OCD: Treatments for Non-Cookie Cutter Disorder 1

Obsessive Compulsive Disorder:

Treatments for a Non-Cookie Cutter Disorder
Micaela Fosdick
Dr. Johnson
PSY 227 01
07 April 2015

OCD: Treatments for Non-Cookie Cutter Disorder 2

Integrated Writing Component

Abnormal psychology and mental disorders are incredibly diverse. Research is only just
beginning to scratch the surface of understanding the brain and possible treatments for the
multiple disorders that have been classified. A particular disorder of interest is Obsessive
Compulsive Disorder. Although there is a current accepted model of treatment for OCD,
current research suggests that this model could stand to be supplemented.
Obsessive Compulsive Disorder (OCD) is characterized by obsessive thoughts and
repetitive behaviors (compulsions) a person feels compelled to do in order to relieve the stress of
these thoughts. Although in adults these compulsions and obsessions must be recognized as
excessive, disruptive, or unreasonable, this distinction is not made in children (Dembo 2014).
However, it is important to not here that even if it does not have to be recognized, research does
show that children with OCD do have a significantly lower quality of life than children who do
not (Weidle et al. 2014). Furthermore, OCD does fall on a spectrum, meaning that there is not a
one shoe fits all description or severity of OCD. What is interesting is that where someone falls
on a spectrum is not determined by how harmful or deviant the obsessions are, but rather how
well the individual can resist the compulsions (Brodesser-Akner 2015). In addition, individuals
diagnosed with OCD are likely to not have just OCD. Weidle et al. 2015 found that in a study of
135 participants, only about 50% had OCD alone. A few comorbid disorders that were present in
this same study were ADHD (13.6%), tic disorder (28%), anxiety disorders (21%), and
depression (Weidle 2015). It should be noted that were individuals who were diagnosed with
more than one comorbid disorder. Another important component to understanding OCD is that
the cause is anything but straight forward. It is more or less a cocktail of both environmental
and genetic factors. Because of the variety of possible sources, one would think the treatment of

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such a disorder would be equally diverse individualized. However, this is not the case as it
stands today.
The default treatment for OCD is known as cognitive-behavioral therapy (CBT) almost
exclusively (Dembo 2014). This approach generally uses a technique known as exposure and
response prevention (ERP). The goal of this technique is not to psychoanalyze the obsessions,
but rather attempt to give the individual tools necessary to recognize the obsessive thoughts or
beliefs as unreasonable and the compulsion as not needed (Brodesser-Akner 2015). The idea
being that someone with OCD can overcome both obsessions and compulsions by recognizing
what is real using logic alone. ERP specifically is a process of exposure in order to desensitize
an individual. For example, if someone has obsessive thoughts about germs and compulsion is
to wash their hands thousands of times a day, then ERP therapy may require that person to have
exposure to something he/she deems as being dirty without being able to wash his/her hands.
This type of therapy has been shown to be somewhat effective.
For instance, Dembo 2014 found that CBT played a vital role in the particular case he
was working on. A 12 year old girl who had severe OCD. She had one particular ritual with
going up the stairs. If anyone moved or talked while she was doing this process, she would have
to go back and start from the beginning. She stopped eating because she was afraid of a specific
type of contamination from her family. As part of her therapy, Dembo had her create a hierarchy
of objects/people/behaviors that caused her distress or to be uncomfortable. Then, starting from
the least objectionable, they would have her hold the object or put her in that situation. Dembo
points out however that this was only effective because they first used other treatments that got
her (the patient) engaged.

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This is one of the main limitations of CBT that in order to be effective, the patient has to
be engaged (Dembo 2014). Furthermore, about 30% of people who have been diagnosed with
OCD cannot/will not be helped by CBT; and for those who do try it there is a 25% drop out rate
(Murphy and Perera 2014; Wettleneck, Steinberg, and Hart 2014). Of those that do engage in
CBT treatment and find relief, long-term follow up statistics show that there is a success-rate
of 55%, suggesting a relapse rate of 45% (Murphy and Perera 2014). A study done by Murphy
and Perera (2014) attempted to find possible explanations for these statistics. They discovered
through several interviews, that although CBT is functional, the distance it creates does not
always go over so well with the patients. People like to understand themselves, dive deeper than
simply trying to out think their disorder. A common theme found in this particular study was that
those undergoing CBT treatment felt like they were being treated as machines. Expected to
simply turn off the obsessive thoughts and compulsions without ever giving any meaning to the
type of thoughts they might have had (Murphy and Perera 2014).
What then is the alternative? Or should we simply accept that there is not going to be a
perfect solution and keep going as is? Obviously, the answer to the latter is no. That is
unacceptable. The answer is to stop looking for a cookie cutter solution to an obviously not so
cookie cutter disorder. There are other types of therapy available that could serve to be very
useful in treating OCD. An example of this would be narrative therapy. This was used by
Dembo 2014 and helpful in getting his patient to engage in the ERP. The primary goal of
narrative therapy is to increase an individuals awareness of the dominant narrative influencing
her life, and to challenge those. (Dembo 2014). In essence you are asking the patient to
indirectly describe their experiences and their perceptions of those experiences. Because it is
taken out of reality and in a narrative format (individual is not restricted to literal constructs), the

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result may actually be more descriptive than a direct retelling of past events. The other key
component is the challenging of those preconceived perceptions and interpretations.
Another type of therapy that has been shown to be helpful is Mindfulness. This approach
was investigated by Fairfax et al. 2014. This research team discovered that after interviewing 15
participants who had been a part of the same therapy group session, the majority found
mindfulness to be most helpful, in addition this was the most well remembered technique to deal
with episodes (Fairfax et al. 2014). Mindfulness is defined as paying attention in a particular
way: on purpose, in the present moment and is non-judgmental (Fairfax et al. 2014). In essence
it requires the individual to pause before the participating in the automatic compulsive response
to an obsessive thought. Similar to CBT, however more meditative/reflective. One aspect of
OCD is often times a person with OCD will judge their thought as good or bad and then the
judgement of that thought becomes a judgement of themselves. That is why the nonjudgmental component is so important.
Another type of therapy that is similar to this is Acceptance and Commitment Therapy
(ACT). This type of therapy is targeted to help treat Experiential Avoidance (Wetterneck,
Steinberg, and Hart 2014). However, when used as a treatment for OCD, it is targeted at the
concept of thought-action-fusion (Fairfax et al. 2014). This approach suggests that it is the link
between the obsessive thought and the compulsion that is the problem. ACT attempts to disrupt
this link by not necessarily ignoring the obsession, but rather accepting the thought as normal
and letting it pass without acting on it.
Obsessive Compulsive Disorder affects about 1 in 100 people in the United States
(Wetterneck, Steinberg, and Hart 2014). This does not mean that it affects 1 in 100 people the
same. None of the alternative treatments were used in isolation. Perhaps a better term than

OCD: Treatments for Non-Cookie Cutter Disorder 6

alternative is supplemental. The only way to begin treating individuals who suffer from OCD is
not to focus on the pathology but rather the person. This is a very individualized disorder and the
treatment has to be just as individualized.

OCD: Treatments for Non-Cookie Cutter Disorder 7

Annotated Bibliography
Brodesser-Akner, T. (May 2015). OCD in Real Life. Cosmopolitan 258(5), 146.
In this article, Brodesser-Akner relays her experience coping with obsessive compulsive
disorder. She discusses her first compulsions from when she was seven (licking her
wrists), to how she has become better at hiding her behaviors. Furthermore, BrodesserAkner goes a step farther and brings attention to how common the term OCD has
become in society. (Generally being used incorrectly.) While there is a spectrum
associated with OCD, being a perfectionist bothered by falling short is not on that
spectrum. Brodesser describes OCD as being characterized by obsessive thoughts,
compulsive behaviors, and often co-occurring with other anxiety disorders, depression, or
phobias.
Brodesser does an excellent job of relaying the facts of OCD while making it
understandable (as much as it can be). The way in which she takes you through an actual
episode in which she experienced her hands smelling like rotten meat for weeks and also
interrupts herself (as this is what her mind does to her) with seemingly random thoughts
was an effective style of writing this piece.
No Abstract/Summary Provided
Dembo, J.S. (2014). The Ickiness Factor. Case Study of an Uncoventional Psychotherepeutic
Approach to Pediatric OCD. American Journal of Psychotherapy, 68(1), 57-79.
In this case study, Dembo conveys his experience with treating a 12 year old diagnosed
with Obsessive Compulsive Disorder. He used not only cognitive-behavioral therapy and
exposure and response prevention, but also incorporated psychoanalysis: existential &
metaphor therapy, and narrative therapy. What was stressed throughout this article was
the necessity of each of these approaches in treating this patient and argues that while
CBT is effective, it should not be the only approach taken with people who suffer from
OCD. The characteristic about OCD is that each case is unique and therefore should be
treated as such. The other key factor to this success story was that the patient was
listened to. Sometimes, especially when dealing with something such as OCD in a child,
people are more inclined to disregard rather than listen and take into consideration the
patients own ideas/thoughts.
Abstract: Obsessive-compulsive disorder (OCD) is a complex condition with biological,
genetic, and psycbosocial causes. Traditional evidence-based treatments include
cognitive-behavioural therapy, either alone or in combination with serotonin-speciflc
rcuptake inhibitors (SSRI's), other serotonergic agents, or atypical antipsychotics. These
treatments, however, often do not lead to remission, and therefore, it is crucial to explore
other less conventional therapeutic approaches. This paper describes a case study in
which psychodynamic, narrative, existential, and metaphor therapy in combination with
more conventional treatments led to a dramatic remission of severe OCD in a 12 year old
hospitalized on a psychiatric inpatient unit. The paper, which is written partly in the form
of a story to demonstrate on a meta-level the power of narrative, is also intended to

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illustrate the challenges of countertransference in the treatment of patients with severe

OCD, and the ways in which a reparative therapeutic alliance can lead to unexpected
and vital change.
Fairfax, H., Easey, K., Fletcher,S., and Barfield, J. (2014). Does Mindfulness help in the
treatment of Obsessive Compulsive Disorder (OCD)? An audit of client experience of an
OCD group. Counseling Psychology Review, 29(3), 17-27.
This research article explores the possible role of mindfulness as a technique for
individuals who suffer from OCD. Mindfulness was defined as paying attention in a
particular way: on purpose, in the present moment and is non-judgmental.
The research team looked at the experience of 15 individuals with Obsessive Compulsive
Disorder in group therapy that included techniques of mindfulness, behavioral hierarches/
experience and response prevention, and relaxation. After interviewing all 15, it was
found that mindfulness was the most well remembered technique and most clients found
Mindfulness to be either very helpful or helpful.
Fairfax et al. 2014 points out that these results were not obtained from individuals who
were only taught Mindfulness, but rather Mindfulness was a part of a multifaceted
approach. Furthermore, limits to the research did not allow for the few who did not
experience Mindfulness to be helpful to be contacted. In future studies, these types of
experiences would be an important addition to the knowledge base.
Abstract:
Background: Obsessive Compulsive Disorder (OCD) can have a debilitating effect on the
sufferer, their family and quality of life. Despite an evidence-based treatment for OCD, it
is recognized as one of the hardest psychological problems to treat. CBT and in particular
ER-P has also been associated with high drop-out rates as some clients found it too
stressful to engage in exposure interventions. There is a need, therefore, to consider other
ways of enhancing expositing treatment. This article presents client experiences of an
OCD group which incorporated Mindfulness as a central part of the intervention.
Methodology: Fifteen clients who attended an OCD group over the last six years were
contacted and interviewed by Research Assistant. Although this was a routine part of
evaluating the service, specific questions about Mindfulness and techniques in the group
were asked.
Results: Twelve of the clients described Mindfulness as helpful and it was the most
remembered skill from the group. It was and continued to be practiced by a majority of
participants. Client reported improvements included, general focusing, concentration,
helping with exposure, noticing awareness, challenging anxiety, acceptance, challenging
the need to repeat behaviours, slowing down thinking, helping to relax and improving
sleep.
Conclusion: The influences of Mindfulness on possible mechanisms for change in OCD
are discussed in particular a process of experiential engagement is explored in relation to
concepts of reperceiving and affective reactivity. The contribution of Mindfulness to

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the therapeutic relationship is also discussed, and the importance of relational process in
understanding outcome.
Murphy, H., and Perera-Delcourt, R. (2014). Learning to live with OCD is a little mantra I often
repeat: Understanding the lived experience of obsessive-compulsive disorder (OCD) in
the contemporary therapeutic context. Psychology & Psychotherapy: Theory, Research &
Practice, 87(1), 111-125.
This article was a compilation of not just research, but interviews of nine different people
with Obsessive Compulsive Disorder. The goal of this research was to compile both
everyday experiences of those who live with OCD and their experience with cognitivebehavioral therapy (CBT). Ultimately looking into where CBT (a common treatment for
OCD) falls short and attempt to understand the somewhat high resistance rate (longterm follow-ups show only 55% success rate of CBT).
Murphy and Perera-Delcourt use two main superordinate themes to categorize the
information they gathered through the interviews: Having OCD and Impact of Therapy.
Each of these themes were then each broken down further into three subordinate themes
each. In essence, the conclusions made were that CBT is functional, providing more or
less a coping mechanism, but attempts to distance compulsions/obsessions from the
individuals experience/past. Murphy and Perera-Delcourt suggest more research should
be done in finding supplementary treatments to lessen this distance.
Abstract:
Objectives. While there has been an abundance of quantitative studies that examine the
clinical features and treatment modalities of obsessive-compulsive disorder (OCD), only
a few qualitative research studies examining the experience of OCD have been
documented. Our objectives were to explore and understand psychosocial aspects of
OCD and to provide qualitative accounts of the condition and its treatment rather than
concentrating on its psychopathology. We also wanted to locate the role cognitive
behavioural therapy (CBT) played in the condition for our participants.
Design. Data for the study came from a series of nine semi-structured interviews carried
out with individuals who self-identied as having OCD. Participants were recruited
through two leading UK-based OCD charities.
Methods. We used interpretative phenomenological analysis (IPA) to analyse the
accounts and participants gave feedback as to the validity of the themes in early stages of
analysis.
Results. We report two superordinate themesHaving OCD (with subordinate themes
wanting to be normal and t it, failing at life and loving and hating OCD) and The
Impact of Therapy (with subordinate themes of wanting therapy, nding the roots and
a better self).
Conclusions. Having OCD as a condition meant that individuals experienced a sense of
overwhelming personal failure matched against age appropriate lifecycle goals. This
crisis of the self was bolstered by public and self-stigma about the condition. While
clinical diagnosis and therapeutic interventions were signicant, participants reported

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dialectical tensions experienced with OCD, pointing to the complexity of psychological

functioning in the condition.
Weidle, B., Jozafiak, T., Ivarsson, T., and Thomsen, P.H. (2014). Quality of life in children with
OCD with and without comorbidity. Heath & Quality Of Life Outcomes, 12(1), 2-24.
The purpose of this research was to compile information comparing quality of life in
children (7-17 years of age) who suffer from OCD. The team also looked into the effect
that comorbidity also has on quality of life. To accomplish this, surveys were answered
by both children and caregivers (128 pairs). Of the patients surveyed, about half had
OCD only with no comorbidity. The disorders that co-occurred in this group in
decreasing order of prevalence: tic disorder, anxiety disorders, ADHD, social phobia,
generalized anxiety disorder, and depression. It should be noted that some cases had
multiple of these, however analysis did not separate these out.
There was a significant difference found between quality of life between children with
OCD and the general population. However, only the caregiver analysis found a
significant difference between OCD only children and those with comorbidity (no
significant difference found in child self-report). Significant correlation was found when
comparing severity of symptoms to quality of life.
Abstract:
Background: Quality of life (QoL) is a well-established outcome measure. However, in
contrast to adult obsessive-compulsive disorder (OCD), little is known about QoL in
children with OCD. This study aimed to assess QoL, social competence and school
functioning of paediatric patients with OCD by comparing them with the general
population and assessing the relations between comorbidity, duration and severity of
symptoms, family accommodation and QoL.
Methods: Children and adolescents (n =135), aged 717 (mean 13 [SD 2.7] years;
48.1% female) were assessed at baseline for treatment. QoL was assessed by self-report
and caregivers proxy report on the Questionnaire for Measuring Health-related Quality
of Life in Children and Adolescents (KINDL-R) and compared with an age- and sexmatched sample from the general population. Social competence and school functioning
were assessed with the Child Behavior Checklist, comorbidity with the Kiddie Schedule
for Affective Disorders and Schizophrenia (Present and Lifetime Version), severity of
OCD with the Childrens Yale-Brown Obsessive Compulsive Scale and the families
involvement with the childs OCD symptoms with the Family Accommodation Scale.
Results: QoL and social competence were reduced (p < .001) in patients with OCD
compared with controls (KINDL-R mean score 62.40 [SD 13.00] versus 69.72 [12.38] in
self-reports and 61.63 [SD 13.27] versus 74.68 [9.97] in parent reports). Patients with
comorbidity had lower QoL (p = .001) in proxy ratings than those with OCD only (mean
score 56.26 [SD 12.47] versus 64.30 [SD 12.75]). In parent proxy reports, severity of
OCD (r = .28) and family accommodation (r = .40) correlated moderately negatively
with QoL.
Conclusions: To our knowledge, this is the largest QoL study of paediatric OCD. QoL
was markedly reduced in children with OCD, especially in those with comorbid

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psychiatric disorders. Based on our findings, we suggest employing QoL assessment in

order to have a more comprehensive understanding of childhood OCD.
Wetterneck, C.T., Steinberg, D.S., & Hart, J. (2014). Experiential avoidance in symptom
dimensions of OCD. Bulletin of the Menninger Clinic, 78(3), 253-269.
This research explored the possible correlation between experiential avoidance (EA) and
Obsessive Compulsive Disorder (OCD). EA is defined as the unwillingness to remain in
contact or experience unpleasant private events. Although previous research findings
have found no correlation between these two, the current study suggest the evaluation
methods used were limited and they utilized updated versions of these methods that
may compensate for the limitations of the previously used methods.
When using the Dimensional Obsessive Compulsive Scale (DOCS) and Acceptance and
Action Questionaire II, a strong and significant correlation was found. The main
difference between this and previous studies is that DOCS takes into consideration
distress, functional interference and frequency/duration of obsessive thoughts. These
results suggest that treatment methods such as Acceptance and Commitment Therapy
(ACT) targeted for treating EA may be an effective alternative or addition to exposure
and ritual prevention (ERP) treatment of OCD.
Abstract: Experiential avoidance (EA) involves an unwillingness to re- main in contact or
experience unpleasant private events through attempts to avoid or escape from these
experiences. EA is hypothesized to play a role in obsessive-compulsive disorder (OCD);
however, previous studies have not found a significant relation- ship between EA and
OCD severity. The present study examined the relationship between EA and OCD
severity as measured by an updated measure of EA, an established measure of OCD
severity (i.e., the Obsessive-Compulsive Inventory-Revised [OCI-R]), and a new measure
of OCD symptom dimension severity, the Dimensional Obsessive-Compulsive Scale
(DOCS). A sample of 83 non-referred individuals meeting criteria for OCD completed
the measures. Correlations between EA and the OCI-R corroborated previous findings;
however, EA was significantly correlated with the DOCS. There were differences across
the symptom dimensions, with EA significantly correlated with unacceptable thoughts,
responsibility for harm, and symmetry, but not with contamination.

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Connection to Learning
With almost any disorder that has been discussed thus far in class, there have been
multiple accepted modes of treatment. It would follow that such an individualist disorder such as
OCD would fall into the same category I was surprised to find that it in fact did not. In class we
talked a lot about how with mood disorders such as Bipolar Depression, the perfect balance of
drugs and therapy has to be met in order for the individual to be able to live his/her life to it
greatest potential. Although there are medications, specifically Serotonin Specific Re-Uptake
Inhibitors (SSRIs), the balance that has to be struck here is not necessarily chemical, but rather
therapeutic: a balance of both cognitive and psychoanalytic. The other tie-in that actually led me
to this topic was the article A Plague of Tics. The child in this article was obviously
struggling, perhaps there was some traces of OC behavior. But regardless, his behavior was
written off by parents and teachers alike, and he was simply labeled the troubled student who had
weird tendencies. I did not focus on this in the paper, however another important component to
treatment, is recognizing when someone (either him/herself or by someone else) needs help. I
really want to assume that changes have been made since the time that article was written and
this does not happen anymore. Unfortunately, I know this is not the case. This is why when
talking about types of treatment, another part of the discussion has to be educating people (such
as teachers) who are in a position to recognize when someone may need help.
Another interesting idea I found was how young the average age of diagnosis is for OCD.
Although the young age could be seen as a negative, there is also some advantage to recognizing
this type of disorder at a young age. We discussed in my previous developmental psychology
class how malleable the mind truly is, and the younger the more malleable. This means that if

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recognized early enough, therapy may be more effective in a younger individual than say
someone in their mid-twenties or thirties.
Something else to ask when looking into OCD is whether or not there actually is a
chemical in-balance or perhaps simply a pathway that results in the obsessive thoughts.
Although I have not studied it in depth, my Introduction to Neuroscience and Hormones &
Behaviors class has taught me just how complicated the networking of the brain is. Not only is it
complex, but also it does not take much to throw something off. The presence or absence of a
single hormone receptor can essentially determine if someone is male or female regardless of the
presence of a Y-chromosome. Who is to say that other types of hormones do not have the same
profound effects on our memory that may lead to obsessive thoughts that in turn cause behaviors
that give a reprieve from those thoughts?