Pat Montgomery was referred by her psychiatrist to a clinic specializing in psychological treatments for anxiety disorders. In the three years preceding her referral to the clinic, Pat had participated in two studies examining medications’ effectiveness in treating obsessive-compulsive disorder (OCD). In the first of these projects, Pat had taken a tricyclic antidepressant called Anafranil (clomipramine). In the second study, Pat was prescribed a different type of antidepressant medication, Prozac (fluoxetine). Although both drugs were antidepressants, research has shown that these medications can be effective for OCD. However, Pat’s symptoms had not responded to either drug. Since Pat had not benefited from two of the leading drug treatments for OCD, her psychiatrist recommended that she try a psychosocial approach to her problem. At the time of her referral to the anxiety disorders clinic, Pat was a 40-year-old Caucasian woman with two daughters (ages 20 and 22). Pat reported that for the past six years, she had been intensely fearful of becoming contaminated by germs that would cause her to come down with some deadly disease. As a result, she would wash her hands several times a day. At the time of her first visit to the clinic, Pat claimed that she washed her hands more than 40 times per day. In fact, the psychologist noticed that Pat’s hands were very red and the skin around her fingernails had receded; each time Pat “cleaned” her hands, she would scour them with a rough pad and detergent. In addition to her handwashing, Pat repeatedly and excessively cleaned other things she came in contact with, including dishes, clothes, furniture, and doorknobs. On a typical day, Pat spent 4 hours washing her hands and cleaning these other objects. Although she usually took one shower daily, Pat would spend 60 to 90 minutes in the shower. When Pat washed her hair, she kept the soap until she counted to 100 to ensure that her head and hair were clean enough and free of contaminants such as germs. Pat also feared that her food could contaminate her. In addition, she worried that her husband and children could contaminate her food. As a result, Pat kept her food separate from her family’s food and would not allow her family to come in contact with her food (nor would she touch her family’s food). For several food products, Pat kept separate containers for herself and for her family. For example, there were always two milk cartons in her refrigerator: one for her and one for the rest of the family. After completing meals, Pat washed her own dishes before washing her family’s dishes. After washing the dishes excessively (dishwashing often took 45 minutes), Pat spent a great deal of time cleaning her hands. Pat reported that a principal source of contamination by germs related to funerals, funeral homes, and dead bodies. For example, Pat felt contaminated if she happened to drive by a funeral home or a funeral procession. Pat feared or avoided many objects because she worried that someone who had been to a funeral might have indirectly come in contact with the dead body and might then have come in contact with those objects. There were dozens of objects in Pat’s environment that she feared had been in contact with a funeral (e.g., clothes, shoes, doorknobs, toys, food, and rooms). One reason Pat considered so many things to be contaminated was that she believed something could become contaminated if it came in contact with something else that was already contaminated. For example, Pat owned a purse that she feared was contaminated by a friend of hers who had visited their home. Because this friend had mistaken Pat’s purse for her own, she had picked it up briefly. When Pat learned that her friend had recently attended a funeral, she insisted that her husband take the purse out of the house. Pat demanded her husband take the purse out of the house by going through the window because it was the shortest path out of their home. Her husband complied and put her purse in the storage shed. Although it had been four years since this occurred, Pat had not gone near the shed or the purse, even though the purse contained two hundred dollars and her credit cards. After her friend’s visit, Pat rarely visited other people because she feared they had attended a funeral. Before Pat would begin washing, she always experienced strong urges to rid herself of germs and contamination. Whereas Pat had attempted to resist her urges to wash in the initial stages of her problem, she noted that she rarely resisted these urges now. In fact, now her attempts to resist the urges often triggered a panic attack. In addition to her fears of contamination, Pat worried that these panic attacks would cause her to go crazy or “flip out” until she gave in to the urges. Once she initiated her cleaning rituals, her panic attack usually subsided quickly. Unlike some individuals with OCD (see the discussion section of this case), throughout the course of her problem, Pat could recognize that her obsessions and compulsions were excessive and unreasonable. Although Pat could sometimes hold an objective view that her chances of being contaminated were very low, her intense fear of contamination overrode this realization (similar in nature to the per- son who fears and avoids air travel but who can concede that the realistic chances of crashing are remote). Pat reported that she began to notice the first signs of her problem during her high school years (e.g., she was more concerned with cleanliness than her peers appeared to be). However, not until six years before her first visit to the anxiety disorders clinic were Pat’s symptoms severe enough to warrant a diagnosis of OCD. Pat could not recall any factors (e.g., stressful life events, death or illness in the family, attendance at a funeral) connected to her increase in symptoms six years ago. Pat also could not recall if any of her family or relatives had a history of OCD-related difficulties. However, Pat did report that both her sister and her father had suffered and sought treatment for anxiety problems that appeared to meet the definition of panic disorder. Since her problem had intensified six years ago, Pat said that her life had been pretty rough. As noted earlier, Pat had sought treatment on two occasions involving drug interventions with little success. Until two years before her first visit to the anxiety disorders clinic, Pat had worked as a vocational counselor at a state-run employment agency. Despite excellent job security and benefits, Pat had quit this position out of her fear of coming into contact with persons who had been to a funeral (or who had been in contact with another person who had been to a funeral). She had been unemployed since then. Pat reported that her family was very supportive of her problem. While her husband would occasionally become frustrated over her compulsions (i.e., washing) and her inability to do certain things or work outside the home, usually he would be cooperative with Pat’s cleaning rituals (e.g., he would take “contaminated” things out of the house and permit her to buy separate foods for herself). As part of her first visit to the anxiety disorders clinic, Pat underwent a structured clinical interview designed to comprehensively evaluate the anxiety and mood disorders and associated conditions such as substance use and somatoform disorders. In addition to establishing the nature of Pat’s OCD symptoms, this interview revealed a few other problem areas. Although it was not a major concern, Pat reported a strong fear of snakes. More important, Pat reported ongoing difficulties with depression that had begun around the time that she completed the first medication program for her OCD and noticed that she was not getting any better. In addition to feeling down most of the time over the last few years, Pat reported moderate symptoms of poor appetite, sleep disruption, and decreased interest in activities she usually found pleasurable (all symptoms of depression). More recently, Pat reported an intensification in her depression. At the time of the interview, Pat stated that in addition to the symptoms that had been present for the past few years (e.g., poor appetite, insomnia), her depression had been accompanied by loss of energy, fatigability, feelings of guilt, concentration difficulties, and mild thoughts about the possibility that life might not be worth living. With regard to this last symptom, Pat denied thoughts or intent of suicide. She related her depression to her increasing doubts and sense of hopelessness about ever recovering from her symptoms of OCD. From reading the initial situational history and Pat’s clinical history. Please provide a few sentences about the signs and symptoms of her condition. What triggers has she been expressing, and which factors have contributed to her condition? When did Pat first begin to notice the first signs of her condition? Select the best answer. At what age did Pat finally seek treatment for her OCD? Please select the best answer. In accordance with the impression of her therapist, Pat’s symptoms during her first visit to the anxiety disorders clinic were quite consistent with the DSM-5 definition of OCD (American Psychiatric Association, 2013). Although OCD was classified as an anxiety disorder in preceding editions of the DSM, it is now categorized as an obsessive-compulsive and related disorder in DSM-5 (body dysmorphic disorder is another example of a DSM-5 obsessive-compulsive and related disorder, see Case 6). In DSM-5, the essential features of OCD are recurrent obsessions or compulsions that are severe enough to be time-consuming (i.e., they take up more than 1 hour a day) or cause marked distress or significant lifestyle impairment (i.e., interfere with the person’s normal routine, occupational or academic functioning, or usual social activities or relationships). DSM-5 defines obsessions as possessing both of these features: (a) the person has recurrent and persistent thoughts, urges, or images that are experienced as intrusive and unwanted and that in most individuals cause marked anxiety or distress, and (b) the person attempts to ignore or suppress such thoughts, urges, or images or tries to neutralize them with some other thought or action (e.g., by per- forming a compulsion). In the previous edition of the DSM, obsessions were also defined by a third criterion—the person recognizes that the obsessions are a product of his or her mind. This criterion was believed to be important in differentiating OCD from psychotic disorders (such as schizophrenia), wherein intrusive and distressing thoughts or the individuals often perceive images as being inserted into their minds from an outside source. However, this criterion has been replaced in DSM-5 by a specifier that denotes the patient’s level of insight about their obsessive-compulsive beliefs. Thus, when OCD is diagnosed under DSM-5 criteria, it should be assigned with one of the following three insight specifiers: (a) with good or fair insight (the individual recognizes their OCD beliefs are definitely or probably not true or that they may or may not be true), (b) with poor insight (the individual thinks the OCD beliefs are probably true), or (c) with absent insight/delusional beliefs (the individual is completely convinced that the OCD beliefs are true). As with the specifiers for other DSM-5 disorders (e.g., “with disso- ciative symptoms” in posttraumatic stress disorder), this specifier is included because it conveys more about the nature of the patient’s OCD, including its treatment prognosis. Indeed, there is some evidence that patients who have OCD with poor insight do not fare as well in exposure and response prevention treatment (Foa, Abramowitz, Franklin, & Kozak, 1999; Keeley, Storch, Merlo, & Geffken, 2008). Although it might be argued that the inclusion of the “with absent insight/ delusional beliefs” specifier obscures the diagnostic boundary between OCD and psychotic disorders (e.g., delusional disorder), OCD is diagnosed when the delusional beliefs are directly linked to obsessions and compulsions. The individual does not have other features of schizophrenia or schizoaffective disorder (see Case 16 for a discussion of psychotic disorders). Pat’s OCD was assigned with the “good or fair insight” specifier because she recognized her fears of contamination as somewhat irrational. Pat suffered from one of the most common types of obsession: thoughts of contamination (e.g., contracting germs from doorknobs, money, toilets, etc.). In addition to fears of contamination, other types of obsessions include excessive doubting (e.g., uncertainty if one has locked the door or turned off appliances; concerns that tasks such as managing personal finances were not completed or were completed inaccurately), fear that one has caused accidental harm to oneself or others (e.g., accidentally poisoning someone, unknowingly hitting a pedestrian while driving), nonsensical or aggressive impulses (e.g., undressing in public, hurt- ing self or others intentionally), horrific or sexual images or impulses (e.g., images of mutilated bodies, images of having sex with one’s parents or a religious figure), and nonsensical thoughts or images (e.g., numbers, letters, songs, jingles, or phrases). Note from this list of examples and the DSM-5 criteria that obsessions may be thoughts, images, urges, and impulses. DSM-5 defines compulsions as having the following features: (a) they are repetitive behaviors or mental acts that the person feels driven to perform in response to an obsession or according to rules that must be applied rigidly, and (b) the behaviors or mental acts are aimed at preventing or reducing anxiety or distress or preventing some dreaded event or situation; however, these behaviors or mental acts either are not connected in a realistic way with what they are designed to neutralize or prevent or are clearly excessive. Pat experienced one of the most prevalent forms of compulsions: washing and cleaning. Note that the DSM-5 criteria state that compulsions can take the form of either overt behaviors (such as Pat’s washing and cleaning) or mental acts. Other common types of behavioral compulsions include checking (e.g., assuring that doors are locked or appliances are turned off, retracing a driving route to make sure that one has not struck a pedestrian, reexamining waste baskets to ensure that important material has not been discarded) and adhering to certain rules and sequences (e.g., maintaining symmetry such as touching an object with one’s left hand if the object had been previously touched with the right hand, adhering to specific routine or order in daily activities such as putting on clothes in the same order). Types of mental compulsions include counting (e.g., certain letters or numbers, objects in the environment) and internal repetition of material (e.g., phrases, words, prayers) in order to “neutralize” one’s obsessions. The DSM-5 diagnostic criteria for OCD do not require the person to experience both obsessions and compulsions to be assigned the disorder. For example, studies have indicated that roughly 25% of patients with OCD do not evidence compulsive behavior (e.g., Brown, Moras, Zinbarg, & Barlow, 1993). However, these studies were conducted when earlier editions of the DSM were in place. It was not until the fourth edition of the DSM (published in 1994) that mental acts such as internal repetition were considered a type of compulsion. Thus, there is likely a much smaller proportion of patients with OCD who do not evidence any form of compulsions whatsoever (as low as 2%; see Foa & Kozak, 1995). A full discussion of the nature and treatment of OCD is presented in the remaining sections of this case. In addition to specific phobia, Pat was assigned persistent depressive disorder, a new category in DSM-5. What is the purpose of the DSM-5 in the diagnosis of psychopathology? Please select all answers that apply. As with the other disorders discussed in this book, the integrative model of OCD is a diathesis-stress model emphasizing biological and psychological factors (Barlow & Durand, 2015); part of the diathesis component of this model is the person’s biological vulnerability to experience anxiety. Indeed, findings of
studies examining twins or the rates of disorders among family members have provided some evidence that OCD tends to run in families (e.g., Billett, Richter, & Kennedy, 1998; Black, Noyes, Goldstein, & Blum, 1992; Fyer, Lipsitz, Mannuzza, Aronowitz, & Chapman, 2005; Hettema, Neale, & Kendler, 2001). This dimension was somewhat evident in Pat, who did not recall a family history of OCD but did indicate a history of panic disorder in her first-order relatives. This provided evidence that Pat may have had a biological tendency to experience anxiety. Although Pat could not recall any life events that contributed to the onset or increase in her OCD symptoms, the integrative model underscores stress’s importance in the disorder’s origins. For example, research has shown that a stressful situation may not only trigger unexpected panic attacks (see Case 2) but also mark an increase in the frequency of both intrusive, unpleasant thoughts and ritualistic behavior (e.g., washing, checking) (Parkinson & Rachman, 1981a, 1981b). Stress may trigger these symptoms, but it is insufficient to produce full-blown OCD. In other words, although many people experience intrusive thoughts or ritualistic behavior after being exposed to stressful life events, most do not go on to develop OCD (Fullana et al., 2009). So what factors determine whether these initial symptoms develop into OCD? As in other anxiety disorders (such as panic disorder), the integrative model asserts that anxiety focused on the possibility of experiencing additional symptoms is a central factor in the cause of OCD. Specifically, a person with some intrusive thoughts in response to life stress may be anxious about having more of these thoughts because he or she perceives them as dangerous or unacceptable. Consequently, the person attempts to suppress these thoughts. However, suppression has the opposite effect of increasing their frequency or intensity, a phenomenon that has been supported by research evidence (e.g., Najmi, Riemann, & Wegner, 2009; Salkovskis & Campbell, 1994). These points are consistent with cognitive models of OCD that underscore the position that people who believe some thoughts are unacceptable or dangerous are at greater risk for developing OCD (Salkovskis, 1985, 1989; Shafran, Thordarson, & Rachman, 1996; Steketee & Barlow, 2002). The integrative model addresses why some people may develop anxiety over experiencing additional OCD symptoms such as intrusive thoughts. Consistent with ideas expressed in cognitive conceptualizations of OCD (e.g., Salkovskis, 1989; Steketee & Barlow, 2002), the model specifies that these individuals may have had previous experiences that have taught them to perceive some thoughts as dangerous or unacceptable. This would represent a psychological diathesis or vulnerability to developing OCD. For example, a person raised in a devoutly religious family may hold strong beliefs about the appropriateness and acceptability of thoughts relating to such areas as sex and abortion. These individuals may respond with considerable distress to having thoughts of this nature. The negative perceptions of obsessive thoughts may often take the form of exaggerated assumptions about whether actual harm can result from the intrusive thoughts themselves (e.g., a thought about something can cause it to happen) and about the degree of personal responsibility for preventing harm to oneself or others (e.g., failure to prevent harm relating to the thought is just as bad as causing the harm directly). These features were evident in Pat, who equated the idea of contamination with the distinct risk of contracting germs that could be passed between herself and her family. This type of cognitive vulnerability has been termed thought-action fusion (Shafran et al., 1996), a specific risk factor for OCD that describes the tendency to believe that thinking about a disturbing event increases the likelihood of its occurrence and thinking about a disturbing action is morally equivalent to actually carrying it out (e.g., a highly religious person who believes that thinking about abortion is the moral equivalent as having an abortion). Although compulsions (e.g., washing, checking) and other attempts at neutralizing obsessional material (e.g., repeating phrases, words, or prayers) contribute to the DSM-5 definition of OCD, they are also considered to be the phenomena that maintain the disorder over time. For example, although Pat’s excessive handwashing would often result in short-term relief (e.g., her panic attacks would subside after she washed), it maintained her problem over the long term by preventing her from disconfirming her predictions regarding the risk and anticipated harm of being contaminated (e.g., she never learned that washing was not necessary to prevent contamination). The patient’s social environment can also contribute to the maintenance of OCD. Pat’s family often acquiesced to her compulsive symptoms. Examples include her husband’s compliance with her demands to take her “contaminated” purse out of the house and her family’s agreement to allow Pat to keep separate food and dishes. Which theory for this case study is the treatment plan based upon? Please select the best answer. The anxiety disorders clinic that Pat was referred to offers a treatment program developed specifically for OCD. Pat was fortunate in that she lived in proximity to a clinic that offered this type of treatment; very few clinics in the United States have expertise in the type of program that Pat would undergo. This treatment approach is referred to as exposure and response prevention (ERP), a highly structured treatment whereby the patient’s rituals (compulsive behavior) are actively prevented while the patient is systematically and gradually exposed to the feared thoughts (obsessions) and situations (e.g., cues that trigger the fear of becoming contaminated, such as shaking hands with a stranger). By arranging for patients to confront these fear cues (obsessions, situations) while at the same time preventing them from engaging in their ritual or neutralizing behavior, the treatment approach is directly addressing the key maintaining features of OCD (e.g., avoidance of feared stimuli, engaging in compulsive behavior to neutralize obsessional thoughts). In addition, cognitive restructuring often represents an important adjunct to ERP to address patients’ beliefs regarding the acceptability or significance of their intrusive thoughts or images (Franklin & Foa, 2014; Salkovskis, 1989). However, ERP is important in changing patients’ cognitions surrounding OCD symptoms. For instance, the procedures aimed at preventing compulsive behavior seem to foster “reality testing” in that the patient learns—at both a rational level and an emotional level—that no harmful consequences will occur, irrespective of whether the rituals are carried out. Finally, as is often the case in treating other emotional disorders, the effectiveness of interventions for OCD can often be enhanced by involving the patient’s social network. Consistent with Pat’s presentation, patients’ families or friends may respond to their symptoms in a manner that helps to maintain the disorder. In addition to helping patients’ significant others better understand the problem, this approach can effectively eliminate behaviors contributing to the maintenance of OCD. Shortly after her initial evaluation, Pat and her husband met the therapist for the first treatment session. The therapist had requested that Pat’s husband attend the first several sessions to increase his understanding of the disorder and assist Pat in applying the treatment techniques in the most effective way possible. In addition to establishing rapport, the therapist’s primary objectives of this session were to (a) obtain additional information that would be relevant to treatment planning, (b) provide the patient with an explanation of the causes of OCD and a rationale and explanation for the treatment approach, (c) define what targets (symptoms) the treatment would address, and (d) instruct the patient in the methods of self-monitoring. During this session, Pat and her therapist agreed that the primary targets of treatment would be to decrease her fear of objects associated with funerals, eliminate her compulsive rituals, and decrease her generalized anxiety and tension levels. This latter target (i.e., high generalized anxiety) was not discussed during Pat’s intake evaluation. Thus, at this time, Pat’s therapist considered incorporating progressive muscle relaxation training as an additional treatment component. Other than this issue, the therapist regarded Pat’s problem to be a relatively straightforward example of OCD. During the first session, the therapist solicited from Pat a list of fear triggers (e.g., objects that elicited panic attacks, thoughts of contamination, and compulsive behavior) and rituals. This information would be very important in the development of ERP exercises. The therapist provided Pat with the integrative model of OCD, emphasizing the factors that had maintained her difficulty over time (e.g., her avoidance of fear triggers and her washing and cleaning rituals). She was pro- vided with self-monitoring forms to generate daily records of the frequency and intensity of symptoms such as anxiety, depression, pleasant feelings, obsessions, and compulsive behavior. Pat was told to continue daily self-monitoring throughout treatment because this information would be very useful in tracking her response to the program. Finally, Pat was informed about the techniques and rationale of ERP. She was told that, for the most part, the ERP would be carried out in a graduated format. For example, the feared objects and situations that were identified in this session were listed in the order of least to most anxiety-provoking. The ERP would be delivered graduated by using less feared objects and situations in the initial exposures or by addressing intensely feared triggers by starting with imaginal exposure before confronting the trigger in real life. Imaginal exposure involves patients confronting feared objects and situations using their imagination (e.g., picturing oneself coming in contact with a contaminated object). To begin this process, the therapist asked Pat to gradually increase, over the next few days, the length of time between when she had the urge to wash or clean and when she engaged in this ritual. Pat made significant progress as early as the second session, three days later. Given that Pat was extremely motivated and compliant with treatment initiatives (e.g., she had been very good about delaying the onset of her rituals between sessions), she and her therapist decided to accelerate the process of ERP. Pat’s husband had brought to the session a pair of his shoes that Pat believed were contaminated because he had worn them to a funeral several years ago. Even though Pat was extremely fearful of these shoes because they were directly connected with a funeral, she asked that they be used in her first ERP practice. After some discussion, they designed the following ERP practice: Pat would touch the top of the shoes with a piece of food and then eat it. Eating the “contaminated” food was part of this exposure because it made Pat’s usual washing ritual less relevant (i.e., there would be little use for washing if she had swallowed the food). Pretzels were selected as the food to be used in the ERP because they were readily available from the vending machine at the clinic. During this session (which lasted 21⁄2 hours), Pat ate a small bag of pretzels that she had touched on the shoes. When eating the first several pretzels, Pat reported a very high level of anxiety, but she never experienced a panic attack. However, this anxiety soon turned to joy because Pat was extremely surprised and pleased by her ability to perform such a feat. Because of the considerable gains achieved in this session, the therapist directed Pat to do several things that he had thought he would not have assigned until later in her treatment. First, Pat was instructed not to engage in any more compulsive rituals (e.g., refrain from handwashing after coming in contact with a “contaminated” object). Second, she was told to limit her daily shower to 10 minutes. Third, Pat was assigned to complete 3 hours of ERP per day. Two hours a day would be spent performing ERP practices using objects previously used in session (e.g., her husband’s shoes) or objects similar to these objects in terms of their difficulty level (rated by Pat as producing a similar level of anxiety). The final hour of ERP would involve imaginal exposure. This exposure required Pat to hold an image of being in contact with an object or being in a situation at the top of her list (e.g., the most feared objects and situations, such as touching a dead body). Pat’s husband was instructed to serve as a coach in these between-sessions ERP exercises. He was also told to monitor Pat’s compliance with the response-prevention aspect of treatment. For example, Pat’s husband ensured that Pat was limiting her showers to 10 minutes per day. He also assisted her (by being supportive and reminding her of the importance of not completing the rituals) in not engaging in a washing-cleaning ritual after coming into contact with an object that evoked an intense urge to “decontaminate” herself. Over the next several sessions, Pat and her therapist continued to apply ERP, including exposures to items at the top of her list. Pat’s husband was assisted in identifying the types of things he and the family did that contributed to the maintenance of Pat’s OCD. As a result, he no longer permitted her to keep separate food and dishes for herself. In addition, Pat was required to wash her dishes and clothes with her family’s (and refrain from washing her hands after these tasks). Unlike many patients with OCD, Pat experienced little difficulty in applying ERP to most of the items on her hierarchy of feared items and situations. However, one of the most difficult ERP exercises that Pat encountered was eating food that had been in contact with the purse that had been in the shed. Recall that several years earlier, Pat had forced her husband to take the purse out of the house (through the window, for that matter) because a woman who had been to a funeral had touched the purse. Even though one might think that other tasks Pat had completed would have been more difficult (e.g., her husband’s shoes had actually been at a funeral), the ERP practices involving this purse were among the hardest for Pat to accomplish. Indeed, after this exposure had been completed in the therapy session, Pat ran into a few problems when she was performing her daily ERP exercises. For instance, she experienced a panic attack a few times during these exposures. How- ever, she prevented herself from washing, and her fear usually diminished by the second hour of the exposure. Moreover, she was rewarded by being now able to access the two hundred dollars that had been stowed in this purse for the last few years! Another difficult practice for Pat involved handling or eating food that was in contact with a business card from a nearby funeral home. In addition, Pat evidenced a brief return to her compulsive rituals following a particularly difficult assignment. For this assignment, Pat was instructed to clean a cupboard in her pantry that contained several objects that had been “quaran- tined” over the past few years and therefore had not been opened. She was also instructed to handle the objects in the cupboard that she had regarded as contaminated. If handling these objects was not difficult enough, Pat realized halfway through the exposure that the “dirt” in the cupboard she was handling was actually rat droppings. This revelation produced a panic attack and a temporary increase in her unnecessary washing and cleaning rituals. However, Pat’s therapist required her to continue the ERP exercise involving the cupboard, despite the presence of the rat droppings. Pat’s cleaning rituals disappeared over the next 2 to 3 days. Another minor complication in Pat’s treatment was the fact that her levels of anxiety and depression increased somewhat during the middle of the program. After some questioning