Clinical Handbook of Mindfulness (53 page)

ence and Practice, 9
, 54–68.

Roemer, L., Salters-Pedneault, K., & Orsillo, S. M. (2006). Incorporating mindfulness-

and acceptance-based strategies in the treatment of generalized anxiety disorder. In

R. A. Baer (Ed.),
Mindfulness-based treatment approaches
(pp. 51–74). San Diego,

CA: Academic Press.

Salzberg, S., & Goldstein, J. (2001).
Insight meditation
. Boulder, CO: Sounds True.

Schneiderman, N., & McCabe, P. M. (1989). Psychophysiologic strategies in laboratory

research. In N. Schneiderman, S. M. Weiss, & P. G. Kaufmann (Eds.),
Handbook of

research methods in cardiovascular behavioral medicine
. New York, Plenum.

Segal, Z. V., Williams, J. M., & Teasdale, J. D. (2002).
Mindfulness-based cognitive

therapy for depression: A new approach to preventing depressive relapse
. New

York: Guilford.

Selye, H. (1976).
The stress of life
(2nd ed.). New York: McGraw-Hill.

Shapiro, S. L., Carlson, L. E., Astin, J. A., & Freedman, B. (2006). Mechanisms of mind-

fulness.
Journal of Clinical Psychology, 62
, 373–386.

Shapiro, S. L., Schwartz, G. E. R., & Santerre, C. (2002). Meditation and positive psy-

chology. In C. R. Snyder & S. J. Lopez (Eds.),
Handbook of Positive Psychology

(pp. 632–645), New York: Oxford University Press.

Shapiro, S. L., & Schwartz, G. E. R. (2000). Intentional systemic mindfulness: An inte-

grative model for self-regulation and health.
Advanced in Mind/body Medicine,

16
, 128–134.

Sheehan, D. W., & Harnett Sheehan, K. (2007). Current approaches to the pharmaco-

logic treatment of anxiety disorders.
Psychopharmacology Bulletin, 40
, 98–109.

Shigaki, C. L., Glass, B., & Schopp, L. H. (2006). Mindfulness-based stress reduction in

medical settings.
Journal of Clinical Psychology in Medical Settings, 13
, 209–216.

Siegel, D. J. (2007).
The mindful brain: Reflection and Attunement in the Cultiva-

tion of well-being
. New York: W.W. Norton.

Smith, J. E., Richardson, J., Hoffman, C., & Pilkington, K. (2005). Mindfulness-based

stress reduction as a supportive therapy in cancer care: A systematic review.
Jour-

nal of Advanced Nursing, 52
, 315–327.

Teasdale, J. D., Moore, R. G., Hayhurst, H., Pope, M., Williams, S., & Segal, Z. V. (2002).

Metacognitive awareness and prevention of relapse in depression: Empirical evi-

dence.
Journal of Consulting and Clinical Psychology, 70
, 275–287.

188

Jeffrey Greeson, Jeffrey Brantley

Thayer, J. F., & Brosschot, J. F. (2005). Psychosomatics and psychopathology: Looking

up and down from the brain.
Psychoneuroendocrinology, 30
, 1050–1058.

Wallace, B. A. (2006).
Contemplative science: Where Buddhism and neuroscience

converge
. New York: Columbia University Press.

Walsh, R., & Shapiro, S. L. (2006). The meeting of meditative disciplines and Western

psychology: A mutually enriching dialogue.
American Psychologist, 61
, 227–239.

Wells, A. (2002). GAD, metacognition, and mindfulness: An information processing

analysis.
Clinical Psychology: Science and Practice
, 9, 95–100.

11

Mindfulness

and Obsessive-Compulsive

Disorder: Developing a Way

to Trust and Validate One’s

Internal Experience

Fabrizio Didonna

Not through actions, not through words

do we become free from mental contaminations,

but seeing and acknowledging them over and over

– Anguttara Nikaya, 557–477 B.C.

Introduction

Obsessive-compulsive disorder (OCD) is a chronic and often severe

psychiatric disease. It is characterized by recurrent, intrusive and distressing

thoughts, images, or impulses (obsessions) and/or repetitive mental or overt

acts (compulsions or neutralizing behaviors) performed to reduce or remove

distress and anxiety caused by these obsessive thoughts and to prevent any

perceived harmful consequences
(American Psychiatric Association, 2000).

This disorder has a lifetime prevalence of approximately 2–3 percent world-

wide
(Weissman et al., 1994)
and often begins in adolescence or early adulthood, usually with a gradual onset
(American Psychiatric Association, 2000).

OCD is the fourth most common psychiatric disorder, following phobias, sub-

stance use disorders, and depression
(Germer, Siegel & Fulton, 2005;
Robins et al.,
1984; Rasmussen & Eisen, 1992),
and the tenth leading cause of disability in the world
(World Health Organization, 1996).
It is associated with high health care costs
(Simon, Ormel, VonKorff, & Barlow, 1995)
and leads to significant impairment in quality of life.

OCD is also sometimes considered a thought disorder. This is why in OCD

intrusive cognitions and obsessions are often, although not always, both the

core feature and the trigger of the syndrome. However, OCD is not only a

thought disorder. If the clinical features and phenomenology of this psycho-

logical condition are more carefully observed, it becomes clear that many

OCD patients have a dysfunctional relationship with their entire private

experience: sensory perceptions, emotional states, feelings and thoughts.

Furthermore, we know that some people with obsessive problems (in

189

190

Fabrizio Didonna

particular chronic ones) may have no awareness of any cognitions during

compulsive actions so that their rituals have became over time automatic

behaviors with no need for conscious thought.

Cognitive-behavioral therapy (CBT) has long been recognized as an effec-

tive treatment for OCD, both in children and adults. In particular, exposure

and response prevention (ERP) is the most widely supported psychological

treatment for OCD; indeed, about 75% of patients treated with this method

improve significantly and stay so at follow-up
(Menzies & De Silva, 2003).

Pharmacotherapy is also an effective treatment for this disorder, in particular

serotonergic antidepressants, with a 40–60% response rate.

In spite of these effective interventions, a substantial number of patients

who suffer from OCD do not respond well to the standard protocols of CBT

and serotonergic medication and in the longer term, pharmacotherapy is

associated with a high relapse rate on full discontinuation (80–90%; Pato,

Zohar-Kadouch & Zohar,
1998).
Furthermore, ERP can be associated with a significant dropout rate (25%) because of the highly anxiety-inducing nature

of the treatment, and it is not very effective with individuals with obsession

without overt compulsions (pure obsessive) and in patients with overvalued

ideas
(Kyrios, 2003).
In addition to being refractory to current treatments, OCD patients very often share comorbidity with a range of DSM Axis I and

II disorders that contribute to a compromised quality of life. This make ther-

apies difficult to apply or reduces their effectiveness. OCD also has such a

diverse, idiosyncratic clinical presentation that is not possible to consider

the disorder as a single homogeneous diagnostic entity. In fact, different sub-

types of the disorder have been identified that may differ in the psychological

processes and fear structure that maintain the obsessive symptoms
(Clark,

2004).

By definition, mindfulness (see Chapters 1 and 2) is a state which may be

conceptualized, in some ways, as the antithesis of many obsessive mecha-

nisms and phenomena and, in this sense, obsessive syndrome can be defined

as a
state of mindlessness
.

This leads clinicians to wonder how and if it is possible to integrate the

current treatments for OCD with “third wave approaches” (mindfulness- and

acceptance-based interventions) in order to deal with these challenges, with

the heterogeneity of the disorder, and to improve the effectiveness and appli-

cation of already established treatment programs.

The aims of this chapter are to analyze the particular features of the rela-

tionship OCD patients have with their inner states (thoughts, emotions and

sensory perception), using a mindfulness-based perspective, and to under-

stand how this relationship might play an important role in activating and

maintaining the obsessive problem. Furthermore, the author hypothesizes

how mindfulness-based interventions may intervene to change and improve

the relation of these patients with their private experience and consequently

help them to deal with their specific
mindfulness deficits
(attention deficits,

thought-action fusion, non-accepting attitude, self-invalidation of perception,

interpretation bias for private experience, etc.), which invariably lead to the

obsessive phenomenology. Preliminary research data and clinical observa-

tion suggest that mindfulness-based training and/or mindfulness techniques

may be a helpful and effective intervention for individuals with OCD, in par-

ticular if integrated with other empirically supported treatments. Integrating

Chapter 11 Mindfulness and Obsessive-Compulsive Disorder

191

more traditional treatments with mindfulness-based interventions may offer a

more holistic approach for obsessive individuals – that is, one that deals with

more than just the primary symptoms of the disorder and treats the “whole”

person. This in turn might be of greater benefit because OCD affects so many

areas and functions of a patient’s life and experience, and because obsessive

symptoms are quite possibly only the most evident manifestation of a more

general dysfunction.

Why Can Mindfulness Be Effective for OCD? Rationale

for the Use of Mindfulness for Obsessive Problems

It is better to fret in doubt than to rest in error

Alessandro Manzoni (1785–1873), Italian novelist, poet, dramatist

A mindfulness-based approach to anxiety disorders and OCD is based

on changing the way in which individuals relate to their own private

experience. Within the framework of a cognitive-behavioral approach, var-

ious authors have made hypotheses which are consistent in some points

with such a perspective.
Salkovskis (1996)
pointed out that the aim of

CBT is not to persuade people that their present manner of interpret-

ing situations is wrong, irrational or excessively negative; the objective is

rather to allow them to identify where they are trapped or stuck in their

way of thinking and to let them discover other ways of looking at their

situation.

A

cognitive-behavioral

technique,

called

the

tape-loop

technique

(Salkovskis, 1983),
developed for individuals with pure obsessions (without overt rituals), consists in helping patients to provoke, listening repeatedly to

and staying in touch with their obsessive thoughts (recorded with a tape-loop

recorder). The aim is to simply observe them without reacting to them with

overt or covert rituals, considering them just as thoughts, refraining from any

evaluation, interpretation, or neutralization. This technique may be consid-

ered a powerful mindfulness exercise in which patients learn to see thoughts

as just thoughts.

Other authors have highlighted the fact that most forms of psychopathol-

ogy are characterized by an intolerance toward aspects of inner experience

and also by consequent modes of avoidance aimed at removing oneself from

such an experience. The most effective forms of psychotherapy tend to

reduce experiential avoidance, helping patients to accept exposure to var-

ious aspects of their inner states which they fear, both in a behavioral man-

ner and by offering encouragement to remain in contact with the painful or

frightening thoughts and emotions which emerge during the course of treat-

ment
(Hayes, Wilson, Gifford, Follette, & Strosahl, 1996).
As is described in other chapters of this book, experiential avoidance has been conceptualized as “the phenomenon that occurs when a person is unwilling to

remain in contact with particular private experiences (e.g., bodily sensa-

tions, emotions, thoughts, memories, images) and takes steps to alter the

form or frequency of these experiences or the contexts that occasion them”

(Hayes et al., 1996).
As is the case for other anxiety disorders, experiential avoidance is a central problem for OCD, taking the form of a number of

192

Fabrizio Didonna

strategies such as safety seeking behavior, rituals, seeking reassurance, and

so forth. The practice of mindfulness encourages patients to suspend the

“struggle” they engage in with their thoughts and emotions and renounce

the ineffective experiential avoidance strategies with which, up until that

time, they have defended themselves against the content of their experience.

Furthermore, the clinical relevance of mindfulness in the treatment of vari-

ous forms of pathology, and for OCD too, may stem from its intervening