Reference
Case characteristics
Number of cases
CBT method
Results
Case reports
Ganesan et al. (2001)
Male, 33 y, since 12 y OCD
3
CBT with ERP + SSRI
8 weeks follow-up:
Female, 25 y, since 1 y OCD
100 % remission
Male, 31 y, since 11 y OCD
25–50 % improvement
60 % improvement
Significant improvement of psychosis
Mac Cabe et al. (2002)
Male, 50 y, since 5 y OCD
1
4 months of CBT with ERP
11 months follow-up:
YBOCS 12 ≥ 4
Stabil remitted psychosis
Ekers et al. (2004)
Male, 31 y, since 15 y OCD
1
20 h of CBT with ERP
6 months follow-up:
YBOCS: 31 ≥ 9
Stabil remitted psychosis
Peasley-Miklus et al. (2005)
Male, 22 y, since 12 y OCD
1
6 months of CBT with ERP
3 years follow-up:
35 % symptom reduction
Washing several hours per day
≥45–60 min 2× per week
Significant improvement of psychosis
Rufer and Watzke (2006)
Female
1
45 h of CBT with ERP + SSRI
15 months follow-up:
HZI: ‘washing’: Stanine 9 ≥ 6
‘Checking’: Stanine 7 ≥ 5
Stabil remitted psychosis
Kobori et al. (2008)
Male, 26 y, since 6 y OCD
1
19 h of CBT + SSRI
24 months follow-up:
YBOCS 31 ≥ 11
Stabil remitted psychosis
Rodriguez et al. (2010)
male 19 y, since ~6 months OCD
1
Few hours of CBT with ERP + SSRI
Initial reduction of OCS after start of CBT, but subsequent dropout
Hagen et al. (2014)
Male, late 20s, OCD for several y
1
9 h of CBT + ERP over 3 weeks
6 months follow-up:
YBOCS: 24 ≥ 5
Case serie
Tundo et al. (2012)
13 male, 8 female, ~ 29.3 y, ~ duration of OCD 6.8 y
21
~32 h of CBT with ERP
12 months follow-up:
YBOCS: SCH: 31,6 ≥26,6
SCH-A: 30,2 ≥22,7
Regarding the demographic and clinical characteristics of treated individuals, 21 (68 %) were male and the mean age was 29 years (range 18–50). All patients reported clinically meaningful symptom severity and were diagnosed with co-occurring OCD. The majority experienced OCS over several years with a mean duration of 6.7 years before start of CBT treatment. With respect to the time course of symptom manifestation, the majority of patients reported first onset of OCD concurrent with or subsequent to the first psychotic episode. Ongoing clozapine treatment was reported in 36 % of these cases. Due to a lack of information, it is impossible to state on causal interrelations; however, this rate would stand in line with previously reported numbers of antipsychotic-induced OCS (Schirmbeck et al. 2011).
At the end of CBT treatment, 15 of 31 (48 %) patients showed a clinically relevant decrease of symptom severity, i.e. a reduction of ≥35 % in the Yale-Brown Obsessive-Compulsive Scale (YBOCS) total score. This percentage of improvement has been defined to represent successful therapy outcome according to the OCD therapy response criteria by Pallanti et al. (Pallanti and Quercioli 2006). Some studies reported follow-up assessments after several months or even years, suggesting stable treatment effects (Table 12.1).
Unfortunately, summarizing case reports is not only limited by the small sample size but also by relevant heterogeneity in patient characteristics and treatment design. While some patients only received few hours of CBT, others were treated for several months. Furthermore, six cases were treated with adjunctive selective serotonin reuptake inhibitors (SSRIs). Although most studies reported limited effectiveness of SSRI treatment prior to CBT initiation (Kobori et al. 2008; Peasley-Miklus et al. 2005; Rodriguez et al. 2010), final conclusions on symptom reduction due to CBT or medication effects cannot be drawn.
More homogeneous information can be derived from the subgroup included in the study by Tundo et al. This investigation in a naturalistic setting evaluated the effectiveness of CBT without concomitant SRI treatment in 21 patients with schizophrenia or schizoaffective disorder and severe, comorbid OCD (mean YBOCS total score = 31.6) (Tundo et al. 2012). Results showed statistically significant OCS reduction over 12 months, as well as improvements in general illness severity and global assessment of functioning. At the end of the trial, the authors classified 52 % of treated patients as ‘much or very much’ improved, 33 % as responders and 19 % as remitters. With a mean pre- to 1-year follow-up change score in the YBOCS of 8.1 (95 % confidence interval: 5.4–10.8), symptom reduction of comorbid OCS was only slightly less than the overall benchmarks observed in pre- to post-treatment comparisons of ERP (11.4; 10.5–12.2) and CBT studies (10.6; 8.5–12.8) in primary OCD (Houghton et al. 2010). Furthermore, insight into the illness significantly increased (Tundo et al. 2012).
12.2.3.2 Predictors of Response
Recently, Tundo et al. carried out secondary analyses to identify outcome predictors of CBT effectiveness on co-occurring OCS (Tundo et al. 2014). Their findings show that patients with alcohol/substance abuse disorder and those with OCD onset preceding psychosis onset were less likely to improve. No differences were found comparing patients with OCD onset primary or secondary to antipsychotic treatment. These preliminary findings suggest that CBT could also be a useful adjunctive treatment for OCS induced by second-generation antipsychotic agents. Accordingly, one case report shows successful reduction of clozapine-induced obsessions and compulsions after 4 months of CBT (MacCabe et al. 2002).
12.2.3.3 Treatment Tolerability and Adherence
High attention has been raised on possible negative effects of CBT with ERP on schizophrenia symptoms. In fact, one reason why CBT as a treatment modality for comorbid OCS in schizophrenia has been so scarcely investigated can be related to safety and tolerability concerns. Accordingly, in clinical ERP trials for OCD, patients experiencing psychotic symptoms or being diagnosed with a psychotic disorder have been excluded. A study evaluating clinician’s perceptions on exposure-based CBT among patients with severe mental illness reported a number of concerns including the fear that ERP and accompanied intervention-related arousal would result in severe exacerbation of psychiatric symptoms (Frueh et al. 2006). Positive results from recent studies which applied CBT with exposure and EMDR for posttraumatic stress disorder (PTSD) in subjects with a psychotic disorder counter these concerns. Studies not only revealed significant PTSD symptom improvement but also positive outcomes for other targeted domains, including auditory hallucinations, delusions, anxiety symptoms, depression symptoms and self-esteem (de Bont et al. 2013; Frueh et al. 2009; van den Berg and van der Gaag 2012).
Accordingly, mentioned cases suggest that CBT with ERP results in significant decrease of OCS severity, while ensuring stable remitted psychosis or even improvement of psychotic symptoms during treatment. In fact, the main reasons for treatment discontinuation were not tolerability concerns but the patient’s disbelief that CBT would be helpful. An increase of psychotic positive symptoms was reported in 2 of 31 cases. In one of these cases, the patient showed reluctance to commit to exposure elements and interfering psychotic symptoms. The therapist therefore decided to suspend exposure-based treatment and focused on cognitive techniques (Peasley-Miklus et al. 2005). Tundo et al. reported CBT discontinuation in another case because of psychotic exacerbation and subsequent hospitalization after more than 6 months of psychotherapy (Tundo et al. 2012). In the opinion of the authors, in this case, the worsening of psychotic symptoms represented a natural course of schizophrenia more than symptom intensification related to the involvement in ERP.
In conclusion, reported evidence is certainly limited by the small sample size and the lack of controlled clinical trials. However, preliminary results suggest good adherence to CBT. The drop-out rate of 24 % in the case series is comparable to those reported for patients with primary OCD (13–36 %) (Abramowitz et al. 2002; Tundo et al. 2012). CBT adherence resulted in meaningful or marked reduction of OCS severity in the majority of reported cases.
12.3 Implementation of CBT for Comorbid OCS
What needs to be considered….
(a)
Assessing the patient’s symptoms
(b)
Enhancing safety and treatment adherence
(c)
Adapting CBT approaches
(d)
Treatment needs for specific subgroups
12.3.1 Assessing the Patient’s Symptoms
An early and correct detection of OCS in patients with schizophrenia is the first step for an effective treatment. Therefore an increased clinical awareness for the comorbid condition is certainly necessary, especially because of an often substantially high number of undetected cases (Mukhopadhaya et al. 2009). Detailed symptom exploration and careful diagnostic considerations will help to identify comorbid affected cases and provide pivotal evaluations for subsequent treatment approaches.
Differentiating between delusions and obsessions is often possible on the basis of their content. Whereas delusions commonly revolve around persecutory, grandiose, referential, erotomanic and somatic themes, obsessions refer to contamination, symmetry, exactness or forbidden thoughts and are usually associated with corresponding compulsions (cleaning, ordering and arranging, checking and hoarding) performed to reduce distress or prevent a dreaded event. Repetitive psychotic behaviours on the other hand are mainly independent of specific thought contents.
However, the differentiation between delusions and obsessions can become especially difficult if patients show poor insight into the irrational nature of their obsessions or if delusional thoughts resolve around typical OCD topics such as contamination or infection. Similarly, careful exploration of symptoms is needed to differentiate between compulsions and stereotypic reactions to delusions and hallucinations.
Based on the diagnostic criteria for primary OCD, several guidelines have been proposed, to enable consistent and valid diagnostic decisions on the comorbid condition (Bottas et al. 2005; Pallanti et al. 2011; Schirmbeck and Zink 2013b). Patients should attribute their obsessions, impulsive symptoms and compulsions to their own thinking; they should acknowledge that they are unreasonable or excessive and should show at least some degree of resistance against them. Thus, obsessive ruminations or stereotypic thoughts during acute psychosis or repetitive ritualized behaviour clearly related to the patient’s primary psychotic condition should not be rated as OCS. For a final decision on a valid comorbid condition, symptoms should be re-evaluated after the remission of psychotic symptoms (Schirmbeck and Zink 2013b). In cases where a careful differentiation of symptoms was guided by these criteria, reliable assessment of symptom severity of comorbid OCS in patients with schizophrenia has been demonstrated using the Yale-Brown Obsessive-Compulsive Scale (YBOCS) (Boyette et al. 2011).
12.3.2 Enhancing Safety and Treatment Adherence
12.3.2.1 Stable Remitted Psychosis
In patients with schizophrenia and co-occurring OCS, it is imperative to ensure stabilization (remission, if possible) of psychotic symptoms prior and throughout CBT, while challenging OCS. Furthermore, in order to ensure that patients have a good understanding of the development and course of their psychotic disorder, psychoeducational elements focusing on early signs of psychotic exacerbation, individual coping mechanisms and interventions in case of deterioration of schizophrenia should be implemented at the beginning of CBT (Bauml et al. 2006). In addition, the psychotherapist should routinely explore psychotic symptoms throughout sessions and prioritize any signs of exacerbation. By this means, treatment will most likely foster and stabilize remission of the psychotic disorder. In accordance, several case reports not only reported significant improvement of comorbid OCS but also a relevant decrease of psychotic symptoms throughout CBT (Ganesan et al. 2001; Peasley-Miklus et al. 2005).
12.3.2.2 Functional Analysis: Exploring Development and Maintenance of Co-occurring OCS
The analysis of functional interrelations will help to understand the mechanism by which OCS developed and are maintained (Salkovskis 2007; Veale 2007a). Thus, conditional analyses of co-occurring OCS should not only explore the content and frequency, degree of insight and feared consequences but also capture the reactivity to environmental factors and possible interrelations between psychotic symptoms and OCS. Here, assessing possible interrelations between symptom onset or aggravation and antipsychotic medication seems crucial (Schirmbeck et al. 2013; Schirmbeck and Zink 2013b). In addition to possible pharmacologic effects, the impact of other environmental factors on the course of symptoms, such as exposure to critical life events or chronic stress, should also be explored.
The aim of these detailed evaluations is to reach a consensus understanding of symptom development and course, formulate treatment goals, explain treatment rationales and increase adherence to subsequent interventions.
12.3.3 Adapting CBT Approaches
Psychological treatment can be tailored to each patient after careful consideration of their level of insight, treatment adherence and the presence of another comorbid Axis I or alcohol/substance use disorder. Established CBT manuals originally designed to treat primary OCD should be adapted to the unique issues that arise in the comorbid population. Based on successfully treated cases, different authors provided such treatment recommendations including sequencing of treatment elements and adjustment of ERP (Kobori et al. 2008; Rufer and Watzke 2006; Tundo et al. 2014).
As mentioned above, ERP has been shown to be one of the most effective elements in treating primary OCD (Rosa-Alcazar et al. 2008) and has successfully been applied in the mentioned cases. Accordingly, patients are systematically exposed in both imaginary and in vivo ways. Therefore, together with the patient, a hierarchy of most relevant situations with regard to OCS is formulated. Subsequent gradual exposure starts with the least distressing of feared situations (Ekers et al. 2004; Hagen et al. 2014; Rufer and Watzke 2006). With the primary goal not to worsen psychotic symptoms, patients should never be forced into ERP but encouraged to follow the rational of habituation and resist the urge to carry out a particular compulsion. A conjoint goal may be defined in gradually reducing compulsions or delaying them for as long as possible.
Further behavioural and cognitive techniques (relaxation training, modelling, normalization, cognitive restructuring) could supplement exposure and ritual-prevention strategies (Andrews et al. 2003; Hayes et al. 2006; Veale 2007b). At the start of treatment, especially normalization technique could be useful to clarify to patients that the content of the intrusive thoughts and urges are part of the human condition. So, the problem does not lie in the intrusions but in the meaning that they attach to those thoughts and the various strategies that they adopt to try to control or suppress them. Because unreasonable assumptions and cognitive biases play a particularly important role not only in the pathogenesis and maintenance of OCS but also in the formation of psychotic symptoms, cognitive interventions challenging these beliefs represent an indispensable part of treatment (Moritz et al. 2010; Veale 2007b).
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