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Obsessive Compulsive Disorder: Seven Effective Behavioral Strategies
Obsessive Compulsive Disorder: Seven Effective Behavioral Strategies

Section 9
Treatment of Obsessive-Compulsive Disorder in Patients
who have Comorbid Major Depression Part Two

CEU Question 9 | Answer Booklet | Table of Contents | OCD
Psychologist CEs, Social Worker CEUs, Counselor CEUs, MFT CEUs, Nurse CEUs 

Case Illustration
Client Description and Case Formulation
“Bruce” was a 37-year-old man from the rural midwestern United States who entered our clinic in response to a radio advertisement and described “obsessive-compulsive hand washing and depression.” His hands Major Depression Obsessive Compulsive Disorder mft CEUwere visibly sore and cracked from the 50 to 75 episodes of washing each day. Bruce was unmarried and lived with his parents on their farm. He was unable to date, start relationships, or work despite attaining a bachelor’s degree in agriculture from a state university about 15 years earlier. He was, however, able to help with various chores on the farm.

Assessment using the Yale-Brown Obsessive Compulsive Scale (Y-BOCS) and Symptom Checklist indicated prominent contamination obsessions and cleaning/washing rituals. Specific obsessional cues included bodily fluids, particularly urine and feces, and ideas that perhaps he might have had contact with such substances. As mentioned earlier, Bruce washed his hands upward of 75 times, took multiple showers, and changed his clothes a few times each day. He was engaged in elaborate avoidance strategies to prevent spreading contamination from his bathroom to other areas that had to be kept “clean,” and he involved his parents in many of his rituals and avoidances. His pretreatment score on the Y-BOCS severity scale was 27, which indicates fairly severe OCD symptoms.

A diagnostic interview confirmed a diagnosis of both OCD and major depression. His OCD symptoms had begun while he was in high school and had become progressively worse. For the last few years Bruce reported feeling down, having decreased energy and interest in activities or hobbies, and experiencing feelings of worthlessness, hopelessness, and passive suicidal thinking. His BDI score was 29 and his Hamilton Depression Rating Scale (HDRS) score was 20, suggesting clinical depression of moderate severity.

Bruce had never received treatment for OCD or depression; he had discussed it with the pastor at his church. After several sessions Bruce mentioned the advertisement for our research to the pastor, who suggested he be evaluated. After an assessment and discussion of treatment options, Bruce was quite ambivalent about beginning therapy, primarily because he feared engaging in exposure exercises. The evaluator explained that therapy would be a challenge but would progress at a level with which Bruce was comfortable and that he would never be forced to confront exposure. Instead, it would be the therapist’s job to help Bruce to see how trying exposure and response prevention (ERP) would help him achieve relief from his symptoms even if it meant “investing anxiety in a calmer future.” After some discussion with his parents, Bruce opted to enter our program.

Course of Treatment
Treatment involved 16 90-minute twice-weekly sessions over the course of about 2 months (8 weeks). During the first two treatment sessions the therapist continued to collect information about Bruce’s depressive symptoms and Bruce was introduced to the cognitive model of emotional disorders, wherein negative emotions are considered to be evoked by dysfunctional interpretations of situations. It became clear that Bruce’s depression was secondary to his OCD symptoms; he described feeling guilty and worthless and considering himself a failure as a result of the impairment caused by OCD. He saw no way out of his affliction after more than 20 years. Cognitive therapy for depression was begun and the therapist taught Bruce to recognize cognitive errors, including “overgeneralizing,” “catastrophizing,” and “discounting the positive.” Bruce was helped to generate more realistic appraisals of himself and his future. For example, “Everyone, including me, views me as a failure” was modified to “I have failed at some things because of my problem with OCD, but I have also managed to succeed at other things—such as school— and therefore I am not a failure, but a person with personal strengths and limitations.”

Bruce was instructed in how to use daily thought diaries to practice identifying and modifying dysfunctional thoughts himself. He also worked with his therapist to develop a routine of activities that he enjoyed (behavioral activation), such as watching certain humorous television shows and renting movies he liked. It became clear that Bruce considered others’ impressions of him as very important. Numerous cognitive therapy worksheets were dedicated to thoughts regarding the importance of what others thought of him. Thus, Bruce was helped to reduce the emphasis he placed on what he thought others might be thinking of him.

Sessions 3 and 4 involved learning to apply the cognitive model (and cognitive therapy) to OCD symptoms. In particular, Bruce was taught that his obsessional anxiety was the result of overestimates of the dangerousness of bodily fluids and misinterpretations of intrusive thoughts and doubts about contamination. For example, the therapist pointed out how Bruce misappraised thoughts that he might have stepped in dog feces as meaning that he probably had. A model of OCD in which obsessional anxiety leads to urges to avoid and perform rituals, which paradoxically reinforce obsessional anxiety, was applied to Bruce’s specific obsessions, compulsions, and avoidance habits. Bruce comprehended this model quite easily. He understood that once he realized that bodily fluids (1) are not as likely to be encountered as he thought and (2) are not as dangerous as he feared, his urges to engage in compulsive behavior and avoidance would be diminished.

In the fourth session, an exposure hierarchy was developed collaboratively. After a thorough discussion of the rationale for therapeutic exposure and response prevention, Bruce agreed to confront a number of situations that he had been avoiding for fear of contamination and illness over the remaining 11 sessions, while also attempting gradually to drop his compulsive rituals.

Bruce continued to practice cognitive restructuring for depressive symptoms during (and between) the first several sessions. During the fifth visit he reported that his mood was improved, that he felt a good deal of confidence in his therapist, and that he was hopeful that he would make headway with therapy. Exposure began with confronting objects from rooms that had been off limits to him for years. Bruce was instructed to allow his parents to enter these rooms before he entered. He was able to hug his parents without immediately washing for the first time in several years. Although Bruce had some difficulty refraining from compulsive washing rituals at first, by the seventh treatment session, he had cut his washing to seven times per day, was taking one shower every other day, and was not doing any extra changing of clothes. His parents had attended an early exposure session and had been instructed by the therapist in how to offer supportive reinforcement for successful exposure practice. At the eighth session a midtreatment evaluation revealed a Y-BOCS score of 20, BDI score of 13, and HDRS score of 10.

Sessions 9 through 16 included reviewing exposure and cognitive therapy homework assignments as well as conducting in-session exposure practice with gradually more difficult situations. With some reluctance, Bruce was able to confront most items on his exposure hierarchy, including sweat, urine, bathroom floors and toilets, and stepping in dog feces and wiping it from his shoe with a tissue without washing afterward. He had “contaminated” his room with many of these substances and reported a substantial reduction in the time he required to clean himself after using the bathroom. Although urges to perform compulsive behavior and avoidance persisted, Bruce understood the importance of resisting these urges and practicing exposure to fear cues. He reported taking on more tasks on the farm and feeling “worthwhile.” An important aspect of Bruce’s reduction in depression were the genuine recognition and reinforcement he received from his family and friends, who had observed his hard work and improvement over the course of his therapy.

At the end of treatment, Bruce’s Y-BOCS score was 13, indicating a 55% reduction in OCD symptoms. His BDI score was 7 and his HDRS score was 4, both within normal range. Although Bruce still had mild to moderate OCD according to the Y-BOCS, he subjectively felt much more in control of these symptoms and was able to resist them in most cases. He felt able to continue his trajectory of improvement after the end of therapy and had discussed with his therapist the possibility of working part time and going back to school to update his agricultural studies.

Three months after the end of treatment Bruce’s Y-BOCS score was 12. He arranged to see his therapist for four additional sessions to practice exposure to a few situations that continued to give him trouble, including public bathrooms and a certain pair of shoes he had been avoiding because they had had contact with animal feces. Bruce was washing his hands only five or six times each day for a total of about 2 minutes. He was also attending a local community college, working as a store clerk, and planning to move out of his parents’ home within the next few weeks (and he eventually did so successfully).

Clinical Issues and Summary
Bruce’s case indicates that cognitive-behavioral therapy using CT methods to augment traditional ERP procedures holds potential for treating OCD patients who have comorbid major depression. At least for this particular individual, the 16-session, twice-weekly comprehensive treatment regimen appeared to improve the tolerability of anxiety-evoking exposure assignments so that he was able to engage in (and benefit from) them. Given Bruce’s disposition to ERP during his initial assessment it is likely that he would have had difficulty with adherence (if not discontinued therapy altogether) if ERP had been begun immediately. Instead, by introduction of CT first, Bruce had the opportunity (1) to establish rapport with his therapist, (2) to see that the therapist understood his OCD, (3) to understand his own symptoms better, and (4) to develop cognitive coping strategies to reduce his depressive symptoms and prepare himself for ERP exercises. It is interesting to speculate whether these factors contributed to his engagement in the more difficult aspects of the therapy. Indeed, some have advocated that CT strategies be used routinely to help patients confront feared situations during exposure (e.g., Kozak, 1999).

Bruce’s depression was quite straightforward and clearly secondary to his OCD. That is, he was primarily depressed about having OCD. Very likely, reduction in his OCD symptoms in the middle and later stages of treatment resulted in further improvements in his depression. In some instances, however, patients’ depressive symptoms actually represent primary disorders, which transcend the distress associated with OCD. For example, one patient we evaluated had experienced depression for several years before the onset of her OCD. An important question is whether patients whose depressive symptoms are related to the distress or functional impairment associated with OCD would fare better in cognitive-behavioral therapy for OCD when compared to patients for whom OCD and depression represent truly unrelated diagnoses.

Although this single case provides reason for cautious optimism, much work is required before more firm conclusions regarding the effectiveness of this treatment can be made. Our current study of 15 patients will provide additional data on the treatment’s effectiveness. However, even more important questions need to be answered in order to determine the clinical efficacy and cost-effectiveness of this treatment. For example, it will be necessary to determine whether or not this comprehensive treatment package is more effective than ERP, CT, or SRIs alone, or whether it is superior to the combination of psychotherapy and medication in this population.

In summary, although research demonstrates that ERP is the best available treatment for OCD, the presence of comorbid disorders may interfere with its strong effects. In particular, severely depressed OCD patients tend not to fare as well with ERP as nondepressed patients. The introduction of cognitive therapy techniques is one strategy that might improve depressed OCD patients’ response to exposure therapy. Given that SRI medications are effective in the treatment of OCD, pharmacotherapy might also be suggested in such cases.
- Jonathan S. Abramowitz Mayo Clinic Journal of Clinical Psychology 2004.

Personal Reflection Exercise #2
The preceding section contained information about treatment of obsessive-compulsive disorder in patients who have comorbid major depression. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 9
What are four opportunities the OCD client, Bruce, was given because of the introduction of cognitive therapy before exposure and response prevention (ERP)? Record the letter of the correct answer the CEU Answer Booklet

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Obsessive Compulsive Disorder: Seven Effective Behavioral Strategies

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