Q: Is it true that persons with the more purely obsessional form of OCD are more difficult to treat or are untreatable?
A: Until very recently, most cognitive-behavioral research has tended to stay away from treatment studies involving non-ritualizing pure obsessionals. However, in 1997, a research protocol was published involving cognitive-behavioral treatment for 29 subjects. Interestingly, the study found that approximately 50% of the people who responded to the ad possessed predominant obsessional characteristics, but the vast majority of all persons who responded had a clear combination of both compulsive rituals and obsessive rituals, suggesting that the majority of persons with OCD represent a myriad of subcategories rather than one specific subcategory. The research study demonstrated, fairly convincingly, that cognitive-behavioral treatments for purely obsessional clients are an effective strategy in reducing the disruptive effects of the disorder. My article "Thinking The Unthinkable," published in 1991, highlights specific strategies that were incorporated into the research protocol eight years later. I believe that many behaviorists, whether researchers or clinicians, have found purely obsessional clients to be difficult to work with because they have placed their treatment emphasis on reducing or eliminating the obsessional spike (an unwanted or upsetting thought that evokes an urge to problem solve). It is my belief that focusing on the spike rather than the response style to the spike is a misunderstanding of the disorder. Applying well-tried behavioral methods in treating persons with OCD who have compulsive rituals and integrating that methodology into a strategy which has the same basic therapeutic structure, as in exposure and response prevention, is a very effective intervention.
Q: In a recent book Dr. Schwartz, author of "Brainlock," suggests that therapeutic gains can be made without extensive exposure exercises. Are you in agreement with that?
My specialty is in treating all forms of anxiety disorders with a particular focus, of course, on obsessive-compulsive disorder, especially those persons with less well-known subcategories such as pure-obsessional and responsibility OCD or hyperscrupulosity. Everything I've ever known about the tremendous success over the last 30 years in behavioral therapy's ability to treat anxiety disorders has involved exposure exercises as its most potent component. Relying on the person's discipline to not give in to ritualizing as a means of starving this disorder, I believe, is possible but a much slower and tedious process in the destruction of this disorder. I strongly feel that having clients become aggressive and develop a disposition whereby they attack their disorder creates a shorter and more powerful response in reversing the momentum from cowering and retreating from the threat to attacking and delegitimizing the threat. If you read Dr. Schwartz's book and my article "Rethinking The Unthinkable," you will find a tremendous amount of similarity. However, on this one point, I cannot support his conclusion and feel very strongly that exposure exercises, albeit initially painful, constitute at least 60% of the potency of this therapy.
Q: Dr. Phillipson, what are your feelings about medication in combination with behavioral therapy?
A: When I first assess a client's degree of severity in their involvement with OCD, I attempt to establish whether or not there is an urgency to combine medication with behavioral therapy. Specific factors that weigh in this determination involve the degree to which a person's life has been disabled due to the disorder's influence. If the person is in imminent danger of losing their job, a relationship such as with a significant other, or being hospitalized, then I have no qualms with recommending a combined course of behavioral therapy and medication. I am also in agreement and can understand why research predominantly suggests that the combination of behavior therapy and medication is the most effective treatment for OCD.
However, for the client who comes in not on medication and does not meet a standard of being in critical condition, I generally recommend that the client remain in behavioral therapy for two months to assess their capacity to independently bring about the initial changes and reverse momentum that the therapy offers. Our rationale is that when one combines medication and behavioral therapy at the onset of their therapeutic course, there may be a tendency for the person to have difficulty making attributions about the source of their success. People unfortunately tend to make attributions about their progress when they've combined the initiation of therapy and medication simultaneously to be more drug-related than therapy-related. This becomes a problem if one's goal is not to be medication-dependent, and fears develop when it comes time to titrate (slowly reduce the levels) off the medication. People, particularly those on Prozac, are frightened of the prospect of flying on their own power; therefore, I generally recommend that people take the time to try behavior therapy independently and assess after two months whether their success and their clinical goals might be reached independent of medication.
Q: What can you tell me about intensive inpatient programs such as offered by Edna Foa in Philadelphia?
A: Anyone who has familiarity as a psychologist in the treatment of obsessive-compulsive disorder cannot deny that Edna Foa, for at least 25 years, has been the predominant national figure in research with behavioral interventions for obsessive-compulsive disorder. What Edna Foa is able to achieve with specific subcategories of OCD in three weeks is undeniably tremendous and amazing. For people with cleaning rituals and certain other behaviorally manifested forms of OCD, Edna Foa offers such a shock to the obsessive-compulsive disorder's system that you find significant reductions in ritualizing post-treatment. I believe strongly that the critical aspect of intensive inpatient programs is not the program's ability to produce tremendous change, but rather that when the patient is discharged, the patient's understanding of the maintenance of their gains is the essential feature. A client of mine who successfully went through Edna Foa's program once said to me, "if you can rub your hands briskly on a toilet seat and immediately eat a sandwich afterward, picking up a pen off the floor is a piece of cake." This statement will remain with me for the remainder of my career as it exemplifies the importance of exposing oneself to inordinately high levels of contamination and potential germs and what that high level of flooding can do in a short time when one has no means of escape available to them. I might add that Edna Foa and programs like hers often offer post-hospitalization home visits where the flooded items are spread thoroughly through one's living environment. I think these services are valuable for people who a) have a time urgency for getting over their OCD and b) are at a point where the quality of their life has deteriorated tremendously.
Q: In my OCD group some of the members seem not to have the understanding that their fears are irrational yet in every other way they seem to have OCD. Can you explain the difference?
A: Within every cluster or subcategory of OCD, there are individuals who are clinically defined as having overvalued ideation (ego-syntonic OCD). This means that the reasoning part of their brain has joined their anxiety center, and they no longer or have never seen the irrational nature of their rituals. Yet, they know that their lives are crumbling around them, and they have no sense of what to do. This form of OCD is by far the most difficult to treat because it usually involves not just an anxiety disorder but also something in psychology which is referred to as a characterological disorder. A characterological disorder implies that the person brings with them a dysfunctional disposition in most, if not all, aspects of their functioning. Most people with OCD, when not triggered by a spike, function in a way that they believe represents their natural selves. For individuals with ego-syntonic OCD, their psychological pathology extends well beyond the areas that their disorder tends to affect. Unfortunately, the prognosis for these people is very poor. For them to be successful, they need not only to deal with specific aspects of their OCD but also come to terms with changing very basic styles of interacting with the world around them and within themselves.
Q: What's the difference between obsessive compulsive disorder and obsessive personality disorder?
A: I have often felt that the similarities of these two diagnoses present more confusion than they explain. Whereas obsessive-compulsive disorder is an anxiety disorder wherein people become alarmed over irrational threats, obsessive-compulsive personality disorder is a personality or philosophical disorder. Individuals with obsessive-compulsive personality disorder are handicapped in many spheres of life unrelated to ritualizing. Typical personality characteristics in individuals with OCP involve tremendous amounts of anger. These people engage in very rigid and moralistic thought processes. My favorite thing to say to individuals with OCP is that they believe they own the truth and have tremendous intolerance when another person's reality conflicts with their own. Individuals with OCP tend to have dysfunctional relationships in which they repeatedly alienate persons who attempt to get close to them. They tend to have a great degree of difficulty with authority figures or, as an authority figure, tend to be feared by and intimidating to their subordinates. Often times individuals with OCP can be very successful in minimal to moderate forms of the condition. Because of their strict adherence to very rigid standards and guidelines, businesses tend to reward their vigilance and seemingly single-minded devotion to their work. At a more serious level of OCP involvement, individuals become handicapped by perfectionism, such that making seemingly noncritical decisions is almost impossible because of the person's desperate need to be certain of their correctness. Individuals with OCP tend to have aspects of OCD rituals; i.e., a need for organization, an inability to let go of items well beyond the item's usefulness for fear that the item might be of value or a sin of wastefulness to get rid of. The treatment for OCP tends to involve much more collaboration with the therapist in recreating the client's most basic philosophies and belief systems about truth, correctness, and certainty.
Q: Dr. Phillipson, what is your success rate and how long should I anticipate therapy lasting?
A: This is one of my most frequently asked questions by prospective clients. Research related to the effectiveness of exposure and response prevention as a treatment for OCD generally reports an 80% success rate. However, the criteria to participate in most research projects tend to be very rigorous, and a large number of people who apply to participate in research are often turned away because they are dealing with multiple life issues. My caseload consists predominantly of individuals with multiple life issues. If I accepted clients with the same stringent criteria as most research projects, I would not be able to see approximately 75% of the clients who come for therapy at the Center. It is impossible not to generalize an overall success rate because clients are made up of a variety of groups in relation to their level of receptivity to the therapeutic principles.
Having a disposition of being at the end of one's rope and being thoroughly committed to engaging in the therapy at all costs generally produces a success rate of approximately 80%. This success rate is exclusively the domain of those who participate in daily home-based challenges. Having an almost complete receptivity to the therapeutic guidelines (see "What is Cognitive-Behavioral Therapy for O.C.D.?") is also imperative. When I hear people say, "I am willing to do anything to get better," I immediately appreciate that their prognosis is very high. Many people enter therapy with the idea that the doctor is going to treat them. This misconception, especially in working with a behaviorist, is critical to address and reformulate. In behavior therapy, there is a collaborative effort between the therapist and the client. If the client does not accept full responsibility for their treatment outcome, the prognosis for using this type of therapy is poor.
For clients who enter treatment for OCD and have a concomitant personality disorder, the rate of success tends to drop to approximately 50%. The average time for treatment ranges between 6 months and 2 years, depending on the client's dedication and commitment to the therapeutic principles, as well as on the severity of the OCD. I have worked with a small number of clients who, within a period of 2 months, have absolutely decimated their OCD. A common characteristic of these clients involved a complete receptivity to the principles of the therapy. These few people (approximately 2 to 3 percent of my caseload over 15 years) had a determination and singular focus to be almost 100% compliant with the in-between session rigors of this treatment.
There are also clients who take a longer course than 2 years in treatment. These clients tend to show moderate to significant gains but seem to have difficulty delivering the final blow to the OCD. This tendency can best be explained by the principle of "diminished returns." This principle states that as our initial investment and dedication to therapy are driven by extreme pain, we tend to show tremendous focus and dedication to the therapeutic process. It is not uncommon, however, that after moderate amounts of gains have been made, the daily pain of the disorder is now perceived to be exceeded by the anticipated discomfort of engaging in exposure exercises. It is at this point that it becomes critical for people to maintain a focus on their long-term objectives and demonstrate a willingness to sacrifice momentary periods of comfort for the long-term objectives of destroying this potentially life-long condition.
Q: Through a combination of behavior therapy I have become almost symptom free and discontinued medication approximately 6 months ago with no dramatic effect on my sympthomology. What would you recommend to insure long-term maintenance and diminish the likelihood of relapse?
A: Congratulations, you have achieved a great and worthy goal. As is the case with most outcomes in behavior therapy, the true challenge seems to be in maintaining treatment effects more than achieving them in the first place. Behavior therapy offers a very powerful treatment component. These therapeutic principles can instill a disposition and provide techniques that a person can take with them and operate independently afterward. However, this is not easy. It is common for clients in the midst of therapy to ask, "Will it be required that I engage in these regular and frequent exposure exercises for the rest of my life?" The answer is no. Upon termination of therapy, I recommend to the clients that they, throughout the week, sporadically engage in exposure exercises as a means of maintaining a disposition of aggressiveness against their condition. Perhaps, during one out of every four bathroom visits, the person may re-expose themselves to a toilet seat before leaving the bathroom, without washing their hands, of course. The Pure-O may purposely create spikes about killing their own child on a ten times per week basis, etc., etc. The most important element to ensure recovery is maintaining the disposition of acceptance and tolerance to ambiguity. Not being disturbed that the thoughts are occurring is also critical. Giving your brain permission to be creative and occasionally activating an unpleasant physical experience of anxiety is also imperative. There are approximately three major hurdles in the course of recovery. The first major hurdle entails the initial homework assignments and the client's ability and willingness to comply with the agreed-upon challenges. The second major hurdle exists at the end of therapy, at the top of the hierarchy, where all elements of risk are now to be embraced and engaged in. The third hurdle takes place after the completion of treatment, sometime down the road, during a period of acute or prolonged stress in one's life. It is at this juncture that the subtle whispers of the OCD's temptations will typically re-emerge. It is critical that the person retaliates in a swift and forceful way to these subtle temptations. Scheduling a buster session or a short stint of sessions may be prudent if the upsurge seems to be creating a manipulation of thought or behavior that is longer-lasting than one week.