Monday, 10 November 2014

Cognitive-Behavioural Therapy (CBT) for OCD

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                                                Cognitive-Behavioural Therapy (CBT)

Cognitive-Behavioural Therapy (CBT) is a widely used therapeutic approach with confirmed positive effects to treat a variety of psychological and psychiatric disorders including depression, phobias and anxiety disorders (Hall & Iqbal, 2010). CBT is a result of the integration of Behaviour Therapy (Edward Thorndike) and Cognitive Psychology or Cognitive Behaviour Modification (Donald Meichenbaum and several other authors) in the late 1970s. It was than labelled as Cognitive Therapy - CT (Albert Ellis and Aaron Beck– Rational Emotive Therapy – RET) and currently known as Cognitive Behaviour Therapy or CBT.

CBT can be defined as a psychotherapeutic treatment in which the client is instructed in how to recognise negative thoughts and feelings and replace them for more adaptive thought patterns, in order to promote psychological well-being (Kazantzis, Reinecke & Freeman, 2010). The cognitive model states that specific life events are interpreted by automatic thoughts, based on beliefs that the person has about themselves, the world and the future called schems, which may lead, when the thought patterns are negative, to dysfunctional emotions and behaviours (Chichester, 2012). The CBT sessions are time-limited, structured, goal-directed, problem-solving oriented, psycho-educational, and focus on the present. In conjunction with these, homework is used as an essential feature and aims to bring self-resources to the client (Prochaska & Norcross, 2010).

Obsessive Compulsive Disorder (OCD) is a disorder described by the presence of intrusive thoughts, obsessions and behaviours compulsively performed in order to reduce the anxiety caused by the intrusive thoughts (Hyman & Pedrick, 2010). Some forms of OCD treatment utilising CBT interventions include inpatient, outpatient, individual, group and family-based approaches (Grave, 2013). The existing literature indicates that CBT has been the first recommended approach to be employed on children and adolescents with OCD symptoms (Zohar, 2012).

In the DSM-V the diagnostic criteria for Obsessive-Compulsive Disorder is established as follows:

Diagnostic Criteria

  1. Presence of obsessions, compulsions, or both:
    • Obsessions are defined by (1) and (2):
    • Recurrent and persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive and unwanted, and that in most individuals cause marked anxiety or distress.
    • The individual attempts to ignore or suppress such thoughts, urges, or images, or to neutralize them with some other thought or action (i.e., by performing a compulsion).
    • Compulsions are defined by (1) and (2):
    • Repetitive behaviors (e.g., hand washing, ordering, checking) or mental acts (e.g., praying, counting, repeating words silently) that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly.
    • The behaviors or mental acts are aimed at preventing or reducing anxiety or distress, or preventing some dreaded event or situation; however, these behaviors or mental acts are not connected in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
      • Note: Young children may not be able to articulate the aims of these behaviors or mental acts.
  2. The obsessions or compulsions are time-consuming (e.g., take more than 1 hour per day) or cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  3. The obsessive-compulsive symptoms are not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication) or another medical condition.
  4. The disturbance is not better explained by the symptoms of another mental disorder (e.g., excessive worries, as in generalized anxiety disorder; preoccupation with appearance, as in body dysmorphic disorder; difficulty discarding or parting with possessions, as in hoarding disorder; hair pulling, as in trichotillomania [hair-pulling disorder]; skin picking, as in excoriation [skin-picking] disorder; stereotypies, as in stereotypic movement disorder; ritualized eating behavior, as in eating disorders; preoccupation with substances or gambling, as in substance-related and addictive disorders; preoccupation with having an illness, as in illness anxiety disorder; sexual urges or fantasies, as in paraphilic disorders; impulses, as in disruptive, impulse-control, and conduct disorders; guilty ruminations, as in major depressive disorder; thought insertion or delusional preoccupations, as in schizophrenia spectrum and other psychotic disorders; or repetitive patterns of behavior, as in autism spectrum disorder).
Specify if:
  • With good or fair insight: The individual recognizes that obsessive-compulsive disorder beliefs are definitely or probably not true or that they may or may not be true.
  • With poor insight: The individual thinks obsessive-compulsive disorder beliefs are probably true.
  • With absent insight/delusional beliefs: The individual is completely convinced that obsessive-compulsive disorder beliefs are true.
Specify if:
  • Tic-related: The individual has a current or past history of a tic disorder (First, 2014, 309.81- F43.10).

The CBT Treatment Manual has been largely used and it is based on fourteen weekly sessions, over twelve weeks, including telephone contacts (Piacentini et al., 2007). Throughout this period, techniques applied include psycho-education, when parents receive information about OCD and how to assist the child with tasks, as well as homework, training and relapse prevention; In addition, cognitive training and mapping OCD, in which obsessions, compulsions, triggers and consequences are defined, as well as a starting point and degree of the exposure to be applied. Exposure/response prevention (E/RP), which consists of the child's gradual increased exposure to what they fear (Piacentini et al., 2007) and relapse prevention are also included (Dulcan, 2010).

Each session specifically involves the gathering of new data, a review of past tasks, the setting of new goals, tasks, homework, monitoring the progress and possible therapist-assisted practice for ERP (Weisz & Kazdin, 2010). Clients with more severe symptoms or comorbidity also make use of medication (Rachman & Silva, 2009). Some of the most common rating scales used to identify the severity of the OCD symptoms in children and adolescents are the Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS) (Galanter & Jensen, 2009) and the National Institute of Mental Health- Global Obsessive-Compulsive Scales (NIMH-GOCS) (Martin et al., 2005).

It is essential that the therapist have a specific CBT training to work with OCD clients and supervision (Clark, 2007). Additionally, attending skills such as unconditional respect, empathy, good listening, appropriate eye contact and body language, will facilitate the development of a safe environment (Carr & Cohen, 2008), where clients are able to down regulate their emotions, collaborate in building a good working alliance as well as enabling the therapist to give a more precise diagnosis, and, in turn, good treatment outcomes (Corey, 2009). A therapist's personality may also directly affect a client's response, as the client will mirror the therapist's behaviour (Siegel, 2012). It would be difficult for a client with OCD symptoms to improve, if for example, they mirrored a therapist with a very formal, organised and meticulous behaviour (Siegel, 2012).

The type of technique and how it is applied is another factor to predict treatment efficacy (Nathan & Gorman, 2007). Most of the the treatments are based on the CBT Treatment Manual and the techniques used in group or individually were Psycho-education, cognitive interventions, exposure and response prevention (ERP), relapse prevention, family involvement, medication and behavioural rewarding (O'Kearney et al., 2006). Behavioural rewarding is not widely used, and more indicated for young children than for adolescents (Turner, 2006). Jackes (2006) argue that one of the advantages in utilising ERP is that this technique, in a short time, stops compulsive behaviours which are the client's defence mechanisms against hidden unconscious feelings, that subsequently open new brain neural pathways, thereby, changing life responses behaviour (Bowers, 2013). The same process, in other approaches would take longer, preventing the client to have quality of life for a greater time (Jackes, 2006).

The recent literature review and measured results concluded that ERP alone can be used as an efficacious treatment for child/adolescent OCD, which can be the only reason why OCD symptoms were reduced in all the studies, despite all mediators and moderators variables (O'Kearney et al., 2006). However, more investigation should be undertaken regarding efficacy of ERP applied alone, as well as the influence of the therapist's style when applying the techniques, as even a very efficacious technique can produce better outcomes if applied with the art of a skilful therapist, especially in children (Clark, 2007). It should always be remembered, that regardless of the type of technique used, the cognitive-behavioural approach still involves a sensitive encounter between two human beings (Weibel, 2005).

Recommendations for the utilisation of CBT for children and adolescents with OCD in clinical settings is supported by the positive results (Turner, 2006). However, in order to confirm effectiveness in clinical practice, more investigation is needed, along with the inclusion of larger samples, a control group, long term follow-up of clients and families to investigate occurrence of relapse and the durability of gains (Piacentini et al., 2002). In addition, more studies to compare outcomes from the use of medication, effectiveness of ERP utilised alone and cognitive therapy alone, as well as to what extent family based treatment is more effective than individual treatment (March et al., 2001). Appropriateness of intensive treatment utilising ERP for children needs to be also carefully assessed (Whiteside et al., 2008). A case-review or re-evaluation of CBT delivered (Nakatani et all., 2009) is needed to identify causes for lack of the response to treatment, as well as what alternative techniques could be used (Barret et al., 2008).

Moreover, the utilisation of CBT for children and adolescents could be implemented by adapting practices and techniques such as telephone or internet support for parents who cannot attend the sessions; resources with appropriate drawings and language which reflect the reality of single parents and families with a low income; an analysis of measures that considers those who are experiencing grief and trauma (Cohen et all., 2012); and preparation of psycho-educational booklets for parents with low education, mental illness or other additional psychosocial stressors (Cohen et all., 2012). Likewise, in order to deliver CBT to children who are the second generation of a culturally and linguistically diverse background (CALD) (Gaxiola & Gullotta, 2009), and also have to deal with their parents' stress of acculturation and chronic grief, CBT practices and techniques should be accommodated to the relevant culture, as different ethnic groups have they particular ways of interpreting and reacting to stressful life events (Simos et all., 2013). Furthermore, provision of all written material for information and psycho-education in the client's and families' first languages (Simos et all., 2013).

A good assessment is also necessary to determine if the client is suited for individual or group formats, what techniques would be more appropriate according to the age range (Piacentini et all., 2004), and developmental level (Chiu et all., 2013), the type of comorbidity, the use of medication, the severity of symptoms, the duration of illness, the home environment and what family support can be expected during and after the treatment (Dale & Vincent, 2010).

Mrs Glaucia Barbosa,
PACFA Reg. Provisional 25212 
MCouns, MQCA(Clinical)  
ABN: 19 476 932 954

Professional tools and resources:
Video: Neurocognitive change in schizophrenia


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