by Eda Gorbis, Ph.D., M.F.CC. with Daniel Anan’yev, B.S.

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​An intensive program that I developed at the Westwood Institute for Anxiety Disorders, Inc. for the treatment of patients with Obsessive Compulsive Disorder (OCD) combines modern exposure treatment with self-analytical writing. This program has consistently and significantly improved the condition of OCD patients who have been treated with it.

 

OCD is a multifaceted anxiety disorder characterized by symptoms of obsessive thoughts and compulsive behavior that is engaged in by the sufferer to gain what ends up as only temporary relief. Heritable in nature, OCD affects 3% of the population of the United States and was untreatable until Victor Meyer developed the first modern exposure and response prevention treatment (E&RP) in 1966. Since then, it has been shown that correctly used, behavioral therapy can produce a 76% rate of continuing symptom relief in patients for between 3 months and six years after the cessation of treatment (Foa & Kozak, 1996). Recent advances in behavioral therapy include Dr. Jeffrey Schwartz's four-step program, which has been shown to significantly change the activity in specific brain circuits of patients with OCD. The National Institute for Mental Health reports that OCD is more common in the United States than schizophrenia, bipolar disorder or panic disorder, making further improvements in cognitive behavioral therapy essential.

 

My variation of Cognitive Behavioral Therapy is based on using writing techniques which increase mindfulness and awareness of the maladaptive associations that reinforce OCD symptoms. It is important for patients to realize what they are obsessing about and/or what they are overvaluing. Special focus is put on the integration of writing in the treatment procedure. Writing utilizes the highest level of cognitive functioning in the human brain. Through a detailed explanation of the motivations and compulsions of OCD type behavior, a complicated web of thoughts and emotions existing in the minds of OCD patients is untangled. Written self-analysis results in clarity and logical understanding of the person's condition.

 

There are several cognitive distortions that occur in the minds of OCD patients. Usually, the misrepresentation involves "all or nothing" thinking, interpreting a thought as an experience, or feeling that failure to perform a ritual perfectly or when dictated will result in disastrous consequences. Along with experiencing a thought as reality, (as has been found by Kozak & Foa), people with OCD have a tendency, not only to overvalue the dangerousness of the situation, but also to think that, despite hundreds of positive experiences, in this circumstance there will be disastrous consequences if the ritual is not performed. Because OCD patients fail to see situations accurately, I feel it is very important to teach mindful awareness. I think this can be done best by adding analytical writing to cognitive behavioral therapy. My theory is that when a thought is transferred into a spoken language, it is a more complex process of the mind and requires more thinking. When a spoken word is translated into a written form, it requires even further, more complicated processing of the word and the thought. The most complicated and the clearest of all, is not what we think, not what we talk about, but it's what we write. Writing is so therapeutic because it enables the person to reprocess information that he/she has been regurgitating.

 

Another important aspect of my methodology is called "fear-structured skeletons." Fear structured skeletons are worksheet assignments designed to increase the mindful awareness via the identification of external and internal cues. This is an exercise where patients describe internal and external cues of their obsessions in a repetitive fashion, reprocessing and re-summarizing information in their own words. The exercise is important in understanding the triggers for obsessive thoughts whether it be things that they see or experiences or feelings that evoke obsessions. It is common for patients to exhibit several triggers and the writing process allows for an analysis of a multitude of causal factors for obsessions. In addition, we teach our patients to determine their Subjective Units of Distress (SUDS) levels and to rate their anxiety on a scale from 0 to 10. This technique allows a patient to self-diagnose, self-treat, and prevent a relapse. Giving a patient the necessary insight separates the person from his anxiety and allows him to learn that the anxiety has a beginning, a middle and an end.

 

Psychoeducation about self-treatment, writing and self-evaluation takes 4-5 days and entails 14-15 self-administered tasks and tests. Following an analysis of the patient's situation by the therapist and a determination of the common denominators1 of the fear structures, the patient is assigned a program specifically tailored to his/her individual needs. The program integrates two of the best approaches available for OCD patients. The first step is the prolonged exposure and response prevention program designed by Drs. Foa and Kozak. It trains an individual to identify OCD-related behaviors that are maladaptive. Patients complete exercises designed to prevent maladaptive associations and the compulsions performed in an attempt to get relief from the anxiety that they experience.

 

The treatment program laid out by Drs. Kozak and Foa is summarized in the following manner:

 

1.Patients increase their mindful awareness via training and recording of ritualized behavior.

 

2.Patients are taught to stay in an OCD situation, without giving in to compulsions, until discomfort decreases.

 

3.Patients receive help in concentrating on and are guided through targeted situations.

 

4.Exposures are repeated daily using patient specific stimuli until distress significantly dissipates.

I have found that combining imaginal and actual exposure helps to prevent relapse. Sometimes, it may be impossible to recreate the actual fears, as is the case of catastrophes. This makes imaginal exposure the only effective method for this phase. Also, adding the imaginal component may keep the patient from using the counterproductive tactic of thinking of less anxiety-producing situations while he is exposing himself to the trigger. As stated in "Mastery of Obsessive-Compulsive Disorder Therapist Guide" by Kozak & Foa on page 23, 1997 ed.; "although imaginal exposure is not necessary for successful outcome, it is often a useful adjunct to in vivo exercises."

 

When therapy begins, I introduce my patient to the concept of fear-structured skeleton analysis. Two of the four steps of cognitive behavioral self-treatment designed by Dr. Schwartz are integrated into the program I use here at Westwood Institute for Anxiety Disorders, Inc. First, the patient is taught to "Re-label," i.e., to recognize the intrusive thoughts and urges are the result of OCD and are not real.Then, I teach the patient to "Reattribute," i.e., to realize that the intensity and intrusiveness of the thought or urge is due to a biochemical imbalance in the brain. Steps 3 and 4 are integrated into the relapse prevention protocol, which is introduced and implemented in the fourth week of treatment (many patients do not require the fourth week). I think the effectiveness of my combined method is due to the decrease of obsessions via the process of over-learning, i.e. paradoxical intervention.

 

When a patient learns that he can induce OCD, he realizes that he can also eliminate or reduce OCD. Through self-induction and overloading the brain with disturbing and distressing images at a frequency and intensity that exceeds obsessive-compulsive intrusions, the patient gains control of his disorder. Utilizing the fear-structured skeleton formulation and the common denominator determination has resulted in very significant reductions for patients tested using the Yale-Brown Obsessive Compulsive Scale (YBOCS).2 Overall, the patients undergoing treatment at the Westwood Institute for Anxiety Disorders improve 75-85% in ability to function, anxiety levels, insight, interpersonal relations, as well as a decrease in interference of the disorder in their studies and work.

The data includes out-patients of the Westwood Institute for Anxiety Disorders and in-patients of the UCLA Neuropsychiatric Institute treated by my-self and the assembled multidisciplinary team of OCD experts. The information presented includes data of patients that underwent treatment up to the spring of 2001. The statistical analysis of scores collected for 90 more patients is currently in progress and will be presented in the next issue.

 

The significant improvement in patients seen at the Westwood Institute for Anxiety Disorders, Inc. has been of great interest to researchers at the UCLA Psychiatry and Behavioral Sciences. I am very happy that Sanjaya Saxena, M.D., director of the UCLA OCD Research Program has added a total of one week testing phase which precedes and follows the Institute's CBT. Using MRI and PET imaging techniques he has focused research on brain regions affected by CBT. Not only is the study examining the specific brain changes that occur during three-week intensive program, but the research also compares intensive CBT to medication treatment. It is crucial to continue investigating the aspects influencing the benefactors of the intensive CBT program in order to someday establish an even more powerful remedy.

 

Endnotes:

 

1.The Common Denominator is a fear which is found in many of the patient's obsessions. For example, people who spend numerous hours washing and avoid touching doorknobs have the common denominator, or the underlying fear, of contamination.

 

2.It has resulted in a mean absolute 19.6 point reduction in patients (SE = 1.78; n = 89) using the Yale -Brown Obsessive Compulsive Scale assessment administered to patients over a median of 36 follow-up days. The value is equivalent to a mean 65.88% Y-BOCS score reduction (SE = 6.02%; n = 89) over a median 36 follow-up days.