Keywords

Prevalence of Obsessive-Compulsive Disorder Among Latinos

Obsessive-compulsive disorder (OCD) is a severe illness that has been considered one of the top ten causes of disability worldwide, with a global burden comparable to that of schizophrenia (Ayuso-Mateos, 2006; Lopez & Murray, 1998). OCD includes the experience of intrusive distressing thoughts, urges, and/or images and accompanying behaviors done in an attempt to neutralize the resulting anxiety (American Psychiatric Association [APA], 2013). Individuals with OCD may struggle with obsessions and compulsions for up to 17 hours a day or more (Gallup, 1990). OCD is highly disabling, with nearly two-thirds of those afflicted reporting severe role impairment (Ruscio, Stein, Chiu, & Kessler, 2010). People with OCD have much higher rates of unemployment (22% vs. 6%; Koran, Thienemann, & Davenport, 1996). The vast majority of individuals with OCD meet criteria for an additional mental disorder (90%), with 40.7% also suffering from major depressive disorder and 38.6% suffering from a comorbid substance use disorder (Ruscio et al., 2010). Lifetime prevalence rates for OCD are estimated at 1.6–2.3% (Kessler et al., 2005; Ruscio et al., 2010).

The National Latino and Asian-American Study (NLAAS) found that Latino/as experience equal rates for most major mental health issues compared to the overall population (Alegria et al., 2007); however, that study did not assess for the presence of OCD. The National Comorbidity Survey Replication (NCS-R; N = 5424) compared mental health prevalence rates in different ethnoracial groups (Breslau et al., 2006) and indicated that Latino Americans had three times the prevalence rate of OCD than European Americans, although this finding was not significantly different. Another study comparing OCD prevalence in European Americans and the Mexican American Latino subgroup found no significant differences (Karno et al., 1989). Thus, it may be most appropriate to report OCD prevalence at the subgroup level, but the extant literature is lacking as data is mostly unavailable. Lack of information is likely the result of difficulty recruiting Latinos for mental health research studies (Wetterneck et al., 2012) and cultural nonequivalence of OCD measures (e.g., Williams, Turkheimer, Schmidt, & Oltmanns, 2005).

OCD Symptoms in Latinos

OCD symptom differences in Latino Americans also remain widely unexplored compared to other groups. OCD is a heterogeneous disorder, and it is important to accurately understand symptom differences cross-culturally because patients without the most common presentations (i.e., compulsive washing and overt repetitive checking) may not be quickly identified by medical professionals. One study that did focus on symptom differences in a nonclinical sample found that Latino/a Americans demonstrated a higher rate of contamination symptoms than European Americans (Williams et al., 2005). Another study compared six symptom dimensions of OCD in a nonclinical sample and found equal rates among most dimensions (i.e., hoarding, obsessing, neutralizing, washing, and ordering), but European Americans were significantly higher on checking than Latino/as (Burgess, Smith, Cervantes, & Wetterneck, 2009). However, findings may differ in a clinical population; thus, it is important to examine these constructs in clinically diagnosed samples. There have been some studies on OCD in Hispanic countries , and overall findings appear to suggest a predominance of contamination, symmetry, and sexual obsessions, as well as washing, checking, cleaning, and repeating compulsions (Chavira et al., 2008; Nicolini et al., 1997). Findings from cross-national epidemiological research indicate differences in OCD symptomology across Latino and European American populations, particularly in the content of obsessions, which may be due to sociocultural influences (Chavira et al., 2008).

One large study comparing European American (N = 3986) and Latino American (N = 473) adults found that Latino/as may have higher levels of interpersonal functioning and social support, but an OCD diagnosis was significantly related to problems with interpersonal functioning (Hernandez, Plant, Sachs-Ericsson, & Joiner, 2005). The resulting impairment could be particularly damaging in youth, who are still struggling to develop their identities. This may result in increased enmeshment with family, which may be more problematic in more collectivistic cultures, such as Latino culture. A recent study of young adults supported this need for investigation as they found that lower familial social support and higher familial stress correlated to higher OC symptoms in Latino , but not in European or African Americans (Sawyer et al., 2013). Given that acculturated adolescents are at increased risk for mental health issues than their less acculturated peers (Gonzales, Deardorff, Formoso, Barr, & Barrera., 2006), acculturation and parenting styles may be important variables.

Another important consideration for the Latino population is the evidence that individuals in this group often express symptoms related to mental health disorders, such as anxiety and depression, in the form of physical complaints (i.e., somatization; Chavira et al., 2008; Guarnaccia, Martinez, & Arcosta, 2005). A clinician without this knowledge may only look for cognitive and behavioral symptoms and potentially miss an OCD diagnosis. Religiosity in the Latino population is another factor clinicians should consider. Fifty-nine percent of Latino/as in the USA identify as Catholic, almost triple the percentage of European Americans (Kosmin & Keysar, 2009). Given that Catholics are more likely to have OCD than other religious groups (Himle, Taylor, & Chatters, 2012), religion may be an important factor in the phenomenology of OCD in the Latino population. Specifically, in Catholic individuals who are highly religious, a belief that thoughts are very important is predictive of OC symptoms (Sica, Novaro, & Sanavio, 2002).

Treatment for OCD in Latinos

There is a persistent mental health disparity among Latino Americans compared to European Americans. At approximately 16% of the US population, the Latino population is expanding at a rate beyond the current research capacity necessary to understand the nature of their risks for psychiatric disorders. Although, the NLAAS epidemiological study did not assess participants for OCD, leaving a vast chasm in our knowledge of the disorder in this underserved population, the study did demonstrate that while U.S.-born Latinos were beginning to use more mental health services, they did so at a lower rate. Interestingly, Latino/as have demonstrated similar utilization of mental health services from social service agencies or general physicians compared to European Americans , but significantly less services from mental health professionals (i.e., psychologists, psychiatrists, and therapists; Alegria et al., 2002). Overall, less than 9% of those with a mental disorder contact a mental health professional and fewer than 20% of these individuals seek help through a general health care provider. The higher number seeking treatment from general health care providers is likely in part due to the tendency of Latino/as to somaticize mental health symptoms, as mentioned previously (Wetterneck et al., 2012). Recent immigrants are even less likely to seek out these services (U.S. Department of Health and Human Services [USDHHS], 2001), even though the very process of immigration may increase stress. An important additional barrier is that twice as many Latino/as are uninsured compared to European Americans (U.S. Census, 2015), although this may be changing with the enactment of the Affordable Care Act (Alexander, Billow, Bufka, Walters, & Williams, 2016).

Despite differences in the OC symptoms and service utilization reported between Latino/as and European Americans, no culturally specific assessment or treatment for Latino/a Americans with OCD has been developed. Research has noted an absence of Latinos being assessed or treated at OCD specialty clinics (Foa et al., 1995; Williams et al., 2015), which supports the epidemiological finding that these groups are undertreated and less likely to receive the most effective treatments for OCD. Based on current knowledge, exposure and response prevention (EX/RP) is the recommended course of treatment, as it has been shown to be efficacious in other groups (Abramowitz, 2006), though it should be noted that conceptualization of OC symptoms in ethnic minority groups using the cognitive-behavioral model remains in question (Wheaton, Berman, Fabricant, & Abramowitz, 2013).

A Treatment Plan

At the initiation of treatment, the client’s language preference should be obtained. Though a Latino/a client may be bilingual, speaking in the client’s preferred language has been shown to lower drop-out rates (Paris, Anez, Bedregal, Andres-Hyman, & Davidson 2005; Sue, Fujino, Hu, Takeuchi, & Zane, 1991). Latino/a clients should not only be matched with a clinician by language but also, when possible, with a clinician of a similar ethnic background, also keeping in mind that Latino/as are a heterogeneous group. Latino/as are similar to other ethnic minority populations in that they face a strong cultural stigma against mental health disorders. Being clear at the beginning of treatment about confidentiality could help push past some of the reticence to disclose. Clinicians may also choose to emphasize the directive, task-oriented, and generally short-term nature of EX/RP treatment because of the evidence that Latino/as prefer directive methods (Anger-Diaz, Schlanger, Ricon, & Mendoza, 2004; Santisteban et al., 2003). In addition to the exposure and response prevention protocol detailed below (based on Foa, Yadin, & Lichner, 2012; Yadin, Lichner, & Foa, 2012), the clinician should be aware of and incorporate cultural values held by many Latino/as such as religious faith and close family relationships. This is particularly important for establishing a therapeutic alliance. The treatment plan below lists names of measures, worksheets, and handouts in Spanish, shown in Table 7.1; however, their English counterparts are also available if the client prefers English.

Table 7.1 List of Spanish tools for OCD
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Session Outline

Session 1: Treatment Planning – Setting the Stage

  1. 1.

    The Basics

    1. (a)

      Begin the session with introductions to help the client familiarize themselves with you. Describe the plan for the session explaining that it will consist largely of information gathering and laying the foundation for the treatment approach.

  2. 2.

    Psychoeducation and Information Gathering

    1. (a)

      Describe the “El Ciclo de TOC” (Appendix A) document to explain this model of the disorder and how compulsions strengthen the OCD.

    2. (b)

      Inquire about the client’s experience of OCD including history and symptom description using “Trastorno Obsesivo-Compulsivo Dimensiones de los Síntomas” (Appendix B) as an aid. If the client has any taboo thoughts, then also review “Pensamientos Inaceptables/ Tabú” (Appendix C).

    3. (c)

      Use the “Información Sobre el Trastorno Obsesivo-Compulsivo” form to define OCD and its components (Appendix D).

    4. (d)

      Guide the client to make a link between their obsessions and compulsions.

  3. 3.

    Why EX/RP? The Rationale

    1. (a)

      Provide a thorough explanation for the use of exposure/response prevention treatment, specifically its aim to disrupt the associations that feed OCD.

    2. (b)

      Recommended worksheet: “Exposición y Prevención de la Respuesta” (Appendix F).

  4. 4.

    What is EX/RP?

    1. (a)

      Outline the highlights of EX/RP treatment such as when you will build the exposure hierarchy, when exposures will begin, and the homework schedule.

    2. (b)

      Acknowledge that treatment may at times be taxing but also emphasize that substantial time and effort are necessary for positive outcomes.

    3. (c)

      Allow time for any questions the client may have.

  5. 5.

    Self-Monitoring and Homework

    1. (a)

      Describe, practice, and troubleshoot self-monitoring of rituals.

    2. (b)

      Assign the “Auto Monitorización de Rituales” (Appendix G) worksheet to be completed daily and brought to the next session.

    3. (c)

      The client is also to review the “El Ciclo de TOC” (Appendix A) document daily to reinforce this model of the disorder.

  6. 6.

    Measurement

    1. (a)

      Give the client the DOCS (Appendix H) to get a baseline of symptom severity by symptom dimension.

Session 2: Treatment Planning – In Depth

  1. 1.

    Review Homework

    1. (a)

      Go over the self-monitoring work sheets, providing clarifications, and making corrections as necessary.

    2. (b)

      Discuss “Información Sobre el Trastorno Obsesivo-Compulsivo” (Appendix D), answer any questions, and ask the client to identify two types of associations that occur in their experience of OCD.

  2. 2.

    Review the Rationale for EX/RP

  3. 3.

    OCD Symptom Information Gathering

    1. (a)

      Expand upon the discussion in session 1 on the client’s OCD symptoms, gathering more details.

    2. (b)

      Introduce the subjective units of distress scale (SUDs) and instruct the client on how it is to be used.

    3. (c)

      Set SUDs anchor points (0, 50, 100).

    4. (d)

      Ask the client to describe specific situations, thoughts, and images that cause distress and have them rate SUDs for each.

  4. 4.

    Create a Treatment Plan

    1. (a)

      Use the information collected to select items for exposure based on SUDs ratings.

    2. (b)

      Build the exposure hierarchy using the “Jerarquía de Evitación” form (Appendix H).

  5. 5.

    Commitment

    1. (a)

      Revisit the conversation on the time and effort necessary for treatment and garner an agreement from the client toward this end.

    2. (b)

      Emphasize the importance of complying with the exposure plan (both in session and at home) and the rules for ritual prevention.

    3. (c)

      Answer any questions.

  6. 6.

    Homework

    1. (a)

      Self-monitoring of rituals.

    2. (b)

      Review OCD informational handouts for reinforcement of this model.

Session 3: Exposure and Ritual Prevention

  1. 1.

    Review Homework

    1. (a)

      Go over the self-monitoring work sheets providing clarifications and making corrections as necessary.

  2. 2.

    Client Explanation of OCD Model

    1. (a)

      Ask the client to describe the model of OCD, and how it is relevant to their treatment.

    2. (b)

      Have the client provide the rationale for using EX/RP.

  3. 3.

    In-Session Exposure

    1. (a)

      Recall the exposure plan, guided by the hierarchy, and do the exposure exercise (imaginal and/or in vivo).

    2. (b)

      Therapist should demonstrate exposure to client before asking client to do it.

    3. (c)

      Use the “Exposición y Prevención de la Respuesta” (Appendix F) to illustrate how the exposure and habituation work.

    4. (d)

      If the client is unwilling to do an exposure, consider a behavioral experiment instead, using “Experimento de Comportamiento” (Appendix J).

  4. 4.

    Prepare for Exposure Homework

    1. (a)

      Explain the importance of practicing exposure independently in between sessions with the therapist.

    2. (b)

      With the client, select items from the hierarchy for exposure homework.

    3. (c)

      Ensure the client is familiar with how to use the “Hoja de Tareas Diarias” (Appendix K) work sheet to track their homework.

  5. 5.

    Ritual Prevention

    1. (a)

      Provide specific instructions for ritual prevention.

  6. 6.

    Homework

    1. (a)

      Continue self-monitoring of rituals daily using the “Auto Monitorización de Rituales” (Appendix G) work sheet.

    2. (b)

      Do the agreed upon exposure practice homework.

Sessions 4–15: Exposure and Ritual Prevention

  1. 1.

    Review Homework

    1. (a)

      Go over the self-monitoring work sheets and, if necessary, bring attention to any problems with ritual prevention.

    2. (b)

      Go over “Hoja de Tareas Diarias” (Appendix K) form to monitor exposure practice homework.

  2. 2.

    Review Progress

    1. (a)

      Make time to review the client’s progress regularly and also ask them to share any changes, struggles, or obstacles they have noticed.

  3. 3.

    In-Session Exposure

    1. (a)

      Use the hierarchy to systematically continue with exposures in session.

  4. 4.

    Homework

    1. (a)

      In session , assign exposure practice homework to be completed before the next session.

    2. (b)

      The client is also to continue self-monitoring of rituals tracking daily for review in the following therapy session.

Sessions 16–17: Home Visits

  1. 1.

    Review Progress in New Setting

    1. (a)

      It is recommended that the therapist conduct home visits during or after the office therapy sessions have ended. This allows the therapist to observe the home environment and the client’s functioning in it as well as provide instructions for exposure exercises in this environment.

    2. (b)

      The “home visit” does not have to be at the client’s home and should be relocated if the client particularly struggles with OCD symptoms in another environment such as work, public places, etc.

    3. (c)

      Note areas of concern to address during home visit.

  2. 2.

    Assess Progress

    1. (a)

      Give the client the DOCS (Appendix H) to determine improvement for each symptom dimension.

Sessions 18–19: Relapse Prevention

  1. 1.

    Review Homework

    1. (a)

      Go over the “Hoja de Tareas Diarias” (Appendix K) to monitor success with exposure practice homework.

  2. 2.

    Review Progress

    1. (a)

      Review the hierarchy to ensure mastery of all items.

  3. 3.

    In-Session Exposure

    1. (a)

      Ask the client to identify any areas of lingering difficulty.

    2. (b)

      Invite the client to devise his/her own exposure for managing the obsession.

    3. (c)

      Conduct the client-devised exposure during the session.

  4. 4.

    Homework

    1. (a)

      Advise the client to devise his/her own exposures for daily homework based on any current concerns using the “Hoja de Tareas Diarias” (Appendix K).

    2. (b)

      Ask the client to make note of any areas of difficulty.

Session 20: Final Session

  1. 1.

    Review Homework

    1. (a)

      Review the “Hoja de Tareas Diarias” (Appendix K) to monitor success with self-devised exposures.

  2. 2.

    Provide guidelines for normal behavior and discuss this with client (i.e., typical washing, cleaning, checking, etc.).

  3. 3.

    Assess Progress

    1. (a)

      Give the client the DOCS (Appendix H) to confirm improvement for each symptom dimension.

  4. 4.

    Review typical causes and signs of relapse and give the handout “TOC Prevención de Recaída: Consejos Rapidos” (Appendix L).

  5. 5.

    Make a plan for follow-up check in appointments in 3–6 months.

Spanish Language Tools for Assessment and Treatment of OCD

There are several psychological assessments that may be used when evaluating a Latino/a client for OCD symptoms. Various measures have been translated into Spanish, many of which have been validated with Latino/a clinical samples. Translated measurement tools include the Yale-Brown obsessive-compulsive scale (Y-BOCS), dimensional obsessive-compulsive scale (DOCS) , and obsessive-compulsive inventory-revised (OCI-R). See Table 7.2 for a detailed list of preferred measures when assessing for OCD in Latino/as.

Table 7.2 Common validated measures for OCD
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