Obsessive compulsive disorder (OCD) was considered for a long time to be a refractory psychiatry condition. Indeed, Rachman and Hodgson (1980) noted that "There is so little confidence in conventional treatment [of OCD] that few writers take the trouble to distinguish between spontaneous remission rates and treatment remission rates" (p. 97). In the last two decades, however, the grim prognosis for OCD has changed considerably with the introduction of behavioral treatment.
In 1966, Victor Meyer reported on the outcome of two patients with washing rituals following treatment by exposure and response prevention. Since then this program has been established as the treatment of choice for OCD. The treatment is based on learning theory that views obsessions as evoking anxiety/distress and compulsions (rituals) as reducing that anxiety/distress. This theory posits that compulsions preserve obsessional anxiety because they disrupt the process of habituation. Furthermore, because compulsions are followed by short-term anxiety reduction, they are reinforced and thus, the urge to ritualize becomes stronger. It follows that effective treatment must: 1) involve procedures that provoke the obsession and maintain the accompanying anxiety for sufficient time to allow its habituation and 2) eliminate the contingency between performing compulsions and anxiety reduction. This is the rationale that underlies exposure and response prevention treatment, and it is presented to patients as an explanation for the success of the treatment.
Thus, in this program patients confront situations that give rise to obsessional distress, and abstain from any compulsions that would reduce the distress. In our clinic at the Medical College of Pennsylvania and Hahnemann University, OCD patients receive an intensive behavioral program which consists of 15 2-hour exposure sessions delivered over three weeks. During the sessions patients are confronted in reality to situations and objects that trigger their obsessions. Also, during these sessions, patients are asked to imagine that the consequences they fear will happen if they did not ritualize do occur, so that they will be able to think about their imaginary disasters without being terrified. Homework assignments consist of repeating the exposures conducted during the therapy sessions. Simultaneously with the introduction of exposure, we implement ritual prevention, i.e., patients are requested to refrain from engaging in their rituals. After the intensive phase of treatment, we implement a maintenance program consisting of about nine visits or telephone calls. This phase aims at reinforcing the improvement achieved during the intensive phase.
For example, a patient who obsesses about the possibility of becoming contaminated with "dirt germs" and consequently inflects serious illness on herself and others, will be instructed to sit on floors and other dirty places for about 45 minutes and do so at home. She will also be asked to imagine that she indeed became ill because she did not engage in washing and cleaning. At the same time, handwashing, showering and cleaning will be restricted. In the first two weeks this patient will be instructed to refrain from any handwashing, and showers will be restricted to 10 minutes every other day. In the third week, normal handwashing will be introduced; this includes five 30-second handwashings per day. Over the past 15 years hundreds of patients graduated from this program; about 75% to 80% showed lasting significant improvement (i.e., their symptoms decreased by more than 30%). (For a detailed description of this treatment, see Foa and Wilson, 1991).
The positive results emerging from our clinic are not unique. In the first outcome study of exposure and response prevention, of 12 patients treated by this method only 2 had relapsed after 6 years (Meyer, Levy, and Schnurer, 1974). These results prompted subsequent outcome studies that lent further support to the efficacy of the treatment. Many studies reported only group means. In a recent review of treatment outcome studies, Foa and Kozak (in press) identified 12 studies that presented information on the number of patients who improved immediately after treatment (improvement was usually defined as at least 30% reduction in severity). Of the 330 patients who participated in these 12 studies, an average of 83% were improved after a mean of 15 sessions. It should be noted, however, that the percent improvement in these studies ranged from 40% to 97%. Sixteen studies reported data on percent of patients improved at follow-up (for a review see Foa and Kozak, in press). Of the 376 patients who were included in the 16 studies, an average of 76% were treatment responders at follow-up (mean of 29 months; 2.4 years). Again, differences among studies on long-term outcome was evident, with percentage of responders ranging from 50 to 100. Nevertheless, 12 of the 16 studies reported long-term outcome falling within the narrow range of 70% to 85% responders. In view of the often debilitating nature of OCD, it is remarkable that not only did the large majority of patients respond to behavior therapy, but they also maintained their improvement for more than 2 years.
Clearly, some studies found greater improvement than others, and several factors may account for differential success among studies. In the earlier studies (e.g., Meyer et al., 1974; Marks, Hodgson, and Rachman, 1975), it was customary to hospitalize patients during treatment, whereas in later studies outpatient treatment became routine. It is not clear whether treatment conducted in the hospital yielded superior outcome to outpatient treatment. In fact, we prefer to treat patients in their natural environment so that they can have access to confronting situations that triggered their obsessions and compulsions. Hospitalization is reserved for patients whose home environment is not conducive to support this quite demanding treatment.
Other factors that can impact on the treatment success are: number of sessions, duration of exposure sessions, intervals between sessions, strictness of response prevention rules, degree of therapist involvement in exposure exercises, extent and nature of homework assignments, and inclusion of imaginal exposure. Several of these factors were examined in controlled studies and were found to influence treatment outcome.
Several studies found that long exposure was superior to short exposure for reducing anxiety symptoms in anxiety disordered patients (Chaplin and Levine, 1980; Rabavilis, Boulougouris, and Stefanis, 1976; Stern and Marks, 1973). It appears that some anxiety disorders require longer exposure duration than others for habitation to occur. Thus, on average, patients with OCD may need longer duration of exposure than patients with a specific phobia such as dog phobia. However, there is no known method for determining in advance the optimal exposure duration for a given individual. In our clinic we ask patients to indicate their level of anxiety/distress every 5 to 10 minutes, and exposure continues until anxiety is decreased by at least 50%.
Treatment programs that combine exposure and response prevention have been found superior to the application of either technique alone for patients with washing rituals (Foa, Steketee, and Milby, 1980; Foa, Steketee, Grayson, Turner, and Latimer, 1984). Treatment by exposure alone reduced discomfort about contaminants, but did not significantly reduce washing rituals. In contrast, response prevention alone reduced washing rituals and the urge to ritualize, but not discomfort. The combined treatment led to the best results.
Studies differed considerably in the degree of therapist involvement in the exposure sessions and in the frequency of contact with patients. In some studies, therapy consisted of 2 to 3 weeks of long (1 to 2 hours), daily therapist contact (e.g., Foa and Goldstein, 1978; Foa et al., 1984; Rachman, Hodgson, and Marks, 1971). In other studies, therapy was conducted over several months, with exposure exercises directed and monitored by the therapist but performed without the therapist being present (e.g., Marks, Lelliott, Basoglu, Noshirvani, Monteiro, Cohen, and Kasvikis, 1988). The effects of therapist's involvement in treatment has not been studied systematically with OCD but with simple phobics, superior outcome was achieved with treatment that included a therapist (Öst, Salkovskis, and Hellstrom, 1991). Although clinical observations suggest that with severe patients intensive programs yield superior results, there are no systematic investigations to guide us on this issue.
While treatment by exposure and response prevention is quite successful, some patients relapse. How can we combat such relapse? It has been found that patients who were much improved immediately after treatment was less likely to relapse than those with partial improvement (Foa, Grayson, Steketee, Doppelt, Turner, and Latimer, 1983). It follows that factors enhancing immediate efficacy also influence long-term outcome. Some of these, such as long duration of exposure and the addition of response prevention, were discussed above. A more extensive discussion of the variables influencing therapeutic outcome and underlying mechanisms can be found in Foa and Kozak (1986).
In addition to techniques that enhance immediate effectiveness of therapy, certain procedures have been found to improve long-term maintenance directly, without being mediated by the immediate outcome. For example, supplementing in vivo exposure with imaginal exposure to feared consequences (e.g., sickness, injury, embarrassment) has been found to improve long-term maintenance without enhancing short-term outcome (Foa, Steketee, Turner, and Fischer, 1980; Steketee, Foa, and Grayson, 1982).
The potential usefulness of procedures designed to reduce relapse has been recognized by clinical researchers who study behavior therapy (Marlatt and Gordon, 1985). Hiss, Foa, and Kozak (1994) evaluated a maintenance program for OCD. The program involved four 90-minute sessions, conducted during the week immediately after intensive exposure therapy, plus nine 15-minute telephone contacts over 12 weeks. Interventions were: cognitive restructuring, training in self-exposure, and planning for changes in lifestyle. The control group was asked to free associate about their obsessive compulsive symptoms for four 90-minute sessions. The results indicated the efficacy of the relapse prevention program. Both treatment groups improved similarly immediately post-treatment. At 6-months follow-up, the relapse prevention group maintained its improvements, but the attention control group showed some return of symptoms.
Three practical suggestions for promoting long-term maintenance of gains achieved with behavior therapy emerge from the literature. First, the therapist should implement a treatment program that maximizes short-term improvement. Second, imaginal exposure should be included if feared disasters can be identified. Third, relapse prevention procedures, monitored via brief contacts over a limited time, should be employed after intensive therapy.
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