OCD & Obsessive Compulsive Personality:
Similar Symptoms, Different Treatments
By Lynn Mollick
On Sunday, June 14, psychologist Dr. Milton Spett gave a workshop on treatments for OCD and OCPD for 57 NJ-ACT members.
Obsessive Compulsive Disorder
Research on OCD utilizes a fixed protocol, usually 8 to 20 sessions of exposure and response prevention (ERP). At the end of treatment most research patients are much improved but still symptomatic.
The success rate in treating OCD can be greatly improved over research outcomes by utilizing longer treatment, incorporating techniques in addition to ERP, and designing a treatment for each patient that will be most effective with that patient.
There are 3 types of behavioral interventions for OCD:
1. Exposure – imaginal or in vivo experiencing the obsession and the anxiety it creates. Many people believe that anxiety must be reduced by 50% during EXP, but recent research indicates that this is a myth.
2. Response prevention – doing nothing to avoid, escape, or diminish the anxiety caused by the obsession.
3. Behavioral experiments to disprove the obsession.
Many people believe that ERP is the treatment of choice for OCD. Dr. Spett asserted that research has found that in individual treatment cognitive therapy is equal to ERP, and cognitive therapy has a lower dropout rate than ERP. (In group therapy, ERP is probably more effective.)
The core metacognitive distortion in OCD is that the obsessive thoughts are valid and important. According to Dr. Spett, the fundamental treatment goal is to change this core belief.
There are 4 types of cognitive interventions for OCD:
1. Disputation – e.g. write an essay marshalling all the evidence that the obsession is incorrect. Read the essay every day and improve it over time; argue it in front of an audience.
2. Socratic questioning – ask questions that gently lead patients to recognize that their obsession is not a realistic concern.
3. Metacognitive therapy – normalize the thought by showing patients research indicating that almost everyone experiences these thoughts of danger.
4. Acceptance & Commitment Therapy – the “clouds in the sky” or “leaves on a stream” techniques help the patient see the obsession as a meaningless thought.
Cognitive techniques will not reinforce compulsive reassurance-seeking unless they are provided when patients have sought reassurance. Furthermore, cognitive techniques are not merely logical advice. They must be well-timed, creative, convincing, and repeated many times in many ways.
Other techniques that Dr. Spett said would improve outcome include:
1. Let patients choose the treatment: response prevention, exposure, or cognitive techniques. Research indicates better outcome with patient choice.
2. Bring family members into treatment. They must learn not to accommodate and reinforce OCD. In addition, they often provide information about the patient’s obsessions and compulsions the patient has not revealed.
3. Treat other problems besides OCD. When any other psychological problem improves, OCD will probably improve as well.
4. Refer the patient to another therapist when treatment is stuck. Another therapist may try some approach you didn’t consider.
Obsessive Compulsive Personality (OCP)
Obsessive Compulsive Personality Disorder (or OCP traits) is a disorder of values.
Patients with OCP value accomplishment over enjoyment.
They value planning over spontaneity.
They value rigidity over flexibility.
They value thrift over pleasure.
They value following rules over handling situations pragmatically.
They value control over good relationships.
They value their rigid morality.
They value their perfectionism.
They overvalue orderliness.
They overvalue attention to minor details.
They value facts and logic over emotions — their own emotions or the emotions of others.
Treatment of Obsessive Compulsive Personality must change these values.
There is virtually no research on cognitive behavioral treatment of OCP. Patients don’t present with OCP. Dr. Spett described the successful treatment of four patients whose presenting problems were GAD, depression, anger, and bulimia. In all four cases, treating their OCP successfully alleviated their presenting problem.
Dr. Spett described 25 different techniques for treating OCP. They fall into 7 categories:
1. Focus on enjoying life as a core value. Every session ask patients what they enjoyed since the last session. Remind them of past pleasures and help them anticipate future pleasures. Encourage humor and playfulness. Teach patients to focus on the enjoyment of doing tasks instead rather than getting them done.
2. Reduce patients’ emphasis on accomplishment. Replace perfectionism with “good enough.” Outlaw multitasking – it’s ineffective anyway. Suggest that patients check their cell phones and email only a few times a day. One study found that subjects randomly assigned to check their email only 3 times a day reported less stress than subjects who checked as usual. Encourage patients to make a reasonable effort rather than setting outcome goals.
3. Practice mindful living. Keep your mind on what’s happening right now. Eat, drive, shower, and pursue daily activities mindfully. Mindful living can replace ruminating about the past and worrying about the future.
4. Overcome time urgency. Do things slowly so that you enjoy them more. Allocate extra time for everything, especially travel — everything takes longer than you think. Get out of the habit of doing “just one more thing.” Remember that you don’t “have to” be on time, and virtually no task has a real deadline. The more you rush the longer tasks take because you have to go back and correct the mistakes you made by rushing.
5. Move from rigidity to flexibility. Do flexibility self-talk and flexibility exercises. Practice changing plans. Ask what makes sense to do now instead of what you are supposed to do.
6. Move from planning to spontaneity. Take a walk without a destination. Schedule time to do nothing and then do whatever you feel like doing. Eat what you feel like eating instead of what you planned to eat.
7. Treating the anger OCP patients experience when others don’t do what OCP patients believe they should do. Remember that anger spoils your day. Focus on the offending person’s positive qualities. Reframe their behavior as just the way they are – not directed at you in particular. Teach OCP patients.
Many patients with other disorders suffer from OCPD or OCP traits. Always assess patients for OCP. Alleviating these traits is often highly effective in the treatment of many other disorders.
Now that you have finished reading this article, don’t rush off to accomplish the next task on your to do list. Think about the article, and then ask yourself what you feel like doing right now.