Advances In The Cognitive Behavioural Treatment Of .

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Advances in the Cognitive Behavioural Treatment of Obsessive Compulsive DisorderRoz Shafran1, Adam S. Radomsky2, A. E. Coughtrey3, S. Rachman41School of Psychology and Clinical Languages Sciences, University of Reading, UK.2Department of Psychology, Concordia University, Montreal, Canada.3Department of Psychology, University College London, UK4Department of Psychology, University of British Columbia, Vancouver, Canada.Corresponding Author: Roz Shafran, School of Psychology and Clinical Language Sciences,University of Reading, Earley Gate, Reading, UK, RG6 6AL. Tel: 0118 378 8525. Email:[email protected] Count: 4014 (5758 total including references etc.)1

Advances in the Cognitive Behavioural Treatment of Obsessive Compulsive Disorder2

AbstractThe aim of this paper is to highlight key advances in the cognitive-behavioural treatment of obsessivecompulsive disorder over the course of Professor Lars Goran Öst’s illustrious career. The paper willfocus on three specific areas of interest: the treatment of obsessions, compulsive checking and the fearof contamination. It will also highlight recent advances concerning the broader need to ensure thattreatment is acceptable. An increase in acceptability could result in improvements in completion ratesso that more patients benefit from the recent improvements in the science and therapy for thisdisabling disorder.KEYWORDS: OCD; checking; obsessions; contamination; safety behaviour; new3

IntroductionIn a keynote address to the British Association of Behavioural and Cognitive Psychotherapyin London in 2011, Professor Lars Goran Öst gave a typically thorough and scholarly review of theefficacy of the psychological treatment of anxiety disorders over the past 20 years and theirimplementation in clinical practice. One of his key findings was that the effect sizes for the treatmentof anxiety disorders, including obsessive compulsive disorder (OCD), had not increased over thistime. This finding is sad but unsurprising. The results of the first Randomized Controlled Trial (RCT)to evaluate the effects of a psychological therapy for OCD, reported in 1979 (Rachman et al., 1979),showed significant but moderate improvements and the results of the latest 3-site RCT were notappreciably superior (Foa et al., 2005).Despite the disappointing stability of success rates, there have been advances in ourunderstanding of anxiety disorders and associated therapeutic interventions. This paper will focus onthree such advances in OCD. First, we are now able to successfully treat obsessions. This form ofOCD would historically have been an exclusion criterion for trials involving the evaluation ofexposure and response prevention. Second, in recent years, we have begun to understand andformulate compulsive checking, resulting in interventions that include attention to cognitive biasesand metamemory. Finally, treatment for the fear of contamination can now help people who feelcontaminated by their own thoughts, images and memories. This paper will review progress in each ofthese areas, and conclude with a comment on new ideas and data that may help increase theproportion of clients who enter and complete therapy.ObsessionsTo meet diagnostic criteria for OCD, an individual must experience recurrent, egodystonic,repugnant obsessions or excessive, ritualistic compulsive behaviors (APA, 1994). Although themajority of patients with OCD have both obsessions and compulsions, 20-25% of patients are thoughtto have obsessions without overt compulsive behaviour (Freeston & Ladouceur, 1997). Some of thesewill have internal compulsions and will engage in covert mental neutralising which appears to be4

similar to overt compulsive behaviour (de Silva, Menzies & Shafran, 2003). Others, however, will besuffering from obsessional thoughts, images and impulses in the absence of any neutralisingbehaviour. This emphasis on exposure and response prevention is problematic for clients withobsessions. The treatment traditionally involved exposure to the obsession using imaginal or in vivoexposure to obsessions on loop tapes. Such interventions are long, typically produce high levels ofanxiety, can be difficult to tolerate, and have been shown to be of limited benefit when used inisolation (Salkovskis & Westbrook, 1989). Obsessions are essentially a cognitive phenomenon andcognitive interventions may be a preferable alternative to exposure and response prevention.The cognitive analysis of OCD (Salkovskis, 1985) paved the way for a new understanding ofthe persistence of obsessions in the absence of compulsions. It was suggested that what was critical inthe aetiology and maintenance of obsession was the person’s appraisal of normal unwanted intrusivethoughts as indicating that the person was responsible for harm.The cognitive analysis was helpful in focusing attention on appraisals, and it inspired anumber of subsequent investigations into the role of cognitive biases in the maintenance ofpsychopathology. One of these was thought-action fusion. Thought-action fusion has twocomponents. The first is the belief that thinking about harm coming to others increases the likelihoodthey will actually come to harm, and the other is that thinking about harming others is almost asimmoral as actually harming them (Shafran, Thordarson & Rachman, 1996). Biases concerning theclose inter-relationship between appraisals of threat, probablility and control (Moulding, Kyrios &Doran, 2007) were identified. A series of elegant studies by David A Clark and Christine Purdonhighlighted the importance of addressing beliefs about the importance of controlling thoughts (Purdon& Clark, 1994; Purdon & Clark, 2002). An important ‘omission-commission’ bias was identified inwhich patients with OCD were found to equate situations when they failed to prevent harm andsituations where they actual caused harm. To bring the work together, the Obsessive CompulsiveCognitions Working Group was formed, in which six beliefs domains of OCD were rationallydetermined (control of thoughts, importance of thoughts, responsibility, intolerance of uncertainty,overestimation of threat and perfection. Three key interpretations were proposed to be fundamental in5

the maintenance of OCD. These were (i) the importance of thoughts, (ii) the control of thoughts and(iii) responsibility. The group produced a measure to assess such beliefs and interpretations in patients(OCCWG 2003, 2005).At the same time, a cognitive theory of obsessions was developed and subsequentlyelaborated (Rachman, 1997, 1998). The cognitive theory of obsessions states that obsessions arecaused when the person makes catastrophic misinterpretations of the personal significance of his/herunwanted, intrusive, repugnant thoughts. A number of treatment interventions derived from thetheory. Critical to the theory was the notion that the content of obsessions is not random, and thathypervigilance for threat can explain the frequency of obsessions in the absence of compulsivebehaviour.The first RCT on the treatment of obsessive thoughts with 29 patients was published ataround this time (Freeston et al. 1997) with a wait-list comparison. As that research was conductedprior to development of the cognitive theory of obsessions and the work on biases and beliefs, thefundamental component of treatment was imaginal exposure (i.e., loop tape exposure to theobsession) although some cognitive strategies were included. Two-thirds of the participants did wellimmediately after the lengthy 40 hour treatment and just over half the participants maintained theirgains at 6 month follow-up. A promising case series using cognitive therapy without exposure wassubsequently published (Freeston, Leger & Ladouceur, 2001). Taken together, the results indicatedthat obsessions can be successfully treated. More than a decade after the cognitive theory ofobsessions was published (such research is never quick and requires the patience of someone like LarsGoran Öst), a RCT for the treatment of primary obsessions in 73 patients based on the theory of thepersistence of obsessional problems reported an effect size of d 2.34 on the obsessions subscale ofthe Y-BOCS for those who completed treatment (Whittal, McLean, Rachman & Robichaud, 2010). Ina previous study by the authors on the treatment of OCD, an effect size of d 1.84 was reported forexposure and respone prevention (Whittal, Thordardson & McLean, 2005). The study on thepersistence of obsessional problems found stress management training was also effective in thetreatment of obsessions (Whittal et al, 2010). The stress management training involved identifying6

stressful areas of the patient’s life and providing skills training following a modular approach,individualized to the participant. Typically treatment began with applied relaxation (Öst, 1987). Thestudy concluded that primary obsessions should no longer be considered to be resistant to treatment,representing a major advance in the field.Compulsive CheckingThe hallmark of a scholarly clinical researcher like Lars Goran Öst is to subject researchfindings that are incongruous with the observation of the clinical phenomenon to rigorous scientificscrutiny and conservative interpretations of the data. For many years, it has been suggested that OCDcan be considered as a neurological deficit (see Tallis, 1997 for a review). The proponents of thisargument explain compulsive checking as a problem in memory based on performance onneuropsychological assessments. The difficulty with this argument is that the apparent memory deficitin people with OCD has always appeared highly specific – they do not have problems with theirmemory in general. In addition, ask anyone with a contamination fear how an object becamecontaminated, they will tell you in exquisite detail about an event that might have happened more than20 years previously. In the past ten years, we have gained a greater understanding into the functioningof the memories of people with OCD which has, in turn, led to advances in the treatment methodsavailable.A cognitive theory of compulsive checking (Rachman, 2002) was developed to try to betterunderstand the nature and persistence of the problem. The cognitive model of compulsive checkingcomprises three major elements, namely inflated sense of responsibility, gross over-estimations of theprobability of a misfortune and over-estimated expectations of the seriousness of the misfortune. Themodel proposes that compulsive checking is self-perpetuating because it (i) increases perceivedresponsibility (although patients are checking to try to reduce responsibility), (ii) increases perceiveddanger (again, in opposition to the patient’s intention), and (iii) impairs meta-memory (i.e.,knowledge about the contents and regulation of memory). The last of these putative self-perpetuatingmechanisms has become the subject of research studies into the impact of repeated checking. A series7

of elegant studies, led by Marcel van den Hout and Merel Kindt (2003a, 2003b, 2004) demonstratedthat repeated checking of virtual objects by nonclinical participants reliably leads to significantdecreases in memory confidence, vividness and detail; memory accuracy was unaffected. Thefindings were replicated for the repeated checking of real, possibly threatening objects inundergraduate students (Coles, Radomsky & Horng, 2006; Radomsky, Gilchrist & Dussault, 2006),for mental checking (Radomsky & Alcolado, 2010) and for checking using perseverative,compulsive-like staring (van den Hout et al., 2008, 2009).One of the hallmarks of clinical research in OCD is that experimental studies such as thoseconducted by van den Hout and colleagues become incorporated into treatment methods. Cognitivebehaviour therapy for OCD has for many years involved normalising intrusive thoughts, conductingexposure and response prevention and observation of the spontaneous decay of anxiety – all of theseoriginated from experimental research (Rachman & Hodgson, 1980). The experimental work oncompulsive checking is no different, and can now be incorporated into therapy in the form ofbehavioural experiments (Radomsky, Shafran, Coughtrey & Rachman, 2010). The repetition andmemory confidence behavioural experiment has particularly high evidential value. Patients are askedto contrast the impact of checking on their confidence in memory, vividness and detail as well as theirestimates of responsibility and danger when they check repeatedly and when they check once. For thevast majority of patients, the research findings are replicated in the therapy room; they find out thatrepeated checking causes memory distrust. Patients report that they become confused after repeatedchecking and their uncertainty as to whether an object is switched off increases. The minority who donot find that their confidence in memory is affected by repeated checking, typically find there is nodifference in their metamemory when they check once compared to when they check repeatedly. Theexperiment allows such patients to conclude that repeated checking does not aid their memory and istaking up time that could be spent more fruitfully. Similar behavioural experiments stem fromexperimental manipulations of beliefs about memory (Alcolado & Radomsky, 2011), showing that thebelief that one has a poor memory can cause urges to check.8

Behavioural experiments are probably the key intervention in advanced CBT for OCD. Theexperiment on compulsive checking naturally gives rise to discussions about how estimates of dangerand responsibility are influenced by checking but also by other variables such as anxiety. In the mid1990s, the cognitive bias of thought-action fusion was a particular topic of interest. The developmentof a measure of thought-action fusion followed by an experimental analysis of its role in themaintenance of psychopathology spawned a multitude of studies that demonstrated this is a commonbias across anxiety