The self psychological: view of obsessive-compulsive disorder: treating the tormented self.
Article Type: Report
Subject: Obsessive-compulsive disorder (Diagnosis)
Obsessive-compulsive disorder (Care and treatment)
Obsessive-compulsive disorder (Social aspects)
Self psychology (Research)
Thought and thinking (Analysis)
Authors: Mahoney, Donna M.
Wilke, Deborah L.
Pub Date: 03/22/2012
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2012 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Spring, 2012 Source Volume: 15 Source Issue: 1
Topic: Event Code: 310 Science & research; 290 Public affairs
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 282741112
Full Text: ABSTRACT

This article discusses obsessive-compulsive disorder (OCD) and the sense of torment that is often experienced in relation to this disorder. While much of the psychological literature attempts to address catastrophic thinking errors and behavioral interventions, this article explores the disorder from a self psychological perspective. The central contention is that the conceptualization and treatment of OCD can be expanded upon by incorporating concepts from self psychology, promulgated by Kohut (1971, 1977) and his followers. Particular attention will be paid to Kohut's (1971) notions of psychopathology and treatment, focusing on deficits in self-object experiences and the restorative nature of the self-object transference. Clinical material from a single clinical case will further illustrate the application of clinical theory to practice. A conceptual framework for OCD is presented with the inclusion of psychoanalytic concepts in an effort to better grasp the experience of inner torment and offer considerations in relation to psychological treatment.

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A SELF PSYCHOLOGICAL VIEW OF OBSESSIVE-COMPULSIVE DISORDER: TREATING THE TORMENTED SELF

Why is it that some of us think the unthinkable? How is it that some people can dismiss disturbing thoughts as irrational, while others are plagued by a sense of danger or harm? Poe called it "the imp of the perverse," noting that there is an unconquerable force that impels us to think what we should not think (Poe, 1984). It is striking how Poe was able to capture a universal human condition in his experience of the unthinkable. We might all entertain disturbing thoughts from time to time, but when the thoughts become intense and intrusive, and our behaviors turn into all-consuming rituals that are executed to rid us of fear and dread, then we are suffering from obsessive-compulsive disorder (OCD) (Schwartz, 1996). Clearly, the individual does not wish for the thought to revisit so hauntingly and persistently, yet the person's best efforts to ignore it are not a sufficient barrier to continue the process of living normally without such hounding. How can we better understand obsessional thinking and OCD? Particularly, what does a self psychological perspective offer in terms of adding to dimensions of this disorder that may be otherwise neglected?

This article will present material related to a patient who suffers from obsessive-compulsive disorder. The discussion will begin by defining obsessive-compulsive disorder and attempting to view the disorder as an effort to deal with anxiety. Three frameworks for understanding OCD will then be provided: the neurobiological model, the cognitive-behavioral model, and the self psychological model. The focus will then shift from theory to the case material, which will include a brief description of the patient's symptom picture, a summary of the clinical issues, and a description of her response to treatment. The discussion will touch upon some of the major tenets of self psychology as aspects of the material were viewed through this conceptual lens. Some of the limitations of the cognitive-behavioral approach will be addressed in this context. Attempts will be made to develop a conceptual framework for OCD with the inclusion of psychoanalytic concepts and to offer clinical considerations in relation to its psychological treatment.

DEFINING OCD

When anxiety becomes a prominent feature of someone's psychological problems, and when it is extreme, it can be considered a disorder. Karen Horney's Drive Reduction Theory describes the need for the body to maintain a certain level of arousal that creates a sense of homeostasis or balance (as cited in Morris & Maisto, 2005). Anxiety sufficient to produce alertness for examination is beneficial, whereas anxiety carrying an individual to extremes in thoughts, feelings, and behaviors puts the person at risk of maladaptive internal and external experiences.

People with OCD grapple with a neurobiological disorder that consumes their minds with unwanted thoughts and threatens them with dread if they fail to act upon senseless, repetitive rituals. About one in 40 people suffer from OCD. The Obsessive-Compulsive Foundation website states that there are approximately 5 million Americans who suffer with the disorder (www.ocfoundation.org). The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, 4th Edition--Revised (2000, DSM-IV-TR) defines obsessions as "persistent and recurring thoughts, ideas, images, or impulses that are experienced as intrusive and inappropriate, that are not simply excessive worries about real-life problems, and that cause marked anxiety or distress (e.g., thoughts of killing a child, becoming contaminated). The person recognizes that they are the product of his own mind and attempts to suppress or ignore the obsessions or neutralize them with some other thought or action" (p. 422). Compulsions are defined in the DSM-IV-TR as "repetitive behaviors (e.g., checking the stove, hand washing) or mental acts (e.g., praying silently, counting numbers) that the person feels driven to perform in response to the obsession or according to rigid rules. The compulsion is aimed at preventing or reducing distress or preventing some dreaded situation; however, the compulsions are either unrealistic or clearly excessive" (p. 423). Additionally, OCD can be differentiated from paraphilias, substance abuse, and pathological gambling in that the latter disorders are associated with the anticipation of pleasure and satiation (Hyman & Pedrick, 2005).

Obsessions can be grouped according to the following categories: obsessions about dirt and contamination, obsessive need for symmetry or order, obsessions about hoarding or saving, obsessions with sexual content, repetitive rituals, religious obsessions (scrupulosity), obsessions with aggressive content, and superstitious fears. Compulsions can also be grouped accordingly: cleaning and washing compulsions, compulsions about having things "just right," hoarding or collecting compulsions, and checking compulsions (Schwartz, 1996). Ambivalence and doubt are the hallmarks of this type of thinking.

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OCD is distinguished from generalized anxiety disorder (GAD) in that GAD is characterized by excessive worry about re al-life situations. Although obsessive-compulsive personality disorder (OCPD) and OCD have similar names, OCPD is not characterized by obsessions and compulsions and instead involves a pervasive pattern of preoccupation with orderliness, perfectionism, and control, and must begin by early adulthood. Unlike people diagnosed with OCPD, those with OCD are aware of their irrational thinking and are ashamed and embarrassed by this pattern (Schwartz, 1996).

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THEORIES OF OCD NEUROBIOLOGICAL THEORY

Despite the fact that it is beyond the scope of this article to provide a thorough discussion of the neurobiological mechanisms of OCD, a brief discussion of some biological findings follows. Positron emission tomography, or PET scans, show increased energy use in the orbital cortex, the underside of the front of the brain, in persons with OCD (Schwartz, 1996). Brain imaging studies have shown that several parts of the brain are involved with OCD, specifically, the thalamus, caudate nucleus, orbital cortex, and cingulate gyrus (Hyman & Pedrick, 2005). Magnetic resonance imaging (MRI) also reveals a larger cortex. The thalamus is the part of the brain that processes sensory messages coming to the brain from the rest of the body. The caudate nucleus is part of the basal ganglia, which controls the filtering of thoughts. The orbital cortex is the area where thoughts and emotions come together. The cingulated gyrus helps shift attention from one thought or behavior to another. When these centers are overactive, the individual gets stuck on certain behaviors, thoughts, and ideas. In other words, the alarm system of the brain has gone awry, leading to neurobiological dysregulation (Hyman & Pedrick, 2005).

THE COGNITIVE-BEHAVIORAL MODEL

Much of the literature attests to the effectiveness of Cognitive-Behavioral Therapy (CBT) for OCD (Foa & Wilson, 1991; Hyman & Perdrick, 2005; McGinn & Sanderson, 1999). The cognitive models address the thoughts and beliefs that serve to create and maintain the OCD symptoms. Persons with OCD attribute catastrophic meaning to their unwanted thoughts. CBT is a short-term, symptom-focused treatment approach that attempts to reduce emotional discomfort and improve functioning in patients with psychological disorders. CBT achieves this by exploring and modifying thoughts and behaviors that such individuals tend to exhibit, which are believed to perpetuate the symptoms and problems (McGinn & Sanderson, 1999). Examples of misattributions include: overestimating the level of danger; perfectionism and the belief that one should be punished for deviations from perfectionism; overestimation of personal responsibility, involving the worry that they will cause, or fail to prevent, terrible catastrophes; and magical thinking, that having a wish makes it so, or thoughts equal deeds (Hyman & Pedrick, 2005).

Behavioral models, in explaining the onset of OCD, would assert that neutral objects such as toilet seats or knives may begin to create discomfort because they were initially paired with an anxiety-provoking event. Compulsions or ritualistic behaviors are developed in order

to reduce the anxiety created by the conditioned stimuli and are maintained by success in doing so (McGinn & Sanderson, 1999). The treatment for OCD, based on cognitive-behavioral principles, is known as exposure and response prevention (ERP). Habituation (Foa & Wilson, 1991) is the process of gradually diminishing the distress by continually confronting the fears. The ritual prevention (Foa & Wilson, 1991) aspect of the treatment consists of attempts to avoid performing the compulsions.

SELF PSYCHOLOGY AND INTERSUBJECTIVITY THEORY

The concept of self is central to self psychology, a theory of development promulgated by Heinz Kohut and his followers. Self psychologists define the essence of human experience in terms of the individual's need to organize one's psychological experience into a cohesive configuration. Self-objects, a term used by Kohut, are objects whose functions are experienced as part of the self and in the service of maintaining and restoring the self (Tolpin & Kohut, 1980). The self disorders are characterized by the significant failure of the self to achieve vigor, cohesion, and harmony (Wolf, 1988).

This model emphasizes the parental capacity (or lack thereof) to respond to the child's mirroring needs, wherein healthy grandiosity emerges from the experience of mirroring and idealization needs, involving the experience of the idealization of the parental imago, which gives rise to healthy ideals (Kohut, 1977). If there are deficits in terms of the early needs for mirroring or idealization, damage to the self structure results (Kohut, 1977). As Roose and Glick (1995) noted, "a patient's anxiety signals structural deficits in the self, resulting from psychic deficiency states in development" (p. 7). Proponents of Intersubjectivity Theory (Stolorow, Bran&haft, & Atwood, 1987) proposed a refinement of Kohut's selfobject concept in stating that psychological conflict develops when central affect states cannot be integrated because they engender massive and consistent malattunenment from caretakers. Such unintegrated affect states lead to a sense of internal torment and an unbearable, overwhelming, disorganized internal state (Stolorow & Atwood, 1992). According to this theoretical scheme, anxiety reflects a state of self and its vulnerability to disorganization and fragmentation experiences. The obsessive and compulsive behaviors function to attempt to compensate for the loss of affect integration capacities. The obsessive thoughts function as an attempt to manage the anxiety associated with the fear of fragmentation. In this vein, Wolfe contended that "self-endangerment experiences appear to be ... associated with interpersonal rejection and loss; to experiences of 'self loss'; and to the processing of extremely painful emotions, particularly shame, humiliation, or despair" (as cited in Norcross & Goldfried, 2003, p. 379). Additionally, executing ritualistic behaviors is the individual's attempt to keep the unacceptable feelings and thoughts (i.e., murderous thoughts, fears of contamination) at bay, while temporarily relieving the anxiety.

To summarize, the cognitive and behavioral models attempt to explain the nature of OCD in relation to its cognitive and behavioral antecedents, while CBT techniques are used to alleviate the symptoms of the disorder. Such a view tends to overemphasize the cognitive components of the disorder, while neglecting to consider relevant affective (overwhelming guilt and shame), developmental, and relational dimensions of the disorder. A self psychological perspective offers a view of OCD that accounts for the developmental, intrapsychic, and relational (transference and countertransference) dimensions of OCD. Instead of being conceptualized as catastrophic cognitions, OCD is viewed in terms of thwarted selfobject needs and a resulting fragmented sense of self. The symptoms of OCD are conceptualized in relation to this sense of fragmentation in that the sense of inner torment is seen in terms of unintegrated affect states that take the form of obsessions. Additionally, the compulsions serve as behavioral manifestations of the attempt to ward off the intolerable affect states.

The case material that follows will highlight issues related to parental mal-attunement while addressing the function of OCD symptoms in terms of unmet selfobject needs. It will be shown that the patient's underlying sense of profound guilt and self-blame, understood within a developmental and relational context, led to her internal torment. The treatment is viewed in terms of the restoration of the self, with one of the goals identified as increasing the individual's tolerance for emotional experience (Norcross & Goldfried, 2003), particularly the internal torment associated with the symptoms.

CASE MATERIAL

Brenda is a 35-year-old married female who presented for treatment of obsessive-compulsive disorder (OCD) and depression. She originally entered into group treatment with one of the authors (DM) to overcome preoccupations with being contaminated by germs and bacteria. If she thought she came in contact with contaminants (e.g., items that were in the garbage or certain foods), she washed her hands repeatedly and began wearing gloves to perform the simplest of household chores. Frequent and prolonged visits to the bathroom while at work (Brenda is a telemarketing representative) interfered with her ability to complete her job-related tasks. An eight-week psychoeducational group for OCD, led by one of the authors (DM), and based on cognitive-behavioral principles, enabled Brenda to function more effectively while at work and alleviated some of the anxiety associated with her obsessions. Brenda also agreed to a psychiatric referral and was placed on a low dose of a serotonin reuptake inhibitor. She terminated group treatment but reentered individual treatment shortly thereafter to "get a better handle on this anxiety problem." She stated that she wanted individual therapy with the hope that this therapy would be "more intensive" and "get to the root of things."

When she subsequently entered individual therapy, an exploration of some of the possible underlying core issues was undertaken. Brenda said that her father was "a constant worrier. He always worried about a fire--like if I didn't turn the curling iron off. I started obsessing about the curling iron."

Brenda described her mother as a woman with low self-esteem, and recalled that her mother was always negative about herself and her appearance. As Brenda was growing up, her mother demanded that she listen to every detail about her day--"like listening to a tape recorder." Brenda's maternal grandmother died when her mother was 6. Brenda remembered that she could never complain to her mother about anything disappointing because her mother would retort, "At least you have a mother." Brenda also related that her mother instilled fears in her about getting pregnant at a young age. She recalled her mother telling her that she would not help her to take care of the baby were that to happen.

SYMPTOM PICTURE

Brenda stated that her frequent hand washing and preoccupation with germs recurred six months prior when her parents (both in their 70s) had accidents resulting in broken hips and her husband, Michael, was diagnosed with irritable bowel syndrome (IBS). She stated that she might be to blame, at least in part, for her loved ones' "downfall." The guilt associated with such a thought was unbearable. Brenda went on to say that she had taken care of her parents since she was originally diagnosed with OCD 13 years prior. "They [parents] are flail now because of me." She was particularly concerned about her mother's mental state when she added, "My mother comes to my rescue when I'm sick. She's been listening to me talk about my OCD for 13 years--it's probably caused her to go crazy!" In terms of her ruminations about her husband's health, she uttered that she used to "cuss and swear" at him during her tirades, about her illness. "Maybe sick now because he couldn't take my anger." Brenda was mildly comforted by the recent discovery that Michael only has a mild case of IBS; she continues to blame herself for his illness and utters the prayer-like statement, "Please let him be OK, God," aloud several times during the day.

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Brenda also noted that she wished to work on obsessions related to her dream to be a kindergarten teacher. Her fear, she said, was that she would have to "fight off" intrusive thoughts about wanting to molest the children. "Even if I don't actually molest them," she said with a nervous grin, "they (the children) might claim that I did and I would be terminated or sued. My life would be ruined."

The therapy sessions addressed Brenda's tendency to idealize the therapist, which reinforced her doubts about her ability to deal with issues herself. She also expressed her sense of shame associated with sexual issues (in connection with her intrusive thoughts about molesting children), expressing the worry that she might have been abused as a child, "but repressed it" (her words). As we discussed the issue, she explained that her father had recently "come out of the closet" with a shameful family secret that he still cries about. During her mother's recent trip to California to visit her sister-in-law (her father's late brother's wife), her sister-in-law brought up the rumor that Brenda's father got a young girl pregnant during his youth. "I know it's not true, he's a nice guy. My mother was fit to kill her." It was pointed out to Brenda that the issue of pregnancy seems to arouse a lot of anxiety in her and that she appears to see her father in a dualistic way (a nice guy if he did not get the woman pregnant or a bad guy if he did). She had trouble even entertaining the possibility that her father impregnated the other woman. Another worry is that she would not be able to have a baby due to her own life being so overwhelming. "I can't even handle myself with this condition (OCD). How could I ever handle a baby too?"

THE APPLICATION OF SELF PSYCHOLOGY PRINCIPLES

This section will briefly present some of the ways that a self psychology model can be used to inform the clinical work with Brenda. This view also addresses essential considerations in relation to the patient's developmental history. It is the contention of the authors that a self psychology model is most appropriate because it attends to issues related to thwarted selfobject needs and the lack of self-soothing capacities. It is assumed that Brenda's internal sense of torment is related to what Stolorow and Atwood (1992) referred to as the loss of affect regulation capacities. Additionally, the individual "blames his or her own reactive affect states for the injuries (or deficits) that produced them. The establishment of such organizing principles often entails wholesale substitution of the caregiver's subjective reality for the individuals' own" (Stolorow, 2007, p. 11).

Based on Brenda's symptom picture and current issues, much of her difficulties and her proneness to anxiety seem to be related to vulnerability to fragmentation experiences and her need to use others (selfobjects) to soothe herself and organize her world.

As Wolf (1988) noted, fragmentation, or the lessened coherency of the self, results from faulty selfobject responses. Her mother's response to Brenda's disappointment, "At least you have a mother," ostensibly reveals resentment toward Brenda and seemingly resulted in an inability (or at least a difficulty) in being emotionally attuned to Brenda. Brenda's conflicted feelings about getting pregnant and caring for a baby also appear to be related to her view that she cannot handle herself and her affect states. The authors also entertained the idea that her contamination fantasies are related to her reluctance to get pregnant. Brenda struggles to make sense of her needs and feelings, and, because she is so threatened by her internal world, wards off feelings and information that could help her to better integrate her experiences.

To Brenda, her thoughts are so potent that she believes just talking about OCD may lead her mother to go crazy. Piaget (1954) spoke of "egocentricity," which relates to the way that children see the world as revolving around them and their actions. In addressing the developmental processes related to magical thinking, Galatzer-Levy and Cohler (1993) stated that magical thinking does not express logical connections between happenings and ideas. They cited the example of the young child who believes that the moon is following him or her. Certain thoughts may need to go underground if parents and other important figures (termed "essential others" by the authors) are threatened or over stimulated by the child's thoughts and fantasies. Brenda's mother, for example, may have made it known early on that she was not willing to care for a child that Brenda would produce. The theme of pregnancy being bad appears to be a dominant motif in Brenda's narrative. She will not even permit herself to think that her father may have impregnated a woman other than her mother because thinking it would mean that it actually happened. Enormous guilt results when she permits herself to "think the unthinkable."

In the transference, while Brenda displayed signs of a mirroring and twinship transference, she mainly showed signs of idealization--the ability to admire the other. To revisit this notion, Lee and Martin (1999) defined the idealized imago as "the magical figure to be controlled and with which to be fused" (p. 140). Brenda often noted that she wished that she would grow up and be like the therapist. This stance seems to reflect what Lee and Martin (1999) addressed in terms of "open admiration for the therapist" (p. 143). Such defensive identification mainly entails a "gross identification with the person who is an independent source of initiative ..." (Lee & Martin, 1999, p. 144). She ostensibly attempted to disavow any sense of anger or disappointment with the therapist, instead attributing characteristics of power and greatness to the therapist. It appears that her parents were difficult to idealize (her father was a "worry wart" and her mother was resentful due to early parental loss), thereby interfering with the process of transmuting internalization (Kohut, 1977). This process is the normal development of young children involving taking over the function of the selfojects and doing for themselves what the selfobjects once did.

For Brenda, therapy informed by self psychology appeared to provide attention to the disavowed feelings of guilt and anger--an important dimension of the work related to the structure of the self. As Stolorow (2007) noted, "the unintegrated affect becomes threatening ... both to the person's established psychological organization and to the maintenance of vitally needed ties" (p. 3). While the initial group work gave her the opportunity to learn about OCD, the thought processes associated with it, and effective strategies for symptom alleviation, the work that was done in the individual context addressed the intolerability of her affect states and the need for a selfobject tie that was responsive to those affect states. When the patient spoke of getting to the roots of her problems, it is the contention of the authors that she was speaking about the affective, developmental, and relational dimensions of the process that were heretofore neglected to be addressed.

TREATMENT CONSIDERATIONS AND CONCLUDING REMARKS

While it is not the aim of this article to imply that only a partial treatment is achieved when patients with OCD are treated using a CBT approach or medications or both, it is asserted that self psychological concepts can more fully inform clinical work. An effective approach, as was cited in this article, may involve an initial phase of exposure and response (ERP) techniques, coupled by a subsequent treatment phase that would focus on increasing the tolerance of painful affect states. Such an approach would serve to broaden the symptom-focused view of treatment and identify and address some of the underlying core issues of the disorder, thus increasing the likelihood of longer-term treatment success. Salkovskis (1996) also noted that "although the cognitive model has provided useful information on the nature and treatment of depression and anxiety disorders, in general it has so far failed to offer a comprehensive approach to the understanding and treatment of obsessional disorders" (p. 173). As was noted in this article, a self psychological model offers a developmental and relational context for understanding the torment that often underlies OCD. Patients are often "resistant" to entering into treatment in the first place due to fears related to intolerable affect states. Therapy, whether it is ERP-based, psychodynamic, or another approach, poses a threat associated with the reemergence of shame, guilt, and other related affects. While appreciating the contributions of neuroscience, cognitive science, and the behavioral models in relation to OCD, the authors are offering a further expansion of the conceptualization of OCD in terms of self psychological, relational, and developmental paradigms. In fact, Lee and Martin (1999) asserted that neurophysiology is a field whose ideas have the potential to influence the concepts of self psychology. Patients like Brenda are encountered who may feel compelled to explore their issues in a more in-depth, insight-oriented fashion. Self psychology offers such an approach.

This article is approved by the following for I continuing education credit:

The American College of Forensic Examiners International is an NBCC-Approved Continuing Education Provider (ACEP[TM]) and may offer NBCC-approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program. The American College of Forensic Examiners International is an approved provider of the California Board of Behavioral Sciences, approval PCE 1896. Course meets the qualification for 1 hour of continuing education credit for MFTs and/or LCSWs as required by the California board of Behavioral Sciences.

The American Psychotherapy Association[R] provides this continuing education credit(s) for Diplomates and certified members, who we recommend obtain 15 credits per year to maintain their status.

LEARNING OBJECTIVES:

1. Describe how three different models, namely neurobiological, cognitive-behavioral, and psychodynamic, attempt to explain the etiology of OCD.

2. Analyze how to diagnostically differentiate OCD from three disorders with similar features, specifically generalized anxiety disorder (GAD), obsessive-compulsive personality disorder (OCPD), and the paraphilias.

3. Identify how to apply concepts from self psychology to the conceptualization and treatment of OCD.

KEYWORDS: obsessive compulsive disorder, psychopathology, selfobject theory

TARGET AUDIENCE: professional counselors, psychologists, and psychiatrists

PROGRAM LEVEL: intermediate

DISCLOSURES: The authors have nothing to disclose.

PREREQUISITES: A basic anxiety course and/or a basic understanding of psychoanalysis/ psychodynamic theory

TO RECEIVE CE CREDIT FOR THIS ARTICLE

In order to receive 1 CE credit, each participant is required to

1. Read the continuing education article.

2. Complete the exam by circling the chosen answer for each question. Complete the evaluation form

3. Mail or fax the completed form, along with the $15 payment for each CE exam taken to: American Psychotherapy Association, 2750 East Sunshine, Springfield, MO 65804. Or Fax to: 417-823-9959. Or go online to www. americanpsychotherapy.com and take the test for FREE.

For each exam passed with a grade of 70% or above, a certificate of completion for 1.0 continuing education credit will be mailed. Please allow at least 2 weeks to receive your certificate. The participants who do not pass the exam are notified and will have a second opportunity to complete the exam, Any questions, grievances or comments can he directed to the Registrar at (800) 205-9165, fax (417) 823-9959. or email to registrar@americanpsychotherapy.com Continuing education credits for participation in this activity may not apply toward license renewal in all states. It is the responsibility of each participant to verify the requirements of his/her state licensing board(s). Continuing education activities printed in the journals will not be issued any refund

CE ACCREDITATIONS FOR THIS ARTICLE

This article is approved by the following for 1 continuing education credits:

The American College of Forensic Examiners International is an approved provider of the California Board of Behavioral Sciences. approval PCE 1896. Course meets the qualification for 1 hour of continuing education credit for MFTs and/or LCSWs as required by the California board of Behavioral Sciences.

The American College of Forensic Examiners International is an NBCC-Approved Continuing Education Provider (ACEP[TM]) and may offer NBCC-approved clock hours for events that meet NBCC requirements. The ACEP solely is responsible for all aspects of the program.

The American Psychotherapy Association[R] provides this continuing education credit(s) for Diplomates and certified members, who we recommend obtain 15 credits per year to maintain their status.

KEYWORDS: obsessive-compulsive disorder, psychopathology, self object theory

TARGET AUDIENCE: professional counselors, psychologists, and psychiatrists

PROGRAM LEVEL: Intermediate

DISCLOSURE: The authors have nothing to disclose.

PREREQUISITES: A basic anxiety course and/or a basic understanding of psychoanalysis/psychodynamic theory.

LEARNING OBJECTIVES

After studying this article, participants should be better able to do the following:

1. Describe how three different models, namely neurobiological, cognitive-behavioral, and psychodynamic, attempt to explain the etiology of OCD.

2. Analyze how to diagnostically differentiate OCD from three disorders with similar features, specifically GAD, OCPD, and the paraphilias.

3. Identify how to apply concepts from sell" psychology to the conceptualization and treatment of OCD.

POST CE TEST QUESTIONS

(Answer the following questions after reading the article) Multiple Choice Examination

1. The neurobiological theory of obsessive-compulsive disorder (OCD) includes all of the following findings except:

a. PET scans shows increased energy use in the orbital cortex.

b. Magnetic resonance imaging (MRI) reveal a larger Cortex.

c. Persons with OCD attribute catastrophic meaning to their unwanted thoughts.

d. Several parts of the brain are involved, including the thalamus, caudate nucleus, orbital cortex. and cingulate gyrus.

2. The cognitive-behavioral (CBT) model of OCD emphasizes the following:

a. Biological finding in relation to OCD.

b. Thoughts and beliefs that maintain OCD symptoms.

c. OCD symptoms function to compensate for the loss of affect regulation capacities.

d. Compulsions are viewed as attempts to ward off intolerable affect states.

3. According to the article, the CBT model tends to underemphasize:

a. The biological components of OCD.

b. The thoughts associated with OCD.

c. The developmental, intrapsychic, and relational components.

d. The use of psychotropics for OCD.

4. How is the sense of inner torment understood from a self psychological perspective (Choose best)?

a. It is viewed as a catastrophic distortion.

b. It is understood as a neorobiological dysregulation state.

c. It is viewed as a symptom of OCD.

d. It is understood in relation to unintegrated affect states that take the form of obsessions.

5. Self psychology conceptualizes OCD in terms of the following:

a. OCD reflects neurobiological dysregulation.

b. OCD functions to compensate for the loss of affect regulation capacities.

c. OCD reflects catastrophic thinking patterns.

d. OCD symptoms reflect a maladaptive coping style.

6. How is OCD distinguished from GAD?

a. GAD is characterized by persistent and recurrent thoughts and behaviors.

b. GAD involves a pervasive pattern of preoccupation with orderliness, perfectionism, and control.

c. GAD is associated with the anticipation of pleasure and satiation.

d. GAD is characterized by excessive worry about real-life situations.

7. How is OCD differentiated from paraphilias, substance abuse and pathological gambling?

a. Paraphilias, substance abuse and pathological gambling involve persistent and recurrent thoughts and behaviors.

b. Paraphilias, substance abuse and pathological gambling involve a pervasive pattern of preocupation with orderliness, perfectionism, and control.

c. Paraphilias. substance abuse and pathological gambling are associated with the anticipation of pleasure and satiation.

d. Paraphilas, substance abuse and pathological gambling are indistinguishable from OCD.

8. The case of Brenda, discussed in the article, emphasized that particular attention was paid to what important dimension of the work?

a. Brenda's disavowed feelings of guilt and anger.

b. Brenda's catastrophic cognitions.

c. Issues related to neurobiological dysregulation.

d. Brenda's relationship with her mother.

EVALUATION:

Circle one (1 =Poor 2=Below Average 3=Average 4=Above Average 5=Excellent)

If you require special accommodations to participate in accordance with the Americans with Disabilities Act, please contact the Regisrar at (800) 205-9165.

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EARN CE CREDIT

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By Donna M. Mahoney, PhD and Deborah L. Wilke, EdD

DONNA MAHONEY, PhD, is an Associate Professor and core faculty member in both the Clinical Psychology and Counseling programs at Argosy University. She received her PhD in Clinical Social Work from the Institute for Clinical Social Work and advanced training at the Institute for Psychoanalysis. Dr. Mahoney has taught in the areas of adult development, psychoanalysis and psychotherapy, self psychology, psychopathology, ethics and the law, and theories and treatment of anxiety. Her private practice, located in Inverness, Illinois, specializes in the treatment of anxiety-related disorders and phobias. She has extensive clinical experience spanning 22 years. Among other presentations on topics related to anxiety, a version of her published article, "Panic Disorder and Self States: Clinical and Research illustrations" was presented at the International Conference for the Psychology of the Self in 1999. Dr. Mahoney's other interests lie in the theoretical and clinical integration of psychodynamic and cognitive behavioral interventions.

DEBORAH WILKE, EdD has served as adjunct faculty at three colleges in the past 11 years and has maintained an active private practice for over thirteen years. She has served the sexual and gender non-conforming populations, including those with sexual addictions. She is also a college instructor, author, lecturer, and frequent presenter on these topics both locally and internationally. Dr. Wilke is also a Life Fellow with the American Psychotherapy Association.
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