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Complexity in obsessive-compulsive and body dysmorphic disorder – a functional approach to complex difficulties

Published online by Cambridge University Press:  27 November 2017

Oliver Sündermann  and
David Veale Open the ORCID record for David Veale [Opens in a new window]
Oliver Sündermann*
Affiliation:
Department of Psychology, National University of Singapore, 02-24, 9 Arts Link, 117570, Singapore The Priory North London, Obsessional Disorders Department, London N14 6RA, UK
David Veale
Affiliation:
Department of Psychology, National University of Singapore, 02-24, 9 Arts Link, 117570, Singapore The Institute of Psychiatry, Psychology and Neurosciences, King's College London, De Crespigny Park, London SE5 8AF, UK Anxiety Disorders Residential Unit, Bethlem Royal Hospital, London BR3 3BX, UK
*
*Author for correspondence: Dr Oliver Sündermann, Department of Psychology, National University of Singapore and The Priory North London, UK (email: psymos@nus.edu.sg).
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Abstract

Obsessive-compulsive disorder (OCD) and related disorders such as body dysmorphic disorder (BDD) can take many different forms of presentations. The term ‘complex’ is common and inconsistently used in both OCD and BDD. Practitioners often refer to complex OCD or BDD when patients present with severe co-morbid problems, often in the context of personality difficulties, dissociation, difficult early relationships and trauma; or when the illness is chronic and debilitating with previous multiple treatment failures. Current best-evidence treatment protocols for both disorders focus heavily on exposure and response prevention (E/RP) but with moderate success, particularly in patients who are deemed ‘complex’, and often those with relevant shame and/or disgust-based past experiences. The aim of the present paper is to (a) describe factors that contribute to complexity in OCD and BDD, and (b) link these with theory and practice. We emphasize the importance of understanding both the function of OCD and BDD-related behaviours (rather than the content of obsessions or compulsion), and the context in which they occur such as the family. We illustrate complexity in OCD and BDD using real case material, using a functional and contextual approach to formulate the client's difficulties, and demonstrate how E/RP can be enhanced successfully with imagery rescripting, family work, and compassion-focused therapy.

Keywords

OCDBDDOCRDtraumaimagery

Information

Type
Special Issue: Complexity within Cognitive Behaviour Therapy
Information
the Cognitive Behaviour Therapist , Volume 10 , 2017 , e15
Copyright
Copyright © British Association for Behavioural and Cognitive Psychotherapies 2017 

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References

Recommended follow-up reading

Sookman, D (2015). Specialized Cognitive Behavior Therapy for Obsessive Compulsive Disorder: An Expert Clinician Guidebook. Routledge.CrossRefGoogle Scholar
Veale, D, Gilbert, P (2014). Body dysmorphic disorder: the functional and evolutionary context in phenomenology and a compassionate mind. Journal of Obsessive-Compulsive and Related Disorders 3, 150–160.Google Scholar
Veale, D, Gilbert, P, Wheatley, J, Naismith, I (2014). A new therapeutic community: development of a compassion-focused and contextual behavioural environment. Clinical Psychology and Psychotherapy 22, 285–303.CrossRefGoogle Scholar

References

Abramowitz, JS, Franklin, ME, Schwartz, SA, Furr, JM (2003). Symptom presentation and outcome of cognitive-behavioral therapy for obsessive-compulsive disorder. Journal of Consulting and Clinical Psychology 71, 1049.CrossRefGoogle ScholarPubMed
Arntz, A (2011). Imagery rescripting for personality disorders. Cognitive and Behavioral Practice 18, 466–481.CrossRefGoogle Scholar
Arnone, D, Patel, A, GMY, Tan (2006). The nosological significance of Folie à Deux: a review of the literature. Annals of General Psychiatry 5, 11.Google Scholar
Belli, H, Ural, C, Vardar, MK, Yesılyurt, S, Oncu, F (2012). Dissociative symptoms and dissociative disorder comorbidity in patients with obsessive-compulsive disorder. Comprehensive Psychiatry 53, 975–980.Google Scholar
Bernstein, EM, Putnam, FW (1986). Development, reliability, and validity of a dissociation scale. Journal of Nervous and Mental Disease 174, 727–735.CrossRefGoogle ScholarPubMed
Boschen, MJ, Drummond, LM (2012). Community treatment of severe, refractory obsessive-compulsive disorder. Behaviour Research and Therapy 50, 203–209.CrossRefGoogle ScholarPubMed
Buhlmann, U, Marques, LM, Wilhelm, S (2012). Traumatic experiences in individuals with body dysmorphic disorder. Journal of Nervous and Mental Disease 200, 95–98.CrossRefGoogle ScholarPubMed
Cloitre, M, Courtois, CA, Charuvastra, A, Carapezza, R, Stolbach, BC, Green, BL (2011). Treatment of complex PTSD: results of the ISTSS expert clinician survey on best practices. Journal of Traumatic Stress 24, 615–627.Google Scholar
De Jongh, A, Resick, PA, Zoellner, LA, van Minnen, A, Lee, CW, Monson, CM, Bicanic, IAE (2016). Critical analysis of the current treatment guidelines for complex PTSD in adults. Depression and Anxiety 33, 359–369.Google Scholar
Didie, ER, Loerke, EH, Howes, SE, Phillips, KA (2012). Severity of interpersonal problems in individuals with body dysmorphic disorder. Journal of Personality Disorders 26, 345.Google Scholar
Didie, ER, Tortolani, CC, Pope, CG, Menard, W, Fay, C, Phillips, KA (2006). Childhood abuse and neglect in body dysmorphic disorder. Child Abuse and Neglect 30, 1105–1115.CrossRefGoogle ScholarPubMed
Drummond, LM, Fineberg, NA, Heyman, I, Kolb, PJ, Pillay, A, Rani, S et al. (2008). National service for adolescents and adults with severe obsessive-compulsive and body dysmorphic disorders. The Psychiatrist 32, 333–336. http://doi.org/10.1192/pb.bp.107.017517 Google Scholar
Ehlers, A, Clark, DM, Hackmann, A, McManus, F, Fennell, M (2005). Cognitive therapy for post-traumatic stress disorder: development and evaluation. Behaviour Research and Therapy 43, 413–431.Google Scholar
Ehlers, A, Hackmann, A, Michael, T. (2004). Intrusive re-experiencing in post-traumatic stress disorder: phenomenology, theory, and therapy. Memory 12, 403–415.CrossRefGoogle ScholarPubMed
Foa, EB, Abramowitz, JS, Franklin, ME, Kozak, MJ (1999). Feared consequences, fixity of belief, and treatment outcome in patients with obsessive-compulsive disorder. Behavior Therapy 30, 717–724.Google Scholar
Freeman, MP, Freeman, SA, McElroy, SL (2002). The comorbidity of bipolar and anxiety disorders: prevalence, psychobiology, and treatment issues. Journal of Affective Disorders 68, 1–23.Google Scholar
Frost, RO, Steketee, G (2002). Cognitive Approaches to Obsessions and Compulsions: Theory, Assessment and Treatment. Elsevier.Google Scholar
Gershuny, BS, Baer, L, Parker, H, Gentes, EL, Infield, AL, Jenike, MA (2008). Trauma and posttraumatic stress disorder in treatment-resistant obsessive-compulsive disorder. Depression and Anxiety 25, 69–71.Google Scholar
Gilbert, P (1998). The evolved basis and adaptive functions of cognitive distortions. British Journal of Medical Psychology 71, 447–463.Google Scholar
Goldberg, JF, Gerstein, RK, Wenze, SJ, Welker, TM, Beck, AT (2008). Dysfunctional attitudes and cognitive schemas in bipolar manic and unipolar depressed outpatients: Implications for cognitively based psychotherapeutics. Journal of Nervous and Mental Disease 196, 207–210.CrossRefGoogle ScholarPubMed
Grabe, HJ, Goldschmidt, F, Lehmkuhl, L, Gänsicke, M, Spitzer, C, Freyberger, HJ (1999). Dissociative symptoms in obsessive-compulsive dimensions. Psychopathology 32, 319–324.Google Scholar
Grey, N, Holmes, EA (2008). ‘Hotspots’ in trauma memories in the treatment of post-traumatic stress disorder: a replication. Memory 16, 788–796.CrossRefGoogle ScholarPubMed
Grover, S, Gupta, N (2006). Shared obsessive-compulsive disorder. Psychopathology 39, 99–101.CrossRefGoogle ScholarPubMed
Gunstad, J, Phillips, KA (2003). Axis I comorbidity in body dysmorphic disorder. Comprehensive Psychiatry 44, 270–276.Google Scholar
Holmes, EA, Brown, RJ, Mansell, W, Fearon, RP, Hunter, EC, Frasquilho, F, Oakley, DA (2005). Are there two qualitatively distinct forms of dissociation? A review and some clinical implications. Clinical Psychology Review 25, 1–23.Google Scholar
Lenzenweger, MF, Lane, MC, Loranger, AW, Kessler, RC (2007). DSM-IV personality disorders in the National Comorbidity Survey Replication. Biological Psychiatry 62, 553–564.Google Scholar
Lewis, G, Appleby, L (1988). Personality disorder: the patients psychiatrists dislike. British Journal of Psychiatry 153, 44–49.Google Scholar
Lochner, C, du Toit, PL, Zungu-Dirwayi, N, Marais, A, van Kradenburg, J, Seedat, S, Niehaus, DJ, Stein, DJ (2002). Childhood trauma in obsessive-compulsive disorder, trichotillomania, and controls. Depression and Anxiety 15, 66–68.Google Scholar
Marks, IM (1987). Fears, Phobias and Rituals: Panic, Anxiety and their Disorders. Oxford University Press on Demand.Google Scholar
Mason, EC, Richardson, R (2010). Looking beyond fear: the extinction of other emotions implicated in anxiety disorders. Journal of Anxiety Disorders 24, 63–70.CrossRefGoogle ScholarPubMed
Mathews, CA, Kaur, N, Stein, MB (2008). Childhood trauma and obsessive-compulsive symptoms. Depression and Anxiety 25, 742–751.CrossRefGoogle ScholarPubMed
McKay, D, Abramowitz, JS, Calamari, JE, Kyrios, M, Radomsky, A, Sookman, D, Taylor, S, Wilhelm, S (2004). A critical evaluation of obsessive-compulsive disorder subtypes: symptoms versus mechanisms. Clinical Psychology Review 24, 283–313.Google Scholar
Melli, G, Chiorri, C, Carraresi, C, Stopani, E, Bulli, F (2015). The two dimensions of contamination fear in obsessive-compulsive disorder: harm avoidance and disgust avoidance. Journal of Obsessive-Compulsive and Related Disorders 6, 124–131.Google Scholar
Mergui, J, Jaworowski, S, Greenberg, D, Lerner, V (2010). Shared obsessive–compulsive disorder: broadening the concept of shared psychotic disorder. Australian and New Zealand Journal of Psychiatry 44, 859–862.Google Scholar
Olatunji, BO, Wolitzky-Taylor, KB, Willems, J, Lohr, JM, Armstrong, T (2009). Differential habituation of fear and disgust during repeated exposure to threat-relevant stimuli in contamination-based OCD: an analogue study. Journal of Anxiety Disorders 23, 118–123.CrossRefGoogle ScholarPubMed
Osman, S, Cooper, M, Hackmann, A, Veale, D (2004). Spontaneously occurring images and early memories in people with body dysmorphic disorder. Memory 12, 428–436.Google Scholar
Perugi, G, Toni, C, Frare, F, Travierso, MC, Akiskal, HS (2002). Obsessive-compulsive–bipolar comorbidity: a systematic exploration of clinical features and treatment outcome [CME]. Journal of Clinical Psychiatry 63, 1129–1134.Google Scholar
Phillips, KA (2004). Psychosis in body dysmorphic disorder. Journal of Psychiatric Research 38, 63–72.Google Scholar
Phillips, KA, McElroy, SL (2000). Personality disorders and traits in patients with body dysmorphic disorder. Comprehensive Psychiatry 41, 229–236.Google Scholar
Rachman, S (2010). Betrayal: a psychological analysis. Behaviour Research and Therapy 48, 304–311.Google Scholar
Ritter, V, Stangier, U (2016). Seeing in the mind's eye: imagery rescripting for patients with body dysmorphic disorder. A single case series. Journal of Behavior Therapy and Experimental Psychiatry 50, 187–195.Google Scholar
Rosen, JC, Reiter, J, Orosan, P (1995). Cognitive-behavioral body image therapy for body dysmorphic disorder. Journal of Consulting and Clinical Psychology 63, 263–269.Google Scholar
Rufer, M, Fricke, S, Moritz, S, Kloss, M, Hand, I (2006). Symptom dimensions in obsessive-compulsive disorder: prediction of cognitive-behavior therapy outcome. Acta Psychiatrica Scandinavica 113, 440–446.Google Scholar
Rufer, M, Held, D, Cremer, J, Fricke, S, Moritz, S, Peter, H, Hand, I. (2005). Dissociation as a predictor of cognitive behavior therapy outcome in patients with obsessive-compulsive disorder. Psychotherapy and Psychosomatics 75, 40–46.Google Scholar
Samuels, J, Nestadt, G, Bienvenu, OJ, Costa, PT, Riddle, MA, Liang, KY, Hoehn-Saric, R, Grados, MA, Cullen, BA. (2000). Personality disorders and normal personality dimensions in obsessive-compulsive disorder. British Journal of Psychiatry 177, 457–462.Google Scholar
Scott, J, Stanton, B, Garland, A, Ferrier, IN (2000). Cognitive vulnerability in patients with bipolar disorder. Psychological Medicine 30, 467–472.Google Scholar
Semiz, UB, Inanc, L, Bezgin, CH (2014). Are trauma and dissociation related to treatment resistance in patients with obsessive-compulsive disorder? Social Psychiatry and Psychiatric Epidemiology 49, 1287–1296.Google Scholar
Speckens, AE, Hackmann, A, Ehlers, A, Cuthbert, B (2007). Imagery special issue: intrusive images and memories of earlier adverse events in patients with obsessive compulsive disorder. Journal of Behavior Therapy and Experimental Psychiatry 38, 411–422.Google Scholar
Stekette, G (1990). Personality traits and disorders in obsessive-compulsives. Journal of Anxiety Disorders 4, 351–364.Google Scholar
Stewart, SE, Beresin, C, Haddad, S, Egan Stack, D, Fama, J, Jenike, M (2008). Predictors of family accommodation in obsessive-compulsive disorder. Annals of Clinical Psychiatry 20, 65–70.Google Scholar
Sündermann, O, Wheatley, J, Veale, D (2016). ‘If you have good skin, you are god. If you have bad skin, you are a piece of rubbish’ – Mastery of shame and anger in treatment-resistant body dysmorphic disorder: a single case study. the Cognitive Behaviour Therapist 9, 1–18.Google Scholar
Thompson-Hollands, J, Abramovitch, A, Tompson, MC, Barlow, DH (2015). A randomized clinical trial of a brief family intervention to reduce accommodation in obsessive-compulsive disorder: a preliminary study. Behavior Therapy 46, 218–229.Google Scholar
Tolin, DF, Maltby, N, Diefenbach, GJ, Hannan, SE, Worhunsky, P (2004). Cognitive-behavioral therapy for medication nonresponders with obsessive-compulsive disorder: a wait-list-controlled open trial. Journal of Clinical Psychiatry 65, 922–931.Google Scholar
Torres, AR, Moran, P, Bebbington, P, Brugha, T, Bhugra, D, Coid, JW, Farrel, M, Jenkis, R, Lewis, G, Meltzer, H, Prince, M (2006). Obsessive-compulsive disorder and personality disorder. Social Psychiatry and Psychiatric Epidemiology 41, 862–867.Google Scholar
Veale, D, Anson, M, Miles, S, Pieta, M, Costa, A, Ellison, N (2014). Efficacy of cognitive behaviour therapy versus anxiety management for body dysmorphic disorder: a randomised controlled trial. Psychotherapy and Psychosomatics 83, 341–353.Google Scholar
Veale, D, Gilbert, P (2014). Body dysmorphic disorder: The functional and evolutionary context in phenomenology and a compassionate mind. Journal of Obsessive-Compulsive and Related Disorders 3, 150–160.CrossRefGoogle Scholar
Veale, D, Gournay, K, Dryden, W, Boocock, A, Shah, F, Willson, R, Walburn, J (1996). Body dysmorphic disorder: a cognitive behavioural model and pilot randomised controlled trial. Behaviour Research and Therapy 34, 717–729.Google Scholar
Veale, D, Naismith, I, Miles, S, Childs, G, Ball, J, Muccio, F, Darnley, S (2015a). Outcome of intensive cognitive behaviour therapy in a residential setting for people with severe obsessive compulsive disorder: a large open case series. Behavioural and Cognitive Psychotherapy 44, 331–346.Google Scholar
Veale, D, Naismith, I, Miles, S, Gledhill, LJ, Stewart, G, Hodsoll, J (2016). Outcomes for residential or inpatient intensive treatment of obsessive–compulsive disorder: a systematic review and meta-analysis. Journal of Obsessive-Compulsive and Related Disorders 8, 38–49.Google Scholar
Veale, D, Page, N, Woodward, E, Salkovskis, P (2015b). Imagery rescripting for obsessive compulsive disorder: a single case experimental design in 12 cases. Journal of Behavior Therapy and Experimental Psychiatry 49, 230–236.Google Scholar
Warnock-Parkes, E, Salkovskis, PM, Rachman, J (2012). When the problem is beneath the surface in ocd: the cognitive treatment of a case of pure mental contamination. Behavioural and Cognitive Psychotherapy 40, 383–399.Google Scholar
Watson, D, Wu, KD, Cutshall, C (2004). Symptom subtypes of obsessive-compulsive disorder and their relation to dissociation. Journal of Anxiety Disorders 18, 435–458.Google Scholar
Weertman, A, Arntz, A, Schouten, E, Dreessen, L (2005). Influences of beliefs and personality disorders on treatment outcome in anxiety patients. Journal of Consulting and Clinical Psychology 73, 936–944.Google Scholar
Wilhelm, S, Phillips, KA, Didie, E, Buhlmann, U, Greenberg, JL, Fama, JM, Keshaviah, A, Steketee, G (2014). Modular cognitive-behavioral therapy for body dysmorphic disorder: a randomized controlled trial. Behavior Therapy 45, 314–327.Google Scholar
Willson, R, Veale, D, Freeston, M (2016). Imagery rescripting for body dysmorphic disorder: a multiple-baseline single-case experimental design. Behavior Therapy 47, 248–261.Google Scholar
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