members is helpful in overcoming this disorder, but SPD patients typically have poor social relations and chaotic family situations. The concept of concomitant schizotypal personality disorder in OCD may help clarify the complex relationship between schizophrenia and OCD. As noted earlier, many OCD patients have previously been diagnosed as schizophrenic.27-29 In addition, Rasmussen and Tsuang* reviewed studies estimating that 1% to 10% of OCD patients subsequently develop schizophrenia. Based on findings of a high prevalence of SPD in OCD patients (32%), it is possible that further research will indicate that OCD patients who subsequently develop schizophrenia may come from this subgroup of OCD patients. Combined Behavior Therapy and Antidepressant Medication
The use of antidepressants concomitantly with behavior therapy may increase patients’ compliance with exposure treatments. In a study of in vivo exposure and clomipramine, Marks et al.” found that: “Clomipramine significantly improved compliance with both relaxation and exposure, possibly by means of improved mood” (p. 22). This result is consistent with our clinical experience. We have found that the addition of antidepressant medications can significantly facilitate the process of exposure therapy. CLINICAL MANAGEMENT
This section describes the behavioral treatment of OCD as it is applied in our OCD clinic. In this presentation, some of the differences in applying these procedures in clinical v research work will become apparent. An expanded discussion of these issues is found elsewhere.30 Several of the controlled studies of behavior therapy for OCD have been conducted in inpatient settings, with resultant greater control over the patients’ environment. In actual practice this is not possible for most clinicians. The following are used with OCD patients who are seen in outpatient settings. Behavioral Analysis
The first step in the treatment of OCD, as in any other behavioral treatment, is to perform a careful behavioral analysis. A behavioral analysis differs from traditional psychiatric or psychological assessment in that the aim is to isolate the target behaviors and to determine the functional relationship between target behaviors and environmental events. Little or no time is spent assessing theoretical constructs such as unconscious conflicts, or early life history except for details directly relevant to the maintenance of problem behaviors. The first step in the behavioral analysis is to identify the ritualistic behaviors. They may include one or more of the following: (a) obsessive thoughts, (b) cognitive rituals (e.g., safe numbers, prayers, formulae), (c) washing and cleaning, (d) checking or seeking reassurance for an action, (e) repeating an action, (f) ordering objects, and (g) compulsive slowness. Questioning is directed toward determining whether or not the behavior occurs only in the home, only away from the home or in both environments. Rachman and
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Hodgson’ have found that many rituals and obsessions are triggered only in the home. This appears to be especially true among patients with checking rituals, since patients feel greatest responsibility for their actions at home. Other assessment questions include: are there times when the patient is completely free of rituals or obsessions? Are there times when rituals are reduced in intensity or frequency? Does the presence or absence of others have an effect on the frequency or intensity of the rituals? In addition to identifying target rituals, the therapist needs to inquire about all objects or situations which the patient avoids in order to avoid engaging in rituals. Once specific rituals are identified and avoidance patterns are established, the focus of questioning moves to the identification of all objects or situations which trigger rituals of washing, checking, cleaning, repeating, or showers. For example: dirt, urine, feces, pesticides which trigger washing rituals; switching off a light, checking a door or viewing an electrical plug in a socket which trigger checking rituals. When all external objects or situations which trigger rituals are identified, the interview moves to the identification of all thoughts, images, or impulses which trigger ritualistic behavior. Examples include: “bad” numbers, sacreligious images, and catastrophic thoughts. It is important at this point to extract information about what patients believe will happen to them if they come in contact with the external objects or situations which trigger their rituals. Also important is the identification of what the patients believe will happen to them if they recite “bad” numbers or have sacreligious images. An assessment is made of the strength of the patients’ belief that catastrophic events will actually happen to them or their loved ones if they fail to engage in ritualistic behaviors. Also important is an assessment of the patient’s level of depression and anxiety. Finally, we determine whether the patient satisfies the DSM-III criteria for schizotypal, or other, personality disorders. Severe depression, overvalued ideation,14 and SPD16 have been identified as poor predictors of response to behavioral treatment. If the patient is found to be severely depressed or suffering from bipolar disorder he or she will be given a trial of medication. We have found that patients with severe depression have responded well to behavior therapy procedures only after their depression was controlled with medication. In addition, we have reported two patients with concomitant bipolar disorder and OCD who did not respond to behavioral treatment until their affective disorder was controlled pharmacologically.” If the patient meets criteria for SPD, we frequently attempt to arrange for the patient to be placed in a structured environment such as a day treatment center or halfway house during and after behavioral treatment. For these patients, exposure and response prevention work very slowly and unpredictably.16*29 During the behavioral analysis, we also determine whether the patient’s rituals are reinforced by family members. If this is the case, then the family members must be instructed to refrain from engaging in vicarious checking or providing reassurance in response to the patient’s frequent requests or engaging in avoidance behaviors that strengthen the patient’s rituals, if the patient is to be maximally assisted in overcoming his OCD. Patients are uncanny in getting family members to
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reinforce their rituals. As an illustration, the family members of one ritualistic washer would enter their home through a cellar entrance, strip of all “contaminated” clothing, and dress in uncontaminated clothes, before being allowed to enter the patient’s living quarters. Treatment Planning
We have found it essential to explain the rationale and the procedure of exposure therapy and response prevention to the patient in detail prior to initiating these procedures. By definition these procedures cause discomfort and the patient must understand this and be willing to accept some discomfort before treatment can commence. It is also helpful to explain to patients that their rituals, their thoughts, and their emotions may well respond to treatment at different speeds. We explain to patients that the easiest and quickest changes usually come in the rituals themselves: as they engage in response prevention the rituals are stopped very rapidly. However, it is explained that thoughts and emotional arousal will take longer to change or “wear out.” It is also explained that individuals vary in the time required for diminution of their obsessive thoughts, impulses, and feelings. This information appears to increase the patient’s motivation and compliance. If the ritualistic behaviors occur only at home, it is essential that a family member or a friend assist with the exposure and response prevention. In some cases, the therapist must make a home visit. If the target behavior occurs only at home, then exposure therapy and response prevention carried out solely in the clinic will be useless. After we determine the specific situations which trigger rituals and the situations which are avoided, they are then ranked from least to most troublesome, forming a hierarchy of target situations which will form the goals of behavioral treatment. Each situation is ranked by the degree of anxiety or discomfort it produces using a loo-point scaleI which represents the Subjective Units of Distress (SUDS) for each situation (100 SUDS = extreme anxiety and 0 SUDS = no anxiety). The patient is asked to rate each target situation based on the amount of anxiety it produces; after the situations are ranked from lowest to highest SUDS ratings, exposure therapy proceeds upward on the scale, beginning with the lowest-rated item. Treatment of obsessions alone. The actual process of treatment will differ depending upon the topography of the target behaviors. For a patient with obsessive, thoughts, without any compulsive rituals, the target behaviors are the thoughts themselves. In some cases the therapist may find that the thoughts are reliably and exclusively triggered by discrete emotional states such as anger, anxiety, or guilt. In these cases procedures designed to decrease these drive states, such as assertiveness training or relaxation training can be useful. In assertiveness training, the patient is taught to express both negative and positive emotions in a socially appropriate way. This technique typically includes instruction, therapist modeling, role-playing, and feedback of the patient’s performance. Our clinical procedure with patients who present with obsessive thoughts only has been to refer them first for a trial of antidepressant medication. Several of our patients with severe obsessive thoughts have responded completely to antidepressants.3’ We also use, as an adjunct, the technique of Thought Stopping. We follow this course of action because the literature on behavioral treatment of pure
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obsessions is generally unconvincing or at best unpredictable, and because we have achieved moderate success with this method. Thought Stopping is sometimes effective and requires only about I5 minutes to teach. The method of teaching Thought Stopping is summarized by Rimm and Masters3*: “The basic technique is extremely straightforward. The client is asked to concentrate on the anxiety-inducing thoughts, and, after a short period of time, the therapist suddenly and emphatically says “stop” (any loud noise or even mild pain administered by snapping a rubber band at the wrist may also suffice), the locus of control is gradually shifted from the therapist to the client. Specifically, the client is taught to emit a subvocal ‘stop’ whenever he or she begins to engage in a self-defeating
rumination”
(p. 430).
We teach Thought Stopping to the patient as a self-control procedure to be used at the onset of an obsessive thought rather than as a habituation technique. As a habituation procedure it was found ineffective in a controlled trial by Stern, Lipsedge, and Marks.** Occasionally, Thought Stopping by itself is effective. In one case, a patient we saw with a longstanding obsession about cancer reported elimination of these thoughts after two sessions with Thought Stopping. It is such intermittent clinical reinforcement that maintains our use of this unproven procedure. We rarely use cognitive techniques such as cognitive restructuring with these patients, because of the lack of evidence of their effectiveness in treating OCD.25 For patients with predominantly washing or cleaning rituals, Cleaning rituals. with none of the aforementioned poor predictors of success, the treatment is usually relatively straightforward. In many respects, the treatment is similar to the behavioral treatment of simple phobics with exposure and prevention of escape. Rachman and Hodgsot? have noted the great similarity between washers and phobics in their physiological reaction to the feared situation, and in their passive avoidance of the object. That is, they both attempt to avoid the feared situations at all costs. Treatment sessions are generally one hour in length and involve engaging the patient in touching the objects he fears. Often this can be done in the clinic, as when the targets are public restrooms or common objects such as shoes or chairs. In addition, when the feared objects are in the home, but are nonetheless movable, the patient or family member can bring items from home into the session. We have had patients bring in objects such as mothballs, dirty clothing, and trash to facilitate in vivo exposure during the session. Typically the therapist will first touch the object to demonstrate the procedure to the patient. This process has been termed “participant modeling” and has been shown to enhance the effects of exposure and response prevention, probably by increasing the patient’s motivation4 After the patient touches the object, he or she is told not to wipe or wash his or her hands for the remainder of the session. No physical force is necessary. In our experience, despite their fears to the contrary, all patients are able to refrain from performing the cleaning ritual during the therapy session. During the time of response prevention, the patient is reminded that it is natural for urges to wash and feelings of contamination to continue for a while, but that these will slowly decrease over time. The patient is given the homework assignment of engaging in the same types of
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activities daily during the week until the next session, and of refraining from engagement in the cleaning ritual for at least one hour after the exposure. If possible, a relative or friend is asked to attend one of the early sessions and is explained the theory and procedure. The relative or friend is then asked to act as the proxy of the therapist during practice sessions at home. If cleaning occurs only in the home, then therapy should begin in the home, with either the therapist or a friend or family member supervising assignments. If a relative/friend participates, the assignments to be performed are determined and negotiated in the therapist’s office with the patient, relative/friend and therapist present. Checking rituals. For patients with checking rituals, the procedure is different in several respects. First, the response prevention must often be self-administered since these patients frequently check only when alone. The presence of another person can decrease the need to check because the patient assumes that the other person would take responsibility and notice if anything wrong or dangerous was done.5 Second, checking occurs largely in the home, presumably because this is the place of greatest responsibility. Therefore, the response prevention assignments that can be carried out in the office or clinic are often limited. Thirdly, generalization is often poor from the clinic session to the home. For example, the patient may be able to shut off the light switch in the treatment office without checking, but may continue to check light switches, electrical outlets, and door locks when alone at home. In some cases, the patient may engage in hundreds of checking activities per day. In these cases, the patient is often unable to enforce response prevention without assistance.5 We attempt to carry out any exposure or response prevention that is possible in the office. If for example, the patient has a fear of throwing away objects, he or she is asked to bring in trash from home and throw it away in the session without checking. If the patient is afraid to enter stores for fear of closing the door on someone behind, or afraid of handling objects in a store for fear of dropping them, the patient is accompanied into stores during the treatment hour and is requested to handle merchandise without checking. If the patient is afraid of walking past cars for fear of unknowingly damaging them, he or she is asked to accompany the therapist on a walk that takes them about 3 feet away from parked cars. As soon as the patient is able to handle this, he or she may then be asked to hold a set of keys in the hand closest to the cars. Patients who avoid driving for fear that they will run over a pedestrian and not know it, are asked to drive the therapist in their car during the session. They are encouraged and assisted in not checking the rear view mirror or turning the car around to check when passing pedestrians or other automobiles. Throughout all these activities, the patient is reminded that it is natural to have urges to check, but that the thoughts about checking will decrease over time because they are misleading signals from his/her body and should not be needed. The patient, and if possible, with the aid of an assistant is then told to practice similar activities between sessions, to keep a log of these activities, and to report back to the therapist at the next session. The patient is reminded that the speed of reduction of the rituals and urges is mainly a function of the number of repetitions without checking. The treatment of checkers is complicated by the fact that they will repeatedly
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request reassurance. They act as if they have an attention disorder. It is very common for a checker to report that he or she will continue to perform an action until “something clicks in my head and I am sure that it is right.” Our practice is to tell patients that a feeling of confidence takes many practice sessions to acquire. They are also told that each time they have given in to the urge to check over the years, they have in fact decreased the visceral and cognitive feeling of confidence that is normally learned in childhood. Despite difficulties in the treatment of checkers, our assertion is borne out for patients motivated to continue this treatment: they report that after many experiences of response prevention (sometimes hundreds) they begin to get a feeling of confidence in their actions. In difficult patients who either do not respond to behavior therapy alone, or who are unable to comply fully with the treatment, a trial of antidepressant medication has been found to be helpful. One patient who was unable to refrain from extensive checking rituals and who was too fearful to engage in exposure activities, found that after treatment with phenelzine, she was able to engage in both the exposure and response prevention, because she felt “braver,” and more sure of herself. Primary obsessional slowness. This is the rarest type of OCD, and clinically it appears most similar to checking rituals. It is characterized by the patient’s inability to proceed with routine tasks without getting “stuck,” and being unable to complete an activity. The patient is often unable to initiate tasks, or will take hours to complete a simple task. Patients suffering from primary obsessional slowness may take hours to get dressed, to move from room to room, to pick up a fork to eat, or to open a medication bottle. These patients are extremely difficult to treat without the cooperation of family members. A great deal of patience and firmness are required of both therapist and family members when interacting with the patient. Behavioral treatment consists of a shaping procedure, wherein the patient is given a specified time limit to initiate or complete a particular task. The patient must engage in the task within the allotted time, even if this means that the therapist or famiIy member forces him or her to do it. Treatment of obsessional slowness with behavioral treatment is generally time-consuming, and progress is slow. SUMMARY
OF CLINICAL
MANAGEMENT
The number of sessions required for treatment varies. We have found that some patients with cleaning rituals have responded in as few as three to five sessions, with appropriate home practice. On the other hand, we have treated patients with checking rituals who have been seen for over 50 sessions and still have some remaining rituals. The sessions are one hour in duration. Patients are instructed to engage in exposure and response prevention sessions at home for one hour per day. At the outset of treatment many patients are not able to tolerate the full time in homework assignments. Clinically, we will use whatever behavioral strategy within reason will help the patient engage in the “active treatment” of exposure and response prevention. We have found that almost all patients are willing to undergo the exposure treatment when adjunctive techniques such as Thought Stopping, self-control relaxation training, or medication are included. It appears that the addition of these techniques
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can reduce the percentage therapy.
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of patients who refuse to participate
in exposure
REFERENCES 1. Black A: The natural
history of obsessional neurosis, in Beech HR (ed): Obsessional States. London, Methuen, 1974, pp 19-54 2. Rasmussen SA, Tsuang MT: The epidemiology of obsessive compulsive disorder. J Clin Psychiatry 45:450-457, 1984 3. Marks IM: Review of behavioral psychotherapy, I: Obsessive-compulsive disorders. Am J Psychiatry 138:584-592, 1981 4. Bandura A: Principles of Behavior Modification. New York, Holt, Rinehart & Winston, 1969 5. Rachman SJ, Hodgson RJ: Obsessions and Compulsions. Englewood Cliffs, NJ, Prentice-Hall 1980 6. Latimer PR, Sweet AA: Cognitive versus behavioral procedures in cognitive-behavior therapy: A critical review of the evidence. J Behav Ther Exp Psychiatry 15:9-22, 1984 7. Rachman SJ: Fear and Courage. San Francisco, WH Freedman, 1978 8. Lang PJ: Fear reduction and fear behavior: Problems in treating a construct, in Schlien JM (ed): Research in Psychotherapy. Washington, DC, American Psychological Association, vol 3, pp 90-93, 1968 9. Hodgson RJ, Rachman S: Desynchrony in measures of fear. Behav Res Ther 12:319-326,1974 10. Seligman MEP: Phobias and preparedness. Behav Ther 2:307-320, 1971 11. Baer L, Minichiello WE, Jenike MA: Behavioral treatment in two cases of obsessive-compulsive disorder with concomitant bipolar affective disorder. Am J Psychiatry, 142:358-360, 1985 12. Deese J, Hulse SH: The Psychology of Learning. New York, McGraw-Hill, 1967 13. Lader M, Wing L: Physiological measures in agitated and retarded depressed patients. J Psychiatr Res 7:89-100, 1969 14. Foa EB: Failures in treating obsessive-compulsives. Behav Res Ther, 17:169-176, 1979 15. Marks IM, Stern RS, Mawson D, et al: Clomipramine and exposure for obsessive-compulsive rituals. Br J Psychiatry 136:1-25, 1980 16. Minichiello WE, Baer L, Jenike MA: Schizotypal personality disorder: A poor prognostic indicator for behavior therapy in the treatment of obsessive compulsive disorder. J Anxiety Disord 1:273-276, 1987 17. Wolpe J: Psychotherapy by Reciprocal Inhibition. Stanford, CA, Stanford University, 1958 18. Beech HR (ed): Obsessional States. London, Methuen, 1974 19. Sturgis ET, Meyer V: Obsessive compuslive disorders, in Turner SM, Calhoun KC, Adams HE (eds): Handbook of Clinical Behavior Therapy, New York, Wiley, 1980, pp 68-102 20. Rachman SJ, Hodgson RJ, Marks IM: The treatment of chronic obsessional neurosis. Behav Res Ther 9~237-247, 1971 21. Foa EB, Steketee G, Milby JR: Differential effects of exposure and response prevention in obsessive-compulsive washers. J Consult Clin Psychol, 48:71-79, 1980 22. Stern RS, Lipsedge MS, Marks IM: Obsessive ruminations: A controlled trial of thought-stopping technique. Behav Res Ther 11:659-622, 1973 23. Hackmann A, McClean C: A comparison of flooding and thought-stopping treatment. Behav Res Ther, 131263-269, 1975 24. Sookman D, Solyom L: The effectiveness of four behavioral therapies in the treatment of obsessional neurosis, in Boulougouris JC, Rabavilas AD (eds): The Treatment of Phobic and Obsessive Compulsive Disorders. Oxford, England, Pergamon Press, 1977 25. Emmelkamp PMG, van der Helm M, van Zanten BL, et al: I. Treatment of obsessive-compulsive patients: The contribution of self-instructional training to the effectiveness of exposure. Behav Res Ther, 18:61-66,198O 26. Foa EB, Goldstein A: Continuous exposure and strict response prevention in the treatment of obsessive-compulsive neurosis. Behav Ther, 17: 169- 176, 1978 27. Carey RJ, Baer L, Jenike MA, et al: MMPI correlates of obsessive-compulsive disorder. J Clin Psychiatry 47:371-372, 1986 28. Jenike MA, Baer L, Minichiello WE, et al: Concomitant obsessive-compulsive disorder and schizotypal personality disorder: A poor prognostic indicator. Arch Gen Psychiatry 43:296, 1986
OBSESSIVE-COMPULSIVE 29. Jenike
MA,
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Baer L, Minichiello
THERAPY
WE, et al: Concomitant
137
obsessive-disorder
and schizotypal
personality disorder. Am J Psychiatry 143530-533, 1986 30. Jenike MA, Baer L, Minichiello WE. Obsessive-Compulsive Disorder: Diagnosis and Treatment. Littleton, MA, PSG Publishing, 1986, pp 45-75, 179-190 31. Jenike MA, Armentano M, Baer L: Disabling obsessive thoughts responsive to antidepressants. J Clin Psychopharmacol7:33-35, 1987 32. Rimm DC, Masters JC: Behavior Therapy: Techniques and Empirical Findings. New York, Academic, 1974, p 430
0
F THE NEUROTIC DISORDERS, Obsessive Compulsive Disorder (OCD) must rank high on the list of the most difficult to treat. Over the years various psychological and somatic treatments have yielded results of 20% to 40% “much improved.“‘,* Behavior therapy techniques on the other hand, have yielded 60% to 70% of patients “much improved” after treatment, and improvement has been maintained at 2 to 3 years follow-up.3,4 Behavior therapy techniques produce the most significant changes in compulsive rituals of washing and checking, whereas the changes in obsessions are less predictable.3 Before proceeding to discuss the theory and the various behavioral strategies used to treat OCD patients let us first clarify some common misconceptions about behavior therapy. MISCONCEPTIONS
Substitute Symptoms
ABOUT
BEHAVIOR
THERAPY
Will Result From Behavioral Change
A frequently-heard criticism of behavior therapy is that although the target behavior may be modified, other insidious substitute symptoms may arise. This idea is a result of the Freudian hydraulic theory which predicts that an unconscious conflict must be resolved or it will express itself in other symptoms. In fact, research on behavior therapy in general, and on behavior therapy for OCD in particular, has found no evidence for substitute symptoms.4 When anxiety, depression, or adjustment in job, martial, or family relationships is examined, the results of follow-up studies show improvements in these areas. It is true, however, that unless a careful behavioral analysis is performed at the outset of treatment, one can overlook an important controlling variable, such as excessive guilt, which might result in a large number of apparently shifting checking rituals.
From the Obsessive-Compulsive Disorders Clinic, Massachusetts General Hospital, Boston. Address reprint requests to William E. Minichiello, M.D., Obsessive Compulsive Disorders Clinic and Research Unit. Psychosomatic Unit, Ambulatory Care Center, Massachusetts General Hospital, Fruit St, Boston, MA 02114. 0 1988 by Grune & Stratton, Inc. 0010-440X/88/2902/0005$03.00/0
Comprehensive
Psychiatry,
Vol. 29, No. 2 (March/April),
1gBB: pp 123-137
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It Is Dangerous to Interrupt Rituals
It has been stated that it is dangerous to interrupt a person who is actively engaged in ritualistic behavior.4 This caveat may be due to the notion that the ritual serves as a defense against the breakthrough into consciousness of an unconscious impulse with its associated anxiety. Thus, it is argued, ritual interruption may produce overwhelming anxiety, which may reach psychotic proportions. In fact, the interruption of rituals in OCD patients does not result in any increase in self-report of anxiety, in psychophysiological measure of anxiety, or in subjective report of discomfort.* Furthermore, follow-up studies after 7 years with over 150 OCD patients have revealed no lasting problems caused by the response prevention procedure.’ Thoughts Are Ignored in Behavior Therapy
Behavior therapy is sometimes accused of being overly simplistic by not dealing with the patient’s thoughts or unconscious motivations. In fact, however, a thorough behavioral analysis examines all variables which can be empirically demonstrated to have an effect on behavior.6 The trend in behavioral analysis is to evaluate the motoric, affective, physiological, and cognitive spheres of behavior. Along these lines, Rachman’ and Lang’ have proposed the three-system approach to fear. In brief, this theory states that instead of the traditional concept of fear as a unitary or “lumped” concept, there are in fact three components involved in the experience and expression of “fear”: motoric, physiological, and verbal responses, which are at best loosely correlated. The lump model of fear implicitly assumes a perfect correlation among these systems, an assumption proven untenable by much behavioral research which has indicated the often low correlation among these systems.’ This low correlation is termed “desynchrony” by Hodgson and Rachman,’ and when it persists after treatment it may predict treatment failure. Behavior Therapy Assumes That all Maladaptive Behavior Is Learned Through Simple Processes
As behavior therapy has moved from the laboratory to clincial populations, it has been forced to take into account factors other than major learning principles of operant and respondent conditioning. Among these additional factors have been individual differences in personality, genetic factors preparing individuals for ease of learning certain associations,” and the concomitant presence of psychiatric diseases such as bipolar disorder and schizophrenia, which require pharmacologic treatment. In addition, behaviors are often seen to fluctuate with the patient’s mood, as when checking rituals increase and decrease with the level of depression.” This phenomenon is consistent with Hull’s mathematical equation for learning in which a prominent term is “drive state,” thought to be a multiplicative factor in determining the strength of a given behavior at a given time.” The Use of Drugs Is Incompatible
With Behavior Therapy
Although behavior therapy first attempts to modify maladaptive behavior through the application of learning principles, without somatic intervention, there are many occasions where psychopharmacology and behavior therapy complement one another. For example, the presence of concomitant depression poses several
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problems for behavioral treatment. For one, agitated depressives do not habituate based on normally to anxiety-provoking stimuli.‘3*‘4 Thus, behavioral treatments habituation, such as exposure therapy, are not effective until the mood disorder is treated. In addition, a mood disorder can make it almost impossible for patients to comply with behavioral programs such as response prevention. In these cases adjunctive psychopharmacologic intervention is often critical for compliance with the treatment protocol, as shown by Marks et al.” with clomipramine, and Baer et al.” with lithium. The decision to treat a patient with behavior therapy or medication should not be an “either-or” decision. In our OCD clinic, patients may be treated with medications alone, behavior therapy alone, or a combination of the two as warranted by the clinical situation. All Patients Respond Equally Well to Behavior Therapy The presence of (1) schizotypal personality disorder,16 (2) overvalued ideationI (3) severe depression or mania,” (4) poor compliance,3 or (5) severe family problems3 are all poor predictors for success with behavioral treatments in OCD. Behavior therapy techniques no matter how powerful or how skillfully employed are ineffective when the above factors are present. THEORETICAL Some of the theoretical discussed below.
underpinnings
CONSIDERATIONS for the behavioral
treatment
of OCD are
Learning and Maintenance of Compulsions Marks3 has cogently argued that it is not necessary to assume that compulsive rituals are learned or conditioned, since this is ultimately an untestable hypothesis. Instead he suggests that we call the environmental event that precedes the ritual not a “conditioned stimulus,” but rather call it an “evoking stimulus.” Further, he suggests that instead of referring to the ritual as the “conditioned response,” we instead operationally identify it as the “evoked response.” As Marks points out, these definitions are not only parsimonious, but they further suggest the effective treatment procedure: break the connection between the evoking stimulus and the evoked response. Nevertheless, a general anxiety-reduction theory of the maintenance of OCD behaviors has developed, and it has implicitly or explicitly influenced most behavioral treatments. The following discussion includes only those theoretical considerations which have clear clinical applications. A complete review of theories of obsessions and compulsions can be found elsewhere.5 The predominant behavioral explanation of the maintenance of obsessive and compulsive behavior has been the two-stage learning theory of Mowrer.” According to this theory, anxiety is classically conditioned to a specific environmental event (stage l-classical conditioning). The person then engages in compulsive or ritualistic behavior in order to decrease anxiety. If the compulsion succeeds in reducing the anxiety, the compulsive behavior is reinforced and is more likely to occur again in the future (stage 2---operant conditioning). Ritualistic behavior preserves the fear response, since the person does not remain in contact with the eliciting stimulus long enough for the conditioned anxiety to habituate. In turn, the
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anxiety reduction following the ritual strengthens the compulsive behavior, producing a cycle which is difficult to break. Wolpe” proposed a modification of the anxiety-reduction hypothesis, suggesting instead that there are two classes of obsessive compulsive behavior: one anxietyincreasing, and another anxiety-decreasing. Anxiety-increasing obsessions occur automatically in response to anxiety-provoking stimulation. Anxiety-reducing compulsion occur as a reaction to the anxiety, and their performance temporarily decreases anxiety. Although the anxiety-reduction theory has been the most accepted behavioral theory of obsessive and compulsive behavior, others have been presented,” based partly on the clincial experience that some rituals actually increase anxiety. However, these are a small minority of all rituals.5 In addition, compulsive behaviors have been conceptualized as stereotyped behaviors.” However, most compulsions appear to be purposeful behaviors, rather than analogs of purposeless stereotyped behaviors as seen in animals or brain-damaged humans. The anxiety-reduction theory was tested in an experimental study of OCD patients by Rachman and Hodgson.’ Subjective measures of anxiety and physiologic measures of autonomic arousal were recorded while subjects were exposed to situations which evoked their compulsive rituals. As predicted by the two-stage theory, exposure to the stimulus resulted in an increase in both physiologic and subjective measures of anxiety. In accord with this theory, when patients were allowed to engage in ritualistic behavior, there were decreases in both measures of anxiety. However, interruption of the compulsive ritual by the experimenters did not result in the predicted increase in anxiety. These patterns hold strongest for patients with washing or cleaning rituals. On the other hand, patients with checking rituals showed smaller increase in anxiety when presented with the evoking situation. Furthermore, engaging in the compulsive rituals produced less reduction in the elicited anxiety of the checkers, and in seven of 36 trials, it was found that engaging in the checking rituals actually increased anxiety, a phenomenon not seen in any of the cleaners. In checkers, changes in anxiety were reflected only on subjective reports, but no significant changes were noted in pulse rate variability, a measure of autonomic arousal.5 Rachman and Hodgson’ summarized their revised theory of obsessions and compulsions and their respective effects on anxiety. “Obsessions and compulsions can (1) reduce anxiety/discomfort or (2) increase anxiety/discomfort or (3) leave anxiety/discomfort unchanged. Compulsive cleaning rituals most often follow the type 1 pattern (ie they reduce discomfort), and checking rituals follow either the first or the second pattern” (p. 166).*
Patients suffering with obsessions but with no compulsive behaviors have been largely ignored both in behavioral theory and practice. It is typically assumed that the obsessive thoughts, images, and urges are subject to operant and classical conditioning just as motoric compulsions, and so are treated in similar ways. AS we will see, the literature is unclear concerning the usefulness of behavioral techniques for such patients. OUTCOME
RESEARCH
Early applications of behavior therapy techniques to OCD were no more effective than other psychotherapies. This was due to the early reliance on imaginal
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techniques for desensitization.’ When these techniques were modified in the early 1970s to emphasize desensitization in real life (in vivo), the success rates of the treatments surpassed those of other psychological or somatic treatments. Exposure and Response Prevention
There have now been more than ten controlled and uncontrolled outcome studies of behavior therapy for OCD over the past 15 years, involving more than 200 patients in various countires.2’3’5The treatment protocol is almost without exception comprised of exposure to the feared situation and response prevention, a procedure in which the patient is prevented from carrying out the ritualistic behavior. These studies have examined only OCD patients exhibiting ritualistic behavior, almost always of the checking or cleaning variety. Patients with only obsessive thoughts, without ritualistic activity, have been studied separately and results have been unpredictable.3 In general, these studies have found that 60% to 70% of patients with compulsive rituals were much improved after behavioral treatment. Approximately 20% to 30% of the patients were found to be treatment resistant, while the dropout rate averaged 20%~~Treatment was carried out over a relatively short period, averaging 3 to 7 weeks, with a ten-session treatment program most common. At follow-ups of 2 years or more, improvements in rituals were maintained in almost all of the patients.3 Early studies were done with hospitalized patients” whereas more recent studies have looked at outpatients. Outpatient studies frequently involved home treatment which appears to be necessary for adequate generalization of treatment gains.5 Although obsessive and compulsive symptoms are usually greatly reduced with behavioral treatment, and interference with occupational and social functioning is reduced, the ritualistic behavior is rarely totally eliminated.3 Outcome studies have differed in their relative emphasis on the various components of the treatment. Meyer et al.” have stressed the importance of strictly enforced response prevention while Rachman et al.’ have emphasized exposure, and the addition of participant modeling (ie, the therapist modeling the desired behavior for the patient). In general, results indicate that the effects of the treatment combination of exposure and response prevention are quite robust across studies, producing comparable results despite various modifications in the procedures. Commenting on the many studies comparing the importance of various components of the treatment package, Rachman and Hodgson’ have summarized the current situation: “The most striking outcome of these comparison studies is that so few significant differences have emerged” (p. 34 1). Several early studies by Rachman et a1.20controlled for the effects of exposure therapy by also including a relaxation-training group as a control for therapist exposure and nonspecific factors. Results indicated that relaxation reduced the anxiety and depression ratings of the OCD patients but did nothing to reduce rituals, thus providing evidence of the specific effects of exposure therapy. Foa, Steketee, and Milby2’ have shed some light on the relative contributions of the components of the treatment package. They found that the exposure and response prevention components produced differential effects in the treatment of compulsive washers. Exposure therapy was found to help mainly in reducing the anxiety component, while response prevention had its greatest effect in reducing the ritualistic washing. Further, it was found that the combined treatment was more
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effective than either component in isolation. They also provide evidence that in the treatment of checking rituals, a combination of imaginal exposure (i.e., having the patient vividly imagine the most feared consequences of not ritualizing) plus response prevention is superior to response prevention alone. This may occur because the catastrophic consequences many checkers fear will never actually occur in real life, so that habituation must be carried out in imagination.” Cognitive Treatments
The use of cognitive techniques in the treatment of obsessions and compulsions has been less predictable than exposure plus response prevention.3 Although the technique of Thought-Stopping is widely used to treat obsessive thoughts, clear empirical support for its usefulness remains lacking. A controlled trial of taperecorded Thought-Stopping in obsessives yielded negative results.” Two other uncontrolled trials of Thought-Stopping on less severely disturbed populations have produced positive results,23~24while several other uncontrolled trials have yielded variable results.3 Because OCD patients commit obvious cognitive errors in inference and in assessing the probability of danger, the application of cognitive therapy techniques to directly change these cognitive processes has been attempted. Emmelkamp et a1.25compared the effects of a congnitive-therapy technique of self-instructions or self-statements added to exposure in vivo v in vivo exposure alone. Both groups improved equally. Thus, cognitive therapy technique did not add significantly to the therapeutic effects of exposure in vivo. The negative finding of Emmelkamp et al.” is consistent with studies of other disorders treated with cognitive therapy and other behavioral techniques: cognitive techniques do not add significantly to the results obtained with behavioral techniques alone.6 Treatment Failures
Outcome studies have shown that poor compliance with the treatment program is the most common reason for treatment failure with behavior therapy for OCD.3 Also, patients who are severely depressed appear not to habituate to the feared situation despite prolonged in vivo exposure.14 Patients who strongly hold the belief that their compulsive rituals are necessary to forestall future catastrophies (i.e., “overvalued ideas”) also have a poorer outcome.i4 Recently, Minichiello et a1.16 have found that patients meeting criteria for Schizotypal Personality Disorder (SPD) do not respond well to behavioral treatment of OCD. The literature on behavioral treatment of Checking versus cleaning rituals. OCD indicates that another factor related to success/failure seems to be whether patients have rituals of the checking or cleaning type. Rachman and Hodgson have hypothesized that the presence of checking compulsions may in some instances be a poor prognostic indicator.’ Although few reports of behavioral treatment of OCD specify the acutal number of checkers v washers who were treated, a review of this literature indicates that in at least some studies, a disproportionate number of treatment failures were compulsive checkers. For example, in discussing treatment failures, Rachman et a1.20reported that five of the seven had checking compulsions. In addition, Foa and Goldstein26 found that checkers appeared to respond to treatment more slowly than
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do cleaners. Rachman and Hodgson’ later noted that many checkers are unable to engage in the prescribed response prevention, especially those who engage in excessive checking when alone at home. Foa et al.,*’ in a study solely of checkers treated with exposure and response prevention, found that many of them relapsed between the end of treatment and 6 month follow-up. Patients with checking rituals required an additional form of treatment, “imaginal flooding” or “imaginal exposure,” in which the patients were helped to imagine the catastrophic results they feared would occur if they did not engage in the ritualistic checking. As an example, a patient with a fear of dropping his baby on concrete was asked to imagine throwing the baby down on concrete and being arrested and tried for murder. Strictly speaking, imaginal flooding is often not a simple habituation procedure like exposure in vivo, since the situations imagined are frequently catastrophies which will never occur in real life. As a result, this procedure may have more in common with paradoxical procedures as used in other forms of therapy, where patients are asked to imagine a situation which is greatlty exaggerated. Schizotypal personality disorder. Over the past two years, the authors have evaluated for behavior therapy 29 patients with OCD. After treating these patients with standard behavior therapy techniques and some with concomitant antidepressant medication, we independently noticed that a certain proportion of our patients were not responding to the standard behavioral treatment. It did not appear that they were merely resistant to treatment, but some seemed to “defy the laws of learning.” We noticed that ten of these 29 OCD patients (35%) met DSM-III criteria for SPD in addition to criteria for OCD. They did not meet criteria for schizophrenia, although many of them had been diagnosed as such in the past, and had been treated ineffectively with neuroleptics.” We retrospecitvely reviewed the treatment outcome of the OCD patients treated with behavior threrapy either alone or in combination with medication, and also determined which of them met DSM-III criteria for SPD. We found that 84% of OCD patients, without SPD, and only 10% of those with SPD achieved at least moderate improvement in their OCD symptoms with combined behavioral and pharmacologic treatment.16 Patients with concomitant SPD and OCD had a distribution of obsessions and compulsions statistically indistinguishable from non-SPD OCD patients: In the concomitant SPD and OCD patients, 30% were pure obsessionals, 25% had checking rituals predominating, 25% had washing rituals predominating, and 20% had mixed checking and washing rituals, a distribution not significantly different from our non-SPD patients. The concept of the schizotypal personality as a poor prognostic indicator in OCD appears to have validity in light of the literature on treatment failure. This personality disorder encompasses several of the poor predictive factors reviewed earlier. Most noticeably, these patients strongly believe their rituals are necessary or some terrible event will occur. They frequently have difficulty complying with prescribed treatment and with assigned record-keeping tasks. Rachman and Hodgson’ have similarly found that the presence of an “abnormal personality” is a negative outcome predictor of behavior therapy for OCD. Our clinical impression is that the poor outcome of these patients is not solely the result of resistance to the treatment. Instead it appears that the overvalued ideas of
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these patients make it difficult for them to comply with treatment. In addition, support and involvement in treatment by family members is helpful in overcoming this disorder, but SPD patients typically have poor social relations and chaotic family situations. The concept of concomitant schizotypal personality disorder in OCD may help clarify the complex relationship between schizophrenia and OCD. As noted earlier, many OCD patients have previously been diagnosed as schizophrenic.27-29 In addition, Rasmussen and Tsuang* reviewed studies estimating that 1% to 10% of OCD patients subsequently develop schizophrenia. Based on findings of a high prevalence of SPD in OCD patients (32%), it is possible that further research will indicate that OCD patients who subsequently develop schizophrenia may come from this subgroup of OCD patients. Combined Behavior Therapy and Antidepressant Medication
The use of antidepressants concomitantly with behavior therapy may increase patients’ compliance with exposure treatments. In a study of in vivo exposure and clomipramine, Marks et al.” found that: “Clomipramine significantly improved compliance with both relaxation and exposure, possibly by means of improved mood” (p. 22). This result is consistent with our clinical experience. We have found that the addition of antidepressant medications can significantly facilitate the process of exposure therapy. CLINICAL MANAGEMENT
This section describes the behavioral treatment of OCD as it is applied in our OCD clinic. In this presentation, some of the differences in applying these procedures in clinical v research work will become apparent. An expanded discussion of these issues is found elsewhere.30 Several of the controlled studies of behavior therapy for OCD have been conducted in inpatient settings, with resultant greater control over the patients’ environment. In actual practice this is not possible for most clinicians. The following are used with OCD patients who are seen in outpatient settings. Behavioral Analysis
The first step in the treatment of OCD, as in any other behavioral treatment, is to perform a careful behavioral analysis. A behavioral analysis differs from traditional psychiatric or psychological assessment in that the aim is to isolate the target behaviors and to determine the functional relationship between target behaviors and environmental events. Little or no time is spent assessing theoretical constructs such as unconscious conflicts, or early life history except for details directly relevant to the maintenance of problem behaviors. The first step in the behavioral analysis is to identify the ritualistic behaviors. They may include one or more of the following: (a) obsessive thoughts, (b) cognitive rituals (e.g., safe numbers, prayers, formulae), (c) washing and cleaning, (d) checking or seeking reassurance for an action, (e) repeating an action, (f) ordering objects, and (g) compulsive slowness. Questioning is directed toward determining whether or not the behavior occurs only in the home, only away from the home or in both environments. Rachman and
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Hodgson’ have found that many rituals and obsessions are triggered only in the home. This appears to be especially true among patients with checking rituals, since patients feel greatest responsibility for their actions at home. Other assessment questions include: are there times when the patient is completely free of rituals or obsessions? Are there times when rituals are reduced in intensity or frequency? Does the presence or absence of others have an effect on the frequency or intensity of the rituals? In addition to identifying target rituals, the therapist needs to inquire about all objects or situations which the patient avoids in order to avoid engaging in rituals. Once specific rituals are identified and avoidance patterns are established, the focus of questioning moves to the identification of all objects or situations which trigger rituals of washing, checking, cleaning, repeating, or showers. For example: dirt, urine, feces, pesticides which trigger washing rituals; switching off a light, checking a door or viewing an electrical plug in a socket which trigger checking rituals. When all external objects or situations which trigger rituals are identified, the interview moves to the identification of all thoughts, images, or impulses which trigger ritualistic behavior. Examples include: “bad” numbers, sacreligious images, and catastrophic thoughts. It is important at this point to extract information about what patients believe will happen to them if they come in contact with the external objects or situations which trigger their rituals. Also important is the identification of what the patients believe will happen to them if they recite “bad” numbers or have sacreligious images. An assessment is made of the strength of the patients’ belief that catastrophic events will actually happen to them or their loved ones if they fail to engage in ritualistic behaviors. Also important is an assessment of the patient’s level of depression and anxiety. Finally, we determine whether the patient satisfies the DSM-III criteria for schizotypal, or other, personality disorders. Severe depression, overvalued ideation,14 and SPD16 have been identified as poor predictors of response to behavioral treatment. If the patient is found to be severely depressed or suffering from bipolar disorder he or she will be given a trial of medication. We have found that patients with severe depression have responded well to behavior therapy procedures only after their depression was controlled with medication. In addition, we have reported two patients with concomitant bipolar disorder and OCD who did not respond to behavioral treatment until their affective disorder was controlled pharmacologically.” If the patient meets criteria for SPD, we frequently attempt to arrange for the patient to be placed in a structured environment such as a day treatment center or halfway house during and after behavioral treatment. For these patients, exposure and response prevention work very slowly and unpredictably.16*29 During the behavioral analysis, we also determine whether the patient’s rituals are reinforced by family members. If this is the case, then the family members must be instructed to refrain from engaging in vicarious checking or providing reassurance in response to the patient’s frequent requests or engaging in avoidance behaviors that strengthen the patient’s rituals, if the patient is to be maximally assisted in overcoming his OCD. Patients are uncanny in getting family members to
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reinforce their rituals. As an illustration, the family members of one ritualistic washer would enter their home through a cellar entrance, strip of all “contaminated” clothing, and dress in uncontaminated clothes, before being allowed to enter the patient’s living quarters. Treatment Planning
We have found it essential to explain the rationale and the procedure of exposure therapy and response prevention to the patient in detail prior to initiating these procedures. By definition these procedures cause discomfort and the patient must understand this and be willing to accept some discomfort before treatment can commence. It is also helpful to explain to patients that their rituals, their thoughts, and their emotions may well respond to treatment at different speeds. We explain to patients that the easiest and quickest changes usually come in the rituals themselves: as they engage in response prevention the rituals are stopped very rapidly. However, it is explained that thoughts and emotional arousal will take longer to change or “wear out.” It is also explained that individuals vary in the time required for diminution of their obsessive thoughts, impulses, and feelings. This information appears to increase the patient’s motivation and compliance. If the ritualistic behaviors occur only at home, it is essential that a family member or a friend assist with the exposure and response prevention. In some cases, the therapist must make a home visit. If the target behavior occurs only at home, then exposure therapy and response prevention carried out solely in the clinic will be useless. After we determine the specific situations which trigger rituals and the situations which are avoided, they are then ranked from least to most troublesome, forming a hierarchy of target situations which will form the goals of behavioral treatment. Each situation is ranked by the degree of anxiety or discomfort it produces using a loo-point scaleI which represents the Subjective Units of Distress (SUDS) for each situation (100 SUDS = extreme anxiety and 0 SUDS = no anxiety). The patient is asked to rate each target situation based on the amount of anxiety it produces; after the situations are ranked from lowest to highest SUDS ratings, exposure therapy proceeds upward on the scale, beginning with the lowest-rated item. Treatment of obsessions alone. The actual process of treatment will differ depending upon the topography of the target behaviors. For a patient with obsessive, thoughts, without any compulsive rituals, the target behaviors are the thoughts themselves. In some cases the therapist may find that the thoughts are reliably and exclusively triggered by discrete emotional states such as anger, anxiety, or guilt. In these cases procedures designed to decrease these drive states, such as assertiveness training or relaxation training can be useful. In assertiveness training, the patient is taught to express both negative and positive emotions in a socially appropriate way. This technique typically includes instruction, therapist modeling, role-playing, and feedback of the patient’s performance. Our clinical procedure with patients who present with obsessive thoughts only has been to refer them first for a trial of antidepressant medication. Several of our patients with severe obsessive thoughts have responded completely to antidepressants.3’ We also use, as an adjunct, the technique of Thought Stopping. We follow this course of action because the literature on behavioral treatment of pure
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obsessions is generally unconvincing or at best unpredictable, and because we have achieved moderate success with this method. Thought Stopping is sometimes effective and requires only about I5 minutes to teach. The method of teaching Thought Stopping is summarized by Rimm and Masters3*: “The basic technique is extremely straightforward. The client is asked to concentrate on the anxiety-inducing thoughts, and, after a short period of time, the therapist suddenly and emphatically says “stop” (any loud noise or even mild pain administered by snapping a rubber band at the wrist may also suffice), the locus of control is gradually shifted from the therapist to the client. Specifically, the client is taught to emit a subvocal ‘stop’ whenever he or she begins to engage in a self-defeating
rumination”
(p. 430).
We teach Thought Stopping to the patient as a self-control procedure to be used at the onset of an obsessive thought rather than as a habituation technique. As a habituation procedure it was found ineffective in a controlled trial by Stern, Lipsedge, and Marks.** Occasionally, Thought Stopping by itself is effective. In one case, a patient we saw with a longstanding obsession about cancer reported elimination of these thoughts after two sessions with Thought Stopping. It is such intermittent clinical reinforcement that maintains our use of this unproven procedure. We rarely use cognitive techniques such as cognitive restructuring with these patients, because of the lack of evidence of their effectiveness in treating OCD.25 For patients with predominantly washing or cleaning rituals, Cleaning rituals. with none of the aforementioned poor predictors of success, the treatment is usually relatively straightforward. In many respects, the treatment is similar to the behavioral treatment of simple phobics with exposure and prevention of escape. Rachman and Hodgsot? have noted the great similarity between washers and phobics in their physiological reaction to the feared situation, and in their passive avoidance of the object. That is, they both attempt to avoid the feared situations at all costs. Treatment sessions are generally one hour in length and involve engaging the patient in touching the objects he fears. Often this can be done in the clinic, as when the targets are public restrooms or common objects such as shoes or chairs. In addition, when the feared objects are in the home, but are nonetheless movable, the patient or family member can bring items from home into the session. We have had patients bring in objects such as mothballs, dirty clothing, and trash to facilitate in vivo exposure during the session. Typically the therapist will first touch the object to demonstrate the procedure to the patient. This process has been termed “participant modeling” and has been shown to enhance the effects of exposure and response prevention, probably by increasing the patient’s motivation4 After the patient touches the object, he or she is told not to wipe or wash his or her hands for the remainder of the session. No physical force is necessary. In our experience, despite their fears to the contrary, all patients are able to refrain from performing the cleaning ritual during the therapy session. During the time of response prevention, the patient is reminded that it is natural for urges to wash and feelings of contamination to continue for a while, but that these will slowly decrease over time. The patient is given the homework assignment of engaging in the same types of
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activities daily during the week until the next session, and of refraining from engagement in the cleaning ritual for at least one hour after the exposure. If possible, a relative or friend is asked to attend one of the early sessions and is explained the theory and procedure. The relative or friend is then asked to act as the proxy of the therapist during practice sessions at home. If cleaning occurs only in the home, then therapy should begin in the home, with either the therapist or a friend or family member supervising assignments. If a relative/friend participates, the assignments to be performed are determined and negotiated in the therapist’s office with the patient, relative/friend and therapist present. Checking rituals. For patients with checking rituals, the procedure is different in several respects. First, the response prevention must often be self-administered since these patients frequently check only when alone. The presence of another person can decrease the need to check because the patient assumes that the other person would take responsibility and notice if anything wrong or dangerous was done.5 Second, checking occurs largely in the home, presumably because this is the place of greatest responsibility. Therefore, the response prevention assignments that can be carried out in the office or clinic are often limited. Thirdly, generalization is often poor from the clinic session to the home. For example, the patient may be able to shut off the light switch in the treatment office without checking, but may continue to check light switches, electrical outlets, and door locks when alone at home. In some cases, the patient may engage in hundreds of checking activities per day. In these cases, the patient is often unable to enforce response prevention without assistance.5 We attempt to carry out any exposure or response prevention that is possible in the office. If for example, the patient has a fear of throwing away objects, he or she is asked to bring in trash from home and throw it away in the session without checking. If the patient is afraid to enter stores for fear of closing the door on someone behind, or afraid of handling objects in a store for fear of dropping them, the patient is accompanied into stores during the treatment hour and is requested to handle merchandise without checking. If the patient is afraid of walking past cars for fear of unknowingly damaging them, he or she is asked to accompany the therapist on a walk that takes them about 3 feet away from parked cars. As soon as the patient is able to handle this, he or she may then be asked to hold a set of keys in the hand closest to the cars. Patients who avoid driving for fear that they will run over a pedestrian and not know it, are asked to drive the therapist in their car during the session. They are encouraged and assisted in not checking the rear view mirror or turning the car around to check when passing pedestrians or other automobiles. Throughout all these activities, the patient is reminded that it is natural to have urges to check, but that the thoughts about checking will decrease over time because they are misleading signals from his/her body and should not be needed. The patient, and if possible, with the aid of an assistant is then told to practice similar activities between sessions, to keep a log of these activities, and to report back to the therapist at the next session. The patient is reminded that the speed of reduction of the rituals and urges is mainly a function of the number of repetitions without checking. The treatment of checkers is complicated by the fact that they will repeatedly
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request reassurance. They act as if they have an attention disorder. It is very common for a checker to report that he or she will continue to perform an action until “something clicks in my head and I am sure that it is right.” Our practice is to tell patients that a feeling of confidence takes many practice sessions to acquire. They are also told that each time they have given in to the urge to check over the years, they have in fact decreased the visceral and cognitive feeling of confidence that is normally learned in childhood. Despite difficulties in the treatment of checkers, our assertion is borne out for patients motivated to continue this treatment: they report that after many experiences of response prevention (sometimes hundreds) they begin to get a feeling of confidence in their actions. In difficult patients who either do not respond to behavior therapy alone, or who are unable to comply fully with the treatment, a trial of antidepressant medication has been found to be helpful. One patient who was unable to refrain from extensive checking rituals and who was too fearful to engage in exposure activities, found that after treatment with phenelzine, she was able to engage in both the exposure and response prevention, because she felt “braver,” and more sure of herself. Primary obsessional slowness. This is the rarest type of OCD, and clinically it appears most similar to checking rituals. It is characterized by the patient’s inability to proceed with routine tasks without getting “stuck,” and being unable to complete an activity. The patient is often unable to initiate tasks, or will take hours to complete a simple task. Patients suffering from primary obsessional slowness may take hours to get dressed, to move from room to room, to pick up a fork to eat, or to open a medication bottle. These patients are extremely difficult to treat without the cooperation of family members. A great deal of patience and firmness are required of both therapist and family members when interacting with the patient. Behavioral treatment consists of a shaping procedure, wherein the patient is given a specified time limit to initiate or complete a particular task. The patient must engage in the task within the allotted time, even if this means that the therapist or famiIy member forces him or her to do it. Treatment of obsessional slowness with behavioral treatment is generally time-consuming, and progress is slow. SUMMARY
OF CLINICAL
MANAGEMENT
The number of sessions required for treatment varies. We have found that some patients with cleaning rituals have responded in as few as three to five sessions, with appropriate home practice. On the other hand, we have treated patients with checking rituals who have been seen for over 50 sessions and still have some remaining rituals. The sessions are one hour in duration. Patients are instructed to engage in exposure and response prevention sessions at home for one hour per day. At the outset of treatment many patients are not able to tolerate the full time in homework assignments. Clinically, we will use whatever behavioral strategy within reason will help the patient engage in the “active treatment” of exposure and response prevention. We have found that almost all patients are willing to undergo the exposure treatment when adjunctive techniques such as Thought Stopping, self-control relaxation training, or medication are included. It appears that the addition of these techniques
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can reduce the percentage therapy.
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of patients who refuse to participate
in exposure
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history of obsessional neurosis, in Beech HR (ed): Obsessional States. London, Methuen, 1974, pp 19-54 2. Rasmussen SA, Tsuang MT: The epidemiology of obsessive compulsive disorder. J Clin Psychiatry 45:450-457, 1984 3. Marks IM: Review of behavioral psychotherapy, I: Obsessive-compulsive disorders. Am J Psychiatry 138:584-592, 1981 4. Bandura A: Principles of Behavior Modification. New York, Holt, Rinehart & Winston, 1969 5. Rachman SJ, Hodgson RJ: Obsessions and Compulsions. Englewood Cliffs, NJ, Prentice-Hall 1980 6. Latimer PR, Sweet AA: Cognitive versus behavioral procedures in cognitive-behavior therapy: A critical review of the evidence. J Behav Ther Exp Psychiatry 15:9-22, 1984 7. Rachman SJ: Fear and Courage. San Francisco, WH Freedman, 1978 8. Lang PJ: Fear reduction and fear behavior: Problems in treating a construct, in Schlien JM (ed): Research in Psychotherapy. Washington, DC, American Psychological Association, vol 3, pp 90-93, 1968 9. Hodgson RJ, Rachman S: Desynchrony in measures of fear. Behav Res Ther 12:319-326,1974 10. Seligman MEP: Phobias and preparedness. Behav Ther 2:307-320, 1971 11. Baer L, Minichiello WE, Jenike MA: Behavioral treatment in two cases of obsessive-compulsive disorder with concomitant bipolar affective disorder. Am J Psychiatry, 142:358-360, 1985 12. Deese J, Hulse SH: The Psychology of Learning. New York, McGraw-Hill, 1967 13. Lader M, Wing L: Physiological measures in agitated and retarded depressed patients. J Psychiatr Res 7:89-100, 1969 14. Foa EB: Failures in treating obsessive-compulsives. Behav Res Ther, 17:169-176, 1979 15. Marks IM, Stern RS, Mawson D, et al: Clomipramine and exposure for obsessive-compulsive rituals. Br J Psychiatry 136:1-25, 1980 16. Minichiello WE, Baer L, Jenike MA: Schizotypal personality disorder: A poor prognostic indicator for behavior therapy in the treatment of obsessive compulsive disorder. J Anxiety Disord 1:273-276, 1987 17. Wolpe J: Psychotherapy by Reciprocal Inhibition. Stanford, CA, Stanford University, 1958 18. Beech HR (ed): Obsessional States. London, Methuen, 1974 19. Sturgis ET, Meyer V: Obsessive compuslive disorders, in Turner SM, Calhoun KC, Adams HE (eds): Handbook of Clinical Behavior Therapy, New York, Wiley, 1980, pp 68-102 20. Rachman SJ, Hodgson RJ, Marks IM: The treatment of chronic obsessional neurosis. Behav Res Ther 9~237-247, 1971 21. Foa EB, Steketee G, Milby JR: Differential effects of exposure and response prevention in obsessive-compulsive washers. J Consult Clin Psychol, 48:71-79, 1980 22. Stern RS, Lipsedge MS, Marks IM: Obsessive ruminations: A controlled trial of thought-stopping technique. Behav Res Ther 11:659-622, 1973 23. Hackmann A, McClean C: A comparison of flooding and thought-stopping treatment. Behav Res Ther, 131263-269, 1975 24. Sookman D, Solyom L: The effectiveness of four behavioral therapies in the treatment of obsessional neurosis, in Boulougouris JC, Rabavilas AD (eds): The Treatment of Phobic and Obsessive Compulsive Disorders. Oxford, England, Pergamon Press, 1977 25. Emmelkamp PMG, van der Helm M, van Zanten BL, et al: I. Treatment of obsessive-compulsive patients: The contribution of self-instructional training to the effectiveness of exposure. Behav Res Ther, 18:61-66,198O 26. Foa EB, Goldstein A: Continuous exposure and strict response prevention in the treatment of obsessive-compulsive neurosis. Behav Ther, 17: 169- 176, 1978 27. Carey RJ, Baer L, Jenike MA, et al: MMPI correlates of obsessive-compulsive disorder. J Clin Psychiatry 47:371-372, 1986 28. Jenike MA, Baer L, Minichiello WE, et al: Concomitant obsessive-compulsive disorder and schizotypal personality disorder: A poor prognostic indicator. Arch Gen Psychiatry 43:296, 1986
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personality disorder. Am J Psychiatry 143530-533, 1986 30. Jenike MA, Baer L, Minichiello WE. Obsessive-Compulsive Disorder: Diagnosis and Treatment. Littleton, MA, PSG Publishing, 1986, pp 45-75, 179-190 31. Jenike MA, Armentano M, Baer L: Disabling obsessive thoughts responsive to antidepressants. J Clin Psychopharmacol7:33-35, 1987 32. Rimm DC, Masters JC: Behavior Therapy: Techniques and Empirical Findings. New York, Academic, 1974, p 430