Dr. Laura Caccico – Psychologist and Psychotherapist.

IPSICO, Institute for Behavioral and Cognitive Psychology and Psychotherapy, Florence.

www.ipsico.it

Cognitive Behavioural Treatment in OCD

Obsessive-Compulsive Disorder is a disabling disorder characterized by the onset of unwanted and distressing intrusive thoughts, images or impulses and/or repetitive behaviours or mental acts aimed to alleviate the discomfort or to prevent dreaded events from occurring.

The lifetime prevalence is 2/3 % worldwide, the tenth among the major disability causes in the world and often starts in adolescence or in early adulthood, usually in gradual onset (APA, 2000).

For these and other reasons it is carefully studied. And the standard cognitive and behavioural approach has been recognized for a long time as the most effective treatment for childhood and adulthood.

In particular, the exposure and response prevention (ERP) is the most validated psychological treatment for this disease. Several studies show that up to 75% of the patients treated with this method, improved significantly and maintain the results in the follow-up (Menzies & De Silva, 2003).

Despite the efficacy of these measures, a significant number of patients suffering from OCD, treated as well as the standard protocol of CBT and the SSRI have a high relapse rate (80-90%) (Pato, ZoharKadouch & Zohar, 1998).

Moreover, the ERP could be associated with a significant drop-out (25%) because the high anxious nature of this intervention. Furthermore, the ERP has a low effect with subjects that show pure obsession and overvalued ideas (Kyrios, 2010).

Another alternative possibility to apply these measures could be intensive treatment, where the application of evidence based measures take place every day in a restricted period of time, usually between 3 and 10 weeks.

The intensive treatment is indicated for that patient who:

• does not respond to the standard treatment.

• Needs a quick clinical improvement (Bevan et al., 2010).
• Needs motivation (Storch et al., 2003).
• Has high emotional reactivity, a low insight or diffculties to comprehend the rational, which makes the ambulatory treatment difficult (Ben-Arush, Wexler, & Zohar, 2008).
• Has severe symptoms that strongly limit the daily functioning (Bohni et al., 2009).
• Live far away from the clinic that provides specialistic facilities (Storch, Merlo, Lehmkul, et al., 2008).

The specific protocol of the intensive treatment use at IPSICO

The protocol that we use in our Institute takes place in some steps:

1. Selection phase before the treatment. Usually one or two months before. If it is necessary, there is also a psychiatric consultation.
2. Initial assessment, usually during the first week, when the therapeutic project is planned.
3. Intensive psychotherapeutic treatment based on the Cognitive and Behavioural approach.
4. If there is a request, there is an initial and final interview with the families.
5. Psycho-diagnostic phase to verify the results.
6. The patient is sent to a reference therapist in his area.
7. Periodic verifying meetings, after the conclusion of the treatment, until 12 months.

The protocol has a fixed duration of five weeks, the first week is for the assessment and  the other four weeks are for the intervention.

The psychotherapeutic CBT procedure is daily applied for five days a week divided in:

• tree hours weekly sittings of psychotherapy
• ten weekly sessions of about two and a half hours, from Monday to Friday for the programme intervention.

The team consists of the psychotherapist in charge, the reference psychotherapist, two co-therapists, that do in an alternative way the daily session of ERP or integrative intervention. We also have a reference psychiatrist.

There is a weekly meetings to follow and reconsider the intervention during the period.

The many obstacles to the path that we must often meet are:

• Functional impairment.
• Personality disorders: we know that comorbidity is always a complication in therapy.
• Intrinsic motivation and resources: especially if there is a secondary benefit.
• Systemic variable: very often the maladaptive relationship or the negative influence of the families becomes a problem during the intervention.
• Time-limited: sometimes, especially when there are personality traits that influence the therapy, 5 weeks is not sufficient.

On the other hand we recognize that the intensive program has a lot of strong points like:

• The possibility for those patients unable to benefit from high quality and specialist psychotherapy services and where the weekly ambulatory treatment was ineffective, to have an effective cure.
• The treatment does not provide the recovery: there’s the possibility to leave the patients free outside the estimated time.
• During the treatment there is generalisation. In fact we act in the patient’s daily environment: for example in the accommodation where they live during the treatment or there is also the possibility that the patient can go back home at the weekend to generalise the expertise.
• We integrate specific measures that are focused on the wider conceptualization of the disease, to improve and consolidate the results. For example, we used Metacognitive Interpersonal Therap (Dimaggio, Semerari, 2003), Schema Therapy (Young, 1999), and mindfulness based therapy like Acceptance and Commitment Therapy (Hayes, 2004) or Compassion Focused Therapy (Paul Gilbert, 2005).
• Of course there is very important attention to the relational aspect.
• During the five weeks we don’t administer other pharmacological treatments and we don’t modify the therapy to evaluate the effective change.

A single case: Sara

Sara is a young woman of 29 years old with an Obsessive and Compulsive Disorder with the fear of contamination.

She arrived with a contamination obsessive and compulsive disorder with the fear of contracting unintentionally infective diseases like AIDS. There were ritual hand and body washing, avoidance and protective behaviour. She had had two past psychotherapies and a pharmacological therapy with Fluvoxamina.

The personality assessment from the SCID-5-PD did not reveal the presence of personality disorder diagnosable on DSM-5. However, histrionics and borderline traits subthreshold emerged.

The specific OCD test shows that at the Y-BOCS-II (Melli et al., 2015) there’s a mild symptomatology emerges (33), and the functioning seems moderately compromised because she claims to have some interference with social activities and therefore avoids some situations.

The DOCS (Abramowitz et al., 2010) have clinical meaningful scores in the subscale “concern about germs and contamination” 14 (9) scores. However, the global scores are not clinically significant.

The OBQ-20 (Fergus, Latendresse, Wu, 2017) shows a high level in 3 subscales: damage responsibility, overstatement threat, perfectionism and intolerance uncertainty.

For the assessment of the depressive symptomatology at the Beck Depression Inventory (Beck, 1961) a mild depressive symptom with a score of 19 emerges.

During the first week we made a general and specific assessment.

We reconstructed the internal disorder profile, identified the imbalance factor, shared the CBT conceptualization with the investigation of predisponing, triggering, mainteinance and protective factors.

We also started to prepare a hierarchy exposure with the SUD scale, so we could start the first treatment steps, namely the first exposure.

Touch door hanlde 15 Touch sink knobs 20 buys unwrapped products 25 Sit on the chiar without strange stains 30 walks up and down without checking 35 Use farmacy products without washing it 40 Wear shop cloths witout washing her self 45 Walking along the street without checking 50 Walking on the sand 55 Stay near strange or souspicious stains 60 Pick up object that are on the floor 65 uses public transport without washing her hands 70 Trow away the garbage 75 Get her nail to the nail salon 80 Goes to the nightclubs where there are black people 85 Buying bracelets to the street people 90  Goes to the doctor and touch the object  95  Touch injury person 100

We analized and described the internal disorder profile, and here I will give you an example:

The event that starts the OCD circle is to see a syringe while walking along the sidewalk.

The first evaluation for the patient is a series of doubts: “If I inadvertently had touched that syringe? And if there was contaminated blood on it? I may have contaminated and spread the contamination everywhere! It would be terrible if someone should get sick because of me.”

The first Solution attempt was washing her hands and every contaminated object, eliminating or not using it and also asking her family, boyfriend and friends for reassurance.

The Second evaluation concerns Sara’s self criticism: “These concerns are exaggerated, I’m ruining myself. I’ll never have goals in my life. In the end my father was right to say that I’m a failure”.

There’s also a second solution attempt: the temptation to stop compulsive washing, intensification of avoidance, further requests of reassurance from the others and from herself.

The vulnerability factors emerged from her history of life:

her father was perceived as unhappy, disappointed, devaluating and verbally aggressive. He had high expectations and was very self-deprecating about her interests, physical aspects or pursued goals. Her mother was perceived as nervous, dependent, passive and fundamentally “good”, and both parents were described as perfectionists and hyperprotective.

The imbalance factors were at first the syringe episode, where she saw one while she was walking along the street near her house and her boyfriend’s criticism. She wasn’t able to calm herself, she also had an emotional dysregulation and avoidance.

The cognitive and behavioural treatment

During the middle weeks of treatment we realized more hierarchy high steps in accordance with the principles of graduation and habituation. For every step we worked to reduce the anxiety at least by 50% and to generalise the results outside the therapeutic setting and during the weekend when the patient returned to her home, and her own environment. Every day there was an agreement and collaboration on the homework.

During the weeks the cognitive measures were about the conceptualization and sharing of the primary and secondary evaluation, with particular attention to catastrofization of the experience of guilt. We also worked for cognitive restructuring on the obsessive belief.

To improve and complete the ERP intervention, we used imagery rescripting to act on the historical vulnerability, for example with the father’s criticism episode. Or we acted on the meta-cognitive ability of integration and mastery as the Metacognitive Interpersonal Therapy (TMI) and the measures on the modulation of the therapeutic relationship.

During the last week of treatment, we worked on the relapse prevention, sharing therapeutic goals of the first month of post-intervention. We also retested the patient with all the tests that we did during the first evaluation to confront the results.

If there is a request by a patient or by the families, we also do an interview with them, and we did it with Sara’s companion to support her in the therapeutic process and give him the psychoeducation about OCD.

At the end, we suggested the name of a therapist in her residential area to continue in an ambulatory therapy to improve the results obtained during the treatment and to work on the aspects that require long term therapy.

To reinforce the patient to achieve results and motivate her to continue the work that we have done so far, we give to the patient a symptomatology card where we sum up the avoidance and compulsions that the patient had after the treatment and their status at the end of the five weeks.

The end of the treatment and follow up

The achieved goals after the treatment were:

• Understanding of the dysfunctional mechanism involved in the obsessive vicious circle and the internal profile of the disease.
• Meaningful reduction of the obsessive and compulsive symptomatology
• Initial generalisation of the result in the environment.

Every two months we do a follow up session with the patient, and we observe a maintenance of the obsessive symptomatology achieved results.

A better recognition of her functioning and ability to use the more functional strategies to handle the problems. And progressive suspension of the pharmacological therapy.

BIBLIOGRAPHY

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Storch, E.A.,  Kenneth, M., Gelfand, Gary, R., Geffken, and Goodman, W.K., (2003). An intensive outpatient approach to the treatment of obsessive-compulsive disorder: case exemplars. Annals of the American Psychotherapy Association.

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