Different psychological approaches and their treatments of Obsessive-Compulsive Disorder

At university you are asked to write a lot of Essays.  In year one, I was asked to discuss Treatment options for Obsessive-Compulsive Disorder.   This is the Essay I came up with and it was graded B.  I hope this helps anyone trying to learn about OCD and what is available to help with this. 

Discuss different psychological approaches and their treatments of Obsessive-Compulsive Disorder

When looking treatments for Obsessive compulsive disorder (OCD) we can approach the treatment from different psychological fields. Firstly we need to understand what obsessive-compulsive disorder is. 

OCD is classified as an anxiety disorder and defined as the presence of obsessions, compulsions, or both.  Obsessions are defined as persistent thoughts that are intruding. Compulsions are repetitive or ritualistic behaviours, such as washing hands, counting or ordering. These are carried out to relieve anxiety caused by the obsessive thought (American Psychiatric Association., 2013). 

Throughout this discussion, this essay will explore the Behaviourist approach to OCD by discussing behaviourist treatments and utilising information of studies carried out by Foa et al (McLeod, 1997). Focus will also be given to the Cognitive theory and their treatment, Cognitive Behavioural Therapy (CBT). This will be done using the case study of Karen Rusa (Oltmanns, Neale and Davison, 1995). To conclude, there will be an evaluation showing why CBT is the most effective method for treatment for OCD.

Skinner (1948) argues that obsessive fears cause anxiety which are reduced using compulsive behaviours. These behaviours are maintained through this negative reinforcement (McLeod, 1997). As Behaviourists do not see these behaviours as symptoms of another issue, only behaviours are treated because they are seen as the key issues. (Gleitman, Gross, and Reisberg, 2011., Schacter, Gilbert, Wegner, and Hood, 2011).

There are several studies which support the Classical conditioning method of Exposure and Response Prevention (ERP). Using ERP, Behaviourists aim to break the connection between the obsessive fear and the anxiety it causes through exposure.  They also concentrate on breaking the habit of the performance of compulsive rituals after the exposure through response prevention. (Foa et al 1985., McLeod 1997). This entails the client being exposed, to what they fear, for instance, a ‘contaminated’ vase, then being delayed or prevented from washing their hands.  This treatment shows  effectiveness amongst patients who suffer from contamination, counting or checking rituals but cannot be generalised to other forms of OCD (Ball et al 1996., McLeod 1997).

Ost (1989) reviewed seven cases in which 85% of patients retained improvements after ERP treatment. Nine further studies by O’Sullivan and Marks (1991) showed improvements maintained from between one and six years.  Follow up findings continue to report improvement at 79% which strongly supports this treatment. (McLeod, 1997).  Keister et al (1994) however, stated that most often the documentation did not account for patients who discontinued treatment, when these were considered the success rate dropped to between 40%-50% (McLeod, 1997).

The Cognitive approach to this condition not only focuses on behaviours but on the thought process behind these. Becks argues that when in a state of depression/anxiety the patient has an unrealistic way of thinking.  They think themselves as useless, their experiences as terrible and their future as being worse.  Becks Calls this the ‘Negative Triad’ (Sammons, 2011) also known as dysfunctional beliefs. These beliefs inflate the patients perceptions of responsibility and they believe that they can stop negative outcomes (Olatunji, Rosenfield, Tart, Cottraux, Powers and Smits, 2013).  This theory also states that the individual controls their own thoughts and that abnormality occurs when that control is faulty in some way (Williamson, Cardwell and Flanagan, 2007). This faulty control is dealt with by working on these dysfunctional beliefs.

In the Case of Karen Ruso, she had put many rituals in place.  Shopping became difficult because of numbering rituals. Smoking was also transformed into a number ritual as she had to smoke one cigarette for each child, one after the other, to prevent harm coming to them.  Karen had a strong religious emphasis within her life.  It was noted that Karen no longer attended church as they had updated things and this horrified her, as she thought these modern changes were disrespectful. Her four children constantly misbehaved. Her husband was out of work due to illness, and was quite demanding of her; ie: asking her to get beers from the refrigerator as he was not supposed to walk far. Karen admitted that things had not been going well and that her situation was stressful (Oltmanns et al., 1995).  She felt unhappy with her life but did not make the connection between her beliefs, rituals and current situation. The demands from her husband and children had caused a lack of assertiveness. The loss of her church routine impacted on Karen's confidence. It was apparent that the rituals were Karens way of maintaining some form of ‘faulty ‘control over her situation (Oltmanns et al., 1995). Treatment began by developing assertiveness to deal with the family. Karen kept a diary to log all situations where she needed to be assertive. She was challenged to write down (dysfunctional) thoughts of what would happen if she was assertive and further challenged to test these thoughts.  She was asked to visit traditional churches, she joined one and gained more confidence. (Oltmanns et al., 1995).  When Karen felt confident, she began the next stage of therapy, ERP. She was exposed to an obsession (cigarette) but the compulsive ritual was delayed. (Oltmanns et al., 1995).  This removed the ‘faulty control’ by only allowing her one cigarette. By the  end of Karen’s treatment her family life had improved and the rituals were minimal with little anxiety.

CBT is widely accepted as the most effective treatments for OCD (Taylor, Thordarson, Spring, Yeh, Corcoran, Eugster and Tisshaw, 2003). Dysfunctional thinking may cause the patient to perceive the treatment as confirmation that they are incapable of improvement. It is apparent however, from Karens case, that by dealing with this dysfunctional thought process as the priority, you can then deal with the faulty control of the rituals with more optimism from the patient.  This can be done during the behavioural aspect of the treatment with less likelihood that patients will discontinue the treatment before completion.

The behaviourist treatment alone, is harsh and abrupt.  Behaviour is the key focus and puts the patient under immediate pressure as they are exposed to their fears.  There is no mental preparation for the patient and the focus is solely on the behaviours.  As evidenced by the CBT Karen received, the behaviours treated during ERP are highly unlikely to have been the cause of her OCD. Alone, ERP can make the patient feel out of control causing patients to discontinue treatment prematurely and success rates to drop as evidenced by Keister. Although Behaviourism does acknowledge fear is the obsession, they see this as a learned behaviour rather than a thought process.  This leaves a gap in the theory causing a lack of insight into the root cause of the patients form of OCD.

In conclusion CBT provides the insight needed to get to the root cause of the issue.    This treatment can support the patient on different levels because it focuses on giving ‘true’ control back to the patient through correction of dysfunctional beliefs, followed by Behavioural therapy to correct faulty control methods such as rituals.  The treatment of dysfunctional beliefs also helps to prepare the patient as treatment moves forward.  This makes the transition into ERP smoother as the patients beliefs are more logical and overall anxiety is lessened, as evidenced clearly in Karens treatment.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders American Psychiatric Association. Arlington: American Psychiatric Publishing.

Gleitman, H., Gross, J. and Reisberg, D. (2011).Psychology. New York: W. W. Norton & Co..

McLeod, D. (1997). Psychosocial treatment of obsessive-compulsive disorder. International Review of Psychiatry, 9 (1), pp. 119--132.

Oltmanns, T., Neale, J. and Davison, G. (1995). Case studies in abnormal psychology. New York [etc.]: Wiley.

Olatunji, B., Rosenfield, D., Tart, C., Cottraux, J., Powers, M. and Smits, J. (2013). Behavioral versus cognitive treatment of obsessive-compulsive disorder: An examination of outcome and mediators of change.. Journal of consulting and clinical psychology, 81 (3), p. 415.

 Sammons, A. (2011). Beck’s Cognitive Theory of Depression. [online] Retrieved from: http://www.psychlotron.org.uk/resources/abnormal/a2_aqa_abnormal_moodcognitivebeck.pdf [Accessed: 11 Nov 2013].

Schacter, D., Gilbert, D., Wegner, D. and Hood, B. (2011). Psychology. Basingstoke: Palgrave Macmillan.

Taylor, S., Thordarson, D., Spring, T., Yeh, A., Corcoran, K., Eugster, K. and Tisshaw, C. (2003). Telephone-administered cognitive behavior therapy for obsessive-compulsive disorder. Cognitive Behaviour Therapy, 32 (1), pp. 13--25.

Williamson, M., Cardwell, M. and Flanagan, C. (2007). Higher psychology. Cheltenham: Nelson Thornes.