Psychological Treatment of OBSESSIVE- COMPULSIVE DISORDER FUNDAMENTALS AND BEYOND EDITED BY Martin M. Antony Christine Purdon Laura J. Summerfeldt AMERICAN PSYCHOLOGICAL ASSOCIATION WASHINGTON, DC Copyright © 2007 by the American Psychological Association. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, including, but not limited to, the process of scanning and digitization, or stored in a database or retrieval system, without the prior written permission of the publisher. Published by American Psychological Association 750 First Street, NE Washington, DC 20002 www.apa.org To order APA Order Department P.O. Box 92984 Washington, DC 20090-2984 Tel: (800) 374-2721; Direct: (202) 336-5510 Fax: (202) 336-5502; TDD/TTY: (202) 336-6123 Online: www.apa.org/books/ E-mail: [email protected] In the U.K., Europe, Africa, and the Middle East, copies may be ordered from American Psychological Association 3 Henrietta Street Covent Garden, London WC2E 8LU England Typeset in Goudy by Stephen McDougal, Mechanicsville, MD Printer: Edwards Brothers, Inc., Ann Arbor, MI Cover Designer: Berg Design, Albany, NY Technical/Production Editor: Tiffany L. Klaff The opinions and statements published are the responsibility of the authors, and such opinions and statements do not necessarily represent the policies of the American Psychological Association. Library of Congress Cataloging-in-Publication Data Psychological treatment of obsessive-compulsive disorder : fundamentals and beyond / [edited by] Martin M. Antony, Christine Purdon, Laura Summerfeldt.—1st ed. p. cm. Includes bibliographical references and index. ISBN-13: 978-1-59147-484-5 ISBN-10: 1-59147-484-1 1. Obsessive-compulsive disorder. 2. Cognitive therapy. 1. Antony, Martin M. II. Purdon, Christine. III. Summerfeldt, Laura. [DNLM: 1. Obsessive-Compulsive Disorder—therapy. 2. Psycho-therapy—methods. 3. Obsessive-Compulsive Disorder—psychology. 4. Comorbidity. WM 176 P9737 2007] RC533.P78 2007 616.85'2270651—dc22 2006023919 British Library Cataloguing-in-Publication Data A CIP record is available from the British Library. Printed in the United States of America First Edition CONTENTS Contributors ix. Acknowledgments xi Introduction 3 Martin M. Antony, Christine Purdon, and Laura J. Summerfeldt I. Fundamentals of Psychological Treatment for Obsessive-Compulsive Disorder 7 Chapter 1. Cognitive-Behavioral Models of Obsessive-Compulsive Disorder 9 Steven Taylor, Jonathan S. Abramowitz, and Dean McKay Chapter 2. General Issues in Psychological Treatment for Obsessive-Compulsive Disorder 31 David F. Tolin and Gail Steketee Chapter 3. Treatment Readiness, Ambivalence, and Resistance 61 C. Alec Pollard Chapter 4- Exposure and Response Prevention 79 Karen Rowa, Martin M. Antony, and Richard P. Swinson Chapter 5. Cognitive Therapy for Obsessive-Compulsive Disorder Ill Christine Purdon II. Strategies for Specific Obsessive-Compulsive Disorder Presentations 147 Chapter 6. Treating Contamination Concerns and Compulsive Washing 149 David S. Riggs and Edna B. Foa Chapter 7. Treating Doubting and Checking Concerns .... 169 Jonathan S. Abramowitz and Christy A. Nelson Chapter 8. Treating Incompleteness, Ordering, and Arranging Concerns 187 Laura]. Summerfeldt Chapter 9. Treating Religious, Sexual, and Aggressive Obsessions 209 S. Rachman Chapter 10. Treating Compulsive Hoarding 231 Ancy E. Cherian and Randy O. Frost III. Strategies for Specific Populations 251 Chapter 11. Treating Obsessive-Compulsive Disorder in Children and Adolescents 253 Martin E. Franklin, John S. March, and Abbe Garcia Chapter 12. Treating Obsessive-Compulsive Disorder in People With Poor Insight and Overvalued Ideation 267 David Veale Chapter 13. Treating Comorbid Presentations: Obsessive- Compulsive Disorder, Anxiety Disorders, and Depression 281 Deborah Roth Ledky, Anushka Pai, and Martin E. Franklin Chapter 14- Treating Comorbid Presentations: Obsessive- Compulsive Disorder and Disorders of Impulse Control 295 Adam S. Radomsky, Antje Bohne, and Kieron P. O'Connor vi CONTENTS Author Index 311 Subject Index 321 About the Editors 337 CONTENTS vii CONTRIBUTORS Jonathan S. Abramowitz, PhD, Department of Psychology, University of North Carolina at Chapel Hill Martin M. Antony, PhD, ABPP, Department of Psychology, Ryerson University, Toronto, Ontario, Canada, and Anxiety Treatment and Research Centre, St. Joseph's Healthcare, Hamilton, Ontario, Canada Antje Bohne, PhD, Institute of Psychology, University of Muenster, Germany Ancy E. Cherian, PhD, Center for Anxiety and Related Disorders, Boston University, Boston, MA Edna B. Foa, PhD, Center for the Study and Treatment of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia Martin E. Franklin, PhD, Center for the Study and Treatment of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia Randy O. Frost, PhD, Department of Psychology, Smith College, Northampton, MA Abbe Garcia, PhD, Child and Adolescent Psychiatry, Brown University Medical School and Rhode Island Hospital, Providence Deborah Roth Ledley, PhD, Adult Anxiety Clinic of Temple University and private practice, Philadelphia, PA John S. March, MD, MPH, Department of Psychiatry, Duke University Medical Center, Durham, NC Dean McKay, PhD, Department of Psychology, Fordham University, Bronx, NY Christy A. Nelson, MA, Department of Psychology, University of Kansas, Lawrence IX Kieron P. O'Connor, PhD, Femand-Seguin Research Centre, Louis H. Lafontaine Hospital, and Department of Psychiatry, University of Montreal, Montreal, Quebec, Canada Anushka Pai, BA, Department of Psychology, University of Texas at Austin C. Alec Pollard, PhD, Anxiety Disorders Center, St. Louis Behavioral Medicine Institute, St. Louis, MO Christine Purdon, PhD, Department of Psychology, University of Waterloo, Waterloo, Ontario, Canada S. Rachman, PhD, Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada Adam S. Radomsky, PhD, Department of Psychology, Concordia University, and Centre de Recherce Fernand-Seguin, Montreal, Quebec, Canada David S. Riggs, PhD, Center for the Study and Treatment of Anxiety, Department of Psychiatry, University of Pennsylvania, Philadelphia Karen Rowa, PhD, Anxiety Treatment and Research Centre, St. Joseph's Healthcare, and Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada Gail Steketee, PhD, Boston University School of Social Work, Boston, MA Laura J. Summerfeldt, PhD, Department of Psychology, Trent University, Peterborough, Ontario, Canada Richard P. Swinson, MD, FRCP(C), FRCPsych, Anxiety Treatment and Research Centre, St. Joseph's Healthcare, and Department of Psychiatry and Behavioural Neurosciences, McMaster University, Hamilton, Ontario, Canada Steven Taylor, PhD, Department of Psychiatry, University of British Columbia, Vancouver, British Columbia, Canada David F. Tolin, PhD, Anxiety Disorders Center, Institute of Living, Hartford Hospital, Hartford, CT David Veale, MD, FRCPsych, South London and Maudsley Trust, Institute of Psychiatry, King's College London, and The Priory Hospital North London, England. CONTRIBUTORS ACKNOWLEDGMENTS We thank Julia Blood for her editorial assistance on several chapters of this book. Thanks also to Susan Reynolds, Judy Nemes, and the staff at the American Psychological Association for their support. Finally, we thank the authors who contributed to this book as well as several anonymous reviewers who provided comments on a draft of the manuscript. XI Psychological Treatment of OBSESSIVE- COMPULSIVE DISORDER INTRODUCTION MARTIN M. ANTONY, CHRISTINE PURDON, AND LAURA J. SUMMERFELDT Until the mid-1960s, obsessive-compulsive disorder (OCD) was con- sidered to be a relatively untreatable condition. In the brief span of time since then, the empirical and clinical literature have converged to point to cognitive-behavioral therapy (CBT) as among the most effective psycho- logical interventions available for any psychiatric condition. Despite the widely recognized efficacy of behavioral and cognitive treatments for OCD, however, clinicians and researchers acknowledge that there are major chal- lenges to implementing them successfully. In their meta-analysis of treatment outcomes for OCD, Eddy, Dutra, Bradley, and Westen (2004) observed that about half of the patients who applied for psychological treatment were excluded from the studies exam- ined. Moreover, despite impressive group effect sizes, only about half of those who were included in treatment efficacy studies showed clinical improve- ment, and only one quarter recovered completely. Of equal concern, many individuals entering therapy did not complete it, although roughly two thirds of those who did complete treatment improved. In short, at each step of the treatment process, it appears that a substan- tial portion of the OCD population fails to benefit from the most effective psychological treatment available. One reason for this poor outcome may be 3 the fact that OCD is a complex and heterogeneous disorder that may not lend itself well to generic interventions. It is also associated with features that can substantially complicate the design, application, and delivery of treatment, such as treatment ambivalence, poor insight, and high comorbidity. Obsessive-compulsive disorder is also a disorder that occurs at many points across the life span, which again may compromise the success