Considering Comorbidity
As highlighted throughout, comorbidity presents as the rule rather than the excep- tion across OCRDs. Often, anxiety disorders and OCRDs co-occur with one another as well as with other functionally related conditions (e.g., substance use disorders, depression). A deeper discussion of comorbidity in anxiety-related disorders can be found in Chap. 5. However, we briefly highlight how comorbidity impacts treatment approaches for OCRDs.
First, depression is very common among the OCRDs [125]. When depression is particularly severe, it may merit acute and focused intervention prior to treating other OCRD symptoms. However, depression may often arise from the impairment and avoidance that results from OCRDs (e.g., a client with OCD who engages in time-consuming shower rituals or a client with BDD who can’t leave the house). In such cases, depression may naturally abate in evidence-based interventions target- ing the primary OCRD condition. Finally, in some cases anxiety and depression may be closely entangled, and it may be difficult to distinguish one condition as primary. For individuals with this presentation, combined or sequential, evidence- based interventions may be useful (e.g., integrating behavioral activation into cognitive- behavioral treatments for OCRDs, combining antidepressants and cognitive- behavioral therapy [CBT]). Although various empirically supported psy- chological and pharmacological treatments exist for anxiety and depression, limited research has been conducted to identify the optimal sequencing or combination of these approaches for comorbid cases. As such, the acceptability of interventions for a given client, the case conceptualization, and empirically informed clinical judg- ment should be used to devise the most useful treatment plan. Regular assessment (e.g., of primary symptoms) can be used to modify this plan as needed.
A second important consideration is the comorbid presentation of substance use disorders, which may emerge as a maladaptive coping strategy used to regulate the distress an individual is experiencing due to OCRD symptoms [126]. Similar to clinical considerations for depression, the acute risk associated with the substance use may serve as the primary distinction of appropriate care. For example, if sub- stance use is severe or poses a significant medical risk (e.g., overdose, alcohol with- drawal), it may warrant inpatient or intensive outpatient services in order to assist
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the individual in achieving a medically stable or abstinent state. Moreover, due to the physical and cognitive impacts of substance use, it is necessary to achieve suf- ficient control over the substance use behavior (e.g., sobriety for therapy sessions) in order for the individual to benefit from psychological interventions. Additionally, collaboration with medical providers may be necessary (e.g., primary care physi- cians) to ensure client safety and appropriateness for therapy. However, in many cases substance-related comorbidities may be subthreshold or secondary to the OCRD. For such individuals, these symptoms may abate by treating core, underly- ing mechanisms (e.g., improving coping skills, distress tolerance). Moreover, research suggests that integrating treatment to directly target both substance use and OCD symptoms concurrently may be most effective [127].
Frontline Psychological Treatment: Cognitive-Behavioral Techniques
Cognitive-behavioral approaches are the leading, evidence-based techniques for the treatment of both anxiety disorders and OCRDs [128]. As follows, given the histori- cal and conceptual overlap between anxiety disorders and OCD, the theory and guiding principles of CBT are the same. Moreover, the support for the efficacy of CBT for OCD (as well as BDD, though less research has been done) largely mirrors that of anxiety disorders [129]. For this reason, our discussion of treatment will focus on the specifics and nuances of CBT for OCRDs, including the empirical evidence and applied use of CBT techniques for OCD and BDD, as well as the dis- tinctions for hoarding, HPD, and SPD. A detailed discussion of the history, theory, and principles of CBT for anxiety can be found in Chap. 12.
Across anxiety disorders, and several OCRDs, two principle components of CBT appear effective: exposure and cognitive therapy. These approaches may be admin- istered independently or integrated. Of note, in behavioral therapy, cognitive tech- niques are often used (e.g., in the processing of exposure exercises) [52]. Similarly, behavioral experiments (i.e., exposures to test the validity of beliefs) are often included in cognitive therapy.
Psychoeducation and Self-Monitoring
Of note, as with anxiety disorders, effective treatments for OCRDs typically begin with psychoeducation and self-monitoring [130]. These initial components of treatment are essential to allow the client to understand the cognitive-behavioral conceptualization and the usefulness of practicing therapeutic exercises (e.g., self- monitoring, exposure). These initial components may be especially helpful for individuals with lower insight into the nature or impairment associated with their symptoms, which presents more often in OCRDs than anxiety disorders.
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Psychoeducation for OCRDs stems from the functional assessment of symp- toms. Clinicians orient the client to the overall CBT model of their presenting con- cerns and work collaboratively to identify ways in which the model extends to his/
her symptoms. The clinician then builds upon this formulation to discuss the utility and effectiveness of CBT exercises in the context of this model and highlight treat- ment targets for the individual. This component of treatment is particularly impor- tant for motivating clients to engage in challenging therapeutic work by ensuring that individuals understand the rationale for such challenging exercises and their relevance to the particular sources of anxiety and impairment in their lives.
Self-monitoring is a critical component of CBT and consists of between-session, self-reported assessments of cognitive, behavioral, and affective symptoms and rel- evant contextual experiences. Individuals are asked in the beginning, and through- out treatment, to monitor their symptoms (e.g., rituals in OCD/BDD, hair pulling/
skin picking) as well their antecedents (i.e., triggers) and consequences. Self- monitoring can be used to progressively refine the case conceptualization and treat- ment plan accordingly. It also teaches the client to identify symptoms in the moment as they arise and to develop greater self-awareness. In this way, self-monitoring can facilitate a more robust self-conceptualization of symptoms, including greater insight into the causal links between symptoms, their triggers, and their relation- ships to impairment.
Cognitive Therapy
In cognitive therapy, various techniques (similar to those for anxiety disorders) are used to challenge the maladaptive beliefs that contribute to and maintain symptoms of OCRDs: thought challenging and behavioral experiments [131]. First, thought challenging exercises have similar targets and mechanisms for OCRDs as anxiety disorders. For OCD, thought challenging often targets themes including the overes- timation of personal responsibility for harm, the importance and need to control thoughts, or the need for perfection and order [132]. For example, therapist and client might use a pie chart to examine all the possible factors that could be respon- sible for a feared outcome (to challenge overestimates of responsibility). Of note, the research is mixed as to whether conducting cognitive restructuring before begin- ning exposure is necessary [133, 134]. In BDD, cognitive techniques are more stan- dard practice and involve specific focus on cognitive restructuring of body dysmorphic beliefs about appearance and the self (e.g., “If I looked better, my whole life would be better”) [113].
Although results for cognitive therapy in hoarding are less robust [42, 135], thought challenging can be useful and involves examining core beliefs regarding the importance of acquiring or saving items and one’s ability to tolerate discard- ing items [136]. Given that the CBT formulation of HPD and SPD differs, CBT typically focuses more on behavioral components (e.g., habit reversal, described below). However, some evidence suggests thought challenging may be useful spe- cifically for challenging transdiagnostic factors linked with symptoms, such as
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firmly held beliefs about the need for perfectionism as well as examining cogni- tions that may maintain pulling/picking for an individual (e.g., permission-giving thoughts) [137].
Finally, behavioral experiments aim to further cognitive restructuring to provide real-life opportunities to challenge unhelpful or inaccurate beliefs. As such, the effectiveness and approach to behavioral experiments parallel that described for exposure below.
Exposure and Response Prevention
Exposure is a core component of effective treatment for anxiety-related conditions and OCRDs, including OCD, BDD, and to some extent hoarding [113, 125]. In exposure, individuals test their primary fears and challenge distorted cognitions in imagined and real-life experiences. Exposures are informed by the person-specific, functional assessment and can be tailored to address a client’s specific feared out- comes. For this reason, exposure for OCRDs largely maps onto that described for anxiety disorders. Clinicians and clients collaboratively work together to identify the anticipated severity of distress associated with different triggers in a fear hierar- chy. Traditionally, exposures for anxiety-related disorders have relied upon on a gradual, sequential implementation of exposures [138]; however, recent research suggests that selecting exposure intensity in a varied fashion may provide additional gains by further challenging intolerance of uncertainty (common among individuals with anxiety-related conditions) and bolstering self-efficacy (i.e., by implying that an individual is ready and able to handle even more challenging exposures) [139, 140]. Further, variety in exposure intensity more closely aligns with the way in which challenges and fear stimuli are encountered in real life and as such may aid in the generalization of therapeutic gains. Thus, clinicians and clients can choose the order in which they conduct exposure exercises based on the client’s goals. Of note, as described in greater detail for anxiety disorders (Chap. 12), even with var- ied intensity approaches, it is necessary to assure that exposures are designed for early and continued success in order to cultivate self-efficacy and mastery, as well as protect against symptom worsening or early dropout.
Taken together, exposure can serve many important functions in the treatment of anxiety and OCRDs. First, in line with the emotional processing theory of anxiety disorders [141], exposure can facilitate habituation, or gradual decreases in anxious responding, to the fear stimulus. In the case of OCD, for example, this might involve remaining in contact with a feared, contaminated item (e.g., public restroom toilet) for as long as it takes for anxiety to habituate. Importantly for OCRDs, individuals do not engage in compulsions during this extended period of time (i.e., response prevention), which allows fear to naturally abate without rituals or avoidance (simi- lar to eliminating safety behaviors in the treatment of anxiety). Exposure can also facilitate cognitive change, since the individual can test distorted beliefs via expo- sure and develop more accurate appraisals (e.g., of the likelihood and severity of a feared outcome such as getting sick).
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For OCRDs, as with anxiety disorders, research has suggested that, although habituation may occur in the context of exposure, it is not necessarily predictive of long-term treatment outcome [139]. Moreover, an overreliance on habituation may incidentally reinforce maladaptive beliefs that anxiety and obsessions are intoler- able and should be eliminated, which can be a source of symptom maintenance [140]. Thus, it may additionally be useful to emphasize the client’s willingness or ability to handle the exposure when conducting these exercises. Given that anxiety is a natural emotional experience, clinicians can help clients set goals for exposure that emphasize distress tolerance. Indeed, due to patterns of avoidance and com- pulsions, individuals have limited opportunities to learn or apply adaptive coping behaviors and to accurately appraise their ability to manage distress in the context of fear triggers. As such, exposure provides an opportunity for the individual to take in more accurate information about their ability to sit with their emotions and associated physical sensations (e.g., the ability for a client with BDD to tolerate the distress from having their photograph taken). Thus, exposure goals focus on the process of the exercise (e.g., “Wow, that’s terrific – you are staying in this even though it’s uncomfortable”), over the outcome (e.g., habituation). This can help buffer against feelings of failure when exposures are challenging and anxiety may not decrease or for when feared occurrences do happen following exposure (e.g., an individual gets sick after a contamination exposure), using this as an opportu- nity to commend their efforts, to highlight whether the actual sickness is as bad as anticipated severity of illness, as well as their ability to tolerate the distress of their feared event occurring.
In applying exposure techniques to the various OCRDs, exposures in the con- text of contamination concerns in OCD, for example, might involve a client sitting on a toilet in a public restroom, touching door handles and elevator buttons, or sitting in a hospital waiting room where others may be sick. For each of these exercises, the client would aim to sit with feelings of being “dirty,” test maladap- tive beliefs that doing these activities will mean he will contract an illness/disease, and practice tolerating anxiety/distress. For an individual with BDD, hierarchy items might include leaving the house without wearing makeup (for skin-related concerns), wearing shorts (for leg-related concerns), wearing hair in a ponytail (for ear-related concerns), working with mirrors to support exposure (e.g., approaching physical features a client has been avoiding), and perceptual retrain- ing (i.e., learning to describe one’s whole body objectively and nonjudgmentally when looking in the mirror and shifting attentional focus away from the perceived defect). The therapist and client might aim to specify an amount of time, for instance, that the client estimates she can manage these activities (and test out whether she can exceed it).
Finally, for hoarding disorder, exposure exercises can also be designed around discarding items in the home as well as refraining from acquiring new possessions [136]. For example, discarding hierarchies might quantify anticipated distress if a client were to sort through mail and paperwork, discard old clothes, donate books, etc. Moreover, nonacquisition exposures can be designed for a client to spend time in a place that normally triggers acquiring (e.g., yard sale) and practice observing
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and tolerating urges to acquire without purchasing anything. Of note, in treating hoarding disorder, these behavioral exercises are often preceded by skills training that addresses deficits that can interfere with discarding exercises including skills for sustaining attention, prioritizing tasks, organization and planning, and decision- making [65].
Habit Reversal Training (HRT)
HRT is one of the leading approaches implemented in CBT for HPD and SPD [142, 143]. HRT recognizes the unique cognitive-behavioral conceptualization of these phenomena and the importance of positive as well as negative affect and reinforce- ment to the maintenance of these concerns. HRT was derived from behavioral the- ory as well as neurological evidence regarding the acquisition, maintenance, and extinction of repetitive behaviors [144]. Moreover, it recognizes the potential for cognitive, affective, and contextual factors to trigger or exacerbate such behaviors.
In this way, both the core behavioral mechanisms of HPD/SPD can be addressed, as well as individual factors (e.g., workplace stress, not-just-right experiences, perfec- tionism) that are linked with an individual’s symptom presentation.
The components of HRT typically include self-monitoring, awareness training, competing response training, and motivational training [145]. In HRT, psychoed- ucation and self-monitoring are critical for the individual to become aware of urges to engage in hair pulling or skin picking in the moment, as well as their personal triggers and associated consequences for the behavior. Next, the focus shifts to developing and implementing competing, adaptive responses that prevent hair pulling or skin picking including relaxation training (e.g., mindfulness, breathing techniques) and other activities that reduce the urge to engage in or prevent the behavior from occurring (e.g., performing an alternate activity with one’s hands like clenching fists). Motivational training is an important component of HRT, as clients often present with low intrinsic motivation to cease the behav- ior due to the rewarding aspects. Functional consequences noted in self-monitor- ing (e.g., interpersonal strain, medical care, skin damage) may be used to highlight the negative consequences of engaging in skin picking or hair pulling and thus motivate consistent engagement in HRT exercises. Further, given that these behaviors are often positively reinforced, it is critical to assure that alternative behaviors include rewarding experiences (e.g., replacing hair pulling with a sooth- ing scalp massager).
HRT has been demonstrated to be a highly effective behavioral treatment approach for HPD and SPD [145] and common cognitive-behavioral elements are key to more comprehensive cognitive-behavioral approaches [146].
Additionally, promising new research demonstrates the utility of integrating technology to augment awareness training and the effectiveness of HRT. For example, a recent open trial demonstrated promising feasibility, tolerability, and efficacy of HRT augmented by a wearable device that alerted individuals of hand-to-head contact [147].
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Promising Psychological Treatments
Recently, newer CBT-based approaches have been developed and shown promise for augmenting the treatment of OCRDs. These approaches consist of the unified protocol (UP) [148] and acceptance and commitment therapy (ACT) [149]. It is important to acknowledge that with both the UP and ACT, considerable research is still needed to provide evidence-based guidelines about which interventions and treatment components work best for whom and how these approaches can be opti- mally sequenced and tailored to the individual.
Unified Protocol (UP)
The UP was designed based on extensive empirical evidence implicating shared risk and maintenance factors in emotional disorders, such as anxiety disorders, OCD, and other mood-related disorders [150]. Transdiagnostic, skills-based modules include present-focused affective awareness, psychological flexibility, affective avoidance and maladaptive coping behaviors, tolerance of internal experiences, and exposure to distressing experiences and challenging emotion. Randomized con- trolled trials support the efficacy of the UP in reducing anxiety and depression symptoms [151, 152] as well as OCD symptom severity (e.g., 46% decrease in OCD severity, 83% qualified for responder status by follow-up) [152]. The UP has not be specifically examined for the other OCRDs, although its overlap with treat- ment targets for BDD suggests it may be helpful.
Acceptance and Commitment Therapy (ACT)
ACT is another promising treatment for OCRDs [153] that focuses on improving psychological flexibility and the tolerability of internal experiences such as obses- sions (in OCD and BDD) and urges (in HPD and SPD). ACT techniques have been applied to specific OCRDs including OCD [154], body dissatisfaction [155], skin picking [156], and hair pulling [157]. ACT alone has shown initial evidence for the treatment of OCD [158, 159]. Additionally, a recent randomized controlled trial demonstrated that ACT-informed ERP demonstrated comparable effectiveness to ERP alone [160]. ACT has also shown promise for targeting body dissatisfaction among individuals with eating disorders [161, 162]. Finally, ACT combined with HRT may facilitate treatment gains (e.g., improved acceptance of urges to pick/pull) for HPD and SPD [157, 163]. Given the extant evidence, clinicians may choose to implement ACT in combination with other empirically supported techniques for OCRDs (e.g., exposures that focus on one’s willingness to have unwanted internal experiences).
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