Behavioral assessment and treatment planning with obsessive compulsive disorder: A review emphasizing clinical application

BEHAVIOR THERAPy 25,

613-633, 1994

Behavioral Assessment and Treatment Planning With Obsessive Compulsive Disorder: A Review Emphasizing Clinical Application GAIL STEKETEE Boston University

This paper provides an overviewof the current state-of-the-art in behavioral assessment and treatment planning for obsessivecompulsivedisorder (OCD). New developments in assessment include the availability of the Yale-BrownObsessiveCompulsive Scale and Symptom Checklist for detailed interviewing regarding multiple types of obsessions and compulsions and the self-report Padua Inventory. Cognitive features and personality traits specific to OCD are being examined with increasing frequency. Behavioral treatment methods continue to rely on the highly successful combination of exposure to feared situations and prevention of avoidance and compulsions, with or without serotonergicmedications. Severalvariants of these methods are discussed, including group behavioral treatment and involvementof family members. Cognitive treatments have been increasinglystudied with recent positiveoutcomes reported using this method. It seems likely that efforts to improve treatment efficacywill include assessment that is continued throughout treatment, and focus on personality and associated cognitive features and on interventions involving family members. This paper focuses o n recent research findings p e r t i n e n t to effective clinical practice using behavioral a n d cognitive assessment a n d i n t e r v e n t i o n s for obsessive compulsive disorder (OCD). Step-by-step guidelines for clinical assessm e n t a n d t r e a t m e n t c a n be f o u n d elsewhere (e.g., Steketee, 1993b; T u r n e r & Beidel, 1988). A l t h o u g h biological models a n d t r e a t m e n t s are equally import a n t i n OCD, they are b e y o n d the scope o f this article a n d the reader is referred to several excellent reviews of this work (e~g., Jenike, Baer, & Minichiello, 1990; Zohar, Insel, & Rasmussen, 1991). This p a p e r begins its focus o n assessment by considering the diagnostic criteria for OCD. T h e n , m e t h o d s o f evaluating obsessions a n d c o m p u l s i o n s , a n d differentiating O C D f r o m other similar c o n d i t i o n s are described. Models for the c o n c e p t u a l i z a t i o n o f O C D are t h e n considered before assessment a n d t r e a t m e n t m e t h o d s are considered in detail.

Preparation of this paper was supported in part by NIMH grant #MH44190 awarded to the author. Address reprint requests to Gall Steketee, Ph.D., Boston UniversitySchool of Social Work, 264 Bay State Rd., Boston, MA 02215. 613 0005-7894/94/0613-063351.00/0 Copyright 1994 by Association for Advancement of Behavior Therapy All rights of reproduction in any form reserved.

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Diagnostic Formulation Diagnostic Criteria for OCD A s u m m a r y o f d i a g n o s t i c criteria for O C D f r o m D S M - I V ( A P A , 1994) is given in Table 1. P a r t i c u l a r l y p r o b l e m a t i c in assessing this disorder, in contrast to o t h e r a n x i e t y disorders, are the m a n y different s y m p t o m m a n i f e s t a tions t h a t can be c o n f u s i n g to the clinician. B o t h cognitive (obsessions a n d mental rituals) a n d behavioral c o m p o n e n t s (avoidance a n d rituals) are present. Critical to a n u n d e r s t a n d i n g o f this disorder is t h e finding t h a t obsessions p r o voke u n p l e a s a n t e m o t i o n a l responses (e.g., fear, guilt) w h i c h are relieved by c o m p u l s i v e behaviors o r m e n t a l acts ( R a c h m a n , 1971).

Description of Obsessions and Compulsions O C D is p e r h a p s m o s t c o m m o n l y identified b y the t y p e o f c o m p u l s i v e beh a v i o r a n i n d i v i d u a l exhibits, a l o n g with the obsessive fear it is i n t e n d e d to reduce. M o s t clients have m o r e t h a n o n e t y p e o f ritual, a n d s o m e have n o n e at all. T h e s e include: (1) checking i n t e n d e d to prevent such c a t a s t r o p h e s as burglary, fire, h a r m i n g others, a n d social e m b a r r a s s m e n t ; (2) washing a n d cleaning to remove perceived " c o n t a m i n a t i o n " f r o m germs, chemicals, o r other sources a n d restore a state o f safety; (3) repeating o f o r d i n a r y a c t i o n s to "magically" prevent a n i m a g i n e d terrible consequence; (4) o r d e r i n g o r a r r a n g i n g items to relieve feelings o f a n x i e t y o r d i s c o m f o r t ; a n d (5) saving o r collecting

TABLE 1 SUmaARY Or DSM-III-IV CRITERIAFOR OCD A. Either Obsessions or Compulsions as defined below: Obsessions are: (a) recurrent thoughts, impulses, or images experienced as intrusive and inappropriate, and causing marked anxiety or distress (b) not simply excessive worries about real-life problems (c) accompanied by efforts to ignore, suppress, or neutralize them (d) recognized as the product of one's own mind. Compulsions are: (a) repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession, or according to rigid rules (h) aimed at preventing or reducing distress or preventing some dreaded event or situation; clearly excessive or not realistically connected to the obsessive fear. B. At some point, the person has recognized that their behavior is excessive or unreasonable. (Does not apply to children.) C. The obsessions or compulsions cause marked distress, are time-consuming (take more than an hour a day), or significantly interfere with the person's normal routine, occupational functioning, or usual social activities or relationships with others. D. The content of the obsessions or compulsions cannot be accounted for by another disorder (e.g., eating disorder, trichotillomania, body dysmorphic disorder, substance use disorder, hypochondriasis, or major depressive disorder).

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objects to ensure their availability in case of need. In addition, mental rituals (e.g., praying, forming corrective images) associated with various obsessive fears are quite common, though rarely mentioned by clients except on questioning. Associated Conditions Several disorders have been likened to OCD and the term OCspectrum disorder has recently gained wide usage (e.g., Brady, Austin, & Lydiard, 1990; Hollander, Liebowitz, Winchel, Klumker, & Klein, 1989). Some of these, such as hypochondriasis, body dysmorphic disorder, anorexia, and bulimia, share a very similar functional analysis: anxiety increases in response to obsessivelike ideas (illness, appearance) and is reduced by specific behaviors (medical consultation, testing, purging, exercise) (Salkovskis & Warwick, 1986; Tynes, White, & Steketee, 1990). Further, behavioral treatments similar to those found effective for OCD have also been successfully employed for some of these disorders (Rosen & Leitenberg, 1982; Salkovskis, 1989). Similarities of OCD to generalized anxiety disorder (GAD) have also been noted (e.g., Brown, Moras, Zinbarg, & Barlow, 1993), but OCD appears to be distinguishable by the specificity of the obsessions, perception of their senselessness, and efforts to suppress or neutralize them. Nonetheless, both share mental intrusions as a hallmark of the disorder (Freeston et al., 1994; Tallis & de Silva, 1992). Several impulse control disorders (trichotillomania, face picking, compulsive shopping, gambling) have been likened to OCD (e.g., Christenson, Mackenzie, & Mitchell, 1991) but appear functionally quite different. Unwanted mental intrusions and associated discomfort are often lacking, and the "compulsive" act is typically experienced as satisfying (positively reinforcing), rather than merely discomfort-reducing (negative reinforcement) as in OCD. The positive response of some of these disorders to serotonergic drugs that are also helpful for OCD (Swedo, Lenane, Leonard, & Rapoport, 1990) may have contributed to diagnostic confusion, although similar treatment response does not necessarily indicate similar underlying pathology.

Functional Analysis Behavioral Models Mowrer's (1960) two-stage theory for the acquisition and maintenance of fear and avoidance behavior has been commonly adopted to account for the development of anxiety disorders in general (Dollard & Miller, 1950) and OCD in particular (Foa et al., 1985b). This theory posits that the neutral objects (knives, toilets) or thoughts (image of the devil, number 13) become associated with fear/anxiety by being paired with a traumatic stimulus that provokes discomfort. Escape and avoidance of the feared objects or internal events are negatively reinforced by reduction in anxiety. Because many cues for obsessive fear cannot be avoided easily (using bathrooms, locking doors, horrific images), passive avoidance is often ineffective in controlling anxiety and active compulsions are employed to prevent harm or restore a feeling of safety (Rachman, 1976a).

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This model is insufficient to account for the etiology of OCD, and several theorists have proposed additions to the model (e.g., Foa & Kozak, 1986; Otto, 1992; Rachman, 1971; 1977; Salkovskis, 1985). Because many patients cannot recall specific conditioning events associated with symptom onset, other modes of acquisition, such as observation (modelling) or informational learning, have been proposed (Foa & Kozak, 1986; Rachman, 1977; Rachman & Wilson, 1980). Support for the role of parental modelling of obsessive symptoms and traits has been found (see Steketee, 1993b for review), but it is noteworthy that parents with OCD often have different rituals than their children (Swedo, Rapoport, Leonard, Lenane, & Cheslow, 1989). OCD onset often follows stressful life events (Rasmussen & Tsuang, 1984), but rarely does so immediately, as postulated by Mowrer's theory. Stressful events may serve to sensitize the individual to cues that have an innate or historical/cultural tendency to elicit fear (Rachman, 1971; Teasdale, 1974). The two-stage theory does appear to adequately account for the maintenance of OCD symptoms. That obsessions increase subjective and physiological discomfort and compulsions (active escape/avoidance behaviors) reduce it is well substantiated (e.g., Boulougouris, Rabavilas, & Stefanis, 1977; Hornsveld, Kraaimaat, & van Dam-Baggen, 1979). Seemingly contradictory reports of increases in discomfort during or following rituals for chronic clients can be readily explained by clients' intense frustration with their inability to control these behaviors. Assessment and treatment implications. According to the above behavioral model, assessment should examine and treatment must focus on (1) disconnecting obsessive ideas from their associated discomfort, and (2) eliminating avoidance and ritualistic behaviors that negatively reinforce obsessive fears (Foa & Tillmans, 1980). Imagined and/or direct exposure to feared obsessive situations, usually in a graduated manner progressing from the easier to more difficult cues, has proven highly effective in reducing anxiety (e.g., Foa & Goldstein, 1978; Marks, Hodgson, & Rachman, 1975). Concurrent with exposure, blocking of rituals, either abruptly or gradually, accomplishes substantial reduction in compulsive behavior after treatment and at long-term follow-up (Foa, Steketee, Grayson, Turner, & Latimer, 1984; Foa, Steketee, & Milby, 1980). From a clinical standpoint, the manner by which exposure and blocking of rituals is accomplished has varied considerably across research trials that show essentially similar rates of benefit (for reviews and clinical procedures see Steketee, 1993b; Turner & Beidel, 1988). This suggests that there is considerable latitude in how these methods are delivered, so long as both exposure and prevention of rituals and avoidance behaviors are included in a comprehensive program. Ongoing assessment can inform the treatment agent concerning current levels of success and can assist in making decisions to continue or to change strategies. Treatment implementation is discussed further below. Cognitive Models The recent explosion of research directed at cognitive phenomena (beliefs, attitudes, information processing, memory) common to those with OCD may

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complement behavioral models in accounting for OCD symptoms. Foa and Kozak (1986) conceptualized anxiety disorders in general and OCD in particular as specific impairments in affective memory networks characterized by overestimates of threat, high negative valence for the threatening event, and excessive responding to such perceived threats (e.g., physiological, avoidance, etc.). They argued that most obsessive compulsives expect danger in the absence of guarantees of safety and are unable to generalize from experiences of exposure to feared situations in which no harm occurs. Because rituals do not guarantee safety, they must be repeated frequently. Foa and Kozak (1986) suggested that anxiety may also persist because of cognitive defenses, excessive arousal, or faulty premises underlying beliefs and erroneous rules of inference and that these hinder the processing of information that would otherwise alter the problematic fear structure. Related to these conceptualizations is Salkovskis' (1985, 1989) proposal that normal intrusive thoughts, images and impulses become obsessions when they are particularly salient for the individual and are associated with negative automatic thoughts about responsibility for harm to others, leading to selfcondemnation and efforts to remove or prevent blame (and shame). Efforts at neutralization (rituals) reduce discomfort, feelings of responsibility and possible feared consequences of having such thoughts. Supporting Salkovskis' model is the finding that individuals with OCD showed greater sensitivity about responsibility for harm, but not for threat or loss which lacked the responsibility component (Salkovskis, 1989). Further, negative appraisals (responsibility, disapproval and guilt) in non-clinical subjects predicted avoidance and compulsive activity (Freeston, Ladouceur, Thibodeau, & Gagnon, 1992). In a broader rational-emotive cognitive model, Warren and Zgourides (1991) hypothesized a general biological vulnerability influenced by developmental and learning experiences that determine what thoughts are considered unacceptable and what meaning is attached to particular thoughts as well as general beliefs about the self, others, and the world. Stressful events foster intrusive thoughts (e.g., about mistakes, uncertainty) which become salient if they are associated with irrational beliefs and thinking styles that generate negative affect. Attention narrows on these intrusive thoughts, and individuals become hypervigilant for them. Additional irrational beliefs are directed at the unacceptability of and intolerance for the restrictions of the disorder. Evidence for these theoretical assertions has not yet been provided, although as noted below, there is some support for the efficacy of rational emotive therapy (Emmelkamp & Beens, 1991). Others have also proposed that OCD may be characterized by perceptual and/or memory failure to distinguish thought from action (Rachman, 1993; Rubenstein, Peynircioglu, Chambless, & Pigott, 1993; TaUis, 1994). The poorer memory for actions found among non-clinical checkers partly supports this contention (Sher, Frost, & Otto, 1983). Treatment implications. The above cognitive models argue for assessments that probe and interventions that alter OCD clients' (1) attitudes and beliefs with regard to the several traits hypothesized to be important (e.g., perfectionism, responsibility, risk), (2) judgements about intruding thoughts, images

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or impulses, and (3) efforts at suppression. It is not yet clear whether change in problematic attitudes and beliefs and problematic suppression strategies is best accomplished by exposure alone, which appears at least to alter attitudes regarding danger (Foa & Kozak, 1986), or whether direct cognitive therapy is needed as models by Salkovskis and by Warren and Zgourides imply. Individualized assessment plans may yield some information about the need to go beyond exposure in each patient. Education may be partly helpful in reducing negative judgements about the presence of obsessions and in promoting exposure rather than suppression of feared ideas, but again this has not been tested. Research substantiating cognitive models and testing efficacy of cognitive treatments is only beginning at the present time. The results of comparative treatment trials are described shortly.

Assessment Methods and Instruments Ideally, assessment should encompass not only obsessions and compulsions, but also co-occurring symptoms and personality traits. Clinical interviews with the client and with family members provide the primary sources of information, and can be supplemented by self-report questionnaires, behavioral observations, and physiological recordings if appropriate. In view of the multiple manifestations of OCD, it is not surprising that many instruments have been developed and that several of these have limited validity and clinical utility (for review see Steketee, 1993b). The most useful methods are discussed below, omitting those that have not stood the test of time. Although many of these methods are typically used for initial diagnosis or treatment planning only, some, such as Behavioral Avoidance Tests, can continue to yield important information on treatment effects throughout the course of intervention. Interview Instruments Diagnostic instruments. Among the standardized interviews developed that reliably diagnose OCD according to DSM criteria, the Structured Clinical Interview for DSM (SCID, Spitzer, Williams, & Gibbon, 1987) and the Anxiety Disorders Interview Schedule (ADIS, DiNardo, Brown, & Barlow, 1994) are the most commonly used. In the absence of data comparing these two methods, the ADIS may be preferred because it is somewhat more thorough in detailing and quantifying OCD symptoms, especially regarding insight into obsessive fears (see below), resistance, and avoidance. It may be used formally or informally during initial clinical interviews to identify major OCD symptoms. YBOC Symptom Checklist and Scale. The Yale Brown Obsessive-Compulsive Scale (YBOCS) is an exceptionally useful adjunct to the clinical interview discussed above (Goodman et al., 1989a, b) and has become the gold standard for assessment in outcome studies. The interviewer begins by defining obsessions and compulsions and inquiring about current or past experience of 36 obsessions and 23 rituals on a checklist containing the following general categories: aggressive/harming, contamination, sexual, hoarding/saving, religious, symmetry/exactness, somatic, and miscellaneous. Although not exhaustive, the YBOC Checklist is far more comprehensive than other available instru-

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ments. To assess severity, the YBOC Scale includes Obsessions and Compulsions subscales, each examining five aspects of OCD pathology (time spent, interference, distress, resistance, and perceived control) on scales from 0 (no symptoms) to 4 (extreme symptoms). Items are summed to yield a total score ranging from 0 to 40. Scores above 16 have been used to select subjects for treatment studies (e.g., Clomipramine Collaborative Study Group, 1991). The YBOCS has shown good to excellent reliability (test-retest, inter-rater, and internal consistency) (Frost, Steketee, Krause, & Trepanier, 1994; Goodman et al., 1989b; Kim, Dysken, & Kuskowski, 1990, 1992; Woody, Steketee, & Chambless, 1994) and reasonably good convergent validity, although it correlated poorly with one widely-used measure, the Maudsley Obsessional Compulsive Inventory (Goodman et al., 1989a; Kim et al., 1990; Woody et al., 1994). Divergent validity was somewhat problematic due to high correlations with measures of anxiety and depression. It proved sensitive to changes following pharmacological treatments (e.g., The Clomipramine Collaborative Study Group, 1991; Goodman et al., 1989b; Kim et al., 1990) and behavioral treatment (e.g., Woody et al., 1994). Overall, the YBOCS performed well, except for divergent validity. A modified version has been developed as a self-report or computer-administered instrument, but has not as yet been adequately tested (Rosenfeld, Dar, Anderson, Kobak, & Greist, 1992). Specific information on cues and rituals. In addition to questioning to establish diagnosis, Foa, Steketee and Ozarow (1985) recommended that the clinical interview include information about external sources of obsessive fear (seeing lights on, touching a doorknob, reading about AIDS, hearing a news story about a hit-and-run accident), internal cues (thoughts, images, impulses, feared consequences of not performing compulsions), and avoidance behavior (e.g., not driving because of fears of running over a pedestrian). Especially helpful is the patient's detailed description of a typical day from arising until bedtime (Steketee, 1993b). Because rituals maintain obsessive fear (Foa & Tillmans, 1980), determination of all behavioral and cognitive compulsions (washing, cleaning, checking, repeating, ordering, saving, counting, other mental events), as well as abbreviated versions of rituals (wiping, rinsing) is needed for planning treatment. Role of relatives. The need to directly assess relatives' involvement in rituals is reinforced by a recent study by Calvocoressi (personal communication, April, 1994) who found that 75% of OCD relatives were participating at least minimally in rituals or avoidance or modifying their behavior to accommodate patients' symptoms. Greater family participation was significantly correlated with perceived family dysfunction (using the Family Assessment Device), family stress, and rejecting attitudes toward the patient. In a related vein, family members' responses (anger, criticism, beliefs that patients can control their symptoms) have been found to influence outcome (e.g., Steketee, 1993a), consistent with an extensive literature on Expressed Emotion (EE) in families of schizophrenic patients and depressed patients (see Kavanagh, 1992). These findings suggest the need to assess the attitudes and involvement in OCD symptoms of close others for possible intervention with family members during behavioral treatment. The role of relatives is considered further in the section on treatment parameters.

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Evaluations of insight. Clients who overestimated the probability of harm failed to benefit from behavior therapy (Foa, 1979), and from medication treatment (Perse, 1988), although some studies have failed to find a significant association (e.g., Basoglu, Lax, Kasvikis, & Marks, 1988; Hoogduin & Duivenvoorden, 1988). Most clients with OCD spontaneously acknowledge the irrationality of their fears and rituals, although clinical experience indicates that they may lose this rational perspective during a high anxiety state. However, a small percentage are consistently convinced of the validity of their obsessive fears, and the above research suggests that these individuals may respond less well to exposure treatment. Questions from the ADIS and the YBOCS (see below) can be used to assess insight, or clients can be asked about the actual probability of their feared consequences using a scale from 0 to 100°70. Unfortunately, the adequacy of these methods for evaluating insight has not been examined, and new measures are presently under development. Target rating scales. Likert-like scales adapted from phobia research have been used by independent assessors during evaluation interviews, as well as by clients and therapists, to measure severity of main obsessions, avoidance and compulsions (e.g., Foa & Goldstein, 1978). Targets are selected jointly by the client and assessor. Examples of target obsessions include "contact with pesticides," "thoughts of harming others"; target compulsions might be "checking locks," "washing hands," and so forth. Freund (1986) reports generally good psychometric properties of target ratings when the range of scores was not constricted, although stability over time was inadequate. These instruments are particularly useful for rating change following behavioral treatment because they assess the particular symptoms targeted during therapy, but they may therefore be overly sensitive to treatment effects. Self-Report Questionnaires Maudsley Obsessional Compulsive Inventory (MOCI). A commonly used self-report measure of OCD symptoms, this 30-item true/false questionnaire yields a total score and five subscale scores (checking, cleaning, slowness, doubting, conscientiousness, and ruminating) (Hodgson & Rachman, 1977). It has proven highly sensitive to treatment effects and has demonstrated adequate validity and test-retest reliability (Rachman & Hodgson, 1980; Sternberger & Burns, 1990a, b). Normative data collected for the MOCI has facilitated its use in studies of nonclinical subjects who score high or low on obsessive compulsive symptoms. Unfortunately, obsessive compulsives with atypical symptoms (especially mental rituals) may not score in the pathological range in this measure, despite incapacitating symptoms. Padua Inventory (PI). This newly developed 60-item instrument assesses common obsessive and compulsive symptoms (Sanavio, 1988). Testing on several nonclinical samples and on an obsessional Italian sample indicated satisfactory internal consistency and reliability, as well as convergent and discriminant validity (Sternberger & Burns, 1990c; van Oppen, 1992). Similar factors emerged across studies: control of mental activities, contamination, checking, and control of motor behavior. This measure is increasingly being used in research studies and offers some clinical utility as a result of its inclusion of items not contained in other instruments.

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Other measures of OCD symptoms. Several other instruments have been developed to assess obsessive traits and symptoms, including the Leyton Obsessional Inventory, the Lynnfield Obsessional Compulsive Questionnaire, the Compulsive Activity Checklist, the Sandler-Hazari Obsessional Compulsive Inventory, the obsessive-compulsive subscale of the Symptom Checklist-90, and the obsessive-compulsive profile from the Minnesota Multiphasic Personality Inventory (MMPI) (for review see Kozak et al., 1987; Steketee, 1993b). These instruments have various psychometric difficulties and cannot at present be recommended for clinical or research use. Several newer measures have received preliminary study (e.g., Beliefs Inventory by Freeston, Ladouceur, Thibodeau, & Gagnon, 1991, 1992; Cues Checklist by Ristvedt, Mackenzie, & Christenson, 1993), but require further testing. Direct Observation A hallmark of behavioral treatment is the therapist's careful assessment of actual behavior before, during, and after treatment. Two types of observational measures have been employed with OCD patients, Behavioral Avoidance Tests (BAT) and self-monitoring of the frequency of obsessions and/or the amount of ritualizing. Behavioral avoidance test. The number of steps and amount of subjective anxiety on a hierarchy of feared situations have occasionally been employed in research studies of OCD (e.g., Foa et al., 1980; Marks et al., 1975). Examples include approach toward selected contaminated objects or ability to remain in a situation or complete a task without ritualizing. In its strict form this measure is less well-suited to checking or repeating rituals, unless recording of subjective anxiety and/or intensity of thoughts, images, or impulses is permitted. Despite extensive use of the BAT for phobics, little psychometric data has accumulated for its utility for OCD symptoms (see Freund, 1986), although some research is currently in progress in our laboratory. Behavioral avoidance tests are usually employed in research contexts, but clinician observation of clients in their natural settings may be very useful in assessing OCD symptoms and planning treatment. Behavioral monitoring. Self-monitoring of the frequency and duration of OCD symptoms and associated anxiety provides useful clinical insight into the patient's typical routine (Steketee, 1993b). Because the wide variability in responses across clients makes scoring difficult, these measures have not usually been employed as outcome measures (for an exception see Foa et al., 1980). Nonetheless, they can be valuable in providing detailed clinical information about severity and specific cues for compulsive behavior, as well as about compliance with homework assignments. Unfortunately, however, such self-monitoring suffers from reactivity (Haynes, 1990). Physiological Measures Physiological recordings of heart rate, skin conductance, and respiration have been used to assess anxiety responses (e.g., Lang, 1979), but usually only in research contexts (e.g., Kozak et al, 1987). Apart from their expense and inconvenience, they are not useful for many clients whose feared situations cannot be reproduced accurately in the lab. Further, the symptoms of OCD

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are rarely associated with particular somatic manifestations (in contrast, for example, to panic disorder), although some cases may involve obsessive fears associated with physical behaviors (e.g., obsessions about choking to death, ritualistic breathing patterns to prevent suffocation). In such situations physiological assessment may be quite useful for behavioral analysis and treatment planning. Biochemical responses on OCD clients (e.g., DST, cortisol, cerebral blood flow) have also been studied, as well as neurological activity using MRI and PET scan technology (for reviews see Jenike, Baer, & Minichiello, 1990). The clinical utility of these assessments for obsessive discomfort and behavior has not been established.

The Process of Therapy Treatment Parameters Inpatient vs. outpatient. There appear to be no clear advantages for either inpatient or outpatient treatment, given that neither has proved superior in a controlled trial (van den Hout, Emmelkamp, Kraaykamp, & Griez, 1988). Because hospitalization may remove some clients entirely from important cues that provoke their fears, outpatient treatment is preferred to allow clients better access to exposure situations. Hospitalization can be arranged if clients lack support to carry out treatment without supervision, are potentially suicidal, or are functioning very poorly in everyday living situations (Megens & Vandereycken, 1989). Group vs. individual Group treatment using exposure and response prevention procedures for groups of 5 to 12 OCD clients has proved effective in reducing OCD symptoms in uncontrolled reports (e.g., Krone, Himle, & Nesse, 1991) and in a large controlled comparison (Fals-Stewart, Marks, & Schafer, 1993). In the latter study, benefits from a 24-session twice weekly treatment were comparable to those achieved by individual behavioral treatment and were superior to a relaxation placebo. These findings argue for the efficacy and cost-effectiveness of behavioral group treatment for OCD, although the strict exclusion criteria in the controlled trial (significant depression and Axis II diagnoses) limit the generalizability of these findings. Frequency and duration o f treatment. The ideal frequency and number of sessions has not been established, but 15 to 20 sessions applied over 4 to 16 weeks produced positive gains in most clients (Steketee & Shapiro, 1993). Better long-term gains have been associated with longer trials of exposure therapy (O'Sullivan, Noshirvani, Marks, Monteiro, & Lelliott, 1991). Although behavioral therapy has been successfully conducted strictly by therapist assignment of homework (Emmelkamp & Kraanen, 1977), in most successful treatments, some therapist-accompanied exposure is employed. The therapist may therefore need to plan to travel occasionally to the patients' feared settings. Family members. With regard to inclusion of family members in behavioral treatment, Mehta (1990) observed more positive outcomes in family-assisted treatment in India compared to individual behavior therapy. Non-anxious, firm, supportive family members were most effectivein helping to reduce rituals. In contrast, two Dutch studies reported that spouse-assisted exposure did not

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produce better long-term gains than patient-alone treatment (Emmelkamp, De Haan, & Hoogduin, 1990; Emmelkamp & De Lange, 1983). The discrepancy in findings may be due to the greater intensity of treatment in Mehta's study (24 sessions twice weekly versus 8 sessions in five weeks). As Emmelkamp (1982) noted, including a family member as co-therapist may be detrimental when interaction is marked by conflict or strong dependence. These findings argue for the need to assess the reactions of relatives to clients' symptoms before including any family members directly in the therapy process. Imagined vs. direct exposure. Although direct exposure is more effective than imagined exposure (Foa, Steketee, & Grayson, 1985), the combination of both with blocking of rituals has produced excellent outcomes (e.g., Foa & Goldstein, 1978). The addition of imagined exposure to direct exposure improved the gains of clients with checking rituals and feared catastrophes at follow-up (Foa et al., 1980). Beidel and Bulik (1990) demonstrated that imagined exposure to fears of fecal incontinence, somatic sensations, distressing thoughts and feared social consequences facilitated subsequent in vivo exposure in two cases with "bowel obsessions." These findings suggest that inclusion of imagined exposure is appropriate for any patient who reports obsessional fears of catastrophes that are readily accessed through imagination. Exposure in fantasy may also be indicated for clients with severe avoidance and anxiety who are reluctant to begin direct exposure. Patient Factors Comorbid conditions. The outcome of behavioral treatment may be affected by the presence of particular comorbid psychiatric disorders. OCD rarely occurs in isolation, the most common accompaniments being other anxiety and mood disorders (Karno, Golding, Sorenson, & Burnam, 1988; Rasmussen & Tsuang, 1984). Panic and social phobia commonly occur in 15°/0 of cases (Karno et al., 1988), but in most cases do not appear to pose special threats to long term benefits (e.g., Rasmussen & Tsuang, 1984, 1986). Nonetheless, clinical experience suggests that if obsessions trigger panic attacks during exposure treatment, the addition of panic coping skills and cognitive correction of catastrophic thinking may be needed. Despite initial findings to the contrary, depression has not been found to consistently predict behavioral treatment outcome (e.g., Foa, Kozak, Steketee, & McCarthy, 1992; Mawson, Marks, & Ramm, 1982; Steketee, 1988). Clinical wisdom suggests that for cases with severe depression, especially with suicidal ideation, antidepressant medications (especially serotonergic ones also useful for OCD symptoms) may be prescribed prior to beginning behavioral treatment. Alcohol dependence occurs less frequently among OCD clinic patients compared to the general population (e.g,, Karno et al., 1988; Riemann, McNally, & Cox, 1992), and in most cases, appears to follow the onset of OCD symptoms (Karno et al., 1988), suggesting that it may be used to reduce anxiety. Although no empirical data are available, it seems likely that excessive use may interfere with learning during treatment and that measures to reduce consumption should precede behavioral therapy for OCD. Schizotypal, borderline, and passive-aggressive personality disorders have been found to impede

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benefits from behavioral therapy (e.g., Hermesh, Shahar, & Munitz, 1987; Minichiello, Baer, & Jenike, 1987; Steketee, 1990). A recent case report provides preliminary evidence for the usefulness of restricting environmental stimulation to enhance exposure treatment effectiveness for an OCD client with schizotypal personality disorder (Walker, Freeman, & Christensen, 1994). Empirical studies of the effects of these and other comorbid conditions on treatment outcome and of methods for addressing them are needed. Motivation for treatment. Good motivation for behavioral treatment predicted positive treatment outcome for obsessive compulsive clients (Foa, Steketee, Grayson, & Doppelt, 1983; Hansen, Hoogduin, Schaap, & de Haan, 1992), suggesting that efforts to enhance motivation to undergo exposure and response prevention may be helpful in improving outcome. Unfortunately, we have little information about how this might be done for OCD, although it seems likely that clear explanations of treatment procedures and expected benefits will be helpful.

Progress During Therapy Expected benefit from exposure and response prevention. To date, 25 open trials and controlled studies representing over 500 clients with OCD from sew eral countries have examined the effects of exposure combined with prevention of rituals. On average, approximately 85°70 of clients were at least "improved," and about 55070 fell into the "much" or "very much improved" categories (see Steketee & Lam, 1993). Gains were generally maintained at follow-up, with some relapse evident and some clients needing additional therapy (Emmelkamp, Visser, & Hoekstra, 1988; Foa et al., 1984). Overall, most measures of OCD symptoms showed 50 to 70 percent improvement. Kirk (1983) demonstrated that the beneficial effects of this research-based treatment were readily transferable to routine clinical practice: 58070achieved their goals and 17070 were moderately improved, leaving 25070 with unsatisfactory outcomes. In the clinical setting, therapists placed greater reliance on homework assignments than accompanied direct practice, and relatives or friends played an important part in treatment for one-third of cases. Additional treatments such as assertiveness training and marital therapy were used in several cases. Interestingly, treatment was relatively brief, with more than half having 10 or fewer sessions directed at the OCD symptoms. Thmtment of obsessions without overt rituals. Until recently, clients without overt rituals were considered much less likely to benefit from behavioral treatment (e.g., Emmelkamp & Kwee, 1977; Stern, 1978). Many appeared to have had mental rituals which remained undetected and therefore untreated (Rachman, 1976b; Robertson, Wendiggensen, & Kaplan, 1983; Salkovskis & Westbrook, 1989). Such mental rituals were found to actually increase rather than reduce discomfort as intended (Salkovskis & Westbrook, 1989). This accords with findings in nonclinical subjects that efforts to suppress even neutral or negative thoughts tended to increase them (Salkovskis & Campbell, 1994; Wegner, 1989). It appears that exposure should be applied only to anxietyprovoking thoughts, and mental rituals should be blocked, via thought-stopping, distraction, or direct substitution of non-ritualistic thoughts. Indeed,

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several studies have demonstrated the benefits of blocking mental rituals (Headland & MacDonald, 1987; Rachman, 1976b; Salkovskis, 1983), particularly by using continuous audiotaped exposures to narrated obsessions (Salkovskis & Westbrook, 1989). Cognitive therapy. Early research on cognitive treatments using selfinstructional training and rational emotive therapy (RET) alone or in combination with behavior therapy was not promising (Emmelkamp, van der Helm, van Zanten, & Plochg, 1980). However, in more recent studies, RET produced good outcomes that were equivalent to those from exposure and response prevention (Emmelkamp et al., 1988), although the combined treatment did not produce an additive effect (Emmelkamp & Beens, 1991). RET led to improvement in both OCD symptoms and in dysfunctional thoughts, the latter requiring more time than the former. Cognitive therapy for OCD using Beck's treatment model to correct dysfunctional beliefs and underlying schema (Salkovskis, 1985) has been tested only in single case studies (Salkovskis & Warwick, 1985) and in a preliminary trial (van Oppen & Arntz, 1994) with good results. More research is certainly needed to confidently identify thoughts, beliefs, and assumptions underlying obsessive fears that constitute appropriate targets for cognitive therapies (see Freeston & Ladouceur, 1993) and to determine whether these cognitions change during exposure and response prevention without deliberate cognitive intervention. While such research is in progress, clinicians may wish to first determine whether clients' problematic thoughts and attitudes change during treatment and if not, whether they can be modified directly via cognitive interventions. Medications and behavioral treatment. Several serotonergic medications have been found helpful for OCD, including clomipramine, fluoxetine, fluvoxamine, and sertraline (for review see Jenike, 1992). Newer medications (e.g., paroxetine) are presently under study. The few studies that have examined the effects of these medications in comparison to or in combination with behavioral treatment have so far reported no advantage of drugs over behavioral treatment and minimal additive effect (Cottraux et al., 1990; Marks, Stern, Mawson, Cobb, & McDonald, 1980; Marks et al., 1988). With this in mind, the addition of serotonergic medications is suggested when clients appear unable to tolerate exposure to feared situations, preferably sequentially applied to allow clients to distinguish the separate effects of medication and the addition of behavioral treatment. Because medication withdrawal often leads to relapse in OCD (e.g., Pato, Zohar-Kadouch, Zohar, & Murphy, 1988), it is advisable to allow clients to remain on medication for several months after intensive behavioral treatment has ended, weaning them slowly when OCD symptom reduction is stable.

Maintenance o f Gains Greater gains on OCD measures after therapy were generally found to reduce the risk of relapse at follow-up, indicating that clients who only partially improved tended to relapse (Foa et al., 1983; O'Sullivan et al., 1991). Although there are some discrepant findings (Emmelkamp, Hoekstra, & Visser, 1985), it appears that clients have difficulty continuing to improve after intensive ex-

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posure and response prevention has ended unless they have made considerable strides during treatment. Those who have achieved substantial initial benefits may be more likely to reapply treatment methods if minor relapses occur (e.g., following life stressors). Therapists are therefore advised to continue intensive treatment until assessment confirms that symptoms are much reduced.

Summary Current State of the Art Methods for diagnosis and assessment of OCD are now well established, with the availability of standardized diagnostic interviewing instruments and reliable and valid interviewer and self-rated instruments for determining types and severity of symptoms (YBOCS, target ratings, MOCI, Padua Inventory, and self-monitoring of OCD symptoms). Theoretical models specifying the relationship of anxiety/discomfort to obsessions and compulsions have led to the very effective use of behavioral treatments using direct exposure (with or without imagined exposure) combined with prevention of rituals as the psychosocial treatment of choice for OCD. Special considerations in applying this therapy include the use of group formats and inclusion of family members. Obsessions without overt rituals have responded to interventions directed at both obsessions and associated mental rituals. Exposure treatment can be combined with serotonergic medications (such as clomipramine and fluvoxamine), preferably sequentially applied and gradually reduced when improvement in symptoms allows. Considerable recent attention has been focused on cognitive features of OCD and on their treatment, with some evidence of the effectiveness of cognitive interventions for OCD symptoms and dysfunctional beliefs.

Challenges for the Future Personalfactors. As noted earlier, several problematic personality traits have been hypothesized to be common in OCD (e.g., perfectionism, risk aversion, over-responsibility) but definitive research on this issue has not been conducted. Nor has the role of such traits been examined with regard to the etiology or maintenance of OCD symptoms or their response to treatment. Further, research on how best to intervene when significant personality disturbance is present is extremely limited. Anxiety-provoking exposures may exacerbate symptoms of clients with extreme mood fluctuations, requiring careful monitoring and perhaps more controlled exposures. Dependent and avoidant traits may impede participation in treatment or require extra effort to counter avoidance of risk, excessive sensitivity to criticism, and dependency on others to make decisions. Whether cognitive treatment would improve outcome for clients with particular personality features is not known. More research is clearly needed to determine the role played by various personality features and whether and how to intervene effectively. As noted earlier, overvalued beliefs (poor insight) regarding catastrophes have been found to interfere with effectiveness of behavioral treatment. In their

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comprehensive review of this subject, Kozak and Foa (1994) noted that overvalued ideas also occur in several other disorders (e.g., schizophrenia, morbid jealousy, hypochondriasis, anorexia nervosa, body dysmorphlc disorder), some of which have gained clinical reputations as difficult to treat, perhaps precisely because of the firmly held convictions. Although Kozak and Foa point to treatments that have been reported to modify delusional beliefs in schizophrenic cases, successful efforts to rectify overvalued OCD beliefs have not been reported, leaving a significant gap in knowledge about the ability of behavioral and/or cognitive interventions to reduce such assumptions. Cognitive assessment and treatment. Related to the above discussion of personality features and insight is the considerable research regarding cognitive processes in individuals with OCD symptoms which has appeared recently, indicating increasing efforts to refine cognitive theories of OCD. It is too early to fully determine its relevance for clinical practice, because treatment research lags considerably behind studies of phenomenology. Nonetheless, this is a long overdue endeavor likely to assist both clinicians and researchers in developing effective interventions that improve success rates even further. However, to be fully comprehensive, such a model would also need to include biological observations such as Otto (1992) has identified in his proposed model for the etiology of OCD, wherein neuropsychological problems in perception, memory, discrimination, and feedback mechanisms are hypothesized to play a role.

Conclusion The outlook for accurate assessment and treatment of OCD symptoms has improved considerably since Meyer (1966) first reported on the highly successful application of exposure and response prevention. With the development of YBOCS, assessment instrumentation is more comprehensive and seemingly more accurate than previously available, although determination of the YBOCS adaptability as a less time-consuming self-report instrument would be useful. Exposure and blocking of rituals has been shown repeatedly to be effective for 75% of subjects so treated. What remains is to determine who has not benefitted sufficiently from this treatment and how to improve their success. To this end, research focused on personality and cognitive features, which are undoubtedly intertwined, is needed to assist in identifying specialized features of OCD that require alternative interventions and to develop and test such treatments. Likewise, the usefulness of including family members in treatment deserves further investigation.

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