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Evidence Based Practices for Mental Health Professionals

By Jim Messina, Ph.D., CCMHC, NCC, DCMHS


Chapter 10 Obsessive Compulsive Disorders 

LEARNING OBJECTIVES FOR

OBSESSIVE COMPULSIVE DISORDERS

After reading this section, you will learn the answers to the following questions:

  1. What are the ICD-10-CM Codes for Obsessive Compulsive Disorders?
  2. What are the clinical descriptors for Obsessive Compulsive Disorders?
  3. What are the common symptoms of Obsessive Compulsive Disorders?
  4. What are the common populations which are treated for Obsessive Compulsive Disorders?
  5. What are the common treatment settings for Obsessive Compulsive Disorders?
  6. What are the Evidence Based Practices for treating Obsessive Compulsive Disorders?
  7. What area the common psychopharmacological treatments for Obsessive Compulsive Disorders?
  8. What are some common manuals, guideline books and client workbooks for treating Obsessive Compulsive Disorders?
  9. What are some good references you can use to learn more in-depth information about Obsessive Compulsive Disorders?

ICD-10-CM Codes for Obsessive Compulsive Disorders in DSM-5

F42 Obsessive-Compulsive Disorder Specify if Tic-related

F45.22 Body Dysmorphic Disorder Specify if with muscle dysmorphia

F42 Hoarding Disorder Specify with excessive acquisition

F63.3 Trichotillomania (Hair-Pulling Disorder)

I.98.1 Excoriation (Skin Picking) Disorder


ICD-10-CM Codes for Disruptive, Impulse-Control, and Conduct Disorders

F63.1 Pyromania

F63.2 Kleptomania

F91.9 Unspecified Disruptive, Impulse-Control and Conduct Disorder

 

American Psychiatric Association (APA). (2013). Diagnostic and statistical manual of mental disorders (5th ed.) (DSM-5). Washington, DC: Author.

Tony: Obsessive Compulsive Disorder


Tony was fifteen minutes early for his appointment and has been pacing in your waiting room ready to get started. When your secretary tells him you will be five minutes late he explodes saying: “I must be seen on time by my counselor since it is important for me to trust that she will be able to help me by meeting all the professional standards required by her being licensed in our state.”


Your secretary tells you of this interaction and you tell her to send Tony in immediately and you put aside the notes you were typing which you prefer to be done before meeting your next client. 


Tony comes in and it is five minutes prior to the appointed time and he says he appreciates the fact that you saw him immediately since he was getting stressed just waiting to see you. He proceeds to tell you that in the last six months he has become extremely upset, anxious and concerned over his need for order in his life. He says that he must be sure that his alarm clocks are all operating correctly and that he has six of them to wake him up so that he is never late for work. He then must have his water boiling to poach his eggs within five minutes of his getting to the kitchen for breakfast. He eats his egg and drinks his coffee and must have them in the dishwasher within 5 minutes from starting to eat breakfast. He then takes his shower in no more than five minutes, shaves and gets dressed in no more than five minutes and then is ready to go. He leaves his house and gets to the bus stop where his bus is scheduled at 5 minutes before 8:00 am so that he can get the 30 minute trip over to be at his office no later than 8:35 am even though he does not need to be at his office until 9 am. He then proceeds to explain to you how 5 is a recurrent theme in his day. He never stays on the phone longer than 5 minutes to talk with clients. He never spends more than 5 minutes to type out reports on his client contacts. He stops for lunch at 11:55 and goes to the building’s deli which has a sandwich and drink ready for him so that he can be done by 12:05 to get back to his desk. He again begins his routine of client contacts and report writing until 5:05 when he leaves to catch the bus at 5:15 so that he can get home by 5:45. The rest of his night at home is dictated by 5’s as well. He says that this process has exhausted him, stressed him out and he would like to be able to enjoy his life, relax and be at peace with himself, his career, his home and his life. 


You explain to him that the Cognitive Behavioral Therapy approach you are going to train him in has been well researched and documented as an effective treatment for his condition. You tell him he will be given at least 12 sessions over the next six months and you give Tony his first homework assignment which must be brought to his next session.

Obsessive Compulsive Disorder’s (OCD) most identifiable symptoms are: 

1) Obsessions: recurrent and intrusive thoughts that evoke distress and anxiety (Schurers, Koning, Luermans, Haack and Griez, 2005) and

2) Compulsion: repetitive acts or rituals which are driven by the obsessive thoughts. 

There is a strong genetic link to the onset of OCD. For this reason a complete clinical assessment of clients must include gathering extensive family histories to uncover this diathesis (Hettema, Neale and Kendler, 2001; Abramowitz, Taylor and McKay, 2009).


EBP treatments that serve populations with OCD include:

1) Children and adolescents (Abramowitz, Whiteside and Deacon, 2005; Barrett, Farrell, Pina, Peris and Piacentini, 2008; Nakatani, Mataix-Cols, Micali, Turner and Heyman, 2009; Lewin and Piacentini, 2010; Franklin et al., 2011; Olino, Gillo, Rowe, Palermo,Nuhfer, Birmaher and Gilbert, 2011).

2) Adults (Schurers, Koning, Luermans, Haack and Griez, 2005; Hoffman and Smits, 2008; Jonsson and Hougaard, 2008; Abramowitz, Bonchek, 2009; Rector, Cassin and Richter, 2009; Taylor and McKay, 2009; Jakubovski et al., 2012; Bloch et al., 2013)

3) Older adults.


Identified EBPs for OCD disorders include the following types of treatments:

1) Cognitive Behavioral Therapy or Cognitive (Kohn, 2006; Barrett, Farrell, Pina, Peris and Piacentini, 2008; Jonsson and Hougaard, 2008; Bonchek, 2009; Nakatani, Mataix-Cols, Micali, Turner and Heyman, 2009; Rector, Cassin and Richter, 2009; Lewin and Piacentini, 2010). 

2) Exposure and Response Prevention (ERP) (Renshaw, Steketee and Chambless, 2005; Rosa-Alcazar, Sanchez-Meca, Gomez-Conesa, and Marin-Martinez, 2008; Olino, Gillo, Rowe, Palermo, Nuhfer, Birmaher and Gilbert, 2011; Hertenstein, Rose, Voderholzer, Heidenreich, Nissen, Thiel, Herbst and Kulz, 2012).

3) Pharmacotherapy (Choi, 2009; Van Nieuwerburgh, Denys, Westenberg and Deforce, 2009; Sayyah, Sayyah, Boostani, Ghaffari and Hosenini, 2012; Bloch et al., 2013; Wen, Cheng, Cheng, Yue and Wang, 2013).

4) Combination CBT/CT or ERP and Pharmacotherapy (Eddy, Dutra, Bradley and Westen, 2004; Abramowitz, Whiteside and Deacon, 2005; Renshaw, Steketee and Chambless, 2005; Schurers, Koning, Luermans, Haack and Griez, 2005; Abramowitz, Taylor and McKay, 2009; Ravindran, da Silva, Ravindran, Richter and Rector, 2009; Taylor, 2009: Franklin et al., 2011; Jakubovski, et al., 2012).

Homework Assignment for Tony after his first visit


People who struggle with needing to have everything go perfectly as long as they meet their imagined requirements to do so need to learn how let go of the uncontrollable and unchangeables in their lives.


So read the following and then sign and date if you are willing to work on this issue.

What is letting go of the uncontrollables and unchangeables?

Letting go of the uncontrollables and unchangeables in life is the:

  1. Admitting that you are not responsible to affect a change or correct a problem which is beyond your competency, power, authority or responsibility.
  2. Releasing of yourself from an overresponsible sense of obligation, duty, or requirement to make everything perfect in your life and the life of others.
  3. Allowing yourself to rid yourself of the perfectionistic need to control every aspect of your life so that nothing goes wrong in it.
  4. Getting rational and realistic about what is and is not your obligation or duty to correct, change, or control.
  5. Freeing up of yourself to be able to say no or I can't when faced with insurmountable problems out of your reach.
  6. Accepting that it is better to hand things over those things out of your control.
  7. Accepting of your powerlessness over things and handing these things over to regain some power over your own life.
  8. No longer taking a direct action to effect a change but handing over the situation in hope that the solution will rest outside of your needing to control things to make it happen.
  9. Admitting that you can only do so much and after that it is up to you to hand it over and let go of it.
  10. Realistic acceptance after fully grieving a loss that there is nothing left to be done but to accept the loss and let go of the loss from that point on.
  11. Culmination of extensive problem solving, brainstorming, and testing alternatives with the final conclusion that you can do nothing to change the circumstances of the issue out of your reach and control and that it would be saner and more realistic to free your energy up by letting go of the issue and handing it over.


I agree that I will work from this point on to let go of those things which are out of my control and which I cannot change on my own.

Signed:                                                   Date:


Adapted from: Chapter 7 Letting Go of the Uncontrollables and Unchangeables in: Messina, J.J. (2013). Tools for Handling Control Issue retrieved at: www.coping.us

Researchers have identified major depression as a comorbidy with OCD (Cassin, Richter, Zhang. and Rector, 2009; Rector, Cassin and Richter, 2009) which explains why clinicians often use SSRIs to complement the OCD psychological treatments. Some clinicians support using SRIs and CBT in combination for treating OCD in children and adolescents (Franklin et al., 2011). Clinicians have consistently supported combining CBT and antidepressants or atypical antipsychotics for sustaining remission of OCD symptoms (Eddy, Dutra, Bradley and Westen, 2004; Abramowitz, Whiteside and Deacon, 2005; Schurers, Koning, Luermans, Haack and Griez, 2005; Sayyah, Sayyah, Boostani, Ghaffari and Hosenini, 2012).


Medications Used for Obsessive Compulsive Disorder

Classification

Drug Name (Generic Name)

Tricyclic Antidepressants

Elavil (Amitriptyline) 

Sinequan (Doxepin)

Anafranil (Clomipramine)

Pamelor (Nortriptyline)

Tofranil (Imipramine)

Monoamine Oxidase Inhibitors (MAOI)

Nardil (Phenelzine)

Parnate (Tranylcypromine)

Marplan (Isocarboxazid)

Selective Serotonin Reuptake Inhibitors (SSRI)

Prozac (Fluoxetine)

Zoloft (Sertraline)

Paxil (Paroxetine)

Celexa (Citalopram)

Lexapro (Escitalopram)

Serotonin and Norepinephrine Reuptake Inhibitors (SNRI)

Effexor (Venlafaxine HCl)

Cymbalta(Duloxetine HCI)

Pristiq (Desvenlafaxine)

Serotonin Antagonist Reuptake Inhibitor (SARI)

Serzone (Nefazodone)

Dopamine Reuptake Inhibitor

Wellbutrin (Bupropion)

Atypical

Remeron (Mirtazapine)

Desyrel (Trazodone)

Atypical Antipsychotics (when ODC is retractable)

Risperdal (Risperdone)

Zyprexa (Olanzapine)

Seroquel (Quetiapine fumarate)

Geodon (Ziprasidone)

Abilify (Aripiprazole)  

Invega (Paliperidone palmitrate)

Clozaril (Clozapine)

Anticonvulsants (when ODC is retractable)

Tegretol(Carbamazepine)

Depakote (Valproic Acid, Divalproex Sodium) 
Neurontin (Gabapentin) 
Lamictal (Lamotrigine)
Trileptal (Oxcarbazepine) 
Gabitril (Tiagabine)
Topamax (Topiramate) 
Lyrica (Pregabalin)

Research has supported the use of SRIs and CBT interventions with related OCD disorders body dysmorphic disorder, trichotillomania, excoriation, compulsive buying, pyromania (Ravindran, da Silva, Ravindran, Richter and Rector, 2009) and kleptomania (Kohn, 2006).


Typical CBT work with clients with OCD involves 1) psychoeducation about OCD and the necessary skills to extinguish the triggers leading to obsessive and compulsive thinking and acting; 2) identifying, assessing and ranking triggers as to their influence; 3) systematic development of new rational responses to the identified triggers; and 4) homework assignments of recording in a daily log or journal the triggers that one experiences and how the new responses worked in dealing with triggers and modifications made in the prevention plan based on outcomes (Hettema, Neale and Kendler, 2001). 


Researchers have demonstrated that using mindfulness-based cognitive therapy (MBCT) is an effective additional form of cognitive therapy in working with OCD clients (Hertenstein, Rose, Voderholzer, Heidenreich, Nissen, Thiel, Herbst and Kulz, 2012).


Current research is in progress to prove the effectiveness of delivering OCD treatment via technology assisted models (Lovell and Bee, 2011) and the Internet (Wootton, Titov, Dear, Spence and Kemp, 2011). However, it is still unclear how effective these models are. 


Research is also underway to treat OCD with Eye Movement Desensitization Reprocessing (EMDR) and it is an emerging EBP for this disorder (Nazari, Momeni, Jariani and Tarrahi, 2011).


Involvement of family members in treating OCD is highly supported when clinicians and clients utilize the EBPs for OCD. Given that the presence of OCD can have a negative impact on family functions, whether the client is a child or adult, it is important to involve family members to handle family conflicts and distress which exacerbate OCD symptoms (Renshaw, Steketee and Chambless, 2005).

Handouts for Tony to better explain the elements involved in his treatment

  1. TEA System
  2. ALERT System
  3. ANGER System
  4. LET GO System
  5. CHILD System
  6. RELAPSE System
All available online at: www. coping.us at: http://coping.us/seastoolsforrecovery.html

Treatment Workbook for Obsessive Compulsive Disorder


Baer, L. (2000). Getting control: Overcoming your obsessions and compulsions, Revised edition. New York: Plume.

 

Crane, R. (2009). Mindfulness-based cognitive therapy. New York: Routledge

 

Freeman, J.B. and Garcia, A.M. (2009). Family-based treatment for young children with OCD: Therapist guide. New York: Oxford University Press

 

Foa, E.B. and Wilson, R. (2001). Stop obsessing! How to overcome your obsessions and compulsions. Revised edition. New York: Bantam Books.

 

Herbert, J.D. and Forman, E.M. (2011). Acceptance and mindfulness in cognitive behavior therapy: Understanding and applying the new therapies. Hoboken, NJ: Wiley and Sons, Inc.

 

Messina, J.J. (2013). Tools for coping series: (1) Self-esteem seekers anonymous-The SEA’s program manual; (2) Laying the foundation: Personality traits of low self-esteem; (3) Tools for handling loss; (4) Tools for personal growth; (5) Tools for relationships; (6) Tools for communications; (7) Tools for anger work-out; (8) Tools for handling control issue; (9) Growing down:Tools for healing the inner child; (11) Tools for a balanced lifestyle, retrieved at www.coping.us

 

Penzel, F. (2003). The hair-pulling problem: A complete guide to tichotillomania. New York: Oxford University Press.

 

Veale, D. and Neziroglu, F. (2010). Body dysmorphic disorder: A treatment manual. Chichester, West Sussex: Wiley-Blackwell.

 

Steketee, G. and Frost, R.O. (2007). Compuslive hoarding and acquiring: Therapist guide. New York: Oxford University Press.

 

Steketee, G. and Frost, R.O. (2007). Compulsive hoarding and acquiring: Workbook.. New York: Oxford University Press.

References for Obsessive Compulsive Disorder


Abramowitz, J.S., Whiteside, S.P. and Deacon, B.J. (2005). The effectiveness of treatment of

pediatric obsessive-compulsive disorder: A meta-analysis. Behavior Therapy, 36, 55-63. DOI: 005-7894/05/0055-0063$1.00/0 

 

Abramowitz, J.S., Taylor, S. and McKay, D. (2009). Obsessive-compulsive disorder. Lancet

374, 491-499. 

 

Bagadia, A. and Drummond, L.M. (2009) Obsessive-compulsive disorder-good clinical

care. Foundations Years Journal, 2(9), 9-14. 

 

Barrett, P.M., Farrell, L., Pina, A.A., Peris, T.A. and Piacentini, J. (2008). Evidence-based

psychosocial treatments for child and adolescent obsessive-compulsive

disorder. Journal of Clinical Child and Adolescent Psychology, 37(1). 131-155. DOI: 10.1080/15374410701817956 

 

Bloch, M.H., Green, C., Kichuk, S.A., Dombrowski, P.A., Wasylink, S., Billingslea, E.,

Landeros-Wesenberger, A., Kelmendi, B., Goodman, W.K., Lockman, J.F., Corie, V. and Pittenger, C.(2013). Long-term outcome in adults with obsessive-compulsive disorder. Depression and Anxiety, 30, 716-722. DOI 10.1002/da.22103

 

Bonchek, A. (2009). What's broken with cognitive behavior therapy treatment of obsessive-

compulsive disorder and how to fix it. American Journal of Psychotherapy, 63. 

 

Cassin, S.E., Richter, M.A., Zhang, K.A. and Rector, N.A. (2009). Quality of life in treatment-

seeking patients with obsessive-compulsive disorder with and without depression. Canadian Journal of Psychiatry, 54(7), 460-467.

 

Choi, Y.J. (2009). Efficacy of treatments for patients with obsessive-compulsive disorder: A

systematic review. Journal of the American Academy of Nurse Practitioners 21, 207-213.

doi:10.1111/j.1745-7599.2009.00408.x 

 

Clement, P.W. (2007). Story of "Hope": Successful treatment of obsessive compulsive

disorder. Pragmatic Case Studies in Psychotherapy, 3(4), 1-36. 

 

Eddy, K.T., Dutra, L., Bradley, R. and Westen, D. (2004) A multidimensional meta-analysis of

psychotherapy and pharmacotherapy for obsessive-compulsive disorder.Clinical Psychology Review,24, 1011-1030. doi:10.1016/j.cpr.2004.08.004 

 

Franklin, M.E., Sapyta, J., Freeman, J.B., Khanna, M., Compton, S., Almirall, D., Moore, P.,

Choate-Summers, M., Garcia, A., Edson, A.L., Foa, E.B. and March, J.S. (2011). Cognitive behavior therapy augmentative of pharmacotherapy in pediatric obsessive-compulsive disorder-The pediatric OCD treatment study II (POTS II) randomized controlled trial. JAMA, 306, 11, 1224-1232. doi:10.1001/jama.2011.1344

 

Hertenstein, E., Rose, N., Voderholzer, U., Heidenreich, T., Nissen, C. Thiel, N., Herbst, N. and

Kulz, A.K. (2012). Mindfulness-based cognitive therapy in obsessive-compulsive disorder-A qualitative study on patients’s experiences. BMC Psychiatry, 12, 1-10. doi:10.1186/1471-244X-12-185

 

Hettema, J.M., Neale, M.C. and Kendler, K.S. (2001). A review and meta-analysis of the genetic

epidemiology of anxiety disorders.  American Journal of Psychiatry, 158,1568-1578. 

 

Hoffman, S.G. and Smits, J.A.J. (2008). Cognitive-behavioral therapy for adult anxiety

disorders: A meta-analysis of randomized placebo controlled trials. Journal of Clinical Psychiatry, 69(4), 621-632. 

 

Jakubovski, E., Diniz, J.B., Valerio, C., Fossaluza, C., Belotto-Silva, C., Gorenstein, C., Miguel,

E. and Shavitt, R.C. (2012). Clinical predictors of long-term out in obsessive-compulsive disorder. Depression and Anxiety, 30, 763-772. DOI 10.1002/da.22013

 

Jonsson, H. and Hougaard, E. (2008). Group cognitive behavioural therapy for obsessive-

compulsive disorder: a systematic review and meta-analysis. Acta Psychiatrica Scandinavica, 2009,1-9. DOI: 10.1111/j.1600-0447.2008.01270.x 

 

Kohn, C.S. (2006). Conceptualization and treatment of kleptomania bheaviors using cognitive

and behavioral strategies. International Jouranl of Behavioral and Consultation Therapy, 2(4), 553-559.

 

Lewin, A.B. and Piacentini, J. (2010). Evidence-based assessment of child obsessive-

Compulsive Disorder: Recommendations for Clinical Practice and Treatment Research.Child Youth Care Forum, 39, 73-89. DOI 10.1007/s10566-009-9092-8 

 

Lovell, K. and Bee, P. (2011). Optimising treatment resources for OCD: A review of the

evidenced base for technology-enhanced delivery. Journal of Mental Health, 20(6), 525-   542. DOI: 10.3109/09638237.2011.608745

 

Nakatani, E., Mataix-Cols, D., Micali, N., Turner, C. and Heyman, I. (2009). Outcomes of

cognitive behavior therapy for obsessive compulsive disorder in a clinical setting: A 10-year experience from a specialist OCD service for children and adolescents. Child and

 

Nazari, H., Momeni, N., Jariani, M. and Tarrahi, M.J. (2011). International Jouranl of

Psychiatry in Clinical Practice 15, 270-274. DOI: 10.3109/13651501.2011.590210

 

Olino, T., Gillo, S., Rowe, D., Palermo, S., Nuhfer, E.C., Birmaher, B. and Gilbert, A.R. (2011).

Evidence for successful implementation of exposure and response prevention in a naturalistic group format for pediatric OCD. Deprression and Anxiety, 28, 342-348. DOI 10.1002/da.20789

 

Ravindran, A.V., da Silva, T.L., Ravindran, L.N., Richter, M.A. and Rector, N.A. (2009).

Obsessive-compulsive spectrum disorders: A review of the evidence-based treatments. The Canadian Journal of Psychiatry, 5(45), 331-343.

 

Rector, N.A., Cassin, S.E. and Richter, M.A. (2009). Psychological treatment of obsessive-

compulsive disorder in patients with major depression: A pilot randomized controlled trial. Canadian Journal of Psychiatry, 54(12), 846-851.

 

Sayyah, M., Sayyah, M., Boostani, H., Ghaffari, S.M. and Hosenini, A. (2012). Effects of

aripiprazole augmentation in treatment-resistant obsessive-compulsive disorder (a double blind clinical trial). Depression and Anxiety, 26, 850-854. DOI 10.1002/da.21996

 

Schurers, K., Koning, K., Luermans, J., Haack, M.J. and Griez, E. (2005). Obsessive-compulsive

disorder: A critical review of therapeutic perspectives. Acta Psychiatrica Scandinavica, 111, 261-271. DOI: 10.1111/j.1600-0447.2004.00502.x

 

Ravindran, A.V. , da Silva, T.L., Ravindran, L. N., Richter, M.A., and Rector, N.A.

(2009). Obsessive-Compulsive Spectrum Disorders: A Review of the Evidence-Based Treatments. The Canadian Journal of Psychiatry, 54(5), 331-343. 

 

Renshaw, K.D., Steketee, G. and Chambless, D.L. (2005). Involving family members in

treatment of OCD. Cognitive Behavior Therapy, 34(3), 164-175. DOI 10.1080/16506070510043732

 

Rosa-Alcazar, A.I., Sanchez-Meca, J., Gomez-Conesa, A. and Marin-Martinez, F. (2008).

Psychological treatment of obsessive-compulsive disorder: A meta-analysis.Clinical Psychology Review, 28, 1310-1325. 

 

Schruers, K., Koning, K., Luermans, J. Haack, M.J. and Griez, E. (2005). Obsessive-compulsive

disorder: a critical review of therapeutic perspectives. Acta Psychiatrica Scandinavica, 111, 261-271. DOI: 10.1111/j.1600-0447.2004.00502.x 

 

Taylor, C. (2009). Obsessive-compulsive disorder. InnovAiT, 2(6) 358 - 363.

doi:10.1093/innovait/inp058 

 

Van Nieuwerburgh, F.C.W., Denys, D.A.J.P., Westenberg, H.G.M. and Deforce, D.L.D. (2009).

Response to serotonin reuptake inhibitors in OCD is not influenced by common CYP2D6 polymorphisms. International Journal of Psychiatry in Clinical Practice, 13, 345-348. DOI: 10.3109/13651500902903016

 

Wen, S., Cheng, M, Cheng, M., Yue, J. and Wang, H. (2013). Pharmacotherapy response and

regional cerebral blood flow characteristics in patients with obsessive-compulsive disorder. Behavioral Brain Functions, 9, (31), 1-8. doi:10.1186/1744-9081-9-31

 

Wootton, B.M., Titov, N., Dear, B.F. Spence, J. and Kemp, A. (2011). The acceptability of

internet-based treatment and characteristics of an adult sample with obsessive compulsive disorder: An Internet survey. PLoS ONE, 6(6), e20548. doi:10.1371/journal.pone.0020548

WHERE DO I GO FROM HERE?

CONCERNING OBSESSIVE COMPULSIVE DISORDER (OCD)

Now that you have read this section, in “My Mental Health Professional Practitioner Journal” record your answers and reactions to the following questions:

  1. How will this information help me as a Mental Health Professional?
  2. How interested am I in implementing Evidence Based Practices concerning OCD in my clinical practice?
  3. Why is it important that I learn more about OCD?
  4. What more do I need to know about OCD?
  5. Where can I go to obtain more information about OCD?
  6. Where can I go to obtain the journal articles, manuals, workbooks or guidebooks on OCD?