The Therapy in Treating Obsessive-Compulsive Disorder - Essay Example

? The Effectiveness of Cognitive-Behavioral Therapy in treating Obsessive-Compulsive Disorder Nixon Cornay MGH Institute of Health Professions Individual Psychotherapeutic Interventions: Adults and Elders NP 855 Susan Stevens, DNP, PMHNP-BC & Janice Goodman, PhD, PMHCNS-BC Obsessive-compulsive disorder (OCD) is a pervasive, frequently debilitating, and often severe anxiety disorder characterized by the presence of obsessions and/or compulsions. The disorder affects up to three percent of the population and affects both genders equally, with a modal onset of six to fifteen years of age for males and twenty to twenty-nine for females (Bjorgvinsson, Hart, & Heffelfinger, 2007; Bjorgvinsson et al., 2008). According to the Diagnostic Statistical Manual of Mental Disorders Text Revision (DSM-IV-TR), the essential features of Obsessive-Compulsive Disorder are recurring severe obsessions or compulsions that are be time consuming (i.e., they last for more than one hour per day) or cause marked distress or significant impairment. Obsessions can be thought of as constant ideas, thoughts, impulses, or images (not simply excessive worries about real-life problems, such as financial work or school problems) that are invasive, inappropriate, and may cause severe anxiety or distress (American Psychiatric Association, 2000). On the other hand, compulsions are recurring behaviors (e.g., hand washing, ordering, or checking) or mental acts (e.g., praying, counting, or repeating words silently), the goal of which is to put off or decrease anxiety or distress and not to provide pleasure or gratification (American Psychiatric Association, 2000). Although, in a limited number of cases, a patient may have only obsessions or compulsions, the vast majority of patients experience both. A combination of these may cause significant distress and impairment in daily functioning and can have a substantial effect on the quality of life of the sufferer (Bjorgvinsson, 2007). In fact, in the year 2000, OCD was among the top twenty causes of illness-related disabilities for people aged fifteen to forty-four (Bjorgvinsson, 2007). The majority of sufferers are diagnosed by the age of nineteen, and symptoms of OCD may be felt on or off or fluctuate at different times (National Institute of Mental Health, 2011). The reported lifetime prevalence of pediatric OCD is similar, at between one and three percent, while one-third of adults suffering from OCD had suffered from its symptoms during childhood (Bjorgvinsson et al., 2008). This essentially indicates that when the disorder occurs in childhood it continues into adulthood without remitting itself. Cognitive-behavioral theories have been developed for several anxiety disorders, including panic disorders, social phobias, generalized anxiety disorders, and, of course, OCD (Storch, Mariaskin, & Murphy, 2009). Over the years, researchers have examined and compared the effectiveness of cognitive behavioral therapy (CBT) to no treatment at all, stress management training, randomized controlled trials, wait list controls, and SRIs to treat OCD. The findings indicate that the first-line treatments are cognitive-behavioral therapy (CBT) along with exposure and response prevention (ERP) and pharmacotherapy. Serotonin reuptake inhibitors (SRIs) (e.g., clomipramine and various selective serotonin reuptake inhibitors (SSRIs)) are effective in roughly sixty to seventy percent of patients (Simpson, et al., 2008; Freyer et al., 2011). It was also found that in clinical practice, SRIs are used most frequently. But, because they typically yield only a twenty to forty percent reduction in OCD symptoms, many SRI responders continue to have clinically significant symptoms (Simpson et al., 2008). Therefore, exposure and response prevention (ERP) is a firmly established psychosocial treatment for obsessive-compulsive disorders (Whittal et al., 2008). For example, in a wait-list-controlled open trial study that included 20 adult OCD patients who were non-responders to multiple medications, after a one-month wait-list period and fifteen sessions of outpatient CBT incorporating exposure and ritual prevention, it was found that OCD severity decreased significantly and gains appeared to have been maintained over a six-month follow-up period (Tolin et al., 2004). In a more recent randomized controlled trial that included 111 patients at two academic outpatient clinics to compare the effects of augmenting SRIs with exposure and ritual prevention versus stress management training, it was found that exposure and ritual prevention was superior to stress management training in reducing OCD symptoms. In fact, after eight weeks of the trial, more patients who received exposure and ritual prevention than patients who received stress management training had a decrease in symptom severity of at least twenty-five percent (Simpson et al., 2008). Similarly, exposure-based cognitive-behavior therapy (CBT) is well-documented as an effective and relatively robust intervention for pediatric obsessive compulsive disorder (OCD). Its advantages over other treatment modalities (e.g. relaxation treatment (RT)) and serotonin reuptake inhibitor medication in terms of safety and response durability make it the current first-line treatment for pediatric OCD (Peris et al., 2012). For instance, Freeman et al. (2008) conducted a randomized study of family-based CBT versus relaxation treatment for pediatric OCD of forty-two children ranging in age from four to eight years old; parents were randomly selected to receive twelve sessions of family-based CBT or family-based RT. For the completer sample, CBT had a large effect (d=0.85) and there was a significant group difference favoring CBT. In the intent-to-treat sample, fifty percent of children in the CBT group achieved remission compared to twenty percent in the RT group. In the completer sample, sixty-nine percent of children in the CBT group achieved clinical remission compared to twenty percent in the RT group. OCD is a neuropsychiatric and biologically-based disorder that is associated with abnormal neuronal functioning in a corticostriatal circuitry mediating inhibitory control and flexible responding. The disorder’s symptomalogy has been linked to problems in adequate regulation of brain neurotransmitter serotonin. Several studies have demonstrated that patients with OCD exhibit a quicker metabolism during rest conditions, predominantly in the orbitofrontal cortex and striatal areas in comparison to healthy controls (Bjorgvinsson et al., 2007; Freyer et al., 2011). Therefore, in addition to treating and managing symptoms of OCD, the neurobiological and cognitive functioning of the brain has also been investigated. Porto et al. (2009) conducted a systematic review of the various studies that used neuroimaging techniques (e.g., MRI and PET) to examine if any neurobiological changes exist when anxiety disorders are treated with CBT, SRIs, or both. In order to carry this out, Porto et al. (2009) reviewed ten studies on neurobiological changes due to CBT and the adult patients involved with anxiety disorders, particularly OCDs, post-traumatic stress disorders, specific phobias, panic disorders, and social phobias. In one study, participants presented improvement of symptoms both in the fluoxetine and in the behavioral therapy group. The neuroimaging findings after treatment showed a decrease of the right anterior cingulated and left thalamus in the fluoxetine group that responded to the treatment. The head of the right caudate nucleus presented a significant decrease in both treatments. As such, it was concluded that the glucose metabolism of the head of the right caudate nucleus changed in patients who were treated successfully with both behavioral therapy and fluoxetine. There was also significant correlation of activity of the orbital cortex with the caudate nucleus and thalamus before treatment in patients who responded; this disappeared after the treatment’s success (Porto et al., 2009). Subsequent studies also found that patients presented activation of the left orbital frontal cortex, temporal cortex, and parietal cortex during the task of symptom provocation before receiving treatment. After CBT treatment, patients showed a decrease of activation in the orbital frontal cortex (Porto et al., 2009). Clearly, patients’ neural activity associated with OCD was positively modified with the use of CBT; thus, this should spark more interest for further research. Evidently, obsessive-compulsive disorder has puzzled experts in the field for centuries (Starcevic & Janca, 2011). Recent work has focused on categorizing OCD beyond symptom presentation, including age of onset, neuropsychological functioning, and genetic and cognitive factors (Bjorgvinsson et al., 2007). The heterogeneity and idiosyncratic nature of OCD symptoms presents unique challenges to the development of content valid assessment instruments (Abramowitz et al., 2010). Although there is no agreed-upon method for identifying OCD subtypes, unwanted intrusions with repugnant content (e.g., sexual, physical, or blasphemous) have been identified as one potential subtype (Woody et al., 2011). Furthermore, unlike other subtypes of OCD (where there is a predominance of overt compulsions such as contamination/washing or doubting/checking), primary obsessions are more commonly associated with covert responses (Woody et. al., 2011), whereby a person feels compelled to perform an action repeatedly until it “feels right” (Bjorgvinsson et al., 2007). Therefore, a dilemma still exists as to whether OCD is primarily an affective disorder, a disorder of thinking characterized by obsessions, or a behavioral disorder characterized by compulsions (Starcevic, V. & Janca, A., 2011); the DSM-IV-TR classifies OCD as an anxiety disorder (American Psychiatric Association, 2000). Experts have now proposed removing OCD from the anxiety disorders section and grouping it with putatively related conditions in the fifth edition of the DSM (Bievenu et al., 2012). In this proposal, it is suggested that OCD is better explained as occurring on a spectrum of disorders that share overlapping symptoms. Three categories of obsessive-compulsive spectrum disorders (OCSDs) have been identified: (1) neurological disorders with repetitive behaviors (e.g., tic disorders); (2) impulse control disorders (e.g., tricholillomania); and (3) body image, body sensitization, and body weight concern disorders (e.g., body dysmorphic disorders) (Bjorgvinsson et al., 2007). As experts continue to work on the appropriate diagnosis for OCD in the upcoming DSM-V, patients continue to struggle with its daunting symptoms. An accurate diagnosis of OCD and the identification of a qualified treatment provider remain the two greatest obstacles to OCD treatment (Storch & Merlo, 2006). As of right now, treatments for OCD that have shown efficacy are the cognitive-behavioral therapy, which include ERPs, and pharmacotherapy, which include SRIs (Bjorgvinsson et al. 2007). The majority of those who complete treatment will experience substantial decreases in obsessions and compulsions and will retain this over time (Whittal et al., 2008). On the other hand, researchers do not yet understand why CBT works as well as it does; this suggests the need for more robust and advanced research in the field. References Abramowitz, J. S., Deacon, B. J., Olatunji, B. O., Wheaton, M. G., Berman, N. C., Losardo, D., & Hale, L. R. (2010). 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L., Robichaud, M., Thordarson, D. S., & McLean, P. D. (2008). Group and individual treatment of obsessive-compulsive disorder using cognitive therapy and exposure plus response prevention: A 2-year follow-up of two randomized trials. Journal of Consulting and Clinical Psychology, 76(6), 1003-1014. Woody, S. R., Whittal, M. L., & McLean, P. D. (2011). Mechanisms of symptom reduction in treatment for obsessions. Journal of Consulting and Clinical Psychology, 79(5), 653-664. Read More