454 TREATMENT OF SPECIFIC ANXIETY DISORDERS
disorders, with a lifetime prevalence rate of 65–85% (Brown, Campbell, et al., 2001;
Crino & Andrews, 1996). Presence of depression is associated with a worsening of
obsessional symptoms (e.g., significant positive correlation between OCD and depres-
sion symptom measures; D. A. Clark, 2002). However it is more likely that a preexisting
OCD leads to the subsequent development of major depression than the reverse path-
way (Demal, Lenz, Mayrhofer, Zapotoczky, & Zirrerl, 1993). Whereas severe major
depression can lead to a poorer treatment response in OCD, presence of mild to moder-
ate depression does not appear to interfere in the patient’s response to treatment (e.g.,
Abramowitz, Franklin, Street, Kozak, & Foa, 2000). Other disorders commonly found
in OCD include social phobia, specific phobias, body dysmorphic disorder, tic disor-
ders, and various Cluster C personality disorders (see D. A. Clark, 2004).
Clinician Guideline 11.4
A cognitive evaluation of OCD should assess for the presence and severity of depressive
symptoms. If a severe major depressive episode is present, treatment might have to focus on
the alleviation of depression before targeting OC symptoms.Treatment Utilization and Response
Although OCD is associated with a high rate of mental health service utilization second
only to panic among the anxiety disorders (Karno et al., 1988; Regier et al., 1993), the
majority of individuals with OCD never seek treatment (Pollard, Henderson, Frank,
& Margolis, 1989). Even among treatment seekers there is usually a delay of 2–7 years
from initial onset to the first treatment session (e.g., Rasmussen & Tsuang, 1986). How-
ever, even with the demonstrated effectiveness of CBT, only a minority of sufferers with
OCD will actually receive this type of treatment (Pollard, 2007). Approximately 30% of
individuals with OCD refuse exposure/response prevention treatment and another 22%
fail to complete treatment (Kozak, Liebowitz, & Foa, 2000).
Pollard (2007) has suggested a number of characteristics that might affect an indi-
vidual’s readiness to accept CBT for OCD. Individuals who believe they can deal with
their obsessional problems on their own or those who are ashamed or embarrassed by
their obsessions may be less likely to seek treatment (e.g., person with obsessional doubts
about whether he sexually touched a child may try to conceal such thoughts from oth-
ers; Newth & Rachman, 2001). In addition a person with low motivation or negative
expectations about treatment success may be quite ambivalent about treatment.
A number of other factors have been shown to predict a poorer response to treat-
ment. Certain subtypes of OCD show a more difficult treatment response such as those
with compulsive hoarding (Cherian & Frost, 2007) or pure obsessions (D. A. Clark &
Guyitt, 2008), and individuals with a severe comorbid major depression tend to have
a less favorable response to treatment of OCD symptoms (e.g., Abramowitz & Foa,
2000). Lack of insight into the excessive or irrational nature of one’s obsessions (i.e.,
believing that one’s obsessional fears are realistic and somewhat probable and so the
compulsive ritual is necessary) may predict poor response to treatment (Franklin, Riggs,
& Pai, 2005). In the more extreme case where conviction in the reasonableness of one’s
obsessional concerns becomes rigid and absolute to the point of being an overvalued