This interview took place on April 29, 2008, and was conducted by Norman Sussman, MD.
This interview is also available as an audio PsychCastTM at http://psychcast.mblcommunications.com.
Disclosure: Dr. Allen reports no affiliation with or financial interest in any organization that may pose a conflict of interest.
Dr. Allen is both assistant professor in the Department of Psychiatry at the Mount Sinai School of Medicine (MSSM) in New York City and director of psychological services at MSSM’s Center of Excellence in Compulsive and Impulsive Disorders. Her research interests primarily include the treatment of disorders within the obsessive-compulsive spectrum, including obsessive-compulsive disorder and body dysmorphic disorder. In addition, she trains psychiatrists and psychologists on these conditions. Dr. Allen is a widely published author of numerous original research publications and review articles.
What are the basic principles upon which cognitive-behavioral therapy (CBT) is based?
CBT refers to a general approach to therapy that includes many different therapies (eg, behavior therapy, cognitive therapy, dialectical behavior therapy, rational emotive therapy) that share the same general philosophy and basic principles. These therapies focus on relieving current symptoms. CBT is an active, directive therapy wherein a therapist acts as a patient’s coach and collaborates with the patient to determine the goals of treatment and the process. The work outside the sessions is an important part of these therapies. There is a big focus on applying what is learned during sessions to the patient’s life. CBT tends to be very evidence based.
One of the most basic assumptions these therapies share is that emotional reactions come from our interpretations of events, not from the events themselves. An ordinary event can seem like a catastrophe to people with obsessive-compulsive disorder (OCD) because of how they are interpreting it. For example, if someone touches a patient with OCD, this action could cause the patient to internally panic. The patient may feel contaminated and be concerned about bringing this contamination home to his or her children, exposing them to serious illnesses. In this example, CBT would focus on identifying, challenging, and modifying the OCD patient’s faulty beliefs and reasoning.
Basic learning principles underlie the behavioral techniques. When they are applied to OCD, the learning principles would predict that the compulsive rituals and avoidance associated with OCD increase a patient’s fears and reinforce his or her obsessions. For example, an OCD patient who repeatedly checks the stove to confirm that it is turned off feels relieved by that checking. According to learning theory, this relief is reinforcing and increases the patient’s need to check. Taking part in these rituals or avoiding uncomfortable circumstances prevents the fear from subsiding; that is, if the person could resist checking the stove, his or her anxiety would end.
Is there empirical evidence showing the effectiveness of CBT for the treatment of OCD?
Most studies concerning CBT for OCD focused on the major components of CBT, specifically exposure and response prevention and cognitive therapy. In the studies of exposure and response prevention, the participants are placed in a situation that provokes their OCD and they resist the ritual or the response they feel compelled to perform. Empirical evidence is provided by multiple randomized clinical trials1-4 in which exposure and response prevention outperforms an active treatment control. In general, these trials cannot be double blind as the therapist and patient know which treatment is used. However, there have been trials5,6 comparing exposure and response prevention conducted by a therapist versus by a computer (with the patient also using written self-help materials) that show exposure and response prevention is more effective than placebo or control treatments in reducing OCD symptoms.
The most powerful evidence for the efficacy of exposure and response prevention comes from brain imaging research during the early 1990s. Studies7,8 using positron emission tomography scans prior to and following treatment showed that exposure and response prevention as well as serotonin reuptake inhibitors normalize brain activity.
In terms of the cognitive approach, correcting the patient’s cognitive errors and faulty reasoning is the primary focus. There is evidence from several randomized controlled trials9-12 showing that cognitive approaches are as effective as exposure and response prevention in certain ways and definitely more effective than control treatments. However, the studies showing cognitive therapy to be as effective as exposure and response prevention include behavioral experiments. In these experiments, the patients participate in brief exposures to test the validity of their fears, that is, to see if the feared consequences occur. The major difference between exposure and response prevention and cognitive therapy in these trials is that the exposures were shorter in length in the cognitive therapy conditions. In addition, it is not clear what other kinds of exposures the patients may have faced during the studies, so whether cognitive therapy is effective without exposures is still debatable. At this point, it is unclear that exposure and response prevention is not the central or most powerful curative element in OCD.
Cognitive therapy research indicates that the main drawback to exposure and response prevention is that some patients will avoid such therapy altogether or will drop out of it because they find the very idea of the exposures too scary. I think it is important to consider that perhaps exposures do not need to be as long as we had believed in order to be effective. In reality, most cognitive-behavioral therapists use both exposures and cognitive techniques. Teasing apart the contributions of each might not have that much of an impact on the treatment in the real world.
What is relaxation training?
It is a part of CBT that is frequently used, but it is not an effective monotherapy for OCD. However, OCD symptoms are often exacerbated by stress; therefore, relaxation and stress management is part of the treatment. For patients who have a terrible time tolerating anxiety and a phobia of the anxiety itself, decatastrophizing anxiety and helping them learn to be less anxious is imperative.
Relaxation training usually has two elements, ie, deep breathing and muscle relaxation. Deep breathing techniques are taught in sessions and practiced out of session. After patients learn it, they can apply it in stressful situations, possibly reducing the autonomic elements of stress. Progressive muscle relaxation techniques ordinarily include having the patient listen to a 10–30-minute long tape that gets him or her to relax each muscle group, starting with the toes. The goal is to have patients learn what relaxed muscles feel like while following the tape and be able to relax them in the real world when they feel stressed. The more patients practice and perform these techniques, the more relaxed they can become.
Some patients with OCD will get extremely anxious (eg, sweat, have palpitations) when they are in situations that provoke their OCD fears. For example, a patient of mine with contamination fears had a lot of trouble at work when colleagues would pat him on the back. Since he could not avoid this or immediately leave and wash his clothing, it was helpful for him to learn relaxation techniques to help him to control his anxiety in these situations. He learned deep breathing, so as soon as he started to feel symptoms of anxiety he would take a few deep breaths. This often turned the situation around and enabled him to stay and behave appropriately. Relaxation training is not going to cure the disorder, but it can make unavoidable situations more manageable. Training patients to be aware of their anxiety early is key. If they wait until they are already panicking, then the techniques are not as effective.
Does CBT help people realize that their symptoms result from the illness?
Yes. Most patients with OCD have fairly good insight. However, when they are faced with a scary situation, a contamination situation, or a situation wherein they think they did not turn off the stove, they might lose their insight in those moments and think there is real danger. If patients completely lack insight, it presents real problems in treatment, but it is more likely for insight to be a problem in OCD situations.
It is very valuable for patients both to know that their symptoms result from OCD and to be able to identify the specific thoughts and behaviors related to the disorder. Some patients might not know about OCD; they may think they are going crazy. When a clinician educates the patient about OCD, it can be reassuring to find out what the problem is and that there is a name and treatment for it. In addition, I typically use a cognitive assignment wherein people label their OCD thoughts and behaviors to help them become aware of when their thoughts and behaviors are an expression of their OCD. Over time, labeling helps patients with OCD to recognize that a thought or behavior is OCD rather than a realistic concern or reaction, ultimately helping them to be less upset by their intrusive thoughts and to resist performing their rituals.
Do symptoms get worse during the course of treatment as the patient attempts to alter behavior or thoughts?
When patients are in CBT, the exposure and response prevention exercises will be more stressful than the same situation would be if the patient just went ahead and performed an OCD ritual; that is to be expected and the patients should be educated to understand that. However, trying to do too much too quickly can be a problem. It is important to make sure that the exposures are not too stressful for the patient. The goal is for the exposures to be tolerable, to increase anxiety but not so much that the patient will resort to a ritual to reduce his or her anxiety; this is considered necessary for exposure and response prevention to succeed in reducing OCD symptoms. An exposure can backfire if it is too severe because the patient can get extremely upset, lose confidence in the technique, or even leave therapy. Having patients work on too many things simultaneously can also be a problem; a realistic plan of action should be created. If a patient tries to stop performing many rituals at the same time, the patient’s likelihood of success is lowered. For example, when a person decides to go to the gym every morning before work to get in better shape, he or she most likely will not stick to that plan. A more realistic exercise plan would have a better chance of being carried out.
Sometimes, symptoms will worsen during a fairly typical treatment. For example, the patient may have successfully reduced his or her checking the stove as part of an assignment but may find he or she is checking something else such as the windows to make sure they are locked. This situation does not usually create a problem, despite the worsening symptoms. Once they realize that another symptom is increasing, patients can usually reduce the behavior back to the baseline level and keep it there; if not, the increased symptoms can be specifically targeted in therapy. In my experience, a significant worsening in symptoms that cannot be easily reversed is usually due to one of three factors. First, another stressor could be increasing the OCD in general. Second, the patient could be completing assignments incorrectly and inadvertently reinforcing the OCD. Third, the patient may be at a major point of improvement and is getting anxious about that.
Is there a specific time course for treatment with CBT?
It is reasonable to expect to see improvement in as early as 3–4 weeks. If the patient is completing the assignments and the exposures, then he or she is going to benefit from therapy. Whenever a patient cannot complete an assignment, the patient and the therapist need to trouble shoot to figure out what might be interfering. If the patient is still not able to complete assignments after the first 3–4 weeks, the therapist has to consider the problem and discuss it with the patient in terms of possible treatment options. For example, it is possible that a medication could help the patient tolerate exposures. If a patient does not want to go on medication, the therapist can negotiate with him or her. The therapist could suggest that the patient try the exposures without medication for a few more weeks, but if the patient is still not able to do the exposures within that time period then medication will become part of treatment. That may motivate the patient to do the exposures.
Certainly after 6–8 weeks patients should notice that they can manage specific situations better, though they may not feel that the disorder is markedly improved. Results show quickly, but most studies are conducted within 12 weeks, which is not adequate time for treatment in most OCD cases. A clinically meaningful response will be found in that period of time, but there will be many residual symptoms. In private practice, I would generally recommend much longer treatment in order to do a better job of getting rid of symptoms.
How would the importance of consistent reinforcement versus intermittent reinforcement impact the treatment negatively or positively?
I think consistency is very important. There is a long line of basic learning research13 that shows things learned with random, intermittent reinforcement are very difficult to extinguish. For example, in some research conducted using rats, the researchers would train rats to press a lever to get a piece of kibble. Using continual reinforcement, the rat would get a piece every time they pressed the lever. Using random, intermittent reinforcement, the rats receive a piece of kibble unpredictably; the outcome of pressing the lever is unpredictable. Other rats might be given kibble consistently, say every tenth time the lever was pressed. When the researchers stopped feeding them, the rats that were fed on the random intermittent reinforcement schedule continued to press the lever for food for much longer than rats in any of the other conditions; the rats that were fed every time they pressed the lever stopped pressing the quickest. The lever pressing behavior was much more difficult to extinguish in the random, intermittently fed rats.
In OCD, the concept of intermittent reinforcement can easily be applied to reassurance seeking. OCD patients will often ask their families for reassurance (eg, whether something is contaminated), and families will reassure them to calm them, thus unknowingly reinforcing the OCD. If families realize this is reinforcing the disorder, they may attempt to stop it. However, they are often inconsistent in doing so. For example, patients may beg their families for reassurance and the families may occasionally give in and provide this reassurance. Based on learning theory, this is going to make patients continue to seek reassurance and it will be even more difficult to extinguish than if they had kept reassuring them continuously. That is, OCD patients will continue to ask for reassurance because it succeeds; they get the reassurance and it calms them for the moment. Importantly, not getting reassurance on a particular occasion will just make them ask more because they have learned that they will get reassurance eventually.
In addition, since the families are most likely to give in when the patient is upset and out of control, the patient’s more extreme behavior is selectively reinforced. Not only is the patient going to continue to ask for reassurance, but the intensity of the requests will increase since that is what is being reinforced and that is what persuades the family.
This can also be applied to situations in which a patient tries to resist performing rituals. The patient will resist until he or she cannot take it anymore. When the individual can no longer take it, he or she will give in to the urges and perform the behavioral rituals. The OCD urges are reinforced intermittently. However, there is a pattern—the more intense a patient’s OCD distress, the more likely he or she is to give in and perform the ritual, so the OCD is strongly reinforced. This is common among patients who try to apply CBT on their own. Numerous patients believe that CBT does not work based on their efforts to stop their rituals on their own. However, that is only because they intermittently reinforced the disorder.
It is common for OCD patients to seek reassurance from their clinicians and it is important for the clinicians to avoid reinforcing their patients’ OCD. I usually tell obsessive patients that they cannot ask repeat questions during phone calls or therapy sessions. They can ask any question once, including matters concerning particular side effects or whether or not something is OCD or is really dangerous. An obsessive patient can be very repetitive, and this is harmful to them. If a patient asks a question once and repeats it, a therapist should remind him or her that the question has already been answered, but that is all that should be done. The patient should not get to ask that question anymore. In explaining that to the patient, I emphasize how repeating questions is not good for them, not that it is bothersome. I tell them that performing these rituals reinforces their OCD and that I cannot be complicit to worsening their condition. PP
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