The anxiety disorders clinic that Pat was referred to offers a treatment program developed specifically for OCD. Pat was fortunate in that she lived in proximity to a clinic that offered this type of treatment; very few clinics in the United States have expertise in the type of program that Pat would undergo. This treatment approach is referred to as exposure and response prevention (ERP), a highly structured treatment whereby the patient’s rituals (compulsive behavior) are actively prevented while the patient is systematically and gradually exposed to the feared thoughts (obsessions) and situations (e.g., cues that trigger the fear of becoming contaminated, such as shaking hands with a stranger). By arranging for patients to confront these fear cues (obsessions, situations) while at the same time preventing them from engaging in their ritual or neutralizing behavior, the treatment approach is directly addressing the key maintaining features of OCD (e.g., avoidance of feared stimuli, engaging in compulsive behavior to neutralize obsessional thoughts). In addition, cognitive restructuring often represents an important adjunct to ERP to address patients’ beliefs regarding the acceptability or significance of their intrusive thoughts or images (Franklin & Foa, 2014; Salkovskis, 1989). However, ERP is important in changing patients’ cognitions surrounding OCD symptoms. For instance, the procedures aimed at preventing compulsive behavior seem to foster “reality testing” in that the patient learns—at both a rational level and an emotional level—that no harmful consequences will occur, irrespective of whether the rituals are carried out.
Finally, as is often the case in treating other emotional disorders, the effectiveness of interventions for OCD can often be enhanced by involving the patient’s social network. Consistent with Pat’s presentation, patients’ families or friends may respond to their symptoms in a manner that helps to maintain the disorder. In addition to helping patients’ significant others better understand the problem, this approach can effectively eliminate behaviors contributing to the maintenance of OCD.
The course of Treatment and Treatment Outcome
Shortly after her initial evaluation, Pat and her husband met the therapist for the first treatment session. The therapist had requested that Pat’s husband attend the first several sessions to increase his understanding of the disorder and assist Pat in applying the treatment techniques in the most effective way possible. In addition to establishing rapport, the therapist’s primary objectives of this session were to (a) obtain additional information that would be relevant to treatment planning, (b) provide the patient with an explanation of the causes of OCD and a rationale and explanation for the treatment approach, (c) define what targets (symptoms) the treatment would address, and (d) instruct the patient in the methods of self-monitoring. During this session, Pat and her therapist agreed that the primary targets of treatment would be to decrease her fear of objects associated with funerals, eliminate her compulsive rituals, and decrease her generalized anxiety and tension levels. This latter target (i.e., high generalized anxiety) was not discussed during Pat’s intake evaluation. Thus, at this time, Pat’s therapist considered incorporating progressive muscle relaxation training as an additional treatment component. Other than this issue, the therapist regarded Pat’s problem to be a relatively straightforward example of OCD.
During the first session, the therapist solicited from Pat a list of fear triggers (e.g., objects that elicited panic attacks, thoughts of contamination, and compulsive behavior) and rituals. This information would be very important in the development of ERP exercises. The therapist provided Pat with the integrative model of OCD, emphasizing the factors that had maintained her difficulty over time (e.g., her avoidance of fear triggers and her washing and cleaning rituals). She was pro- vided with self-monitoring forms to generate daily records of the frequency and intensity of symptoms such as anxiety, depression, pleasant feelings, obsessions, and compulsive behavior. Pat was told to continue daily self-monitoring throughout treatment because this information would be very useful in tracking her response to the program. Finally, Pat was informed about the techniques and rationale of ERP. She was told that, for the most part, the ERP would be carried out in a graduated format. For example, the feared objects and situations that were identified in this session were listed in the order of least to most anxiety-provoking. The ERP would be delivered graduated by using less feared objects and situations in the initial exposures or by addressing intensely feared triggers by starting with imaginal exposure before confronting the trigger in real life. Imaginal exposure involves patients confronting feared objects and situations using their imagination (e.g., picturing oneself coming in contact with a contaminated object). To begin this process, the therapist asked Pat to gradually increase, over the next few days, the length of time between when she had the urge to wash or clean and when she engaged in this ritual.
Pat made significant progress as early as the second session, three days later. Given that Pat was extremely motivated and compliant with treatment initiatives (e.g., she had been very good about delaying the onset of her rituals between sessions), she and her therapist decided to accelerate the process of ERP. Pat’s husband had brought to the session a pair of his shoes that Pat believed were contaminated because he had worn them to a funeral several years ago. Even though Pat was extremely fearful of these shoes because they were directly connected with a funeral, she asked that they be used in her first ERP practice. After some discussion, they designed the following ERP practice: Pat would touch the top of the shoes with a piece of food and then eat it. Eating the “contaminated” food was part of this exposure because it made Pat’s usual washing ritual less relevant (i.e., there would be little use for washing if she had swallowed the food). Pretzels were selected as the food to be used in the ERP because they were readily available from the vending machine at the clinic. During this session (which lasted 21⁄2 hours), Pat ate a small bag of pretzels that she had touched on the shoes. When eating the first several pretzels, Pat reported a very high level of anxiety, but she never experienced a panic attack. However, this anxiety soon turned to joy because Pat was extremely surprised and pleased by her ability to perform such a feat. Because of the considerable gains achieved in this session, the therapist directed Pat to do several things that he had thought he would not have assigned until later in her treatment. First, Pat was instructed not to engage in any more compulsive rituals (e.g., refrain from handwashing after coming in contact with a “contaminated” object). Second, she was told to limit her daily shower to 10 minutes. Third, Pat was assigned to complete 3 hours of ERP per day. Two hours a day would be spent performing ERP practices using objects previously used in session (e.g., her husband’s shoes) or objects similar to these objects in terms of their difficulty level (rated by Pat as producing a similar level of anxiety). The final hour of ERP would involve imaginal exposure. This exposure required Pat to hold an image of being in contact with an object or being in a situation at the top of her list (e.g., the most feared objects and situations, such as touching a dead body). Pat’s husband was instructed to serve as a coach in these between-sessions ERP exercises. He was also told to monitor Pat’s compliance with the response-prevention aspect of treatment. For example, Pat’s husband ensured that Pat was limiting her showers to 10 minutes per day. He also assisted her (by being supportive and reminding her of the importance of not completing the rituals) in not engaging in a washing-cleaning ritual after coming into contact with an object that evoked an intense urge to “decontaminate” herself.
Over the next several sessions, Pat and her therapist continued to apply ERP, including exposures to items at the top of her list. Pat’s husband was assisted in identifying the types of things he and the family did that contributed to the maintenance of Pat’s OCD. As a result, he no longer permitted her to keep separate food and dishes for herself. In addition, Pat was required to wash her dishes and clothes with her family’s (and refrain from washing her hands after these tasks). Unlike many patients with OCD, Pat experienced little difficulty in applying ERP to most of the items on her hierarchy of feared items and situations. However, one of the most difficult ERP exercises that Pat encountered was eating food that had been in contact with the purse that had been in the shed. Recall that several years earlier, Pat had forced her husband to take the purse out of the house (through the window, for that matter) because a woman who had been to a funeral had touched the purse. Even though one might think that other tasks Pat had completed would have been more difficult (e.g., her husband’s shoes had actually been at a funeral), the ERP practices involving this purse were among the hardest for Pat to accomplish. Indeed, after this exposure had been completed in the therapy session, Pat ran into a few problems when she was performing her daily ERP exercises. For instance, she experienced a panic attack a few times during these exposures. How- ever, she prevented herself from washing, and her fear usually diminished by the second hour of the exposure. Moreover, she was rewarded by being now able to access the two hundred dollars that had been stowed in this purse for the last few years! Another difficult practice for Pat involved handling or eating food that was in contact with a business card from a nearby funeral home.
In addition, Pat evidenced a brief return to her compulsive rituals following a particularly difficult assignment. For this assignment, Pat was instructed to clean a cupboard in her pantry that contained several objects that had been “quaran- tined” over the past few years and therefore had not been opened. She was also instructed to handle the objects in the cupboard that she had regarded as contaminated. If handling these objects was not difficult enough, Pat realized halfway through the exposure that the “dirt” in the cupboard she was handling was actually rat droppings. This revelation produced a panic attack and a temporary increase in her unnecessary washing and cleaning rituals. However, Pat’s therapist required her to continue the ERP exercise involving the cupboard, despite the presence of the rat droppings. Pat’s cleaning rituals disappeared over the next 2 to 3 days.
Another minor complication in Pat’s treatment was the fact that her levels of anxiety and depression increased somewhat during the middle of the program. After some questioning, the therapist concluded that Pat’s negative emotions were related to her concerns that she would not be able to hold onto the considerable gains she had made. Consequently, the therapist utilized the procedures of cognitive therapy for a good part of the next two sessions. In addition to assisting Pat in identifying and challenging her thoughts that elicited these negative emotions, the therapist underscored the importance of continued application of ERP in maintaining- ing her treatment gains.
Another issue that arose during Pat’s treatment involved her fear of snakes. This issue became salient because spring arrived midway through the treatment pro- gram. In the warmer weather, Pat encountered a snake in her backyard occasionally. At the time of her intake evaluation, Pat’s fear was considered a typical case of snake phobia. However, in discussing her encounters with snakes, the therapist noted that these incidents had provoked intense fear and obsessional thoughts of contamination. Pat reported that on two occasions, she had washed after seeing the snake. Hence, the therapist considered exposure to snakes to be relevant to the treatment of Pat’s OCD; her fear was not a straightforward instance of a specific phobia (persons with a specific phobia of snakes usually fear snakes for other reasons such as being bitten).
Fortunately (although it did not seem so fortunate to Pat at the time), the clinic housed a live snake for use in the treatment of patients with snake phobias. To address Pat’s fear, she and her therapist developed a plan for graduated exposure to snakes. The initial ERP items included handling and viewing the following objects: (a) a book on snakes, (b) a rubber snake, and (c) a rubber snake that had been contaminated by the therapist who had previously handled the clinic’s live snake. After she began to feel comfortable with these tasks, Pat progressed to watching her therapist handle the live snake. For homework, Pat was requested to perform daily ERP trials using the rubber snake and the book on snakes.
At the next session, Pat reported that while her funeral-related obsessions and compulsions had not returned, she had washed on two occasions after completing her ERP practices involving snakes. Thus, a good portion of the session was spent having Pat watch her therapist handle the snake. For homework, Pat was instructed to continue her exposures to the rubber snake and the snake book. In addition, she was asked to visit pet stores and spend prolonged periods watching live snakes in their cages.
These exercises proved helpful because Pat reported at the next session that she was minimally anxious over being in the presence of the rubber snake or the book about snakes. However, she still reported apprehension over live snakes and declined her therapist’s suggestion that she handle the clinic’s snake during this session. Instead, Pat was instructed to walk around and touch the area in her backyard where she had previously encountered snakes. Also, because Pat denied any fear of funeral-related objects, she agreed with her therapist’s suggestion that they spend their next session visiting a funeral home.
Indeed, Pat’s assertion that she was no longer troubled by funeral-related objects was confirmed by the visit to the funeral home. She experienced no anxiety or urges to wash during the visit. Because of the possibility that Pat may have felt safer on this visit in the presence of the therapist, she was assigned to visit the funeral home with her husband during the week. Despite the significant strides she had achieved with her OCD symptoms, Pat reported that she continued to experience moderate levels of generalized anxiety and tension. Thus, she and her therapist decided to focus on progressive muscle relaxation as the final main component of treatment.
Pat responded very well to relaxation training. The initial exercises involved hour-long procedures during which she was guided in tensing and relaxing 16 different muscle areas throughout her body. The relaxing effects of these procedures were deepened by having Pat imagine pleasant and calming scenes (e.g., lying on a sunny and quiet beach). The therapist audiotaped this in-session relaxation induction so Pat could practice with the tape at home. In later sessions, the relaxation exercises were modified to be more “portable” (i.e., readily applied wherever Pat was in the event she noticed an increase in anxiety or tension). This goal was achieved by first reducing the number of target muscle areas to eight and later to four. Finally, Pat was taught to deploy the technique of “cue-controlled relaxa- tion,” which is a very portable procedure for relaxing.
Even though relaxation training was afforded considerable attention in these sessions, Pat was instructed to continue applying ERP throughout.
Once all of the procedures of relaxation training had been covered, Pat and her therapist met on a monthly basis for three more sessions. At the last session (of 14 sessions in all), Pat’s therapist considered her to be virtually symptom-free. Her therapist regarded the following as factors that were instrumental in Pat’s favorable response to treatment: (a) the nature of Pat’s symptoms made it relatively straightforward to design ERP practices (e.g., her fear triggers such as funeral home business cards were readily defined and easily accessible) and (b) Pat’s compulsive rituals were overt in nature (i.e., they were behaviors such as washing and cleaning) and thus were fairly easy to prevent (response prevention can be difficult if the patient’s attempts at neutralizing obsessional material entail covert acts such as mentally repeating phrases or counting). In addition, the therapist considered Pat’s high level of compliance and motivation as contributing to her positive outcome. Nevertheless, the therapist discovered that because nearly all her symptoms had been remitted, Pat was not currently completing ERP trials at the rate that had been suggested to ensure the maintenance of her gains. To conclude this session, the therapist emphasized the importance of continued practice and offered Pat the opportunity to contact the clinic in the future should any questions or problems arise.
A few days after this final session, an independently conducted interview by another clinician confirmed her therapist’s impression that Pat had come a long way with her OCD. Pat showed no signs of obsessional or compulsive symptoms related to what used to be her most central fear: objects that had been in contact with funerals or funeral-related materials. Moreover, Pat reported very low levels of anxiety and tension in response to the relaxation component of the treatment. She also remarked that her family life had improved (e.g., the frustration that her family had occasionally expressed due to her OCD symptoms was now gone). Indeed, the fact that Pat’s husband was very supportive and made himself available for her treatment was another important factor in her success with the program. Despite these tremendous strides, which Pat had not been able to achieve with previous trials of antidepressant medication, a few symptom areas remained. First, Pat still evidenced a mild fear of contamination when she encountered a live snake in her neighborhood (she never got to the stage in therapy where she agreed to handle the clinic’s snake). Second, many mood disorder symptoms (major depression, dysthymia) remained that had been noted prior to treatment. Although these symptoms had decreased significantly in response to her improvement with the OCD, some of Pat’s depression seemed to be unrelated to her OCD. Rather, the interviewer noted that some of Pat’s negative affect was related to her belief that she was not employable or worthy of a steady job. Pat was referred to a clinical psychologist who specialized in the cognitive-behavioral treatment of depression.
Pat came back to the clinic 12 months later for a follow-up interview. The interview results indicated that Pat was still doing much better than she had before entering the OCD program. However, she reported that, in the previous two months, her obsessional thoughts of being contaminated by funeral-related objects had increased somewhat; her mild fear of being contaminated by snakes had remained unchanged. It was apparent to the interviewer that this increase in symptoms was related to Pat’s performing ERP exercises infrequently. Pat acknowledged that she knew what she had to do to overcome this recent exacerbation of symptoms; nevertheless, she stated that she found it difficult to push herself to initiate ERP practices independently. Consequently, Pat was scheduled to meet with another therapist for two or three “booster” sessions to reestablish the exposure exercises. This strategy successfully resolved her partial relapse and reinitiated the regularity with which Pat completed ERP practices. However, at this point, some of Pat’s symptoms of depression remained (Pat did not follow through on the referral for depression treatment), and she had not begun to look for work outside her home.
Question 6
How effective do you think Pat’s therapy sessions have been treating her OCD? Do you think the therapist could have provided different interventions instead of those used in the case study? If so, why?
Question 7
How do obsessions differ from excessive worry as described with a condition known as “Generalized Anxiety Disorder”?
