Article

Common pitfalls in exposure and response prevention (EX/RP) for OCD

Center for the Treatment and Study of Anxiety, Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, 3535 Market Street, 6 Floor, Philadelphia, PA 19104 USA.
Journal of Obsessive-Compulsive and Related Disorders (Impact Factor: 1.18). 10/2012; 1(4):251-257. DOI: 10.1016/j.jocrd.2012.05.002
Source: PubMed

ABSTRACT

Obsessive-compulsive disorder (OCD) is a highly debilitating disorder. Fortunately there are treatments that help the majority of OCD sufferers. The behavioral treatment with the most empirical support for its efficacy is exposure and response prevention (EX/RP). Over the years in our supervision meetings and in our clinical practice we have noted a number of relatively common therapist pitfalls that decrease the effectiveness of EX/RP. These pitfalls include not encouraging patients to approach the most distressing situations, doing imaginal exposure when in vivo is called for (and vice versa), encouraging distraction during exposure, providing reassurance, failing to address the core fear, ineffective handling of mental compulsions, and difficulty working with close others in the patient's life. In the current article we describe these common pitfalls and how to avoid them.

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Available from: Monnica T Williams
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    • "His Global Assessment of Functioning (GAF) typically ranged from 5 to 15 on a 100 point scale. His treatment history included over 15 years of multiple medication trials, including clomipramine and multiple SSRIs at high doses, including fluoxetine at 80 mg by mouth daily, along with several attempts with outpatient exposure and ritual prevention (ERP) therapy (Gillihan et al., 2012). MA inquired and was evaluated by GJL at the University of Utah and then at two other centers independently offering deep brain stimulation for OCD. "
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    ABSTRACT: Background. In recent years, there has been an explosion in the number of technical and medical diagnostic platforms being developed. This has greatly improved our ability to more accurately, and more comprehensively, explore and characterize human biological systems on the individual level. Large quantities of biomedical data are now being generated and archived in many separate research and clinical activities, but there exists a paucity of studies that integrate the areas of clinical neuropsychiatry, personal genomics and brain-machine interfaces. Methods. A single person with severe mental illness was implanted with the Medtronic Reclaim® Deep Brain Stimulation (DBS) Therapy device for Obsessive Compulsive Disorder (OCD), targeting his nucleus accumbens/anterior limb of the internal capsule. Programming of the device and psychiatric assessments occurred in an outpatient setting for over two years. His genome was sequenced and variants were detected in the Illumina Whole Genome Sequencing Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory. Results. We report here the detailed phenotypic characterization, clinical-grade whole genome sequencing (WGS), and two-year outcome of a man with severe OCD treated with DBS. Since implantation, this man has reported steady improvement, highlighted by a steady decline in his Yale-Brown Obsessive Compulsive Scale (YBOCS) score from ∼38 to a score of ∼25. A rechargeable Activa RC neurostimulator battery has been of major benefit in terms of facilitating a degree of stability and control over the stimulation. His psychiatric symptoms reliably worsen within hours of the battery becoming depleted, thus providing confirmatory evidence for the efficacy of DBS for OCD in this person. WGS revealed that he is a heterozygote for the p.Val66Met variant in BDNF, encoding a member of the nerve growth factor family, and which has been found to predispose carriers to various psychiatric illnesses. He carries the p.Glu429Ala allele in methylenetetrahydrofolate reductase (MTHFR) and the p.Asp7Asn allele in ChAT, encoding choline O-acetyltransferase, with both alleles having been shown to confer an elevated susceptibility to psychoses. We have found thousands of other variants in his genome, including pharmacogenetic and copy number variants. This information has been archived and offered to this person alongside the clinical sequencing data, so that he and others can re-analyze his genome for years to come. Conclusions. To our knowledge, this is the first study in the clinical neurosciences that integrates detailed neuropsychiatric phenotyping, deep brain stimulation for OCD and clinical-grade WGS with management of genetic results in the medical treatment of one person with severe mental illness. We offer this as an example of precision medicine in neuropsychiatry including brain-implantable devices and genomics-guided preventive health care.
    Full-text · Article · Oct 2013 · PeerJ
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    • "His Global Assessment of Functioning (GAF) typically ranged from 5 to 15 on a 100 point scale. His treatment history included over 15 years of multiple medication trials, including clomipramine and multiple SSRIs at high doses, including fluoxetine at 80 mg by mouth daily, along with several attempts with outpatient exposure and ritual prevention (ERP) therapy (Gillihan et al., 2012). MA inquired and was evaluated by GJL at the University of Utah and then at two other centers independently offering deep brain stimulation for OCD. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background. In recent years, there has been an explosion in the number of technical and medical diagnostic platforms being developed. This has greatly improved our ability to more accurately, and more comprehensively, explore and characterize human biological systems on the individual level. Large quantities of biomedical data are now being generated and archived in many separate research and clinical activities, but there exists a paucity of studies that integrate the areas of clinical neuropsychiatry, personal genomics and brain-machine interfaces. Methods. A single person with severe mental illness was implanted with the Medtronic Reclaim ® Deep Brain Stimulation (DBS) Therapy device for Obsessive Compulsive Disorder (OCD), targeting his nucleus accumbens/anterior limb of the internal capsule. Programming of the device and psychiatric assessments occurred in an outpatient setting for over two years. His genome was sequenced and vari-ants were detected in the Illumina Whole Genome Sequencing Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory. Results. We report here the detailed phenotypic characterization, clinical-grade whole genome sequencing (WGS), and two-year outcome of a man with severe OCD treated with DBS. Since implantation, this man has reported steady improve-ment, highlighted by a steady decline in his Yale-Brown Obsessive Compulsive Scale (YBOCS) score from ∼38 to a score of ∼25. A rechargeable Activa RC neurostimula-tor battery has been of major benefit in terms of facilitating a degree of stability and control over the stimulation. His psychiatric symptoms reliably worsen within hours of the battery becoming depleted, thus providing confirmatory evidence for the efficacy of DBS for OCD in this person. WGS revealed that he is a heterozygote for the p.Val66Met variant in BDNF, encoding a member of the nerve growth factor family, and which has been found to predispose carriers to various psychiatric illnesses. He carries the p.Glu429Ala allele in methylenetetrahydrofolate reductase (MTHFR) and the p.Asp7Asn allele in ChAT, encoding choline O-acetyltransferase, with both alleles having been shown to confer an elevated susceptibility to psychoses. We have found thousands of other variants in his genome, including pharmacogenetic and
    Full-text · Dataset · Oct 2013
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    ABSTRACT: Background: Obsessive-compulsive disorder (OCD) is a severe condition with varied symptom presentations. Currently, the cognitive-behavioral treatment with the most empirical support is exposure and ritual prevention (EX/RP); however, clinical impression and some empirical data suggest that certain OCD symptoms are more responsive to treatment than others. Methods: Prior work identifying symptom dimensions within OCD is discussed, including epidemiological findings, factor analytic studies, and biological findings. Symptom dimensions most reliably identified include contamination/cleaning, doubt about harm/checking, symmetry/ordering, and unacceptable thoughts/mental rituals. The phenomenology of each of these subtypes is described and research literature is summarized, emphasizing the differential effects of EX/RP and its variants on each of these primary symptom dimensions. Results: To date it appears that EX/RP is an effective treatment for the various OCD dimensions, although not all dimensions have been adequately studied (i.e. symmetry and ordering). Conclusions: Modifications to treatment may be warranted for some types of symptoms. Clinical implications and directions for future research are discussed.
    Full-text · Article · Apr 2013 · Psychopathology
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