CBT FOR OCD
To qualify as an obsession, the thought, impulse, or image must be (1) persistent,
intrusive, inappropriate, and distressing, (2) subject to control efforts, (3) recognized
as having an internal origin (i.e., not due to thought insertion), and (4) distinct from
worries about daily problems.
Overt compulsions, on the other hand, are fairly easy to recognize, although mental
(covert) rituals can present a more complicated picture. The purpose of an overt or
covert compulsion is to relieve distress associated with the obsession or to prevent
some anticipated dreaded outcome. It is not for pleasure or gratification which is a
distinguishing factor from impulse control disorders.
EPIDEMIOLOGY
Prevalence rate: Obsessive-Compulsive Disorder (OCD) affects 0.5% of the
population in India, according to the National Mental Health Survey (2015-16).
Risk factors: Individuals with a family history of OCD are 1.5 times more likely to
experience OCD, and brain structure and function abnormalities, such as differences
in the frontal lobe and basal ganglia, also contribute to the risk. Additionally,
stressful life events like trauma, abuse, and neglect can trigger OCD.
Comorbidities: OCD often co-occurs with other mental health conditions, including
depression, which affects 30% of individuals with OCD, anxiety disorders, which
affect 25% of individuals with OCD, and substance use disorders, which affect 10% of
individuals with OCD.
COURSE AND OUTCOME
Anxiety disorders are often chronic conditions. Long-term follow-up studies focused
on clinical populations indicate that many people continue to experience symptoms of
anxiety and associated social and occupational impairment many years after their
problems are initially recognized. On the other hand, some people do recover
completely. The most general conclusion, therefore, is that the long-term outcome for
anxiety disorders is mixed and somewhat unpredictable (Tyrer et al 2004)
The long-term course of obsessive–compulsive disorder also follows a pattern of
improvement mixed with some persistent symptoms. One remarkable study has
reported outcome information for a sample of 144 patients with severe OCD who
were assessed at two follow-up intervals: first about five years after they were
initially treated at a psychiatric hospital and then again more than 40 years later
(Skoog & Skoog, 1999). The data are interesting both because of the very long
follup, and were treated between 1947 and 1953, well before the introduction of
modern pharmacological and psychological treatments for the disorder.
Slightly less than 30 percent of the patients were rated as being recovered at the
first follow-up interval.
By the time of the 40-year followup, almost 50 percent of the patients were
considered to show either full recovery or recovery with subclinical symptoms.
More than 80 percent of the patients showed improved levels of functioning if we
also count people who continued to exhibit some clinical symptoms.
Nevertheless, half of the patients in this sample exhibited symptoms of OCD for
more than 30 years. This study shows that although many patients do improve,
OCD is a chronic disorder for many people
The disorder usually begins by young adulthood and typically persists for many
years, although its symptoms and their severity may fluctuate over time (Angst et
al., 2004)
A large minority of patients experience an intermittent course with obsessive–
compulsive symptoms waxing and waning, possibly in response to stressful life
experiences (Demal et al., 1993; Lensi et al., 1996; Rasmussen & Tsuang, 1986).
Rachman and Hodgson (1980) distinguished between patients who exhibited a
parttime or a full-time OCD lifestyle. For “full-timers” the disorder can be
malignant, affecting all aspects of a person’s life, whereas “part-timers” have
relatively benign obsessive–compulsive symptoms that allow them to lead
productive and satisfying lives.
FAMILY DYNAMICS
Family members may be directly drawn into the illness either by trying to stop the
symptoms or by cooperating with the patient’s ritualistic behavior. Family members
and relatives frequently make accommodations for the patient’s rituals, which in turn
increases family stress and dysfunction (Calvocoressi et al., 1995). A higher rate of
critical and rejecting comments may have a limited negative impact on the patient’s
symptom severity, and the level of depression and anxiety in family members
influences how they respond to the patient’s obsessions and compulsions (Amir,
Freshman, & Foa, 2000). Clearly, family members are caught in a difficult dilemma.
Regardless of whether they refuse to be drawn into the patient’s rituals or whether
they accommodate to the rituals, they end up feeling the ill effects of living with
OCD.
SYMPTOM SUBTYPES
OBSESSIONAL CONTENT
May have a single primary obsession. Half to three quarters have multiple
obsessions (Akhtar et al., 1975; Rasmussen & Eisen, 1998)
The content of obsessional thoughts, images, or impulses is highly individualistic
and is shaped by personal experiences, sociocultural influences and critical life
incidents
Gender differences exist
o Men : Sexual, symmetry, exactness obsessions
o Women : dirt, aggression and sexual victimization
Cultural: For example, dirt and contamination obsessions were more prevalent in
an Indian OCD sample, whereas sex and religion obsessions were relatively rare
(Akhtar et al., 1975). Religious obsessions may be more common in cultures with
strict religiously based moral codes
Preoccupation with aggression may be evident in obsessional patients with a
primary depressive disorder (Rachman & Hodgson, 1980).
The onset of an obsessional episode may be preceded by certain traumatic or
critical incidents that are thematically related to the content of the obsession (de
Silva & Marks, 1999;
Esquirol was probably the first to describe a case of OCD in 1838, although the
term obsession is attributed to Morel in 1866 (Black, 1974).
In 1878 the German neurologist Karl Westphal offered one of the first
comprehensive definitions of obsessions, which emphasized the emergence into
consciousness of ideas that are against the will, difficult to control or suppress,
but are recognized by the person as abnormal and uncharacteristic of him- or
herself (Black, 1974; Rosenberg, 1968
Intrusiveness: Intrude into conscious awareness against a person’s will.
Occurrence stops ongoing activity by capturing attentional resources
Unacceptable: The content is unacceptable to the person as negative affect is
associated with its occurrence. Degree of discomfort caused by intrusive thought,
and its perceived unacceptability are closely associated.
Subjective resistance: Hallmark: Feels compelled to deal with the obsession,
terminate its dominance of conscious awareness through control strategies such
as reassurance seeking, avoiding, rationalization, distraction, compulsive rituals
and neutralization. The desire to rid the mind of the obsession is related to the
person’s belief that highly undesirable, even threatening, consequences will befall
him or her, or others, if the obsession is not successfully terminate
Unacceptability: Despite this motivated resistance, the individual fails to exercise
the desired level of control over the obsession. This results in a heightened sense
of uncontrollability of the thought
Ego dystonic: Degree that the content of obsession is inconsistent with the
person’s sense of self as seen in ideals, values, moral attributes.
Intrusive thoughts are viewed as occurring outside the context of valued aspects
of the self; they are not the type of thought, image, or impulse that a person would
expect of him- or herself, and so the obsession represents a threat to the person’s
self-view
This ego alien quality
of the thought makes
it more important and
causes individuals to
question their true
character. This results
in more desire for
avoidance and
suppression.
The ego-dystonic
nature of obsessions is
most clearly evident in
the harm, injury, and
sex obsessions that
the patient may
consider abhorrent,
even repugnant.
Intrusive thoughts of child molestation, rape, stabbing individuals, running over
pedestrians, and the like are completely at odds with the highly conscientious,
passive and moralistic nature of individuals. Such thoughts may cause them to
wonder whether they might have latent sexual and aggressive desires that will
overtake their egos and cause them to engage in abhorrent acts of harm and
injury against self or others
Other types of obsessions also have this ego-dystonic quality because they may be
at variance with the self in more subtle ways. For example, persons who are
meticulous, conscientious, and perfectionistic may suffer from obsessive doubt
over whether a task is done completely because they believe that mistakes reflect
an unacceptable level of personal irresponsibility and carelessness.
STRATEGIES TO DEAL WITH RESISTANCE TO ASSESSMENT
1. The clinician should adopt an empathic, supportive, and collaborative style,
similar to the orientation assumed during treatment. The therapist should explain
that many people with OCD find answering questions during assessment quite
anxiety provoking. It should be noted that this is part of the problem with OCD;
that is, assessment is difficult because of the OCD.
2. Validation of the patient’s feelings should occur as the person first begins to
experience distress with assessment Validation involves acknowledging patients’
feelings about the assessment, discussing their fears and anxieties, and allowing
sufficient time for expression of these anxieties and reservations. Together the
therapist and patient can work out an approach to assessment that may lessen
personal anxiety.
3. For example, individuals can review each questionnaire with the therapist
beforehand to ensure that they understand each question.
4. Psychoeducate on nature and purpose of assessment during introductory phase
5. The clinician should explain that the use of questionnaires, interviews, and rating
scales is important for providing a detailed understanding of the nature of the
patient’s disorder, for formulating a treatment plan, and for evaluating the
effectiveness of treatment.
6. “I understand that it is very difficult for you to answer these questionnaire items.
[validation statement] Why don’t you complete the questionnaire on your own
based on your first impression? [instructions to counter OC symptoms] I will then
look over your questionnaire responses and I think that any of your answers seem
different or inaccurate given what you have already told me about your
psychological problems, I will discuss them with you and we can make the
appropriate changes. [reassurance and transfer of responsibility] In this way I can
take ultimate responsibility for insuring that the questionnaire is completed
accurately. (p. 12)
7. Be highly selective in the instruments chosen for the assessment process, and
provide extra time to complete each measure.
8. The therapist discovers that the person is thinking that there are so many items in
the questionnaire, it will take a very long time to complete, and by that time the
anxiety will be intolerable. The therapist could inquire about the evidence for this
belief. “Were there other times when this happened to you?” “Were there any
times when you did complete a form and your anxiety was less than you
expected?” “Are there things that increase or decrease the anxiety?” “What might
be done in the current situation to lessen your anxiety?
SITUATION ANALYSIS
As part of the assessment process, it is important to gather specific information on
the situations or stimuli that trigger the patient’s primary obsessions.
Level of distress experiences when exposed to the situation
Likelihood that the person will try to avoid the situation
Likelihood that the primary obsession will be triggered when in the situation
SELF MONITORING DIARIES
Critical to obtain a pretreatment baseline assessment of the frequency and
intensity of target obsessions over at least a 2-week period.
CASE FORMULATION
Distal and Proximal Contributors
The therapist first lists all the current events and experiences that have contributed
or even provoked the occurrence of obsessions and compulsions. This information
can be obtained from the diagnostic and psychological assessment conducted with
the patient. It may include the following types of information:
• Major or even minor life events, • Critical learning experiences involving unlucky or
improbable events that crystallize the person’s doubts and irrational assumptions
(Rhéaume et al., 1998),
• A comorbid condition like depression or another anxiety disorder, • Particular
personality vulnerabilities such as introversion, low self esteem, or excessive
conscientiousness, and/or
• Other clinical phenomena such as worry or overvalued ideas.
The therapist should also note any distal factors arising from the patient’s childhood
or family experiences that may have contributed to the development of OCD, as well
as any current family or marital factors that may be involved in the persistence of the
obsessional state. Together, the contributing factors and determinants noted in the
case formulation provide some general indications of distal and, even more so,
proximal factors that may be involved in the etiology of the person’s OCD.
Core Symptom Features
At the heart of the case formulation is the specification of the primary obsessions and
compulsions that will be targeted for treatment. This information is obtained from
the diagnostic interview, symptom-based obsessive–compulsive measures, and self-
monitoring records administered during the assessment. In many cases multiple
obsessions and compulsive rituals may be present. All significant obsessions and
compulsions should be noted, but some effort should be made to prioritize which
symptoms are primary and which are secondary.
Additional information should be noted about the obsessivecompulsive symptoms,
such as their frequency, duration (amount of time), level of interference in daily
activities, and situational triggers (con-text). It should also be noted whether there
are any additional factors that worsen the symptoms or that enable some reprieve
from the obsessions. The clinician should also highlight any factors that may be
especially important to the success or failure of treatment, such as the patient’s level
of motivation, expectation for success, compliance with the assessment, treatment
history, or any indications of resistance to therapy.
Profile of obsessions
One begins by specifying the affective experience associated with the obsession.
Does the obsession primarily elicit anxiety or fear, or are there elements of guilt,
anger, or even sadness? What makes the obsession so salient for most individuals
with OCD is that it is associated with such intense negative affect. Thus, it is
important to understand the nature and intensity of the emotional state associated
with the obsession
Core appraisals of obsession
The process focuses on such constructs as responsibility, threat estimation,
intolerance of uncertainty, overimportance of thought, control of thoughts, and the
like. This information can be obtained from specific cognitive measures and the
idiographic self-monitoring and rating scales previously described. From the types of
appraisals associated with the obsession, the therapist will be able to infer the core
obsessional beliefs that are maintaining the individual’s obsessional symptoms.
Profile of compulsions
