New Therapy Shows Promise for Swift Treatment of Obsessive Compulsive Disorder

Symptoms of obsessive compulsive disorder can range from uncontrollable thoughts to excessive hand washing. Treating these symptoms can be challenging, often taking months. But a new treatment for OCD offers the possibility that symptoms can be reduced or eliminated in eight or fewer weekly sessions lasting about 15 minutes each.

Preliminary findings from case studies involving 19 participants with OCD suggest that the new treatment, called Response Disequilibrium Therapy (RDx), may be a promising alternative to traditional OCD treatments, producing similar outcomes more efficiently and with less stress to the client and therapist.

APS Fellow Richard M. McFall and his colleagues at Indiana University report their findings in Clinical Psychological Science.

Unlike some OCD treatments, RDx does not focus on the causes of a client’s symptoms or other aspects of the client’s life or feelings. Instead, it establishes a controlled link between the client’s symptomatic behavior and a positive daily activity. Access to the positive activity now must be earned by decreasing the baseline level of the negative behavior. This link, or constraint, puts the two behaviors in disequilibrium relative to their baseline levels. Clients will work to establish a new equilibrium by reducing or eliminating their symptomatic behavior.

To illustrate this disequilibrium concept, consider an OCD client who engages in 18 episodes of excessive hand washing per day (not counting normal occasions, such as after using the restroom). The client’s positive behavior is watching TV about 90 minutes per day. The RDx treatment links access to TV viewing to a scheduled reduction in hand washing episodes. The goal in the first week is to cut the hand washing in half, from 18 to 9 episodes per day. Each decrease in daily hand-washing episodes earns 10 minutes of TV time, which the client deposits in a metaphorical “checkbook.” The client cannot watch TV without having earned the time; but if the treatment goal has been met, the client will not be deprived of the normal amount of TV time. Over subsequent weeks the treatment goal is to continue cutting the client’s symptom level in half until it has been reduced or eliminated.

Exposure and response prevention therapy (ERP), the current treatment of choice for OCD, requires therapists to expose clients to the triggers for their symptoms, such as shaking hands for someone who dwells on the spread of germs. Therapists provide clients with calming reassurance and the exposure exercise continues until clients’ arousal levels recede significantly, which can take considerable time.

RDx puts clients in charge of implementing their own treatment procedure outside of the therapy session in the same environment that triggers their symptoms.

“In effect, clients learn new behaviors that replace and control their previous symptomatic responses to distressing situations,” McFall explains.

To test the treatment, the researchers randomly assigned a group of 41 patients to either RDx or ERP treatment. Of the 34 clients assigned to RDx, 15 received interventions that deviated from the protocol and were reclassified into a mixed/no treatment group.

All 19 of the study’s OCD clients who received the full RDx treatment and complied with the procedure experienced good to excellent outcomes, the research team reports. Three of the mixed/no treatment patients also showed symptom reductions, although the researchers caution that they can’t attribute the improvements solely to RDx.

RDx may not work for all clients or all problems, the researchers say, but future research could confirm it to be an efficient, cost-effective, and valuable addition to mental health-care providers’ toolbox.

McFall’s Indiana University collaborators on the project include James Allison, Richard J. Viken, and William Timberlake. The article includes an online link to case summaries for individual clients and a handout summarizing the procedure.

Comments

Have you done any follow up to ensure permanence of TX?

Figures in the supplemental materials with the article show positive follow up results for RDx clients.

This seems, from the description, to be operant conditioning, the basis of behavioral treatments that have been around for years. These types of programs have been implemented (with varying levels of success) to help with problematic behaviors of all types: addictions, obsessive thoughts, problematic eating, child and adolescent behavioral problems, parenting, to name a few. If this is true, then one of the problems that your approach will face is compliance. Will your clients be able to self-reward (easy) and self-punish (harder) with sufficient consistency to possibly effect change?

In this article on OCD treatment I would have appreciated at least some mention of Deep Brain Stimulation, an OCD treatment used mainly in Europe and promoted by Rietveld, et al.

It seems that blocking access to the desired behavior, or reward, until achievement of treatment goal is dependent on self-regulation of behavior (e.g., disciplining oneself not to watch TV until achieved reduction in frequency of hand washing). Given that OCD may be linked to poor behavioral self regulation to begin with, I wonder how clients manage to delay the desired behavior until goal is achieved.
Relatedly, how is this different than employing positive reinforcement in the context of behavior modification?

The comments by D and Calderon suggest a mistaken notion of RDx’s theoretical heritage. As our introduction explains in some detail, RDx is based on a theory that explicitly rejects conventional conceptions of reinforcement, reward and punishment rooted in Thorndike’s thoroughly discredited Law of Effect. D and Calderon also seem puzzled by the ability of OCD patients, supposedly deficient in self-regulation, to comply with the requirements of RDx. We too were surprised by how well the clients were able to stick to the protocol, but the evidence shows that the majority of them could and did. Maybe OCD patients are just very good at following directions—especially when they discover so quickly that doing so alleviates or eliminates their troublesome symptoms.

This includes a very inaccurate description of ERP. There is absolutely NO “calming reassurance” given by the therapist. We do the opposite of that. I’m concerned about the writers actual knowledge of OCD and it’s treatment of it.
Also wondering if YBOCS was administered for before and after measurements.

The term “calming reassurance” in this case refers to the therapist’s role of orchestrating the exposure experience while keeping the client from escaping from the arousing situation or from engaging in the usual symptomatic behavior until the arousal level has decreased significantly. I can see how our use of the term could be misleading, but the therapist’s presence and oversight of the process is reassuring. The YBOC was administered pre and post intervention, and reflected the changes in symptomatic behavior. Of course, the criterion measure of treatment effects is the recorded change in symptomatic behavior.

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