Journal Article Final: Journal of Personality Disorders

Journal Article Final: Journal of Personality Disorders Exploring Potential Effective Treatments for Obsessive Compulsive Disorder and Obsessive Compulsive Personality Disorder

Julian Storrer, Stefan Genet, Miranda Helm

There are many treatments available to patients suffering from either OCD or OCPD. This paper explores the possible treatments and comes to the conclusion that Cognitive Behavioral Therapy (CBT) is the most effective. ERP, invasive medical procedures, and pharmaceutical drugs as an exclusive treatment may be effective in the reduction of OCD or OCPD symptoms, but also come with more risks or drawbacks associated with their application.

It is estimated by the International OCD Foundation that about 1% of adults and 0.5% of children in the U.S. are diagnosed with Obsessive Compulsive Disorder. In addition, about 1% of Americans are diagnosed with Obsessive Compulsive Personality Disorder (IOCD, 2010).

Obsessive Compulsive Disorder is a mental illness characterized by the manifestation of obsessions and compulsions. Obsessions, as defined by the Diagnostic and Statistical Manual of Mental Disorders(DSM) IV-TR, are categorized by any of the following: abnormal recurring persistent thoughts or urges, the patient’s acknowledgement that these thoughts and urges are abnormal, and the attempted suppression of these thoughts and urges (APA, 2000). Compulsions, as defined by the DSM IV-TR, are repetitive behaviors triggered by obsessions that the patient feels are necessary to repress the thoughts and urges. In the patient’s mind, they complete these compulsions in order to prevent an unrealistic scenario from occurring (APA, 2000). In order to be diagnosed as OCD, these obsessions and compulsions must have a significant and negative impact on the patient’s daily life. These obsessions and compulsions are also independent of any other psychological disorder or substance that results in a physiological effect (APA, 2000).

Obsessive Compulsive Personality Disorder is characterized in the DSM IV-TR as being an excessive fixation with control, order, and overall perfectionism and manifests itself as at least four of the following characteristics: hoarding either money or seemingly worthless objects, excessively prioritizing work over socialization, inflexibility, unwillingness to delegate, fixating over details, rules, etc., having a strong sense of what is valuable or moral, and impossibly high standards (APA, 2000).

It is important that the most effective treatment be applied as early as possible upon the diagnosis of OCD to prevent progression of the detrimental effects of the disorder. After exploring various treatment options for both OCD and OCPD, we have come to the conclusion that cognitive behavioral therapy is the most effective type of therapy in treating OCD and OCPD.

METHOD

For our study, we analytically reviewed various studies concerning the application of alternate treatments to be used on patients with OCD or OCPD. Though many of the studies were statistically significant, not all were strongly significant. In such cases, we evaluated the study based on its clinical significance.

PARTICIPANTS

The participants for our study greatly vary because the studies themselves utilize patients with varying degrees of OCD and OCPD symptoms severity. Most of the subjects of the studies were adults ranging in age from 18 to 35. In the studies concerning invasive medical procedures, the patients were resistant to other forms of treatment. On average, both male and female patients were equally represented throughout the studies. Furthermore, the participants did not have substance abuse prior to entering the studies.

MEASURES

A majority of our studies utilized the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) to evaluate the severity of both OCD and OCPD symptoms. According to Fenger et al., "Y-BOCS measures the severity of OCD [and OCPD] symptoms on five obsession items and five compulsion items... Y-BOCS assesses the time spent engaged in the symptoms; the degree of interference with functioning; the level of distress; attempts to resist the symptoms; and the level of control over the symptoms" (Fenger, 2007). In one case, an alternative form of measurement was used called the Leyton Obsessional Inventory (Wellen, 2007). For this measurement, questionnaires are completed by people suffering from OCD or OCPD to report their symptoms and severity. This was the first time the scale had been used to distinguish between OCD and OCPD (Wellen, 2007).

DATA ANALYSIS

Data that we utilized from different studies was both raw and statistically analyzed. The data presented in each study were analyzed by the respective researchers. The focus of our study pertains to evaluating the quality and significance of their analyses.

RESULTS

Studies Primarily Concerning Therapy as a Treatment

The study conducted Krebs and Haymen focused on the importance of finding the correct treatment for each patient. Failure in the treatments is common, but they stress that when a patient fails to respond to a treatment, a review of the diagnosis and environmental factors should be completed. Changing the treatment before determining the problem could prove to be detrimental to the patient. Krebs and Haymen demonstrate that each patient needs different treatment and motivation enhancement strategies should be employed. They also mention that there are many forms of treatment for OCD that range from therapy to surgery, but Cognitive Behavioral Therapy and Serotonin Reuptake Inhibitors are the most successful treatments (Krebs, 2010).

A study done to compare cognitive therapy (a subtype of CBT) to ERP therapy found that cognitive therapy was significantly more effective. Though both the CBT group and the ERP group showed significant improvement, the CBT group improved more (Van Oppen, 1995).

Fenger et al conducted a study which was primarily concerned with investigating the effectiveness of treating OCD using CBT group sessions. The groups consisted of 3 to 4 patients who underwent 3 months of therapy lead by two licensed clinical psychologists. Upon completion of therapy, researchers found "moderate to large effect sizes" relating to the reduction of patient's OCD symptoms based on Y- BOCS scores and participating patients' self reports (Fenger, 2007).

Another study that investigated the comparison of ERP and CBT for treating patients with OCD was done by Whittal et al in 2008. In their study, they compared the long term effectiveness of both CBT and ERP on the individual and group level. The research found that at a two year follow up post therapy, both CBT and ERP showed similar improvements based on Y-BOCS scores. Also, ERP therapy in the group setting showed a significantly greater drop in the patients’ Y-BOCS scores compared to patients in group therapy CBT (Whittal et al 2008.)

Studies Primarily Concerning Medication as a Treatment

A more unique study done by Rucklidge discussed how patients who are resistant to conventional treatments for OCD may benefit from micronutrient supplementation. Rucklidge found that when negative results to CBT appeared in an 18 year old male with OCD, micronutrient supplementation proved to be an effective treatment for this individual (Rucklidge, 2009).

Franklin et al investigated the effectiveness of using CBT for patients with OCD both with and without Serotonin Reuptake Inhibitor (SRI) drugs. After one month of daily CBT sessions lasting 2 hours each, researchers found that both patients who were taking SRI’s and patients not taking SRI’s showed significant improvement (between 70-80% of both groups) in the reduction of their symptoms (Franklin, 2002.)

Studies Primarily Concerning Invasive Medical Procedures as a Treatment

The data synthesized by Lakhan et al was also concerned with the developing treatment of OCD known as deep brain stimulation for patients who had previously showed minimal or no response to psychotherapy or pharmacological therapy. Although the treatment itself varied in the several clinical trials described, the data presented suggested that about half of the 42 patients with OCD showed “dramatic improvement” in the reduction of their symptoms along with minimal surgical complications (Lakhan, 2010).

Another study that investigated the application of deep brain stimulation in the treatment of 6 OCD patients showed significant improvements in the long term condition in each patient with minimal complications relating to the procedure (Goodman, 2010).

A study that investigated the long term effectiveness of a neurosurgical procedure known as a capsulotomy showed that after 4 to 14 years post operation, patients with OCD could see significant improvement in their symptoms. However, many of the patients that took part in this study experienced serious complications as a result of the procedure such as brain edemas, memory loss, sexual disinhibition, and cognitive dysfunctions (Ruck 2008).

DISCUSSION

Based upon the studies analyzed, we found that OCD and OCPD both show the most improvements with minimalized drawbacks when treated with Cognitive Behavioral Therapy. Not only does it effectively help the patients, but studies have shown that is helps over a longer period of time. One important positive aspect of CBT is that it can be administered with the same amount of success, in either a group setting, private setting, or even over the phone (Krebs, 2010).

The use of pharmaceutical drugs in the treatment of OCD and OCPD displays the greatest benefit to patients when coupled with therapy. However, when pharmaceutical drugs are used exclusively in the absence of some form of therapy, they prove to be relatively ineffective in the long term treatment of OCD, since they must be consistently consumed (Rapoport, 1989). Aside from effectively decreasing obsessions and therefore compulsions, pharmaceutical treatments also serve to prevent potential side effects of the therapy such as depression (Franklin, 2002). Nevertheless, the medication presents its own side effects that may become severe. The side effects of Clomipramine (Anafranil), for example, may range from fatigue and dry mouth to tremors and impotence (Rapoport, 1989). Drugs are not as prevalent in OCPD therapy because of the patient being less stressed as a result of the sessions.

The second most effective therapy for both OCD and OCPD proved to be Exposure and Response Prevention (ERP) Therapy. This form of therapy as the name states exposes patients to excessive amounts of stimuli that trigger obsessive thoughts and compulsions. After the patient has been exposed to these excessive amounts of stimuli, they are educated on how to cope with the resulting urges that lead to compulsive behavior (Whittal, 2008). Drawbacks of this particular type of therapy include high dropout rates in therapy sessions due to the overwhelming nature of exposure (Van Oppen, 1995).

Invasive medical procedures prove to be a last resort method for patients who are non-responsive to any other form of treatment for specifically OCD (Lakhan, 2010). In general, the lack of studies regarding invasive procedures on OCPD patients indicates that the disorder is not severe enough to warrant extreme and high risk operations. The most effective form of invasive procedures is deep brain stimulation because of its higher success rates and smaller amount of surgical complications (Goodman, 2010). Deep brain stimulation involves the placement of electrodes at specific sites in a patients’ brain through neurosurgical methods in order to provide small amounts of electric current to treat their OCD symptoms (Goodman, 2010). However, due to its lack of establishment in the medical field, it is still subject to clinical studies (Lakham, 2010). Traditional forms of neurosurgical procedures such as a capsulotomy can have major complications despite their relative effectiveness to reduce long term OCD symptoms. In these traditional forms of procedures, surgical lesions are created at specific sites in the patients’ brain in order to reduce the severity of OCD symptoms (Ruck, 2008). Some complications that arise from these types of procedures include brain edemas, seizures, incontinence, sexual disinhibition, memory loss, weight gain, and cognitive dysfunction (Ruck, 2008).

In conclusion, there are multiple effective treatments available to OCD and OCPD patients. Of these, Cognitive Behavioral Therapy appears to be the best due to its relatively high rate of success coupled with the least amount of drawbacks. Treatment effectiveness is partially dependent on the patient. What works well for one may not prove as effective for another. Some newer treatments, specifically deep brain stimulation, show relatively high rates of success paired with minimal surgical complications. Despite being in a state of early development, this treatment may prove to be equally successful to CBT, but more research must first be done.

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