A Letter From Janet Emmerman:

I've just returned to Chicago after three days in New Orleans attending the 154th American Psychiatric Association Convention. This was the OCF's 14th year exhibiting at the APA. We unveiled our new exhibit booth which was purchased with funding from Pfizer Pharmaceuticals and designed for us by Ellen Moore Design of Brockton, MA.

Hundreds of psychiatrists from all over the globe stopped by our booth to pick up copies of the OCD Newsletter and our 8th Annual OCF Conference brochure, ask about the latest treatment advances, and sign up to be on the by OCF referral list. They were interested in learning about new options for treating refractory patients and intensive treatment programs for children and adolescents as well as adults.

Treatment providers worldwide are interested in treating OCD and care about their patients with OCD. And, pharmaceutical companies have improved some of the medications currently used to treat OCD. That's the good news.

Among the hundreds of presentations, seminars, workshops and symposia held during the Convention, there was only one symposium that included OCD topics and very few presentations.

What does this mean? Unfortunately, it does not signal that a cure has been found for everyone with OCD. The absence of feature programs on OCD tells a more problematic story:

• The drugs currently being used for OCD are at a stage in their "patent life" that does not encourage pharmaceutical companies to expend more money on further research.

• The estimated number of individuals suffering from OCD is small by comparison to those with "depression." Consequently, drug research is aimed at depression.

• This shortage of seminars underlines the fact that OCD is under-recognized. Many suffer and go undiagnosed. Therefore, there is less urgency felt by the academic researchers who might otherwise aim their studies at OCD.

• A very small percentage of National Institute of Mental Health's research dollars are aimed exclusively at OCD.

• Finally and most importantly, that there are not significant research funds available to encourage and direct basic and clinical OCD research.

While there are effective treatments at this time, they only work for 60% of OCD sufferers and they only relieve 60% of the symptoms. The cure has not been found; nor do we have much information regarding the causes. To find these causes and cures we need to stimulate research.

What I didn't see at the APA Convention tells me that we must seek out research funding. The OCF and its members have to become responsible for securing the funding needed to discover effective treatments and maybe even prevention for OCD. In this Newsletter there's an article highlighting the fund-raiser held by the Chicago affiliate. This affiliate was able to raise a substantial amount of money through an event benefit.

Last fall, Joy and Douglas Kant from the Boston Affiliate held "An Afternoon with Dr. Jenike" and raised over $30,000 for research. A support group in the Denver area sold poinsettias at Christmas and gave a portion of the proceeds to the OCF Research Fund. The St. Louis Support Group mailed out copies of Dr. Jenike's year-end letter with donation envelopes. This effort continues to bring in contributions for the Research Fund.

With your help, your energy and your ideas, we can do it. With your active support, we can encourage established researchers and attract new investigators to OCD research. We welcome your suggestions, your initiative and your hard work. Please contact me at the Foundation.

Janet Emmerman,
President OCF Board of Directors

From the Foundation:

We were pretty proud ... and we were dwarfed.

BIG at the APA included booths from some of the pharmaceutical companies that covered as much acreage as the Great Pyramid at Giza. BIG also included over 158 pages in the Conference program of seminars, symposia and workshops. BIG was a continually rotation of Poster Presentations. BIG was filling the many meeting rooms in the cavernous Morial Convention Center and spilling over into the meeting rooms of the Marriott, Hilton and Sheraton.

At first, we were a little intimidated, measuring the scope and breadth of our 8th Annual OCF Conference against the 154th APA. Then, vowing to triumph over GAD and SAD as well as OCD, we realized we have in true Ed Sullivan style (for those of you old enough to remember) "a really BIG SHOW for you in Denver."

We're starting off early Friday morning with two Orientation Presentations: one for newcomers and one for kids. What we want to do here is give a crash course in OCD and get people acquainted and acclimated. Drs. Claiborne and Mansbridge are going to teach the basics of OCD to the Newcomers and Charlie Schatz and Chris Vertullo are going to make everyone feel at home. Drs. Fitzgibbons and Mansueto with the help of Kathleen Parrish and Carter Waddell are going to orient the kids.

We're BIG in tracks this year, too. We have three: families, people with OCD and professionals. Unlike presents under the tree at Christmas, we weren't able to make sure each group had the same number of presentations, but we think we have a lot of interesting workshops for everyone. On Friday, Dr. Geller from Harvard/McLean Hospital is going to talk about the diagnosis and treatment of children and adolescents with OCD while Dr. Wayne Goodman lectures on scientific advancements in treating OCD and introduces the new YBOC scale.

Dr. Brad Riemann from Rogers Hospital is going to explain to the children with OCD "Why Them?" and Dr. Katzelnick from the Madison Institute is going to talk about SAD and why some of us are painfully shy and what can be done about it.

Through Friday afternoon and evening, the program is BIG too: Lee Baer talking about his new book, "Imp of the Mind;" Aureen Pinto Wagner using her books to demonstrate preparing a child for behavior therapy; and Lisa Bertman, Ph.D., showing people how to do Exposure and Response Prevention on their own or with a buddy.

For family members who want to help but not enable, there are two seminars with Barbara Van Noppen, Constantina Boudouvas, Bobbi Jo Haney, Gail Pesses, and Johan Rosqvist. At the same time, folks with OCD and professionals can hear Jeff Schwartz on "Progressive Mindfulness" or learn about the connections between OCD and OCPD or join the Philadelphia Affiliate's workshop on relapse prevention. Kids can spend the afternoon with Charley Mansueto "Dissin' OCD."

On Friday evening, before the Virtual Camping Trip put on by Jon Grayson and the Philadelphia G.O.A.L. Group, there will be a Parents' Support and Information Group, a G.O.A.L. Group for Kids, a Transitions Panel followed by the first screening of the film festival, for young adults, a G.O.A.L. Group for adults with OCD, and an OCA meeting. This is a very BIG evening.

Early Saturday morning (8:15 am) Pierre Blier, MD, Ph.D., is taking everyone via lecture and animated video "A Step Toward More Effective Pharmacotherapies" during the Keynote Address. After that parents can discover a "Survival Manual" by attending a workshop by fellow parents, Wendy Birkham and Kathy Hammes. Kids can go to their drop-in rooms to do art and/or writing projects, listen to music or just socialize in preparation for Marc Summers' talk about what it was like for him as a kid with OCD and the Pool Party.

Professionals and people with OCD can chose from sessions on herbal medicines, genetics and OCD, behavior therapy, body dysmorphic disorder, Trichotillomania, and the impulse control disorders.

On Saturday afternoon, we've scheduled a two-part program on Scrupulosity which will feature clergy members as well as mental health professionals. The second part of the program is a workshop on treatment techniques specifically for mental health professionals.

Jule Monnens and Ed Matisik will be talking to parents about how they should talk "so schools will listen." There will be more sessions on CBT including one by Dr. Mansueto on using CBT for children and adolescents with multiple disorders. There will be workshops on hoarding and the social security disability program. Dr. Jenike is doing an open-mike from 1:30 to 4:00 pm on "Medication and Treatment for OCD: Questions and Answers."

There will be a Reception on Saturday night where the winners of the Art Contest will be announced and the winning raffle tickets will be drawn. Then there will be the second night of the Film Festival. We will be premiering "Extreme Conditions: OCD" produced by Jones Productions for the Discovery Channel. John Metherell, the producer, will talk about how it was made. Then there will be screenings of films made by young adults with OCD.

Sunday is going to be BIG too. So, plan to stay.

David Shannahoff-Khalsa is going to do a two-hour workshop on Kundalini Yoga Meditation for Treating OCD. We've also scheduled a workshop for professionals on Imaginal Exposure Script-Writing. For parents, Gail Adams will be talking about "Improving School Performance" and a panel of support group veterans will discuss how to start and maintain a successful support group. There will be talks on "Pregnancy and OCD" and "GAD." And, Dr. Jenike is moderating a brainstorming session on how to get a loved one into treatment.

As I type all this out, I realized that the 8th Annual OCF Conference is going to be BIG because it is the most important meeting on OCD and its Spectrum Disorders in 2001. I hope I see you there. Ciao!

Patricia Perkins-Doyle
Executive Director

The Making Of A Documentary

by John Metherell

Making a documentary is like that game where you sit in a circle and whisper a message to the person next to you. When the message gets back, it's not the same.

The first whisper was a call from the executive producer to the commissioning editor at The Discovery Channel, suggesting a series on mental health. The response: they'd recently done a program on schizophrenia, but the OCD program sounded interesting. "Yes," replied the executive producer, "some of the things these people do will make the hairs on the back of your neck stand on end."

The associate producer set out some of the topics in a proposal and the production was given the go-ahead. A producer, two researchers and a writer were hired to flesh out the proposal. The production team needed OCD sufferers and doctors to appear. We approached the OCF, got a message on this Web Site and an article in the newsletter. We attended last year's annual conference in Chicago.

Most of the sufferers who approached us have the disease under control. "I'd love to be in your program and tell the world how it's possible to conquer OCD," they typically said. "You should have seen me two years ago. I was in such a state." This wasn't going to move the hairs on the back of anyone's neck. Some doctors wanted to show off their "stars" -- patients they'd "cured." The audience would be reaching for the remote.

The researchers did a great job of tracking down potential interviewees. But what was in it for them? Why would they want to tell a national television audience about some of the things they've hidden from friends, co-workers and even family for years? In trying to answer this, we became more focused.

This was not to be a voyeuristic look at people doing strange things. We would adopt an "educational" approach that tries to show a light at the end of the tunnel.

In sharing their stories, we hoped that sufferers will give encouragement to other people with the disease, offer support to family members and inform the public about the problem. Several people agreed to be interviewed on this basis. We also tried to ensure that we were covering a reasonable part of the OCD spectrum. Things were back on track.

We made plans to travel to various parts of the country. As we were doing this, some of the people who'd agreed to appear called back to say they'd thought about it (obsessed about it?) and changed their minds. We searched for replacements. After three months research it was time to start shooting. I set out on a weekly schedule of early morning flights from Washington, DC. To Florida and Texas one week. To California another. To Massachusetts, Wisconsin and New York. The people I met -- sufferers and doctors -- were delightful.

I tried to assure people that revealing their rituals on TV wouldn't embarrass them. But in the back of my mind was that promise to Discovery that the audience would find the program disturbing.

Some interesting incidents happened on location. Like the sufferer who decided on the morning of shooting that he couldn't go through with it. Like the veterinary science professor who promised animals that exhibited OCD-like symptoms but which didn't perform on camera.

Eventually we had 50 hours of material to turn into a one-hour documentary. I hope we did a good job. Like the whispering game, it's not exactly what we set out to do a year ago, but we're proud of it and it has already won an award. When you watch the program, remember that it's aimed at a general audience who know little about OCD. It's entertainment. Enjoy it.

I want to take this opportunity to thank the OCD community for their help in making the program. It couldn't have happened without you.

John produced the documentary "Extreme Conditions: OCD," which airs on The Discovery Channel on August 6 at 10pm, and is repeated at 2am August 11, and 5pm August 11. It will premier on Saturday night, July 21, at the 8th Annual OCF Conference in Denver.

How We Helped Our Son: A Parents' Story

by Bob McAndrew, a father.

16 year old Kevin McAndrew [pictured] from Staten Island, New York was admitted to the Menninger Clinic's 15 and Older Obsessive-Compulsive Disorder Residential Treatment Center in Topeka, Kansas on Friday, April 20, 2001. This is the first treatment Center of its kind to open in the United States. Kevin has received tremendous help and support from the New York City Board of Education and New York State.

After 3 weeks Kevin is successfully making advances with the help of Pharmacology, Cognitive-Behavioral Therapy and Exposure with Response Prevention Therapy. The staff gives positive reports and Kevin gives negative ones. His OCD behaviors are pushed and shoved daily.

Kevin's life is in disrepair. It is a painful experience for him and us, his parents, but one that must be undertaken.

With great difficulty, he's attended school and a couple of Groups a few hours a day. He meets with his therapist. He's taken two sponge baths, gotten a haircut, gone to a restaurant and "The Mummy Returns." He's traveled in the back seat of a small car with two other people. He's picnicked and rolled down a grassy hill.

Kevin is very bright and mature, about 6'3" and 275 lbs with moderate to severe Tourette Syndrome and severe Obsessive-Compulsive Disorder. Video games and the World Wrestling Federation are a major part of his life. He also likes Disney World, and the Royal Tyrrell Museum of Paleontology, Drumheller Alberta, Canada. Kevin is very sociable and polite. He is funny, erudite, "with it" and an absolutely wonderful dinner partner.

Kevin's Obsessive Compulsive Disorder interferes with all aspects of his life. He has all sorts of contamination problems, extreme tactile sensitivities, hot flashes, snorting, water splashing, face slapping. He has a major whole body abdominal gut tic that makes him dry heave and vomit. Kevin lacks any personal hygiene habits. When he can read, he's above a college freshman. Kevin generally can't touch paper. Sometimes he gets stuck on his bed for days, with major confrontations he comes downstairs to eat though he can't deal with cooking smells. Mostly his family orders in Eggplant Parmagian Heroes.

He has difficulty getting in and out of cars, even taking short trips to the mall are tremendous struggles. Once, it took nearly two hours to get him into an automobile for a two and a half hour weekend trip. It's now down to about five to ten minutes. He's a non-attending high school sophomore. Kevin's story became even more incredibly upsetting around the end of February, when his OCD made it difficult for him to take his medication. All the burning sensations that occurred on the outside of his body began occurring on the inside making it difficult to swallow.

By the middle of March, he essentially went cold turkey off his medications.

The Rebound Effects were absolute hell to witness, but not unfamiliar to us. It was like a heroin addict in withdrawal. Six to eight times a day for forty-five minutes, his body would wrench. His head would fly back. He would choke on his tongue. Veils of phlegm covered his face. Heavy Metal Volume groans, screaming, and swearing could only be relieved by baling him with five gallon buckets of ice cold water.

There were no appropriate adolescent units anywhere in the New York City Area that could take Kevin on a Regular Inpatient, Emergency or Crisis Admission. Two local Mental Health Mobile Crisis Units did not understand the meaning of their title. The Visiting Nurses were supportive but unavailable. Even his General Practitioner was overworked. He called at 10:30 PM one night. He said he could only take him at the Emergency Room the following day because his shift was from 7:30 AM until 11:30 PM. At the time Kevin couldn't even begin to get in the car. After an amazing series of events, Limousine Services, and a Private Ambulance Jet with two nurses, Kevin arrived at the Menninger Clinic unmedicated.

His mother and I would like to express our confidence in the Menninger Staff. During the admission we were pleased, upset, and frustrated at the same time. "How in the world was the Menninger staff going to deal with Kevin's abhorrent behaviors? God forbid if they continued, how could Menninger keep him? How would we even get him home? If we got him home, what in the world would we do?" The kindness, concern, and openness of so many people was deeply appreciated. They professionally accepted his symptoms on a trial basis.

Admitting Kevin to Menninger was emotionally difficult even with a untenable home situation. It's impossible to completely relinquish your parental responsibilities and keep informed. You still need to be an advocate for your child. Throughout the weekend there was a lot of tension while the staff got to know Kevin, and patience until he took his first Prolixin injection. A genuine parental commitment made the adjustment less complicated. The calm began.

Arriving home was intensely sad because Kevin was not there. He loves the flowers and the yard. There was such an empty feeling inside that we just cried. I dried and pressed Magnolias, Tulips, Bluebells, Forsythia, Cherry Blossoms and an odd little blue weed to send to him so Kevin would know what was blooming. His Mom sent him a great New York Times Article on the new feathered Dinosaur. These were forms of Occupational Therapy to work through the tears. There was a real acknowledgment of how much energy was spent trying to make Kevin comfortable, understand what is happening to him, and find out a way to help him. We love him and miss him. We hope and pray that this is the right decision for him.

It's rather like when Kevin's older brother, Patrick, went to college and was on his own for the first time. He had the opportunity to go to Brooklyn Poly Prep and then La Guardia High School for Music, Art, and the Performance Arts which gave him some independence to make college an easier transition. Kevin's Menninger trip came quickly, a matter of days. We are so proud that he got there and is trying so hard. He already has allot of friends at Menninger that are in there pitching for him.

This just happens to be a time that Kevin has to work it out for himself with the help of the people at the Clinic. The best therapists, nurses, and staff will be challenging, maybe too challenging. They are like athletic trainers. You hate them because you think they work your muscles beyond their limit. Somehow you know that they will be good for you. You keep struggling with them because you are committed to wanting a stronger or better body. Kevin does not believe in it.

Kansas is genuinely pretty. Topeka could actually be a vacation spot. The wind, blue sky, birdsong and the distance, that sense of seeing for miles is quite enticing. Two months ago Kevin said his idea of a perfect vacation would be to go somewhere, where he could look out his window and see miles of nothingness. He could see a meadow, or a mountain in which he could take a hike. No civilization. No other buildings. He says the staff is really nice. He cries a lot both on the phone and off. He's homesick, and says the program is too severe. He can't survive it. When we hear that he is crawled up crying in a fetal position in his bedroom because it was washed out with ammonia, we want to give up. Kevin forgets to say that the his therapist encouraged him to do an exposure and stayed with him for an hour and a half. Afterwards he came out and looked proud and the staff applauded him. They are always asking him to do something and no one does anything for him. He says he doesn't remember things from day to day, that everything becomes a big blur. He complains about mood swings. He doesn't know what will happen. He wants his parents to spring him, this weekend. It won't happen.

It appears that the program is working on:

1) Ritualistic or multiple touching of things, (elbows, hands, arms, glasses, when he dresses in the morning, dressing can take 45 minutes or longer, subject to preparation, repetition, tactile sensations, virtually everything).

2) Transitions (going through spaces and doors, outside, etc.).

3) Doing things for himself.

4) Tactile sensations (glass, washcloths, paper towels, getting dressed, changing shirts, water, dirty clothes, laundry, cold steel washer and dryer, doorknobs, toilet flushing, all paper products).

5) Contamination (cleaning products in his room, bathroom, shower, laundry, bus and car exhaust, all smells, colognes deodorant, bodies, cooking, bodily functions, toilet flushing).

6) Exposures to temperature change: The community room is air conditioned and the kitchen is warm (it's difficult for him to walk through the door to get his own glass of water, deal with the different smell of the room, open the cupboard door, pick out the cup, touch the cup, push the cup against the ice machine, push the cup against the water machine, and return through the door way exactly the same way he entered it. He could touch everything 4, 8, 16 or hundreds of times to get it just right. The number of exposures can be broken down to at least 10 things).

7) Fluid intake: a) Sodas (handling money, elevator, going outside, etc. How many sodas a day is considered reasonable?) b) Water.

8) Tics (Tourette's involuntary muscular contractions, currently major stomach tic, snorting, and other things).

9) Relief (His personal cure for hot flashes, and major disturbances is getting splashed with buckets of ice water. With the pharmacology it is limited but he still needs it).

10) Adjusting medications.

11) Hierarchies of OCD Stress (What are the least stressful and what are the most stressful situations).

This list only scratches the surface of Kevin's problems as the staff at Menninger is discovering. It seems like a lot to be working on in the first few weeks. This is pertinent Exposure-Response Prevention Therapy. Kevin is on overload. Is that simply what is necessary?

After some volatile acting out Kevin got another injection of Prolixin IM. We are anxious about the amount of Prolixin, blurry vision and agitation plus the potential rebound side effects as, or if, he is switched to Ziprasidone. (Regarding the Ziprasidone, Kevin did get an EKG which was an achievement.)

We have few expectations other than some help which might allow Kevin to transition into a residential placement like the Grove School in Madison, Connecticut. But we really would still like him home. We wish him a full, complete, and independent life. It takes the discovery of many people along the way, who are willing to help. It takes incredible friends and neighbors. It takes hope.

On the telephone with us initially Kevin sounds very good and together. The middle is generally teary-eyed complaining. Every moment of every day is filled with distress. Kevin's last words are always, "Good-Bye, I love you."

We'd like to thank some people who helped Kevin and us along this journey:

Nurse Rene Azzouz and Dr. Joyce Davidson at Menninger offered in depth advice to us prior to the opening of their program on April 2, 2001. Constantina Boudouvas, CSW, is Kevin's Menninger therapist.

Dr. Bradley Reimann at Rogers Memorial in Oconomowoc, Wisconsin, who is opening a 15 to 17 year old residential OCD Treatment Center in the next 60-90 days, offered his time and energy to help in the decision making process. In addition Doctor Michael Jenike at McClean Hospital in Boston, Massachusetts e-mailed his thoughts.

Marnie Jaffer, Nurse Practitioner, at NYU, Cornell, Presbyterian Hospital counseled me regarding the in depth nature of Residential Exposure with Response Prevention Therapy. It is not easy. Kevin has seen Larry Scahill, Ph.D. and Paul Lombroso, MD at the Yale Child Study Tic and OCD Clinic virtually every few months for the better part of 8 years. They've been handling Kevin's Pharmacology. Larry's personal and telephone sessions help us survive. Kevin has been on many drug trials during this time and was getting ready to start Ziprasidone.

Yale has recommended CBT and Residential Placement for years, but before Menninger there was no place suitable for Kevin. After a four year search, Marnie Jaffer appeared in a NY Times Article and six months later she referred us to Dean McKay, Ph.D. and Scott Greisberg, MA from Fordham University, Cognitive Behavioral and Exposure with Response Prevention Therapists. They've been treating Kevin 4 to 6 days a week since August, 30-90 minute sessions, which actually reduced his dependence on medication. They consider him a tough responder. They discovered the Menninger Clinic and Roger Memorial's programs at the Atlanta Anxiety Disorders Convention March 21-25, 2001.

Ethan Ascedo, Pharmacist, at Miller's Pharmacy, Staten Island, New York is an integral part of all of Kevin's prescriptions. He is a wealth of information, and divertissement. Wayne Lacks, CSW is our family Therapist, confidence builder and the indispensable New York City Chapter's Tourette Syndrome Support Group Leader.

Thank you all.
The McAndrew Family

An Interview with Alec Pollard, Ph.D.
About the Anxiety Disorders Center

Alec Pollard, Ph.D. is the director of Saint Louis Behavioral Medicine Institute's Anxiety Disorders Center as well as a member of the Obsessive Compulsive Foundation's Scientific Advisory Board and the clinical director of the OCF Behavior Therapy Institute program. The following is an interview with Dr. Pollard [pictured] about the treatment programs for OCD and the Spectrum Disorders available at the Anxiety Disorders Center.

NEWSLETTER: What treatment modalities are available at the Anxiety Disorders Center for treating Obsessive Compulsive Disorder and the Spectrum Disorders?

POLLARD: Cognitive behavior therapy (CBT) with exposure and response prevention (ERP) is the primary component of treatment at the Anxiety Disorders Center (ADC).

Pharmacotherapy, family counseling, access to community support groups and our peer support program, other psychosocial therapies for any additional problems, consultation with a variety of specialists, phone evaluations and consultations, and a treatment-readiness program are also incorporated into a patient's treatment plan as needed.

NEWSLETTER: Does ADC offer an intensive behavior therapy program? What is intensive behavior therapy? What differentiates it from regular CBT?

POLLARD: Yes, an intensive program is one level of service available at ADC. The word "intensive" typically refers to therapist-supervised treatment provided more than a couple of hours a week. An intensive program is appropriate for patients who could benefit from a higher dose of CBT or more structure than the usual outpatient service can provide.

In our intensive outpatient program, patients attend therapy during the day and return home at night. Patients from out of town stay at extended stay hotels of their choice. They can receive two to six hours a day of therapy and can attend up to six days a week. This level of intensity is usually sufficient, but residential or inpatient options may need to be considered in some cases.

NEWSLETTER: How long is your typical program?

POLLARD: There is no set length of treatment. Duration of care is dictated by many factors and treatment is tailored to each individual. For example, we have found that patients differ in their level of readiness to engage in therapy and that some may need more preparation before beginning treatment than others. For out-of-town patients, another factor is the level of recovery the patient wants to reach before returning home. Thus, length of treatment is influenced by several factors that are continually assessed by our therapists. We provide a range of 2 to 8 weeks as an estimate for people who contact us before we have sufficient clinical information.

NEWSLETTER: What does your program include?

POLLARD: The heart of the program is the daily supervised Exposure and Response Prevention sessions. Patients can attend up to three of these sessions a day if needed. In addition, patients meet individually several times a week with their primary therapist and attend daily small group meetings with other patients.

Individuals receiving medication also meet regularly with our psychiatrist. Some patients attend support group meetings held in our building and at several other locations in the greater St. Louis area. Family education and counseling is provided by the patient's primary therapist or during family workshops provided by our staff.

Other groups conducted at the Saint Louis Behavioral Medicine Institute that address specific issues (e.g., social anxiety, skill development, etc.) are available also for our patients when needed. In addition to a variety of mental health specialists, the Institute has two internists, a physical therapist, a dietitian, a nurse, spiritual counselors, and other healthcare specialists on staff available for consultation, if needed.

NEWSLETTER: Is medication part of the program? Can someone participate in the Center's program if s/he is on medication? Can someone be evaluated and prescribed medication through the Center's program?

POLLARD: Medication is a very important part of our program. Usually, patients are followed by one of our team psychiatrists, but some local patients continue to see their own physician while in the program. Some individuals elect to try CBT without drug therapy. We educate patients about their treatment options and let them decide.

NEWSLETTER: What alternatives does someone have if s/he hasn't achieved a satisfactory remission of symptoms at the end of the program?

POLLARD: I would not consider such a patient "at the end of" our program. We would continue to explore treatment options, which could include a medication adjustment, greater family involvement, a higher level of care (e.g., inpatient treatment) or other strategies.

In some cases, poor response to treatment is due to a failure to address some other problem interfering with the individual's ability to succeed in treatment. We have developed a special track in our program that addresses these additional problems that can sometimes prevent successful treatment outcomes.

NEWSLETTER: Because it is a chronic illness, relapse is a big issue in OCD. How does your program deal with it?

POLLARD: Relapse prevention training begins on some level the very first day of treatment. Patients are taught to be prepared for and identify the early signs of setbacks and to take positive steps as early in the process as possible. Sometimes family members are involved as well. The goal is to keep temporary setbacks from developing into a more serious and enduring relapse.

NEWSLETTER: What inpatient facilities does Saint Louis Behavioral Medicine Institute have?

POLLARD: For inpatient services we collaborate with an area hospital. We have had an inpatient component to our program since 1982. We do not currently have inpatient services for children or adolescents under 17, but we are exploring the possibility of opening a unit in the future.

NEWSLETTER: If a patient lives too far from the Institute to commute, what accommodations are available?

POLLARD: Unless they are in the inpatient program, out-of-town patients stay at area hotels or short-term stay apartments. The Institute provides prospective patients with a list of options which includes information on price, location, transportation and other features.

NEWSLETTER: Does the Anxiety Disorders Center have a less intensive behavior program?

POLLARD: Yes, we have a very large standard outpatient program. In fact, most of our local patients receive this less intensive level of care.

NEWSLETTER: What factors should someone consider when s/he is trying to determine if an intensive behavior therapy program is appropriate?

POLLARD: The primary consideration is whether standard outpatient therapy is sufficient for the patient to improve. In some cases, the necessity for intensive treatment may be evident from the start. However, usually the determination is made after the patient has tried standard outpatient CBT. Some outpatient nonresponders do well with an intensive approach. It is typically individuals who require the higher level of structure, supervision, or support provided by an intensive program.

Another reason some patients choose intensive therapy is expediency. Typically, an individual will progress more rapidly with higher doses of CBT than he or she would with lower doses. For example, patients who have had to leave work or school because of their OCD may be particularly pressed to recover as quickly as possible.

NEWSLETTER: Are your programs covered by private insurance, Medicare, Medicaid?

POLLARD: Most private insurers cover our services and we are listed as providers on most national plans, but it is important to work with patients to maximize their insurance benefits. Because insurance is such an important factor in a patient's decision to seek help, this is one of the first issues that needs to be researched. Some insurance covers a portion or all of the cost and some may not cover anything. The benefits phone number on the back of the patient's insurance card can be called to determine whether an intensive outpatient level of care is covered.

Even if the service is covered, however, managed care companies often require preauthorization, a review process by which services must be determined to be "medically necessary" by the company before treatment can begin. Patients can call our intake office and we will help them navigate the managed care system once they have decided to attend our program. Medicare covers our services and does not require preauthorization, but it does have its own regulations which must be followed. Medicaid is more complicated because, unlike Medicare, its policies and how it is managed varies from state to state. In some cases, Medicaid systems in some states have paid for our services, but often they do not.

NEWSLETTER: How many staff members are involved in treating OCD at the Anxiety Disorders Center? Do you have a psychiatrist on staff or available to consult about medication?

POLLARD: Our medical director, Reed Simpson, M.D., provides psychiatric coverage for most of our adult patients in the intensive program. We also have a child psychiatrist and other adult psychiatrists available as needed. Gary Mitchell, MSW, LCSW, is our assistant director and Jeanne Kehlenbrink, RN, MA, is the program manager of our intensive program. We currently have eight therapists, two postdoctoral fellows and a variety of consultants representing various specialties.

NEWSLETTER: We've talked about the program, now let's talk a little about you. What is your training and background in the treatment of OCD?

POLLARD: After completing my Ph.D. in 1981, I moved from California to Philadelphia for a postdoctoral fellowship at the Behavior Therapy Unit at Temple University. The BTU helped pioneer the development of behavioral treatments for many psychiatric disorders, including OCD. I was very fortunate to have the opportunity to work with people like Joseph Wolpe, Edna Foa, Gail Steketee, Jon Grayson, Charles Mansueto and others whose names might be familiar to your readers. In the fall of 1982, I left Philadelphia to accept a faculty appointment at Saint Louis University School of Medicine to develop the program we've been discussing. Our program has been in St. Louis since that time.

NEWSLETTER: Do you treat children and adolescents at the Center? Can they participate in the intensive behavior therapy program?

POLLARD: Yes, we treat children of all ages. Most of our therapists work with children as well as adults. Children and adolescents can participate in our intensive outpatient program. For kids whose OCD does not significantly interfere with school attendance or academic performance, the priority is to minimize disruptions to school.

Local kids often attend our after-school program or Saturday morning sessions. Out-of-state kids may try to come during school breaks or to our summer program. However, if OCD is disrupting school, the priority is to get them into treatment as soon as possible.

NEWSLETTER: If someone is interested in more information about the Center's program, who should be contacted?

POLLARD: They can call our intake office (877:245-2688) and ask for Heidi or they can contact us through our Web Site at http://www.slbmi.com

New Program Opens At Mayo Clinic:

The following is an interview with Jonathan Abramowitz, Ph.D., director of the new OCD/Anxiety Disorders program at the Mayo Psychiatry and Psychology Treatment Center at the St. Mary's Hospital Campus in Rochester, Minnesota. Dr. Abramowitz was formerly associated with the Center for the Treatment and Study of Anxiety at the University of Pennsylvania. This is the third interview in this series describing programs where OCD sufferers can receive intensive treatment.

NEWSLETTER: Tell me about your program at Mayo? Is it a brand new program, or are you building on an already established program? Is it just for OCD and the Spectrum Disorders or is it for all Anxiety Disorders?

ABRAMOWITZ: Mayo's OCD/Anxiety Disorders program is brand new -- as are our clinic facilities. We are housed within the Mayo Psychiatry and Psychology Treatment Center at the St. Mary's Hospital Campus in Rochester, Minnesota. The program will aim to treat people with OCD, as well as those with other anxiety disorders (panic, phobias, post-traumatic stress).

NEWSLETTER: Until recently you have been on staff at the Center for the Treatment and Study of Anxiety at the University of Pennsylvania. Will your Mayo program employ the intensive behavior therapy program designed by Dr. Foa?

ABRAMOWITZ: Edna Foa's intensive cognitive-behavior therapy protocol involving exposure and response prevention will be the staple of our OCD treatment program. This 3-week outpatient program has been shown to be highly effective for the majority of patients who complete it. In my three plus years working in Dr. Foa's clinic, I have seen many people with severe OCD regain social, occupational, academic, and leisure functioning following this treatment. We offer the same therapy here at Mayo.

NEWSLETTER: What treatment modalities will you be using to treat OCD and the Spectrum Disorders at your new program?

ABRAMOWITZ: Keeping up to date on the latest research on treatment of OCD is a priority of mine. There are currently two effective forms of treatment for OCD: 1) cognitive-behavior therapy including exposure and response prevention; and 2) medication with serotonin reuptake inhibitors. Both of these treatments will be available at Mayo. During the initial consultation, patients will learn about the available treatment options and what is recommended for them.

Our program offers new treatment procedures that have been shown, in the latest research trials, to be effective. For example, there are new and effective cognitive-behavioral programs for "pure obsessionals," body dysmorphic disorder, and hypochondriasis.

I have a special interest in "pure obsessions;" i.e., where a person has scary obsessional thoughts, such as, fearing that he or she might hurt someone, but no overt compulsions like washing or checking. This problem once baffled psychologists and was considered resistant to treatment; but newly developed treatments by colleagues in Canada and England can be very effective in helping people overcome their frightening obsessional thoughts.

NEWSLETTER: Besides behavior therapy/exposure and response prevention, will medication therapy be available for patients who come to your Treatment Center?

ABRAMOWITZ: Indeed. Some patients with OCD seem to respond best to a combination of cognitive-behavior therapy and medication. We have physicians (psychiatrists) on our staff who will oversee medication treatment.

NEWSLETTER: Is your program going to feature intensive behavior therapy? Will there be non-intensive treatment also?

ABRAMOWITZ: Good question! For patients within commuting distance, we will also offer less intensive treatment regimens, such as "twice-weekly" therapy.

A study I recently completed in collaboration with my colleagues at the University of Pennsylvania suggested that OCD often responds well to less intensive cognitive-behavior therapy. However, we will evaluate each individual patient before deciding on a treatment schedule, because there are some factors that we think influence whether intensive or less-intensive treatment is the best alternative. For example, less severe compulsions and favorable family support may predict more success with less intensive treatment. A recommendation about intensive vs. less intensive treatment will be made following a thorough initial evaluation.

NEWSLETTER: Are you offering in-patient treatment as well as outpatient treatment?

ABRAMOWITZ: At this time, we are offering only out-patient treatment. However, we are working toward an inpatient program for the future and will certainly publicize the opening of such a program.

NEWSLETTER: If you don't have in-patient facilities, what provisions for treatment at your Center can someone from out of the area make?

ABRAMOWITZ: Rochester, Minnesota is a city of over 100,000 people, located in the southeast corner of the state, about one hour from Minneapolis/St. Paul, and 6 hours from Chicago and Milwaukee. Rochester has a new airport with numerous flights daily from Minneapolis and Chicago. There are many hotels that have special "Mayo Clinic Rates" for patients and their families. Indeed, Mayo is the main attraction in Rochester. We have lists of places to stay during treatment that we will send out upon request. There are several nice restaurants and two shopping malls within the city. In addition, the downtown buildings (including most hotels) of Rochester are connected by an impressive series of subways and skyways. So, in the bad weather, one never has to go outside to get around town. By the way, Rochester is consistently ranked among the top 3 places to live in the USA!

NEWSLETTER: Will you be treating children and adolescents as well as adults?

ABRAMOWITZ: We will have the capabilities for evaluating and treating adolescents and children with OCD.

NEWSLETTER: How long typically is your intensive behavior therapy program? What does it involve exactly?

ABRAMOWITZ: Our intensive behavior therapy program is about three to four weeks in length and involves three phases:

• Information gathering;
  
• Exposure and Response Prevention; and
  
• Relapse prevention. Each patient's treatment program is highly individualized and tailored to the specific OCD symptoms that need to be addressed. During the "information gathering" phase (about 3 sessions), details about the patient's history, family, and obsessions, compulsions, and avoidance, are discussed in a way that will help the therapist to develop a treatment plan. The therapist and patient also discuss how the treatment will proceed and together design a hierarchy of the patient's feared situations and thoughts. An important aspect of this part of therapy is that while the therapist is learning about the patient's specific OCD symptoms, the patient is learning how cognitive-behavior therapy will help to weaken OCD symptoms.

During exposure and response prevention (about 15 sessions) patients practice confronting the previously identified situations that evoke obsessional fears. This is "exposure." Therapists also help patients to refrain from compulsive rituals "response prevention." This is the most challenging aspect of treatment because most patients feel uncomfortable confronting things they have spent a lot of their time and energy trying to avoid. Importantly, the therapist closely supervises exposure and helps the patient when difficulties arise. Also, easier situations are practiced before gradually moving toward more difficult ones. No patient is ever forced to do an exposure. This is a voluntary treatment.

However, research suggests that improvement is strongly related to the amount of practice. I often tell patients I work with that: "it's worth experiencing anxiety now, in order to have a calmer future." For patients within driving distance of Mayo, the relapse prevention phase of treatment includes six sessions spaced as necessary (one per week, once per month). Patients work on gradually decreasing their avoidance of everyday situations and practicing difficult exposure situations with the therapist. For patients who have traveled to Mayo from long distances, this phase may include a therapist home visit, where the therapist goes to the patient's hometown and works with the patient in his/her environment.

NEWSLETTER: Do you have a separate regimen for treatment refractory patients?

ABRAMOWITZ: For patients who have failed to respond to cognitive-behavior therapy in the past, we will assess the course of their treatment to determine whether more intensive therapy is recommended, or whether additional trials of medication or other forms of treatment (e.g., inpatient) would be best.

NEWSLETTER: Are you going to have support groups for past and present patients?

ABRAMOWITZ: Indeed. We are working to organize a local OCD support group that will meet regularly.

NEWSLETTER: How many patients do you expect to be able to treat at one time? How big a staff will the clinic have?

ABRAMOWITZ: Presently, we have four full-time cognitive-behavioral therapists and two psychiatrists associated with our program. We are considering adding another therapist. This means we can treat several people with OCD at one time.

NEWSLETTER: Can you tell us about your background? Where did you do your undergraduate work? Your graduate work? Your post doctoral work?

ABRAMOWITZ: I was born and raised in Baltimore, MD (Go Ravens!) and received my undergraduate degree from Muhlenberg College in Allentown, PA. I received my Ph.D. in Clinical Psychology from the University of Memphis in Tennessee. Following graduate school, I completed a post doctoral fellowship at the Center for Treatment and Study of Anxiety (University of Pennsylvania). In November of 2000, I was hired by Mayo Clinic to develop an OCD and anxiety treatment and research program here.

NEWSLETTER: Will your clinic take private insurance? Medicare? Medicaid? Will there be any provisions for individuals who can't afford the program?

ABRAMOWITZ: Because of the diversity in insurance coverage, it is best to telephone Mayo to find out about financial arrangements. I am happy to speak to people with questions regarding insurance and fees. My phone number is 507:284-6145.

NEWSLETTER: You have done a great deal of research during your career, will you be continuing to do research at Mayo? What areas of research do you anticipate being involved with?

ABRAMOWITZ: I have several research interests that I plan to continue at Mayo. Primarily, I am interested in improving treatment for OCD and making this therapy more widely available in clinical settings. We have an effective treatment in exposure and response prevention, but it does not help everyone, and it is not available everywhere. I am planning research to develop programs that will help patients get ready to do this treatment, to design therapies that will address patients-family interactions, and to devise training programs for new therapists. One project we are excited about is the development of a treatment program for people with OCD and severe depression. We have applied for a grant to fund this study and hope to begin enrolling participants later in 2001.

NEWSLETTER: Will you being doing research studies with patients where they will be treated for free?

ABRAMOWITZ: Yes, We hope to be able to treat patients who are eligible for research for free.

NEWSLETTER: Will you have the facilities to handle someone whose OCD is so serious that he needs hospitalization?

ABRAMOWITZ: Mayo has a psychiatric inpatient program that can handle patients with symptoms so severe that they require hospitalization.

NEWSLETTER: Will there be family involvement in the treatment process? Will there be support groups for family members or some kind of orientation so that they can help with the E&RP exercises?

ABRAMOWITZ: It is always a plus to have a friend or relative as a support person during treatment for OCD, and we are happy to include these individuals in treatment as clinically appropriate. At the initial evaluation session, support people will be taught all about OCD and its treatment. In addition, we will put them to work and teach them how to help their loved ones to overcome OCD symptoms.

NEWSLETTER: How will you treat people who are "treatment resistant?"

ABRAMOWITZ: Patients will be evaluated in an individual basis. The first step will be to get a full treatment history to be sure that they have received the correct regimens of CBT and/or medication. If the patient has failed with each of these, we will conduct a thorough assessment to determine why there has been no response, and we will attempt to address these problems.

NEWSLETTER: Does a patient have to be referred to your clinic by a therapist or can he/she self-refer? Who is the Mayo admissions person to contact to learn more about your program?

ABRAMOWITZ: I am happy to discuss treatment options with anyone who is interested in our program. Often, patients are doctor-referred, but not always.

NEWSLETTER: Who should come to your program? Anyone with OCD? People with "treatment resistant" OCD?

ABRAMOWITZ: Our mission is to provide the state-of-the-art treatments for OCD to any and all patients as clinically appropriate. I recommend that people who are interested in our program call to consult with me before scheduling an appointment, especially if they are coming from far away. I will want to find out about particular OCD symptoms and treatment histories in order to make recommendations, or tailor the person's experience to meet his/her needs.

NEWSLETTER: Can individuals with co-morbid conditions be treated at your program?

ABRAMOWITZ: The clinical research indicates that a great many people with OCD also have comorbid conditions. Often patients have depression or another anxiety disorder along with OCD. As I mentioned above, together with experts on depression, we are excited to introduce a treatment program for severely depressed OCD patients. Patients with other comorbid problems such as panic, generalized anxiety, Tourette's Syndrome, and social phobia, are also welcome. Our goal is to work to meet the individual needs of each patient.

Jonathan S. Abramowitz, Ph.D.
Mayo Clinic, Dept. of Psychiatry and Psychology
200 First St. SW, Rochester, MN 55905
phone: 507:284-6145
fax: 507:284-3933
e-mail: abramowitz.jonathan@mayo.edu