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CNWL/RHUL IAPT
CBT PGDip.

Obsessive-Compulsive Disorder
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OBSESSIVE COMPULSIVE DISORDER
SESSION OUTLINE

DEFINITION AND DIAGNOSIS
BEHAVIOURAL AETIOLOGICAL MODELS & TREATMENT
COFFEE/TEA BREAK
CBT AETIOLOGICAL MODELS & TREATMENT
LUNCH
VIDEO & CASE DISCUSSION
SUSAN: CASE FORMULATION EXERCISE
COFFEE/TEA BREAK
ASSESSMENT MEASURES
TROUBLESHOOTING TRAINEE CONCERNS/CASES

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OCD DEFINITION AND DIAGNOSIS
NORMAL WORRIES & COMPULSIONS
DYSFUNCTIONAL/ABNORMAL
OBSESSIONS
DSM IV DIAGNOSIS
A UNITARY CONSTRUCT?
SUBCLASSES OF OCD
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OCD DIAGNOSIS
DSM IV & ICD 10
A significant source of distress and/or interference

OBSESSIONS
Recurrent, persistent thoughts, images or Impulses
experienced, at some point, as intrusive and senseless
Attempts to ignore and/or suppress and/or neutralise.
Recognition of ownership of thoughts, yet perceived as ego-
dystonic; content unrelated to another Axis 1 diagnosis.
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OCD DIAGNOSIS
COMPULSIONS
Repetitive, purposeful and intentional behaviour
Performed in response to an obsession or according to
certain rules
Designed to neutralise or prevent discomfort and/or
catastrophe.
Awareness of their unrealistic and/or excessive nature.
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OCD: DIFFERENTIAL DIAGNOSIS

MAJOR DEPRESSIVE DISORDER
GENERALIZED ANXIETY DISORDER
HYPOCHONDRIASIS
SPECIFIC ILLNESS PHOBIA
ANXIETY DUE TO A GENERAL MEDICAL CONDITION
APPETITIVE DISORDERS
BODY DYSMORPHIC DISORDER
DELUSIONAL DISORDER
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OCD DIFFERENTIAL DIAGNOSIS
OBSESSIVE-COMPULSIVE PERSONALITY DISORDER
ABSENCE OF OBSESSIONS AND/OR COMPULSIONS
PERVASIVE PATTERN OF:
ORDERLINESS
PERFECTIONISM
CONTROL
PREDOMINANTLY EGOSYNTONIC
ONSET BY EARLY ADULTHOOD


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OCD EPIDEMIOLOGY
INCIDENCE AND PREVALENCE
General Population: Point Prevalence <2% Lifetime
Prevalence 3% Psychiatric Population: Estimates
generally 5%

SEX RATIO
Adults: approx 50:50
Children: ? 75% Male
AGE OF ONSET
Mean Age: Approx 17.5 years in Males (Modal 13-15)
& 20.8 years in Females (Modal 20-24)
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OCD EPIDEMIOLOGY
MARITAL STATUS
INTELLIGENCE
PHENOMENOLOGY

OBSESSIONS: Big 7- Contamination, Doubt, Health, Order,
Aggression, Sex & Religion

COMPULSIONS: Big 6 Checking, Washing, Counting,
Confessing. Order, Hoarding

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BEHAVIOURAL MODEL OF ANXIETY
ANXIETY IS A RESULT OF MALADAPTIVE LEARNING
NAMELY, THROUGH:

A. CLASSICAL OR PAVLOVIAN CONDITIONING:

UNCONDITIONED STIMULUS (UCS) UNCOND. RESPONSE (UCR)
(e.g.: shock, trauma, nausea) (i.e.: anxiety symptoms)
+
CONDITIONED STIMULUS (CS) CONDITIONED RESPONSE (CR)
(e.g.: dogs, crowds, dirt) (i.e. anxiety symptoms)


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BEHAVIOURAL MODEL OF ANXIETY
B. INSTRUMENTAL OR SKINNERIAN CONDITIONS:

TWO FACTOR MODEL - 1. CLASSICAL CONDITIONING
OF ANXIETY
2. INSTRUMENTAL LEARNING
OF MALADAPTIVE RESPONSE
(e.g. Fight, Flight, Avoidance or Checking)

MALADAPTIVE RESPONSE PREVENTS EXTINCTION OF CR IN
PRESENCE OF CS
CONDITIONING OR LEARNING HISTORIES EXPLAIN ONSET AND
MAINTENANCE OF ANXIETY DISORDERS AND POINT TO
TREATMENT.
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BEHAVIOURAL MODEL OF ANXIETY
BEHAVIOURAL TREATMENT INVOLVES EXPOSURE TO FEARED
STIMULI/SITUATIONS (CS) WITHOUT THE UCS AND MALADAPTIVE
RESPONSE TO PERMIT THE EXTINCTION OF THE CONDITIONED
RESPONSE (CR)

ADVANTAGES
EXPLICIT PREDICTIONS
DEMONSTRABLE
PLAUSIBLE
PRACTICAL/DIRECT TREATMENT

DISADVANTAGES
PREPAREDNESS
INDIVIDUAL DIFFERENCES
DEVELOPMENTAL INFLUENCES
LACK OF TRAUMATIC ONSET
SOCIAL & SYMBOLIC ACQUISITION OF
ANXIETY
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OCD TREATMENT APPROACHES
BEHAVIOUR THERAPY
Rationale & Behavioural Assessment see Figure 1
Exposure and Response Prevention
Maintenance and Generalizability
Relapse Prevention

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Typical Steps in the Behavioural Assessment
of OCD
Specify the rituals and obsessions in detail

What situations evoke the rituals or obsessions (e.g., do the
rituals occur only at home)?

Are there any fluctuations in the symptoms (e.g. are they worse if
the patient is alone)?

What situations does the patient avoid as a result of OCD?
Fig. 1
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Typical Steps in the Behavioural Assessment
of OCD (Contd.)
Do any thoughts, images, or impulses trigger (eg sacrilegious images,
aggressive impulses) rituals or obsessions ?

Construct hierarchy of target situations based on the amount of anxiety (SUDS
scale), ritualising, or obsessing they evoke.

What does the patient believe will occur if he or she does ritualise? How
strong is this belief?

Are the patients symptoms being maintained by family interactions?

Is the patient severely depressed? If so, consider trial of medication.

Fig. 1
Typical OCD Fear Hierarchy
OCD: Client Exposure Guidelines
ERP Session by Session Habituation
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OCD CBT AETIOLOGICAL MODELS
Primary Cognitions: Threat Appraisal (Figure 2)

Guilt, Responsibility and Resistance (Figure 3 & 4)

Covert Cognitive Rituals (Figure 5)

Metacognition (Figure 6)

Secondary Mood disorder

Overvalued Ideas
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Stimuli and situations
(Internal or external)
Including external triggers,
intrusive thoughts and information
COGNITION
DANGER, THREAT
Safety seeking
Behaviours (including
Avoidance, escape, and
neutralising)
Biological and
Psychophysiological
reactions
Fig 2
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CBT Model of OCD from Salkovskis (1985)
Potential Stimuli
Intrusion Ego Dystonic
Automatic Thoughts Ego
syntonic
Mood Disturbance,
discomfort, dysphoria,
anxiety
Neutralising Response
Escape Behaviour
Rewarding
Non-punishment
Perception of
Responsibility
Increased Acceptance
Avoidance
Triggering Stimuli
(Internal/External)
Extrinsic Mood Disturbance
Schematic Activation:
accessibility of loss, threat or
blame ideation
Expectancy
Reduced Discomfort
Fig. 3
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A COGNITIVE THEORY OF OBSESSIONS

OBSESSION DESCRIPTION INTERPRETATION DISTRESS/ CONSEQUENCES
FEAR

Thought e.g.:Sinful e.g.: Revealing about me I will cause harm e.g. Intense resistance
Image Disgusting Warning signs People will reject me to obsessions
Impulse Alarming Losing control I will be locked up Attempts to block them
Going insane Neutralisations
I am dangerous Avoidance Behaviour


A postulated sequence of descriptions, interpretations and actions (from S.J. Rachman)


Fig. 4
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Cognitive Obsessions and Covert Rituals

Intrusive Thought


Negative Appraisal



Increased Anxiety and Worry


Overcontrol



Vigilance (Could I really do it?) Covert Rituals Testing



Temporary Anxiety Reduction


Cycle starts all over again

Fig. 5
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EXAMPLE OF THOUGHT/ACTION
FUSION AND OC METACOGNITION
Im having a bad thought that must mean Im bad.


I wouldnt be having these thoughts if I wasnt truly bad!


The more bad thoughts I have, the more proof I have that Im bad.


Because Im thinking so much about doing bad things, it must mean that Im highly likely to do something
bad.


If I dont try hard to prevent harm from happening, it is as bad as doing something bad on purpose.


Since it is likely that Im going to do something bad, Id better watch out for it. I may even have to make
sure that others are protected from my bad actions.



Fig. 6
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OCD: COGNITIVE TREATMENT
APPROACHES
Psychoeducation of CBT Model of OCD
Shared Formulation
Identification of Intrusions & Appraisals
Cognitive Restructuring of Appraisals & Beliefs
Role of Compulsions, Neutralization & Avoidance: ERP
Behavioural Experiments
Modifying Metacognitive Beliefs


OCD: Examples of Behavioural Experiments
OCD: Relapse Prevention
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OCD: ADDITIONAL COGNITIVE
TREATMENT APPROACHES
Limited Insight
Discrimination Training
Self Instructional Training

Overvalued Ideation
Distress Tolerance
Reduction of Psychological Reactance
Self-Esteem Enhancement

Secondary Mood Disorder
Cognitive Restructuring of Depressive/Anxious Cognition
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CNWL/RHUL IAPT
CBT PGDip.

Obsessive-Compulsive Disorder
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JEAN: A BATTLE WITH OBSESSION - 1
Idiosyncratic Nature: Order & Cleaning
Extreme Stimulus Generalisation, yet Stereotypy
and Restriction of Cues.
Aversion Rituals: E.g.: Guilt re. Kissing Son.
Secrecy & Family Collusion.
Catastrophic Thinking: E.g. Risk of Fits.
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JEAN: A BATTLE WITH OBSESSION - 2

Level of Over-Arousal
Cognitive Deficits: Need to Sub vocalise
Sense of Responsibility: At Home Vs. In Hospital
Daughter (Tamara: Transgenerational Mechanisms)
Secondary Depression: Attempted Suicide
Treatment: Has included Psychotherapy, ECT, Long-
term Medication and Assessment for Psychosurgery
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JEAN: A BATTLE WITH OBSESSION - 3
BEHAVIOUR THERAPY
Detailed Functional Analysis including the meaning of
behaviour to the Patient
Therapeutic Relationship and Modelling.
Cognitive Factors: Behavioural Experiments.
Facilitating Anger: e.g. viz Religious Guilt
Cost of Treatment: 100K?
Systemic Changes: Family & Marital Function
Identification with Therapists Hairstyle
OCD CBT Case Formulation
Susan is 33 year old primary school teacher, who has been married
6 years. She and her husband, Steve, have a 3 year old son, Brian,
and a 3 month old infant, Jennifer.
Susans GP has referred her due to persistent washing and
checking rituals that failed to respond to SSRI medication.
Susan has had both counselling and psychotherapy that have not
been particularly helpful.
(After Abramowitz 2006)
OCD CBT Case Formulation
Susan Case Formulation Exercise: Instructions
Form Pairs 1 as Therapist and 1 as Patient (Susan)
Role Play Part of the Assessment Interview
Therapist should question Susan about the following and fill in
details below each item on the form:
Nature & Content of Obsessional Thoughts
2. Catastrophic Thinking
3. Safety-Seeking Behaviour
When told to stop the role play please complete the attached draft
formulation:
a) With the information from 1 3 above in the relevant boxes
b) Any other relevant information or points in the other boxes
c) Sketch relationships between different components with
arrows


Susan: OCD Case Formulation (After Abramowitz, 2006)
Susan Case Formulation



External Triggers
e.g. bathrooms, dirty pupils, marking schoolwork,
sharp objects, bathing the baby
Intrusive Obsessional Thoughts
- Ideas: e.g. I am contaminated
- Doubts: e.g. I might assign the wrong mark
- Images: e.g. Stabbing and drowning baby
Catastrophic Interpretations of Obsessions

- I will get ill & make my family ill
- I cant take the chance this will happen
- The more I think it the more likely it is.
- I can & should control my thoughts or I am
fully responsible for the outcome
- These thoughts mean that Im a terrible
mother
Obsessional Anxiety/Fear
Safety-Seeking Behaviours
- Avoidance: e.g. pupils, public toilets, baby
- Rituals: e.g. washing, checking, mental
health
- Neutralising: e.g. concealment, suppression
Dysfunctional Beliefs

- Overestimates of
the probability and
severity of danger
- Inflated sense of
responsibility for
danger
- Certain thoughts
should be
controlled
Lack of Correction of Beliefs
Safety behaviours prevent
correction of catastrophic
beliefs

Thought Suppression
Leads to more unwanted
thoughts
Hypervigilance
Increases
preoccupation and
salience of cues
Negative
Reinforcement
Of safety
behaviours by
distress
reduction
Short-Term Anxiety/Fear Reduction
Susan: An Exposure Hierarchy
OCD: Client Ratings
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Obsessive Compulsive Inventory
(OCI)
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Responsibility Interpretations
Questionnaire (RIQ)
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The Responsibility Attitudes
Questionnaire (RAS)
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OCD Stepped Care Model
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Quick Reference Guide to OCD
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http://www.nice.org.uk/nicemedia/pdf/CG031quickrefguide.pdf

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OCD for CBT: Some Tips
Use Multi-faceted Assessment
Psychoeducation & Motivational Interviewing
Work to an Agenda
Stay focussed and calm
Homework, homework, homework!
Recognise Roadblocks
The perfect is the enemy of the good
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CNWL/RHUL IAPT
CBT PGDip.

Obsessive-Compulsive Disorder