CT/ERP for OCD: Case Study
OCD & Cognitive Therapy (CT)/Exposure and Response Prevention (ERP)
Obsessive-compulsive disorder (OCD) is a type of anxiety disorder that is often comorbid with other anxiety disorders such as agoraphobia, panic disorders, other specific phobias (heights, water, germs, etc.), social phobias (crowds, strangers, etc.), and overall generalized anxiety disorder (Oltmanns, & Emery, 2010). The “obsessions” in OCD have to do with intrusive thoughts that sufferers cannot simply ignore or write-off as something unusual, and manifests the “compulsions,” which are really a form of ritual to erase these thoughts away (Siev, Hubbert, & Chambless, 2010; Wilhelm et al., 2005). This becomes a vicious cycle known as “thought suppression,” which is a way for OCD sufferers to try to stop thinking about intrusive or unwanted thoughts, and a way to suppress the emotions that come along with the thoughts, which ends in ritual and begins again when the thoughts return (Oltmanns, & Emery, 2010). Many of these thoughts have to do with the core beliefs of the sufferer about themselves, for example, someone with OCD may have a core belief that essentially they are a bad person which manifests itself as compulsive symmetry/perfection in his/her environment (Chosak, Marques, Fama, Renaud, & Wilhelm, 2009; Siev, Hubbert, & Chambless, 2010). The intrusive thought may be, “if everything is not perfect, than I am a bad person, and if everything is perfect then I am okay for now.” The main groups of beliefs are, “inflated responsibility, overestimation of threat, overimportance of thoughts, need to control thoughts, need for certainty, and perfectionism.” (Wilhelm, 2005)
There are many forms of therapy for OCD, such as Desensitization and Exposure, Exposure and Response, Relaxation and Retraining, Cognitive Therapy, and medication (Oltmanns, & Emery, 2010). The problem with some of these therapies (especially the ones using exposure) is the high drop-out rate and reluctance to even go to therapy in the first place; it is often a scary and jarring experience for OCD sufferers to face their fears head-on (Chasson et al., 2010; Wilhelm et al., 2005). For the purposes of this paper and case study, the focus will be on Cognitive Therapy (CT), which is cognitive therapy to reform maladaptive thoughts, as well as Exposure and Response Prevention (ERP), which is a prolonged exposure to situations that produce anxiety (Oltmanns, & Emery, 2010).
The cognitive part of CBT focuses on four key strategies, which are Psychoeducation, Cognitive Domains, Core Beliefs, and Relapse Prevention (Chosak et al., 2009). Psychoeducation involves familiarizing the patient with techniques of the therapy, key words (like distortion, ritual, core belief, etc.), setting an agenda for each session (such as going over homework first and then moving on to new topics) (Chosak et al., 2009). The therapist will also take this time to subtly assess the patients OCD symptoms, intrusions, their triggers, emotions, and any avoidance strategies that the patient has developed thus far (Chosak et al., 2009).
After this initial period, the second strategy begins with Cognitive Domains, or examining the patients distortions together and setting new homework for the patient to recognize these himself (Chosak et al., 2009). Some distortions that are taught to the patient include “jumping to conclusions, catastrophizing, should statements, and emotional reasoning,” which are then discussed at length to try and give these any supported evidence that they are true and will actually happen instead of being an irrational thought (Chosak et al., 2009). Supported evidence usually means trying to get the patient to act like a “detective” and prove that the distortions are not causing anything bad to happen (Chosak et al., 2009); for example a patient who thinks that if they think the intrusive thoughts and get emotional they will have a heart attack, a good way to disprove that is to allow the patient to feel the emotion, and of course, they don’t have a heart attack.
The next stage is tackling the patients Core Beliefs about themselves, and this comes toward the end of therapy because it is the most difficult subject for patients to talk about freely, as it is the root cause of the OCD, and shattering these Core Beliefs is a huge step in therapy (Chosak et al., 2009). The final step for the cognitive part of CT is Relapse Prevention, which includes an agenda for after therapy, preparing the patient for a lapse or relapse in OCD behaviors, revisit skills learned in therapy and additional applications, and the patient should be able to “act as their own therapist” to set goals and additional homework for themselves (Chosak et al., 2009).
The Exposure and Response Prevention therapy is highly recommended for those suffering from OCD, and at first glance the success rate for this form of therapy is quite high, with 85% of patients improving after the first 15 sessions, however, the high instance of therapy refusal and dropout (Chasson et al., 2010). ERP therapy is a repeated exposure to the fear and anxiety inducing stimuli (like crowds, heights, messy rooms, etc.), while simultaneously preventing the patient from performing their rituals or “fear-reducing actions,” such as avoiding crowds, heights, or compulsively cleaning, repeating phrases, tics, etc. (Chasson et al., 2010). The antibiotic drug D-cycloserine has been shown to improve symptoms, reduce sessions needed, and reduce the drop-out rate for ERP therapy (Chasson et al., 2010). Despite drop-outs and therapy refusal, ERP has shown to be helpful in reducing OCD behavior, however, for those patients who did not do well in either ERP or CT the reason is usually that the patient is unwilling or unable to confront their own OCD symptoms, and being unaware of what they are is difficult because they are not able to be worked through in CT or exposed to in ERP (Wilhelm et al., 2005).
Case Study: Allen
Allen’s presenting problem is agoraphobia; panic disorder when exposed to any crowds; phobias for heights, animals, bridges, airplanes, and germs; anxiety when around new people/places/situations; and OCD with perfectionism, need for certainty, and an overestimation of threats.
Allen is a 47-year-old man who lives alone in a two-bedroom apartment in downtown Portland, Oregon. He has never been married and owns no pets. The only person he is close to is his slightly younger sister Maggie who is also his full-time nurse. She has her own family and lives a few blocks away in a house. Allen is a website designer and works from home. He rarely leaves the house, but when he does, Maggie must come along with him and he will only go to certain places who know him (grocery store, dry cleaners, therapist, etc.). Through therapy and several meetings with Allen and Maggie (as she must come along) evidence suggests that Maggie has an obsession with cleanliness and orderliness within her own house, which is kept immaculately clean as Allen’s is.
Family background for the brother and sister suggest that OCD is genetic, as their mother Bea, was also obsessed with cleanliness, perfectionism and saved everything in a specific ordered system, however it could also be a learned. If the children made a mess in the house Bea would usually scold the children and tell them they were “bad children for making messes.” Allen’s father was an auto mechanic and left without telling anyone when Allen was 8 and Maggie was 6. From what Allen remembers, his father was a very sullen man who rarely talked to his wife or his children. Bea was a schoolteacher at the school Allen and Maggie attended. She retired and had passed away two years ago. Allen reports his childhood as being very isolated because he did not like playing with other children, and he felt that he didn’t fit in. Allen reports being bullied sometimes and feeling anxious and “like I did something wrong” when he was not invited to birthday parties in the neighborhood. He has always been interested in machines and would often take apart the family’s appliances and put them back together and later when computers were being used he was very interested in those. When asked about his father Allen becomes very quiet and visually upset and refuses to talk about the incident, dismissing it as “in the past.” Allen did very well in school, but had a hard time taking tests. Allen remembers being obsessed with the circles in scantrons (making them perfect), and would have to force himself to not think about those circles. Allen remembers starting to have problems with crowds and his other phobias during the last few years of high school. Once graduating from high school Allen went to college on an accelerated path for business management. When he graduated, he worked odd jobs, but was having trouble staying employed because of his obsessive need for symmetry and perfectionism. He developed a number of eye and shoulder tics when trying to control his urges when working for someone, but he was usually let go after four or five months. During this time, he was still living with his mother. When asked about dating or if he ever saw anyone special, Allen becomes very uncomfortable with this line of questioning and will change the subject or stop talking. Information from his sister reveals that Allen has never had a girlfriend to her knowledge. When Allen was 28, he decided to go back to school for web design and when he finished he started his own company from home. Since that point forward Maggie has been his full-time nurse due to the fact that Allen can no longer leave the house without her. Allen admits that once he was able to work from home he began having more fears and issues that have been gradually getting worse. He says, “they have always been there, I just had some control over them when I had to work outside.”
For anything that involves a phobia (crowds, heights, animals, bridges, airplanes) Allen will refuse to have any interaction with those areas. For more complicated scenarios like avoiding germs Allen carries with him everywhere anti-bacterial wipes and will wipe anything that he has to touch, will refuse to shake someone’s hand, and will refuse to use any public facilitates. If, for some reason, Allen does come into contact will something he didn’t clean he will start having many tics, will start talking rapidly about cleanliness, and will start cleaning everything in sight (as well as straightening and organizing). He has high anxiety when around new people/places/situations and usually tries to avoid those as well. When exposed to any of his phobias Allen reports that it sometimes feels like he is having a heart attack and is dying. In fact, Allen’s biggest fear is that he will have a heart attack and die a horrible death. Allen’s main obsession is making sure his surroundings are always symmetrical, perfect, and clean. Allen reports that it “really bothers him” when he sees other people with crooked ties, lint or hair on their clothes, or anything else out of place and he has many tics when out in public because he is trying to control the urge to “fix their clothes!” Allen’s core belief is that the world is a very dangerous place and that his obsessive perfectionism is a way for him to gain certainty in an uncertain world.
Although Allen doesn’t have any friends, and doesn’t have regular contact with anyone but Maggie and her family (their dog is an exception!), his OCD has a large affect on his family. Allen feels guilty for this, but he doesn’t know how to fix it and only feels safe with Maggie. Maggie reportedly feels “very stressed, anxious and worried all the time” about Allen and his safety. She has fears of her own of what Allen would do if she weren’t able to take care of him anymore. “It’s not like I’m gonna leave, it’s just…well what if Mark [her husband] gets a really good job somewhere else? Or…I don’t know. I will retire someday…I don’t wanna live in Oregon forever!” Overall, Allen’s condition is very stressful for Maggie and their extended family (they have some aunts, uncles, and cousins who visit for holidays because Maggie can’t visit them herself due to Allen), which is a financial hardship for most of them to travel every year.
At Maggie’s suggestion, Allen has been going to regular therapy for two years, which has usually taken the form of talk-therapy. Since that time, Allen’s regular therapist suggested that Allen see an OCD specialist to try to get a hold of his phobias and compulsions so he can lead a more normal life and allow Maggie to lead one as well. Allen came to therapy reluctant to meet a new therapist, but optimistic for what could be accomplished. When asked what type of therapy Allen would like to pursue (since ERP is very intense), Allen asked if doing both was “still okay.” Since Allen does have social phobia when meeting new people we decided to talk about that first, since it was very obvious he was nervous and anxious when meeting me (tics, wouldn’t speak up, wouldn’t meet my gaze, compulsively straightening the room). As the weeks progressed Allen’s homework was to list every single trigger that made him tic, nervous, emotional, made him ritualize (now defined as his compulsive cleaning, organizing, etc.), anxious and/or panicky. After the list was made, Psychoeducation involved going over what types of homework I could have him do, questions I would ask, and therapy strategies we would use. Allen seemed open to this and responded well to the rigid agenda because it was “very organized.” Next, we progressed to Cognitive Domains where Allen had a harder time defining what was “normal, everyone is afraid of germs and dying!” And what was obsessive-compulsive (OC). Actually, this is a hard area to determine for some therapists because some people do carry around anti-bacterial wipes to clean their shopping cart, and some carry them like Allen to clean everything; what constitutes OC? (Oltmanns, & Emery, 2010) Allen was given homework to work through all his fears with Maggie with him at first, and was then encourage to leave his house alone. The rest of CT went well, with only a few stalls when discussing Allen’s core beliefs. After completion of CT Allen reportedly felt “more confident” with the tools he had learned. Subsequent therapy with ERP didn’t go as well (to be expected) at first because Allen was exposed to a number of his fears repeatedly. He went up an escalator to the top floor of a hotel, he shook a stranger hand, he left the house with no wipes, Maggie’s job was permanently reduced, Allen was encouraged to let his house get a little messy at least once a week, was prevented from any ritualizing, and Allen was encouraged to control his tics by using relaxation techniques.
The end of therapy was signaled when Allen agreed to have Maggie work for him only three days a week in a strictly administrative capacity to help with his website design business, which was growing more than Allen was able to meet with different people. Allen reports that he feels more confident than ever and will still utilize the tools he learned from CT to recognize when his OCD takes over and to make himself the therapist, as well as use ERP techniques to do more things he normally wouldn’t and practice relaxation when he becomes nervous or anxious. Reportedly the only phobia Allen hasn’t completely mastered is his animal phobia, but is working on that with Maggie and her family lab, Zoe, who is very friendly and happens to love Allen.
References
Chasson, G.S. et al. (2010). Need for speed: Evaluating slopes of OCD recovery in behavior therapy enhanced with D-cycloserine. Behavior Research and Therapy, 48, 675-679.
Chosak, A., Marques, L., Fama, J., Renaud, S., & Wilhelm, S. (2009). Cognitive therapy for obsessive-compulsive disorder: A case example. Cognitive and Behavioral Practice, 16, 7-17.
Oltmanns, T.F., & Emery, R.E. (2010). Abnormal psychology (6th ed.). Upper Saddle River, NJ: Pearson.
Siev, J., Huppert, J.D., & Chambless, D.L. (2010). Obsessive-compulsive disorder is associated with less of a distinction between specific acts of omission and commission. Journal of Anxiety Disorders, 24, 893-899.
Wilhelm, S. et al. (2005). Effectiveness of cognitive therapy for obsessive-compulsive disorder: an open trial. Journal of Cognitive Psychotherapy: An International Quarterly, 19(2), 173-179.
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