Advanced Casebook of Obsessive-Compulsive and Related Disorders: Conceptualizations and Treatment
By Dean McKay and Jonathan S Abramowitz
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About this ebook
Advanced Casebook of Obsessive-Compulsive and Related Disorders: Conceptualizations and Treatment presents a synthesis of the emerging data across clinical phenomenology, assessment, psychological therapies and biologically-oriented therapies regarding obsessive compulsive disorders, including hoarding, skin picking, body dysmorphic and impulse control disorders. Following the re-classification of such disorders in the DSM-5, the book addresses recent advances in treatment, assessment, treatment augmentation and basic science of OCRDs. The second half of the book focuses on the treatment of OCRDs, covering both psychological therapies (e.g. inhibitory learning informed exposure, tech-based CBT applications) and biologically oriented therapies (e.g. neuromodulation).
- Includes psychosocial theoretical and intervention approaches
- Addresses newly proposed clinical entities, such as misophonia and orthorexia
- Examines neurobiological features of OCRDs across the lifespan
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Advanced Casebook of Obsessive-Compulsive and Related Disorders - Eric A. Storch
Advanced Casebook of Obsessive-Compulsive and Related Disorders
Conceptualizations and Treatment
Editors
Eric A. Storch, PhD
Professor, Vice Chair & Head of Psychology, Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
Dean McKay, PhD
Professor, Psychology, Fordham University, Bronx, New York, United States
Jonathan S. Abramowitz, PhD
Professor, Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States
Table of Contents
Cover image
Title page
Copyright
Dedication
Contributors
Preface
Chapter 1. Chew on this: considering misophonia and obsessive-compulsive disorder
Background
Case example
Treatment implementation
Conclusion
Chapter 2. Treatment of pathologic healthy eating (orthorexia nervosa)
Background
Treatment literature
Treatment of orthorexia nervosa in the context of obsessive-compulsive disorder
Terminology relevant to disordered eating
Assessment
Case example and treatment
Conclusions
Chapter 3. Sensory intolerance
Background
Clinical case
Treatment implementation
Conclusions
Chapter 4. Treatment of incompleteness in obsessive-compulsive disorder
Assessment of incompleteness
Treatment of incompleteness
Case illustration
Conclusions
Chapter 5. Scrupulosity
Background
How is scrupulosity related to OCD?
Treatment outcome studies
A conceptual model of scrupulosity
Case description and conceptualization
Treatment implementation
Treatment outcome
What can be learned from this case
Chapter 6. Addressing comorbid substance use/abuse in obsessive-compulsive disorder
Psychologic mechanisms for substance use in obsessive-compulsive disorder
Treatment strategies for substance use
Treatment strategy for obsessive-compulsive disorder
Case illustration
Chapter 7. Obsessive-compulsive disorder and comorbid posttraumatic stress disorder
Diagnostic overview
Age of onset
Differential diagnosis
Static versus dynamic comorbidity
Static comorbidity case example
Dynamic comorbidity case example
Treatment
Treatment case examples
Chapter 8. Postpartum obsessive-compulsive disorder
Background
Phenomenology
Treatment literature
Theoretic models
Case description
Treatment implementation
What can be learned from the case
Chapter 9. Treatment of obsessive-compulsive disorder in a young person with autism spectrum disorder
Background
Case description and conceptualization
Index
Copyright
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Notices
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ISBN: 978-0-12-816563-8
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Publisher: Nikki Levy
Acquisition Editor: Nikki Levy
Editorial Project Manager: Barbara Makinster
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Cover Designer: Alan Studholme
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Dedication
For Dawn and Rebecca, with love and laughs
Dean McKay
To Stacy, Emily, and Miriam, with all my love
Jonathan S. Abramowitz
For my cowboy (Noah) and cowgirls (Ellie, Maya, and Jill), with much love
Eric A. Storch
Contributors
Jonathan S. Abramowitz, PhD, Department of Psychology, University of North Carolina, Chapel Hill, NC, United States
Kelly N. Banneyer, PhD, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
Andrea Eugenio Cavanna, MD, PhD, FRCP, FANPA
Department of Neuropsychiatry, BSMHFT and University of Birmingham, Birmingham, United Kingdom
School of Life and Health Sciences, Aston Brain Centre, Aston University, Birmingham, United Kingdom
Sobell Department of Motor Neuroscience and Movement Disorders, Institute of Neurology and University College London, London, United Kingdom
Terri L. Fletcher, PhD
Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States
Assistant Professor, Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, United States
Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX United States
VA South Central Mental Illness Research, Education and Clinical Center, A Virtual Center, Houston, TX, United States
Samantha N. Hellberg, BA, Department of Psychology, University of North Carolina, Chapel Hill, NC, United States
Natalie Hundt, PhD
Houston VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, United States
Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX United States
VA South Central Mental Illness Research, Education and Clinical Center, A Virtual Center, Houston, TX, United States
Amita Jassi, DClinPsy, National Clinic for Young People with OCD, BDD and related disorders, South London and Maudsley NHS Foundation Trust, London, United Kingdom
Georgina Krebs, DClinPsy
National Clinic for Young People with OCD, BDD and related disorders, South London and Maudsley NHS Foundation Trust, London, United Kingdom
Social, Genetic and Developmental Psychiatry Centre, King's College London, Institute of Psychiatry, London, United Kingdom
Dean McKay, PhD, Professor, Department of Psychology, Fordham University, Bronx, NY, United States
Lucy J. Puryear, MD, Departments of Obstetrics and Gynecology, and Menninger Department of Psychiatry, Baylor College of Medicine, Houston, TX, United States
Christina A. Treece, MD, Departments of Obstetrics and Gynecology, and Menninger Department of Psychiatry, Baylor College of Medicine, Houston, TX, United States
Nathaniel Van Kirk, PhD, Office of Clinical Assessment and Research (OCAR), OCD Institute, McLean Hospital/Harvard Medical School, Boston, MA, United States
Monica S. Wu, PhD, UCLA Semel Institute for Neuroscience and Human Behavior, Postdoctoral Scholar & Clinical Instructor, Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA, United States
Hana F. Zickgraf, PhD, Postdoctoral Fellow, Psychiatry and Behavioral Neuroscience, University of Chicago Pritzker School of Medicine, Chicago, IL, United States
Preface
Chiesa (1994) highlights how clinical sciences have often advanced by studying outliers. This stands in contrast to how researchers often treat outliers, which is to consider them noise or errors, something to be deleted from the final dataset. However, sometimes we learn that these outliers are not so out of the ordinary after all. Consider, for example, that it was long believed that obsessive-compulsive disorder (OCD) was extremely rare, in other words, an outlier. Instead, as readers of this book likely are aware, OCD is hardly an outlier, with around 1%–2% of the population suffering from the condition.
As efficacious treatments have been developed for OCD, the complexity and variety of clinical presentations of the disorder have been well documented. It is in this spirit that we now turn to some potential outlier illustrations of the condition. These are outliers more because investigators have not systematically examined these clinical presentations, such as co-occurring trauma or autism spectrum conditions. Alternatively, in recent conceptualizations of OCD, perceptual features have become better understood, such as the persistent experience of a feeling of incompleteness,
other sensory intolerance, and irritability over specific sounds. These specific outlier
manifestations, although not well recognized in the broader clinical community, are recognized by specialists in treating OCD and related conditions. Indeed, some might not refer to these presentations as outliers
at all. For example, substance use, trauma, and autism spectrum disorders all commonly co-occur with OCD and yet the research literature is comparably silent on how to best address these clinical presentations.
Into this void, this volume arrives to provide summaries of the extant research and case illustrations of treatment for a variety of presentations of OCD that are likely to present for treatment. The target audience for this volume are any mental health workers routinely treating individuals with OCD or any of the associated conditions described in this book. Much of the treatment depicted in this book is cognitive behavioral in nature, which is to be expected considering that much of the evidence-based treatment for OCD and the associated conditions described herein have efficacious treatments for each derived from cognitive behavior principles.
Case illustrations frequently stimulate additional research and set the occasion for novel treatment developments. It is our hope that this volume will accomplish that aim, in light of the likelihood that the cases presented are not likely outliers after all.
References
Chiesa M. Radical behaviorism: The philosophy and the science. Littleton, MA: Cambridge Center for Behavioral Studies; 1994.
Chapter 1
Chew on this: considering misophonia and obsessive-compulsive disorder
Monica S. Wu, PhD¹, and Kelly N. Banneyer, PhD² ¹UCLA Semel Institute for Neuroscience and Human Behavior, Postdoctoral Scholar & Clinical Instructor, Department of Psychiatry and Biobehavioral Sciences, Los Angeles, CA, United States ²Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
Abstract
Misophonia is a unique condition characterized by an extreme sensitivity to selective sounds. Individuals with this condition often display significant emotional distress in response to everyday noises (e.g., chewing, sniffing, tapping). These negative emotions often lead to avoidance and anger outbursts, ultimately resulting in decreased quality of life and increased functional impairment. Although misophonia is largely understudied, treatment literature supporting the use of exposure-based behavior therapy has been emerging. A summary of the extant research is presented, followed by a case report of an adolescent with misophonia, illustrating how to implement exposure and response prevention for this impairing disorder.
Keywords
Auditory; Misophonia; Sensitivity; Sensory; Sound
When listening to nails screech across a chalkboard, most individuals react universally; cringing, grimacing, covering ears, or trying to make the sound stop are all typical reactions. However, there are a subgroup of individuals who display similar visceral reactions to everyday auditory stimuli, irrespective of the frequency bands of the sound (Jastreboff, 2011). Indeed, seemingly innocuous sounds (or even the mere sight) of someone chewing, tapping their foot, or sniffing elicit considerable emotional and physical reactions in these individuals (Johnson et al., 2013). For some, it can become so unbearable that avoidance becomes the primary way of coping with the distress, leading to a limited lifestyle and decreased quality of life. This understudied, yet impairing, condition is called misophonia.
Background
What is misophonia?
Misophonia is a form of decreased sound tolerance that is characterized by a hypersensitivity to selective types of sounds. Common trigger sounds include the sound of people eating, repeated tapping, breathing noises, and throat sounds (Schröder, Vulink, & Denys, 2013; Wu, Lewin, Murphy, & Storch, 2014). When encountering the triggering auditory stimuli, individuals with misophonia often experience considerable emotional and physical arousal. The severity of the emotional reaction is sometimes dependent on the source of the sound (e.g., parent vs. stranger; McGuire, Wu, & Storch, 2015). In other cases, however, it is equally distressing regardless of the source, and individuals with misophonia may just be more effortful in controlling their emotional reactions around strangers in order to comply with social conventions (e.g., refraining from yelling at a stranger for chewing loudly).
With regard to specific emotions, anxiety, anger, and disgust are common negative reactions to these sounds (Ferreira, Harrison, & Fontenelle, 2013; Wu et al., 2014). Irritation and rage are often observed (Brout et al., 2018), sometimes resulting in verbal or physical aggression (Johnson et al., 2013; Schröder et al., 2013). It is noted, however, that anxiety may play a mediating role in the relationship between misophonia symptoms and rage outbursts (Wu et al., 2014; Zhou, Wu, & Storch, 2017), highlighting the importance of considering the unique role of anxiety in misophonia (Quek et al., 2018). Studies have also highlighted physical arousal in connection with triggering auditory stimuli (Edelstein, Brang, Rouw, & Ramachandran, 2013), specifically demonstrating higher levels of skin conductance responses (SCRs) when compared with a healthy control group. Additionally, a preliminary neuroimaging study revealed aberrant activation and functional connectivity in the anterior insular cortex (Kumar et al., 2017), which are thought to mediate physical responses (i.e., heart rate and SCRs) in the face of misophonia-related triggers.
Because of the emotional distress and physical arousal induced by the triggering sounds, individuals with misophonia often engage in avoidance behaviors in an attempt to escape from the upsetting auditory stimuli (Schröder et al., 2013; Webber, Johnson, & Storch, 2013). This can manifest as physically removing themselves from the source of the sound (e.g., leaving the room) or doing something to prevent themselves from hearing the sound (e.g., wearing headphones). These avoidance behaviors have immediate effects, such as preventing an individual from eating meals with loved ones for the fear of hearing chewing sounds or missing social events because of the possibility of hearing triggering noises. Avoidance also has deleterious long-term effects, as it is a slippery slope that often leads to more avoidance and decreased functioning in day-to-day life. As such, there is likely to be continued maintenance (and potential exacerbation) of the symptoms, given the negatively reinforcing nature of avoidance (see the section Theoretic models relevant to presentation for a more detailed explanation of this cycle). Other behavioral reactions to misophonia-related triggers include attempting to make the sound go away through their own actions, such as yelling at a person to stop making the noise. This can lead to frequent arguments and strained interpersonal relationships, especially if the sounds are coming from family members and other loved ones (McGuire et al., 2015). Collectively, individuals with misophonia experience a variety of negative emotional states and engage in different maladaptive behaviors in response to specific auditory stimuli, unfortunately resulting in decreased quality of life and functional impairment.
Who is affected by misophonia?
Misophonia often begins in childhood or early adolescence, with symptom severity worsening over time (Rouw & Erfanian, 2018). Why certain people develop misophonia and the exact cause of this condition are still unknown, with various putative causes being proposed in the emerging literature (Brout et al., 2018; Palumbo, Alsalman, De Ridder, Song, & Vanneste, 2018). Instead of resulting from damage to or overactivation of the auditory pathway, misophonia is thought to be associated with enhanced connections between the auditory, limbic, and autonomic nervous system (Jastreboff & Hazell, 2004; Jastreboff & Jastreboff, 2013). Additionally, enhanced functional connectivity between various brain regions tied to emotion regulation processes and interoception was observed in individuals with misophonia (Kumar et al., 2017), suggesting potential underlying neurobiological mechanisms.
Because research on this condition is still burgeoning, definitive incidence rates have been difficult to establish. When considering clinical samples of individuals presenting to audiologic clinics for tinnitus (a condition that is characterized by ringing of the ears, despite the lack of external auditory stimuli), an estimated 10%–60% of these patients are affected by misophonia as well (Hadjipavlou, Baer, Lau, & Howard, 2008; Sztuka, Pospiech, Gawron, & Dudek, 2010). Broader undergraduate samples in the United States and China have reported that 6%–20% of the participating students were affected by elevated, impairing levels of misophonia symptoms (Wu et al., 2014; Zhou et al., 2017). The remainder of studies examining misophonia are typically composed of case reports or use self-selected samples (e.g., from misophonia support groups), making it difficult to infer the true incidence rate. However, these preliminary estimates highlight the potentially high rate of occurrence of misophonia across cultures, suggesting its far-reaching impact.
With regard to the clinical characteristics of individuals with misophonia, various case reports and cross-sectional studies have highlighted clinical correlates and comorbidities. Higher numbers of misophonia symptoms have been linked with greater sensory sensitivities, with more moderate associations observed with depressive, anxiety, and obsessive-compulsive symptoms (Wu et al., 2014). Diagnostic criteria for misophonia have yet to be established, as it can be unclear whether the symptoms are better accounted for by other psychiatric disorders at times (Ferreira et al., 2013). However, given its moderate relationship with multiple psychiatric symptoms and a potentially unique cluster of symptoms characterizing the disorder, many consider misophonia to be a stand-alone condition that should have its own set of diagnostic criteria (Brout et al., 2018; Schröder et al., 2013).
Psychiatric comorbidities are often observed in individuals with misophonia. Specifically, the higher numbers of misophonia symptoms have been related to major depressive disorder and posttraumatic stress disorder (Erfanian, Brout, & Keshavarz, 2018; Rouw & Erfanian, 2018). Additionally, a case series suggested the possibility of a link between eating disorders and misophonia (Kluckow, Telfer, & Abraham, 2014), given the shared distress related to food and chewing. Interestingly, a cross-sectional study reported the co-occurrence of obsessive-compulsive personality disorder in approximately half of the sample (Schröder et al., 2013), with the authors suggesting that it may be either a risk factor for developing misophonia or a consequence of having it, but further research is needed to explore these hypotheses. However, perhaps the most researched and reported comorbidity for misophonia has been obsessive-compulsive disorder (OCD) and related conditions, such as Tourette syndrome (Hadjipavlou et al., 2008; Neal & Cavanna, 2013; Schwartz, Leyendecker, & Conlon, 2011). Consequently, clinicians and researchers alike have set forth notable efforts to further examine the similarities in the presentation and treatment of these conditions (Schröder et al., 2013), commonly viewing them within the same theoretic model.
Theoretic models relevant to the presentation
In describing the phenomenology and maintenance of the symptoms, misophonia can be viewed through the lens of a cognitive-behavioral model. Within this model, the triad of thoughts, feelings, and behaviors is thought to influence one another in a multidirectional manner (Kendall & Panichelli-Mindel, 1995). When presented with a trigger for misophonia, individuals typically have various thoughts that occur; they can think about how annoying the sound is, how much they want it to stop, and/or how much they dislike the person making the sound. The related feelings can be emotional or physical, including disgust, anger, anxiety (Brout et al., 2018), tenseness, as well as increased heart rate and sweating (Edelstein et al., 2013; Kumar et al., 2017). These thoughts and feelings are thought to contribute to the individual's reactions and behaviors, such as leaving the situation to avoid the trigger or yelling at the person to stop making the sound. Ultimately, all these thoughts, feelings, and behaviors affect one another in the face of the triggering sound. Exposure-based cognitive behavioral therapy (CBT) emphasizes changes in the individual's behaviors in order to break the negative cycle and teach the individual how to react more adaptively.
Using the cognitive-behavioral model, the maintenance of misophonia symptoms is conceptualized as occurring within a negative reinforcement cycle. Specifically, the individual is presented with a triggering sound (e.g., chewing, sniffing), thereby eliciting a negative emotion (e.g., anger, anxiety, discomfort). Consequently, the individual seeks to engage in a behavior that will help decrease the distress in the moment (short term), such as avoiding the sound or getting the sound to stop. By doing so, this maladaptive behavior is negatively reinforced in the long term, making it more likely for the individual to continue engaging in these behaviors, rather than learning how to handle the distress in a more adaptive manner that will help decrease his/her functional impairment. Given that obsessive-compulsive symptoms follow a very similar negative reinforcement cycle, clinicians and researchers alike have examined the relationship between these two disorders.
How is misophonia related to obsessive-compulsive disorder?
Similarities in the respective negative reinforcement cycles in misophonia and OCD have been observed. Specifically, the cycle starts with a trigger (sound, obsession), leads to subsequent distress (discomfort, anxiety), followed by