New Directions in the Cognitive-Behavioral Treatment of OCD: Theory, Research, and Practice
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Available online at www.sciencedirect.com ScienceDirect Behavior Therapy 49 (2018) 311–322 www.elsevier.com/locate/bt New Directions in the Cognitive-Behavioral Treatment of OCD: Theory, Research, and Practice Jonathan S. Abramowitz Shannon M. Blakey Lillian Reuman Jennifer L. Buchholz University of North Carolina at Chapel Hill CHARACTERIZED BY (a) obsessions—persistent intru- The beneficial effects of cognitive-behavioral interventions sive unwanted thoughts, images, or doubts that (particularly exposure and response prevention) for OCD provoke anxiety and distress—and (b) compul- are among the most consistent research findings in the sions—repetitive or ritualistic behaviors or thoughts mental health literature. Nevertheless, even after an performed deliberately to neutralize the distress adequate trial, many individuals experience residual symp- associated with obsessions, untreated obsessive- toms, and others never receive adequate treatment due to compulsive disorder (OCD) generally follows a limited access. These and other issues have prompted deteriorating course (Pinto, Mancebo, Eisen, Pagano, clinicians and researchers to search for ways to improve &Rasmussen,2006). Moreover, people with OCD the conceptual and practical aspects of existing treatment often have diminished quality of life (Jacoby, Leonard, approaches, as well as look for augmentation strategies. In Riemann, & Abramowitz, 2014; Subramaniam, Soh, the present article, we review a number of recent develop- Vaingankar, Picco, & Chong, 2013), as do their ments and new directions in the psychological treatment of caregivers (Ramos-Cerqueira, Torres, Torresan, OCD, including (a) the application of inhibitory learning Negreiros, & Vitorino, 2008). Still, OCD is under- approaches to exposure therapy, (b) the development of recognized in mental health settings, in part because its acceptance-based approaches, (c) involvement of caregivers symptoms often manifest as private experiences, but (partners and parents) in treatment, (d) pharmacological also because patients may be reluctant to disclose cognitive enhancement of exposure therapy, and (e) the use what they perceive as shameful or embarrassing of technology to disseminate effective treatment. We focus thoughts and behaviors. Accordingly, the mean time on both the conceptual/scientific and practical aspects of from symptom onset to initial treatment can be as long these topics so that clinicians and researchers alike can as 8 years (Altamura,Buoli,Albano,&Dell’Osso, assess their relative merits and disadvantages. 2010). Of the less than half of individuals with OCD who receive diagnosis-specific therapy, fewer than 10% receive evidence-based treatment (Torres et al., Keywords: OCD; CBT; exposure and response prevention; 2007). inhibitory learning; ACT Substantial evidence supports the efficacy and effectiveness of cognitive behavioral therapy (CBT) as the first-line treatment of OCD. A comprehensive meta-analysis reported large effect sizes (ES) in favor of CBT across comparisons with control treatments Address correspondence to Jonathan Abramowitz, Ph.D., De- partment of Psychology and Neuroscience, University of North at posttreatment (e.g., = 1.39), and moderate effects Carolina at Chapel Hill, Campus Box 3270 (Davie Hall), Chapel at follow-up (ES = .43; Olatunji, Davis, Powers, & Hill, NC 27599; e-mail: [email protected]. Smits, 2013). The specific CBT interventions receiv- 0005-7894/© 2018 Association for Behavioral and Cognitive Therapies. ing the strongest support are exposure (planned and Published by Elsevier Ltd. All rights reserved. repeated systematic confrontation with external and 312 abramowitz et al. internal obsessional cues) and response prevention and human research on basic learning processes, (abstaining from compulsive rituals), the use of has been proposed for understanding and imple- which dates back more than half a century (Meyer, menting exposure (e.g., Craske et al., 2008). 1966). Contemporary treatment protocols include Such research indicates that exposure does not (a) a few sessions of treatment planning and result in “unlearning” or the “correction” of psychoeducation about the symptoms of OCD, fear-based associations, rather it facilitates the (b) systematic repeated and prolonged exposure to generation of new safety-based associations. This feared stimuli both in vivo and using imaginal means that following exposure trials, a feared techniques, and (c) strategic elimination of rituals stimulus is associated with both its original (danger) (response prevention). Typically, treatment entails meaning and its new inhibitory (safety) meaning. 12 to 16 weekly (or more frequent) sessions of Thus, the aim of exposure therapy from an inhibitory supervised exposure and response prevention (ERP) learning framework is to help patients generate and along with “homework practices” between sessions. strengthen inhibitory associations relative to older, Consistent findings indicate that ERP is more fearful associations. Although not altogether incon- effective than other psychological interventions gruous with emotional processing accounts, the (Lindsay, Crino, & Andrews, 1997) and medica- inhibitory learning model is distinct in that it rejects tion (Foa et al., 2005) for OCD, with large effect the emphasis on fear reduction (habituation) during sizes (e.g., 2.49 and 0.92 respectively). Indeed, the exposure, focusing instead on short-term fear majority of those who complete a program of ERP tolerance and the longer-term extinction of fear experience at least some symptom relief either alone through the disconfirmation of threat-based expec- or in combination with serotonin reuptake inhibi- tations (Craske et al., 2008). tor medications (Abramowitz, Taylor, & McKay, 2009). Nevertheless, even after an adequate trial, clinical application about half of patients endorse impairing residual There are a number of more or less specific clinical symptoms. This reality has prompted clinicians and strategies for maximizing ERP outcomes by optimiz- researchers to look for ways to improve the ing inhibitory learning (discussed in detail in Jacoby conceptual and practical aspects of ERP, as well & Abramowitz, 2016; but see also Abramowitz & as look for augmentation strategies. Accordingly, Arch, 2014;andArch & Abramowitz, 2015), and our goal in the present article is to review recent these converge to facilitate two critical treatment developments and directions in the psychological goals: the (a) violation of negative expectancies, and treatment of OCD. These advances include the (b) generalization of inhibitory associations across application of inhibitory learning approaches to multiple contexts. In this section we present an ERP, the development of acceptance-based ap- overview of the strategies clinicians can use to address proaches for OCD, greater involvement of care- these aims. The reader is also referred to a recent ERP givers in ERP, pharmacological enhancement of treatment manual written from this perspective ERP, and the use of technology to disseminate (Abramowitz & Jacoby, 2015). effective treatment. Violating Negative Expectancies Application of the Inhibitory Learning Model of This refers to the discrepancy between a patient’s Exposure to OCD anticipated consequence of an exposure task (e.g., One recent development in the treatment of OCD becoming ill after touching a toilet) and the actual (and anxiety-related disorders in general) is the consequence (e.g., not becoming ill). Strong inhibi- consideration of inhibitory learning models of tory associations may be generated by maximally exposure therapy. Traditional accounts of the violating a patient’s fear-based predictions for harm mechanisms underlying the efficacy of exposure/ (Rescorla & Wagner, 1972). To this end, clinicians ERP emphasize emotional processing—the idea might try to maximize the likelihood that patients that (a) repeated and prolonged exposure corrects will be “pleasantly surprised” by the nonoccurrence fear-based associations leading to fear extinction of their feared catastrophe by deliberately orches- (the type of learning that occurs during exposure), trating opportunities for feared outcomes that are and (b) habituation of fear within and between unlikely or impossible (e.g., causing “bad luck” by exposure sessions is an index of such learning (e.g., writing certain numbers), or at least tolerable (e.g., Foa & Kozak, 1986). Research on learning and feeling uncertain). Specifically, clinicians could cap- memory, however, supports neither assertion very italize on the element of surprise by encouraging a strongly (Arch & Abramowitz, 2015; Craske et al., patient to conduct an exposure to a feared stimulus at 2008). Thus, an updated inhibitory learning a greater level of intensity, duration, or frequency framework, which draws on experimental animal than the patient believes would be “safe.” treatment of ocd 313 A second strategy to generate inhibitory associa- considered in relation to the presence of obsessions, tions involves combining multiple fear cues during the client’s history, and the function of the washing. exposure to “deepen” extinction learning (Rescorla, ACT sessions typically involve metaphorical dis- 2006). In practice, this might involve helping a cussions of these concepts with “homework” woman who fears murdering her baby to (a) conduct suggestions to supplement what has been discussed. imaginal exposure to stabbing her infant, then (b) Functional contextualism judges therapies accord-