OCD

Wendy Whipp
E3:02
Wendy.whipp@bucks.ac.uk
Plan for the day

• A definition of OCD
• DSM5 criteria
• What it is
• How it can be treated
• Pure O
Definition
• Oxford English Dictionary

• Obsessive – persistent idea or thought dominating a persons mind

• Compulsive – acting contrary to ones wishes, irresistible
• Disorder – Disturbance of normal state of function
DSM5
• Presence of obsessions, compulsions or both
• Obsessions:
• Thoughts urges or images that are intrusive or unwanted causing
anxiety or distress
• Thoughts are ignored, suppressed or neutralised
• Compulsions:
• Repetitive behaviours that the individual is driven to perform in
response to obsessions or rules
• Intended to reduce anxiety or to prevent a dreaded event
DSM5
• The actions are not realistic in being able to reduce stress or prevent
harm or are clearly excessive
• Obsessions or compulsions are time consuming (take more than one
hour per day) and interfere with functioning
• With good insight
• Poor insight
• Absent insight
Background
• 1.2% of the population have OCD
• 12 per 1,000
• Reported onset – age 8
• Earlier onset reported for males
• Lifetime prevalence if not treated
• Can start in adulthood
• Rare after age 35
• Better prognosis for later onset (Veale 2014; NICE)
• Cross culture similarity
Etiological theories
• Biological and structural brain abnormalities (Pigott &
Seay 1996)
• Neuropsychological factors such as memory deficits
(Tallis, Pratt & Jamani 1999)
• Some OCD sufferers show abnormal brain structures but
many do not
• Neuropsychological deficits i.e. visual-spatial memory
impairment may be a reflection of OCD symptoms rather
than a causal factor
What is it?
• Obsessive Compulsive Disorder (OCD) is characterised by the
presence of either obsessions or compulsions, but commonly both.
• An obsession is defined as an unwanted intrusive thought, image or
urge, which repeatedly enters the person’s mind.
• Obsessions are distressing but are acknowledged as originating in the
person’s mind, and not imposed by an outside agency.
• They are usually regarded by the individual as unreasonable or
excessive.
• The person usually tries to resist an obsession, but in chronic cases
this may be to a very minor degree or not at all.
Common Obsessions
• Contamination from dirt, germs, viruses (e.g. HIV), bodily fluids or faeces,
chemicals, sticky substances, dangerous material (e.g. asbestos) 37.8%
• Fear of harm (e.g. door locks are not safe) 23.6%
• Excessive concern with order or symmetry 10.0%
• Obsessions with the body or physical symptoms 7.2%
• Religious, sacrilegious or blasphemous thoughts 5.9%
• Sexual thoughts (e.g. being a paedophile or a homosexual) 5.5%
• Urge to hoard useless or worn out possessions 4.8%
• Thoughts of violence or aggression (e.g. stabbing one’s baby) 4.3%
https://youtu.be/KOami82xKec
Discuss
• A client you have worked with who has OCD
‘Cognitive Theory of Obsessions’
Rachman (1997)
Cognitive biases increase the likelihood of catastrophic
misinterpretations of intrusive experiences
Thinking about an unpleasant situation makes it more likely or
probable to occur in reality
e.g. thinking about an accident involving a loved one will increase
the probability of it happening in real life
Moral bias. The conviction that having an immoral thought is
morally equivalent to immoral actions
e.g. the thought that having a sexual fantasy about someone other
than their own partner is equitable to committing adultery
‘Cognitive Theory of Obsessions’
Rachman (1997)
• Intrusive thoughts become more distressing as they
are appraised as revealing some hidden part of the
self
• Or leading to some predictable tragic consequences in
the world
• The previous biases constitute the concept of
‘thought-action-fusion’ TAF - a propensity to
overestimate the significance of one’s intrusive
thoughts (Shafran et al 1996; Rachman 1998; Wells
1997)
• Rachman suggests that OCD sufferers make a serious
misinterpretation of their intrusions

• These misinterpretations involve an unrealistic danger

posed by the intrusion

‘thinking I could drown my baby means I am more likely to

do it’

‘thinking I want to push someone in front of a train means

I will do it’
CBT model of maintenance of OCD Rachman (2003)
based on work of Salkovskis et al (2000) & Wells (1997)

Intrusions Serious misinterpretation

Thoughts/Images

Ineffective attempts to regain balance

Destabilisation
e.g. thought suppression, distraction,
e.g. low mood, fear
checking, repetition (compulsion)
‘Cognitive Thought Control Model’
Clark 2004
• Appraisal of a thought is inconsistent with an
individual’s sense of self and/or beliefs and values
(ego-dystonic)
• Higher order beliefs regarding the importance of
thought control
E.g. “I should be able to control my thoughts”
• The above are the main contributors to the
exacerbation of obsessions
• The ego-dystonic nature of the thoughts adds to
its saliency making it the focus of attention
‘Cognitive Thought Control Model’
Clark 2004
• Meta-beliefs that one should be able to control
ones thoughts promotes excessive thought control
behaviours i.e. thought suppression
• Rarely successful
• Creation of a negative feedback loop strengthening
the negative belief and creating further thought
control efforts and behaviours
• Increased distress and escalation in the frequency
and saliency of the thought
An OCD thinker

Did I Didn’t I???????

‘Inflated Sense of Responsibility’
Salkovskis (1989)
• May be associated with a high degree of
conscientiousness
• Dedication to work
• Acute sense of social obligation
• Implication that such individuals are likely to attribute
an increased importance to specific domains of self
E.g. self as a moral being
• Salkovskis argued that neutralising reinforces the
person’s sense of responsibility and subsequent
negative appraisal of thought

• Temporary reduction of anxiety viewed as a

success in preventing the dreaded event

• Reinforcement that one’s actions are pivotal in

preventing harm which leads to an escalation in
neutralising
Cognitive features of OCD

• Overestimation of risk/harm
• Doubt/uncertainty/decision making
• Perfectionism
• Guilt/responsibility/shame -thoughts/behaviours
• Rigidity/morality - religious beliefs/moralistic
attitudes/rigid rules
Behavioural features of OCD

• Avoidance
• Compulsions
• Hand washing
• Counting
• Repetitive behaviours
• Ritualising
• Countering
• Checking
• Religious/praying
OCD Profile

• OCD patients experience intrusive thoughts that they

attempt to suppress or neutralise by some other
thoughts or actions
• The attempt to suppress these thoughts demonstrably
increased the occurrence of these thoughts
• High probability of co-morbidity with other disorders
• Differ from non OCD thinkers not in intrusive thinking
but in meanings attached to intrusions
Thought/Action Fusions (magical thinking)
Bad thought = bad action
Over importance of thoughts
Bad thoughts = increased likelihood
Exclusivity error
Only me/my family etc.
‘Nobility Gambit’
I am saving others by ritualising
What if……????
Intolerance of uncertainty
I have to know 100% - uncertainty = intolerable
Treatment of OCD
• Assessment
• To quantify the severity of the disorder.
• Ex: Y-BOCS A standardised semi-structured interview approx
30 minutes.
• Self report measures
• Interview
1. Collect info re: clients obsessions and compulsions
2. Establish good rapport (will be needed later during ERP)
3. Beliefs about OCD perceived consequences from refraining
from rituals/avoidance
These cues may be external or internal
All idiosyncratic
External cues
• Environmental
• Objects
• Persons
• Toilets, dogs mess
Internal cues
• Images
• Shameful/disturbing abstract thoughts
• Ex: stabbing one’s own child
Consider
• Your client –
• How did they present?
• What were the key features?
Treatment plan

• Explanation of ERP
• Hierarchy
• SUDS ratings
• Imaginal exposure
• In vivo exposure
• Others involvement
• Review of homework (each session)
• What worked for your client?
It is very important to identify the specific
details of the patients feared consequences to
plan an effective exposure programme.
i.e. Contamination - not entering public loos
Rituals - not wearing shirts with buttons
Responsibility - not being last to leave work
Safety behaviours
Avoidance strategies
• Safety behaviours are ineffective

• Exaggerating the significance of a

thought/image
• ‘having a sexual image of Christ means I am
wicked/damned’

• The serious misinterpretations then lead to

a destabilisation or lowering of mood which
leads to safety behaviours
i.e. Avoid bathing the baby, praying harder
• Overt compulsions are repetitive observable
behaviour
• Compulsive behaviour is either an exaggeration of
normal behaviours e.g. Repeated hand washing to
avoid contamination or has no relationship to the
feared scenario e.g. switching kettle on and off 3
times to prevent death of grandmother
• Covert compulsions are trying to replace a ‘bad
thought’ with a ‘good thought’
• Neutralising is any voluntary or effortful mental
action done to prevent or minimise harm or anxiety
with the goal of (for example) controlling a thought,
removing a thought, changing its meaning;
preventing negative/bad consequences from
occurring e.g. self-reassurance
“You wont get me to sit on the couch
and discuss my obsession until I
straighten things up, Dr. Hunter”
• Believing in the ‘possible dangerousness’
would lead onto exposure work because
the idea behind treatment is
a) to drop safety behaviours and
b) start approaching previously avoided
activities/situations
• We cannot guarantee to patients that they
will not do (whatever it is the fear they
might) but we can help them evaluate the
probability (through cog. restructuring) and
help them to face avoided situations to
“test out” their fears
• Exposures will no doubt diminish strength
of belief. i.e., the more a person who
fears they may harm their kids, spends
time with their kids (in the presence of a
knife, etc) and sees that actually, they did
not harm their children……. the anxiety
reduces, and the worry reduces
• Exposure therapy can help them either
a) accept that there is the possibility of
dangerousness, though the probability is
low/next to nil
b) stop believing/thinking they are a
danger, or both
 The aim is to teach patients
to cope with the uncertainty,
rather than trying to
eliminate any doubt
Stepping Stones Example

Sit on the toilet seat at work

Somebody with a contagious disease has sat there chances 1:100

I’m contaminated chances 1:100

I’ll contaminate those closes to me chances 1:10

Others will die and it will be my fault chances 1:50

Stepping Stones continued

• Culminative 1:500,000
• Would you bet on a horse with these odds
• Would you order a yacht today on the chance of winning
the lottery on Saturday
• Should how you behaviour today be affected by such an
unlikely event?
Problems

• Non-compliance
• Family/others reassurances
• New rituals/obsessions
• Avoidance tactics
• Homework
• Inconsistent with belief systems
• Failure/resistance in EX/RP
Transactional model of patient’s OCD symptoms and
relative’s accommodating and critical responses
Pure O
• ERP is a fundamental aspect of treatment for OCD

• What do we do when the client experiences pure O?

• We cannot walk away from our thoughts

• Creates difficulties for conventional treatment

• Cognitive challenges and restructuring are utilised

• Look at beliefs – challenge these

OCPD
• A chronic maladaptive pattern of excessive perfectionism and
need for control over ones environment
• Affects all areas of an individuals life
• Characterised by:
Rigidity
Preoccupation with detail, order, rules, schedules
Overly controlling
Difficulties with relaxing
Over planning schedules
Inflexibility in morality, ethics, societal rules and personal
beliefs
Group Exercise

• Have you worked with pure O?

• Consider how to treat a client with

this presentation.
References
• Rachman,S. (2003) The Treatment of Obsessions. Oxford. Oxford
University Press

• Salkovskis,P. (1999) Understanding and treating obsessive compulsive

• Wilhelm, S. & Steketee, G. (2006) Cognitive Therapy OCD. New

Harbinger: Canada.