Table of Contents

1. Description of Obsessive-Compulsive Disorder (OCD); 1.1. Terminology; 1.2. Definition; 1.2.1 Insight; 1.3. Epidemiology; 1.4. Course and Prognosis; 1.5. Differential Diagnosis; 1.5.1 Generalized Anxiety Disorder; 1.5.2 Depression; 1.5.3 Tics and Tourette's Syndrome; 1.5.4 Delusional Disorders; 1.5.5 Impulse Control Disorders; 1.5.6 Obsessive Compulsive Personality Disorder; 1.5.7 Hypochondriasis; 1.5.8 Body Dysmorphic Disorder; 1.6. Comorbidities; 1.7. Diagnostic Procedures and Documentation; 1.7.1 Structured Diagnostic Interview; 1.7.2 Semi-Structured Symptom Interviews; 1.7.3 Self-Report Inventories; 1.7.4 Documenting Change in Symptom Levels; 2. Theories and Models of OCD; 2.1 Neuropsychiatric Theories; 2.1.1 Neurochemical Theories; 2.1.2 Neuroanatomical Theories; 2.2 Psychological Theories; 2.2.1 Learning Theory; 2.2.2 Cognitive Deficit Models; 2.2.3 Contemporary Cognitive-behavioral Models; 3. Diagnosis and Treatment Indications; 3.1 Form Versus Function; 3.2 The Diagnostic Assessment; 3.3 Identifying the Appropriate Treatment; 3.3.1 Empirically Supported Treatments for OCD; 3.4 Factors that Influence Treatment Decisions; 3.4.1 Age; 3.4.2 Gender; 3.4.3 Race; 3.4.4 Educational Level; 3.4.5 Patient Preference; 3.4.6 Social Support; 3.4.7 Clinical Presentation; 3.4.8 OCD Symptom theme; 3.4.9 Insight; 3.4.10 Comorbidity; 3.4.11 Treatment History; 3.5 Presenting the Recommendation for Cognitive-Behavioral Therapy (CBT); 4. Treatment; 4.1. Methods of Treatment; 4.1.1 Functional Assessment; 4.1.2 Self-Monitoring; 4.1.3 Psychoeducation; 4.1.4 Using Cognitive Therapy Techniques; 4.1.5 Planning for Exposure and Response Prevention; 4.1.6 Implementing Exposure and Response Prevention; 4.1.7 Ending Treatment; 4.2. Mechanisms of Action; 4.3. Efficacy and Prognosis; 4.4. Variations and Combinations of Methods; 4.4.1 Variants of CBT Treatment Procedures; 4.4.2 Combining Medication and CBT; 4.5. Problems in Carrying out the Treatments; 4.5.1 Negative Reactions to the CBT Model; 4.5.2 Nonadherence; 4.5.3 Arguments; 4.5.4 Therapist's Inclination to Challenge the Obsession; 4.5.5 When Cognitive Interventions Become Rituals; 4.5.6 Unbearable Anxiety Levels During Exposure; 4.5.7 Absence of Anxiety During Exposure; 4.5.8 Therapist Discomfort with Conducting Exposure Exercises; 5. Case Vignette; 6. Further Reading; 7. References; 8. Appendix: Tools and Resources.

Reviews

"Dr. Abramowitz has done a remarkable job in taking difficult to understand concepts and making them easy to grasp. This is the most practical, user-friendly guide to date. It is a quick, but informative read by one of the premier thought leaders in the field of OCD. This is a must read for clinicians and students alike, and will be required reading for our staff and trainees." Bradley C. Riemann, PhD Clinical Director, OCD Center at Rogers Memorial Hospital, Oconomowoc, WI "Dr. Jonathan Abramowitz is one of the world's leading experts on Obsessive Compulsive Disorder and has cumulated years of hands-on experience. In this very readable treatment program, he makes these strategies and his experience available to the therapist. Anyone treating patients with Obsessive Compulsive Disorder will want to have this resource." David H. Barlow, PhD Professor of Psychology, Research Professor of Psychiatry, Director, Center for Anxiety and Related Disorders at Boston University "This book does a fine job of combining cognitive and behavioral interventions into an integrated program of therapy. Dr. Abramowitz' detailed attention to symptom subtypes is especially useful for therapists learning to apply CBT to the many varieties of obsessions and compulsions. The highlighting of clinical pearls, vignettes, and therapeutic dialog is particularly helpful and makes this manual very user-friendly." Gail Steketee, PhD Professor, Boston University School of Social Work "This book focuses on the evidence-based intervention for the treatment of obsessivecompulsive disorder (OCD). Relatively short and easy to read, this manual may be very helpful for both beginning therapists and therapists interested in reviewing a detailed background and description of OCD. The book gives a concise but thorough overview of current theories and models of intervention, diagnosis and treatment indications, current methods of treatment options, case examples, and suggested handouts and treatment forms. Abramowitz uses the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) to provide a definition of OCD as an anxiety disorder with a defined presence of obsessions or compulsions. He defines obsessions as "intrusive thoughts, ideas, images, impulses, or doubts that are experienced as unacceptable, senseless, or bizarre and that evoke subjective distress in the form of anxiety or doubt" (p. 1). The book references the Epidemiologic Catchment Area study, which is now 15 years old, regarding OCD having a one-month prevalence of 1.3 percent and a lifetime prevalence of two to three percent in the adult population (Karno, Golding, Sorenson, & Burnam, 1988). The book also references the study regarding the fact that adults with OCD show some range of insight into the oddness of their belief system and acknowledge the irrationality of their ideas and symptoms. OCD has gained public awareness in recent years through a popular movie starring Jack Nicholson (As Good As It Gets; Brooks, 1997). In this movie, also starring Helen Hunt as his love interest, the main character reduces his OCD symptoms by realizing that he will continue down a road to isolation if he does not get treatment. He is resistant to treatment, but medication and involvement with other humans (and a new pet) provide him with the motivation to attend to his peculiar behaviors. This entertaining yet predictable movie probably single-handedly increased awareness and increased the number of patients seeking treatment for OCD. This book on OCD discusses the background and describes the course and prognosis and how it typically develops gradually, although there are some exceptions to this, through childhood games and magical thinking as well as in those exposed to significant hormonal changes (pregnancy, changes in medical conditions). Abramowitz also distinguishes between OCD and obsessive-compulsive personality disorder (OCPD) and identifies that there actually are more differences than similarities between the two. For instance, individuals with OCPD exhibit the traits of rigidity and inflexibility, meticulousness, and sometimes impulsive anger and hostility as part of their worldview; these traits are more characterological of OCPD than OCD. The author describes this as more "ego-dystonic" in nature, thus OCD symptoms are resisted and symptoms in individuals with OCDP are many times seen as second nature and not as a disturbance. The author lays out a number of other symptoms that may be evident in OCD, symptoms that are commonly part of another disorder such as generalized anxiety disorder, depression, tics and Tourette's syndrome, delusional disorder and impulse control disorders, hypochondriasis, and body dysmorphic disorder. There are only brief descriptions of each, but his point is perhaps to assist readers in their awareness of comorbid issues and disorders rather than providing a full education on each of the above-mentioned disorders. There are only a few brief sentences on each, but they are enough to assist the reader to make the link to OCD. Abramowitz identifies a few assessment devices such as the Yale-Brown Obsessive-Compulsive Scale (Goodman, Price, Rasmussen, Mazure, et al., 1989), which is a symptom checklist with a severity rating scale. He discusses the use of this instrument and two other instruments, along with the semistructured symptom interview, to assess the degree of OCD. He also briefly describes several other useful instruments for assessing levels of OCD behavior in conjunction with depression and anxiety. Abramowitz describes these instruments to provide the therapist with the important foundation of working with the patient to provide a baseline of data that can then be revisited and reviewed during the treatment process to assist in the measurement of change. Thus, the evidence-based practice involves the client in the recognition and awareness of change regarding symptoms. He takes the science and applies it to the patient to increase the patient's adherence to and understanding of the treatment phase, which he discusses later and more in detail in the book. Before getting into the treatment issues, Abramowitz gives an excellent review of theories and models of how OCD is learned or biochemically based (influenced). This background gives the reader a better understanding of the fact that treatment is going to work best if the patient can understand how "normalizing" his or her OCD symptoms (anxiety) is actually interfering with his or her ability to adjust and see the irrational belief systems as anything less than an effective "neutralizer" of OCD symptoms. He makes a good point that the patient cannot get past many of these symptoms until they are faced through a safe and structured environment that can be achieved in therapy. It is true that a number of patients reduce and manage their OCD symptoms through medication intervention, and the author does not discount the important of cotreatment with biologically based intervention. I can say, for the many patients that I have treated that have characteristics of OCD, they are tremendously relieved when their drives or compulsions are decreased through medication. Many patients disappear at that stage, and I don't see them for a while. However, it is not long before several of them show up or return and find that they have integrated the medication into their rituals and are now using it as part of the compulsion to deal with their anxiety. The medication becomes an ineffective anxiety reducer. Abramowitz emphasizes a very important point: Patients need to be educated and to specifically agree to the treatment plan. He describes this cooperative plan, including information about the likelihood of confronting anxieties through a "safe" treatment approach that is designed to move the patient forward in his or her treatment regimen while facing, managing, and conquering his or her "perceived" anxieties and fears versus masking them with medication or other ritualistic anxiety reducers. This would provide a cognitive map for the patient on what to expect as part of his or her treatment and may reduce treatment resistance during times when it feels like it is more difficult to go to therapy than to deal with the OCD. The Diagnosis and Treatment Indications section thoroughly discusses the above issues and the importance of a diagnostic assessment as part of the treatment that uses a cognitive behaviorally focused diagnostic interview that obtains the patients'general description of the problem and how it is interfering with their daily life circumstances. The evaluation and assessment also provides a historical course for the problem, in which information is obtained regarding family, medical, psychiatric, and substance use history. After a thorough assessment is completed and the diagnosis is confirmed, the provider works with the patient to identify and spell out the most appropriate treatment for the severity of the condition. This brings the patient into the therapy contract, as this disorder has some special effects that include a pattern of reducing anxiety by avoiding the offending stimulus and developing ritualistic interventions that are now causing more problems than the original fear or anxiety. Abramowitz discusses and reviews the effectiveness of, as well as the advantages for, using specific interventions, primarily cognitive-behavior therapy (CBT). In an excellent section, he discusses presenting the recommendation for CBT to the patient. If his recommendations are followed for presenting the diagnosis and treatment options to the patient, it seems likely that the success of the intervention will increase. I have seen many patients who have been told they have OCD, but their counselors have not done much beyond identifying the characteristics, naming the disorder, and discussing the irrational beliefs the patients may hold. The author's method of presenting the recommendations to the patient will engage the patient to become part of the treatment and to acknowledge that there will be times when the treatment is uncomfortable and that this is an expected phase in a successful outcome. Methods of treatment and functional assessment are discussed in Chapter 4. The author provides snippets of cases that relate to how the patient may or may not respond to certain aspects of the treatment. Specific examples are given for each section, which include assessing obsessional stimuli, cognitive features of obsessional thinking, fears and consequences, misinterpretation of obsessional thoughts, and fears of experiencing long-term anxiety. He also discusses self-monitoring, psychoeducation, normalizing obsessional thinking, the role of dysfunctional interpretation in OCD, and the role of avoidance and safety seeking in maintaining OCD. He also presents an easy to follow method for planning for exposure and response prevention and information on how to design a fear hierarchy as well as how to introduce exposure tasks for patients to practice on their own. There are special situations in which the provider would be with the patient to assist in the responsible confrontation of irrational thoughts and disputing dysfunctional belief systems that are clearly described. A significant component in the successful treatment of OCD is emphasized regarding the conclusion of each treatment session. This includes reviewing progress and discussing plans for the next session's exposure exercise. This is an excellent way to work with the client in building a cognitive strategy that most likely reduces the anxiety of unexpected consequences and anticipatory anxiety, thus leading to treatment withdrawal and resulting in treatment failure. The author also spends some time on problems in carrying out the treatment and nonadherence. He provides an interesting clinical vignette on the use of Socratic dialog to address patient arguments. Chapter 5 provides a few clinical vignettes that are helpful to demonstrate some of the constructs he discusses in previous chapters. I thought it would be helpful to have many more of these vignettes. The three that are provided are fine, but I believe it would be helpful to have a few more. The book also provides some example forms for assessment and rating that the clinician can copy and use in his or her practice, along with some appropriate references. Overall, this book is short and to the point. Clinicians should find this a helpful guide to the treatment of OCD. It can also be used as a refresher on an evidence-based intervention in the treatment of OCD." Reviewed by Jeff Baker in PsycCRITIQUES, 6/12/2006