Promoting Treatment Engagement and Managing Non-Adherence in OCD

1. Promoting Treatment Engagement and Managing Non-Adherence in OCD Dean McKay, PhD, ABPP Fordham University Mount Sinai School of Medicine

2. Obsessions Compulsions • Intrusive and unwanted thoughts/images/ideas • Distinct from worry • Obsessions far less likely to be realistic • Worries not necessarily unwanted • Distinct from ruminations • Obsessions not related to prior real events • Specific behaviors designed to alleviate obsessional ideation • Conforms to a routine that must be engaged in by unique rules Diagnostic Criteria & Distinguishing Features of OCD

3. CBT Illustration of obsessions & compulsions From McKay, D., Taylor, S., & Abramowitz, J. (2010). In D. McKay, J. Abramowitz, & S. Taylor (Eds.), Cognitive-behavior Therapy for Refractory Cases (pp. 89-109). Washington, DC: American Psychological Association.

4. Subtypes of OCD • Obsessions (sexual, aggressive, religious, or somatic) & checking compulsions • Symmetry obsessions and ordering, counting, & repeating compulsions • Contamination obsessions and cleaning compulsions • Hoarding (as per DSM-IV-TR)* From Abramowitz, McKay, & Taylor (2005). Behavior Therapy, 36, 367-369. * Hoarding proposed to be a separate disorder in DSM-5

5. Methods of Assessing OCD* • Yale-Brown Obsessive-Compulsive Scale (checklist & severity rating) • Obsessive-Compulsive Inventory-Revised • Beck-Clark Obsessive Compulsive Inventory • Padua Inventory-Revised • Vancouver Obsessive Compulsive Inventory • Obsessive Beliefs Questionnaire * Each measure discussed at length in Taylor, Abramowitz, & McKay (2010). In M.M Antony & D.H. Barlow (Eds.), Handbook of assessment and treatment planning for psychological disorders (2nd ed.) (pp. 267-300). New York: Guilford.

6. Problems in assessment • Reluctance in describing symptoms • Contamination fears and measure completion • Lack of awareness of symptoms/minimization of symptoms • Problems in assessment completion within reasonable time constraint • Overvalued ideation associated with symptoms

7. Behavior Therapy – Primarily Exposure with Response Prevention Cognitive Therapy – Primarily addressing maladaptive OC cognitions • Assess primary presenting symptom(s) • Develop hierarchy(ies) of symptoms • Identify symptom triggers, consequences • Engage in exposure for symptoms, response prevention of compulsions • Identify major cognitions associated with symptoms (i.e., with OBQ) • Target maladaptive cognitions using direct cognitive challenge, behavioral experiments, downward arrow technique Treatment Methodology Overview

8. Problems in Non-response • Therapy non-response difficult to define • Individuals with OCD especially at risk for non-response • Often referred to as refractory or treatment resistant • Various definitions offered in literature pertaining to medication dosages and trials • In CBT realm, problem of non-response often associated with… • Poor therapeutic homework compliance • Poor interpersonal environment (i.e., Hi Expressed Emotion)

9. Some definitions of non-response or refractoriness in OCD • Overview – approximately 30-40 of all individuals with OCD fail to respond adequately to treatment • Schrurers et al. (2005) defined as failure to respond to consecutive trials of two SRIs, Clomipramine, and CBT. • Jenike & Rauch (1994) defined as failure to respond to all available therapeutics for OCD. • Tolin et al. (2004) defined as inadequate response to at least two SRIs at dosage defined as efficacious for OCD None of these definitions have been widely accepted definitions of refractoriness or resistance

10. A Preliminary template for understanding Non-Response across anxiety disorders From Taylor, Abramowitz, & McKay (2012), J. Anxiety Disorders, 26, 583-589.

11. A Model Non-Adherence across Anxiety Disorders From Taylor, Abramowitz, & McKay (2012), J. Anxiety Disorders, 26, 583-589.

12. Challenges in treatment administration: Motivation • Primary methods of intervention • Motivational interviewing (originally from Miller & Rollnick; since expanded for other conditions <see Westra, 2012> • Cognitive interventions as a preparation for other treatment • Challenge danger of exposure • Identify significant cognitive distortions interfering with treatment engagement

13. Challenges in Treatment Administration: Avoidance • Anticipated to form basis of treatment in some way • For many clients, this overrides ability to engage in therapy • Strategy A: Decontruct hierarchy further to manageable components. • Strategy B: Create conditions whereby aspect of routinely practiced activity violates rules governing symptom related avoidance

14. Challenges in Treatment Engagement: Gulf between words and actions • Nature of the problem: • In session statement: “I can certainly do the things you have described, but they are only relevant at <home, office, in car, other place> • The next session: “I was not able to do <X> because I <was not at home, felt good, didn’t think it was a good time> • Nature of solution: • Create conditions whereby engagement more likely in session (i.e., imagery; home session; other setting) • Create target visualizations/practical interventions between sessions (emphasize better to practice under non-ideal situation than seeking perfect illustration)

15. Prognostic Indicators of Poor Outcome: Comorbid Depression • Significant contribution to poor outcome and poor treatment engagement • Requires direct engagement for mood before addressing complexities of OCD symptoms • Increased salience of several prominent OC related cognitive biases: • Higher appraisal of significance of intrusive thoughts • Increased thought-action fusion • From Keeley, et al. (2008), Clinical Psychology Review, 28, 118-130.

16. Prognostic Indicators of Poor Outcome: Schizotypy • Associated with distorted perceptual experiences • Interferes with information processing necessary for effective CBT • Requires slower pace for developing and implementing exposure • Requires more frequent verification of comprehension of aims of intervention, outcome of exposure

17. Prognostic Indicators of Poor Outcome: PTSD • Treatment compromised significantly for comorbid PTSD • Threat valence at issue • PTSD with higher sense of personal danger • Relevant cognitions in OC now of heightened salience, more difficult to manage • Available literature suggests this combination difficult to engage, treat, and that outcome limited when treatment maintained

18. Trauma and OCD Characteristics

19. Prognostic Indicators of Poor Outcome: Overvalued Ideation • A specific cognitive problem associated with poor outcome • Conceptualized as lying on a continuum between frank acknowledgement of unrealistic intrusion (obsession) and psychosis (Kozak & Foa, 1994, Beh Res & Ther, 33, 343-353.) * * * Overvalued Ideas Obsessions Psychosis

20. Treatment of Overvalued Ideation • Conceptualized as an unstable dimension of cognitive disturbance • Assess degree of fixidity on session-by-session basis for opportunistic exposure to alleviate symptoms • As symptoms alleviate, overvalued ideas weaken (typically) • More opportunities arise with continued opportunistic exposure

21. Prognostic Indicators of Poor Outcome: Scrupulosity • A variant of overvalued ideation: A cultural/religious/personal standard held to an extreme degree, impacting OC symptoms • Particular challenge since it impacts how exposure developed and implemented • Walk line in violating some standard • Most often observed in religious based obsessions and compulsions

22. Prognostic Indicator of Poor Outcome: Stimulus-Environment & Stimulus-Outcome Relationships • Accessibility of stimuli in the environment • Variation in the degree obsessional concerns can be effectively accessed in session • As ability to access stimulus material in session decreases, ability to treat likewise decreases • Stimulus-outcome relations • Perceived outcome after exposure determines ability to engage in, benefit from, intervention • As length of time between exposure and perceived outcome increases, treatment outcome decreases

23. Accessibility to stimuli in session and outcome Relation between exposure and perceived outcome Stimulus-environment and stimulus-outcome relations

24. Anger Disgust • Often not an emotion that is habituated in exposure • Requires additional management aside from mere exposure • Anger management • Other coping mechanisms • Habituates, but with greater difficulty • Common emotional experience for some symptoms of OC • Contamination fears • Some other symptoms Provocation of emotional reactions other than anxiety

25. Accommodation by significant others • Education and multiple family member involvement in treatment • Identification of factors associated with accommodation • Distress tolerance in other family members • Problems in emotional involvement

26. Illustrative case examples • Case 1: Problems in motivation and high overvalued ideation • Case 2: Comorbid PTSD • Case 3: High accommodation and lengthy lag in stimulus-outcome relations