Science and Psychotherapy

Most people closely associate medicine and science, but how many of us think of psychotherapy and science as being related? Maybe we don’t, but we should. A recent research article that has received significant media attention has drawn attention to this issue.

While it's true that psychotherapy has little to do with scientific tools like Petri dishes and test tubes, the process of determining which types of psychotherapy are most helpful for specific problems is a scientific one. For decades, major universities and other research institutions have investigated whether some approaches to psychotherapy are more effective than others. Fortunately, after thousands of such rigorously conducted studies, we now possess scientific knowledge about whether specific psychotherapies are helpful for specific problems. Sounds like good news, right? It is! But here’s the bad news. There is no guarantee that a visit to your local therapist will result in your receiving the best-established type of therapy for your problem.

If you see your primary care doctor for advice on high cholesterol, you’re likely to be counseled on which changes to your diet might be helpful and which medications might be appropriate. You wouldn’t expect to be told to take up model boat building, however useful the physician might deem that to be. Why? Because early last century, medicine committed to the use of a scientific approach in selecting treatments. That means that if research shows that iron supplements are more helpful for anemia than, say, leeches, your physician will recommend iron (even if he is an amateur leech farmer).

Unfortunately, this approach has not been as widely accepted by psychotherapists as it has by physicians. Two important reasons for this involve therapist training and accountability. Many therapists attend training programs in only one type of therapy, and graduate from training thinking that this type of therapy is superior and appropriate for many (or all) types of problems. This represents a shortcoming of some therapy training programs. The other factor creating ambiguity around the standard of care among therapists has to do with accountability. If your doctor gives you penicillin for your melanoma, you can file a complaint with the state licensing board. You might even be able to bring legal action. However, therapists are typically not held accountable in the ways physicians are.

There are many reasons -- some very good -- for the different standards. For one, the consequences of applying the wrong treatment are typically different in psychotherapy than in medicine. Additionally, it’s often much clearer whether or not a broken arm is healing as opposed to whether someone’s depression has improved. So while it may be inappropriate hold therapists to the same standards we have for physicians, it is certainly reasonable to expect that therapists be cognizant of the research base for any type of therapy they provide.

Psychotherapy for OCD

For people suffering from OCD, it can be hard to find help. Being an informed consumer can make all the difference.

It is common for people who think they might have OCD to say, "I'd better see someone," and go to see a psychotherapist. So far, so good. However, there are different types of therapy for OCD, and evidence suggests that some work better than others. Many people who seek help for obsessions or compulsions with a psychotherapist find that sometimes, after months or years of therapy, their symptoms are still a problem. There can be many possible reasons for this.

One possibility is that OCD is not the only problem that the patient has. Other co-occurring conditions (e.g., depression, eating disorders) can worsen prognosis.

Another possibility involves the fact that even the most effective treatments for OCD don't work for everyone. Exposure and Ritual Prevention (ERP), a kind of psychotherapy for OCD, is often found to produce significant improvement in two thirds to three quarters of patients in clinical research studies (e.g, as described in a previous post). This means that a significant proportion of people trying this type of therapy will not see significant improvement.

The most alarming possibility, perhaps, is that the patient sees no improvement, and is not receiving the appropriate type of therapy. Many people have called me over the years saying that they are contemplating switching therapists. When asked why, they often say something like, "Well, I really like my therapist and all, but we've been talking about my childhood and my parents for 2-3 years now, and I'm still checking my kitchen stove 30 times a day. I'm getting tired of it!" If you think you may have OCD and decide to see a therapist to work on it, ask them whether they recommend ERP for you. They may have a good reason for not recommending it; however if they're not familiar with it, you might consider seeking out a second opinion.

Contamination in OCD

Are you a germophobe? People have phobias of all sorts of things -- heights, insects, blood, needles, dogs, you name it. However, people with a fear of germs typically do not have a phobia. Often, this is the contamination subtype of OCD. This will often manifest in tendencies to avoid people, places, or things that are thought to be contaminated. Sometimes the contamination is of a specific disease like HIV or hepatitis, or just general "germs." Other times the contamination can be more vaguely defined. In its extreme forms, contamination OCD can result in people feeling that their homes are too contaminated to continue living in. How do you know if your fear of contamination is a big problem, or just a quirk? Here are some tips -- you should consider seeking help if:

• the contamination can spread from one thing to another and then another
• attempts to rid yourself or your surroundings of contamination of caused you to be late to work, school, or other engagements
• contamination fears have affected your sex life or your romantic relationship(s)
• efforts to prevent/contain contamination have significantly lengthened your daily routines
• time spent washing, disinfecting, or otherwise cleaning has become excessive, or is thought to be excessive by others

OCD research update

This past week saw the annual meeting of the Association of Behavioral and Cognitive Therapies, or ABCT. This is the largest American organization of cognitive-behavioral researchers and therapists. Every year, the latest research is presented on cognitive-behavioral therapies for various types of problems, ranging from anxiety to depression to psychosis. This year one of the important projects discussed was the Brown Longitudinal OCD Study. This research study focused on the long-term changes seen in people with OCD who sought help for their symptoms. The study is one of the largest of its kind.

One of the interesting findings to come from this study are estimates of how many people with OCD have tried various forms of treatment. Of the people studied, 86% had been prescribed SSRI's like Paxil, Prozac, or Zoloft. 54% of the people had received cognitive-behavioral therapy (CBT). That means that the medications were tried more than 50% more frequently than CBT. This may have occurred for several reasons. People may be more interested in a treatment that doesn't require weekly visits, or at-home exercises. Perhaps people tended to visit a physician about their symptoms instead of a therapist. Perhaps CBT was not readily available in the places the study participants lived. Perhaps they were not aware of CBT, but were aware of medications that can help OCD symptoms. Whatever the reasons, the Brown Longitudinal OCD study showed that among people who were taking an SSRI at the time they started the study, 62% described themselves as experiencing significant improvement. Of those people who had received CBT in the past year, 67% rated themselves as experiencing significant improvement. These two numbers (62% vs. 67%) are close enough that we can describe SSRIs and CBT as comparably helpful in this study. Other studies have shown similar results.

Since CBT and medications for OCD work about equally well in many research studies, why are medications used more widely? Perhaps part of the answer lies in people's personal preference. But perhaps part lies in the media's messages about the topic. Here I am referring to advertising. While the pharmaceutical industry only allocates 14% of its advertising moneys on television, radio, and other advertising directly to consumers, this amounts to approximately $8 billion per year (using 2004 figures as described in a January 2008 study published in the Public Library of Science - Medicine). When one considers the essentially negligible amount of funds dedicated to the advertising of CBT, the we can begin to make sense of the disparity between how often each treatment is given.

A future post will be devoted to other ways in which the pharmaceutical industry affects the practice of healthcare in the U.S., and some of the reasons why this happens (see also http://www.sciencedaily.com/releases/2008/01/080105140107.htm).

Mental health parity law

With the recent passage of the federal bailout of the financial industry, a groundbreaking piece of legislation was passed that will significantly affect mental healthcare in the U.S. This bill stipulates that mental health conditions must receive the same insurance coverage as physical health conditions. Thus, treatment for schizophrenia or OCD will not be covered with different annual limits, co-payments, and deductibles than those for, say, arthritis.

This legislation became necessary because health insurance companies in the past 15 years have found it profitable to limit coverage for mental health services, and because existing laws did not prohibit such a practice. Individual states had passed legislation in recent years to prohibit this practice on a statewide basis. Timothy's law in New York is one example, but other states have passed similar laws, including Massachusetts, Oklahoma, and California.

The states' parity laws have varied, to this point, on which mental health disorders would be covered. The federal law does not specify which disorders must have parity. Some states' laws state that only "biologically based" conditions would be covered. What these are, however, varies from state to state. Most typically, OCD, schizophrenia, major depressive disorder, and schizoaffective disorder are considered to be "biologically based." However, the notion that some mental disturbances (and not others) are rooted in physiological problems is a dubious one. The brain contains billions of neurons connected through trillions of synapses, each of which has relevance for how we understand, perceive, move, think, or behave. Learning occurs by reconnecting neurons to one another in different patterns. So, by reading this paragraph, e.g., your brain cells are physically affected. Similarly, anytime that organisms learn to fear something, changes in neurophysiology occur. This means that if you develop a fear of elevators, water, or flying, brain changes occur. Someone who suffers a traumatic event like an assault or an accident and then avoids reminders of the event can also say their neurons were "rewired." The notion that some disorders have "neuronal correlates" in the brain and some do not is oversimplified. However, out of this oversimplification, millions of Americans have the beginnings of fair access to mental health coverage.

David Shern, the president and CEO of Mental Health America, was quoted in the New York Times as saying "this is a historic day and a great civil rights victory for millions of Americans who have been unable to access mental health treatment... With approval of this bill we will tear down the walls of stigma and discrimination and open the doors to the power and promise of treatment and recovery." History may prove this to be more hyperbole than prophetic, but the years-long efforts of legislators and mental health advocates should be recognized in getting this bill passed.

Handwashing - how much is too much?

Many people with OCD I have worked with have described compulsively washing their hands. This habit can become excessive, at times resulting in raw and broken skin. There are two ways that handwashing can get out of control: 1) time spent washing, and 2) frequency of washing.

Excessive handwashing may be the single most common observable symptom of OCD, and is probably the behavior most commonly associated with OCD. But how much is too much? Many people with OCD become quite comfortable washing their hands several times per day. However, the frequency of handwashing can sometimes escalate, becoming a real impediment to living a "normal" life. By the time someone with compulsive handwashing seeks help, they often say that they have forgotten how often a "normal" person will wash their hands.

A good guideline for typical handwashing situations is as follows: after using the restroom, before inserting contact lenses, and before eating. A good guideline for the typical length of time it takes to wash one's hands is fifteen seconds, including time to wet hands and apply soap. If you or someone you know is washing your hands in excess of this, it may be helpful to get a consultation with a professional. This is especially true if handwashing is getting in the way of leading your (or their) life.

CBT for OCD

For many sufferers of Obsessive-Compulsive Disorder (OCD) and other types of anxiety, deciding to seek help can be a difficult decision to make. Once that decision is made, another choice is required: what kind of help is best for me? Two of the most researched treatment options available are pharmacological treatment (medication) and cognitive-behavioral therapy. Many people will prefer one or the other, saying, “Oh, I would never want to take medication unless I had to,” or alternatively, “Just give me the pill, what’s the big deal?” This is a very personal choice that each person must make individually. For those that wonder how effective each option may be for them, good news – there is a good deal of research on exactly how effective each of these two treatment options can be.

Much of the research on the effectiveness of various medications for OCD focuses on the class of medications known as the SSRIs (selective serotonin reuptake inhibitors). This class of medications is relatively new, having been first used in the late 1980’s. Medications like Celexa, Lexapro, Prozac, Zoloft, Luvox, and Paxil belong to this class. They are widely used, partially because their side effect profiles are favorable. Some possible side effects are difficulties with sexual arousal, lowered interest in sex, headache, and changes in appetite. However each medication will have a different set of potential side effects, and of course you should consult your prescriber before deciding which medication might be best for you.

Much of the research on the effectiveness of psychotherapy for OCD and anxiety disorders focuses on different types of cognitive-behavioral therapy (CBT). For OCD, a form of cognitive-behavioral therapy known as Exposure and Ritual Prevention (ExRP) has been shown to be effective in treatment. ExRP is the updated form of Exposure and Response Prevention (ERP), and it focuses on changing the strategies used by the OCD sufferer to cope with anxiety. For more on ExRP, click here.

Both SSRI and CBT are considered first-line treatments for simple OCD, meaning that one of the two will typically be the first thing recommended for someone with OCD. Research has generally not shown either one to be more effective than the other; both are considered effective in reducing symptoms of COD. Occasionally there is research that compares these two types of OCD treatment, and a study was published in July 2006 that did just that. Some researchers in Brazil compared Zoloft to a CBT group therapy. CBT group therapy for OCD has been shown to be comparably effective to individual CBT for OCD. In the Brazilian study, a summary of which is included below, the CBT that was studied included “techniques of ERP” as well as some classic elements of CBT. While details were not explicit in the article, the therapy used may be best understood as a hybrid of ERP and conventional CBT.

Here is the summary, as reported in 2006 by Reuters:

OCD Responds Better to Cognitive-Behavioral Therapy Than to Sertraline

NEW YORK (Reuters Health) Aug 28 - Combination treatment withcognitive-behavioral group therapy plus sertraline (Zoloft) is effective for the treatment of obsessive-compulsive disorder (OCD), but when each treatment is given alone, cognitive-behavioral therapy is superior to sertraline. Although OCD is responsive to the combination of these two therapeutic approaches, Dr. Aristides V. Cordioli and colleagues from Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil, wrote, "there is no consensus about which of these forms of treatment is more effective" when used alone.

In the current study, published in the July issue of the Journal of Clinical Psychiatry, the researchers compared the efficacy of cognitive behavioral therapy versus sertraline in reducing symptoms of OCD. They evaluated 50 OCD outpatients randomized to 100 mg/day sertraline or cognitive behavioral group therapy for 12 weeks. The patients were assessed at baseline and weeks 4, 8, and 12.

While the patients responded to both treatments, "the reduction of symptoms for cognitive behavioral group therapy patients was 44.07% while in the sertraline group it was 27.78% (p = 0.033)," Dr. Cordioli's team reports.

Patients who received cognitive behavioral group therapy also experienced asignificantly greater reduction in the intensity of compulsions (p = 0.030).

Complete remission of OCD symptoms was observed in eight patients in the cognitive behavioral therapy group compared with only one patient in the sertraline group.

No significant reductions in the intensity of anxiety and depression symptoms were seen with either treatment.

This study showed that the group receiving CBT experienced greater reduction in symptoms than the group receiving Zoloft. The authors point out that the study was conducted on patients suffering from OCD but not from any other psychological problems (e.g., depression, social anxiety), and that the results obtained in the study may not apply to people with other difficulties in addition to OCD. This study can be interpreted as confirmation of the effectiveness of both CBT and Zoloft in treatment of OCD, and also as showing some newer results about the superiority of CBT in the “intensity of compulsions, the rate of symptom reduction, and in complete remission.”

Some people with OCD wonder about the advisability of taking medication while in therapy. There are advantages and disadvantages to this. One advantage to not taking any psychoactive medication while in CBT is that you will learn new skills to cope with your OCD, anxiety, depression, etc., while you are experiencing those symptoms. If you began CBT while on medication, and then later came off the medication, your symptoms may overwhelm your ability to use the tools you had learned in CBT. Some people report that while medication is helpful for them, it is not helpful anymore after they stop taking it, and they are vulnerable to feeling that they are “back at square one.”

There has been other recent research on the neurophysiology of OCD that shows differences in brain activity patterns in people with OCD compared to people without OCD. Research has also found that these patterns change after successful CBT or SSRI treatment. While some sufferers of OCD may be alarmed at the notion that their brains are different than anyone else’s, it is important to remember that the brain is a remarkable, dynamic, constantly changing organ. Every time we learn something new, nerve cells in our brains form new and different connections that were not there before. Patterns of activity in the brain change when we perform seemingly simple tasks: every time we open our eyes in the morning, a complex wave of electrical activity makes its way from our optic nerve to various parts of our cerebral cortex. Given the sensitivity of the brain to new information and new habits (both mental and physical), it should not be a surprise, nor undue cause for alarm, that patterns of activity in the brain should be different in people with OCD. Some interpret research studies on the effects of CBT and medication on the brain as simply complementary to other studies showing the effectiveness of these treatment options.

In conclusion, the choice of whether to pursue CBT, medication, or both can be a difficult one. Fortunately, sufferers of OCD today can take some comfort in the fact that both of these treatments have been shown to be effective, as neither was available just a few decades ago.