People with OCD Prefer Exposure to Alternative Treatments

Mad in America published a summary of a recent study that surveyed people with OCD about treatment preferences. I spent the last hour trying to track down a copy of the actual research article, which has not been officially published yet, but I was unable to locate a pdf and read it myself.

One of the authors is Dr. Helen Blair Simpson, whose brief information video about OCD is a good one.

The study

The researchers surveyed 216 people with OCD about their treatment preferences. Most people preferred Exposure and Response Prevention (ERP) as a 1st line treatment. The 2nd most popular treatment was serotonin reuptake inhibitors (i.e., antidepressants). Based on how the abstract was worded, there may be no statistically significant difference between preference for ERP (55%) and preference for antidepressants (45%).

Interestingly, people who preferred antidepressants were more likely to have higher income, private insurance, and a longer history of OCD treatment. According to the Mad in America article:

The researchers theorized that this may be due to this group having “received high-quality psychiatric care that afforded them the time and attention to discuss and resolve concerns about medication.” That is, people without these resources may have had poor experiences with medication management in which they felt pressured or their concerns were not heard. Psychotherapy may have provided an approach tailored to their individual concerns, making it more desirable.

People with OCD didn’t want antipsychotic drugs

People with OCD already taking antidepressant medication preferred ERP as an adjunct treatment over augmenting the antidepressant medication with an antipsychotic. In a prior post, I wrote about research that suggested that antipsychotics were not a useful adjunct treatment for OCD.

Acceptance and Commitment Therapy (ACT), an evidence-based treatment that we offer, was also well received among alternatives to ERP and medications. In a prior blog I used to write for, I wrote about a study on the use of ACT for OCD without deliberate exposure, and OCD researcher Dr. Michael Twohig has a page about ACT and OCD on the IOCDF website.

One theme that stood out to me reading about the study was how well-informed the sample of people with OCD is. Their preferences are remarkably consistent with current research about OCD treatment.

You can read the Mad in America article here, and an abstract of the research study here.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic. If you would like to learn more about my approach to OCD specifically, check out my OCD website, where I described how I use Acceptance and Commitment therapy to help enhance exposure and response prevention.

Self-Help for Anxiety in an International Sample

Since I saw him present on some preliminary results at a conference 6 years ago, I’ve been following with interest University of Albany – SUNY professor John Forsyth’s, PhD, research on his self-help book, The Mindfulness and Acceptance Workbook for Anxiety. (The Workbook was recently published in a 2nd edition but the research is on the 1st edition.)

The Workbook is based on Acceptance and Commitment Therapy (ACT) principles, and it is designed to treat a wide range of anxiety-related problems (it’s “transdiagnostic”).

Self-help books have great potential to help people who don’t have access to or don’t want to pursue psychotherapy. Unfortunately, self-help books are rarely based on well-researched treatments, let alone studied themselves as standalone treatment. Dr. Forsyth and his co-author Dr. Georg Eifert have been working very hard to make their book an exception.

The Most Recent Study

In the most recent published study, Dr. Forsyth’s lab gave out copies of the Workbook to a large (503 people!) international sample—mostly American, with people from the UK, Canada, Australia, New Zealand, and other countries. Participants either received a copy immediately, or they were assigned to a 12-week waiting period before receiving a copy. They completed questionnaires before receiving the book and 12-months later, with follow-up assessment at 6 and 9 months. All waitlist participants received a copy after 12-weeks and completed the same post-treatment and follow-up measures.

Contrary to research studies of self-help books that may include regular phone consultation or other forms of therapist/researcher contact, Dr. Forsyth’s lab deliberately chose to not offer guidance for participants using the Workbook in order to examine how useful it was in the way it would normally be used.

What They Found

The sample included people with generalized anxiety disorder, OCD, major depressive disorder, panic disorder, obsessive-compulsive disorder, social anxiety disorder, and posttraumatic stress disorder, among other conditions.

Participants in both conditions showed improvements in anxiety, depression, worry, quality of life, mindfulness, and self-compassion after using the book, and some continued to show improvement at the 6 and 9-month follow-ups. As a comparison sample, people on the waitlist did not show significant improvement until after receiving and working through the Workbook.

What was really interesting is that some of the improvements in scores on the measures were comparable to studies that involved individual ACT treatment delivered by therapists.

Summary

Dr. Forsyth’s recent publication offers further evidence that The Mindfulness and Acceptance Workbook for Anxiety is a helpful, cost effective treatment option for people struggling with a variety of anxiety-related problems. In my work as an anxiety specialist, I recommend this book more than any other because of the strong research support behind it—and because it offers a number of useful worksheets and recordings.

Here’s a link if you want to check out the 2nd edition of The Mindfulness and Acceptance Workbook for Anxiety.

If you or some you know is struggling with anxiety-related problems, please check out the Portland Psychotherapy Anxiety Clinic.

Evaluating Self Help: The Mindfulness & Acceptance Workbook for Anxiety

There’s no shortage of self-help books on the market. There is, however, a paucity of research on whether those self-help books are actually helpful to the people who use them. In an ideal world, every self-help book would be submitted to scientific scrutiny to determine if people actually benefit from using them. Unfortunately, this happens only rarely.

Even a self-help book that is based on well-researched cognitive behavioral principles and written by leaders in the field is not guaranteed to be effective.  For example, one recent study found that college students with greater rumination exhibited more depressive symptoms after using Greenberger & Padesky’s Mind over Mood, a well-respected cognitive behavioral self-help book for depression. These findings suggest that evidence-based psychotherapy interventions don’t always translate into effective self-guided techniques that people can use on their own, and in some instances can actually be harmful.

The Mindfulness & Acceptance Workbook for Anxiety

Over 5 years ago, I wrote a few blogs posts about Forsyth & Eifert’s The Mindfulness & Acceptance Workbook for Anxiety in 2 prior blogs for which I used to contribute. The first, on my blog Scientific Mindfulness, reported on pre-publication research I heard about at a conference. (Unfortunately, it appears the other post has been taken down.) The first author of the workbook, SUNY-Albany professor John Forsyth, PhD, conducted 2 studies on his ACT-based self-help book. He gave copies of the book to people for free, and had them complete online self-report measures at various intervals.

Dr. Forsyth recently posted a summary of this research on his personal blog in anticipation of the upcoming 2nd edition of The Mindfulness & Acceptance Workbook for Anxiety that will be released April 1, 2016. One paragraph in his blog post caught my attention:

Reductions in anxiety and fear did not happen by going after anxiety and fear directly. It was just the opposite. By first focusing on the skills needed to live a more valued life, readers then experienced a decline in their anxiety, fears, and depression, and ultimate improvements in their lives. This is an important message––one that supports the approach we offer in this workbook.

The workbook emphasizes ACT skills to help people engage in meaningful living, and it appears that those skills—rather than interventions aimed at alleviating anxiety and worry—appear the most effective.  Said another way, the findings suggest that people using the workbook improved more from doing things that were important to them than from any particular technique. This is quite profound, if you think about it, and very different from how many people approach anxiety. Attempting to directly suppress or control anxiety-related thoughts and feelings can often backfire.

Because it’s one of the rare self-help books that has been researched specifically as a self-help book, I find myself recommending The Mindfulness & Acceptance Workbook for Anxiety more than any other self-help books, and I was excited to hear there’s an updated edition coming out. I encourage readers to check it out.

Anxiety Treatment at Portland Psychotherapy

Hair Pulling (AKA Trichotillomania) and Skin Picking Problems – Greater Research Support for Behavior Therapy over Medication

Trichotillomania (or trich for short) is a condition in which people repeatedly pull out their body hair, often leading to bald patches and thinning. The scalp is a common site—as are eyebrows and eyelashes—but some may pick at hair anywhere on the body. A related condition is repetitive skin picking. This condition did not have an official diagnostic name until 2013, when the most recent edition of the DSM psychiatric guide decided on the name excoriation. People with an excoriation disorder pick or scratch at their skin—often at perceived imperfections or blemishes—to the degree that they may cause marks, bleeding, and scarring.

Both are broadly categorized as body-focused repetitive behaviors, and these have recently been more broadly categorized and obsessive-compulsive and related disorders. People with these problems often experience a great deal of shame and embarrassment about their difficulties and have an extremely tough time stopping.

Unfortunately, both conditions are understudied and not well-known. Many people struggle with them without realizing there is even a name for their condition.

The treatment literature is relatively small compared to problems such as depression and anxiety. However, I recently came across a nice summary of treatment options for trichotillomania and skin picking, as well as other conditions more broadly called obsessive-compulsive and related disorders.

Cognitive Behavioral Therapy

For hair pulling, cognitive behavioral therapy has the greatest research support. An intervention called habit reversal training has been the most studied, either by itself or in combination with a more comprehensive cognitive behavioral treatment such as Acceptance and Commitment Therapy (called “act” for short).

With excoriation, there is evidence that treatments that work for hair pulling also work for skin picking. Unfortunately, the treatment evidence for excoriation is more limited. Although it was studied for decades before being given an official diagnosis in 2013, I suspect not having an official diagnosis slowed research interest. Hopefully, we will begin to see more research on skin picking.

Medication

Rigorous research on the use of medication is much less robust than the research on therapy. There’s some evidence that the antidepressant clomipramine may help reduce hair pulling, but controlled studies on the use of SSRI’s—the most common class of antidepressants—have not shown much effectiveness. Of the SSRI’s, fluoxetine has been the most studied, but it’s effectiveness with hair pulling has been very mixed.

There’s some research support for the use of antidepressants in reducing skin picking; however, there have been no large controlled trials.

My Impressions

The research matches my experience as a therapist. Many people I’ve treated for hair pulling or skin picking have tried medication first and have either not found it helpful at all or have been unclear about whether it was effective or not. If someone’s anxiety is contributing to pulling or picking behavior, medication may help reduce the tendency somewhat but is not likely to be a total cure.

I should also acknowledge that behavioral treatment for picking and pulling is hard work. It takes a lot of attention and effort to change these habits, and many people who do well with treatment continue to struggle with it to some degree. For these reasons, it is important to see a specialist in hair pulling and skin picking. Generic talk therapy is unlikely to be of much help.

Summary

In sum, some form of cognitive behavioral treatment—especially with habit reversal training—with an experienced specialist should be the first-line treatment for hair pulling and skin picking.

As I’ve written about before, the Trichotillomania Learning Center is a great grassroots resource for learning more about hair pulling and skin picking.

If you’d like to read the full article yourself, you can download it here.

Chinese Finger Traps: What a Novelty Item Can Teach Us about Acceptance

Let’s start with the obvious. In most cases, human beings want to minimize pain and discomfort. This is doubly true for emotional pain. While some people enjoy extreme temperatures, endurance sports, and pushing their body to its limits, it’s very rare that anyone enjoys anxiety, panic, or depression. Unfortunately, the inner experiences we want to escape—our thoughts, feelings, and bodily sensations—are often the hardest to get away from.

Acceptance

People talk a lot about “acceptance,” but what does it really mean? I practice a form of treatment called Acceptance and Commitment Therapy; in practice, though, I don’t use the term acceptance much because the word is easily misunderstood. For this post, I won’t bother trying to give a definition of acceptance. Instead, I’d like to explain a metaphor I commonly use with the people I work with.

Introducing the Chinese finger trap

When I was a child, my pediatrician had a drawer of cheap toys I could choose from at the end of my appointments. Almost invariably, I chose a Chinese finger trap. If you’ve never seen one, finger traps are woven bamboo tubes (check out the picture above). You place your index fingers in either end, and when you try to pull them out, the tube constricts, trapping your fingers. When you push your fingers inward, it causes them to loosen.

I don’t just talk about this metaphor. I reach into a nearby box and pull out a few finger traps. I sit with the individual across from me, and we alternate between pulling and away and pushing our index fingers into the finger traps in effort to highlight the contrast. At the end of the session, I give them the finger trap to take with them, to serve as a reminder to check-in with their own experience between sessions—what happens when they struggle against pain?

Struggling with pain is like trying to get of a Chinese finger trap

When we try to get away from emotional hurt or from bodily pain, the pain may tighten up on us, like the woven bamboo finger traps. Sometimes the struggle to change what we are feeling can make things worse, not better. Our life narrows down to a focus on what’s painful. We tell stories about it, and worry about it, and justify it, and explain it, and all we get for our troubles is more, not less, pain. But when we lean into our discomfort, as when we gently press our index fingers into the finger trap, we create some space.

Here’s a thought experiment: think about an uncomfortable experience. It could be a physical illness, a break-up, work stress, anxiety, depression—whatever. Now imagine someone told you that the pain would be gone in 5 minutes—would that allow you to experience that pain with less struggle? For most people, the answer is, “yes.” There’s very little we cannot experience in the moment, when we sit and really experience it as it is in the present. It is our attempts to struggle against the pain and our stories about it that amplify the pain.

This is the message I want to impart: “Leaning into discomfort doesn’t free you—you’re still in the trap—but you gain some wiggle room. A desire to pull away is natural—it tends to be our default—but it often gets us stuck.”

When we accept, we let go of the struggle against what we’re feeling—in this very moment. In the next moment, we get a choice about what to do next. Acceptance frees us from the struggle with pain and allows for new possibilities. When your entire focus is getting away from pain, this leaves few alternatives. If you’re willing to accept pain—even for a single moment—you’ve expanded your options.

Anxiety Treatment at Portland Psychotherapy

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