Case study

Pat’s History and Situation

Pat Montgomery was referred by her psychiatrist to a clinic specializing in psychological treatments for anxiety disorders. In the three years preceding her referral to the clinic, Pat had participated in two studies examining medications’ effectiveness in treating obsessive-compulsive disorder (OCD). In the first of these projects, Pat had taken a tricyclic antidepressant called Anafranil (clomipramine). In the second study, Pat was prescribed a different type of antidepressant medication, Prozac (fluoxetine). Although both drugs were antidepressants, research has shown that these medications can be effective for OCD. However, Pat’s symptoms had not responded to either drug. Since Pat had not benefited from two of the leading drug treatments for OCD, her psychiatrist recommended that she try a psychosocial approach to her problem.

At the time of her referral to the anxiety disorders clinic, Pat was a 40-year-old Caucasian woman with two daughters (ages 20 and 22). Pat reported that for the past six years, she had been intensely fearful of becoming contaminated by germs that would cause her to come down with some deadly disease. As a result, she would wash her hands several times a day. At the time of her first visit to the clinic, Pat claimed that she washed her hands more than 40 times per day. In fact, the psychologist noticed that Pat’s hands were very red and the skin around her fingernails had receded; each time Pat “cleaned” her hands, she would scour them with a rough pad and detergent. In addition to her handwashing, Pat repeatedly and excessively cleaned other things she came in contact with, including dishes, clothes, furniture, and doorknobs. On a typical day, Pat spent 4 hours washing her hands and cleaning these other objects. Although she usually took one shower daily, Pat would spend 60 to 90 minutes in the shower. When Pat washed her hair, she kept the soap until she counted to 100 to ensure that her head and hair were clean enough and free of contaminants such as germs.

Pat also feared that her food could contaminate her. In addition, she worried that her husband and children could contaminate her food. As a result, Pat kept her food separate from her family’s food and would not allow her family to come in contact with her food (nor would she touch her family’s food). For several food products, Pat kept separate containers for herself and for her family. For example, there were always two milk cartons in her refrigerator: one for her and one for the rest of the family. After completing meals, Pat washed her own dishes before washing her family’s dishes. After washing the dishes excessively (dishwashing often took 45 minutes), Pat spent a great deal of time cleaning her hands.

Pat reported that a principal source of contamination by germs related to funerals, funeral homes, and dead bodies. For example, Pat felt contaminated if she happened to drive by a funeral home or a funeral procession. Pat feared or avoided many objects because she worried that someone who had been to a funeral might have indirectly come in contact with the dead body and might then have come in contact with those objects. There were dozens of objects in Pat’s environment that she feared had been in contact with a funeral (e.g., clothes, shoes, doorknobs, toys, food, and rooms). One reason Pat considered so many things to be contaminated was that she believed something could become contaminated if it came in contact with something else that was already contaminated. For example, Pat owned a purse that she feared was contaminated by a friend of hers who had visited their home. Because this friend had mistaken Pat’s purse for her own, she had picked it up briefly. When Pat learned that her friend had recently attended a funeral, she insisted that her husband take the purse out of the house. Pat demanded her husband take the purse out of the house by going through the window because it was the shortest path out of their home. Her husband complied and put her purse in the storage shed. Although it had been four years since this occurred, Pat had not gone near the shed or the purse, even though the purse contained two hundred dollars and her credit cards. After her friend’s visit, Pat rarely visited other people because she feared they had attended a funeral.

Before Pat would begin washing, she always experienced strong urges to rid herself of germs and contamination. Whereas Pat had attempted to resist her urges to wash in the initial stages of her problem, she noted that she rarely resisted these urges now. In fact, now her attempts to resist the urges often triggered a panic attack. In addition to her fears of contamination, Pat worried that these panic attacks would cause her to go crazy or “flip out” until she gave in to the urges. Once she initiated her cleaning rituals, her panic attack usually subsided quickly.

Unlike some individuals with OCD (see the discussion section of this case), throughout the course of her problem, Pat could recognize that her obsessions and compulsions were excessive and unreasonable. Although Pat could sometimes hold an objective view that her chances of being contaminated were very low, her intense fear of contamination overrode this realization (similar in nature to the per- son who fears and avoids air travel but who can concede that the realistic chances of crashing are remote).

Clinical History

Pat reported that she began to notice the first signs of her problem during her high school years (e.g., she was more concerned with cleanliness than her peers appeared to be). However, not until six years before her first visit to the anxiety disorders clinic were Pat’s symptoms severe enough to warrant a diagnosis of OCD. Pat could not recall any factors (e.g., stressful life events, death or illness in the family, attendance at a funeral) connected to her increase in symptoms six years ago. Pat also could not recall if any of her family or relatives had a history of OCD-related difficulties. However, Pat did report that both her sister and her father had suffered and sought treatment for anxiety problems that appeared to meet the definition of panic disorder.

Since her problem had intensified six years ago, Pat said that her life had been pretty rough. As noted earlier, Pat had sought treatment on two occasions involving drug interventions with little success. Until two years before her first visit to the anxiety disorders clinic, Pat had worked as a vocational counselor at a state-run employment agency. Despite excellent job security and benefits, Pat had quit this position out of her fear of coming into contact with persons who had been to a funeral (or who had been in contact with another person who had been to a funeral). She had been unemployed since then. Pat reported that her family was very supportive of her problem. While her husband would occasionally become frustrated over her compulsions (i.e., washing) and her inability to do certain things or work outside the home, usually he would be cooperative with Pat’s cleaning rituals (e.g., he would take “contaminated” things out of the house and permit her to buy separate foods for herself).

As part of her first visit to the anxiety disorders clinic, Pat underwent a structured clinical interview designed to comprehensively evaluate the anxiety and mood disorders and associated conditions such as substance use and somatoform disorders. In addition to establishing the nature of Pat’s OCD symptoms, this interview revealed a few other problem areas. Although it was not a major concern, Pat reported a strong fear of snakes. More important, Pat reported ongoing difficulties with depression that had begun around the time that she completed the first medication program for her OCD and noticed that she was not getting any better. In addition to feeling down most of the time over the last few years, Pat reported moderate symptoms of poor appetite, sleep disruption, and decreased interest in activities she usually found pleasurable (all symptoms of depression). More recently, Pat reported an intensification in her depression. At the time of the interview, Pat stated that in addition to the symptoms that had been present for the past few years (e.g., poor appetite, insomnia), her depression had been accompanied by loss of energy, fatigability, feelings of guilt, concentration difficulties, and mild thoughts about the possibility that life might not be worth living. With regard to this last symptom, Pat denied thoughts or intent of suicide. She related her depression to her increasing doubts and sense of hopelessness about ever recovering from her symptoms of OCD.

Question 1

From reading the initial situational history and Pat’s clinical history. Please provide a few sentences about the signs and symptoms of her condition. What triggers has she been expressing, and which factors have contributed to her condition? 

Question 2

When did Pat first begin to notice the first signs of her condition? Select the best answer. 

1. In early adulthood.
2. During her childhood.
3. In junior high school.
4. During her high school years.

At what age did Pat finally seek treatment for her OCD? Please select the best answer. 

15
20
32
40

DSM-5 Diagnosis

On the basis of this information, Pat was assigned the following DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) diagnosis: 

• 300.30 Obsessive-compulsive disorder, with good or fair insight (principal diagnosis)
• 300.40 Persistent depressive disorder, late-onset, with intermittent major depressive episodes with the current episode, moderate
•  300.29 Specific phobia, animal type (snakes)

In accordance with the impression of her therapist, Pat’s symptoms during her first visit to the anxiety disorders clinic were quite consistent with the DSM-5 definition of OCD (American Psychiatric Association, 2013). Although OCD was classified as an anxiety disorder in preceding editions of the DSM, it is now categorized as an obsessive-compulsive and related disorder in DSM-5 (body dysmorphic disorder is another example of a DSM-5 obsessive-compulsive and related disorder, see Case 6). In DSM-5, the essential features of OCD are recurrent obsessions or compulsions that are severe enough to be time-consuming (i.e., they take up more than 1 hour a day) or cause marked distress or significant lifestyle impairment (i.e., interfere with the person’s normal routine, occupational or academic functioning, or usual social activities or relationships).

DSM-5 defines obsessions as possessing both of these features: (a) the person has recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that in most individuals cause marked anxiety or distress, and (b) the person attempts to ignore or suppress such thoughts, urges, or images or tries to neutralize them with some other thought or action (e.g., by per- forming a compulsion). In the previous edition of the DSM, obsessions were also defined by a third criterion—the person recognizes that the obsessions are a product of his or her mind. This criterion was believed to be important in differentiating OCD from psychotic disorders (such as schizophrenia), wherein intrusive and distressing thoughts or the individuals often perceive images as being inserted into their minds from an outside source. However, this criterion has been replaced in DSM-5 by a specifier that denotes the patient’s level of insight about their obsessive-compulsive beliefs. 

Thus, when OCD is diagnosed under DSM-5 criteria, it should be assigned with one of the following three insight specifiers: (a) with good or fair insight (the individual recognizes their OCD beliefs are definitely or probably not true or that they may or may not be true), (b) with poor insight (the individual thinks the OCD beliefs are probably true), or (c) with absent insight/delusional beliefs (the individual is completely convinced that the OCD beliefs are true). As with the specifiers for other DSM-5 disorders (e.g., “with disso- ciative symptoms” in posttraumatic stress disorder), this specifier is included because it conveys more about the nature of the patient’s OCD, including its treatment prognosis. Indeed, there is some evidence that patients who have OCD with poor insight do not fare as well in exposure and response prevention treatment (Foa, Abramowitz, Franklin, & Kozak, 1999; Keeley, Storch, Merlo, & Geffken, 2008). Although it might be argued that the inclusion of the “with absent insight/ delusional beliefs” specifier obscures the diagnostic boundary between OCD and psychotic disorders (e.g., delusional disorder), OCD is diagnosed when the delusional beliefs are directly linked to obsessions and compulsions. The individual does not have other features of schizophrenia or schizoaffective disorder (see Case 16 for a discussion of psychotic disorders). Pat’s OCD was assigned with the “good or fair insight” specifier because she recognized her fears of contamination as somewhat irrational.

Pat suffered from one of the most common types of obsession: thoughts of contamination (e.g., contracting germs from doorknobs, money, toilets, etc.). In addition to fears of contamination, other types of obsessions include excessive doubting (e.g., uncertainty if one has locked the door or turned off appliances; concerns that tasks such as managing personal finances were not completed or were completed inaccurately), fear that one has caused accidental harm to oneself or others (e.g., accidentally poisoning someone, unknowingly hitting a pedestrian while driving), nonsensical or aggressive impulses (e.g., undressing in public, hurt- ing self or others intentionally), horrific or sexual images or impulses (e.g., images of mutilated bodies, images of having sex with one’s parents or a religious figure), and nonsensical thoughts or images (e.g., numbers, letters, songs, jingles, or phrases). Note from this list of examples and the DSM-5 criteria that obsessions may be thoughts, images, urges, and impulses.

DSM-5 defines compulsions as having the following features: (a) they are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly, and (b) the behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. Pat experienced one of the most prevalent forms of compulsions: washing and cleaning. Note that the DSM-5 criteria state that compulsions can take the form of either overt behaviors (such as Pat’s washing and cleaning) or mental acts. Other common types of behavioral compulsions include checking (e.g., assuring that doors are locked or appliances are turned off, retracing a driving route to make sure that one has not struck a pedestrian, reexamining waste baskets to ensure that important material has not been discarded) and adhering to certain rules and sequences (e.g., maintaining symmetry such as touching an object with one’s left hand if the object had been previously touched with the right hand, adhering to specific routine or order in daily activities such as putting on clothes in the same order). Types of mental compulsions include counting (e.g., certain letters or numbers, objects in the environment) and internal repetition of material (e.g., phrases, words, prayers) in order to “neutralize” one’s obsessions.

The DSM-5 diagnostic criteria for OCD do not require the person to experience both obsessions and compulsions to be assigned the disorder. For example, studies have indicated that roughly 25% of patients with OCD do not evidence compulsive behavior (e.g., Brown, Moras, Zinbarg, & Barlow, 1993). However, these studies were conducted when earlier editions of the DSM were in place. It was not until the fourth edition of the DSM (published in 1994) that mental acts such as internal repetition were considered a type of compulsion. Thus, there is likely a much smaller proportion of patients with OCD who do not evidence any form of compulsions whatsoever (as low as 2%; see Foa & Kozak, 1995).

A full discussion of the nature and treatment of OCD is presented in the remaining sections of this case. In addition to specific phobia, Pat was assigned persistent depressive disorder, a new category in DSM-5. 

What is the purpose of the DSM-5 in the diagnosis of psychopathology? Please select all answers that apply. 

1. The DSM-5 provides a common language forclinicians to communicate about their patients and establishes consistent and reliable diagnoses that can be used in research on mental disorders.
2. It provides different types of treatment plans.
3. It is a medical psychiatric assessment system.
4. The priority was to ensure the best care of patients possible and, in the process, improve usability for clinicians and researchers.

Case Formation Using the Integration Model

As with the other disorders discussed in this book, the integrative model of OCD is a diathesis-stress model emphasizing biological and psychological factors (Barlow & Durand, 2015); part of the diathesis component of this model is the person’s biological vulnerability to experience anxiety. Indeed, findings of studies examining twins or the rates of disorders among family members have provided some evidence that OCD tends to run in families (e.g., Billett, Richter, & Kennedy, 1998; Black, Noyes, Goldstein, & Blum, 1992; Fyer, Lipsitz, Mannuzza, Aronowitz, & Chapman, 2005; Hettema, Neale, & Kendler, 2001). This dimension was somewhat evident in Pat, who did not recall a family history of OCD but did indicate a history of panic disorder in her first-order relatives. This provided evidence that Pat may have had a biological tendency to experience anxiety.

Although Pat could not recall any life events that contributed to the onset or increase in her OCD symptoms, the integrative model underscores stress’s importance in the disorder’s origins. For example, research has shown that a stressful situation may not only trigger unexpected panic attacks (see Case 2) but also mark an increase in the frequency of both intrusive, unpleasant thoughts and ritualistic behavior (e.g., washing, checking) (Parkinson & Rachman, 1981a, 1981b). Stress may trigger these symptoms, but it is insufficient to produce full-blown OCD. In other words, although many people experience intrusive thoughts or ritualistic behavior after being exposed to stressful life events, most do not go on to develop OCD (Fullana et al., 2009).

So what factors determine whether these initial symptoms develop into OCD? As in other anxiety disorders (such as panic disorder), the integrative model asserts that anxiety focused on the possibility of experiencing additional symptoms is a central factor in the cause of OCD. Specifically, a person with some intrusive thoughts in response to life stress may be anxious about having more of these thoughts because he or she perceives them as dangerous or unacceptable. Consequently, the person attempts to suppress these thoughts. However, suppression has the opposite effect of increasing their frequency or intensity, a phenomenon that has been supported by research evidence (e.g., Najmi, Riemann, & Wegner, 2009; Salkovskis & Campbell, 1994). These points are consistent with cognitive models of OCD that underscore the position that people who believe some thoughts are unacceptable or dangerous are at greater risk for developing OCD (Salkovskis, 1985, 1989; Shafran, Thordarson, & Rachman, 1996; Steketee & Barlow, 2002).

The integrative model addresses why some people may develop anxiety over experiencing additional OCD symptoms such as intrusive thoughts. Consistent with ideas expressed in cognitive conceptualizations of OCD (e.g., Salkovskis, 1989; Steketee & Barlow, 2002), the model specifies that these individuals may have had previous experiences that have taught them to perceive some thoughts as dangerous or unacceptable. This would represent a psychological diathesis or vulnerability to developing OCD. For example, a person raised in a devoutly religious family may hold strong beliefs about the appropriateness and acceptability of thoughts relating to such areas as sex and abortion. These individuals may respond with considerable distress to having thoughts of this nature. The negative perceptions of obsessive thoughts may often take the form of exaggerated assumptions about whether actual harm can result from the intrusive thoughts themselves (e.g., a thought about something can cause it to happen) and about the degree of personal responsibility for preventing harm to oneself or others (e.g., failure to prevent harm relating to the thought is just as bad as causing the harm directly). These features were evident in Pat, who equated the idea of contamination with the distinct risk of contracting germs that could be passed between herself and her family. This type of cognitive vulnerability has been termed thought-action fusion (Shafran et al., 1996), a specific risk factor for OCD that describes the tendency to believe that thinking about a disturbing event increases the likelihood of its occurrence and thinking about a disturbing action is morally equivalent to actually carrying it out (e.g., a highly religious person who believes that thinking about abortion is the moral equivalent as having an abortion).

Although compulsions (e.g., washing, checking) and other attempts at neutralizing obsessional material (e.g., repeating phrases, words, or prayers) contribute to the DSM-5 definition of OCD, they are also considered to be the phenomena that maintain the disorder over time. For example, although Pat’s excessive handwashing would often result in short-term relief (e.g., her panic attacks would subside after she washed), it maintained her problem over the long term by preventing her from disconfirming her predictions regarding the risk and anticipated harm of being contaminated (e.g., she never learned that washing was not necessary to prevent contamination). The patient’s social environment can also contribute to the maintenance of OCD. Pat’s family often acquiesced to her compulsive symptoms. Examples include her husband’s compliance with her demands to take her “contaminated” purse out of the house and her family’s agreement to allow Pat to keep separate food and dishes.

Question 5

Which theory for this case study is the treatment plan based upon? Please select the best answer. 

1. Psychoanalytic theory
2. Diathesis-stress model theory
3. Cognitive theory
4. Behavioral theory

Treatment Goals and Planning

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”?

Discussion

Findings from a large epidemiological study of psychological disorders indicate that the 12-month and lifetime prevalence of OCD is 1% and 1.6%, respectively (Kessler, Berglund, et al., 2005; Kessler, Chiu, Demler, & Walters, 2005). However, this estimate pertains to the frequency with which people meet the diagnostic definition of OCD sometime during their lives. Additional evidence suggests that many people experience symptoms of OCD that, while not meeting the DSM definition of the disorder, are nonetheless associated with some degree of distress or lifestyle interference. For example, one study found that 16% of young adults with no mental disorders reported experiencing obsessions or compulsions within the past year; many of these participants indicated that their DSM-IV subthreshold OCD symptoms were associated with significant interference or distress (Fullana et al., 2009). As noted earlier, the OCD symptoms (e.g., intrusive thoughts, checking) of these nonclinical persons frequently are precipitated by some form of life stress (Parkinson & Rachman, 1981a, 1981b).

Adult patients with OCD are slightly more likely to be female. Evidence from patient and epidemiological samples indicates that 55% to 60% of patients with OCD are female (Karno & Golding, 1991; Rasmussen & Eisen, 1992). The average age of onset of the disorder ranges from early adolescence to the early 20s (e.g., Brown, Campbell, Lehman, Grisham, & Mancill, 2001; Kessler, Berglund, et al., 2005). However, males have an earlier peak age of onset (i.e., 13 to 15) than females (ages 20 to 24; Rasmussen & Eisen, 1990). If left untreated, the majority of persons with OCD experience a chronic “waxing and waning” course, with an increase in symptoms that is often related to life stress (e.g., Steketee & Barlow, 2002).

As was true for Pat, patients with OCD often have a history of a current or past mood disorder, such as major depression or persistent depressive disorder (Brown, Campbell, et al., 2001). In fact, some researchers have suggested that the high rate of co-occurrence between OCD and mood disorders, as well as the evidence that OCD may respond to antidepressant medication, points to the possibility that OCD is not an anxiety disorder but a variant of a mood disorder (e.g., Insel, Zahn, & Murphy, 1985). The association between OCD and depression may be relevant to treatment as well. Although the evidence is somewhat mixed, a review of the extant treatment outcome literature concluded that depression, especially in severe form, was a consistent predictor of poorer response to cognitive-behavioral therapy (Keeley et al., 2008).

Interestingly, several studies have shown an association between OCD and the tic disorders such as Tourette’s syndrome, which involves both motor tics (involuntary movements of the head or limbs) and vocal tics (involuntary utterances of words or sounds such as clicks, grunts, yelps, snorts, or coughs). Studies of patients with Tourette’s syndrome indicate that 36% to 52% meet the criteria for OCD (Leckman & Chittenden, 1990; Pauls, 1992; Pauls, Towbin, Leckman, Zahner, & Cohen, 1986). Approximately 10% to 40% of children and adolescents with OCD also have had a tic disorder at some time during their lives (Leckman et al., 2010). In DSM-5, OCD can now be diagnosed with the “tic-related” specifier when the individual has a current or past tic disorder.

Prior to undergoing the cognitive-behavioral treatment program, Pat had been prescribed two medications that have frequently been used in studies of the treatment of OCD (i.e., Anafranil [clomipramine] and Prozac [fluoxetine]). Although Pat’s problem did not respond to these medications at all, the results of outcome studies suggest that these drugs can be effective for some patients (see Steketee & Barlow, 2002, and Pigott & Seay, 1998, for a review). The most effective drugs seem to inhibit the reuptake of serotonin (such as Prozac). They, therefore, belong to a class of drugs called serotonin-specific reuptake inhibitors (SSRIs) (Ackerman & Greenland, 2002). However, the average treatment gain is modest, and relapse frequently occurs when the medication is discontinued (e.g., Dougherty, Rauch, & Jenike, 2012; Lydiard, Brawman-Mintzer, & Ballenger, 1996; Pato, Zohar- Kadouch, Zohar, & Murphy, 1988). For patients with severe cases of OCD who do not respond to any other form of conventional treatment, neurosurgery (e.g., a surgical lesion to the cingulate bundle of the brain) and deep brain stimulation represent other types of medical intervention (McLaughlin & Greenberg, 2012; Jenike et al., 1991).

Although medications can be effective for some patients, cognitive-behavioral treatments appear to be the treatment of choice for OCD. Evidence indicates that most patients treated with ERP show substantial improvement by the end of the treatment program, and unlike the long-term results of medication treatments, the majority maintain their improvement over the long term (Franklin & Foa, 2014; Rosa-Alcázar, Sánchez-Meca, Gómez-Conesca, & Marín-Martínez, 2008). How- ever, whereas ERP is effective in reducing OCD symptoms, a substantial minority of patients either do not respond to the treatment, do not maintain their gains, or refuse this form of intervention altogether. Thus, researchers continue to strive to develop more effective treatments and to identify predictors of treatment outcomes. A review of the literature concluded that greater symptom severity, certain symptom subtypes (hoarding, sexual/religious symptoms), comorbid depression and personality disorders, family dysfunction, and weaker therapeutic alliance were the most consistent predictors of poorer response to cognitive-behavioral therapy for OCD (Keeley et al., 2008). An earlier review indicated that patients with OCD who do not evidence overt compulsions were the least responsive to treatment (Christensen, Hadzi-Pavlovic, Andrews, & Mattick, 1987). This poorer outcome might be related to clinicians’ failure to identify and address mental compulsions (Salkovskis & Westbrook, 1989), a problem that may have been
reconciled by the acknowledgment of this form of compulsion in the most recent editions of the DSM.

More recently, researchers have begun to examine the effectiveness of interventions that combine medications and ERP to see whether this combination treatment is more effective than either treatment alone. In the first large-scale study of this kind, Foa et al. (2005) examined the comparative efficacy of ERP, clomipramine (an SSRI), and their combination in 122 adults with OCD. Short-term outcome results indicated that these three active treatments were more effective than the placebo. Moreover, the short-term effects of ERP did not significantly differ from the combination treatment (ERP plus clomipramine), although both were significantly more effective than clomipramine only. Long-term outcome efficacy is still under study, although initial results suggest that relapse rates are high in the medication-only group after withdrawal.

Question 8

True or False: Medications are a more effective treatment for patients with OCD, compared to cognitive behavioral treatments, according to recent research within the last several years. 

1. Question 9
2. True or False: Pat was prescribed two medications before undergoing cognitive behavioral therapy. 

   True
   False

1. After reading the content, please address the following questions below. 
2. Question 10 Research has indicated that in some persons, a strict, devoutly religious upbringing was a factor that contributed to the development of OCD. Based on the information provided in the section “Case Formulation Using the Integrative Model” in this case, why might this be? What other social and developmental factors do you think might contribute to the origins of OCD?

Question 11

As noted in this case, a person can meet the DSM-5 criteria for OCD without having overt behavioral compulsions such as repetitive handwashing or showering or repetitive checking of door locks, appliances, and so on. Do you think it would be harder to treat such cases using the intervention described in Pat’s treatment? If so, what alterations in the intervention do you think would help treat OCD when behavioral compulsions are not present?

Question 1210 Points

What are the different types of obsessions and compulsions? Does this diversity suggest that the different forms of obsessions and compulsions might vary in their modes of onset (i.e., they develop in response to different causal factors)? Do the various types of obsessions and compulsions require differing treatment approaches? For example, would you treat a person with washing rituals differently from someone with prominent hoarding rituals? How would these interventions differ?

Question 13

What do you think Pat’s long-term outcomes and abilities to deal with OCD will be over the next ten years?