AUSTRALIAN CLINICAL PSYCHOLOGIST - ACPA · Australian Clinical Psychologist ! Volume 1, Issue 1, 2015 4! From the President Judy Hyde, PhD I would like to start this first message

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Australian Clinical Psychologist ! Volume 1, Issue 1, 2015 2

CONTENTS – Volume 1, Issue 1, January 2015

3 Editorial Kaye Horley

4 From the President Judy Hyde

6 The Role of Death Fears in Obsessive–Compulsive Disorder Ross G. Menzies, Rachel E. Menzies, and Lisa Iverach

12 Assessment and Treatment of Sexual Orientation Obsessions in Obsessive–Compulsive Disorder Monnica T. Williams, Ghazel Tellawi, Darlene M. Davis, and Joseph Slimowicz

21 Body Dysmorphic Disorder: Identifying and Treating an Invisible Problem Ben Buchanan

22 A Review of Body Dysmorphic Disorder after 20 Years of Research Fugen Neziroglu and Nicole Lippman

29 Thought Suppression in Obsessive–Compulsive Disorder Jessica R. Grisham and Melissa J. Black

36 Danger Ideation Reduction Therapy for Obsessive–Compulsive Disorder: A Brief Overview Mairwen K. Jones and Lisa D. Vaccaro

42 Biological Aspects of Obsessive–Compulsive Disorder Cathrin Kusuma, Malcolm Hopwood, and David Castle

47 Internet-Delivered Cognitive Behaviour Therapy (iCBT) for Obsessive–Compulsive Disorder Bethany M. Wootton and Gretchen J. Diefenbach

53 Development, Evaluation, and Implementation of an Online Metacognitive Therapy Program for Obsessive–Compulsive Disorder Caitlin Pearcy

58 Obsessive–Compulsive Disorder A Client's Perspective

60 Youth Corner Fiona Jamieson

60 "Not Just Right Experiences" in Childhood Obsessive–Compulsive Disorder Emily O'Leary

64 New Directions in Treatment for Obsessive–Compulsive Disorder among Young People An Overview of the OCD? Not Me! Online Treatment Program Clare S. Rees, Rebecca Anderson, and Amy Finlay-Jones

70 Body Dysmorphic Disorder in Adolescents Cynthia M. Turner and Beth O'Gorman

74 An Overview of Psychometric Measures for Obsessive–Compulsive Disorder Dixie Statham

77 Editorial Policy and Guidelines


EDITORIAL Kaye Horley, PhD Editor1 Welcome to our journal in the preliminary stages of its new inception. We will be continuing to publish scholarly papers for clinicians that are informative for clinical practice. As models for conceptualising obsessive–compulsive disorder (OCD) continue to evolve, the articles in this special edition address various facets of OCD, with several devoted to the associated body dysmorphic disorder (BDD). The obsessions commonly associated with OCD are generally based upon threat-relevant stimuli. An emphasis on death fears is expounded by Menzies, Menzies, and Iverach as underlying various OCD presentations. Many are obvious - for example, a compulsive washer's fears of contracting a fatal disease. Behaviours aimed at preventing harm are perceived as a response to this fear, and may be understood within a terror management framework. Illustrative cases and treatment options are provided. Sexual obsessions in OCD are well known; however, less well known are concerns associated with sexual orientation. The importance of recognition, along with cognitive behavioural treatment of this fear, is outlined by Williams, Tellawi, and Slimowicz. Obsessive preoccupation with imagined or slight defects in appearance are the hallmarks of BDD, considered a related disorder of OCD in the DSM-5 (American Psychiatric Association, 2013). A brief overview of the aetiology, presentation, focus on cosmetic consultation, diagnosis, and cognitive behavioural treatment of this under-recognised disorder is provided by Buchanan. Neziroglu and Lippman reveal the difficulties of diagnosis, and the core beliefs these individuals may have. They examine the effectiveness of treatments and consider the concept of overvalued ideation in this disorder. Treatment modalities and associated difficulties are explored. The study of the processes involved in obsessional thinking, and management of intrusive thoughts in OCD, is particularly challenging. Thought suppression is a common method of attempting to control the intrusive, distressing thoughts that are implicit in OCD. Evidence from the famous white bear experiment by Wegner (1989) is illustrative of the consequential difficulties encountered. A discussion exploring the implications of the experiment on effective treatment models is presented by Grisham and Blake. For those individuals who do not respond to standard psychological exposure and response prevention management, alternative treatments are necessary. A relatively new intervention strategy, developed in Australia and described by Jones and Vaccaro, is that of danger ideation reduction therapy. It is based on cognitive therapy that focuses on providing corrective information for

1Editor: [email protected]

treatment-resistant obsessive–compulsive checkers and washers. Biological treatments, such as pharmacotherapy, may be necessary for individuals with OCD who do not respond to conventional psychological therapy, particularly those with severe OCD. Kusuma, Hopwood, and Castle provide a brief summary of the current knowledge underlying the pathophysiology of OCD. This is followed by an overview of current OCD medications that distinguishes between first- and second-line medications, and charts their benefits and their risks. Consideration is also given to deep brain stimulation as a possible new treatment. New internet-based therapy (iCBT) offers much needed help for those to whom access to evidence-based treatment, such as exposure and response prevention, is difficult, or who are on a waiting list. Wootton and Diefenbach review the efficacy and associated difficulties of this innovative therapy. Online delivery of therapy for OCD was also the study of Pearcy's doctoral thesis, highlighted in our PhD spotlight. The study was based on the author's development and evaluation of an online interactive website that provides for self-help metacognitive therapy (MCT). The difficulties encountered by an individual with OCD are exemplified by Mike, who graphically writes about the intrusive obsessions and time consuming compulsions that significantly affected him and his family. Three papers in the Youth Corner specifically address OCD concerns in young people. In the first paper, an explanation of "not just right experiences" (NJREs) within OCD is given by O'Leary. Useful treatment techniques are considered. The second paper by Rees, Anderson, and Finlay-Jones presents an innovative online OCD program they recently developed to improve accessibility of services. The program stages, based on cognitive behavioural principles, are outlined, and demonstrated in an informative case study. The third paper by Turner and Gorman specifically examines BDD in adolescents, summarising the relevant literature and current treatment. Finally, an overview of various psychometric measures that may be used as a useful adjunct to the clinical interview is provided by Statham. Many thanks to the authors.

References American Psychiatric Association. (2013). Diagnostic and

statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

Wegner, D. M. (1989). White bears and other unwanted thoughts. New York, NY: Viking/Penguin.


From the President Judy Hyde, PhD I would like to start this first message for 2015 to Members with an expression of great gratitude to the Board of ACPA for all ongoing work undertaken last year with such commitment, dedication, and mutual support. It is with great sadness that we said goodbye to Ms Suzanne Midford, who has been a committed and unfaltering member of the Board since 2011. Suzanne leaves us to manage her large private practice in Perth and her duties in the relatively new clinical psychology program at Charles Darwin University. Suzanne’s steady and thoughtful approach to the challenges we manage, her care and consideration of the potential outcomes of actions, and her vigilant review of all Board documents has been invaluable and will be very sorely missed. Suzanne’s presence on the ATAPS Committee has been invaluable; her presence on the Constitution Committee, gave representation to Western Australian members for whom this issue was most troubling. It was wonderful to see this work come to fruition at the AGM in Sydney in November. I would like to personally thank Mr Tony Merritt and the entire Constitution Committee for all the hard work undertaken to ensure the Constitution meets the needs of ACPA and its Membership going forward. This has been quite a task with ongoing consultation and feedback. When we started ACPA we were advised to simply put a Constitution together to enable us to operate, but we quickly outgrew and found flaws in what was developed. This new Constitution will take us forward on a very solid foundation. The most salient professional issue for ACPA in the near future is the submission to the Psychology Board of Australia (PsyBA) for specialist recognition of qualified clinical psychologists. Specialist recognition would undo the damage to clinical psychology as a result of the grandparenting into endorsement of their unqualified members of the College of Clinical Psychologists. We understand from the Chief Executive Officer of the National Mental Health Commission that this issue has been raised as problematic by other professional bodies whose members refer to psychologists and clinical psychologists. They rightfully complain of being unable to identify those clinical psychologists who have the appropriate qualifications, and are therefore struggling to make appropriate referrals. This poses a strong disadvantage to the public, who do not have the capacity to choose their clinical psychologist based on qualifications and training. We held many meetings over 2014 with other professional bodies whose members work in mental health and Government. Many submissions have been written, and changes brought about. The most outstanding issue currently is the registration standards for psychology. Two proposals put forward by the Australian Psychology Accreditation Council (APAC) have been considered entirely inadequate and unacceptable by the PsyBA and the

profession generally. With the reconstitution of APAC and a broader contributory base on the Board, of which two Directors are ACPA members, it is hoped that a proper, well founded, and strong proposal can be developed to move the profession closer to the international standards to which we aspire. Also outstanding are the difficulties that have arisen through the new Australian Qualifications Framework (AQF) that defines degree content for universities. This has placed professional Doctoral programs under exceptional pressure financially, leading to the demise of several internationally equivalent Doctoral programs, such as the one at the University of Sydney. ACPA awaits an opportunity to submit to the review of the AQF in what appears to be a year's time. For ACPA itself, 2013–2014 was a year of consolidation, extension, and growth. Membership grew by over 50%. A large focus of ACPA is providing benefits to Members. Student Membership has been enhanced by the waiver of fees, and Associate Membership by free AHPRA compliant insurance for those undertaking Registrar programs who have a qualified clinical psychologist as a supervisor. Insurance House Group approached ACPA with this generous offer in recognition of the value and quality of training of clinical psychologists. These new members of the profession have also strongly taken up the ACPA Mentorship program.

All members are benefitting from the free monthly Continuing Professional Development (CPD) recordings and the general sharing of resources through the ACPA listserv, website, and free access to EBSCO journals. The ACPARIAN has provided clinically focussed articles written by expert clinicians for all mental health professionals. The ACPARIAN transforms in its current edition to the Australian Clinical Psychologist in recognition of its developing format as a peer reviewed journal.

2014 saw the further strengthening and development of the Victorian Section Committee and the formation of the NSW and Queensland Section Committees. This is a credit to Section Chairs Carol Hulbert, Alice Shires, and Lee Kannis-Dymand. It is wonderful to see member benefits being brought to these States locally. A new Section Committee in Western Australia is currently being launched.

On a personal level, the formation of the Student Section, led by students at the University of Sydney and chaired by Ms Phoebe Lau, was incredibly gratifying. Those of us who have worked so hard to establish and administer ACPA see our Student Members as the future of ACPA and the profession. ACPA will support these new members in every way we can to enhance the experience of clinical psychology trainees nationally.


I also would like to thank the Members who work so tirelessly for ACPA on our working committees: The Finance Committee, Membership Committee, Editorial Board, CPD Committee, Medicare Taskforce, ATAPS Committee, and our Events Committee. Our working committee members are rarely acclaimed, but most deserving of our great appreciation, respect, and gratitude. Also, our appreciation goes to our administrative staff members who, quietly in the background, keep ACPA operating for us.

Most of all, our gratitude also goes to you, our members, who make it all worthwhile and who give meaning and reason for all we do. I hope to see you at the 2015 conference in Hobart, Tasmania on 14–15 November where there will be presentations and workshops on complex trauma. We also look forward to celebrating five years of operation of ACPA with you through various initiatives designed to enhance the ACPA experience and reward our membership.


The Role of Death Fears in Obsessive–Compulsive Disorder

Ross G. Menzies, PhD1, Rachel E. Menzies1, and Lisa Iverach, PhD2

1 University of Sydney, Australia 2 Macquarie University, Australia

Abstract Death anxiety is considered to be a basic fear that may underpin a range of psychiatric conditions. The present paper proposes that the dread of death is a central driver of most presentations of obsessive–compulsive disorder (OCD). Compulsive washers often identify chronic or fatal diseases, such as HIV, as being associated with their anxiety, and with their behavioural responses to threat cues. Avoidance of perceived toxins, poisons, heavy metals, and bodily fluids of strangers is commonplace in the condition. Similarly, compulsive checkers typically report the prevention of fire, home invasion, and the subsequent death of the self and loved ones as the driving force behind their behaviours. Even the atypical compulsive cases, which may be dominated by tapping, blinking, magical numbers, and counting sequences, usually involve a stated attempt to prevent harm or death to a loved one. Therefore, the present paper explores the role of terror management theory and experimental existential psychology in understanding death anxiety. Research evidence implicating death anxiety in OCD is presented, and two illustrative cases are described. Finally, implications for treatment and future research directions are examined. It is argued that cognitive behaviour therapy outcomes in OCD could be enhanced by the addition of procedures drawn from acceptance and commitment therapy, dignity therapy, and meaning centred therapy. 2 Awareness of mortality and fear of death can be found throughout recorded history (Eshbaugh & Henninger, 2013; Furer & Walker, 2008). According to Yalom (2008), humans are the only creatures to be "forever shadowed by the knowledge that we will grow, blossom, and inevitably, diminish and die" (p. 1). Although humans are generally believed to have developed adaptive coping mechanisms for death anxiety, life stressors and threats to the health of self or loved ones can sometimes result in pathological or maladaptive coping strategies (Kastenbaum, 2000; Yalom, 1980, 2008.) As such, death anxiety is argued to be at the root of the development and maintenance of numerous psychological disorders (Arndt, Routledge, Cox, & Goldenberg, 2005; Furer & Walker, 2008; Iverach, Menzies, & Menzies, 2014; Menzies, 2012; Strachan et al., 2007). Evidence suggests that most presentations of obsessive–compulsive disorder (OCD), in particular, may be accounted for by death anxiety.

Terror Management Theory Terror management theory (TMT) is based on the work of Ernest Becker (1973), and is arguably the leading theoretical approach to death anxiety (Greenberg, 2012). Becker proposed that the human motivation to live, coupled with the knowledge that death is inevitable, can induce a crippling fear of death. TMT can be understood as a "social psychological theory that draws from existential, psychodynamic, and evolutionary perspectives to understand the often potent influence that deeply rooted concerns about mortality can have on our sense of self and social behaviour" (Ardnt & Vess, 2008, p. 909). In an attempt

2 Acknowledgments: This paper was supported in part by a grant (#1052216) awarded to the third author by the National Health and Medical Research Council of Australia.2 Corresponding author: [email protected]

to manage existential fear of death, the theory suggests that cultural worldviews and self-esteem serve to buffer against anxiety (Greenberg et al., 1992; Pyszczynski, Greenberg, & Solomon, 1999). Cultural worldviews are shared, and symbolic concepts of the world are believed to provide a sense of permanence and meaning, such as one's belief in an afterlife (Greenberg, 2012). Similarly, self-esteem emerges through the belief that one is fulfilling the expectations and values of the cultural worldview. Accordingly, TMT suggests that when an individual's worldview is threatened, they are likely to feel anxious and to defend against these threats in order to maintain self-esteem, regain psychological stability, and uphold faith in their cultural worldview (Greenberg, 2012; Hayes, Schimel, Arndt, & Faucher, 2010). TMT provides a powerful framework through which to view death anxiety. It proposes that the emergence of death-related thoughts in conscious awareness triggers various proximal and distal defence mechanisms (Pyszczynski et al., 1999). Proximal defences can include denial of vulnerability to mortality, as well as strategies involved in the maintenance of physical health for self or loved ones (Pyszczynski et al., 1999). However, when death-related thoughts have slipped out of conscious awareness, distal defences are triggered. Distal defences are unconscious and symbolic in nature, and include strategies to protect the symbolic self, such as upholding cultural worldviews and shared identities, and assuring oneself that one will not be forgotten after death (Pyszczynski et al., 1999). TMT has much in common with experimental existential psychology, an area which focuses on rigorously investigating the effects of existential concerns on human cognition and behaviour (Fiske, Gilbert, & Lindzey, 2010; Greenberg et al., 2004; Pyszczynski et al., 2010; Yalom, 1980). According to this theoretical approach, human beings are forced to manage five major existential concerns: death,


freedom, isolation, identity, and meaning (Greenberg et al., 2004; Koole et al., 2006). These concerns are believed to have a pervasive impact on behaviour, even when outside conscious awareness (Pyszczynski et al., 2010). Within experimental existential psychology, a substantial number of experimental studies have used a mortality salience paradigm to evaluate terror management defences against death anxiety (Koole et al., 2006). These studies have provided strong evidence that existential concerns have a pervasive, and usually unconscious, effect on human behaviour (Koole et al., 2006). These findings support the tenets of TMT (e.g., McGregor et al., 1998), and confirm the potential for mortality salience and death fears to significantly influence human behaviour.

Death Anxiety and OCD While death anxiety may play a significant role in a range of psychological conditions, its pervasive nature is perhaps most clearly apparent in OCD. The two dominant subtypes of OCD, in terms of prevalence, involve compulsive washing and compulsive checking (Krochmalik & Menzies, 2003). Many compulsive hand washers identify chronic or fatal diseases, such as HIV, as being associated with their anxiety and behavioural responses to threat cues (Jones & Krochmalik, 2003; St Clare, Menzies, & Jones, 2008). Avoidance of perceived toxins, poisons, heavy metals, and bodily fluids of strangers is commonplace in the condition (Jones & Krochmalik, 2003). Similarly, compulsive checkers often report the prevention of fire, home invasion, and the subsequent death of the self and loved ones (including pets) as the driving force behind their behaviours (Vaccaro, Jones, Menzies, & St Clare, 2010). Indeed, compulsive checking is dominated by the repeated inspection of power points, gas and electric cooktops, heaters, hair dryers, and door and window locks (Rachman, 2003). Checking behaviours may also include close examination of roads in a search for injured or dead bodies that the obsessional patient fears they have hit (Rachman, 2003). Even the atypical compulsive cases, which may be dominated by tapping, blinking, magical numbers, and counting sequences, usually involve a stated attempt to prevent harm or death of a loved one (Einstein & Menzies, 2003). Similarly, the stated fear of 'harm' or 'aggressive obsessional' patients is typically that they may 'snap' or otherwise inadvertently assault or murder a loved one or stranger (Einstein & Menzies, 2003). Thus, on the basis of verbal reports from OCD sufferers, the major subtypes of OCD can be readily reduced to the dread of death. Laboratory research also appears to support the conclusion that death fears underpin obsessional thoughts and compulsive behaviours. Much of the relevant experimental work to date has been conducted with compulsive washers. In a study conducted by Strachan and colleagues (2007), participants who scored high on compulsive hand washing spent more time washing their hands, and used more paper towels to dry their hands, following mortality salience induction (i.e., being asked questions concerning their own eventual death). Similarly, Jones and Menzies (1997a) have argued that washing behaviour is driven by the anticipation of disease severity and, ultimately, of death. In a laboratory 'contamination' experiment, participants placed their hands into a mixture of

potting soil, animal hair, and food scraps. Following this, they were asked to rate their expected severity of illness on a scale ranging from 0 (no symptoms) to 100 (death). The findings revealed that obsessive–compulsive washers gave significantly higher estimates of both 'probability of illness' and 'severity of illness' ratings. In addition, high positive correlations were found among anticipated severity of illness and anxiety, urge to wash, and time spent washing. Further, when illness severity ratings on the single item "death" scale were held constant, no other mediator (e.g., perfectionism, inflated perceived responsibility) remained significantly related to OCD phenomena. Based on these results, Jones and Menzies (1997a) argued that expectancy of disease drives washing behaviour. Providing further support for this proposition, Jones and Menzies (1997b) found that 6-12 sessions of cognitive therapy specifically targeting illness expectancy, without any exposure or ritual prevention, was able to return those suffering with severe OCD to relatively normal functioning. This treatment program is known as danger ideation reduction therapy (DIRT), and various studies and research paradigms have demonstrated its efficacy (Govender, Drummond, & Menzies, 2006; Hambridge & Loewenthal, 2003; Jones & Menzies, 1997b; Jones & Menzies, 1998; Jones & Menzies, 2002; Krochmalik, Jones, & Menzies, 2001; Krochmalik, Jones, Menzies, & Kirkby, 2004; O'Brien, Jones, & Menzies, 2004; St Clare, 2004; St Clare et al., 2008). These findings further suggest that illness expectancy and associated existential concerns play a causal role in the development and presentation of OCD washing. OCD is, of course, a complex disorder. Individuals with OCD rarely present with 'pure' washing. More typically, they present with a range of comorbid conditions, including panic disorder, illness anxiety disorder, separation anxiety disorder, major depression, and somatoform disorders (Krochmalik & Menzies, 2003). This complexity suggests that transdiagnostic constructs may underpin a range of related problems. Iverach et al. (2014) argue that death anxiety can potentially account for much of the commonality in thinking and behaviour across these disorders. In line with this, two brief case reports will be used to demonstrate the core role of death anxiety in complex presentations.

Illustrative Cases Case 1 Julie, a 23-year-old student, presented with a long history of separation anxiety, substance abuse, OCD, panic disorder, illness anxiety disorder, and major depression. She had received a diagnosis of bipolar disorder after a private hospital admission in 2008, but neither her current psychiatrist nor the first author could find evidence of mania in her history. Although panic and hypochondriasis had dominated her presentation in earlier years (with repeated visits to the GP and emergency department), she was presently plagued by aggressive and magical obsessions. She reported images of harming herself in a variety of ways. Her thoughts were dominated by such ideas as: "I might jump off this balcony against my will", "I'll just lose control and do it because of the images", "I'll get confused and think the


images are my intent", and "I think I like the images". She also had the notion that she could already be dead: "What if I've already jumped off the balcony and I'm not really here?" She saw similarities between her fear and the plot of the film, The Sixth Sense, in which the protagonist is dead, but is unaware of this fact. She had partial insight into the irrationality of her fears, but this seemed to vary markedly from session to session. Julie had read extensively in 'eternalism', which she explained as a philosophy of time. In eternalism, all points in time are equally 'real', and time is said to have a similar ontology to space, with future events 'already there'. That is, there is no objective flow of time. According to eternalism, the ticking of a clock is said to measure the duration between events, as a ruler measures the distance between locations. Julie couldn't explain her fascination with eternalism, although she declared that it was a sound position. She wanted to extend her reading on the topic. Julie was a volunteer with two wildlife organisations. Her role involved caring for injured animals. In her home she regularly had large numbers of animals she was slowly preparing for return to the wild. She also had to regularly attend road-side accidents, often holding animals at the point of death: "Someone has to be with them when they pass". She seemed both disturbed and deeply moved by the moment of the loss of life. Most recently, Julie had become concerned about the possibility of sudden death from shock. She claimed to have witnessed this occur in animals. She spent many weeks searching on the internet for evidence that this could happen to humans. She became particularly concerned after reading the following report in The Daily Mail, a British newspaper:

Like most children her age, Jennifer Lloyd loves watching her favourite programmes on TV. But when a scary bit is about to happen the ten-year-old has to leave the room quickly - because the sudden shock could kill her. Jennifer is one of just six known sufferers of polyglandular Addison's disease, which causes her to become ill whenever she is surprised or shocked. The condition means she is unable to produce adrenaline in response to alarm or any sudden form of emotional or physical stress. Instead her body goes into shock and her organs could shut down unless she receives medical treatment. It means Jennifer can only watch television with the permission of her parents, who also watch with her then ensure she leaves the room if they fear something startling is about to happen" (Narain, 2008, February 6).

Julie had also become concerned about the possibility that her dreams could harm her. She reported that, after a dream involving a physical assault, she had awoken with pain in the bodily region that had been struck in the dream. She began ruminating about the possibility that her body would respond to pain in a dream with actual tissue damage. Her fears had arisen from watching the film, The Matrix, in which several individuals die from injuries sustained in a simulated world.

Treatment emphasised the link between Julie's various presentations from age 6 to 23 years. The formulation was centred on a deep fear of death that was first apparent in separation fears, followed by health anxiety, panic attacks, and then aggressive obsessions (i.e., the fear that "if nothing else is going to kill me, my own actions may bring about my greatest fear"). Her recent 'death by shock' and 'pain after I dream' experiences were presented to Julie as simply creative roads to death that her mind was conjuring up. Her interests in eternalism and assisting injured animals were presented within the same formulation. In addition to standard exposure and ritual prevention, treatment also involved writing short versions of her 'stories' as creative pieces, and finding her ideas in film and literature. Julie's magical and aggressive obsessions resolved after 12 sessions. Case 2 Peter, a 55 year old public servant, presented with a long history of panic disorder, OCD, generalised anxiety disorder, and, more recently, major depression. His panic attacks had begun in his teens and had been associated with fear of sudden death. He was convinced that he had heart problems at the time. He was treated successfully at a major hospital anxiety disorders clinic. His obsessional problems had begun in his 30s; they centred on handwashing (in response to contamination fears), power point and stove checking (in response to fears of fire), and tapping/blinking rituals (in response to magical ideation concerning 'something bad' happening if he failed to perform the behaviours). He had returned to the previous treatment centre and had been somewhat responsive to standard cognitive behaviour therapy (CBT) for anxiety issues. Peter had fallen into a depressive episode in recent years, following the death of his mother. At our first session, he wondered whether his depression was related to mortality. His mood was chronically low and he experienced regular tearfulness, fatigue, and a general sense of pointlessness. He did not drink or smoke ("I wouldn't do that to my body"), and did not exercise (for fear of raising his heart rate). His appetite was moderately impaired but his libido was intact. On the Depression Anxiety Stress Scales (DASS-21; Lovibond & Lovibond, 1995) he scored in the 'extremely severe' band for depression, and the 'moderate' band for anxiety and stress/tension. The only activity that continued to give him pleasure was photography. In particular, he reported night excursions into an isolated parkland "to capture moments that would never be seen again". He used only natural light (e.g., lightning, moonlight) and would stay out all night in an attempt to freeze "interesting moments in time". Peter responded well to a CBT program that included: (1) cognitive restructuring; (2) activity scheduling (including an increase in hours dedicated to photography); (3) daily exercise; (4) reduction to a 0.6 appointment in his administrative role; (5) exposure and ritual prevention; (6) DIRT for washers and DIRT for checkers; and (7) behavioural activation. Peter's DASS-21 profile normalised over 8 weeks, his washing returned to community standards (i.e., 8 x 7 second washes per day), his checking rituals were eliminated, and his magical behaviours (e.g., foot tapping) improved but


were not eliminated. He left treatment 4 months after initial assessment. Peter returned to treatment four years later. Although older, he looked at least 10 years younger. He had lost weight, coloured his hair, bought new 'younger men's' clothes (e.g., black jeans, tight t-shirt, black belt), and was a regular at the gym. Despite these positive changes in his life, his mood was low again. He became tearful in the clinic and had difficulty explaining his current condition. He had maintained the positive aspects of his earlier life changes and kept up his photography. However, he still felt stuck:

Do you know, I can't even see the subjects of my photography in the present … it takes eight minutes for light to travel from the sun … everything I see is in the past … I am imprisoned in the past … I can never know the present.

In uncovering the happiest time period in his life, he referred to working on efforts to save environmental landmarks in various states. Peter argued that "making a meaningful contribution is the only way I can beat death". In addition to his previous CBT program, Peter was set various tasks to assist him with his death and existential issues, including: (1) reading Yalom's (2008) Staring at the Sun: Overcoming the Dread of Death; (2) identifying tasks that could satisfy the dual concerns for 'meaning' and 'permanence' (e.g., he had begun working on a photo book of his local National Park); and (3) reading the values-based sections from Hayes & Smith (2005) Get out of Your Mind and Into Your Life. Peter's mood has again normalised. Most notably, for the first time in nearly 30 years, his foot tapping rituals and related 'magical' behaviours have stopped.

Treatment Options and Future Directions Several therapies may be applied in the treatment of death anxiety and OCD. Existential psychotherapy, developed by Yalom (1980), focuses on existential concerns including isolation, fear of death, and a lack of meaning. These fears are addressed across various clinical presentations, and the defensive structures surrounding this anxiety are examined. Existential psychotherapy has been used in the treatment of a range of psychological disorders (Goldner-Vukov, Moore, & Cupina, 2007; Randall, 2001; Stalsett, Gude, Ronnestad, & Monsen, 2012). Other existential-humanistic therapies that appear to be successful in treating death anxiety in end-of-life care include dignity therapy, meaning-centred therapy, and cognitive-existential group therapy (Barrera & Spiegel, 2014; Breitbart et al., 2000; Chochinov et al., 2004; Kissane et al., 2004). These therapeutic approaches focus on increasing a sense of meaning, psychosocial support, and improving dysfunctional or maladaptive behaviour patterns. In particular, there appears to be promising evidence for the use of dignity therapy in treating anxiety and depression among patients nearing the end of life (Johns, 2013). Dignity therapy has also been applied in the treatment of major depressive disorder (Avery & Baez, 2012), indicating its potential application across a range of psychological disorders. Meaning-centred therapy has also been shown to alleviate depression and hopelessness among the terminally ill, suggesting that an

emphasis on meaning and spiritual wellbeing may improve psychological outcomes (Breitbart et al., 2000). These existential therapeutic approaches may also inform other paradigms in the treatment of death anxiety. For example, CBT may benefit from the contextual base offered by existential therapies, and an integration of the two approaches has been encouraged (Ottens & Hanna, 1998). It has been argued that this complementary approach, aiming to increase agency, self-esteem, and meaning, may assist in the alleviation of anxiety and broader psychopathology (Maxfield, John, & Pyszczynski, 2014). Traditional elements of CBT have been employed in the treatment of death anxiety across various psychological disorders (Ottens & Hanna, 1998), applying exposure therapy, systematic desensitisation, and cognitive reappraisal to death anxiety and hypochondriasis (Furer & Walker, 2008; Hiebert, Furer, McPhail, & Walker, 2005). In particular, Hiebert and colleagues (2005) reported significant reductions in both hypochondriacal symptoms and death anxiety following group CBT, compared with a waitlist control condition, suggesting that CBT is a promising paradigm for death anxiety. Further controlled studies are needed to establish the efficacy of this therapeutic approach in reducing death anxiety (Furer & Walker, 2008), particularly among individuals with OCD.

In addition, the efficacy of acceptance and commitment therapy (ACT) and its impact on death fears should also be explored. ACT includes various tasks with an explicit focus on death, including writing differing versions of one's own eulogy, as well as the text for one's own tombstone (Hayes & Smith, 2005). It also focuses on the identification of values which may assist in leading a purposeful life and in clarifying meaning (Waltz & Hayes, 2010). In this way, ACT may offer those with death fears additional therapeutic value over traditional CBT tasks. Future studies are necessary to evaluate the efficacy of ACT's broader focus on impermanence and meaning in the treatment of death anxiety, OCD, and related conditions.

Conclusion

Death anxiety is a uniquely human dilemma and a central therapeutic issue in OCD. The present paper has shown that the majority of obsessional presentations can be readily linked to the dread of death. Perhaps most importantly, death anxiety appears to be a transdiagnostic construct that underpins a range of disorders and explains high levels of comorbidity across particular types of conditions (for further discussion, see Iverach et al., 2014. This raises a range of important issues. For example, can these disorders be successfully treated without addressing the underlying fear of death? Is it possible that death anxiety is responsible for the 'revolving door' effect that we so often see in mental health services? That is, are patients with a complex history of disorders (e.g., separation anxiety disorder in childhood, illness fears in early adolescence, panic disorder in late adolescence, OCD in adulthood) simply displaying manifestations of an underlying fear of death? For these reasons, it is suggested that research focus on the treatment of death anxiety may significantly impact the outcomes across a range of mental disorders, including OCD.


References Arndt, J., Routledge, C., Cox, C. R., & Goldenberg, J. L. (2005).

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Assessment and Treatment of Sexual Orientation Obsessions in Obsessive–Compulsive Disorder

Monnica T. Williams, PhD1, Ghazel Tellawi, MA1, Darlene M. Davis, MA1, and Joseph Slimowicz, MA2

1 University of Louisville, USA

2 Nova Southeastern University, USA Abstract Sexual orientation obsessions in OCD (SO-OCD) are common but under-recognised and frequently misdiagnosed. SO-OCD may include worries of experiencing an unwanted change in sexual orientation, fears that others may perceive one as a member of the lesbian, gay, bisexual, transgendered (LGBT) community, or fear that one has hidden same sex desires. The phenomenology of SO-OCD is described and contrasted with internalised homophobia/heterosexism. Examples of SO-OCD and related obsessions and compulsions are provided. Cognitive behavioural treatment of SO-OCD with exposure and ritual/response prevention (Ex/RP) is described using psycho-education, in vivo exposure, imaginal exposure, and ritual/response prevention, along with mindfulness/acceptance approaches. Due to the extreme distress caused by sexual orientation symptoms, it is important that clinicians properly identify and treat this manifestation of OCD. 3 Obsessive–compulsive disorder (OCD) is estimated to occur in approximately 2% of the general population (Kessler et al., 2005; Ruscio, Stein, Chu, & Kessler, 2010), and generally includes both obsessions and compulsions, resulting in significant distress and interference with daily activities. OCD is highly heterogeneous, as both obsessions and compulsions come in many different forms; therefore, each individual's symptom presentation may be different (Williams, Mugno, Franklin, & Faber, 2013).

Sexual Orientation Themed Obsessions

Much research has been conducted on primary symptom presentations that involve checking and contamination concerns (Ball, Baer, & Otto, 1996); however, obsessions surrounding sexual thoughts have received little attention. Approximately 10.5% of those seeking treatment for OCD report sexual obsessions as their primary symptom (Foa et al., 1995). Sexual orientation obsessions are a type of sexual obsession that includes worries over experiencing an unwanted change in sexual orientation, fears that others may perceive one as a member of the lesbian, gay, bisexual, transgendered (LGBT) community, or fears that one has hidden same sex desires (Williams, 2008). Lifetime rates for sexual orientation obsessions in OCD (SO-OCD) are 9.9% and 11.9% among research and treatment-seeking populations, respectively (Pinto et al., 2008; Williams & Farris, 2011). Compared to others with OCD, people with SO-OCD spend significantly more time obsessing, experience more interference from obsessions, experience greater distress from the obsessions, and have increased avoidance behaviours (Williams & Farris, 2011). Despite experiencing

3 Acknowledgements: Chad Wetterneck, PhD for his helpful contributions to an earlier version of this manuscript, and Claire Lewis for editing assistance. Corresponding author: [email protected]

greater dysfunction, there is no difference in level of insight exhibited by clients concerning the reasonableness of their obsessional concerns, but people with sexual obsessions may have greater suicidal ideation and experience greater treatment duration than people with other types of OCD (Grant et al., 2006; Williams & Farris, 2011; Williams, Wetterneck, Tellawi, & Duque, 2014). A case study of this specific type of OCD found that exposure and ritual prevention was effective (Ex/RP; Williams, Crozier, & Powers, 2011). SO-OCD is often included in the broader symptom category of unacceptable/taboo thoughts (e.g., Pinto et al., 2008) or autogenous symptoms, which are egodystonic and come to mind abruptly, without an identifiable trigger (Lee & Kwon, 2003). It was previously believed that people with this type of OCD did not have compulsions, but were considered "pure obsessional" (e.g., Baer, 1994). However, recent work has found that unacceptable/taboo thoughts like SO-OCD tend to be most strongly correlated with mental compulsions, the need for reassurance, and checking (Williams, Farris, et al., 2011).

Sexual Orientation Themed Compulsions Compulsions associated with SO-OCD may be cognitive, behavioural, or physiological. Mental compulsions, or rituals, include a wide array of cognitive acts (e.g., mental repetition of special words, mental reviewing, mental undoing). Reassurance seeking within the context of SO-OCD may involve checking with others for reassurance, self-assurance, searching the internet for answers, or the need to confess sexual orientation concerns to others (Williams, 2008; Williams, Farris, et al., 2011). This ritual is not often identified or recognised by clients and can be a particularly troubling symptom for those living with the OCD sufferer, as repeated demands for assurance can contribute to family stress (Calvocoressi et al., 1995). Reassurance seeking from partners may mirror the reassurance seeking of individuals with more


general obsessions about their relationship (Moulding, Aardema, & O'Connor, 2013). Similarly, an individual may engage in physiological checking or somatic checking. A person with SO-OCD may check for signs of sexual arousal when around people of the opposite sex to ensure their heterosexuality, or they may check for signs of non-arousal when around people of the same sex to ensure they have not become LGBT (e.g., Williams, Crozier & Powers, 2011). These testing behaviours can then increase obsessions, as a person may actually experience momentary arousal in response to checking behaviours (Moulding et al., 2013).

Avoidance Like compulsions, avoidance maintains the disorder and contributes to dysfunction (e.g., Starcevic et al., 2011). People with SO-OCD may avoid situations that provoke the unwanted thoughts, such as gym locker rooms, movies with same sex themes, or even people perceived to be members of the LGBT community. They may avoid dating or sexual activity out of concerns that failure in these endeavours will only prove their fears.

Assessment of Sexual Orientation Symptoms in OCD Assessing SO-OCD using clinical measures can be difficult, especially if obsessional concerns are restricted to sexual orientation. Few screening instruments specifically address sexual orientation obsessions (Williams, Slimowicz, Tellawi, & Wetterneck, 2014); however, these instruments are still valuable as SO-OCD clients often have obsessive–compulsive symptoms in other areas as well. Measures such as the Yale-Brown Obsessive–Compulsive Scale (Y-BOCS; Goodman et al., 1989) can be important tools in gaining a comprehensive picture of OCD symptomology; however, the Y-BOCS checklist and its successor, the Y-BOCS-II (Storch et al., 2010), have only one question about sexual orientation fears. Therefore, the Y-BOCS cannot be used as a standalone measure to assess these obsessions. The assessment of OCD in a clinical interview is when sexual orientation obsessions first come to the attention of most clinicians. In some cases, clients may not share their sexual orientation concerns due to shame or catastrophic fears; others may have sought reassurance from numerous clinicians, and, therefore, it is important to inquire about consultations with other clinicians. Typically, the distress experienced by the client is not related to actual events, but is instead attached to worries about loss of identity as a heterosexual individual—something that is highly valued. The person may fear that the sexual life they have enjoyed (or may someday enjoy) will be suddenly taken away and replaced with something foreign and unappealing (Williams, 2008).

Differential Diagnosis Differential diagnosis is important, since mental health professionals who do not typically treat OCD clients may attribute the symptoms to an unconscious wish, emerging homosexuality, or difficulties with sexual identity formation (Williams, 2008). A recent study assessed clinicians'

abilities to correctly identify common symptom presentations of OCD (Glazier, Calixte, Rothschild, & Pinto, 2013). Members of the American Psychological Association from each state were randomly selected to participate, and each was assigned to one of five OCD symptom vignettes. When asked to provide a diagnostic impression, 77% misidentified the vignette on obsessions about sexual orientation and classified the problem as sexual identity confusion. SO-OCD is not the same as ambivalence towards one's sexual orientation (Gordon, 2002). LGBT individuals who have negative feelings about their sexuality may have internalised homophobia/heterosexism (IH; Szymanski, Kashubeck-West, & Meyer, 2008), and these worries may overlap with SO-OCD. People with IH and individuals with SO-OCD may both fear that LGBT identity represents an end to lifelong dreams of a more socially desirable lifestyle, a traditional wedding, or raising a family (Williams, 2008). Both groups may suffer from anxiety, depression, and low self-esteem, and both may share concerns about being accepted by others (Meyer, 2003). Nevertheless, a person with IH usually has some positive feelings about LGBT identity and will enjoy same sex fantasies, whereas a person with SO-OCD dreads such thoughts and finds them intrusive (Gordon, 2002). People with SO-OCD generally see no consistency between homosexuality and their actual sexual desires. However, it should not be assumed that people with SO-OCD are homophobic/heterosexist, since people with SO-OCD have a wide range of feelings about homosexuality. Additionally, it is possible for LGBT individuals to have unwanted OCD-related sexual orientation obsessions as well (e.g., Goldberg, 1984).

Treatment of SO-OCD Cognitive Behaviour Therapy Ex/RP has emerged as a behavioural treatment of choice for OCD, with an extensive body of literature to support its efficacy (Abramowitz, Whiteside, & Deacon, 2005; National Institute for Health and Clinical Excellence, 2005; Rosa-Alcazar, Sanchez-Meca, Gomez-Conesa, & Marin-Martinez, 2008). Below, we review the critical components of Ex/RP and how these are relevant for SO-OCD, and then we discuss mindfulness and acceptance-based approaches that supplement Ex/RP. Psycho-education. Psycho-education provides a rationale for the nature of treatment to be provided and socialises the client into the treatment process. A general discussion regarding the functional relationship between obsessions and compulsions should be provided to broadly inform individuals about how OCD is maintained. Next, a discussion of the frequency and nature of the sexually intrusive thoughts within both the general and the clinical population is helpful to normalise the intrusive thoughts. Sexually intrusive thoughts, including those with same sex themes, are common not only in OCD populations, but also in the nonclinical general population (Renaud & Byers, 1999). Thus, sexual thoughts that are LGBT in nature are normative and should not be taken as an indicator of


LGBT sexual identity. Similarly, just as heterosexual individuals may experience thoughts with gay or lesbian thematic content, gay or lesbian individuals may also experience intrusive thoughts with heterosexual content (e.g., Goldberg, 1984). Individuals with SO-OCD may often erroneously equate sexual arousal with romantic attraction. Addressing this distinction and educating clients on the nature of physiological arousal as something that may be unconnected to actual desire may assist them in placing physiological arousal cues in the appropriate context. Finally, individuals should be introduced to the pragmatic aspects of treatment, including the use of the Subjective Units of Distress Scale (SUDS; Wolpe, 1969). Situations listed are ranked from least to greatest, as measured by the client's reported SUDS, with numbers ranging from 0 (no anxiety, calm) to 100 (very severe anxiety, worst ever experienced). Clients start in a challenging but manageable area and then work up to the top of the hierarchy. The use of SUDS ratings allows both the client and therapist to quickly assess perceived levels of distress during the implementation of exposures and monitor progress within and across exposure trials. In vivo exposures. In vivo exposures should be tailored to the primary obsessional concern and core fear underlying a client's concerns (Brauer, Lewin, & Storch, 2011).

Common SO-OCD fears include doubting one's sexual orientation, having same sex romantic experiences, and the fear that others perceive one as having a different sexual orientation. In an in vivo exposure, the therapist and the client work collaboratively to identify specific obsessional triggers to complete the hierarchy and rank each item based on projected SUDS levels. Each client's hierarchy will be somewhat different (see Table 1 for a hierarchy developed for a woman with SO-OCD concerns). When implementing exposures, the therapist should start at a lower or a mid-range SUDS point on the hierarchy (i.e., SUDS rating of 50) and guide the client through the exposure during the session. For example, a therapist might elect to start with item #3 ("Political story about LGBT rights") in the session by providing a politically themed article on LGBT rights and instructing the client to read the article aloud, while monitoring for avoidance behaviours or covert rituals. Generally, the exposure should continue for 30 to 60 minutes, or until the client's SUDS has decreased by at least half. If the exposure does not evoke a SUDS above 50, or the client habituates after only a few minutes, the therapist may make the exposure more challenging or move to the next item. The in-session exposures are then assigned as daily homework, which will allow the client to practise completing the exposures independently and promote greater generalisation across various environments.

Table 1 Hierarchy for a Female Client with SO-OCD

Exposure SUDS

1 Touch women shoulder to shoulder 30

2 Looking at own breasts 35

3 Political story about LGBT rights 40

4 Being around women 50

5 Looking at a picture of attractive woman with clothing on 50

6 Seeing someone breastfeed 50

7 Looking at masculine / "butch" females 60

8 Seeing women in low-cut tops/ short skirts 70

9 Talking to lesbian women 70

10 Wearing a Gay Pride bracelet 70

12 A man and woman kissing 75

13 Imaginal exposure of sexual encounter with a woman 75

14 Looking at sexy Asian women 80

15 Hearing "coming out" stories 80

16 Go to a LGBT club/bar 80

17 Pictures of bare breasts 85

18 Lesbian/gay themed shows/movies (e.g., "The L word") 90


After mastery and competency of lower-level items has been obtained (as demonstrated by between-session habituation accompanied by no ritualising), items rated higher on the hierarchy are selected for exposure. It is important to note that the actual achieved SUDS levels will vary depending on the context and elements of the exposure. For example, item #7 ("Looking at masculine / 'butch' females") may be associated with greater difficulty depending on the length of time the client must look at the individual or the setting in which they are looking at the person. Item #9 ("Talking to lesbian women") may be conducted by visiting a local gay bar, and the therapist may need to accompany the client initially. In this example, there may be differences in the SUDS rating depending on the location, the number of people in the bar, and how many lesbian women the client must engage in conversation. The client may be directed to interact with LGBT individuals while assuming a temporary LGBT identity (e.g., place themselves in the presumed mindset of an LGBT person and interact accordingly with others, wear clothing the client considers incongruent with her sexual identity). Imaginal exposures. Imaginal exposures are designed to allow clients to confront the feared catastrophe related to their obsessions that they generally could not otherwise confront. To conduct an imaginal exposure, the therapist and client develop a detailed story about the worst outcome of the client's obsession (Foa, Yadin, & Lichner, 2012). The story will describe a catastrophe that is a direct result of failing to perform rituals. The client is instructed to imagine the scenario as vividly as possible while being confronted with the narrative over and over. The exposure is typically recorded to facilitate repeated listening during the session and as homework (Abramowitz & Zoellner, 2002; Freeston, Leger, & Ladouceur, 2001). SUDS levels are assessed every five minutes to assure that the story is evoking enough anxiety to be productive. Box 1 presents an imaginal exposure for use in association with item #13 ("Imaginal exposure of sexual encounter with a woman") of our hypothetical client's hierarchy. Several different imaginal

exposures may be utilised throughout treatment, with varying catastrophic consequences. Imaginal exposure is particularly effective for those with OCD symptoms that involve a fear of changing in some way, such as the sexual orientation change involved in SO-OCD fears (Gillihan, Williams, Malcoun, Yadin, & Foa, 2012). Response/ritual prevention. Response prevention involves not engaging in the rituals used to decrease anxiety about an obsession. Response prevention serves to increase exposure time to the stimulus that provokes anxiety (Foa, Steketee, & Milby, 1980), and it is the conjunction of exposure and response prevention together that creates the most effective treatment for OCD (Foa, Steketee, Grayson, Turner, & Latimer, 1984). Similar to obsessions, rituals in SO-OCD can take many forms, such as reassurance-seeking. The client may ask the therapist, "Do you think I'm gay?", or seek reassurance from friends and family members. Response prevention would involve the client not indulging in self-assurance or seeking reassurance from others, while being exposed to stimuli that provoke anxiety related to SO-OCD. To help increase awareness of the behaviour the therapist should point out when the client is engaging in a ritual. Once it is clear that the client understands the behaviour is a ritual, the therapist may respond with an exposure statement, such as "You can never be sure " or even "You really are gay!" Individuals with SO-OCD also typically engage in a variety of mental rituals. This may involve thinking positive thoughts to neutralise negative ones. A client may also review or check their memories for times when they did not have SO-OCD concerns as a form of self-reassurance, or remembering when they were sexually attracted to an opposite sex partner. Response prevention would require the client to not engage in these mental rituals during exposures and in daily life. Because these rituals cannot be seen by the therapist, it is important to check in with the client about whether or not they are engaging in rituals during exposure exercises.

Box 1

Imaginal Exposure Script for Sexual Encounter with a Woman

I had been struggling with worries about my sexual orientation for a very long time, and doing all sorts of behaviours to make sure that I was not actually becoming gay. This included going back through my memory to be sure that there were no signs that I was a latent lesbian. I also was constantly checking myself for signs of interest around attractive men and women.

Through the course of getting treated for my OCD, I realised that I was not gay and that all of these behaviours were compulsions. I stopped doing all the rituals and just decided to live my life and let go of the worries. I would stop being vigilant for signs that I might change my orientation.

One day I was at a sports bar in Houston called Nick's Place. I was watching the world series of the White Sox versus the Astros. A young woman was sitting next to me at the bar and also cheering on my team. She was very beautiful, athletic, with long brown hair and stylish clothes. We started talking and noticed we both liked sports. Her name was Erica and she was also a doctor working at Memorial Hermann Hospital as a paediatric orthopaedic surgeon. It seemed too good to be true to find such an amazing woman that I could really connect with.

I was dating a guy named Ben at the time, and we had been on 10 dates. I really liked him and was thinking about having The Talk, but I found my thoughts drifting to Erica more and more. I decided I was not interested in Ben any longer. I just didn't feel that spark anymore and he was too agreeable. I can't really pinpoint what it is that I don't like and that bothers me. Maybe it is something about me.

I start hanging out with Erica, and I tell her all about Ben. I realise that I feel nervous talking about him because I have a bit of a crush on her. She shares with me that she thinks I should dump Ben for someone who will really know how to love me. I feel the same way, and we start kissing. Eventually one thing leads to another and we are having sex all the time. I spend the night at her place on weekends. I really enjoy our new relationship and realise that I am a lesbian and have been all along. I think if I had kept doing compulsions I would have never discovered this exciting part of who I am.


Clients who have been practising covert rituals for some time may believe it is impossible to simply stop.

Therapists should emphasise that change is a process. Clients should simply do their best, and, as they continue to practise, they will become better at resisting. Clients may also have difficulty distinguishing obsessions from mental rituals. Clinicians can help identify mental rituals by determining the mental processes that the client employs after having an obsessive thought (Gillihan et al., 2012). Another way to teach clients how to distinguish obsessions from mental rituals is to determine the function of their thoughts: obsessions increase anxiety, while compulsions are designed to reduce anxiety. It may be helpful to have clientssubstitute their mental rituals with exposure statements, such as "I am a lesbian," to prevent engaging in those rituals. If a client does engage in a mental ritual, the therapist can encourage the client to re-expose themselves to the anxiety-provoking stimulus to cancel the anxiety-reducing effects of the ritual. The client should not usestatements like "That is my OCD" to combat covert rituals, since such statements can in turn become mental rituals. As discussed previously, an individual may check for sexual arousal in the presence of an attractive opposite sex individual to determine whether they are still attracted to members of the opposite sex. Conversely, clients may compulsively check to be sure they are not aroused by persons of the same sex, and they should be discouraged from this sort of checking. Clients with SO-OCD may also engage in overt behaviours, such as watching pornography, in response to obsessions to compare levels of sexual arousal to heterosexual versus same sex sexual activity. Additionally, they may increase their sexual activity to "prove" that they are not LGBT, or they may search the internet to find reassurance that their sexual orientation will not suddenly change. Response prevention for clients with these overt compulsions involves stopping such behaviours and not overcompensating for possible deficits. Mindfulness and Acceptance-Based Strategies

Mindfulness and acceptance-based approaches emphasise taking a nonjudgmental stance toward inner experience and focusing on the present moment, despite the present moment including thoughts and feelings that are unwanted. These approaches do not emphasise getting rid of unwanted thoughts. Instead, they encourage the individual to accept such thoughts as a necessary part of human existence (Hayes, Strosahl, & Wilson, 2012). More recently, efforts have been made to assess the effectiveness of mindfulness and acceptance-based strategies in the treatment of OCD (Patel, Carmody, & Simpson, 2007; Twohig et al., 2010). Mindfulness can be used during exposures to help individuals take a nonjudgmental stance toward themselves when they continue to perform rituals even when they are trying not to; this may help to reduce shame or self-judgment during a difficult change process (Fairfax, 2008).

Additionally, mindfulness encourages clients to halt their struggles with their thoughts and accept that avoidance

strategies are only helpful in the short term (Didonna, 2009). This helps clients manage their unwanted thoughts by letting go of their struggles or compulsions. Learning to accept SO-OCD thoughts as part of their experience allows clients to better tolerate these thoughts and subsequently reduce compulsions. This also facilitates greater ease in engaging in exposure exercises.

Conclusion

Cognitive behavioural treatments are effective for OCD, including SO-OCD (Williams et al., 2014). However, due to the heterogeneity of this disorder, additional work is needed to ensure the availability of effective treatments for this symptom presentation (Williams et al., 2013). Despite effective behavioural and pharmacological treatments for OCD, there remain many individuals who are unable to access treatment due to a lack of knowledge and misinformation, which may be tragically perpetuated by clinicians. Greater awareness of SO-OCD among mental health professionals and the public is essential to ensure that people with this under-recognised form of the disorder can readily access the help they need.

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Body Dysmorphic Disorder: Identifying and Treating an Invisible Problem

Ben Buchanan, DPsych

Monash University, Australia Abstract Body dysmorphic disorder (BDD), previously classified as a somatoform disorder, has recently been reconceptualised as related to obsessive–compulsive disorder. BDD is similar to obsessive–compulsive disorder in terms of having obsessions (body image) and compulsions (checking behaviours related to appearance). People with BDD can spend hours each day checking their appearance in the mirror because they believe they are ugly or disfigured, when in fact they look normal. BDD is surprisingly common and has about five times the prevalence of anorexia nervosa, yet is underdiagnosed. However, the research indicates that, once recognised, cognitive behaviour therapy, with an emphasis on exposure and response prevention, is an effective treatment. 4 Body dysmorphic disorder (BDD) is a mental disorder characterised by a preoccupation with an imagined defect in physical appearance, or excessive concern for a slight physical abnormality. BDD-type symptoms were first formally documented in 1886 when it was referred to as 'dysmorphophobia' to reflect its phobic-like nature. Since then, it has been recognised using different names and conceptualisations. BDD diagnosis has again been reconceptualised in the DSM-5 (American Psychiatric Association, 2013), where it is classified within the newly formed obsessive–compulsive and related disorders category. This reclassification reflects its similarities to obsessive–compulsive disorder (OCD) in terms of aetiology, symptomatology, and treatment response (Buchanan, Rossell, & Castle, 2011). BDD is a relatively common disorder, with a reported prevalence rate in Australia of approximately 2.3% (Bartsch, 2007). This makes BDD more common than schizophrenia and anorexia nervosa combined, yet it remains under-recognised. The reasons BDD is an "invisible disorder" are many, including the private and social phobic nature of BDD sufferers, as well as the strongly held belief that they possess a physical defect rather than a psychological one. Unfortunately, this results in few individuals with BDD seeking or receiving appropriate treatment.

Cosmetic Procedures Before a BDD patient ends up in a clinical psychologist's office, it is likely that they have first consulted with dermatologists and cosmetic surgeons in an effort to 'fix' their perceived defect. In fact, one study showed 76% of BDD patients sought procedures like rhinoplasty, breast implants, or botox before getting mental health treatment (Phillips, Grant, Siniscalchi, & Albertini, 2001). A major problem with cosmetic surgery is that the vast majority of BDD patients (83% in some research; e.g., Phillips et al., 2001) experience either no improvement, or a worsening of symptoms after surgery, and most are dissatisfied with the

4 4Corresponding author: [email protected]

procedure. This differs from people without BDD who are generally satisfied with cosmetic procedures and even report psychological benefits on follow-up (Rankin, Borah, Perry, & Wey, 1998). This information is important to clinical psychologists whose advice may be sought in regard to someone's suitability for surgery. The data is clear: BDD is a contraindication to cosmetic surgery.

Presentation Individuals with BDD are greatly in need of care from clinical psychologists. Without treatment, psychosocial outcomes are unfavourable, with many experiencing prolonged unemployment, severe social isolation, and suicidal ideation, with approximately 25% of individuals with BDD attempting suicide (Buhlmann et al., 2010). Perhaps another reason that BDD is underdiagnosed is that many individuals with primary BDD also fulfil the criteria for other mental disorders, including social phobia (Coles et al., 2006), major depression (Phillips, Didie, & Menard, 2007), and, most commonly, OCD (Stewart, Stack, & Wilhelm, 2008). Routinely and directly asking new patients about body image concerns is important in order to identify BDD in clinical practice, as few people with the disorder disclose their concerns without prompting. In contrast to other disorders relating to body image (such as anorexia nervosa), the prevalence of BDD is similar in men and women. However, there are consistent gender differences in the body parts of concern (Rief, Buhlmann, Wilhelm, Borkenhagen, & Brahler, 2006). Women tend to focus on skin, legs, and breast size while men are concerned with baldness, body hair, genitals, and build. Muscle dysmorphia (or, more informally, bigorexia) is a subtype of BDD recognised in DSM-5. It mostly afflicts men, and is characterised by concerns about muscularity. Those who suffer from muscle dysmorphia tend to hold delusions that they are "skinny" or "too small" and will often spend hours at the gym building muscle and comparing themselves unfavourably to other men. The prevalence of BDD seems to be consistent across cultures, with people in different cultures dissatisfied


with different body parts (Rief et al., 2006). The similarity in gender and culture prevalence rates suggest that the onset of BDD is separate from culture, while the differences in body part manifestations of BDD reflect different societal values.

Causes The onset of BDD is usually during adolescence, with patients recounting hypersensitivity about their physical appearance for all, or much of, their lives, leading them to remember and fixate upon teasing instances (Phillips, Menard, Fay, & Weisberg, 2005). The majority of BDD patients remember teasing during their adolescence when they 'realised' that they were ugly, and they attach considerable self-meaning to these memories. In fact, the therapeutic use of 'imagery rescripting', allowing imaginary exposure to this event, is often used in treatment of BDD (Veale & Neziroglu, 2010). Revisiting this traumatic memory provides an opportunity to reflect on the resultant unhelpful and perpetuating thought processes. A comprehensive model of the causes of BDD includes biological and genetic susceptibility upon which adverse life events interact with cognitive abnormalities and lead to maladaptive learned behaviours (Buchanan et al., 2011). A large portion of the aetiology of BDD is likely to be genetic. This was well demonstrated in a large twin study (n = 2,148) (Monzani et al., 2012) showing that BDD and OCD traits were largely accounted for by genetic influences common to both phenotypes (64%). It is likely that genetics causes neurobiological differences in the brain that predispose some individuals to develop BDD (Buchanan et al., 2013). Recent neuroimaging research has indicated a key difference in the amygdala and limbic system, the emotion centres of the brain (Buchanan et al., 2014).

Diagnosis Many people with BDD have very low insight and difficulty accepting that their perceived defect in appearance is psychological, rather than truly physical. This creates an opportunity to use the formal diagnosis as the starting point in the therapeutic process. In fact, many individuals with BDD may experience significant relief when they receive a diagnosis of BDD because it provides the first glimmer of hope that their perceived defect may, in fact, not be real. Diagnostic evaluation, according to DSM-5, should place emphasis upon assessing the compulsions associated with BDD (see Figure 1). These may include, for example, repeatedly checking one's hair line to make sure balding is not occurring, or spending hours applying and reapplying makeup to cover a few blemishes. Because of the new conceptualisation, simply being obsessed with a perceived defect is no longer sufficient for a diagnosis. Thus, when determining a diagnosis, and trying to differentiate subclinical body image concerns from BDD, an emphasis on the time spent engaged in compulsive behaviour is important. As in OCD, the ability of the patient to resist compulsions, and the disruption caused by compulsions, is a key component in determining the level of dysfunction.

Cognitive Behaviour Therapy (CBT)

Most published studies of CBT for BDD have included cognitive restructuring, exposure (e.g., to avoided social situations), and response prevention (e.g., not seeking reassurance) that are tailored specifically to BDD symptoms (Veale & Neziroglu, 2010). Additional strategies used in combination with these approaches include perceptual retraining with mirrors, habit reversal for BDD-related skin picking or hair plucking, cognitive approaches that target core beliefs, incorporation of behavioural experiments into exposure exercises, and motivational interviewing (Phillips & Rogers, 2011). In essence, a clinical psychologist who has experience working within an exposure and response prevention framework for OCD can transfer many of these skills to working with BDD. BDD patients, however, tend to have markedly lower insight compared to individuals with OCD. Useful resources have recently been published by the Centre for Clinical Interventions (2013) and are freely available through their website. CBT targets the mechanisms that maintain the preoccupation with appearance, avoidance behaviours that prevent the patient from habituating to the sight of his or her appearance, and checking behaviour that may provide immediate relief, but, in the long run, keeps the person's attention focused on aspects of appearance that elicit anxiety. It is important to note that the aim of treatment is not to convince patients they look normal, as this will be ineffective given BDD's delusional nature. The emphasis is on reducing the disruption caused by their faulty body image beliefs. The good news is that CBT treatment is effective. Two comprehensive reviews of treatment efficacy for BDD have been conducted: a Cochrane Review (Ipser, Sander, & Stein, 2009), and a Treatment Practice Guideline for OCD and BDD from the United Kingdom's National Institute for Health and Clinical Excellence (2005). Both these reviews recommended CBT and selective serotonin reuptake inhibitors as first line treatments, though acknowledged that more research is needed. An evaluation of randomised control trials, published in 2009, included three separate psychotherapy studies (83 participants) (Ipser et al., 2009). The largest of these studies compared 12-week intensive CBT with a waiting list comparison group and found significant improvements, with 81.5% of participants receiving CBT no longer meeting diagnostic criteria post-treatment. Another meta-analysis showed that CBT treatment was significantly more effective than medication after 16 weeks of treatment (Williams, Hadjistavropoulos, & Sharpe, 2006). Longer term follow-up showed that the course of BDD for many individuals was chronic no matter what treatment was received. Phillips, Menard, Quinn, Didie, and Stout (2013) investigated remission rates over 4 years and found that full remission or partial remission of BDD symptoms occurred in 55% of cases.

While most individuals will receive significant benefits from treatment, experience suggests that some patients will continue to struggle. They may seek


psychological treatment and ostensibly accept the BDD diagnosis, while simultaneously investigating or undergoing cosmetic procedures to fix their perceived defect. This level of duplicity is not uncommon, and patients may spend thousands of dollars undergoing risky cosmetic procedures while commitment to therapy can be challenging. Motivational interviewing skills are, therefore, important to keep BDD patients on track, and an emphasis on management of symptoms, rather than a cure, may be more important for those with chronic BDD.

Conclusion

Correctly identifying and diagnosing BDD is the first challenge for clinical psychologists, given that few individuals with BDD have the insight to identify having BDD themselves. Forging professional connections between dermatologists and cosmetic surgeons represents a key opportunity for clinical psychologists to protect and advocate for this vulnerable patient group. Once BDD is identified and someone commits to treatment, however, research shows that outcomes are good. CBT represents the most effective treatment option for people with this debilitating disorder.

References

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Bartsch, D. (2007). Prevalence of body dysmorphic disorder symptoms and associated clinical features among Australian university students. Clinical Psychologist, 11(1), 16–23.

Buchanan, B. G., Rossell, S., Maller, J., Toh, W., Brennan, S., & Castle, D. (2013). Brain connectivity in body dysmorphic disorder compared with controls: A diffusion tensor imaging study. Psychological Medicine, 43, 2513-2521.

Buchanan, B. G., Rossell, S., Maller, J. J., Toh, W. L., Brennan, S., & Castle, D. (2014). Regional brain volumes in body dysmorphic disorder compared to controls. Australian and New Zealand Journal of Psychiatry, 48(7), 654–662.

Buchanan, B. G., Rossell, S. L., & Castle, D. J. (2011). Body dysmorphic disorder: A review of nosology, cognition and neurobiology. Neuropsychiatry, 1(1), 71–80.

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Centre for Clinical Interventions. (2013). Overcoming Body Dysmorphia. Retrieved from http://www.cci. health.wa.gov.au/resources/infopax.cfm?Info_ID=55

Coles, M. E., Phillips, K. A., Menard, W., Pagano, M. E., Fay, C., Weisberg, R. B., & Stout, R. L. (2006). Body dysmorphic disorder and social phobia: Cross-sectional and prospective data. Depression and Anxiety, 23, 26–33.

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Monzani, B., Rijsdijk, F., Iervolino, A. C., Anson, M., Cherkas, L., & Mataix‐Cols, D. (2012). Evidence for a genetic overlap between body dysmorphic concerns and obsessive–compulsive symptoms in an adult female community twin sample. American Journal of Medical Genetics Part B: Neuropsychiatric Genetics, 159B(4), 376–382.

National Institute for Health and Clinical Excellence. (2005). Obsessive–compulsive disorder: Core interventions in the treatment of obsessive–compulsive disorder and body dysmorphic disorder. (NICE Clinical Guideline 31). Manchester, UK: Author. Retrieved from http://www.nice.org.uk/guidance/cg031

Phillips, K., Didie, E. R., & Menard, W. (2007). Clinical features and correlates of major depressive disorder in individuals with body dysmorphic disorder. Journal of Affective Disorders, 97(1–3), 129–135.

Phillips, K., Grant, J., Siniscalchi, J., & Albertini, R. (2001). Surgical and nonpsychiatric medical treatment of patients with body dysmorphic disorder. Psychosomatics, 42(6), 504–510.

Phillips, K. A., Menard, W., Fay, C., & Weisberg, R. (2005). Demographic characteristics, phenomenology, comorbidity, and family history in 200 individuals with body dysmorphic disorder. Psychosomatics, 46(4), 317–325.

Phillips, K. A., Menard, W., Quinn, E., Didie, E. R., & Stout, R. L. (2013). A 4-year prospective observational follow-up study of course and predictors of course in body dysmorphic disorder. Psychological Medicine, 43(5), 1109–1117.

Phillips, K., & Rogers, J. (2011). Cognitive-behavioral therapy for youth with body dysmorphic disorder: Current status and future directions. Child and Adolescent Psychiatric Clinics of North America, 20(2), 287–304.

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Stewart, S., Stack, D. E., & Wilhelm, S. (2008). Severe obsessive–compulsive disorder with and without body dysmorphic disorder: Clinical correlates and implications. Annals of Clinical Psychiatry, 20(1), 33–38.

Veale, D., & Neziroglu, F. (2010). Body dysmorphic disorder: A treatment manual. West Sussex, UK: John Wiley & Sons.

Williams, J., Hadjistavropoulos, T., & Sharpe, D. (2006). A meta-analysis of psychological and pharmacological treatments for body dysmorphic disorder. Behaviour Research and Therapy, 44(1), 99–111.


A Review of Body Dysmorphic Disorder after 20 Years of Research

Fugen Neziroglu1, PhD and Nicole Lippman2, PhD

1 Hofstra University, USA 2 Bio Behavioral Institute, USA

Abstract Body dysmorphic disorder (BDD) is characterised by a preoccupation with an imagined or slight defect in appearance. The perceived flaw, real or imagined, may be on any part of the body, though it is most common around the face. Data on the prevalence rates of BDD vary from .7% to 2.4%. Typical age of onset is during adolescence, but individuals are usually not diagnosed by mental health professionals until 10-15 years after the onset. Exposure and response prevention (ERP) is the preferred method of treatment for BDD and has been shown to be the most effective. BDD presents as a difficult disorder to treat due to high comorbidity levels, low motivation levels, and varying degrees of insight and readiness to change. Overvalued ideation (OVI), a belief that is unreasonable, tends to be a poor prognostic indicator for treatment. BDD requires a combination of many modalities of treatment including ERP, attentional training, and image rescripting, in conjunction with pharmacological treatment. Treatment for individuals with BDD will most likely be prolonged and require flexibility on the parts of the patient and the clinicians involved. 5It is common for many people to not like something about their physical appearance, or to have the desire to change something about themselves. People with body dysmorphic disorder (BDD), however, are preoccupied with, and ruminate about, a perceived flaw on their body, the defining characteristic of the diagnosis of BDD. The perceived flaw, real or imagined, may be on any part of the body, although it is most common around the face, especially the nose, skin, hair, eyes, eyelids, mouth, lips, jaw, and chin. Other common complaints include asymmetry, body features felt to be out of proportion, baldness, acne, wrinkles, vascular markings, scars, or extremes of complexion, ruddiness, or pallor. In addition to this preoccupation, diagnostic criteria include significant distress or impairment in social, occupational, or other important areas of functioning. In DSM-5 (American Psychiatric Association, 2013), two specifiers have been added – level of insight and the presence or absence of muscle dysmorphia. BDD is challenging to treat due to a high degree of comorbid diagnoses, including mood disorders (Neziroglu & Yaryura-Tobias, 1993b), anxiety disorders (Phillips, McElroy, Keck, Pope, & Hudson, 1993), and personality disorders (Neziroglu, McKay, Todaro, & Yaryura-Tobias, 1996). The results of one comorbidity study demonstrated that comorbid depression tended to occur after the onset of BDD, suggesting that depression may be a complication of BDD (Gunstad & Phillips, 2003). Comorbidity rates between obsessive–compulsive disorder (OCD) and BDD range from 16% to 37% of OCD patients meeting criteria for BDD (Hollander, Cohen, & Simeon, 1993). BDD is also commonly associated with social phobia. Individuals diagnosed with BDD engage in time consuming behaviours to examine the "defect" repeatedly or to camouflage, disguise, or try to improve it. Common behaviours include mirror gazing, social comparison, excessive grooming, and camouflaging the "defect" with


clothes or make-up, skin picking, reassurance seeking, dieting, and even cosmetic surgery or dermatological treatment.

Prevalence and Demographics Data on the prevalence rates of BDD in the general population vary from .7% (Faravelli, Salvatori, Galassi, & Aiazzi., 1997) to 2.4% (Koran, Abujaoude, Large, & Serpe, 2008). BDD remains very common in cosmetic surgery clinics. Most studies indicate that approximately 5 to 7 percent of patients in cosmetic surgery clinics have BDD (Sarwer, Pertschuk, Wadden, & Whitaker, 1998), and an incidence of 12% has been reported from a dermatology clinic in the United States (Phillips, Dufresne, Wilkel, & Vittorio, 2000). Phillips et al. (2001) reported the outcomes for 58 BDD patients seeking cosmetic surgery. The majority (82.6%) reported that symptoms of BDD were the same or worse after surgery. Additionally, after examining 25 BDD patients who had a total of 46 procedures in a psychiatric clinic in the UK, Veale (2004) reported that repeated surgery tended to lead to increasing dissatisfaction. Research reports an equal sex incidence among the single or separated in surveys of BDD patients attending a psychiatric clinic (Neziroglu & Yaryura-Tobias, 1993a; Phillips & Diaz, 1997; Phillips, McElroy, Keck, Pope, & Hudson, 1993). Phillips et al. (2006) examined gender differences in 200 individuals with BDD and found significant differences between men and women. The men were significantly older and more likely to be single and living alone. They were more likely to be preoccupied with their genitals, body build, have thinning or balding hair, lift excessive weights, and have a substance abuse disorder. Women were more likely to be preoccupied with their skin, stomach, weight, breasts or chest, buttocks, thighs, legs, hips, toes, and excessive body or facial hair. Women also engaged in more repetitive and safety behaviours, and were more likely to camouflage, use certain camouflaging techniques, mirror check, change their clothes, pick their skin, and have an eating disorder.


Individuals diagnosed with BDD may have few friends and may tend to avoid situations where they believe they will be evaluated negatively, similar to those with social phobia. Typical age of onset for BDD is during adolescence. However, individuals are usually not formally diagnosed by mental health professionals until 10-15 years after onset because patients are most likely to present to cosmetic surgeons, dermatologists, or their general practitioners (Veale & Neziroglu, 2010). When patients do present to mental health professionals, they are more likely to complain of depression or social anxiety, unless they are specifically asked the appropriate screening questions about symptoms of BDD (Neziroglu, Khemlani-Patel, & Jacofsky, 2009). As a result, quality of life is greatly affected and has been found to be worse than for those suffering from diabetes or heart attack. In addition, it has been reported that the incidence of suicidal ideation and attempts ranged from 40-45%, and there was a high incidence of BDD related hospitalisations (Phillips et al., 1993).

Treatment Models

A social learning model has been proposed to elucidate the acquisition and maintenance of BDD (Neziroglu et al., 2009; Neziroglu, Khemlani-Patel, & Santos, 2012; Neziroglu, Roberts, & Yaryura-Toias, 2004; Veale & Neziroglu, 2010). Social or vicarious learning occurs when others are observed being rewarded or punished for a specific behaviour or belief (Bandura, 1977). By observing experiences in which other attractive individuals are positively reinforced, and by society's overvaluation of physical attractiveness, the association between self-worth and physical attractiveness is strengthened (Rabinowitz, Neziroglu, & Roberts, 2007). These ideas are pervasive throughout the media and in popular culture. Vicarious learning can also extend to one's immediate environment in which family members can express over-concern about their own appearance, and extend this preoccupation to their children. The cognitive behavioural (CB) model of BDD parallels the diathesis-stress model concerning mental disorders in that some individuals are genetically predisposed to develop a psychological disorder during times of stress. The development of any psychological disorder, including BDD, is the result of an interaction of factors, including biological predisposition and environmental stress. The development of BDD is defined to be a function of classical or evaluative conditioning. Negative events about one's physical appearance can serve as the unconditioned stimulus (UCS; e.g., being teased about one's appearance) and cause an unconditioned emotional response (UCR; e.g., anxiety, depression, shame, disgust). The UCS is appraised as negative and anything paired with it is also evaluated as negative. For instance, a person is bullied (UCS) for having big ears and this evokes a negative affect. Consequently, a word (conditioned stimulus [CS]: "big") or a body part (CS: "ears") is appraised as being negative. According to evaluative conditioning, any previously neutral body part or word ("big") can have the same negative reaction and meaning as the UCS.

The CB model has been shown to be helpful in reducing symptoms in both individual and group formats (Veale & Neziroglu, 2010). Cognitive behaviour therapy (CBT) aims to improve quality of life and overall functioning through the reduction of compulsive behaviours and distress associated with appearance concerns. The CB model purports that the cycle of BDD begins with an event or a trigger, either external or internal. An example of an external event would be looking in a mirror or seeing an attractive person. An internal trigger may be a somatic sensation (e.g., feeling puffiness under the eyes) or an intrusive thought (e.g., "Why is my nose so big?"). Triggers are thought to activate a process of self-focused attention that consists of feelings of extreme self-consciousness and being excessively aware of one's body image from an observer perspective. The outcome of self-focused attention is that individuals with BDD experience mental imagery of how they appear to others from an observer perspective. Individuals with BDD are more likely to rate their images as significantly more negative. Images in people with BDD are more "distorted", and the "defective" features typically take up a greater proportion of the whole image. In BDD, physical appearance becomes fused with the self, or the identity of the person, and the consequences include having negative appraisals and assumptions (Neziroglu, Khemlani-Patel, & Veale, 2008; Veale & Neziroglu, 2010). Typical assumptions include: "If I am unattractive, then life is not worth living", or "How I feel about myself as a person is related to how I feel about how I look" (Geremia & Neziroglu, 2001; Veale et al., 1996). Typical core beliefs that are activated include: being a failure; being worthless; being ugly or repulsive; being unlovable; and being rejected by others and alone for the rest of one's life (Osman, Cooper, Hackmann, & Veale, 2004; Wilhelm & Neziroglu, 2002). Avoidance, rumination, and comparing one's appearance to others that are more attractive, reinforce the emotional distress and negative appraisals evident in BDD.

Exposure and response prevention (ERP) is the preferred method of treatment for BDD. It applies basic behavioural principles (i.e., habituation and extinction) to reverse learning that has occurred through classical and operant conditioning. ERP involves repeated exposures of the defective body part (CS) across various situations that elicit negative conditioned responses and prevent the individual from engaging in the compulsive behaviours that reduce negative mood. Two behavioural changes result from this. Continued and repeated exposure to the negative mood state without escape leads to eventual habituation to the negative feelings of anxiety, disgust, and shame elicited by the perceived flaw; as a consequence, the intensity of the emotions alleviates. Not engaging in the compulsive and safety seeking behaviours results in extinction of these behaviours.

In addition to the cognitive aspects of therapy, patients are gradually exposed to anxiety-provoking situations and learn strategies to help them eliminate avoidance and ritual behaviours (e.g., comparing self to others). Patients are also asked to repeat the exposure exercises until the anxiety or discomfort decreases. They are taught to "see the big picture" by learning how to view themselves from a more holistic and non-judgmental


perspective, particularly when in front of the mirror (Veale & Neziroglu, 2010).

Treatment

Studies reporting on the effectiveness of CBT and other psychological interventions with BDD are sparse. Neziroglu and Yaryura-Tobias (1993b) reported on ERP and cognitive therapy where patients received either weekly or daily 90 minute sessions for 4-12 weeks. Results suggested that intensive sessions, more than once a week, provided the greatest gains in therapy, which was defined as obsessing for less than one hour a day. Two randomised controlled trials of CBT for BDD in adults have been conducted. The meta-analysis of randomised controlled trials shows evidence in favour of CBT, compared with a wait list control, on reducing BDD symptoms, as measured by the Body Dysmorphic Disorder Examination (Rosen & Reiter, 1996). In one of the studies, 54 participants with BDD received treatment in a small group format for an eight-week period. Treatment consisted of education about causation and treatment of BDD, constructing a hierarchy of distressing aspects of physical appearance, homework assignments involving exposure to the anxiety provoking situations and preventing body checking behaviours, and keeping a body image diary. Results indicated that 81.5% of the 27 patients were clinically improved after treatment (Rosen, Reiter, & Orosan, 1995). In the second study, 19 predominantly female participants were randomly allocated to either 12 sessions of individual CBT by three different therapists or a waiting list control over 12 weeks. Treatment focused on educating the individual to have a full understanding of the facts that maintained the symptoms, behavioural experiments to test an alternative theory, exposure to situations avoided, and elimination of excessive safety behaviours and rituals. Seven out of the nine treated patients were rated as having either absent or subclinical BDD at the end of the trial, whereas all patients on the waiting list were rated as having a disorder in the clinical range at the end of the trial (Veale et al., 1996).

In terms of medication, there is evidence for the modest benefit of selective serotonin reuptake inhibitor (SSRI) antidepressants in two randomised controlled trials. The SSRI clomipramine (n = 29 randomised patients) was shown to be more effective than the non-SSRI antidepressant desipramine in a double blind cross over trial (Hollander et al., 1999). The only placebo controlled study performed (n = 67 randomised patients) demonstrated that the SSRI fluoxetine was more effective than placebo (Phillips, Albertini, & Rasmussen, 2002). BDD often requires higher doses of medication to show efficacy, and, in most studies, the average time required for BDD to respond to medications has been 6-9 weeks, with some patients requiring up to 14 weeks (Phillips, 2002). It is recommended that patients receive an SSRI for at least 12 weeks before trying a different medication, and that the highest dose recommended by the manufacturer be reached if lower doses are ineffective. There is also evidence that patients with and without a delusional disorder did equally well with an SSRI. There is no evidence for the benefit of antipsychotic medication alone in BDD (Veale, 2004).

Predictors of, and Variables Affecting, Treatment Outcome

In addition to the high rate of comorbidity associated with BDD, other variables that affect treatment outcome involve motivation levels. BDD individuals tend to exhibit a low motivation to seek psychiatric and psychological treatment (Neziroglu, Anderson, & Yaryura-Tobias, 1999). As with individuals with OCD, BDD individuals who have overvalued ideation, which can be defined as "a fixed belief with doubting overtones that is unresponsive to challenges", present with considerable difficulty, and this greatly affects treatment outcome (Neziroglu & Yaryura-Tobias, 1997, p. 327). According to Neziroglu and Khemlani-Patel (2003), delusional patients are more challenging to treat despite research that indicates that the delusional and non-delusional forms of BDD do not differ on many variables and they do respond similarly to treatment (Phillips, McElroy, Keck, Hudson, & Pope, 1994). BDD patients tend to be more resistant to traditional behaviour therapy techniques, and, consequently, require a combined psychological and pharmacological treatment strategy. Before implementing ERP, treatment should consist of cognitive therapy, with the appropriate medication, to decrease the strength of beliefs. Rather than challenging maladaptive beliefs related to appearance, the cognitive therapy should address compliance and motivation to engage in treatment. BDD patients with high overvalued ideation are typically not in agreement with the standard goals of treatment, because they attribute the cause of their suffering and impairment to their physical appearance rather than a psychiatric illness. They may also require more case management strategies, such as collaboration with cosmetic surgeons and dermatologists. Pinto, Neziroglu, and Yaryura-Tobias (2007) examined whether motivation to change predicted degree of treatment response in a sample of 32 outpatients diagnosed with OCD. Participants completed an open-label 10 week trial of fluvoxamine, and completed the University of Rhode Island Change Assessment (McConnaughy, DiClemente, Prochaska, & Velicer, 1983) at baseline, a measure designed to assess motivation to change. OCD symptom severity was also rated at baseline and at the end of treatment. It was reported that the relationship between overall readiness and degree of change in OCD symptom severity was not significant. However, there was a significant inverse relationship between pre-contemplation (no intention to change a problem behaviour in the near future) and change in severity, indicating that individuals who reported greater resistance to changing their behaviour were less likely to experience improvement. Additionally, participants who reported greater awareness and serious consideration about changing their obsessive–compulsive behaviours were more likely to experience symptom improvement.

Phillips, Pagano, Menard, Fay, and Stout (2005) conducted the first naturalistic, prospective study of the course of BDD. Researchers examined predictors of remission in 161 subjects over 12 month follow-up. Data was obtained on clinical characteristics at the intake interview and weekly BDD symptom severity over 12 months using the Longitudinal Interval Follow-Up Evaluation (Keller et al.,


1987). The factors that predicted a lower likelihood of partial or full remission from BDD included more severe BDD symptoms at intake, longer BDD duration, and the presence of a comorbid personality disorder. BDD remission was not predicted by gender, race or ethnicity, socioeconomic status, being an adult versus an adolescent, age of BDD onset, delusionality of BDD symptoms, or the presence at intake of major depression, a substance use disorder, social phobia, OCD, or an eating disorder. Mental health treatment or non-mental health treatment (e.g., surgery, dermatologic treatment) during the follow-up year also did not predict remission from BDD.

Insight Insight is a multidimensional construct (Eisen et al., 1998; Kendler, Glazer, & Morgenstern, 1983; Kozak & Foa, 1994), which includes components such as recognition that the belief has a psychological or psychiatric cause, and willingness to consider that the belief may be false (Amador et al., 1993; Eisen et al., 1998). Overvalued ideation (OVI; Neziroglu, McKay, Yaryura-Tobias, Stevens, & Todaro, 1999), a concept associated with insight, is defined as a sustained, unreasonable belief, not ordinarily accepted by other members of society, that is maintained with less than delusional intensity (American Psychiatric Association, 2013). OVI is conceptualised as midway on the continuum between rational thoughts and delusions. Neziroglu, Mashaal, and Mancusi (2013) reported that, as obsessions became more realistic and accurate, insight became worse, and OVI then increased until it reached delusionality. Phillips et al. (2012) examined insight and delusionality of OCD and BDD related beliefs in 211 individuals with primary OCD and 68 individuals with primary BDD. Investigators used the reliable and valid Brown Assessment of Beliefs Scale (BABS; Eisen et al., 1998). In both disorders, levels of insight exhibited the full range, from excellent to absent (i.e., delusional beliefs). However, the distribution of BABS scores across insight categories differed significantly by disorder, with the majority of OCD subjects demonstrating excellent or good insight, and the majority of BDD subjects demonstrating poor or absent insight. Compared to OCD subjects, BDD subjects had significantly poorer insight, both overall (total BABS score) and on all individual BABS items. In addition, BABS score was significantly correlated with BDD and OCD severity. These results were previously reported by Eisen, Phillips, Coles, and Rasmussen (2004) using the BABS. They found that patients with BDD (n = 85) had poorer global insight (higher total BABS score), and were more likely to have their disorder-related beliefs classified as delusional, than patients with OCD (n = 64). Reese, McNally, and Wilhelm (2011) similarly found poorer global insight on the BABS (higher total score) in BDD (n = 20) than in OCD (n = 20). Furthermore, Eisen et al. (2004) found large between-group differences for most individual components of insight on the BABS, with BDD characterised by greater conviction that the disorder-related belief is accurate, greater certainty that other people think the belief is accurate, greater certainty that their own perspective is more accurate than the perspective of others, greater reluctance to accept the

possibility that the belief is not accurate, and poorer insight into the psychological or psychiatric cause of the belief. In addition, Neziroglu, Pinto, Yaryura-Tobias, and McKay (2004) examined whether OVI predicted medication treatment response. The sample consisted of 34 outpatients, diagnosed with OCD, who completed 10 weeks of an open-label clinical trial of fluvoxamine. Clinicians administered the Overvalued Ideas Scale (OVIS) at baseline, and symptom severity was rated both at baseline and at the end of week 10 using the Yale-Brown Obsessive–Compulsive Scale (Goodman et al., 1989). Of those who completed the trial, 68% showed a reliable change in obsessions and 62% showed a reliable change in compulsions. Additionally, baseline OVIS predicted outcome for obsessions, but not compulsions, meaning that higher OVI was associated with poorer outcome for obsessions, but compulsions were not affected by the degree of conviction. The sample consisted of a relatively low number of individuals in the upper quartile on the OVIS, thus reducing the predictive power of the measure in relation to treatment outcome. More studies are needed that examine higher scoring OVI patients and medication treatment response.

Conclusion There remains a need for more controlled treatment outcome studies on individuals with BDD. In particular, future research is warranted to help elucidate what is most effective in treatment (i.e., duration and frequency of sessions). There is also sparse research on what is most effective for treatment with individuals with BDD with high OVI versus those with lower OVI. The available evidence suggests that CBT and pharmacological approaches are most effective in treating BDD. Improvement is possible for many BDD sufferers, but it remains that consistency in treatment is necessary and it is important to remain realistic by reviewing goals and expectations for treatment. Treatment for individuals with BDD will most likely be prolonged and require flexibility on the parts of patient and involved clinicians. It is vital for individuals with BDD to seek psychological treatment, as the damage in functioning in many areas of life can be affected greatly. Given its early onset and chronic course, early identification and treatment are necessary.

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Thought Suppression in Obsessive–Compulsive Disorder

Jessica R. Grisham, PhD and Melissa J. Black, BPsych(Hons)

University of New South Wales, Australia Abstract Understanding the effects of thought suppression is critical to our understanding of obsessive–compulsive disorder (OCD); a disorder characterised by persistent intrusive thoughts and efforts to suppress these thoughts. In the current paper, we explain the prominent theoretical model of thought suppression, Wegner's Ironic Process Theory, which posits that attempts to suppress our intrusions are counterproductive at best. We also provide an overview of the empirical findings regarding this theory in nonclinical and clinical OCD samples. We then outline current directions in thought suppression research that extend beyond simply measuring frequency of intrusive thoughts, including consideration of the persistence of intrusions, disengagement from them, and the associated distress. We conclude with a discussion of the implications of thought suppression research with respect to clinical interventions for OCD. This includes consideration of opportunities for future clinical research on OCD and thought suppression, including novel interventions such as cognitive bias modification. 6A professional woman attends a formal work function and experiences an unexpected intrusive image of tearing off her clothes and jumping in the fountain. She is horrified by this image and fiercely attempts to banish it from her mind. Unfortunately, the harder she tries to block this disturbing thought, the more she catches it popping up during her conversations with colleagues. Similar to this woman, many people find that intentional attempts to control unwanted thoughts, desires, and feelings are unsuccessful and produce a so-called rebound effect, in which they increase rather than decrease in frequency and intensity (Wegner, 2009). However, the nature of intrusive thoughts, and the impact of efforts to control them, has critical relevance to understanding obsessive–compulsive disorder (OCD). In this review, we focus on the notion of the thought suppression as a key maintaining mechanism for OCD. We also discuss clinical implications and strategies for addressing thought suppression in OCD. OCD is characterised by recurrent and persistent ideas, thoughts, images, or impulses that are intrusive, unwanted, and cause marked anxiety or distress (American Psychiatric Association, 2013). Individuals with OCD often try to suppress distressing intrusive thoughts (Freeston & Ladouceur, 1997). Research has found that intrusive thoughts in the general population are similar in content to obsessions in OCD, which has led to the suggestion of continuity between normal and abnormal obsessions (Clark et al., 2014; Rachman & de Silva, 1978; Salkovskis, 1985). Individuals with OCD, however, experience obsessions as more frequent, more unacceptable, more difficult to dismiss, and more intense (Garcia-Soriano, Belloch, Morillo, & Clark, 2011; Rachman & de Silva, 1978). Cognitive behaviour therapy (CBT) models assert that a normal intrusive thought can escalate into an obsession if it is interpreted as signifying a threat to self or others, which leads to efforts to suppress and neutralise thoughts (i.e., via compulsions). These efforts to control or suppress obsessions are proposed to lead to a

6Corresponding author: [email protected]

paradoxical increase in the thoughts and in distress (Tolin, Abramowitz, Przeworski, & Foa, 2002). Thus the process of responding to obsessions by attempting to suppress them has been proposed to be a significant factor in the aetiology and maintenance of OCD (Salkovskis, 1985, 1989).

Wegner's Model In the seminal "white bear" study of the paradoxical effect of thought suppression, Wegner, Schneider, Carter, and White (1987) demonstrated that participants instructed not to think about a white bear were unable to suppress intrusions about the white bear while verbalising a stream of consciousness. Perhaps more interestingly, these participants subsequently reported more white bear thoughts than individuals who had not been instructed to suppress. A follow-up experiment showed that participants were more likely to successfully suppress the unwanted thought if they were given a specific thought (a red Volkswagen) to use as a distractor, although this finding was not reliable (Wegner, Schneider, Carter, & White, 1987). To explain this phenomenon, Wegner (1994) proposed the ironic process theory. This theory describes two processes that may occur during attempted mental control, such as when participants suppressed white bear thoughts. The first is an intentional search for a distracter thought, and the second is an automatic search for the unwanted thought (Wegner, 1994). The automatic monitoring paradoxically increases the target thought's accessibility to consciousness by continually searching for the target (Wegner, Erber, & Zanakos, 1993). Many studies have attempted to replicate the white bear effect, usually with nonclinical undergraduate samples. In these studies, researchers compare individuals instructed to suppress a target thought and those simply asked to monitor their thoughts with respect to the frequency of thoughts during the experimental period and during a subsequent "rebound" period. Abramowitz, Tolin, and Street (2001) conducted a quantitative meta-analysis of controlled


studies examining thought suppression. Although the literature findings were inconsistent, many studies found support or partial support for a post-suppression rebound effect. Their analysis found that participants were often able to suppress unwanted thoughts over a short period of time, but that with longer suppression periods and difficulty sustaining efforts, thought suppression became more difficult.

Thought Suppression among Individuals with OCD Chronic thought suppression has been shown to be associated with OCD. Wegner and Zakanos (1994) found that a measure of thought suppression (the White Bear Suppression Inventory) correlated with a measure of OCD, and also predicted clinical obsessions among individuals prone to OCD. Other studies have documented the common use of thought suppression in OCD samples. Freeston and Ladouceur (1997) found that 76% of their sample used thought suppression to manage their obsessions. Similarly, Purdon, Rowa, and Antony (2007) found that OCD patients were spending more than 3.5 hours per day trying to suppress unwanted intrusive thoughts. In addition to naturalistic studies, researchers have conducted experimental studies in which they compare the effects of thought suppression with a control condition among individuals diagnosed with OCD. Contrary to the predictions of the model, however, several studies in clinical OCD samples have failed to demonstrate that suppression leads to an increase in thought frequency (Janeck & Calamari, 1999; Najmi, Riemann, & Wegner, 2009; Purdon, Rowa, & Antony, 2005). One possible explanation for this finding is that individuals with OCD have a great deal of practice as they are constantly suppressing and resisting their obsessions. Abramowitz and colleagues (2001) noted that an instruction to suppress an unwanted thought is the equivalent of asking OCD participants to maintain their natural tendency to resist these thoughts. Indeed, Purdon (2001) found that asking OCD participants to not suppress their thoughts was more aversive than a suppression induction, given the short-term relief that neutralisation strategies induce. Other studies, however, have demonstrated a paradoxical thought suppression effect in OCD samples (McLaren & Crowe, 2003; Rassin & Diepstraten, 2003; Tolin et al., 2002). Tolin and colleagues (2002) found that OCD participants showed a paradoxical increase in unwanted thoughts when asked to not think of a white bear, whilst anxious and non-anxious control participants did not. To address the limitations associated with self-report data for thought suppression, Tolin et al. (2002) conducted a second study in which they used a lexical decision task to test decision times for suppressed words compared to non-suppressed words. The results of this study replicated those of the previous study, showing an increase in white bear thoughts for OCD participants, but not for anxious or non-anxious controls (Tolin et al., 2002). Many studies with clinical OCD samples have shown that, even if there is no increase in frequency associated with suppression, appraisals of failures of thought

control are also associated with greater suppression effort and poorer mood state (Belloch, Morillo, & Gimenez, 2004; Corcoran & Woody, 2008; Grisham & Williams, 2009; Najmi et al., 2009; Purdon, 2001; Purdon et al., 2005). Indeed, a recent meta-analysis found that people with OCD displayed a reduced initial enhancement effect of thought suppression, associated with increased motivation and effort to suppress unwanted thoughts (Magee, Harden, & Teachman, 2012). Purdon (2004) suggested examining the impact of thought suppression on thought persistence rather than thought frequency. Similarly, Lambert, Hu, Magee, Beadel, and Teachman (2014) suggested that thought return duration is equally important to thought frequency as it may reflect the ease with which participants can disengage from unwanted thoughts. Amongst clinical populations, persistence and/or disengagement may represent a key target for a clinical intervention for unwanted thoughts; that is, being able to experience an unwanted thought and reducing the distress associated with it by reappraising the thought or dismissing it through distraction or substitution. A limited number of studies have examined whether individuals with OCD may experience more thought suppression failures due to neuropsychological characteristics (e.g., Demeter, Keresztes, Harsanyi, Csigo, & Racsmany, 2014; Grisham & Williams, 2013; Harsanyi et al., 2014). Brewin and Smart (2005) found some evidence that individual differences in cognitive abilities affect the ability to suppress thoughts in a nonclinical sample. Better working memory was related to fewer intrusions in a suppression condition, suggesting a specific association with attempts to inhibit unwanted thoughts. A study conducted in our laboratory compared responses to an experimentally induced intrusive thought in a group of participants diagnosed with OCD, an anxious comparison group, and a nonclinical control group (Grisham & Williams, 2013). Although the OCD group demonstrated significantly worse performance on several neuropsychological tasks, their performance did not predict their response to a novel intrusive thought. The critical factor in determining their cognitive and emotional response was their beliefs about the importance of controlling one's thoughts, in other words, their interpretative bias. Another recent study with a clinical OCD sample also found that self-reported obsessions were not associated with impaired executive functions on a cognitive test battery (Harsanyi et al., 2014).

Implications for Intervention Wegner (1989) suggested that the lesson from thought suppression studies is: "in many cases of unwanted thought, it may be best to stop suppressing" (p. 174). The question of how we should stop suppressing, however, has yet to be sufficiently addressed. However, it is possible that asking what is the best response is the wrong question with respect to obsessions. Rather than focussing on response to an intrusive thought, evidence of the importance of interpretation suggests that cognitive restructuring and reappraisal of the intrusion is still the best strategy. Cognitive behavioural therapy for OCD focuses on challenging distorted beliefs about thoughts: inflated responsibility, need to control thoughts, overestimation of threat, intolerance of


uncertainty, and perfectionism (Obsessive Compulsive Cognitions Working Group, 1997). A recent meta-analysis of 16 randomised controlled trials supports the efficacy of cognitive and behavioural approaches for OCD (Olatunji, Davis, Powers, & Smits, 2013). In cognitive approaches to OCD, several techniques help patients challenge and modify these dysfunctional beliefs and reduce their need to control thoughts (Wilhelm & Steketee, 2006). For example, a therapist may begin with normalising intrusions by showing clients a list of intrusive thoughts reported by individuals without OCD. Therapists may also conduct behavioural experiments to test maladaptive predictions. For example, a client may deliberately think about a negative outcome (e.g., breaking a leg) to happen to the therapist, make predictions, and assess the outcome. Similarly, a therapist may ask her client to record the frequency of intrusions when suppressing versus not suppressing a target thought. Although CBT has the strongest evidence, other adjunctive and complementary approaches for altering interpretations may ultimately prove useful in treating OCD. For example, researchers have been developing cognitive bias modification for interpretation (CBM-I) specifically for modifying maladaptive beliefs in OCD. CBM-I protocols for OCD are derived from existing methodologies that have demonstrated efficacy in inducing interpretation biases by resolving the ambiguity of threat information in a positive or negative manner (Mathews & Mackintosh, 2000). In CBM-I, participants are typically presented with relevant scenarios that are emotionally ambiguous up to a final missing word. For example, "You and a friend are having a personal discussion. You tell her that you occasionally have bizarre unpleasant thoughts about hurting people you care about. Your friend tells you this is really ___". For a positive training item, the final word resolves the ambiguity in a benign way (e.g., "normal"). For a negative training item, the word "weird" would be used to resolve the scenario. Participants are typically randomised to either a positive cognitive bias modification (CBM) condition or a neutral condition containing half positive and half negative CBM items. Outcomes are assessed on self-report symptom measures, interpretations of novel ambiguous scenarios, behavioural tasks, and physiological measures. Preliminary work from our laboratory and others suggests that CBM may be useful in reducing OCD-relevant biases such as importance of thoughts, control of thoughts, perfectionism, intolerance of uncertainty, responsibility, contamination, and estimation of threat (Obsessive Compulsive Cognitions Working Group, 1997). However, findings are still mixed (Clerkin & Teachman, 2011; Grisham, Becker, Williams, Whitton, & Makkar, 2014; Williams & Grisham, 2013). Our ongoing research examines whether using CBM to modify biases regarding the importance of thoughts could result in decreased use of thought suppression. Future research should also examine the clinical utility of CBM for OCD with treatment-seeking individuals. CBM may ultimately be used as an adjunct that could improve clinical outcomes and/or reduce relapse rates for OCD when combined with traditional cognitive and

behavioural approaches. More specifically, CBM could be administered prior to exposure-based treatment or as homework throughout therapy. CBM may also be delivered remotely at a low cost as part of internet-delivered CBT (Williams & Grisham, 2013). Other possible approaches promote alternative strategies for the management of unwanted thoughts. Acceptance and commitment therapy (ACT; Hayes, Strosahl, & Wilson, 1999) focuses on encouraging patients to experience uncomfortable thoughts and feelings without avoiding, struggling with, or viewing them as being true. Hayes and colleagues suggested that acceptance is achieved through the absence of control attempts. Marcks and Woods (2005) found that nonclinical participants who used an acceptance-based strategy experienced a decrease in discomfort level associated with intrusive thoughts (although not thought frequency) compared to suppression. Also, using an undergraduate sample, Fabricant, Abramowitz, Dehlin, and Twohig (2013) extended this work by comparing ACT with a well-established treatment, imaginal exposure (IE), and an expressive writing control condition for obsessional thoughts. The authors reported significant reductions on several outcome measures, including obsessional severity, distress and willingness to experience intrusive thoughts, and negative appraisals of intrusive thoughts. Counter to predictions, however, there were no differences between ACT and IE with respect to either efficacy or change processes (Fabricant et al., 2013). Examining research on acceptance with clinical OCD samples, Najmi et al. (2009) compared suppression, focused distraction, and acceptance for individuals diagnosed with OCD and healthy control participants. They found that for the OCD group, suppression was not associated with more frequent intrusions, but it was associated with a rebound of distress once suppression was abandoned, whereas acceptance led to a reduction in distress. OCD participants who used focused distraction experienced low distress both during and after the task. However, the authors acknowledged that although distraction may be effective in the short term, there is some evidence that distraction may not be the most effective strategy (Wahl, Huelle, Zurowski, & Kordon, 2013; Wegner, 2011). A related study compared the effectiveness of mindfulness-based strategy versus a focussed distraction strategy on responses to obsessive thoughts in OCD participants. Those who engaged in mindfulness of obsessive thoughts reported lower anxiety and fewer urges to neutralise or suppress than the distraction condition (Wahl et al., 2013). Despite a smaller research base, a recent meta-analysis found that ACT is equally effective as CBT in the treatment of anxiety and OCD spectrum disorders (Bluett, Homan, Morrison, Levin, & Twohig, 2014). Wegner (2011) noted that while some of these strategies for managing thought suppression are helpful, many are experimental and thus future research is needed to determine their effectiveness and the mechanisms through which they work. Future research may also examine how cognitive appraisal of intrusive thoughts interacts with various suppression strategies to determine how best to reduce the distress associated with experiencing unwanted thoughts in OCD (Wegner, 2011).


Conclusion Wegner's ironic process theory proposes that the suppression of intrusive thoughts is a counterproductive strategy that leads to rebound of thoughts. Experimental work in undergraduate and clinical OCD samples has provided mixed evidence regarding whether suppression of intrusive thoughts leads to an increase in intrusions, with more consistent evidence that suppression leads to increased distress, especially for those with OCD. From a clinical perspective, the best supported therapeutic approach to thought suppression in OCD is to alter the client's interpretations of their intrusive thought so they do not feel that they need to suppress in the first place. Accordingly, several cognitive behavioural techniques may be used to challenge client's maladaptive beliefs about the meaning and importance of intrusive thoughts and reduce suppression efforts. Other emerging treatment strategies, such as CBM-I and acceptance-based approaches, may also prove useful in promoting more adaptive responses to obsessional thoughts. Future research should continue investigating the mechanisms by which suppressing thoughts maintains OCD.

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Danger Ideation Reduction Therapy for Obsessive–Compulsive Disorder: A Brief Overview

Mairwen K. Jones, PhD and Lisa D. Vaccaro, PhD

University of Sydney, Australia

Abstract Obsessive–compulsive disorder (OCD) is a common and debilitating condition. Excessive, ritualised, time consuming checking and washing compulsions are frequently experienced by people living with this disorder. While current pharmacological and behavioural OCD treatments can be effective for many people with OCD, there are significant limitations to both approaches. As such, the development of alternative treatment options is warranted. This paper describes cognitive psycho-educational treatment packages – danger ideation reduction therapy (DIRT) for OCD washing (DIRT-W) and OCD checking (DIRT-C). These were developed specifically to reduce danger beliefs, and thus assist the person to develop more realistic beliefs about both the likelihood and severity of bad things happening. Findings regarding the effectiveness of DIRT-W and DIRT-C will be presented. While further research is required, the current evidence suggests that DIRT-W and DIRT-C are promising treatments for the repertoires of clinicians treating people living with this distressing and disabling disorder. 7This paper provides a description of the two danger ideation reduction therapy (DIRT) treatment packages: DIRT for OCD washing (DIRT-W; Jones & Menzies, 1997a; Jones & Menzies, 1998a; St Clare, Menzies & Jones, 2008), and DIRT for OCD checking (DIRT-C; Vaccaro, Jones, Menzies, & St Clare, 2010). The paper will begin with a brief discussion of the theoretical underpinnings of DIRT, specifically the threat expectancy model of OCD. The findings from research conducted to date on DIRT-W and DIRT-C will also be presented.

Obsessive–Compulsive Disorder and Treatment Obsessive–compulsive disorder (OCD) is a common disorder with a lifetime prevalence of between 1.6% and 3% (Karno, Golding, Sorenson, & Burnam, 1988; Kessler et al., 2005; Weissman et al., 1994). In the general Australian population, OCD has a 12-month prevalence rate of 1.9% (Australian Bureau of Statistics, 2009). OCD is often distressing and debilitating and is frequently accompanied by isolation, family dysfunction, difficulty forming and maintaining relationships, and unemployment (e.g., de Silva, 2003). Excessive, ritualised, time consuming checking rituals and related obsessions are frequently experienced by people with this condition (e.g., Fullana et al., 2009; Samuels et al., 2006); they occur in approximately 80% of patients (Ball, Baer, & Otto, 1996; Rasmussen & Tsuang, 1986; Summerfeldt, Antony, Downie, Richter, & Swinson, 1997). Obsessions about contamination and washing/cleaning compulsions are also common features of this disorder (de Silva, 2003; Karadag, Oguzhanoglu, Ozdel, Atesci, & Amuk, 2006; Rasmussen & Eisen, 1992). The two dominant OCD treatment approaches are pharmacotherapy, using serotonin reuptake inhibitors (SRIs), and behaviour therapy in the form of exposure and response prevention (ERP). Both are moderately effective. For example, 40–60% of OCD patients respond to an SRI (Jenike, 2004), and


response rates for ERP range from 63% to 90% (Riggs & Foa, 1993; Stanley & Turner, 1995). However, relapse rates after SRI discontinuation are as high as 90% (Pato, Zohar-Kadouch, Zohar, & Murphy, 1988) and side effects from taking medication may also occur (e.g., Fava, Thase, & Debattista, 2005). Refusal rates for ERP of 25–30%, and dropout rates of about 28%, have been reported (Emmelkamp & Foa, 1983; Foa et al., 2005; Kozak, Liebowitz, & Foa, 2000). As such, the development of alternative treatment options is warranted.

Theoretical Bases Many theorists and clinicians have identified cognitions of danger in individuals with obsessive–compulsive washing (OC-W; e.g., Cloke, 2011) and obsessive–compulsive checking (OC-C; e.g., de Silva & Rachman, 1992; Rachman 2003). Many people with OCD can readily name feared outcomes associated with not performing their rituals. For example, the possibility of a fire leads to the checking of electrical appliances, wires, and stoves; fear of burglary, to checking of windows and door locks (de Silva & Rachman, 1992; Marks, 1987). Findings that provide support for the threat expectancy account of OC-W and OC-C have been reported. Jones and Menzies (1997b) showed that threat expectancies were the most likely cognitive mediators of washing-related behaviour in OCD patients. They also demonstrated that increasing beliefs of the likelihood and severity of harmful outcomes led to increases in OC-W symptoms, including avoidance and hand washing (Jones & Menzies, 1998b). Additionally, Overton and Menzies (2002) found significant differences on ratings of harm between 21 OCD checkers and 21 nonclinical controls, and that changes in perception of danger significantly correlated with improvement in compulsive checking behaviours in a weekly analysis during treatment (Overton & Menzies, 2005). Similarly, changes in perception of threat have been found to correlate with improvements in OC-W symptoms (Jones & Menzies, 1998a).


The notion that threat expectancies play an important role in OCD was proposed four decades ago by Carr (1974) who argued that optimal treatment of OCD must involve procedures that maximise a patient's opportunity to decrease excessive danger beliefs (e.g., "a therapeutic technique that maximises the patient's opportunity for acquiring new subjective estimates of the probability of unfavourable outcomes", p. 317). Both DIRT-W and DIRT-C were developed specifically to reduce danger beliefs and thus assist the person to develop more realistic beliefs about both the likelihood that bad things would happen and how severe they would be if they did occur.

The Development of DIRT The original DIRT-W was developed for OC-W in the late 1990s (Jones & Menzies, 1997a) and the treatment manual was available for therapists in 2008 (St Clare et al., 2008). DIRT-W is a brief and inexpensive package to administer. Substantial reductions in OCD symptomatology have been achieved in as few as six clinical hours (Jones & Menzies, 1997a; Jones & Menzies, 1998a; Krochmalik, Jones, & Menzies, 2001). The therapy is highly structured and manualised (see St. Clare et al., 2008; Vaccaro, Jones, Menzies, & St Clare, 2010) and does not include direct or indirect exposure, behavioural experiments, or response prevention so the person is not required to confront aversive, anxiety provoking stimuli. Unlike other cognitive therapy packages, biased reasoning styles, such as inflated personal responsibility (e.g., van Oppen & Arntz, 1994), are not addressed.

Research Evaluating the Effectiveness of DIRT A number of treatment trials have demonstrated the therapeutic benefits of this new approach (Drummond, Pillay, Kolb, & Rani, 2007; Jones & Menzies, 1997a; Jones & Menzies, 1998a; Krochmalik, Jones, Menzies, & Kirkby, 2004), even for those who have poor insight and are not helped with standard therapy (Krochmalik et al., 2001). During 2003 to 2008, five case reports verified the usefulness of DIRT-W (Drummond & Kolb, 2008; Govender, Drummond, & Menzies, 2006; Hambridge & Loewenthal, 2003; O'Brien, Jones, & Menzies, 2004; St Clare, 2004). More recently, Jones, Harris, and Vaccaro (2012) reported a case study of a 50-year old female with a 20-year history of OC-W who took part in a 14-week self-administered DIRT-W program. They found decreases of between 23% to 33% on measures of OCD and depression from pre-treatment to 3-month follow-up. Following the promising findings regarding the effectiveness of DIRT-W, and results demonstrating the importance of danger beliefs in OCD checking, DIRT-C was developed (Vaccaro, Jones, Menzies, & Wootton, 2010). This involved the modification of the components of DIRT-W, which were adapted to address the dominant concerns and specific threat expectancies observed in OCD checkers. As will be described, additional novel components were also formulated.

Evidence for the effectiveness of DIRT-C has been reported in a small pilot series (Vaccaro, Jones, Menzies, & Wootton, 2010) and a randomised clinical trial that compared

DIRT-C to ERP in a sample of 50 OCD checkers (Vaccaro, Jones, Menzies, & Wootton, 2013). The findings indicated that while both ERP and DIRT-C were effective, participants receiving DIRT-C experienced greater reductions in OCD symptoms from post-treatment to follow-up than those receiving ERP. Further, Jones, Wootton, and Vaccaro (2012) reported the effectiveness of DIRT-C for an 86-year old man with a 63-year history of OCD-C. Clinician-based Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989; Goodman, Price, Rasmussen, Mazure, Fleischmann, et al., 1989) scores reduced 84% from 25 (severe) at pre-treatment, to 4 (subclinical) at 6-month post-treatment follow-up interview.

DIRT-W and DIRT-C DIRT components that are common to both DIRT-W and DIRT-C are attentional focusing, cognitive restructuring, filmed interviews, the probability of catastrophe, and corrective information. With the exception of attentional focusing, all components have been tailored to the specific issues and themes related to OCD washing or OCD checking. Each package has additional novel components: the microbiological experiments in DIRT-W, and the double-checking experiments and relapse prevention components in DIRT-C. Brief discussions of each follow. Attentional Focusing This procedure, described in detail by Clarke and Wardman (1985), is a focusing task used to reduce the frequency of intrusive thoughts by increasing ability to attend to alternative cognitive targets in a rhythmic breathing exercise. Daily practice of attentional focusing, consisting of two 10-min focusing sessions, is prescribed. To assist this process, an instruction sheet and task monitoring form were developed. Cognitive Restructuring This component combines elements of systematic rational restructuring (Goldfried & Goldfried, 1980) and rational–emotive therapy (Ellis, 1962, 1994). Clients identify their irrational thoughts (e.g., relating to contamination/illness as per DIRT-W, or fire/theft/loss as per DIRT-C). They are asked to re-evaluate these so they are more realistic and accurate given the situation. Once constructed, clients are advised to spend 15 minutes per day rote learning these reappraisals, by reading, copying, and elaborating further. Later sessions involve demonstrations of applying and adapting reappraisals to novel situations. Filmed Occupational Interviews In a series of filmed interviews, workers employed in a variety of occupations discuss frequent job-related tasks that are typically anxiety-provoking for OCD washers (e.g., a bank teller touching money, a laboratory worker touching chemicals, a gardener touching garden soil), or for OCD checkers (e.g., an electrical appliance salesperson turning off appliances and locking up at work at the end of a day, a pathology laboratory technician making up specific concentrations of drugs or chemicals). Workers are


questioned about the frequency of negative outcomes (e.g., poor health and high level of sick leave as per DIRT-W; forgetting to turn off appliances, or lock up at work, and the shop being burnt down or robbed, as per DIRT-C) The absence of anxiety in these workers when performing these tasks, and the lack of work-related harmful consequences, are highlighted. Worksheets require the participant to consider the information provided by each interviewee. The Probability of Catastrophe The probability of catastrophe procedure is based on that of Hoekstra (1989). The client compares their initial global estimate of the probability of a feared event occurring, with an estimate derived from an analysis of the sequence of events necessary for that feared event to occur. Each scenario, such as one's house being robbed if doors are left unlocked during the day when at work, is broken down into a sequence of steps that are required to occur for a harmful outcome to eventuate. Discrepancies are highlighted and discussed. For example, a client with OC-W may initially calculate the probability of developing an illness, after handling a garbage bin while putting it out for collection, as 0.9, or 90%, likely. The client then rates the likelihood of each of the steps necessary for contact with the bin to result in illness (e.g., disease-producing bacteria are present on the bin (0.9), bacterial transfer to hand occurs (0.7), bacteria enter the body (0.3), initial immune system failure occurs (0.2)). The probability estimates for each step in the sequence are multiplied together to give a new estimate of the likelihood of the catastrophic event occurring (here, 0.038, or 3.8%). Incongruities between the individual's initial global estimates and those obtained through the probability-sequencing task are highlighted and form the basis of worksheets. This task illustrates to clients their bias towards perceiving the probability of an event as much higher than it really is. Clients are encouraged to adopt this process when challenging thoughts about the likelihood of their particular feared outcomes. DIRT-W comprises 10 catastrophic scenarios. Fifteen scenarios were developed for DIRT-C since OCD checkers tend to have a wider variety of concerns. These include risk of explosion and killing neighbours if a gas tap is leaking or gas has been left on, risk of losing money if it is transferred into the wrong bank account because the incorrect details were written on the bank transfer form, and the risk of hitting someone, without knowing it, while driving. The DIRT-C package provides clients with an information sheet describing and illustrating the task, along with worksheets covering the 15 catastrophic scenarios commonly expressed in OC-C concerns. Corrective Information Fact sheets and worksheets are provided that address a wide range of common fears relevant to OC-W (e.g., the immune system, HIV-AIDS, rates of disease and illness) and OC-C (e.g., driving, electricity and gas safety, house fires, burn injuries, and motor vehicle theft). Information about normal non-checking and non-washing behaviours of people who do not have OCD, and the realistic consequences of not performing these excessive washing or checking compulsions, are also discussed. The information in this component highlights common misconceptions about

the probability and severity of the harm that can realistically occur. The corrective information components in both DIRT packages include a range of fact and corrective information sheets along with corresponding worksheets. Microbiological Experiments The results of a series of microbiological experiments conducted at the Microbiology Department of the University of Sydney form the basis of this component. Each experiment involved analysing the number and type of microorganisms present on a human hand that had been in contact with stimuli commonly found to be anxiety-provoking to OCD-washers (e.g., cats, garbage bin liners, public toilet doors, people's hands) compared to the number and type of microorganisms present on a 'control' hand which had not been in contact with the stimuli. The number and type of microorganisms present on the 'contaminated' and control hands were analysed through isolating the microflora from the fingerprints on microbiological agar plates that were incubated for 24 hours at 37 degrees Celsius. The number of organisms growing on the plates at each fingerprint site was counted, and their potential for pathogenicity determined. The results of all experiments showed that no potentially pathogenic organisms were isolated from either the contaminated or control plates. A microbiologist concluded that contact with the stimuli did not lead to the presence of any dangerous or pathogenic organisms. Worksheets required the participant to consider their estimates of risk of contamination. Double-Checking Experiments The double-checking experiment component involves the discussion of experiments conducted by Radomsky, Gilchrist, and Dussault (2006) and van den Hout and Kindt (2003, 2004). These studies showed that compulsive checking (e.g., to see if a door is locked, a stove is turned off, or an offensive word is not written in an email) heightened memory distrust and doubt and reduced confidence in one's memory. The findings highlighted the fact that repetitive checking was detrimental to the aim of achieving certainty, since the more a person checked, the less confident they became about whether or not they did actually check. This information is presented and discussed, and supported by worksheets. Relapse Prevention The final session formalises preparation for clients to move forward with the skills they have learnt. Clients review their progress, identify the techniques most useful in overcoming their OCD, and plan for utilising these in the future.

Considerations when Planning DIRT Sessions While there is no prescribed order of presentation for the components described above, it is recommended that, to maximise their efficacy, the treatment components are used concurrently. Additionally, when planning the order of sessions, the clinician should be aware that early components could act as groundwork for later components.


Since cognitive restructuring is the cornerstone of DIRT-W and DIRT-C, it should be presented early in therapy and incorporated into all other treatment components to challenge existing thoughts and beliefs about the probability and severity of harm or error. The novelty of components for the client could potentially affect their expectancies of change and motivation. Therefore, if the client has previously undertaken meditation or breathing type interventions and not found them to be helpful, it may be preferable to introduce attentional focusing in a later session. However, the therapist needs to keep in mind that mastery of the attentional focusing component requires approximately six weeks of daily practice.

Conclusion Findings regarding the effectiveness of DIRT-W and DIRT-C highlight the benefits of directing efforts toward reducing danger expectancies in people with OCD washing or checking concerns. Additionally, DIRT overcomes some of the recognised limitations of other dominant treatment approaches, such as SSRIs and ERP. However, while the gains experienced by participants receiving DIRT-W or DIRT-C are substantial, further research is clearly warranted.

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Biological Aspects of Obsessive–Compulsive Disorder

Cathrin Kusuma1, MBBS, Malcolm Hopwood2, MD, and David Castle2, MD

1 Albert Road Clinic, Melbourne, Australia 2 University of Melbourne, Australia

Abstract Obsessive–compulsive disorder (OCD) is a debilitating disorder. Treatment often includes medication in combination with psychological therapy. This article provides an overview of the aetiology of OCD, along with the most recent evidence for biological treatments, and the role that psychiatrists can have in managing patients with OCD. First- and second-line treatments (medications) are considered, as well as their varied side effects which need to be balanced with their benefits. Additionally, deep brain stimulation is a promising new treatment; however, its use has been restricted due to the invasive nature of the procedure. 8

Obsessive–compulsive disorder (OCD) is characterised by obsessions (recurrent thoughts, images, or impulses that are intrusive and may be experienced as egodystonic) and compulsions (behaviours or mental acts which are performed in order to neutralise the obsession, or reduce the anxiety it causes) that are time consuming (taking over 1 hour a day), and that cause distress and disability. It is often an enduring disorder with an estimated prevalence of 1% to 3% of the population (Castle, Olver, & Crino, 2012). It commonly starts in childhood, with males tending to have an earlier onset, but by adulthood both males and females are equally affected. Untreated, OCD often has a fluctuating, unremitting course which can severely affect quality of life (Hollander, Stein, Fineberg, Marteau, & Legault, 2010), with pervasive functional impairment affecting education, work, social life, and relationships (Castle et al., 2012).

Conceptualisation and Symptomatology of OCD In the recently released DSM-5 (American Psychiatric Association, 2013), 'obsessive–compulsive and related disorders' is now a separate chapter, reflecting the evidence that they are distinct from the other anxiety disorders. The 'related disorders' include body dysmorphic disorder, trichotillomania, hoarding disorder, and excoriation disorder. OCD symptoms tend to fall into three clusters (Stein et al., 2009): (1) Symmetry obsessions, and repeating, ordering, and counting compulsions; (2) Forbidden thoughts, aggressive, sexual, religious, and somatic obsessions, and checking compulsions; and (3) Obsessions and compulsions related to contamination and cleaning.

Differential Diagnosis and Comorbidity As OCD requires a specific approach to treatment, it is important to diagnose accurately. Obsessions and compulsions can occur in a number of other psychiatric disorders – for example, intrusive thoughts or images can occur in posttraumatic stress disorder; obsessive ruminations, in depression; and obsessions and compulsions, in


schizophrenia. Vigilance for the symptoms of OCD is also necessary because patients may present for treatment only when suffering from comorbid disorders (such as depression, alcohol, or substance abuse) or secondary consequences, such as functional impairment.

Aetiology Recent evidence suggests that OCD arises from a dysregulation of neurocircuitry in the orbitofrontal-striatal areas via serotonergic and dopaminergic mechanisms

(Fineberg, Chamberlain, Hollander, Boulougouris, & Robbins, 2011). Evidence for the areas of the brain involved comes from neuroimaging in patients with OCD. Investigations undertaken when OCD symptoms are present have indicated increased blood flow or glucose metabolism in the basal ganglia (the caudate and putamen, known collectively as the striatum), and the orbitofrontal and anterior cingulate cortex (Saxena, Brody, Schwartz, & Baxter, 1998). Once the OCD symptoms have been reduced through treatment (either by therapy or medication), blood flow or glucose metabolism in those regions has been found to be reduced. Additionally, the limbic system is also thought to be implicated, and is believed to be a factor in the affective and anxiety components of OCD (Corse et al., 2013). This knowledge has led to therapies aimed at ablating or disrupting the neurocircuitry between those regions – for example, psychosurgery and, more recently, deep brain stimulation. Evidence for the neurotransmitters involved in OCD has largely implicated the serotonergic system, as drugs that strongly block the reuptake of serotonin at the synapse (such as selective serotonin reuptake inhibitors [SSRIs]) have shown benefit, whereas antidepressant drugs with little serotonin reuptake activity (such as noradrenaline reuptake inhibitors) have been ineffective (Fineberg & Gale, 2005). Other neurotransmitters thought to be involved include dopamine and glutamate (Fineberg, Reghunandanan, Brown, & Pampaloni, 2013). Trials of medications targeting these neurotransmitters have produced some promising, albeit inconsistent, results, and they are increasingly being used as adjunctive therapy when SSRI treatment alone has failed.


Evaluating Severity and Treatment Response in OCD

The Yale-Brown Obsessive Compulsive Scale (Y-

BOCS; Goodman et al., 1989) is a widely used rating scale that is used to evaluate the severity of OCD, and, when administered after a suitable interval, response to treatment. It is a 10-item, clinician administered scale with five questions each for obsessions and compulsions – the scores can be considered separately to indicate severity of obsessions and compulsions, or added to provide an approximate index of overall severity. However, whilst there is "no universally accepted definition of treatment response or remission in OCD" (Fineberg & Brown, 2011, p. 419), it is often accepted as a period of time during which the symptoms of OCD no longer interfere with daily life (Simpson, Huppert, Petkova, Foa, & Liebowitz, 2006). For example, the patient may still have symptoms of OCD, but spends less time obsessing and performing compulsive behaviours, such that they are less disruptive at work or school.

As the symptoms of OCD can impact on many domains of a patient's life (e.g., family, social, leisure, work), a rating scale that examines this in a broader sense is a useful adjunct in measuring a patient's quality of life at the start of, during, and after treatment. Scales, such as the World Health Organization Quality of Life Survey (World Health Organization, 2002), can help to show the patient how much OCD has affected their life.

Psychological Therapy In the treatment of OCD, the decision to commence

psychological therapy, pharmacotherapy, or both as a first-line is based on patient choice and the availability of each form of treatment. Factors influencing a patient's choice may include access to therapy, weighing up the risks and benefits of medication, and the severity of symptoms. In patients with particularly severe OCD, medication treatment may assist in diminishing symptoms so that the patient can then engage in psychological therapy. Cognitive behaviour therapy (CBT) that involves an exposure and response prevention component has the best evidence of the psychological therapies (Koran, Hanna, Hollander, Nestadt, & Simpson, 2007) and indeed is also recommended as first-line therapy in a variety of clinical guidelines for the treatment of OCD. Whilst there is little information available regarding the benefits of medication and CBT in combination, CBT should be considered essential for the treatment of OCD, with some follow-up studies suggesting that it may "delay or mitigate relapse" when medication treatment is ceased (Koran et al., 2007, p. 9). First-Line Biological Treatment Based on evidence from randomised controlled trials, SSRIs and clomipramine (from another family of antidepressant medications called tricyclics) are considered first-line medications for the treatment of OCD (Kellner, 2010). A variety of generic brands is available for each of the first-line medications (see Table 1).

Table 1 Australian Brand Names of First-Line Medications Used for Treatment of OCD Generic name Brand names Clomipramine Anafranil Citalopram Celepram, Celica, Ciazil, Cipramil, Talam Fluoxetine Auscap, Fluohexal, Lovan, Prozac, Zactin Fluvoxamine Faverin, Luvox, Movox, Voxam Paroxetine Aropax, Extine, Paxtine, Roxet Sertraline Eleva, Sertra, Sertracor, Zoloft, Sertrona, Xydep Escitalopram Cilopam-S, Escicor, Esipram, Esitalo, Lexam, Lexapro, Loxalate

In determining the suitability of a medication for a patient, it is important to recognise that "a drug's clinical effectiveness is dependent on the balance between efficacy, safety and tolerability" (Fineberg & Brown, 2011 p. 423). For

this reason, although meta-analyses have found clomipramine to be superior to SSRIs, SSRIs are still often prescribed first, as they are better tolerated and have fewer worrisome side effects (see Table 2).


Table 2 Actions and Side Effects of Clomipramine and SSRIs Drug Actions Side effects Clomipramine Inhibit serotonin and noradrenaline Sedation, blurred vision, dry mouth, uptake, as well as having effects on constipation, urinary retention, weight other neuroreceptors gain, postural hypotension Can cause serious cardiac side effects in higher doses/overdose SSRIs Slow down reabsorption of Nausea, indigestion, diarrhoea, serotonin in gaps between nerve headache, irritability, sleep disturbance, cells sexual dysfunction, drowsiness

In regard to the many SSRIs available, a Cochrane review of the drugs citalopram, fluoxetine, fluvoxamine, paroxetine, and sertraline found none was superior to the others (Soomro, Altman, Rajagopal, & Oakley-Browne, 2008). However, for all these medications, higher doses than those used to treat depression are necessary, and the response is expected to be slow (in the order of 12 weeks) before it can be adequately assessed (Castle et al., 2012). Thus, it is

advisable for the patient to take the medication at the highest tolerated dose for a minimum of 12 weeks before its effectiveness is assessed. Regardless of the dose, side effects can be minimised by increasing the dose slowly, over weeks and even months if necessary. Table 3 sets out the usual and OCD dose ranges, and titration, for first-line OCD treatment drugs.

Table 3 Usual and OCD Daily Dose Ranges, and Titration, for First-Line OCD Treatment Medications Drug Usual daily dosage Titration OCD daily dosage Clomipramine 100mg to 250mg Start at 25mg daily, increasing 100 to 250mg by 25mg every few days Citalopram 20mg to 40mg Start at 20mg daily, increasing 60mg to 100mg by 10mg weekly Fluoxetine 20mg to 60mg Start at 20mg daily, increasing 60mg to 100mg by 20mg weekly Fluvoxamine 50mg to 300mg Start at 50mg daily, increasing 300 to 400mg by 50mg every 4 days Paroxetine 20mg to 60mg Start at 20mg daily, increasing 60mg to 100mg by 10mg weekly Sertraline 50mg to 200mg Start at 25mg daily, increasing 200mg to 400mg by 25mg every 4 days Escitalopram 10mg to 20mg Start at 10mg daily, increasing 40mg to 50mg by 10mg every 4 days

In those who have responded to treatment, there is evidence that continued medication at higher doses can confer additional improvements (Romano, Goodman, Tamura, & Gonzales, 2001), indicating that longer-term treatment continues to be effective. Treatment should be continued for at least 12 to 18 months to prevent relapse,

and patients often require lifetime treatment (National Institute for Health and Clinical Excellence, 2005).

Second-Line Biological Treatments In terms of medications, augmentation with a drug from a different class can be considered after two


consecutive trials with different SSRIs have failed. The addition of clomipramine to an SSRI is a combination that requires careful monitoring of the patient's electrocardiogram, and consideration of whether the drugs may interact with each other's excretion from the body

(Fineberg & Brown, 2011). Atypical antipsychotics have effects on dopamine, serotonin, and other neurotransmitters. They are increasingly used to augment SSRI therapy in OCD patients. Whilst there are at present few trials investigating the effects of adding an atypical antipsychotic to an SSRI regime, a Cochrane review found that there is some evidence that adding quetiapine or risperidone increases efficacy (Komossa, Depping, Meyer, Kissling, & Leucht, 2010). However, use of an antipsychotic as monotherapy to treat OCD has not generally been shown to have beneficial effects; indeed, some may exacerbate obsessive–compulsive symptoms. Other, more novel medications include adjunctive morphine, glutaminergic agents, and topiramate (Castle et al., 2012); however, more research is needed to assess their effectiveness.

Despite medication and cognitive behaviour therapy, there may still be a significant proportion of patients (approximately one third in double-blind, placebo controlled studies) who do not experience substantial benefit (Kronig et al., 1999). In cases of extremely severe treatment-resistant OCD, neurosurgical interventions may be considered. Research has focused on ablating the connections between the frontal lobes and subcortical structures, or neuromodulation methods. Neurosurgery to ablate connections between areas of the brains, such as cingulotomy, capsulotomy, and limbic leucotomy, are performed with modern stereotactic techniques, and have been shown to offer some relief for patients with previously severe, untreatable OCD (Corse et al., 2013). However, the irreversible nature of the treatments, and the difficulty in determining longer term side effects, mean that they should only be considered treatments of last resort.

Deep brain stimulation is a form of neuromodulation treatment, consisting of electrodes surgically implanted in the brain at specific sites, to deliver electric charges. These then cause modulation of the underlying neurocircuitry, which in effect mimics a lesion there. Unlike ablative techniques, this is reversible. So far, the results from small, uncontrolled trials have been promising, with response rates of up to 50% (Fineberg & Brown, 2011). However, more research is needed to identify the optimal targets and stimulation parameters. For example, recent studies have identified that stimulation at the ventral capsule/ventral striatum site has effects on mood, anxiety, obsessions, and compulsions, whilst stimulation at the subthalamic nucleus has effects only on compulsions (Corse et al., 2013).

The Treatment Team

Psycho-education and the development of a therapeutic alliance are vital in engaging the patient as an active participant in their treatment. The general practitioner often plays a role in making the initial diagnosis, excluding other medical diagnoses, facilitating referrals to OCD specialists and support agencies, and prescribing medication

and monitoring its effects. They are also important sources of support and psycho-education for the patient and their family. The clinical psychologist is an essential part of the treatment team, both in providing acute CBT and longer term follow-up or 'booster' sessions. They are also well placed to provide psycho-education about CBT, as well as realistic expectations about the challenges that CBT may raise, along with the benefits.

Referral to a psychiatrist should be considered if there are difficulties in any of the assessment, treatment, or maintenance processes. Commonly, this involves uncertainties in diagnosis (e.g., unusual symptoms, comorbidities), treatment resistance, or increased risk to self or others. As medical practitioners, psychiatrists are able to consider a patient's other medical issues and analyse the impact OCD or OCD treatment may have on them. They have undergone further training in a range of treatment modalities (Patton, 2014), including pharmacotherapies, and can provide advice in this field, particularly if tolerability has been a problem. Depending on the patient's needs, psychiatrists can provide once off opinions or ongoing care, in collaboration with the clinical psychologist, general practitioner, the patient's family, and any other health professionals or social agencies involved.

Other Considerations in the Treatment of OCD

Whilst the majority of patients with OCD are treated in an outpatient setting, in some circumstances, treatment as an inpatient is necessary. This usually involves situations of risk to life, extreme functional impairment such that activities of daily living are substantially impaired, or the presence of comorbid conditions that threaten treatment (Castle et al., 2012). In these circumstances, a psychiatrist may be able to help facilitate admission to a psychiatric hospital. Psychosocial rehabilitation may also be necessary if a patient has had longstanding OCD, with impairment of their psychosocial development. Whilst there is a scarcity of psychosocial rehabilitation services specific to OCD in Australia, rehabilitation targeted at developing independent living may be accessed via nongovernment organisations, or the public mental health system.

For some individuals, consumer-based organisations can be invaluable in reducing the sense of isolation and misunderstanding that can be part of the experience of OCD. In Australia, such organisations as the Anxiety Recovery Centre Victoria and the Anxiety Disorders Associations of Victoria offer online information, as well as regular support groups and short practical recovery programs and workshops. These can be a useful resource to recommend to patients, and their families and friends.

Conclusion The treatment of OCD can be both challenging and rewarding, as it is a disorder that has a strong evidence base for psychological and biological treatments. However, it has high rates of comorbidities and follows a chronic course. Medication is an important mode of treatment for OCD, optimally in combination with psychological treatments. However, the benefits of medication need to be balanced with possible side effects, which may vary in severity and


tolerability. Thus, close liaison among the patient's clinical psychologist, general practitioner, and psychiatrist is important. Psychiatrists are well placed to provide advice about assessment and treatment, particularly in cases of severe or treatment resistant OCD.



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Internet-Delivered Cognitive Behaviour Therapy (iCBT) for Obsessive–Compulsive Disorder

Bethany M. Wootton1, PhD and Gretchen J. Diefenbach2, PhD

1 University of Tasmania, Australia

2 Anxiety Disorders Center/Center for Cognitive Behavioral Therapy, Institute of Living, Hartford Hospital, USA Abstract Obsessive–compulsive disorder (OCD) is a common psychiatric condition that causes a considerable impact on the functioning of the client and is costly to society. Fortunately, effective cognitive behavioural treatments exist, and include exposure and response prevention as the primary treatment approach. However, many clients face multiple barriers to accessing empirically supported treatment. Internet-delivered cognitive behaviour therapy (iCBT) has recently been investigated as a way to reduce barriers and improve access to empirically supported treatment for OCD. This article reviews the efficacy of iCBT for OCD and discusses the barriers to the wider dissemination of this innovative treatment format. 9Obsessive–compulsive disorder (OCD) is a common mental health condition, with a lifetime prevalence rate of approximately 2% in Australia (Australian Bureau of Statistics, 2007), and a similar prevalence rate is seen in other developed countries (Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012). Recent research indicates that the age of onset may be bimodal (onset peaking at ages 13 and 25) (Anholt et al., 2014), and OCD is often diagnosed in women more than men (Kessler et al., 2012). Symptoms include a heterogeneous constellation of obsessions (intrusive and unwanted thoughts, images, urges, or doubts) and compulsions (repetitive and time consuming overt or covert behaviours). Contemporary conceptualisations report four main symptom categories or subtypes: (1) Contamination obsessions and cleaning compulsions; (2) Responsibility obsessions and checking or repeating compulsions; (3) Unwanted and egodystonic sexual, aggressive, or religious obsessions with mental rituals, and; (4) Ordering and arranging obsessions and compulsions (Williams et al., 2011). OCD commonly co-occurs with anxiety, mood, and personality disorders (Ruscio, Stein, Chiu, & Kessler, 2010; Torres et al., 2006), and the disorder causes considerable impact on the individual's quality of life (Ruscio et al., 2010). OCD is extremely costly when incorporating both direct and indirect costs of treatment, with estimates of costs in the United States equating to US$8.4 billion per year (DuPont, Rice, Shiraki, & Rowland, 1995). Effective cognitive behavioural treatments for OCD exist, and use exposure and response prevention (ERP) as the core treatment component. Contemporary ERP involves (1) exposure in-vivo (confronting the OCD trigger in real life); (2) imaginal exposure (confronting the OCD trigger in imagination); (3) response prevention (eliminating compulsions); and (4) a processing component (discussing with the client the outcome of the exposure and what they learnt from it) (Foa, 2010). ERP has been used successfully


since the 1960s (Meyer, 1966). However, despite the well documented efficacy of ERP (Eddy, Dutra, Bradley, & Westen, 2004; Rosa-Alcázar, Sánchez-Meca, Gómez-Conesa, & Marín-Martínez, 2008), there are many barriers to accessing this treatment, including the cost of treatment, geographical isolation, lack of access to trained clinicians, and stigma (Baer & Minichiello, 2008; Belloch, Valle, Morillo, Carrió, & Cabedo, 2009; Goodwin, Koenen, Hellman, Guardino, & Struening, 2002; Marques et al., 2010). Unfortunately, when clients do access treatment services, they are often provided with a non-evidence-based intervention, or inefficient dose of ERP (Stobie, Taylor, Quigley, Ewing, & Salkovskis, 2007), which is detrimental not only to the client (because their symptoms are unlikely to remit without treatment), but also the profession (as the client disengages from therapy and considers it ineffective). Internet-delivered cognitive behaviour therapy (iCBT) can be used as a way to overcome these barriers and improve access to evidence-based interventions for OCD. iCBT involves the same components of effective face-to-face treatment, but the treatment information is provided via a secure online web portal. Often this information is supplemented with brief clinician contact (either via email or telephone); however, self-guided treatments have also been investigated. Recently, a number of research groups have investigated the efficacy of internet-delivered treatments for OCD, with at least four programs worldwide demonstrating treatment efficacy. An overview of the literature to date is provided in Table 1, and the outcomes are discussed in detail below. Australia is well placed to be a leader in the provision of iCBT for OCD due to our national registration system for psychologists (which allows a clinician to work with clients located in different states across the country) and a large proportion of the population living outside a large city (Australian Bureau of Statistics, 2014) (as these are likely to have difficulty accessing evidence-based treatment).


Table 1 Overview of Effect Sizes in iCBT for OCD

Study Study

location Type of trial n

Length of intervention

(weeks) Pre-treatment to post-treatment

Pre- treatment

to follow-up

Guided interventions Andersson et al. (2011)

Sweden

Open trial

23

15

1.56

-

Wootton, Titov, Dear, Spence, Andrews, et al. (2011)

Australia

Open trial

22

8

1.52

1.28

Diefenbach et al. (2014)

USA

Open trial

17

17

1.15

-

Andersson et al. (2012)

Sweden

RCT

101

10

1.55

1.45

Wootton et al. (2013)

Australia

RCT

8

2.16

1.28

Wootton et al. (2013)

Australia

Open trial

56

17

8

1.11

1.56

Herbst et al. (2014)

Germany

RCT

34

8

0.83

0.89

Self-guided interventions Wootton et al. (2014) – Study 1

Australia

Open trial

16

8

1.05#

1.34#

Wootton et al. (2014) – Study 2

Australia

Open trial

33

10

1.37#

1.17#

Note. Effect sizes in this table are within-group effect sizes on the Y-BOCS, calculated using Cohen's d. # Self-report version of the Y-BOCS was used.

Three open trials investigating clinician-guided iCBT for OCD have been conducted by different research groups worldwide, and generally demonstrate similar outcomes. In the first open trial, conducted at the Karolinska Institutet, Sweden, 23 participants completed a 15-week iCBT program, supplemented with regular (more than once a week), but brief, therapist email contact (Andersson et al., 2011). This study found large effect sizes at post-treatment (d = 1.56), and 61% of participants were classified as treatment responders (Andersson et al., 2011). In the second open trial, conducted at the eCentreClinic, Australia, 22 participants completed an 8-week intervention, with brief (less than 10 minutes), twice weekly telephone support (Wootton, Titov, Dear, Spence, Andrews, et al., 2011). Large effect sizes were found at post-treatment (d = 1.53) and 3-month follow-up (d = 1.28). At post-treatment, 71% of participants no longer met criteria for OCD (Wootton, Titov, Dear, Spence, Andrews, et al., 2011). The third open trial was conducted recently at the Institute of Living, USA, using a commercial iCBT program called OCFighter. In this study, 24 participants commenced a 17-week treatment with clinician contact provided 9 times

across the 17 weeks (Diefenbach, Wootton, Bragdon, Moshier & Tolin, 2014). The results from those who completed the treatment (n = 17) indicated a large pre-post within-group effect size (d = 1.15), and 29% met conservative criteria for remission. The results of the open trials, conducted by different research groups, produced similar findings, demonstrating preliminary evidence to support iCBT for OCD. These initial feasibility studies then led to larger randomised controlled trials (RCTs). In the largest RCT conducted to date, 101 participants were randomised to either iCBT (Karolinska Institutet program) or supportive counselling with brief, but frequent (more than once a week), clinician support (Andersson et al., 2012). Results demonstrated a large between-group effect size (d = 1.12), favouring the iCBT group, and 60% met criteria for clinically significant improvement, compared with 6% in the control condition (Andersson et al., 2012). Six months after completing the intervention, participants were randomly assigned to either a 3-week internet booster group or a


group that received no further treatment (Andersson et al., 2014). Results from this long-term follow-up study indicated that all participants maintained their treatment gains at each follow-up point (d = 1.58–2.09); however, those who received the booster treatment reported fewer relapses (Andersson et al., 2014). In the second RCT, 56 participants were randomised to either iCBT (eCentreClinic program), bibliotherapy administered CBT (bCBT), or a waitlist control (Wootton, Dear, Johnston, Terides, & Titov, 2013). Participants received twice weekly contact over the phone with a clinical psychologist. At post-treatment and follow-up, there were small and non-significant between-group differences for the active treatment conditions (d = 0.17) and both active treatments were significantly better than no treatment, with large within-group effect sizes at post-treatment (iCBT, d = 1.57; bCBT, d = 1.40). Additionally, 47% met criteria for clinically significant change at post-treatment and 27% met criteria at 3-month follow-up in the iCBT group. When the control group entered treatment, they commenced the same iCBT treatment, but the amount of therapist contact was reduced to once per week. Despite the reduction in clinician contact, participants still obtained good outcome (pre-treatment to post-treatment effect size, d = 1.11; pre-treatment to 3-month follow-up effect size, d = 1.56), and 33% met criteria for clinically significant change. Less than one hour total was required on average per participant across the 8 weeks of the treatment. In the most recently published RCT, conducted in Germany, Herbst and colleagues (Herbst et al., 2014) randomly assigned 34 participants to either immediate treatment or a waitlist control group. During the treatment, participants were contacted via an online portal only. Participants were followed up at post-treatment and 6 months post-intervention. Results from this study demonstrated a large between-group effect size (d = 0.83), and when all results were pooled (after the waitlist group commenced treatment), large within-group effect sizes at post-treatment (d = 0.83) and follow-up (d = 0.89) were also demonstrated. These initial iCBT studies were all guided, meaning that some level of clinician contact was provided (via phone or email). The amount of the contact differed, however, ranging from multiple times per week (Andersson et al., 2011; Andersson et al., 2012; Wootton et al., 2013; Wootton, Titov, Dear, Spence, Andrews, et al., 2011) to less than once per week (Diefenbach et al., 2014). Clinician contact time in these studies equated to less than 2 hours on average per participant. This represents a considerable cost saving when compared to face-to-face treatment, which often requires 14 sessions on average (with session lengths ranging from 30-120 minutes) (Abramowitz, 1996). While generally iCBT studies for other disorders demonstrate that guided interventions outperform self-guided interventions (Spek et al., 2007), stigma is a major barrier to accessing treatment for OCD (Marques et al., 2010). For this reason, self-guided iCBT options may be important for this population.

The eCentreClinic at Macquarie University has now completed two open trials investigating self-guided iCBT

interventions for OCD (Wootton, Dear, Johnston, Terides, & Titov, 2014). In the first study, 16 participants completed 5 online treatment modules across 8 weeks. There was no clinician contact at assessment or during the treatment, and participants were entered into the treatment based on a score of 16 or more on the self-report version of the Yale-Brown Obsessive–Compulsive Scale (Y-BOCS; Baer, 1991). Forty-four per cent of the participants completed all the treatment modules within the 8 weeks, and a large within-group effect size was found from pre-treatment to post-treatment (d = 1.05) and pre-treatment to 3-month follow-up (d = 1.34). Nineteen per cent met criteria for clinically significant change, and this increased to 29 per cent at 3-month follow-up. In the second open trial, the amount of time that participants had to complete the program was increased and an additional ERP module was introduced (6 modules across 10 weeks). This increased the focus on ERP as the primary treatment component, and allowed participants more time to practise ERP tasks. In this study, 33 participants completed the study and a large pre-post effect size was obtained at post-treatment (d = 1.37) and 3-month follow-up (d = 1.17) (Wootton et al., 2014). At post-treatment, 36% met criteria for clinically significant change, and 32% met criteria at follow-up. We also recently obtained results from a 12-month follow-up from this study, and found that effect sizes were maintained (d = 1.08); however, only 43% of participants responded to the questionnaires at this time-point (Wootton, Dear, Terides, Johnston, & Titov, 2014). The proportion of respondents meeting criteria for clinically significant change reduced to 25% at 12-month follow-up (Wootton et al., 2014). While replication of these findings using a more rigorous approach (such as an RCT) is required, these initial results are promising, especially considering the relatively low cost of self-guided interventions. A larger RCT investigating self-guided iCBT for OCD is currently in preparation at the eCentreClinic. Overall, the results from guided and self-guided studies indicate that iCBT for OCD is a promising treatment direction. While further research is required, an additional area of investigation is who responds best to this form of treatment, and who may be unsuitable. A preliminary investigation of such predictors of outcome has recently been completed by Diefenbach and colleagues (2014), and preliminary evidence suggests that deficits in emotion regulation, readiness to reduce avoidance of OCD triggers, and early treatment engagement may be particularly important in understanding who responds best to guided iCBT for OCD. This study found that when taking these factors into consideration, treatment response could be predicted correctly in nearly 90% of participants who commenced guided iCBT for OCD (Diefenbach et al., 2014). Identifying who is likely to improve with iCBT is important for the dissemination of such programs into wider community treatment, and may help to ascertain appropriate entry points into stepped care treatments for OCD.

Whilst the outcomes from the literature to date are promising, there are a number of barriers to the wider dissemination of iCBT programs for OCD, including therapist attitudes and the cost of developing the treatment platforms.


No study of how clinicians view iCBT, specifically for OCD, has yet been conducted. However, studies investigating the use of iCBT programs more generally have found that clinicians view these programs less favourably than do their clients. For instance, multiple studies have now demonstrated that clinicians often believe that remote treatments such as iCBT can only be successful when applied as an adjunct to face-to-face treatment, rather than as a standalone treatment (Keeley, Williams, & Shapiro, 2002; Sinclair, Holloway, Am, & Auret, 2013; Wangberg, Gammon, & Spitznogle, 2007). However, the literature indicates that, at least for other disorders, when the remote treatments are guided by a therapist, they are as effective as treatment administered face-to-face (Cuijpers et al., 2009; Kiropoulos et al., 2008; Spek et al., 2007; Wright et al., 2005). This comparison still awaits empirical evaluation in the OCD literature. An additional criticism of iCBT treatments is that the individuals who do well in them are not the same as the clients psychologists see in their practice, or are not as distressed as the typical client. However, it has been demonstrated that individuals in Australia who are interested in iCBT tend to have a similar level of distress as the general population with OCD (Wootton, Titov, Dear, Spence, & Kemp, 2011), and the Y-BOCS scores of individuals in iCBT programs are similar to those seen in face-to-face clinical trials.

In contrast with therapist attitudes, clients in iCBT programs tend to find them highly acceptable. Wootton, Titov, Dear, Spence, and Kemp (2011) found that participants identified a number of advantages of iCBT, and 53% indicated that they "definitely would" use iCBT if they were seeking treatment for OCD. This study was conducted with participants accessing an iCBT treatment website, introducing potential bias. In a separate study, however, Diefenbach and colleagues (2014) found that, in a sample that was mostly recruited from a face-to-face treatment clinic, participants equally preferred iCBT and face-to-face treatment. Additionally, in the iCBT studies conducted to date, there has been a high level of acceptability from patients. For instance, in the eCentreClinic studies, between 70-100% of participants have indicated that they were either "satisfied" or "extremely satisfied" with the program (Wootton et al., 2013, 2014; Wootton, Titov, Dear, Spence, Andrews, et al., 2011). Also, in the OCFighter program, participants reported "good" overall satisfaction on the Client Satisfaction Questionnaire (Diefenbach et al., 2014). Therefore, an important step in the dissemination of iCBT for OCD involves educating clinicians and clients about the availability and effectiveness of such treatments, both in isolation and in conjunction with existing support. A second limitation to the wider dissemination of iCBT for OCD is the cost of developing the programs. Currently, there are a limited number of clinics worldwide that provide iCBT treatments and, while they are increasing in number, there are several practical barriers associated with online research and treatment. One of these barriers is cost. For example, a recent study indicated that the cost of developing an internet platform for multiple programs was over A$1.5 million (Klein, Meyer, Austin, & Kyrios, 2011). An additional issue is that the development of iCBT interventions requires not only clinical expertise, but also the expertise of computer programmer and IT staff that are not normally found in psychological research teams; for this

reason, multidisciplinary research and clinical teams are required. Due to the high prevalence and costs associated with the disorder, improving access to treatment using cost-effective avenues is important. Therefore, an important step in addressing this barrier is for funding agencies to make grants available for research teams to develop, evaluate, and disseminate iCBT interventions more broadly.

Conclusion

OCD is a common and significant mental health problem that is costly to both the individual and society. Effective treatments have been developed; however, there are multiple barriers to accessing this treatment. Internet-delivered treatments have been developed and tested worldwide, and there is now a substantial literature demonstrating the efficacy of these interventions. Further research is required in order to understand who responds best to this treatment, and how to improve outcomes. There are a number of barriers that need to be addressed, however, to improve the dissemination of these innovative treatments, including the education of psychologists and other mental health professionals about the availability and effectiveness of iCBT interventions, and the provision of funding support to develop new internet platforms in the future.

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PhD Spotlight

Development, Evaluation, and Implementation of an Online Metacognitive Therapy Program for Obsessive–Compulsive Disorder

Caitlin Pearcy, PhD (Clinical Psychology) Candidate

Curtin University, Australia

Abstract My doctoral study explores a new approach to the treatment of obsessive–compulsive disorder (OCD) based on online delivery of metacognitive therapy (MCT). This involves the development and evaluation of an interactive website called The OCD Doctor Online, an online self-help MCT program. The project consists of two main studies: (1) Development and review of an online self-help MCT program; and (2) Online self-help MCT for OCD: A case series. A short background regarding OCD and the need for alternative therapeutic services is provided, followed by a brief explanation of each study.

10 According to DSM-5 (American Psychiatric Association, 2013), the diagnostic features of obsessive–compulsive disorder (OCD) include the presence of obsessions and compulsions. Obsessions are thoughts, images, or impulses, which are experienced as intrusive in nature. Compulsions, on the other hand, are repetitive and intentional behaviours, which occur in response to obsessions, and often reduce anxiety and fear in the short-term (Brüne, 2006). The prevalence of OCD in Australia in a 12-month period is approximately 1.9% of the adult population (Slade et al., 2009). OCD can cause significant impairments in social, occupational, academic, and other important areas of functioning, often resulting in a low quality of life (Moritz, Jelinek, Hauschildt, & Naber, 2010). The availability of effective and reliable treatment is therefore highly important. Cognitive behaviour therapy (CBT) and exposure and response prevention (ERP) are currently the gold-standard treatments for OCD (Abramowitz, 1997; Whiteside, Brown, & Abramowitz, 2008). Although clients may show symptomatic improvement, the majority of those treated with ERP are not symptom free post-treatment and may continue to experience distressing symptoms (Fisher, 2009). Refusal of treatment, withdrawal from treatment, and partial adherence to treatment are common, and demonstrate the limitations of ERP (Kozak & Coles, 2005). Such limitations have led to few professionals actually engaging in ERP therapy (Cordioli et al., 2002). As such, access to effective and reliable treatment continues to be somewhat limited within the adult population (Whiteside et al., 2008). Given the lack of available services provided to the public, as well as the limited number of professionals engaging in ERP therapy, there is a strong need for alternative evidence-based psychological treatments for

10 10 Corresponding author: [email protected]

OCD. A stepped care approach could provide a solution to this problem (Bower & Gilbody, 2005). A stepped care approach simply refers to treatments delivered at differing levels of intensity, depending on the level of need required by the client (Bower & Gilbody, 2005; Salkovskis, 2007). An internet-based self-help program for OCD fits well within this model and could act as an attractive first step to treatment. Self-help therapy is regarded as one of the lower levels or steps, and is less restrictive and intrusive than individual and group therapy. Internet delivered self-help therapy provides clients with the comfort of their own homes, as well as providing a least restrictive step to treatment, especially when treatment for OCD is not more readily available (Salkovskis, 2007). If clients are found on waitlists or cannot find any available trained specialist therapists, an online self-help treatment program could provide them with a step of therapy that they can do on their own, or whilst waiting to see a therapist if needed. Metacognitive therapy (MCT) has been trialled in individual, self-help, and group settings and found to show promising results (Fisher & Wells, 2008; Moritz et al., 2010; Rees & van Koesveld, 2008). Wells and Matthews (1994) developed an information processing model, self-regulatory executive function (S-REF), which formed the basis of MCT. This model suggests that the style of thinking of an emotional disorder is the key to the treatment of that disorder (Wells & Matthews, 1994). Maladaptive thinking styles that take the form of worry and rumination, threat monitoring, and maladaptive coping are central to MCT (Fisher & Wells, 2009). Based on the metacognitive model of OCD (Wells, 1997, 2000), MCT is focused on the meaning and significance of intrusive thoughts, in contrast with CBT, which is focused on the content of intrusive thoughts. Given that focus is not on the actual content of the thoughts, it is applicable to all subtypes of OCD (Rees & van Koesveld, 2008). Therefore, MCT may be well suited to a more generalised approach to treatment (such as group therapy and self-help therapy).


Studies have successfully applied MCT to OCD across a number of different research settings and found promising results. Fisher and Wells (2008) conducted a case series, using an A-B replication across-patients design with follow-ups at 3 and 6 months, in order to test the effectiveness of MCT for OCD. They assessed four participants who were referred to them and who met the diagnostic criteria for OCD set out in DSM-IV-TR (American Psychiatric Association, 2000). At post-treatment and 3-month follow-up, compared to pre-treatment, all four participants showed reductions in OCD symptomatology and anxiety. They also met the standardised recovery criteria on the Yale-Brown Obsessive Compulsive Scale (Y-BOCS; Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989; Goodman, Price, Rasmussen, Mazure, Fleischmann, et al., 1989). Data from one participant was not available at 6-month follow-up; however, 2 of the 3 remaining participants maintained recovery. Overall, all 3 participants continued to show reductions in anxiety and OCD symptomatology. Rees and van Koesveld (2008) conducted an open trial of group MCT for OCD. The treatment they used was based on the original version of a manual for individual and group MCT later revised by Rees and van Koesveld (2009). At 3-month follow-up, 7 out of 8 participants were found to have achieved recovery, according to the Y-BOCS. Although a preliminary study, it showed promising results for larger randomised controlled trials to be conducted in group MCT for OCD. Online treatments for OCD and other anxiety disorders are increasing, as evidenced by over 200 studies on computer and internet-based mental health interventions (Marks, Cavanagh, & Gega, 2007). A number of studies and articles have suggested that online treatments have been developed for several reasons: (1) Cost effectiveness; (2) Accessibility; (3) Availability of computers in multiple settings (e.g., homes, schools, remote areas); (4) A therapeutic tool for those who are reluctant to initiate treatment in individual or group format; (5) Improved standardisation and enhanced adherence to treatment; and (6) Lack of stigma associated with using them (Kendall, Khanna, Edson, Cummings, & Harris, 2011; Kenwright, Marks, Gega, & Mataix-Cols, 2004). Online therapy treatments bridge the gap between needing help and receiving help, particularly for some groups in need. Moritz and colleagues (2010) conducted a self-help therapy trial for OCD using an MCT program. This trial was completely self-administered with no therapist contact (pure self-help). Participants with a diagnosis of OCD were recruited online and either emailed an e-book of the MCT training program, called MyMCT, or placed on a waitlist. Participants were required to complete the MyMCT within 4 weeks, when a second assessment using the Y-BOCS, Obsessive Compulsive Inventory – Revised (OCI-R; Foa et al., 2002), and the Beck Depression Inventory - Short Form (BDI-SF; Beck & Steer, 1993; Furlanetto, Mendlowicz, & Romildo Bueno, 2005) was conducted. Participants who received the e-book showed significant reductions in OCD symptom severity from baseline to post-treatment compared to those participants on the waitlist. Moritz and colleagues suggested that the use of MCT in an online self-help format

could be an effective step in treatment when clients are unable or unwilling to attend individual or group therapy, or when this therapy is not available. Although CBT is widely used in an online format, little is known about the internet delivery of MCT. It is necessary to explore the effectiveness of online self-help MCT for OCD. This may help to provide an effective alternative when other treatment is unavailable. The aim of this paper is to provide a brief overview of two studies currently being conducted as part of a research project at Curtin University in Western Australia. Specifically, the research objectives were: (1) to develop an online self-help MCT program for individuals diagnosed with OCD; and (2) to investigate the effectiveness of online self-help MCT for OCD by conducting a case series.

Study I. Development and Review of an Online Self-Help MCT Program

In order to meet the first objective, a number of specific aims were identified for Study I: (1) Develop a self-help MCT program for OCD; and (2) Incorporate a self-help program into a multimedia internet-based intervention. Three secondary aims were also identified: (1) Conduct a review and incorporative feedback on flow, quality, and comprehensiveness of the program and website; (2) Gather qualitative information via an online survey (from a community perspective) on the essential features required in the development of an online self-help program for OCD; and (3) Incorporate findings from qualitative information in order to increase participant motivation and reduce potential dropout rates. Prior to the development of the program and website, an online survey was distributed. Sixty-four participants from the general community provided qualitative information on: (1) the motivational aspects required to complete self-help programs; (2) how to gain initial interest in online self-help programs; (3) the most popular search engines and search phrases used among participants when searching online for internet-based self-help programs; and (4) the advantages and disadvantages of self-help therapy. Thematic analysis was incorporated to analyse the data, using methods described by Braun and Clarke (2006). Each of the themes identified was reviewed and incorporated into the program and website accordingly. Treatment was based on the manual Metacognitive therapy treatment manual: Group and individual protocol (Rees & van Koesveld, 2009). The original version of this manual had been used previously by Rees & van Koesveld (2008) in an open trial of group MCT for OCD and was found to have large effect sizes. This manual was reviewed, updated, and modified for use as a pure MCT online self-help program. Furthermore, MCT strategies identified by Wells (2009) were also incorporated in the treatment program. Corresponding with the modification of the manual, a website was developed to provide the self-help MCT program to participants. The website and program were named The OCD Doctor Online. The website was developed, designed, and hosted through Squarespace, a


web-hosting platform used for creating and maintaining websites. An advisory panel (three clinical psychologists and an internet consultant and developer) was established to review and modify the manual, as well as provide feedback

on the flow, quality, and comprehensiveness of the program and website (see Table 1 for an overview of The OCD Doctor Online).

Table 1 Outline of The OCD Doctor Online Modules Part I: Engagement in therapy and introduction to MCT (weeks 1-2 of The OCD Doctor Online) Week 1 Module 1: The nature of obsessions and compulsions Module 2: Are you ready to change? Module 3: What are metacognitions and what is MCT? Week 2 Module 4: Becoming more familiar with thoughts about thoughts Module 5: Examples of metacognitions and introducing detached mindfulness Part II: Development and implementation of metacognitive skills, and maintenance (weeks 3-4 of The OCD Doctor Online) Week 3 Module 6: Over importance of thoughts Module 7: Attention training and starting to experiment Week 4 Module 8: Continuing to experiment and staying on top of it Study II. Online Self-help MCT for OCD: A Case Series In order to meet the second objective, this study evaluated the MCT program for OCD (The OCD Doctor Online) developed in Study I. This was a 4-week program that implemented strategies from Wells' (2009) metacognitive model of OCD. The aim of Study 2 was to investigate whether an online self-help treatment using MCT would reduce symptoms of OCD, reduce unhelpful metacognitions, and improve quality of life. Treatment effectiveness was assessed using a case series methodology in three consecutively referred individuals with a primary diagnosis of OCD (according to the Mini International Neuropsychiatric Interview [MINI]; Sheehan et al., 1998). Clients were recruited from referrals made to the specialised OCD outpatient treatment clinic within the Curtin Psychology Clinic in Western Australia. Symptoms were measured at three time points (pre-test, post-test, and 4-week follow-up) using the following measures: OCI-R; Depression Anxiety Stress Scales (DASS-21; Lovibond & Lovibond, 1995); Metacognitions Questionnaire – Short Form (MCQ-30; Cartwright-Hatton & Wells, 1997; Wells & Cartwright-Hatton, 2004); Y-BOCS; and Quality of Life Enjoyment and Satisfaction Questionnaire – 18 (Q-LES-Q-18; Ritsner, Kurs, Gibel, Ratner, & Endicott, 2005).

Following an initial assessment interview, participants were required to attend four weekly sessions at the clinic, at which time they completed the self-help program online. No therapeutic contact was provided during this time. Within each session participants were provided with hard copies of worksheets and extra readings. Participants were also provided with a weekly feedback questionnaire to: (1) determine compliance in completing homework and readings; (2) determine satisfaction and the usefulness of materials provided each week; and (3) provide qualitative feedback on the helpful and unhelpful aspects of the program. Graphical representation and visual inspection of the data were conducted among the three participants and across time (baseline, post-treatment, and follow-up) on the self-report measures. Clinical significance and reliable change was also calculated.

Conclusion This paper provides an overview of a current research project being conducted at Curtin University in Western Australia. The research project contains two major studies, which involve the development of an internet-based self-help MCT program for OCD, and the evaluation of this program in a case series. The findings from this research could provide evidence for alternative treatment programs available for individuals suffering from OCD.


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Obsessive–Compulsive Disorder

A Client's Perspective

Mike* 11Mike presented with obsessive–compulsive disorder (OCD) with associated significant depression and mild anxiety. Distressing, intrusive thinking centred upon ever-changing environmental health hazard concerns. This resulted in distressing, time-consuming compulsions, including extensive fact finding, constant checking of the environment, and avoidance behaviour. His family was also affected by his behaviour, as he changed focus from his own health to his children's health. Finances were depleted by buying expensive pollution measuring equipment and even moving house to a considered safer place. Following cognitive behaviour therapy, Mike improved significantly and has not had a major episode for several years.

My OCD obsessions are generally focused around environmental and health worries. For example I have had obsessions relating to air pollution from freeways, lead in water and paint dust, and asbestos. My fears centre around my family and health and the ever present dangers of environmental toxicity. I often find that an incident or thought (usually an incident) that sparks OCD is something that I recognise immediately as being a "trigger"... something uncomfortable that feels out of my control. In the moment that the incident occurs, I feel like something has changed, but can't put my finger on it. This feeling of unease makes me slightly irritated at first, as if there is something that you're trying to remember that you need to do, but have forgotten what that thing is. The feeling that there's something I've "forgotten to do" is very consistent and persistent in my case. There is usually a moment when I step back and realise that the thing I've "forgotten to do" is related to the incident that made me uncomfortable. Until that moment occurs, I can only describe the feeling as a cloud of irritation that seems to slowly envelop me. After I realise that the trigger has occurred and that the irritation is related to the trigger, I feel a sense of frustration and ineffectualness. I start to think catastrophically about the consequences of the trigger. Intrusive thoughts result in intense agitation at not being able to escape them. It feels a little like falling into an emotional rut of some kind, except that there is an impulse to correct the

11 11* Mike is a pseudonym. This contribution has not been edited.

situation by taking some physical action, and a suspicion that by performing a certain action I will either extinguish the effect (now in the past) of the initial trigger, or at least make some progress towards resolving whatever I imagine the environmental trigger's effects are. For example, fears of contamination lead me to constantly check equipment I have bought (at great expense) to measure air pollution. However, I know even at the time that I perform the action that I'm still not completely at comfort with the situation. If I attempt to avoid performing the action that corresponds with the trigger, my mental energy becomes more directed at worst case scenarios. If there is currently NO action I can perform to reduce the level of anxiety/frustration, my anxiety turns to a sense of hopelessness, eventually leading to depression. In my case OCD seems to be closely tied to a need for control. I think that I would "be OCD" about many more things in my life if there were more thing that were outside of my control. My fears and anxieties seem to come in waves lasting for 2 or 3 days, then dissipating a bit, then returning, each time slightly more intense and more concerning to my family and I, until eventually a sort of crescendo is reached, when I feel my anxieties overcome me completely (a crisis). This situation usually affects my family, since this is when I tend to take some desperate, dramatic action to deal with (or flee from) the anxiety. For example last year I drove my family for hundreds of kilometres to escape smoke pollution in my suburb overnight. This mental crisis eventually resolves itself (in this example, the smoke eventually cleared!), and for a few months, my OCD almost disappears. This wavelike scenario, with gradually increasing "amplitudes" of OCD impact/severity, has happened to me many times with different obsessions. The feeling of relief after the resolution to the crisis (maximum anxiety) each time is quite emotional (for a few days afterwards I often become teary-eyed and more empathic than usual). I can only thank my beautiful family for putting up with my ridiculous anxieties and bearing with me.

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Youth Corner

Fiona Jamieson, MPsych(Clin)

Associate Editor At some point in the careers of many clinical psychologists working with young people, there will be a need to assess and treat an obsessive–compulsive or related disorder. As basic clinical training informs us, these disorders are typically triggered by the presence of an obsession, which can be defined as an unwanted, persistent, and recurring thought, image, and/or impulse (Coleman, 2001) and a compulsion, that can be defined as a ritual which, when carried out, eases anxiety (Marks, 2003). In this edition’s issue of Youth Corner, we have two papers that focus on child and youth obsessive–compulsive disorder (OCD). The first, a paper written by O’Leary, on a feeling of things not being quite right or, as the literature terms it, a Not Just Right Experience (NJRE). The second, written by Rees, Anderson, and Finlay-Jones, discusses an online OCD program designed to increase consumer accessibility to evidence-based treatment. A third paper is also presented in which Turner and Gorman provide an overview of current treatments for body dysmorphic disorder in an adolescent population. References: Coleman, A. M. (2001). Oxford dictionary of psychology. New York, NY: Oxford University Press. Marks, M. (2003). Cognitive therapy for OCD. In R. G. Menzies & P. de Silva (Eds.), Obsessive–compulsive disorder: Theory, research and

treatment (pp. 275-290). Chichester, UK: John Wiley & Sons.

"Not Just Right Experiences" in Childhood Obsessive–Compulsive Disorder

Emily O'Leary, PhD

The OCD Clinic, Brisbane, Australia

Abstract Obsessive–compulsive disorder (OCD) is reported to occur in 1-3% of children. OCD is characterised by repetitive unwanted intrusive thoughts, images, or urges which lead the child to perform repetitive actions and behaviours that are designed to neutralise the anxiety. Some children with OCD describe an internal sense of discomfort rather than thought. These "not just right experiences" (NJREs) occur in clinical and nonclinical samples, but in the context of OCD these uncomfortable sensations can be very distressing. As these inner experiences are not the typical expression of OCD, they can be overlooked. In this article we examine research on NJREs and describe clinical examples of this type of OCD. Lastly, we discuss certain cognitive behavioural techniques that may prove useful in treating NJREs in OCD. 12 Obsessive–compulsive disorder (OCD) is a heterogeneous disorder with a number of symptom expressions. Obsessions are defined by recurrent unwanted persistent thoughts, urges, or images that are experienced, at some time during the disturbance, as intrusive, and cause marked anxiety or distress; compulsions are repetitive behaviours or mental acts that the individual performs to reduce the distress (American Psychiatric Association, 2013). Treatment of OCD involves directly challenging the cognition and confronting the feared stimuli. However, what do you do when the obsession is a "felt sense" rather than an active cognition? This article describes "not just right experiences" (NJREs) in OCD which are an "uncomfortable sensation that things are not right" (Coles, Frost, Heimberg, & Rhéaume,


2003, p. 681). Using clinical examples, we compare symptom profiles and discuss treatment differences. Up to 95% of the general population can experience NJREs (Coles et al., 2003; Fergus, 2014). Despite their prevalence, only 12% of adolescents report feeling highly distressed as a result of NJREs (Ravid, Franklin, Khanna, Storch, & Coles, 2014). This suggests that NJREs are similar to intrusive thoughts in that they are both common in the general population, but do not cause distress to the majority of those who experience them (Ravid et al., 2014). While NJREs appear to be a normal part of early childhood development (Evans et al., 1997), in the context of OCD they are highly distressing. They have been correlated with obsessive–compulsive symptom severity (Ferrão et al., 2012)


and poorer response to treatment (Foa, Abramowitz, Franklin, & Kozak, 1999). NJREs occur alongside common obsessions and compulsions (see Table 1). However, as opposed to contamination fears, a child with NJREs in the context of OCD may describe a need to "lift a heavy head" or have the feeling that "it's not right". Cases involving this type of OCD have

included: (1) Exhaling onto another person to prevent not feeling right; (2) Using a certain foot to exit rooms to gain a sense of completeness; (3) Waiting to move on an even number (e.g., 12.48 p.m.) so it would be right; (4) Avoidance of walking in busy streets in case someone is touched, and their touch would need to be mentally rubbed off to feel just right; and (5) Collecting items because they feel like a part of the person.

Table 1 Common Obsessions and Compulsions in Childhood OCD Obsessions Compulsions Fear of contamination (dirt, germs) Certain grooming rituals, hand washing, teeth brushing, toilet,

dressing Wanting things to be in certain spots/places Repeating rituals, including going in and out of doorways Worry about "bad luck" Needing to move through spaces in a special way, or rereading,

erasing, and rewriting Lucky and unlucky numbers Checking rituals to make sure house is locked, homework in bag,

mum going to pick me up, books not in rubbish Angry thoughts about loved ones being hurt/violent images

Avoiding certain things or people being they are "dirty" (relates to germs and bad luck)

Fear of dying or getting a disease Touching, tapping and rubbing rituals Intrusive sounds or words Rituals to prevent harming self or others Not 'just right' experiences Ordering or arranging objects Becoming convinced that he or she hasn't done something he or she is supposed to do

Counting and blinking rituals

(Scahill et al., 1997).

The common features of NJREs are a felt sense of incompleteness coupled with physiological shifts and behavioural urges to make things right. Some studies have reported the prevalence of NJREs to range from 70% to 80% in OCD patients (Ferrão et al., 2012; Leckman, Walker, Goodman, Pauls, & Cohen, 1994; Miguel et al., 2000). Research investigating NJREs in OCD in nonclinical samples found: (a) significant association between severity of NJREs and obsessive–compulsive symptoms, after controlling for anxiety, depression, and perfectionism (Ghisi, Chiri, Marchetti, Sanavio, & Sica, 2010); and (b) the number and intensity of NJREs predicted compulsive hand-washing duration (Cougle, Goetz, Fitch, & Hawkins, 2011) and compulsive checking (Cougle, Fitch, Jacobson, & Lee, 2013). There are also specific types of NJREs (e.g., auditory, visual, tactile) that are elicited by behavioural tasks emphasising the corresponding sense, more so for people with greater obsessive–compulsive symptom severity. For instance, viewing a cluttered table provokes a more severe visual "not just right" experience, measured by discomfort and urge to

counteract, in people with more severe obsessive–compulsive symptoms such as ordering (Summers, Fitch, & Cougle, 2014). Some authors (e.g., Coles et al., 2003) believe that NJREs may represent a specific form of "sensation based perfectionism" (p. 683). Rasmussen and Eisen (1992) commented that many patients with OCD described a desire to have things perfect, and until this sense of perfection was achieved, patients reported feeling "not right". Coles et al. (2003) examined NJREs in large undergraduate samples and found them to be related to features of both OCD and perfectionism. In a follow-up study, Coles and colleagues (2003) assessed: (a) the relationship of NJREs to OCD symptomology; and (b) whether NJREs are specific to OCD when compared to other anxiety and mood disorders. The authors found that NJREs were significantly related to specific OCD symptom clusters (e.g., checking, ordering) and were more strongly correlated with features of OCD compared to social anxiety, trait anxiety, worry, or


depression. Collectively, these two studies strengthened the link between NJREs, perfectionism, and OCD. Treatment of children with OCD, where the presentation is mostly NJREs, remains cognitive behaviour therapy (CBT) with exposure and response prevention (ERP), but there are some additional considerations and these are considered next. Symptom Profile Some evidence suggests that NJREs are more common in ordering and checking behaviours (Ecker, Kupfer, & Gonner, 2014). Therefore, if this is the presenting issue, it may be beneficial to directly assess for NJREs alongside the "What is making you feel so worried?" question. Techniques Instead of giving the OCD thought a nickname, label the feeling as "Mr Annoying" to externalise the anxiety. There may need to be an increased focus on diaphragmatic breathing, urge surfing, and habituation in-session and between-session exposures so the child can build tolerance to the physiological discomfort. Oppositional Behaviour NJREs can present as disruptive behaviours (e.g., refusing to wear a certain T-shirt because it does not feel right). Children with NJREs have "rules" that may mask as "normal behaviours" (e.g., having to sit on the left in the car) in order to feel in control. While they appear as disruptive behaviours, they are often in the context of anxiety. Behavioural vs. Cognitive Behavioural experiments encouraging tolerance to the emotional state of "incompleteness" rather than direct thought challenging (e.g., "Is there any proof?") may provide more success with this symptom presentation. Education and Awareness It is important to educate family or partners about NJREs in OCD because it can be confusing to both parties when "there is no thought". Likewise, conflict can arise between what a child and their parents perceive as OCD. A discussion about how to manage these occurrences (e.g., list of OCD behaviours) and avoiding power struggles can be beneficial.

Expectations

Treatment may be more difficult because young people with NJREs can be affected at virtually every part of the day, whereas more typical OCD symptoms are triggered by specific things (Reid, Storch, & Lewin, 2009). Increased use of labelling the OCD to create distance from the disorder, education for the family, and careful screening for comorbid conditions (e.g., tic, autism spectrum disorder) may also be beneficial.

Conclusion

This article sought to increase the awareness of this symptom profile of OCD and highlight treatment implications. The understanding of NJREs is an "uncomfortable sensation that things are not right" (Coles et al., 2003). These experiences occur in the general population, but in OCD they can present additional challenges for the clinician, client, and family. A child with OCD who reports "it does not feel right" may have more checking and ordering compulsions and a poorer response to treatment. They can appear oppositional because they are not reporting the more "typical obsessions" and so be overlooked. Selecting specific behavioural techniques rather than thought challenging may be helpful. Future research on OCD and NJREs will hopefully yield more tailored interventions and improve success rates in treating childhood OCD.



Coles, M. E., Frost, R., Heimberg, R. G., & Rhéaume, J. (2003). Not just right experiences: Perfectionism, obsessive–compulsive features and general psychopathology. Behaviour Research and Therapy, 41, 681–700. doi:10.1016/S0005-7967(02)00044-X

Cougle, J. R., Fitch, K. E., Jacobson, S., & Lee, H. J. (2013). A multi-method examination of the role of incompleteness in compulsive checking. Journal of Anxiety Disorders, 27(2), 231–239. doi:0.1016/ j.janxdis. 2013.02.003

Cougle, J. R., Goetz, A. R., Fitch, K., & Hawkins, K. A. (2011). Termination of washing compulsions: A problem of internal reference criteria or 'not just right' experience? Journal of Anxiety Disorders, 25, 801–805. doi:10.1016/j.janxdis.2011.03.019

Ecker, W., Kupfer, P., & Gonner, S. (2014). Incompleteness as a link between obsessive–compulsive personality traits and specific symptom dimensions of obsessive–compulsive disorder. Clinical Psychology and Psychotherapy, 21, 394–402. doi: 10.1002/cpp.1842

Evans, D. W., Leckman, J. F., Carter, A., Reznick, J. S., Henshaw, D., King, R. A., & Pauls, D. (1997). Ritual, habit, and perfectionism: The prevalence and development of compulsive-like behavior in normal young children. Child Development, 68(1), 58–68. doi:10.2307/1131925

Fergus, T. A. (2014). Are "Not just right experiences" (NJREs) specific to obsessive‐compulsive symptoms?: Evidence that NJREs span across symptoms of emotional disorders. Journal of Clinical Psychology, 70(4), 353–363. doi:10.1002/jclp.22034

Ferrão, Y. A., Shavitt, R. J., Prado, H., Fontanelle, L. F., Malavazzi, D. M., de Mathis, M. A., … do Rosário, M. C. (2012). Sensory phenomena associated with repetitive behaviours in obsessive–compulsive disorder: An exploratory study of 1001 patients. Psychiatry Research, 197, 253–258. doi:10.1016/ j.psychres.2011.09.017


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Ghisi, M., Chiri, M., Marchetti, I., Sanavio, E., & Sica, C. (2010). In search of specificity: "Not just right experiences" and obsessive–compulsive symptoms in non-clinical and clinical Italian individuals. Journal of Anxiety Disorders, 24, 879–886. doi:10.1016/j.janxdis.2010 .06.011

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Miguel, E. C., do Rosario-Campos, M. C., da Silva, P. H., do Valle, R., Rauch, S. L., Coffey, B. J., … Leckman, J. F. (2000). Sensory phenomena in obsessive–compulsive disorder and Tourette's disorder. Journal of Clinical Psychiatry, 61, 150–156.

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Summers, B. J., Fitch, K. E., & Cougle, J. R. (2014). Visual, tactile, and auditory 'not just right' experiences: Associations with obsessive–compulsive symptoms and perfectionism. Behavior Therapy 45(5), 678–689. doi:10.1016/j.beth.2014.03.008


New Directions in Treatment for Obsessive–Compulsive Disorder Among Young People

An Overview of the OCD? Not Me! Online Treatment Program

Clare S. Rees, PhD, Rebecca Anderson, PhD, and Amy Finlay-Jones, BPsych(Hons)

Curtin University, Australia

Abstract Obsessive–compulsive disorder (OCD) is a relatively common condition in children and adolescents, and is associated with significant lifetime impairment. Despite the recognised need for early identification and treatment of this disorder, the clinical progression of effective intervention for child and adolescent OCD has been hampered by limited treatment accessibility. This article gives an overview of "OCD? Not Me!", a fully online OCD treatment program for young people aged 12-18 years, recently developed by researchers at Curtin University. 13 Early onset obsessive–compulsive disorder (OCD) is associated with substantial impairments in academic, social, and family functioning (Albano, March, & Piacentini, 1999; Allsopp & Verduyn, 1990; Toro, Cervera, Oseio, & Salamero, 1992), and can have significant deleterious effects on a child or adolescent's developmental trajectory (Moore, Mariaskin, March, & Franklin, 2012). Childhood OCD often persists in adulthood (Leonard et al., 1993; Stewart et al., 2004), and is a risk factor for future psychopathology, including personality disorders, social phobia, depression, and poor social adjustment (Wewetzer et al., 2001). While a considerable body of research supports the efficacy of cognitive behaviour therapy (CBT) in the form of exposure and response prevention (ERP) for early onset OCD, this treatment approach is underutilised due to difficulties in the availability, accessibility, and delivery of treatment (Shafran et al., 2009). As such, a stepped care model—which prioritises the development and implementation of treatments at differing intensities—has been recommended as a way of optimising clinical benefits from available resources (Bower & Gilbody, 2005). Based on the need to advance the stepped care approach to early onset OCD treatment in Australia, we developed a new, fully online OCD treatment program for young people aged 12-18 years. The rationale for this program is given below, and an overview of the program is illustrated with a case study.

Program Rationale and Objectives The National Institute for Health and Clinical Excellence (2005) guidelines for OCD endorse the use of a stepped-care model in the prevention and treatment of early onset OCD, and promote a collaborative approach in which families and carers are included within the treatment model. Online self-help treatments—i.e., programs delivered via a website that users primarily engage with independently and which aim to promote positive change (Barak, Klein, &


Proudfoot, 2009)—are regarded as one of the lower "steps" within the stepped-care approach. Online self-help treatments are advantageous in that they provide clients with access to treatment that is: (1) cost-effective; (2) accessible; (3) available across multiple settings (e.g., homes, schools, remote areas); (4) potentially preferable for clients who are reluctant to initiate treatment in individual or group format; (5) standardised; and (6) less stigmatised than face-to-face treatment (Kendall, Khanna, Edson, Cummings, & Harris, 2011; Kenwright, Marks, Gega, & Mataix-Cols, 2004). The development of online treatments for OCD and other anxiety disorders is increasing (Marks, Cavanagh, & Gega, 2007), with a growing body of data supporting their feasibility and effectiveness (e.g., Cuijpers & Schuurmans, 2007; Wootton et al., 2011). The objectives of the OCD? Not Me! project were to: (1) address a gap in the existing provision of online mental health services in Australia; (2) improve accessibility to evidence-based treatment for children and adolescents with OCD; (3) reduce the burden of the disorder by providing effective treatment to this group; (4) provide support for family and carers, and thus reduce the psychosocial burden experienced by this group; (5) provide an evidence-based treatment that has high acceptability and cost-effectiveness; (6) provide effective interventions earlier to reduce the burden of disease associated with ongoing OCD; and (7) improve mental health literacy by creating online psycho-educational and treatment resources for children and adolescents with OCD, and their families.

Program Overview The basic structure of the OCD? Not Me! program maps onto a standard ERP protocol and involves eight interactive stages comprising psycho-education, interactive online exercises, and graded exposure exercises. Given the low treatment adherence and high attrition rates often associated with online interventions (Kelders, Kok, & Van


Gemert-Pijnen, 2012), creating a rich and engaging online environment is considered crucial to maximise treatment compliance and minimise program dropout. As such, the OCD? Not Me! online program incorporates a number of the elements of persuasive system design outlined by Kelders et al. (2012), such as reduction, tunnelling, personalisation, self-monitoring, and reminders. In addition, the design of the website (www.ocdnotme.com.au) and the online structure of the program are informed by the considerations outlined by Ritterband, Thorndike, Cox, Kovatchev, and Gonder-Frederick (2009). These include website appearance, the nature of behavioural instructions and prompts, ease of use, accuracy and clarity of content, mode and message of content delivery (including form, style, likeability, and credibility), participation (including interactivity and opportunities for rehearsal and rewards), and assessment (including the provision of personalised feedback). Finally, in order to make the OCD? Not Me! program accessible and appealing to young people, the treatment protocol is framed around the basic metaphor of making a journey up "OCD Mountain". The use of metaphor in cognitive–behavioural treatment for young people is an effective way of expressing complex or abstract concepts in a clear and engaging way (Ronen, 2011). The metaphors used to explain key concepts across the eight stages of the OCD? Not Me! program are described further below. These concepts and related outcomes are illustrated with the use of the case study of Ben, a fictional 12-year-old boy, who is suffering from OCD with contamination obsessions and washing compulsions.

Stage One In the first stage of the program, Ben is introduced to the idea that the treatment protocol in the OCD? Not Me! program is like a mountain expedition which is to be completed step-by-step. On this journey, a virtual backpack of equipment is available to assist Ben to make it to the summit. This contains a guidebook (psycho-educational information about OCD), an anxiety barometer (a method for estimating levels of anxiety before, during, and after a challenge), a breathing control regulator (a technique to reduce anxiety through breathing slowly), wise cards (brief tips to help Ben "talk back" to OCD thoughts), and a mountain map (a pictorial representation of treatment progress). In addition, Ben is introduced to five OCD Mountaineers – cartoon characters who each have a different symptom constellation, and who have made it to the top of OCD Mountain. These characters appear throughout the program with advice and encouragement on how to make it to the top of OCD Mountain. Following this, the details of Ben's OCD symptoms are elicited using the OCD Worksheet (see Figure 1). Using this worksheet, Ben is asked to record his OCD thoughts, how much anxiety they elicit, and how he copes with the anxiety through avoidance and engaging in rituals. This worksheet is a starting point for conveying one of the central tenets of the cognitive-behavioural model of OCD; namely, that individuals with OCD engage in avoidance behaviours, rituals, and reassurance-seeking as a way of attempting to neutralise the anxiety brought about by obsessional thoughts (Clark, 1999).

Figure 1. Ben’s OCD Worksheet

Another important aspect of the initial stage of

treatment is for Ben to formulate a treatment goal. Often young people experience more than one OCD symptom at one time. Symptoms frequently change (Moore et al., 2012), and may differentially affect a young person's functioning in various domains. For example, while Ben's contamination obsessions and associated washing rituals may affect him at home, he may also have rituals to do with counting or arranging that affect him more at school. In order to simplify and focus treatment, Ben is encouraged to identify one area

of his life where his symptoms are having a significant impact, and to formulate a goal based on improved functioning in this area (e.g., getting ready for school on time). Following this, in collaboration with his parents/caregivers, Ben is asked to plan rewards for the halfway and final stages of his treatment plan. Involving parents/caregivers in this way has the potential to promote motivation and adherence with treatment throughout the course of the program (Freeman et al., 2008).


Stage Two In Stage Two, the symptoms Ben has recorded on the OCD Worksheet are used to formulate his OCD Cycle: a pictorial diagram that illustrates the functional link between Ben's obsessions and compulsions (see Figure 2). The OCD Cycle further reinforces the link between obsessions, distress, and compulsions, thereby emphasising the rationale for response prevention (Himle & Franklin, 2009). The OCD Cycle is used as the basis for constructing Ben's OCD Challenges: self-guided ERP exercises involving a combination of deliberate exposure to anxiety-provoking thoughts, objects, or situations, and modifying or stopping rituals that relieve obsession-related anxiety. The rationale for including OCD Challenges as part of the treatment protocol is that prolonged exposure to anxiety-provoking stimuli allows an individual to habituate to the anxiety, and expectations of negative consequences gradually decline when these consequences fail to occur (Foa & Kozac, 1986). Using brainstorming exercises, Ben is asked to come up with a hierarchy of 10 challenges that (a) allow him to face what he has been avoiding; and (b) involve stopping or modifying his current rituals. Ben is asked to assign an "anxiety rating" from 1-10 for each challenge (i.e., an estimation of how much anxiety the exercise will provoke); challenges are then graded in order of anxiety ratings, from least to most.

Working through these challenges in a gradual way maximises the possibility of successfully habituating to the anxiety, and completing the challenge (Piacentini, Bergman, Jacobs, McCracken, & Kretchman, 2002). Once Ben's challenge hierarchy has been formulated, his "path" up OCD Mountain is illustrated, with each challenge representing one step up the mountain. Ben is then asked to attempt his first challenge as the final step of Stage Two. When undertaking the OCD Challenges, Ben is encouraged to use his mountaineering equipment to help him stay with his anxiety until it goes away. To facilitate this, an online logbook is available. This lists the details of Ben's challenge and asks him to record (a) any "equipment" he uses; (b) his anxiety ratings over time, which appear automatically in graph form to illustrate the process of habituation; (c) what happened during the challenge; and (d) whether the challenge was completed successfully. An example of Ben's logbook is given in Figure 3. On the successful completion of each challenge, Ben is invited to use the interactive mountain map to plant a flag at the corresponding step of the mountain. Finally, as part of the homework for Stage 2, Ben is encouraged to repeat the initial challenge a few times, so that he becomes accustomed to the process of habituating to anxiety before he moves on to more difficult challenges (Himle & Franklin, 2009).

Figure 2. The OCD Cycle


Stages Three to Eight In Stages Three to Eight, Ben continues to work through his hierarchy of OCD Challenges. Additional metaphors congruent with the OCD Mountain concept are used at each stage to convey key concepts, such as how to talk to other people about OCD, managing stress, and dealing with setbacks. Ben is encouraged to refrain from subtle forms of avoidance, such as asking friends and family members for reassurance or help with carrying out his challenges or rituals. Such behaviours are liable to form barriers to effective treatment as they prevent Ben from fully confronting the distress brought about by anxiety-provoking thoughts, objects, or situations (Himle & Franklin, 2009). Emphasis is also placed on dealing with self-sabotaging thoughts that may lead Ben to doubt his ability to make it through the program. Individuals with OCD often suffer from low self-efficacy for dealing with challenging situations (Rees, 2009), so it is important to teach Ben to "talk back" to his self-

doubt so that his motivation to engage in treatment is maintained. In Stages Three to Eight, motivation is also maintained by asking Ben's parents/caregivers to deliver his "half-way reward" once he has completed his fifth challenge. At this point in the program, Ben is also asked to reflect on what he has learned and achieved in the program so far. In the final stage of the program, this process is repeated and Ben is encouraged to celebrate making it to the top of OCD Mountain by receiving his final reward and "enjoying the view" – that is, reflecting on his progress in relation to the goals he set himself early in the program. It is reiterated that Ben should continue to practise his "mountaineering skills" so that his treatment gains are maintained, and he is provided with a list of tips to help him do so. Lastly, Ben is asked to complete a number of post-intervention measures so that he and his parents/caregivers are able to receive feedback on his progress. At this point, Ben also has the option to repeat the program to focus on other obsessive–compulsive symptom constellations he may have.

Figure 3. Ben's challenge logbook

Parent/Caregiver Resources

Involving parents/caregivers in OCD treatment with young people is considered an important adjunct to therapy (Renshaw, Steketee, & Chambless, 2005; Steketee & Van Noppen, 2003). Parents tend to report finding their child's OCD symptoms distressing (Futh, Simonds, & Micali, 2012; Peris et al., 2008), and their responses to these symptoms may range on a continuum from antagonistic/punitive to overly accommodating. Responses at both ends of this spectrum are thought to maintain OCD symptoms through exacerbating stress or facilitating avoidance in young people (Livingston-Van Noppen, Rasmussen, Eisen, & McCartney,

1990; Van Noppen & Steketee, 2003). As such, it is considered important to involve parents/caregivers directly by providing them with information regarding the role of the family in a young person's OCD symptoms. Likewise important is to support parents/caregivers to manage their own stress, better interact with their child, and help them manage their child's OCD (Freeman et al., 2008). In addition, the program provides parents/caregivers with general information regarding the nature of OCD symptoms, and an overview of the content of each stage of the program, so that they are able to provide relevant support for their child at each stage. These resources are assembled into a series of online psycho-educational materials that are made available to


parents/caregivers as their child starts each stage of the program. In this way, family members can provide valuable support for young people by providing encouragement, helping them to construct appropriate exposure exercises, facilitating problem-solving, and modelling "normal" behaviour in the face of anxiety triggers (Himle & Franklin, 2009).

Program Eligibility, Assessment, and Access As the OCD? Not Me! program is designed as a low-intensity self-help program, only young people with low associated risk factors are accepted for treatment in the program. To screen for OCD symptoms and potential risk factors, young people interested in participating in the program are asked to complete an online screening battery that is designed to assess OCD symptoms, suicide and self-harm risk, and symptoms of psychosis and eating disorders. Young people who are eligible for the program are also asked to complete further online assessments designed to elicit specific details of their OCD symptom presentation, and measure associated distress and interference, as well as self-esteem and quality of life. Parents/caregivers are asked to complete assessments evaluating: (a) parent/caregiver reports of their child's OCD symptoms; (b) parent/caregiver involvement in their child's OCD rituals; and (c) parent/caregiver distress. Young people and their parents/caregivers are also asked to complete these measures at the end of the program, so we can provide them with feedback about their symptom change, and so we are able to evaluate the effectiveness of the program. In addition, at the beginning of each stage, young people are asked to provide a brief report of their OCD symptoms and any self-harm or suicide risk they may be experiencing. Young people who report moderate to high suicide or self-harm risk at any point in the program are asked to seek more intensive and specialised treatment, with resources provided to their parents via email.

Conclusion This paper presents an overview of a novel, online, self-guided program for the treatment of paediatric OCD. Although CBT with ERP is currently considered the gold standard treatment for paediatric OCD, difficulties in the dissemination and take-up of this intervention as a face-to-face treatment have given rise to novel treatment formats as part of a stepped-care approach. Internet-based self-help interventions represent one such format, and growing evidence supports the effectiveness of such interventions for the treatment of a range of different psychological problems. The intervention described in the current study is a viable low-intensity treatment for paediatric OCD. Anyone interested in accessing or learning more about the program is invited to visit the website (www.ocdnotme.com.au). Clinicians interested in reviewing the content online are welcome to review the demonstration video available by clicking the “Vimeo” button on the homepage of our website. As the assessment process and treatment program is fully automated, families interested in accessing the program may be directed to the website at any time.

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Body Dysmorphic Disorder in Adolescents

Cynthia M. Turner, PhD and Beth O'Gorman, BPsySc(Hons)

University of Queensland, Australia Abstract Body dysmorphic disorder (BDD) is a relatively common condition in adolescents; however, there is very limited research in this area. This review summarises the existing literature and reports on the clinical phenomenology of BDD, including prevalence, diagnostic features, aetiology, and treatment. The authors identify a number of single case reports and one case series documenting cognitive behaviour therapy (CBT) for BDD, with successful symptom reduction and maintenance of gains over small follow-up periods. Clinical treatment recommendations suggest that CBT be offered as a first line treatment for adolescent BDD, coupled with a selective serotonin reuptake inhibitor in patients suffering from moderate or severe functional impairment. However, given the small body of evidence and limited understanding of the condition, further research into this area is required. 14 Body dysmorphic disorder (BDD) is a relatively common disorder in adolescents, with prevalence rates ranging from 2.2% to 4.8% in the general adolescent population (Bartsch, 2007; Cansever, Uzun, Donmez, & Ozsahin, 2003; Mayville, Katz, Gipson, & Cabral, 1999). BDD constitutes approximately 6.7% of adolescents in a psychiatric inpatient setting (Dyl, Kittler, Phillips, & Hunt, 2006). However, despite these prevalence rates, accurate recognition and diagnosis of the disorder remains poor. This paper aims to provide a brief review and summary of current literature in relation to BDD, including an overview of current treatment approaches.

Diagnostic Features and Common Characteristics BDD is a psychological condition characterised by a preoccupation with one or more minor or imagined defects in physical appearance (American Psychiatric Association, 2013). Such a preoccupation can result in significant interference to a young person's ability to function in academic, social, familial, or other important areas of life (Phillips, Didie, et al., 2006). For BDD sufferers, the most common preoccupations focus on perceived (or minor) flaws in skin (e.g., acne, wrinkles, lines, pallor or ruddiness of skin tone, vascular markings), hair (e.g., excessive body and/or facial hair, thinning hair), or nose (e.g., size, shape) (Phillips & Rogers, 2011). However, preoccupations can focus on any area of the body, or on several body parts, simultaneously (McElroy, Phillips, Keck, Hudson, & Pope, 1993). It is common for BDD sufferers to be preoccupied with an average of five to seven areas of physical appearance (Phillips & Diaz, 1997). In addition, body dysmorphic concerns can be about asymmetry or disproportionality in various body parts, or even a vague or general perception of ugliness (Veale, 2004). A key feature characterising BDD is repetitive behaviour. The repetitive behaviour seen in BDD is akin to compulsions in obsessive–compulsive disorder (OCD) in that it is performed in response to a preoccupation, it seeks to


alleviate distress, it is often time-consuming, and it is difficult to control or resist (Phillips et al., 2010). Common repetitive behaviours include checking the perceived defect in mirrors or other reflective surfaces, camouflaging the area of preoccupation (typically with clothes, hair, or makeup), comparing features of one's appearance to those of others, seeking reassurance about the perceived flaw, compulsive skin-picking, and touching the perceived defect (Dawes & Mankin, 2004; McElroy et al., 1993 ; Rabinowitz, Neziroglu, & Roberts, 2007). Many BDD sufferers seek assistance from dermatology or cosmetic surgery clinics in an effort to alleviate their concerns (Buhlmann, Reese, Renaud, & Wilhelm, 2008). Significant avoidance of social situations is also evident. Excessive exercising or weight-lifting is a repetitive behaviour that is typically reserved for a very specific form of BDD known as 'muscle dysmorphia'. This occurs almost exclusively in males, and is characterised by the preoccupation that the body is too small or insufficiently muscular, despite having normal or even overly muscular body builds (American Psychiatric Association, 2013; Kanayama & Pope, 2011). People with muscle dysmorphia may also have other areas of preoccupation and dissatisfaction (Dawes & Mankin, 2004). Insight into BDD can be highly variable, ranging between 'good or fair insight' (those who understand that their dysmorphic beliefs are probably not true), and 'absent or delusional' (those with a complete conviction that their dysmorphic beliefs are true). In DSM-5 (American Psychiatric Association, 2013), BDD was reassigned to the classification of obsessive–compulsive and related disorders, whereas it was previously considered to be a somatoform disorder. Age of Onset BDD has a typical onset in adolescence. Phillips et al. (2010) found a mean age of onset between 16 and 17 years, with a median age of onset of 15 years. It is not uncommon, however, for onset to be significantly earlier than this (Phillips, 2001). In stark contrast, the typical age of


diagnosis is between 26 and 31 years (Phillips, 1991; Phillips & Diaz, 1997; Veale et al., 1996). Comorbidity BDD has a high level of comorbidity with other disorders, particularly depression, social phobia, and OCD. Gunstad and Phillips (2003) conducted the largest study of comorbidity in BDD to date, surveying 293 (largely adult) patients. They found a comorbidity rate of 59% for major depression (MDD), 32% for social phobia, 25% for OCD, and 8% for a substance use disorder. Phillips, Pagano, Menard, and Stout (2006) investigated the longitudinal course of the disorder, and found that BDD symptoms persisted, even with the remission of comorbid conditions. The exception to this finding was in the case of MDD and OCD, where improvement in these symptoms predicted BDD remission (Phillips & Stout, 2006). Course The course of BDD is typically chronic (Phillips, Pagano, et al., 2006), with low probability of remission and high probability of relapse. A 4-year prospective observational study identified the probability of full remission from BDD as 20%, which is lower than remission probabilities reported for MDD (57%), and anxiety disorders (31%-66%) (Phillips, Menard, Quinn, Didie, & Stout, 2013). The same study also found that severity of BDD symptoms at intake and earlier age of onset predicted a higher chance of relapse, while severity of symptoms at intake, duration of BDD symptoms, and being in adulthood predicted a lower likelihood of full or partial relapse. Aetiology Research has identified a genetic influence in the development of BDD, with the risk of developing the disorder increasing 5.8% if another first-degree relative has BDD (Phillips, Menard, Fay, & Weisberg, 2005). A study using self-report measures of "dysmorphic concern" (referring to an excessive concern with a slight or perceived defect in physical appearance) found a greater similarity in outcome measured in monozygotic twins compared to dizygotic twins, with a minimal influence for shared environment (Monzani et al., 2012).

BDD and Adolescents While the clinical features of BDD in the adult and adolescent population are similar, compared to adults, adolescents with BDD experience a higher rate of suicidal ideation and suicide attempts, as well as poorer quality of life (Phillips, 2001; Phillips & Diaz, 1997). A study comparing BDD in adults and adolescents found that adolescents with BDD were 44.4% more likely to attempt suicide than adults with BDD (Phillips, Didie, et al., 2006). Adolescents also tended to display a higher degree of delusion toward their focal areas of preoccupation, and displayed less insight into their thoughts and behaviour. Adolescence is a unique time for peer influence, and a time involving distinctive psychosocial challenges,

including pubertal development, identity formation, and sexuality issues (Greenberg et al., 2010). The onset of BDD in adolescence can be detrimental to the development of a stable self-concept, social skills, autonomy, and independence (Greenberg et al., 2010). While appearance concerns are a typical and inherent part of adolescence, appearance concerns in adolescents with BDD differ from developmentally appropriate appearance concerns both in terms of the significant distress caused by the preoccupation with their appearance, as well as the time spent engaging in the repetitive behaviours that relate to these preoccupations (Greenberg et al., 2010; Lambrou, Veale, & Wilson, 2012). Adolescents with BDD commonly spend between 3 and 8 hours daily engaged in repetitive behaviours and attempting to camouflage their perceived defect.

Treatment of BDD Cognitive Behaviour Therapy There is an emerging body of literature demonstrating the efficacy of cognitive behaviour therapy (CBT) as the psychological treatment of choice for BDD. Cognitive behavioural models of BDD highlight the key processes that are responsible for the maintenance of symptoms (e.g., repetitive behaviours, avoidance), and then seek to develop treatment strategies that reverse these maintaining factors (Veale, 2004; Veale et al., 1996; Veale & Neziroglu, 2010). The evidence for the effectiveness of CBT treatment is strongest in adult populations, with two randomised control trials comparing CBT versus a waitlist condition (Rosen, Reiter, & Orosan, 1995; Veale et al., 1996); in addition, there are a number of case series. The content of CBT has varied from being largely behavioural with a primary focus on exposure with response prevention (ERP; McKay, Neziroglu, & Yaryura-Tobias, 1997) to being purely cognitive (Geremia & Neziroglu, 2001), while most protocols have incorporated both behavioural and cognitive techniques (Neziroglu, McKay, Todaro, & Yaryura-Tobias, 1996; Rosen et al., 1995; Wilhelm, Otto, Lohr, & Deckersbach, 1999). The current CBT treatment literature for BDD in adolescents is limited to a small number of single case reports (e.g., Aldea, Storch, Geffken, & Murphy, 2009; Greenberg et al., 2010) and a larger case series of 6 patients (Krebs, Turner, Heyman, & Mataix-Cols, 2012). These studies suggest that developmentally tailored CBT can be effective, and that treatment gains can be maintained through to 6-month follow-up (e.g., Aldea et al., 2009; Greenberg et al., 2010; Krebs et al., 2012). Typically, a CBT treatment protocol includes education about the disorder, including information about individual maintaining factors, ERP with use of various cognitive strategies, and relapse prevention (see Krebs et al., 2012). ERP is similar to that included in OCD treatment protocols (e.g., an adolescent with BDD is asked to enter into a social situation and not conceal or camouflage the body part with which they are uncomfortable). The available evidence suggests that CBT is likely to be associated with a treatment response, at least for most adolescents. There is some evidence to suggest that symptoms of a comorbid diagnosis may also reduce with successful CBT (e.g., Aldea et al., 2009; Krebs et al., 2012). However, with such a small evidence base, response and remission rates for adolescents


have yet to be determined, but the available literature suggests that CBT will not be effective for all. Pharmacological Treatment for BDD A small amount of research has indicated that serotonin reuptake inhibitors (SRIs) and the newer selective serotonin reuptake inhibitors (SSRIs) are effective in treating adolescent BDD (Phillips, Atala, & Albertini, 1995; Phillips & Rogers, 2011). In a case review of 33 adolescent patients with BDD, Albertini and Phillips (1999) found that adolescents who were prescribed an SRI or SSRI had the greatest degree of symptom improvement compared to adolescents prescribed other psychotropic medications, or those receiving psychotherapy. Within the adult BDD literature, randomised controlled trials as well as open-label and clinical series, have established SSRIs as the most efficient medications to treat BDD (Phillips & Rogers, 2011). Other Treatment Approaches A meta-analysis of treatment strategies for adult BDD examined the effectiveness of a range of interventions used in studies published from 1978-1999. It found that psychodynamic psychotherapy and social skills training were less effective in reducing BDD symptoms than ERP, pharmacotherapy, and cognitive treatments (Cororve & Gleaves, 2001). Additionally, research has indicated that BDD patients do not benefit from cosmetic surgery (Crerand, Franklin, & Sarwer, 2006).

Clinical Treatment Recommendations A small body of evidence has led to clinical treatment guidelines which recommend that adolescents with BDD should be offered CBT as the first line treatment. Further, these guidelines recommend that CBT should be combined with an SSRI when the impairment associated with the disorder is moderate or severe, or where an initial course of CBT alone has failed (National Institute for Health and Clinical Excellence, 2005).

Conclusion BDD is a serious mental health problem that typically has its onset in adolescence. It is rarely presented to mental health professionals as a primary concern, and it is more likely to be diagnosed when mental health professionals specifically probe for it. It commonly co-occurs with depression, social phobia, and OCD; the presence of these disorders should prompt professionals to assess for BDD. Given the significant impact of the disorder and its chronicity, mental health professionals should seek to provide evidence-based treatment whenever possible. Although the literature base with regard to treatment for adolescents is currently limited, there is evidence for the efficacy of CBT, combined with an SSRI medication when indicated. Further research with regard to effective treatments is required, and dissemination of effective treatments remains important.

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Rosen, J. C., Reiter, J., & Orosan, P. (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology, 63(2), 263–269. doi: 10.1037/0022-006X.63.2.263

Veale, D. (2004). Advances in a cognitive behavioural model of body dysmorphic disorder. Body Image, 1(1), 113–125. doi: 10.1016/s1740-1445(03)00009-3

Veale, D., Gournay, K., Dryden, W., Boocock, A., Shah, F., Willson, R., & Walburn, J. (1996). Body dysmorphic disorder: A cognitive behavioural model and pilot randomised controlled trial. Behaviour Research and Therapy, 34(9), 717–279. doi: 10.1016/0005-7967(96)00025-3

Veale, D., & Neziroglu, F. (2010). Evidence for cognitive behavior therapy in BDD. In D. Veale & F. Neziroglu (Eds.), Body Dysmorphic Disorder (pp. 167–174). Chichester, UK: John Wiley & Sons.

Wilhelm, S., Otto, M. W., Lohr, B., & Deckersbach, T. (1999). Cognitive behavior group therapy for body dysmorphic disorder: A case series. Behaviour Research and Therapy, 37(1), 71–75. doi: http://dx.doi.org/10.1016/ S0005-7967(98)00109-0


Student and Training Matters

Dixie Statham, DPsych(Clin)

Associate Editor

Conducting careful and comprehensive assessments of obsessive–compulsive disorder (OCD) and then developing ideographic formulations to inform treatment is a complex and potentially time-consuming process. Clients vary in their ability to describe their symptoms and in estimating the extent to which their symptoms impair their functioning. For the clinician, the process of differential diagnosis may not be entirely straightforward as it can be difficult to distinguish OCD from anxiety disorders such as generalised anxiety disorder. Self-report measures are a useful adjunct to clinical interviewing and are a valuable way of obtaining access to the client's internal experience of their obsessive–compulsive symptoms. Brief self-report measures are also useful for assisting with assessing severity, ongoing monitoring, and measuring treatment outcome. The measures discussed here are used very frequently for these purposes and have demonstrated sound psychometric properties.

An Overview of Psychometric Measures for

Obsessive–Compulsive Disorder

15 Adult Measures The Yale-Brown Obsessive Compulsive Scale (Y-BOCS) The Y-BOCS (Goodman, Price, Rasmussen, Mazure, Delgado, et al., 1989; Goodman, Price, Rasmussen, Mazure, Fleischmann, et al., 1989) is considered the gold standard for assessing obsessive–compulsive symptoms and severity. It is a much researched and widely used, clinician rated, semi-structured interview that assesses the presence and severity of the obsessions and compulsions. The severity scale consists of 10 items and two subscales: obsessionality and compulsivity. Obsessionality items include the amount of time occupied by intrusive thoughts, the extent to which obsessive thoughts interfere with role functioning, the amount of distress caused, the amount of effort made to resist them, and the degree of control the individual has over obsessive thoughts. The compulsivity subscale items measure the amount of time spent performing compulsive behaviours, the amount of interference in social or work functioning, the amount of distress that would be experienced if prevented from performing compulsions, the amount of effort made to resist compulsions, and the amount of control over compulsions. Items are rated on a 5-point Likert scale ranging from 0 to 4. Three scores are derived: a total score (range = 0-40), an obsession severity score (range = 0-20), and a compulsion severity score (range = 0-20). Higher scores indicate greater symptom severity. The Y-BOCS also contains a symptom checklist (Y-BOCS-SC) to augment the severity scale. The Y-BOCS-SC consists of a list of 54 obsessions and compulsions that tap the areas of contamination/washing, aggressive/checking, religious/sexual, symmetry/ordering/repeating, and


hoarding. Items are rated dichotomously to indicate the absence or presence (current [in the past week] and past [in the past, but no longer problematic]) of symptoms. The client and clinician can then collaboratively develop a short list of the most severe obsessions and compulsions. The Y-BOCS has been translated into multiple languages and also modified for compulsive shopping (Y-BOCS-SV; Monahan, Black, & Gabel, 1996) and for body dysmorphic disorder (BDD-Y-BOCS; Phillips et al., 1997). The Y-BOCS-SV measures severity and change in individuals with compulsive buying. It has demonstrated good-to-excellent interrater reliability (r = .81 – .99), high internal consistency, sensitivity to clinical change, and moderate test-retest reliability (r = .59) (Monahan et al., 1996). Psychometric evaluation of the BDD-Y-BOCS showed strong internal consistency (α = .90), excellent interrater reliability (r = .77 to 1.00), good convergent and discriminant validity, and sensitivity to change. The BDD-Y-BOCS has two factors but its factor structure differs from the factor structure of the Y-BOCS (Phillips, Hart, & Menard, 2014). Y-BOCS-II A second edition of the Y-BOCS, in which the item content and scoring of the severity scale were revised, was published in 2010 (Storch et al., 2010). The Y-BOCS-II has also demonstrated excellent psychometric properties, and has clinical utility as an alternative method for assessing the presence and severity of OCD symptoms. The Brief Obsessive–Compulsive Scale (BOCS) The BOCS is a modified and shortened version of the Y-BOCS and the Children's Y-BOCS (CY-BOCS; Gallant et al., 2008; Scahill et al., 1997) and is self-administered. It


consists of a 15-item checklist made up of 12 OCD symptoms and an additional three items, consistent with DSM-5 (American Psychiatric Association, 2013) "obsessive–compulsive and related disorders" section. These items address hoarding, dysmorphophobia, and self-harm. These items are followed by a 6-item severity scale for obsessions and compulsions. Items load on five subscales: symmetry, forbidden thoughts, contamination, magical thoughts, and dysmorphic thoughts. Internal consistency, specificity and sensitivity, and discriminant validity are high (Bejerot et al., 2014). The Obsessive–Compulsive Inventory—Revised (OCI–R) The OCI–R is an 18-item self-report measure that assesses the presence of, and the distress associated with, obsessive–compulsive symptoms. It consists of 6 subscales (washing, checking/doubting, obsessing, mental neutralising, ordering, hoarding), each with 3 items that are rated on a 5-point Likert scale, ranging from 0 (not at all disturbed) to 4 (extremely disturbed) (Foa et al., 2002). The OCI-R is highly correlated with the OCI (r = .98), is internally consistent for those with OCD (α = .83) and for those with other anxiety disorders (α = .88), and demonstrates good construct validity (Abramowitz & Deacon, 2006). Clark-Beck Obsessive–Compulsive Inventory (CBOCI) The CBOCI is a self-report, brief screening measure that consists of 25 items across two subscales: obsessions and compulsions. It provides subscale scores and a total score that measures frequency and severity of obsessive and compulsive symptoms (Clark, Antony, Beck, Swinson, & Steer, 2005). Good internal reliability was demonstrated (α = .90, .87, and .93 for obsessions, compulsions, and total score, respectively), along with moderate test-retest reliability. The measure reliably distinguished clients with OCD from those with depression and other anxiety disorders (Clark et al., 2005). The OCD Family Functioning (OFF) Scale The OFF scale is a 42-item measure that looks at the context, extent, and perspectives of functional impairment in families affected by OCD. It is a 3-part self-report scale (Stewart et al., 2011). Part 1 is completed by the client and consists of 21 questions rated on a 4-point Likert scale ranging from 0 (never) to 3 (daily). The 21 questions relate to the frequency with which OCD interferes with family activities (e.g., mealtimes, shopping, appointments), affects the social life and work/school performance of self, other family members with and without OCD, and the client's feelings when OCD has interfered. Part 2, symptom-specific impairment, consists of 16 symptoms of OCD which the client rates in terms of how frequently each symptom has interfered with their family functioning.

Part 3, family role-specific impairment, asks the client to rate how much OCD has impacted on their ability to fulfil 5 family roles. There is also a parallel version that can be completed by relatives to measure the impact of the client's OCD on the family's functioning. The authors reported excellent internal consistency (α = .96), adequate test-retest reliability (r = .80), and excellent convergent validity. They concluded that the OFF was a valid and reliable instrument for examining family functioning in children and adults with OCD.

Child Measures CY-BOCS The Y-BOCS has also been modified for using with children; the CY-BOCS has good psychometrics and is considered a valid and reliable tool for using with children and adolescents with OCD (Gallant et al., 2008; Scahill et al., 1997). The CY-BOCS has also been used with young people with autism spectrum disorders, and has demonstrated utility for assessing clinically significant obsessive–compulsive symptoms in this population. It has adequate psychometric properties: higher internal consistency for the obsessive subscale (α = .86) than the compulsive scale (α = .59), good to excellent interrater reliability for the total score and both subscales, and satisfactory convergent and divergent validity for total score and both subscales (Wu et al., 2014). Child Behavior Checklist (CBCL) The obsessive–compulsive subscale of the CBCL consists of 8 items and can be used as a measure of OCD (Hudziak et al., 2006). The items include: (9) Can't get his/her mind off certain thoughts; obsessions (describe); (31) Fears he/she might think or do something bad; (32) Feels he/she has to be perfect; (52) Feels too guilty; (66) Repeats certain acts over and over; (84) Strange behaviour (describe); (85) Strange ideas (describe); and (112) Worries. Multidimensional Anxiety Scale for Children (MASC 2) The MASC 2 measures anxiety in young people aged 8 to 19 years, across several domains, including separation anxiety/phobias, social anxiety, physical symptoms, and harm avoidance, as well as obsessions and compulsions. There is a self-report and a parent version (March, 2013). In both versions, the obsessions and compulsions subscale consists of 10 items, rated on a 4-point Likert scale from 0 (never true) to 3 (often true). Scores are expressed as T-scores, and higher T-scores indicate higher levels of anxiety. Items capture the symptoms of uncontrollable thoughts, repetitious behaviour, contamination, washing, responsibility, checking, checking for negative outcomes, counting, wrong doing, and feeling just right (March, 2013).


Conclusion These adult, child, and family measures, all of which can be completed in 5 to 20 minutes, can be used clinically as sources of converging evidence to supplement the clinical interview, help the clinician to understand the contextual variables of OCD, assist with diagnosis and differential diagnosis, and evaluate treatment-related changes in symptoms.

References Abramowitz, J. S., & Deacon, B. J. (2006). Psychometric

properties and construct validity of the Obsessive–Compulsive Inventory—Revised: Replication and extension with a clinical sample. Journal of Anxiety Disorders, 20, 1016–1035.


Bejerot, S., Anckarsater, E. G., Berglund, G., Gillberg, C., Hofyander, B., Humble, M. B., ... Frisen, L. (2014). The Brief Obsessive–Compulsive Scale (BOCS): A self-report scale for OCD and obsessive–compulsive related disorders. Nordic Journal of Psychiatry, 68, 549–559. doi: 10.3109/08039488.2014.884631

Clark, D. A., Antony, M. M., Beck, T. A., Swinson, R. P., & Steer, R. A. (2005). Screening for obsessive and compulsive symptoms: Validation of the Clark-Beck Obsessive–Compulsive Inventory. Psychological Assessment, 17, 132–143.

Foa, E. B., Huppert, J. D., Leiberg, S., Langner, R., Kichic, R., Hajcak, G., & Salkovskis, P. M. (2002). The Obsessive–Compulsive Inventory: Development and validation of a short version. Psychological Assessment, 14, 485–496.

Gallant, J., Storch, E. A., Merlo, L. J., Ricketts, E. D., Geffken, G. R., Goodman, W. K., & Murphy, T. K. (2008). Convergent and discriminant validity of the Children's Yale-Brown Compulsive Scale-Symptom Checklist. Journal of Anxiety Disorders, 22, 1369–1376. doi: 10.1016/j.janxdis.2008.01.017.

Goodman, W. K., Price, L. H., Rasmussen, S. A., Mazure, C., Delgado, P., Heninger, G. R., & Charney, D. S. (1989). The Yale-Brown Obsessive Compulsive Scale. II. Validity. Archives of General Psychiatry, 46, 1012–1016.


Hudziak, J, J., Althoff, R. R., Stanger, C., van Beijstervedt, C. E. M., Nelson, E. C., Hanna, G. L, … & Todd, R. D. (2006). The Obsessive Compulsive Scale of the Child Behavior Checklist predicts obsessive–compulsive disorder: A receiver operating characteristic curve analysis. Journal of Child Psychology and Psychiatry, 47, 160–166.

March, J. S. (2013). Multidimensional Anxiety Scale for Children (MASC 2), Technical Manual. New York, NY: Multi-Health Systems.

Monahan, P., Black, D. W., & Gabel, J. (1996). Reliability and validity of a scale to measure change in persons with compulsive buying. Psychiatry Research, 64, 59–67.

Phillips, K. A., Hart, A. S., & Menard, W. (2014). Psychometric evaluation of the Yale-Brown Obsessive–Compulsive Scale Modified for body dysmorphic disorder (BDD-YBOCS). Journal of Obsessive–Compulsive and Related Disorders, 3, 205–208.

Phillips, K. A., Hollander, E., Rasmussen, S. A., Aronowitz, B. R., DeCaria, C., & Goodman, W. K. (1997). A severity rating scale for body dysmorphic disorder: Development, reliability, and validity of a modified version of the Yale-Brown Obsessive Compulsive Scale. Psychopharmacological Bulletin, 33, 17–22.

Scahill, L., Riddle, M. A., McSwiggin-Hardin, M., Ort, S. I., King, R. A., Goodman, W. K., … Leckman, J. F. Children's Yale-Brown Obsessive Compulsive Scale: Reliability and validity. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 844–852.

Stewart, S. E., Hezel, D. M., Proujansky, R., Walsh, C., Ben-Joseph, E. P., Jenike, M., … Pauls, D. L. (2011). Development and psychometric properties of the OCD Family Functioning (OFF) Scale. Journal of Family Psychology, 25, 434–443. doi: 10.1037/a0023735

Storch, E. A., Rasmussen, S. A., Price, L. H., Larson, M. J., Murphy, T. K., & Goodman, W. K. (2010). Development and psychometric evaluation of the Yale-Brown Obsessive–Compulsive Scale—Second Edition. Psychological Assessment, 22, 223–232. doi: 10.1037/a0018492.

Wu, M. S., McGuire, J. F., Arnold, E. B., Lewin, A. B., Murphy, T. K., & Storch, E. A. (2014). Psychometric properties of the Children's Yale-Brown Obsessive Compulsive Scale in youth with autism spectrum disorders and obsessive–compulsive symptoms. Child Psychiatry and Human Development, 45, 201–211. doi: 10.1007/s10578-013-0392-8


Editorial Policy and Guidelines The Australian Clinical Psychologist is the official e-journal of the Australian Clinical Psychology Association and is published twice a year. Aim The Australian Clinical Psychologist provides for the dissemination of knowledge on topics of interest informative to clinical psychologists. Its focus is on the latest clinical theory and research relevant to clinical practice, including assessment, treatment intervention, training, and professional issues. Content Submissions to the Australian Clinical Psychologist may include:

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