Advances in Psychiatric Treatment (2007), vol. 13, 438â446â doi:â10.1192/apt.bp.107.003699
Deliveringâ cognitiveâbehaviouralâ therapyâ (CBT)â forâobsessiveâcompulsiveâdisorderâ(OCD)ârequiresâ aâ detailedâ understandingâ ofâ theâ phenomenologyâ andâ theâ mechanismâ byâ whichâ specificâ cognitiveâ processesâandâbehavioursâmaintainâtheâsymptomsâ ofâtheâdisorder.âAâtextbookâdefinitionâofâanâobsessionâ isâ anâ unwantedâ intrusiveâ thought,â doubt,â imageâ orâ urgeâ thatâ repeatedlyâ entersâ aâ personâsâ mind.â Obsessionsâ areâ distressingâ andâ ego-dystonicâ butâ areâ acknowledgedâ asâ originatingâ inâ theâ personâsâ mindâ andâ asâ beingâ unreasonableâ orâ excessive.âAâ minorityâareâregardedâasâovervaluedâideasâ(Veale,â 2002)â and,â rarely,â delusions.â Theâ mostâ commonâ obsessionsâconcern:
theâpreventionâofâharmâtoâtheâselfâorâothersâ resultingâfromâcontaminationâ(e.g.âdirt,âgerms,â bodilyâ fluidsâ orâ faeces,â dangerousâ chemi-cals)â
theâpreventionâofâharmâresultingâfromâmakingâ aâmistakeâ(e.g.âaâdoorânotâbeingâlocked) intrusiveâreligiousâorâblasphemousâthoughtsâ intrusiveâ sexualâ thoughtsâ (e.g.â ofâ beingâ aâ paedophile)â intrusiveâthoughtsâofâviolenceâorâaggressionâ (e.g.âofâstabbingâoneâsâbaby)â theâneedâforâorderâorâsymmetry.â AâcognitiveâbehaviouralâmodelâofâOCDâbeginsâ withâtheâobservationâthatâintrusiveâthoughts,âdoubtsâ orâimagesâareâalmostâuniversalâinâtheâgeneralâpopu-lationâandâtheirâcontentâisâindistinguishableâfromâthatâ ofâclinicalâobsessionsâ(Rachmanâ&âdeâSilva,â1978).âAnâ ⢠⢠⢠⢠⢠⢠exampleâisâtheâurgeâtoâpushâsomeoneâontoâaârailwayâ track.â Theâ differenceâ betweenâ aâ normalâ intrusiveâ thoughtâandâanâobsessionalâthoughtâliesâbothâinâtheâ meaningâthatâindividualsâwithâOCDâattachâtoâtheâ occurrenceâorâcontentâofâtheâintrusionsâandâinâtheirâ responseâtoâtheâthoughtâorâimage.â
Thoughtâaction fusion
AnâimportantâcognitiveâprocessâinâOCDâisâtheâwayâ thoughtsâorâimagesâbecomeâfusedâwithâreality.âThisâ processâisâcalledââthoughtâactionâfusionââorââmagicalâ thinkingââ(Rachman,â1993).âThus,âifâaâpersonâthinksâ ofâharmingâsomeone,âtheyâthinkâthatâtheyâwillâactâ onâtheâthoughtâorâmightâhaveâactedâonâitâinâtheâpast.â Aârelatedâprocessâisââmoralâthoughtâactionâfusionâ,â whichâisâtheâbeliefâthatâthinkingâaboutâaâbadâactionâ isâ morallyâ equivalentâ toâ doingâ it.â Lastly,â thereâ isâ âthoughtâobjectâfusionâ,âwhichâisâaâbeliefâthatâobjectsâ canâbecomeâcontaminatedâbyââcatchingââmemoriesâorâ otherâpeopleâsâexperiencesâ(Gwilliam et al,â2004).âResponsibility
OneâofâtheâcoreâfeaturesâofâOCDâisâanâoverinflatedâ senseâofâresponsibilityâforâharmâorâitsâprevention.â Responsibilityâisâdefinedâhereâas:ââTheâbeliefâthatâoneâ hasâpowerâthatâisâpivotalâtoâbringâaboutâorâpreventâ subjectivelyâcrucialânegativeâoutcomes.âTheseâout-comesâmayâbeâactual,âthatâisâhavingâconsequencesâinâ theârealâworld,âand/orâatâaâmoralâlevelââ(SalkovskisCognitiveâbehavioural therapy
for obsessiveâcompulsive disorder
DavidâVeale
Abstractâ InâtheâUK,âtheâNationalâInstituteâforâHealthâandâClinicalâExcellenceâsâguidelinesâonâobsessiveâcompulsiveâ disorderâ(OCD)ârecommendâcognitiveâbehaviouralâtherapy,âincludingâexposureâandâresponseâprevention,â asâanâeffectiveâtreatmentâforâtheâdisorder.âThisâarticleâintroducesâaâcognitiveâbehaviouralâmodelâofâ theâmaintenanceâofâsymptomsâinâOCD.âItâdiscussesâtheâprocessâofâengagementâandâhowâtoâdevelopâaâ formulationâtoâguideâtheâstrategiesâforâovercomingâtheâdisorder.Davidâ Vealeâ isâ anâ honoraryâ seniorâ lecturerâ atâ theâ Instituteâ ofâ Psychiatry,â Kingâsâ Collegeâ Londonâ andâ aâ consultantâ psychiatristâ inâ cognitiveâbehaviouralâtherapyâatâtheâSouthâLondonâandâMaudsleyâTrustâ(CentreâforâAnxietyâDisordersâandâTrauma,âTheâMaudsleyâ Hospital,â99âDenmarkâHill,âLondonâSE5â8AF.âEmail:âDavid.Veale@iop.kcl.ac.uk;âwebsite:âhttp://www.veale.co.uk)âandâtheâPrioryâHospitalâ NorthâLondon.âHeâisâPresidentâofâtheâBritishâAssociationâofâBehaviouralâandâCognitiveâPsychotherapies,âwasâaâmemberâofâtheâNationalâ InstituteâforâHealthâandâClinicalâExcellenceâgroupâthatâproducedâguidelinesâonâtreatingâobsessiveâcompulsiveâdisorderâ(OCD)âandâbodyâ dysmorphicâdisorderâ(BDD)âandârunsâaânationalâspecialistâunitâatâtheâBethlemâRoyalâHospitalâforârefractoryâOCDâandâBDD.
et al,â1995).âTheâdifferenceâinâOCDâisâtheâindividualâsâ appraisalâofâsituations:âtheâbeliefâthatâharmâmightâ occurâtoâtheâself,âaâlovedâoneâorâanotherâvulnerableâ personâthroughâwhatâtheâindividualâmightâdoâorâ failâtoâdo.âHarmâisâinterpretedâinâtheâbroadestâsenseâ andâincludesâmentalâsuffering;âforâexample,âsomeâ peopleâwithâobsessiveâworriesâaboutâcontaminationâ fearâtheyâwillâgoââcrazyââorâthatâtheâanxietyâwillâgoâonâ forâever.âIndividualsâwithâOCDâbelieveâtheyâcanâandâ shouldâpreventâharmâfromâoccurring,âwhichâleadsâ toâcompulsionsâandâavoidanceâbehaviours.â
Non-specific cognitive biases
PeopleâwithâOCDâhaveâaânumberâofâotherâcognitiveâ biasesâ (Boxâ 1)â thatâ areâ notâ necessarilyâ specificâ toâ theâ disorderâ but,â inâ combinationâ withâ cognitiveâ fusionâandâanâinflatedâsenseâofâresponsibility,âleadâtoâ anxietyâandâcompulsiveâsymptoms.âTheâexcessivelyâ narrowâfocusingâonâmonitoringâforâpotentialâthreatsâ (e.g.â fearâ ofâ contaminationâ fromâ blood,â resultingâ inâ constantâ checkingâ forâ redâ marks),â evenâ whenâ noâ immediateâ threatâ isâ present,â meansâ thatâ lessâ attentionâisâfocusedâonârealâevents.âThisâreducesâtheâ individualâsâconfidenceâinâtheirâmemory,âwhichâinâ turnâleadsâtoâfurtherâcheckingâbehaviours.âIntrusiveâ thoughts,âimagesâorâurgesâareâoftenâaccompaniedâ byâ anâ excessiveâ attentionalâ biasâ onâ monitoringâ them.â Thisâ leadsâ toâ aâ heightenedâ cognitiveâ self-consciousnessâandâanâincreaseâinâtheâdetectionâofâ unwantedâintrusiveâthoughtsâandâworriesâaboutânotâ performingâaâcompulsionâorâsafetyâbehaviour.
Emotion
Theâ dominantâ emotionâ inâ anâ obsessionâ mayâ beâ difficultâ forâ someâ patientsâ toâ articulateâ butâ itâ isâ commonlyâanxiety.âSomeâalsoâexperienceâdisgust,â especiallyâwhenâtheyâthinkâthatâtheyâcouldâhaveâbeenâ
inâcontactâwithâaâcontaminant.âOthersâfeelâashamedâ andâ condemnâ themselvesâ forâ havingâ intrusiveâ thoughtsâ of,â forâ example,â aâ sexualâ orâ aggressiveâ nature,â thatâ theyâ believeâ theyâ shouldâ notâ have.â Occasionally,âaâpersonâwithâOCDâbelievesâthatâtheyâ areâresponsibleâforâaâbadâeventâinâtheâpast;âinâsuchâ cases,âtheâmainâemotionâisâguilt.âManyâindividualsâ areâalsoâdepressed,âwithâvariousâsecondaryâproblemsâ causedâbyâtheâhandicap;âcomorbidityâwithâaâmoodâ disorderâ isâ relativelyâ common.â Atâ times,â anger,â frustrationâandâirritabilityâareâprominent.âBecauseâofâ theârangeâofâemotions,âitâisânotâsurprisingâthatâsomeâ patientsâfindâitâdifficultâtoâarticulateâandâuntangleâ theirâdominantâemotion.â
Compulsions and safety-seeking
behaviours
Compulsionsâareârepetitiveâbehavioursâorâmentalâ actsâ thatâ aâ personâ feelsâ drivenâ toâ perform.â Aâ compulsionâ canâ eitherâ beâ overtâ andâ observedâ byâ othersâ(e.g.âcheckingâthatâaâdoorâisâlocked)âorâaâcovertâ mentalâactâthatâcannotâbeâobservedâ(e.g.âmentallyâ repeatingâ aâ certainâ phrase).â Covertâ compulsionsâ areâgenerallyâmoreâdifficultâtoâresistâorâmonitor,âasâ theyâareââportableââandâeasierâtoâperform.âTheâtermâ âruminationââ coversâ bothâ theâ obsessionâ andâ anyâ accompanyingâ mentalâ compulsionsâ andâ acts.â Asâ withâobsessions,âthereâareâmanyâtypesâofâcompulsionâ (Boxâ2).â
Earlyâ experimentalâ studiesâ establishedâ thatâ compulsions,â especiallyâ cleaning,â areâ reinforcingâ becauseâtheyâseemâtoâreduceâdiscomfortâtemporarily.â Furthermoreâtheyâstrengthenâtheâbeliefâthat,âhadâtheâ compulsionânotâbeenâcarriedâout,âdiscomfortâwouldâ haveâincreasedâandâharmâmayâhaveâoccurredâ(orâ notâhaveâbeenâprevented).âThisâincreasesâtheâurgeâ toâ performâ theâ compulsionâ again,â andâ aâ viciousâ circleâ isâ thusâ maintained.â However,â compulsionsâ doânotâalwaysâworkâbyâreducingâanxietyâandâareâ oftenâintermittentlyâreinforcing.âCompulsionsâmayâ functionâasâaâmeansâofâavoidingâdiscomfort,âasâinâ examplesâ ofâ obsessionalâ slownessâ (Veale,â 1993).â Box 1 Non-specific cognitive biases
Overestimationâofâtheâlikelihoodâthatâharmâ willâoccur
Beliefâinâbeingâmoreâvulnerableâtoâdanger Intoleranceâ ofâ uncertainty,â ambiguityâ andâ change
Theâneedâforâcontrol
Excessivelyânarrowâfocusingâofâattentionâtoâ monitorâforâpotentialâthreats
Excessiveâ attentionalâ biasâ onâ monitoringâ intrusiveâthoughts,âimagesâorâurges Reducedâattentionâtoârealâevents ⢠⢠⢠⢠⢠⢠â˘
Box 2 The most common compulsions Checkingâ (e.g.â gasâ taps;â reassurance-seeking) Cleaning/washing Repeatingâactions Mentalâcompulsionsâ(e.g.âspecialâwordsâorâ prayersârepeatedâinâaâsetâmanner) Ordering,âsymmetryâorâexactness Hoarding ⢠⢠⢠⢠⢠â˘
Compulsionsâareâusuallyâcarriedâoutâinâaârelativelyâ stereotypedâwayâorâaccordingâtoâidiosyncraticallyâ definedâ rules.â Theâ compulsionâ toâ hoardâ refersâ toâ theâacquisitionâofâandâfailureâtoâdiscardâpossessionsâ thatâappearâtoâbeâuselessâorâofâlimitedâvalue,âandâtoâ clutteringâthatâpreventsâtheâappropriateâuseâofâlivingâ spaceâ(Frostâ&âHartl,â1996).â Theâindividualâsâcriteriaâforâterminatingâcompul-sionsâareâanâimportantâfactorâinâtheirâmaintenance.â SomeoneâwithoutâOCDâfinishesâanâactionâsuchâasâ hand-washingâwhenâtheyâcanâseeâthatâtheirâhandsâareâ clean;âsomeoneâwithâOCDâandâaâfearâofâcontaminationâ finishesânotâonlyâwhenâtheyâcanâseeâthatâtheirâhandsâ areâcleanâbutâwhenâtheyâfeelââcomfortableââorââjustâ rightâ.â Othersâ mayâ endâ aâ compulsionâ whenâ theyâ haveâaâperfectâmemoryâofâanâevent.âTheseâadditionalâ criteriaâforâterminatingâcompulsionsâmayâcauseâthemâ toâlastâevenâlonger.âProgressâinâovercomingâOCDâ canâbeâmadeâonlyâwhenâtheâcriteriaâforâterminatingâ aâcompulsionâareârestrictedâtoâobjectiveâcriteria.â Aââsafety-seekingâbehaviourââisâanâactionâtakenâ inâ aâ fearedâ situationâ withâ theâ aimâ ofâ preventingâ catastropheâandâreducingâharmâ(Salkovskis,â1985);â itâthereforeâincludesâcompulsionsâandâneutralisingâ behaviours.âNeutralisingâisâanyâvoluntaryâorâeffort-fulâmentalâactionâcarriedâoutâtoâpreventâorâminimiseâ harmâandâanxietyâwithâtheâgoalâofâeitherâcontrollingâaâ thoughtâorâchangingâitsâmeaningâtoâpreventânegativeâ consequencesâfromâoccurringâ(e.g.âvisualisingâthatâ theâ doctorâ isâ tellingâ meâ thatâ Iâ donâtâ haveâ cancerâ untilâIâfeelârelief).âOtherâsafety-seekingâbehavioursâ includeâmentalâactivitiesâsuchâasâtryingâtoâbeâsureâ ofâtheâaccuracyâofâoneâsâmemory,âtryingâtoâreassureâ oneselfâandâtryingâtoâsuppressâorâdistractâoneselfâ fromâ unacceptableâ thoughts.â Suchâ behavioursâ mayâreduceâanxietyâinâtheâshortâtermâbutâleadâtoâaâ paradoxicalâenhancementâofâtheâfrequencyâofâtheâ thoughtâinâaâreboundâmanner.
Avoidance
Althoughâ avoidanceâ isâ notâ partâ ofâ theâ definitionâ ofâOCD,âitâisâanâintegralâpartâofâtheâdisorderâandâ isâmostâcommonlyâseenâinâfearsâofâcontamination.â Anâexampleâofâavoidanceâisâaâwomanâwithâaâfearâ ofâ contaminationâ whoâ willâ notâ touchâ toiletâ seats,â doorâhandlesâorâtapsâusedâbyâothers.âSheâwillâhoverâ overâtheâtoiletâseat,âuseâherâelbowâtoâopenâdoorsâ andâtaps,âuseârubberâglovesâtoâputârubbishâinâtheâ dustbin,âavoidâpickingâupâitemsâfromâtheâfloor,âavoidâ shakingâhandsâwithâpeopleâorâtouchingâaâsubstanceâ thatâ looksâ dangerousâ toâ her.â Avoidanceâ canâ alsoâ occurâmentally:âtryingânotâtoâthinkâorâfeelâsomethingâ upsetting.â Notâ allâ situationsâ canâ beâ avoidedâ andâ safety-seekingâbehavioursâareâoftenâusedâwithinâaâ fearedâsituation.â
Linking obsessions, compulsions
and avoidance behaviour
Theâ contentâ ofâ obsessions,â compulsionsâ andâ avoidanceâ behaviourâ inâ OCDâ areâ closelyâ related.â Forâexample,âwhenâaâpatientâhasâtoâtouchâsomethingâ thatâtheyânormallyâavoid,âtheâcompulsiveâwashingâ starts.â Whenâ avoidanceâ isâ high,â theâ frequencyâ ofâ compulsionsâ mayâ beâ low,â andâ viceâ versa.â Ifâ aâ womanâsâ obsessionâ isâ ofâ stabbingâ herâ baby,â sheâ mightâavoidâbeingâaloneâwithâhimâorâputâallâknivesâ orâsharpâobjectsâoutâofâsight,ââjustâinâcaseâ.âIfâthisâ failsâtoâreduceâherâobsession,âsheâmayâensureâthatâ someoneâisâwithâherâallâtheâtimeâ(aâsafety-seekingâ behaviour)âorâtryâtoâneutraliseâtheâthoughtâinâherâ head.âTheseâactsâinâturnâincreaseâherâdoubtsâandâ preventâherâfromâdisconfirmingâherâfears,âandâtheâ cycleâcontinues.â
Assessment
ClinicalâassessmentâofâOCDâisâsummarisedâinâBoxâ 3.âTheâassessmentâofâavoidanceârequiresâaâratingâofâ predictedâdistress,âsoâthatâaâhierarchyâofâavoidedâ situationsâ withoutâ safety-seekingâ behavioursâ mayâ beâ identifiedâ forâ therapy,â togetherâ withâ anâ understandingâofâhowâtheâavoidanceâinteractsâwithâ theâobsessionsâandâtheâdistressâexperienced.âSomeâ patientsâalsoâtryâtoâavoidâideas,âthoughtsâorâimagesâ byâdistractionâorâattemptsâtoâsuppressâthem.Theâ patientâsâ problems,â goalsâ inâ therapyâ andâ valuedâ directionsâ (e.g.â toâ beâ aâ goodâ parentâ andâ partner)âshouldâbeâclearlyâdefined.âProgressâshouldâ beâ ratedâ onâ standardâ outcomeâ scalesâ atâ regularâ intervals.âTheâstandardâobserver-ratedâtoolâisâtheâ YaleâBrownâObsessiveâCompulsiveâScaleâ(Goodmanâ et al,â1989).âTheâObsessiveâCompulsiveâInventoryâ (Foaâet al,â1998)âisâaâstandardâsubjectivelyâratedâscale.â Patientsâareâusuallyâofferedâtime-limitedâCBTâforâ betweenâ6âandâ20âsessions,âdependingâonâtheâseverityâ andâchronicityâofâtheâproblem.âPatientsâwithâmoreâ severeâOCDâmayârequireâaâmoreâintensiveâprogrammeâ inâaâresidentialâunitâorâinâtheirâhome.â
Family involvement
Someâfamiliesâaccommodateâanâindividualâsâavoid-anceâ andâ compulsions;â someâ areâ overprotective,â aggressiveâ orâ sarcastic;â theyâ mayâ minimiseâ theâ problemâorâavoidâtheâindividualâasâmuchâasâpossible.â SometimesâtheâbehavioursâassociatedâwithâtheâOCDâ restrictâ theâ activitiesâ ofâ familyâ membersâ (suchâ asâ gainingâaccessâtoâtheâbathroom)âorâtheirâfreedomâtoâ useâcertainâroomsâinâtheâhomeâbecauseâofâhoarding.â PeopleâwithâOCDâmayâreactâwithâaggressionâwhenâBox 3 Areas to cover in clinical assessment TheâcontextâinâwhichâOCDâhasâdeveloped Theâ natureâ ofâ theâ obsession(s):â theirâ con-tent;â theâ degreeâ ofâ insight;â theâ frequencyâ ofâtheirâoccurrence;âtheâtriggers;âtheâfearedâ consequenceâ(Whatâisâtheâworstâthingâthatâ canâhappen?);âtheâpatientâsâappraisalâofâtheâ obsessionâ (Whatâ didâ havingâ theâ intrusiveâ thoughtâmeanâtoâyou?âWhatâsenseâdidâyouâ makeâofâit?âCouldâharmâoccurâasâaâresultâofâ this?âWhatâwouldâhappenâifâyouâcouldânotâ getâridâofâtheâintrusions?)â
Theâ mainâ emotion(s)â linkedâ withâ theâ obsessionâorâintrusionâ
Theâ compulsion(s)â andâ neutralising:â whatâ theâpersonâdoesâinâresponseâtoâtheâobsession;â aâratingâofâpredictedâdistressâifâtheâcompul-sionâisâresisted;âtheâfearedâconsequencesâofâ resistingâit;âtheirâexperienceâofâtryingâtoâstopâaâ compulsion;âtheâcriteriaâusedâforâterminatingâ theâcompulsionâandâtheâassumptionsâheldâifâ theyâstoppedâusingâaâcompulsion.âIndirectâ assessmentâmightâincludeâactivitiesâsuchâasâ theânumberâofârollsâofâtoiletâpaperâorâbarsâofâ soapâusedâperâweek Theâavoidanceâbehaviour:âallâtheâsituations,â activitiesâorâthoughtsâavoidedâareâlistedâandâ ratedâonâaâscaleâ(e.g.â0â100âinâstandardâunitsâ ofâdistress),âaccordingâtoâhowâmuchâdistressâ theâ personâ anticipatesâ ifâ theyâ experienceâ theâ thoughtâ orâ situationâ withoutâ aâ safety-seekingâbehaviour
Theâdegreeâofâfamilyâinvolvementâ
Theâ degreeâ ofâ handicapâ inâ theâ personâsâ occupational,âsocialâandâfamilyâlife
Goalsâandâvaluedâdirectionsâinâlifeâ
Readinessâ toâ changeâ andâ expectationsâ ofâ therapy,â includingâ previousâ experienceâ ofâ CBTâforâtheâdisorder ⢠⢠⢠⢠⢠⢠⢠⢠⢠theirâcompulsionsâareânotâadheredâtoâbyâtheirâfamily.â Frequently,âfamilyâmembersâhaveâdifferentâcopingâ mechanisms,âleadingâtoâfurtherâdiscordâwhenâtheyâ disagreeâ overâ theâ bestâ wayâ ofâ dealingâ withâ theâ situation.âAssessmentâshouldâfocusâonâhowâdifferentâ membersâ ofâ theâ familyâ copeâ andâ theirâ attitudesâ toâ treatment.â Theâ goalsâ ofâ CBTâ includeâ helpingâ familyâmembersâtoâbeâconsistentâandâemotionallyâ supportive,âwithoutâaccommodatingâtheâOCD.âTheyâ mayâbeâencouragedâtoâassistâinâexposureâtasksâandâ behaviouralâexperimentsâifâtheseâwouldâfacilitateâ recoveryâfromâOCD.â
OCD in children and adolescents
Chronic,âsevereâOCDâcanâbeâparticularlyâdisablingâ inâyoungâpeople,âwhoâoftenâhaveâlittleâinsightâintoâ theirâconditionâandâareânotâreadyâtoâchange.âUsingâ theâMentalâHealthâActâisâusuallyâunhelpfulâunlessâ forâ aâ trialâ ofâ medication,â forâ reasonsâ ofâ physicalâ healthâ orâ becauseâ thereâ isâ aâ needâ toâ removeâ theâ patientâfromâtheirâfamilyâandâhomeâenvironment.â Itâisâpreferableâtoâtryâtoâengageâyoungâpatientsâinâ understandingâtheâcognitiveâbehaviouralâmodelâofâ OCDâandâtoâhelpâthemâfollowâtheirâvaluedâdirectionsâ inâlifeâdespiteâtheâdisorder.âIfâtheâOCDâisâsoâsevereâ thatâitâpreventsâtheâindividualâfromâcopingâwithoutâ supervision,â theâ parentsâ mayâ makeâ theirâ childâ homelessâandâaskâforâtheâchildâtoâbeârehoused,âasâ thisâmayâmotivateâtheâindividualâtoâchange.
Exposure and response prevention
BehaviouralâtherapyâforâOCDâisâbasedâonâlearningâ theory.â Thisâ positsâ thatâ obsessionsâ have,â throughâ conditioning,âbecomeâassociatedâwithâanxiety.âVariousâ avoidanceâbehavioursâandâcompulsionsâpreventâtheâ extinctionâofâthisâanxiety.âThisâtheoryâofâtheâdisorderâ hasâledâtoââexposureâandâresponseâpreventionâ,âinâ whichâtheâpersonâisâexposedâtoâstimuliâthatâprovokeâ theirâobsessionâandâthenâhelpedânotâtoâreactâwithâ escapeâandâcompulsions;ârepetitionâofâtheseâstagesâ leadsâtoâextinctionâofâtheâfearedâresponse.âExposureâ andâresponseâpreventionâremainsâaâgoodâevidence-basedâtreatmentâforâOCDâ(NationalâCollaboratingâ CentreâforâMentalâHealth,â2005).âThe treatment method
First,âaâfunctionalâanalysisâisâconductedâandâaâhier-archyâofâtheâpatientâsâfearedâsituationsâandâthoughtsâ isâgenerated.âGradedâexposureâfollows,âbeginningâ withâtheâstimuliâthatâareâtheâleastâanxiety-provoking.â Theâ rationaleâ ofâ habituationâ isâ explainedâ toâ theâ patient:â repeatedâ self-exposureâ toâ fearedâ stimuliâ willâleadâtoâextinction.âResponseâpreventionâinvolvesâ instructingâtheâpatientâtoâresistâtheâurgeâtoâcarryâoutâ aâparticularâcompulsionâandâwaitâforâtheâensuingâ anxietyâtoâsubside.âPatientsâareâneverâforcedâtoâstopâ aâcompulsion,âbutâtheâtherapistâmayâactâasâaâmodelâ forâexposureâandâresponseâpreventionâandâgentlyâ encourageâtheâpatientâtoâfollow.âCompulsionsâmayâ beâreducedâgraduallyâorâpatientsâinstructedâtoâdelayâ theirâcompulsiveâresponseâforâasâlongâasâpossible.âAâ patientâunableâtoâresistâaâcompulsionâtoâwashâtheirâ handsâwouldâbeâaskedâtoâre-exposeâthemselvesâtoâ theâfearedâstimuliâââforâexampleârecontaminatingâ themselvesâ byâ touchingâ aâ toiletâ seatâ andâ thusâ negatingâtheâeffectâofâtheâcompulsion.â
Therapist-supervisedâexposureâisâgenerallyâmoreâ effectiveâ thanâ exposureâ andâ responseâ preventionâ practisedâaloneâbyâtheâpatientâasâhomeworkâassign-ments.âHowever,âitâisâessentialâthatâtheâinvolvementâ ofâ theâ therapistâ fadesâ overâ time,â withâ theâ patientâ takingâresponsibilityâforâtheirâprogress.âProlongedâ (90â minute)â exposureâ sessionsâ heldâ severalâ timesâ weeklyâwithâfrequentâhomeworkâwillâresultâinâgreaterâ symptomâreduction.âCombiningâactualâandâimaginedâ exposureâisâsuperiorâtoâactualâexposureâalone.â
Outcome with exposure and response
prevention
Aboutâ 25%â ofâ patientsâ refuseâ orâ dropâ outâ fromâ exposureâ andâ responseâ prevention,â andâ ofâ thoseâ thatâ adhereâ toâ theâ therapyâ aboutâ 75%â improveâ (NationalâCollaboratingâCentreâforâMentalâHealth,â 2005).âPoorâprognosisâisâassociatedâwithâcomorbidityâ (particularlyâdepressionâorâschizotypalâpersonality);â severeâavoidance;âovervaluedâideation;âexpressedâ hostilityâfromâfamilyâmembers;âandâhoarding.â
Adding cognitive therapy
Addingâcognitiveâtherapyâtoâexposureâandâresponseâ preventionâincludesâmanyâofâtheâsameâprocedures,â butâtheyâareâpresentedâasâbehaviouralâexperimentsâ toâ testâ outâ specificâ predictions.â Theâ emphasisâ isâ stillâonâbehaviouralâchangeâandâfollowingâvaluedâ directionsâinâlife.âItâattemptsâtoâimproveâengagementâ andâprovideâaâformulationâthatâhelpsâtheâpatientâtoâ identifyâaâbroaderârangeâofâcognitiveâprocessesâ(e.g.â inflatedâresponsibilityâandâthoughtâactionâfusion)â thatâ maintainâ symptomsâ ofâ OCD.â Theâ approachâ isâ toâ questionâ theseâ processesâ andâ theâ patientâsâ appraisalsâ ofâ theirâ intrusiveâ thoughtsâ andâ urgesâ (notâtheâcontent).â
Cognitiveâbehaviouralâtherapyâhasânowâbeenâfoundâ toâbeâsuperiorâtoâexposureâandâresponseâpreventionâ (P.âM.âSalkovskis,âpersonalâcommunication,â2007).
Normalising intrusive thoughts
and urges
Theâ initialâ strategyâ inâ CBTâ isâ toâ normaliseâ theâ occurrenceâofâintrusionsâandâtoâemphasiseâthatâtheyâ areâirrelevantâtoâfurtherâaction.âTheâpatientâmightâ beâpresentedâwithâaâlongâlistâofâintrusiveâthoughtsâ andâurgesâdrawnâfromâaâcommunityâsampleâorâexam-plesâthatâtheâtherapistâhasâpersonallyâexperienced.â Therapistâ andâ patientâ wouldâ thenâ discussâ theâ similaritiesâofâintrusiveâthoughtsâbetweenâpeopleâ withâOCDâandâpeopleâwithoutâââthatâis,âtheâcontentâofâ theâthoughtsâdoesânotâdifferâbutâtheâdegreeâofâdistress,â effortâandâdurationâdoes.âPatientsâlearnâthatâintrusiveâ thoughtsâandâurgesâareâpartâofâtheâhumanâconditionâ andâareânecessaryâforâproblem-solvingâandâthinkingâ creatively.âTherapyâthereforeâseeksâtoâmodifyâtheâ wayâtheâindividualâinterpretsâtheâoccurrenceâand/ orâcontentâofâtheirâintrusions,âasâpartâofâaâprocessâ ofâreachingâanâalternative,âlessâthreateningâviewâofâ intrusiveâthoughts.âTheâconclusionâtoâbeâdrawnâisâ thatâtheâproblemâliesânotâwithâtheâintrusionsâbutâwithâ theâmeaningâthatâtheâindividualâattachesâtoâthoseâ thoughtsâandâtheâvariousâstrategiesâthatâtheyâadoptâ toâtryâtoâcontrolâorâsuppressâthem.âPatientsâlearnâthatâ theirâcurrentâstrategiesâincreaseâratherâthanâcontrolâ theâfrequencyâofâintrusiveâthoughts,âtheirâlevelsâofâ distressâandâtheâurgeâtoâneutraliseâtheirâthoughts.
Therapy in practice
The formulation
Takeâ theâ exampleâ ofâ Ella,â aâ womanâ withâ OCDâ whoâ hasâintrusiveâthoughtsâ ofâ molestingâaâchild.â Herâtherapistâwouldâdrawâupâaâformulationâofâtheâ factorsâmaintainingâtheâsymptomsâandâwouldâshareâ itâwithâherâ(Fig.â1).âEngagementâmayâbeâassistedâbyâ aâSocraticâdialogueâandâsettingâupâtwoâcompetingâ theoriesâ toâ beâ testedâ outâ (Clark et al,â 1998).â Theâ therapistâsâsideâofâsuchâanâinteractionâisâoutlinedâinâ Boxâ4.âInâthisâexample,âEllaâwasâableâtoâpredictâthatâifâ
Box 4 How does Ella prove to herself that her problem is worrying that she is a paedophile?
Therapist: âIâ wantâ toâ seeâ ifâ weâ canâ buildâ aâ betterâ understandingâ ofâ whatâ yourâ problemâ isâ andâ thereforeâ howâ toâ solveâ it.â Itâ seemsâ toâ meâthereâareâtwoâexplanationsâtoâtestâout.âTheâ firstâ explanation,â whichâ Iâ willâ callâ theoryâA,â isâ theâ oneâ youâ haveâ beenâ usingâ forâ theâ pastâ fewâyears,âthatâis,âtheâproblemâisâthatâyouâareâ aâpaedophile.âTheoryâB,âwhichâweâwouldâlikeâ toâtestâoutâinâtherapy,âisâthatâyouâareâextremelyâ worriedâaboutâbeingâaâpaedophileâandâinâyourâ valuesâcareâveryâdeeplyâaboutâchildren.â â Haveâyouânoticedâthatâtreatingâitâasâtheoryâ Aâmakesâtheâworryâandâdistressâaboutâbeingâaâ paedophileâworse? â Haveâyouâeverâtriedâtoâdealâwithâtheâproblemâ asâifâwasâaâworryâproblem?â
â Wouldâ youâ beâ preparedâ toâ actâ asâ ifâ itâ wasâ theoryâBâforâatâleastâ3âmonthsâandâthenâreviewâ yourâ progress?â Youâ canâ alwaysâ goâ backâ toâ treatingâitâasâaâpaedophileâproblemâifâitâsânotâ working.âThisâwillâmeanâgraduallyâdroppingâ allâyourâsafetyâandâavoidanceâbehaviours.â
theoryâAâwereâtrueâandâsheâreallyâwereâaâpaedophile,â thenâsheâwouldâbeâfeelingâexcitedâatâtheâprospectâofâ babysitting.âIf,âhowever,âtheoryâBâwereâtrueâthenâsheâ mightâbeâfeelingâveryâworriedâandâfrightenedâaboutâ abusingâherâniece.âTheâtreatmentâstrategyâshouldâbeâ toâreduceâsuchâworriesâ(notâtoâreduceâtheâriskâtoâaâ child),âwhichâwereâinterferingâwithâherâabilityâtoâbeâ aâgoodâauntâandâwishâtoâbecomeâaâmother.
Identifying cognitive processes
TheâtherapistâwouldâdiscussâwithâEllaâtheâprocessâ ofâcognitiveâfusion,âherâoverinflatedâsenseâofârespon-sibilityâandâotherâbeliefsâaboutâherâintrusiveâthoughtsâ orâ urges.â Sheâ wouldâ beâ helpedâ toâ differentiateâ betweenâthoughtsâandâactionsâwithâintention.âThisâ mightâinvolveâbehaviouralâexperimentsâtoâtestâoutâ theoryâ Bâ andâ beingâ aloneâ withâ children.â Thisâ isâ akinâ toâ traditionalâ âexposureâ,â butâ becauseâ ofâ theâ detailedâdiscussionâandâexperimentsâonâtheânatureâofâ intrusiveâthoughts,âitâmayâbeâmoreâacceptableâandâlessâ distressingâthanâjustââfacingâyourâfearsâ.âTheâcognitiveââ behaviouralâ modelâ isâ presentedâ inâ someâ detailâ andâreferredâtoâthroughoutâtreatmentâââtheâaimâforâ theâpatientâisânotâthatâsheâstopsâhavingâintrusiveâ thoughtsâbutâthatâsheâaltersâherârelationshipâwithâ herâthoughtsâandâdevelopsâanâunderstandingâofâwhyâ someâstrategiesâincreaseâorâdecreaseâherâsymptoms.â Furtherâdiscussionâwouldâfocusâonâtheâassumptionsâ involvedâinâherâappraisalsâofâherâthoughtsâ(e.g.âtheâ therapistâ mightâ questionâ theâ mechanismâ ofâ howâ thinkingâcanâmakeâanâeventâhappenâandâquestionâ theâvalidityâofâanâintrusiveâthoughtâandâhowâitâcanâ
reflectâanâactualâevent).âThisâmayâleadâtoâaâmentalâ experimentâ ofâ tryingâ deliberatelyâ toâ induceâ badâ actionsâorâeventsâ(e.g.âhavingâthoughtsâofâcausingâ theâtherapistâtoâhaveâaâseriousâaccidentâbeforeâtheâ nextâappointmentâorâhavingâthoughtsâofâharmingâ theâtherapistâwhileâholdingâaâknifeâagainstâhisâorâ herâneck).â
Safety behaviours and compulsions
Theâtherapistâmightâconductâaâfunctionalâanalysisâofâ theâunintendedâconsequencesâofâEllaâsâavoidance,â safetyâbehavioursâandâcompulsionsâandâhowâtheyâ preventâ disconfirmationâ ofâ herâ worries.â Patientsâ tendâ toâ believeâ thatâ theirâ distressâ andâ worryâ willâ continueâ unlessâ theyâ carryâ outâ theirâ safetyâ behavioursâ orâ compulsions.â Thisâ canâ beâ testedâ outâ inâ aâ behaviouralâ experimentâ byâ askingâ theâ patientâ deliberatelyâ toâ performâ oneâ ofâ theirâ lessâ disturbingâ obsessions.â Forâ exampleâ Mark,â aâ manâ withâOCDâwhoâfearsâbeingâcontaminatedâbyâHIVâ (seeâbelow),âmightâbeâencouragedâtoâperformâhisâ compulsionâ(e.g.âcheckingâandâreassurance-seeking)â onâoneâdayâandâonâtheânextâtoâresistâtheâurge,âonâ eachâoccasionâmonitoringâtheâdegreeâofâhisâdistressâ orâ worryâ andâ theâ effectâ onâ hisâ confidenceâ inâ hisâ memory.âHeâwouldâthenâbeâaskedâtoâcompareâtheâ twoâexperiences.âAnotherâexperimentâmightâinvolveâ theâparadoxicalâeffectâofâthoughtâsuppressionâonâtheâ frequencyâofâtheâintrusiveâthoughts.âThisâmayâleadâ toâanâexperimentâthatâinvolvesâaskingâtheâpatientâtoâ recordâtheâfrequencyâofâaâneutralâthoughtâunderâtwoâ conditions,âwithâandâwithoutâthoughtâsuppression.â Fig. 1 A formulation in obsessiveâcompulsive disorder.
Trigger object, event or sensation
Babysittingâaâniece
Intrusive thought, image or urge
Iâmâgoingâtoâsexuallyâmolestâher
Meaning of intrusive thought, image
or urge Thinkingâsuchâthoughtsââ meansâIâcouldâbeâaâpaedophileââ andâthatâIâcanâtâhaveâorâ âlookâafterâchildren Avoidance and safety behaviours Avoidâbeingâaloneâ withânieceâandââ usualâbabysitting V C Compulsions Mentallyâcheckââ whetherââ Iâmolestedâher C V Attentional bias Monitoringâveryââ carefullyâlevelââ ofâarousalââ andâthoughts C V Physical feelings and emotional reaction Anxiousâ AmâIâsexuallyââ aroused? V C
Thisâmayâlaterâbeâextendedâtoâtheirâownâintrusiveâ thought.âBehaviouralâexperimentsâmayâappearâtoâ beâ theâ sameâ asâ exposureâ butâ withâ aâ rationaleâ ofâ testingâoutâcertainâbeliefsâaboutâsafetyâbehavioursâ andâmakingâpredictionsâaboutâwhatâwouldâhappenâ wereâtheyânotâperformed.â
Distancing
Anâimportantâstrategyâisâtoâhelpâtheâpatientâdistanceâ themselvesâ fromâ theirâ thoughtsâ orâ urgesâ andâ toâ ceaseâtoâengageâinâ(âbuyâintoâ)âthem.âAâmetaphorâforâ thoughtsâandâurgesâareâcarsâonâaâroad.âIfâoneâengagesâ withâtheâcarsâ(thoughts)âthenâoneâmightâstandâinâtheâ roadâandâtryâtoâdivertâthemâ(andâgetârunâover)âorâtryâ toâgetâintoâaâcarâandâparkâit.âHowever,âevenâwhenâ oneâhasâmanagedâtoâdivertâorâtoâparkâoneâcarâthereâ areâalwaysâmoreâcarsâtoâbeâdealtâwith.âTheâkeyâisâtoâ acknowledgeâtheâthoughtsâ(andâthankâoneâsâmindâ forâitsâcontributionâtoâoneâsâmentalâhealth),âbutânotâ toâattemptâtoâstopâthemâorâtoâcontrolâthem.âTheâgoalâ isâtoâembraceâintrusiveâthoughtsâandâurges,âtoâwalkâ alongâtheâsideâofâtheâroad,âandâtoâengageâwithâlife.â Thisâmeansâalwaysâexperiencingâtrafficânoiseâinâtheâ backgroundâââintrusiveâthoughtsâneverâgoâawayâandâ reflectâaâpersonâsâworries.âIfâaâpatientâstrugglesâwithâ distancingâthemselvesâfromâtheirâintrusiveâthoughts,â thisâmayâbeâlinkedâtoâbeliefsâaboutâtheâconsequencesâ ofânotârespondingâtoâthemâ(e.g.âaâpersonâwhoâfearsâ beingâcontaminatedâmayâbelieveâthatâtheyâwouldâ loseâcontrolâandâgoâmad).âInâgeneral,âpatientsâareâ taughtâtoânoticeâandâexperienceâtheirâthoughtsâandâ feelingsâwithoutâtryingâtoâevaluateâthemâorâtryingâ toâavoidâorâcontrolâthem.â
Beliefs about contamination
Thoughtâobjectâfusionâ(describedâabove)âcanâbeâusedâ toâenhanceâexposureâtoâcontamination.âForâexample,âaâ personâcanâputâtheâtiniestâdropâofâaâcontaminantâ(e.g.â urine,âsaliva,âsemen)âintoâaâlargeâvolumeâofâwater,âsoâ thatâtheâwaterâhasââthoughtsââofâcontamination.âTheâ solutionâcanâthenâbeâtransferredâtoâaâhand-heldâsprayâ withâwhichâtheyâcanââcontaminateââthemselvesâorâ possessionsâforâwhichâtheyâareâresponsible.âThisâmayâ leadâthemâtoâquestionâtheâprocessâofâthoughtâobjectâ fusion,âandâtheâusefulnessâofâexcessiveâwashingâorâ cleaningâandâanyâspecificâpredictionsâthatâtheyâhadâ madeâbeforehand.â
Beliefs about intolerability
of uncertainty
TheâneedâforâcertaintyâisâaâcommonâthemeâinâOCD,â especiallyâforâeventsâinâtheâdistantâfutureâthatâareâ
impossibleâtoâdisprove.âForâexampleâMark,âtheâmanâ withâ OCDâ mentionedâ earlier,â demandsâ toâ knowâ forâ certainâ whetherâ heâ isâ HIVâ positive,â despiteâ repeatedâreassuranceâfromânegativeâtestsâorâpositiveâ explanationsâforâhisâsymptoms.âSuchâpatientsâalwaysâ haveâ aâ naggingâ doubtâ ââ theâ bloodâ sampleâ couldâ haveâbeenâaccidentallyâswitched,âthereâcouldâbeâaâ newâtypeâofâHIVâwhichâhasânotâyetâbeenâdiscovered,â theâsero-conversionâhasânotâyetâoccurredâandâsoâon.â Markâisâdemandingâaâ100%âguaranteeâorâabsoluteâ certainty,âwhichâisâofâcourseâimpossible.âHowever,â whileâ heâ continuesâ toâ believeâ thatâ heâ hasâ toâ beâ 100%âcertain,âheâwillâfocusâonâtheâpossibleâdoubts.â Obviouslyâ theâ fearedâ situationsâ areâ possible,â butâ theyâareâhighlyâimprobable.âItâisâimportantânotâtoâ getâinvolvedâinâaâdetailedâanalysisâofâprobabilitiesâ butâtoâhelpâtheâpatientâtoâfocusâonâtheâprocessâandâ recogniseâtheâlinkâbetweenâtheâdemandâforâcertaintyâ andâtheirâdistressâandâfurtherâdoubt.âThisâwillâhelpâ themâtoâstepâbackâandâfocusâonâtheâmuchâhigherâ likelihoodâofâaâpoorâqualityâofâlifeâifâtheyâcontinueâ toâseekâreassurance.âPatientsâcanâbeâhelpedâtoâtackleâ theirâbeliefsâusingâhumour:âweâcanâguaranteeâtwoâ thingsâinâlifeâââdeathâandâtaxes!âAâthirdâguaranteeâ isâ thatâ whileâ theâ patientâ continuesâ toâ demandâ aâ guaranteeâthatâaâfearedâconsequenceâwillânotâoccurâ theyâwillâcontinueâtoâdisturbâthemselvesâwithâtheirâ symptoms.
Beliefs about terminating
compulsive behaviours
Asâ hasâ alreadyâ beenâ noted,â peopleâ withâ OCDâ tendâ toâ useâ problematicâ criteriaâ suchâ asâ beingâ âcomfortableâ,ââjustârightââorââtotallyâsureââtoâterminateâ aâcompulsion.âPatientsâcanâbeâtaughtâthatâtheyâareâ divertingâ increasingâ amountsâ ofâ attentionâ andâ tryingâ tooâ hardâ toâ determineâ theâ indeterminableâ (e.g.â whetherâ oneâ canâ beâ totallyâ sureâ everythingâ hasâbeenâdoneâtoâmakeâsomethingâclean).âPatientsâ whoâ checkâ theirâ memoryâ haveâ specialâ difficulty.â Theyâ areâ demandingâ toâ haveâ aâ perfectâ orâ totallyâ clearâpictureâofâeverythingâtheyâhaveâdone,âinâtheâ orderâthatâitâhappened.âSocraticâquestioningâcanâbeâ usedâtoâillustrateâtheâimpossibilityâofâthisâdemandâ andâhowâeachâcheckâcreatesâfurtherâambiguousâdataâ andâmoreâscopeâforâdoubt.âTheâcriterionâofââfeelingâ comfortableââisâparticularlyâimpossibleâtoâachieveâ whenâconfrontingâdisturbingâfearsâaboutâtheâharmâ thatâ oneâ mayâ cause.â Inâ thisâ case,â patientsâ shouldâ beâhelpedâtoâfocusâtheirâattentionâawayâfromâtheirâ subjectiveâfeelingsâandâtowardsâtheâexternalâworldâ (e.g.âwhatâtheyâcanâseeâwithâtheirâeyesâorâfeelâwithâ theirâhands).âAlternatively,âpatientsâmayâbeâshownâ thatâ demandingâ toâ feelâ comfortableâ orâ confidentâ beforeâtheyâcanâterminateâaâcompulsionâorâconfrontâ
aâfearâisâakinâtoâputtingâtheâcartâbeforeâtheâhorse.â Patientsâusuallyâneedâtoâdoâtasksâuncomfortablyâandâ unconfidentlyâbeforeâtheyâcanâachieveâcomfortâandâ confidenceâinâdoingâthem.â
Hazards of cognitive therapy
in OCD
Aâ hazardâ ofâ cognitiveâ therapyâ inâ inexperiencedâ handsâ isâ thatâ theâ therapistâ becomesâ engagedâ inâ subtleârequestsâforâreassuranceâandâargumentsâaboutâ minorâprobabilities.âInâsuchâcases,âitâisâespeciallyâ importantâtoâuseâSocraticâdialogueâtoâhelpâtheâpatientâ generateâtheâinformationâneededâbyâaâbehaviouralâ experiment,âorâtoâaskâtheâpatientâhowâaâcolleagueâ orâ relativeâ wouldâ thinkâ orâ act.â Mostâ problemsâ inâ CBTâforâOCDâstemâfromâtwoâfailures:âchallengingâ theâ contentâ ofâ intrusiveâ thoughtsâ ratherâ thanâ theâ patientâsâappraisalâofâthemâorâtheâcognitiveâprocess;â andâ notâ spendingâ enoughâ timeâ onâ exposureâ andâ behaviouralâ experiments.â Alwaysâ relateâ requestsâ forâreassuranceâorâmoreâinformationâtoâtheâpatientâsâ formulationâandâtheâcognitiveâbehaviouralâmodelâ ofâOCD,âwithâanâemphasisâonâtheâeffectâofâvariousâ cognitiveâprocessesâandâbehaviours.
Keyâ goodâ practiceâ pointsâ forâ usingâ CBTâ areâ summarisedâinâBoxâ5âandâfurtherâreadingâisâsuggestedâ inâBoxâ6.â
Declaration of interest
None.âReferences
Clark,â D.â M.,â Salkovskis,â P.â M.,â Hackmann,â A.,âet al (1998)ââ Twoâ psychologicalâ treatmentsâ forâ hypochondriasis.â Aâ ran-domisedâ controlledâ trial.âBritish Journal of Psychiatry,â173,â 218â225.
Foa,â E.â B.,â Kozak,â M.â J.,â Salkovskis,â P.â M.,âet alâ (1998)â Theâ validationâofâaânewâobsessive-compulsiveâdisorderâscale:âtheâ ObsessiveâCompulsiveâ Inventory.âPsychological Assessment,â
10,â206â214.
Frost,âR.âO,â&âHartl,âT.âL.â(1996)âAâcognitiveâbehaviouralâmodelâ ofâcompulsiveâhoarding.âBehaviour Research and Therapy,â34,â 341â50.
Goodman,âW.âK.,âPrice,âL.âH.,âRasmussen,âS.âA.,âet al (1989)âTheâ Yale-BrownâObsessiveâCompulsiveâScale.âI:âdevelopment,âuseâ andâreliability.âArchives of General Psychiatry,â46,â1006â1011. Gwilliam,â P.,â Wells,â A.â &â Cartwright-Hatton,â S.â (2004)â Doesâ
meta-cognitionâorâresponsibilityâpredictâobsessiveâcompulsiveâ symptoms:âaâtestâofâtheâmetacognitiveâmodel.âClinical Psychology and Psychotherapy,â11,â137â144.
NationalâCollaboratingâCentreâforâMentalâHealthâ(2005)âObsessiveâ Compulsive Disorder: Core Interventions in the Treatment of ObsessiveâCompulsive Disorder and Body Dysmorphic Disorderâ (Clinicalâ guidelineâ CG31).â Britishâ Psychologicalâ Societyâ &â Royalâ Collegeâ ofâ Psychiatrists.â http://www.nice.org.uk/ CG031
Rachman,â S.â J.â (1993)â Obsessions,â responsibilityâ andâ guilt.â
Behaviour Research and Therapy,â31,â149â154.â
Rachman,â S.â J.â &â deâ Silva,â P.â (1978)â Abnormalâ andâ normalâ obsessions.âBehaviour Research and Therapy,â16,â233â248. Salkovskis,â P.â M.â (1985)â Obsessiveâcompulsiveâ problems:â aâ
cognitiveâbehaviouralâanalysis.âBehaviour Research and Therapy,â
23,â571â583.
Salkovskis,âP.âM.,âRichards,âC.âH.â&âForrester,âE.â(1995)âTheârela-tionshipâbetweenâobsessionalâproblemsâandâintrusiveâthoughts.â
Behavioural and Cognitive Psychotherapy,â23,â281â299.
Box 5 Good practice points in CBT for OCD Patientsâshouldâhaveâclearlyâdefinedâprob-lemsâandâgoalsâforâtherapyâ
Thereâ shouldâ beâ aâ sharedâ formulationâ ofâ theâproblemâthatâprovidesâaâneutralâexpla-nationâofâtheâsymptomsâandâofâhowâtryingâ toâavoidâandâcontrolâintrusiveâthoughtsâandâ urgesâ maintainsâ theâ patientâsâ distressâ andâ disabilityâ
Doâ notâ becomeâ engagedâ inâ theâ contentâ ofâ obsessionsâandârequestsâforâreassurance,âandâ doânotâargueâaboutâtheâlikelihoodâofâaâbadâ eventâhappeningâââhelpâpatientsâtoâuseâtheirâ formulationâandâtheâcognitiveâbehaviouralâ modelâofâOCD,âandâuseâaâSocraticâdialogueâ toâfocusâonâtheâprocessâandâconsequencesâ ofâtheirâactions Doânotâgiveâupâusingâexposureâandâresponseâ prevention:â integrateâ itâwithâtheâ cognitiveâ approachâinâtheâformâofâbehaviouralâexperi-mentsâtoâmakeâpredictionsâ
Ensureâthatâpatientsâdoânotâincorporateânewâ appraisalsâ orâ self-reassuranceâ asâ anotherâ compulsionâorâwayâofâneutralising ⢠⢠⢠⢠â˘
Box 6 Further reading
Antony,âM.âM.,âPurdon,âC.â&âSummerfeldt,â L.â J.â (eds)â (2007)âPsychological Treatment of ObsessiveâCompulsive Disorder: Funda mentals and Beyond.âAmericanâPsychologicalâ Association.â
Salkovskis,âP.âM.â&âKirk,âJ.â(2007)âObsessionalâ disorders.âInâCognitive Behaviour Therapy for Psychiatric Problems: A Practical Guideâ (edsâ K.âHawton,âP.âM.âSalkovskis,âJ.âKirk,âet al),â pp.â129â168.âOxfordâUniversityâPress. Veale,â D.â &â Willson,â R.â (2005)âOvercoming Obsessive Compulsive Disorder: A SelfÂHelp Guide Using Cognitive Behavioral Techniques.â Constableâ&âRobinson.â
Wells,â A.â (2000)âEmotional Disorders and Metacognition,â pp.â 179â199.â Johnâ Wileyâ &â Sons.
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â˘
â˘
Veale,â D.â (1993)â Classificationâ andâ treatmentâ ofâ obsessionalâ slowness.âBritish Journal of Psychiatry,â162,â198â203.
Veale,â D.â (2002)â Over-valuedâ ideas:â aâ conceptualâ analysis.â
Behaviour Research and Therapy,â40,â383â400.
MCQs
1 Neutralising an intrusive thought or image:
leadsâtoâanâimmediateâincreaseâinâanxiety isâanâinvoluntaryâstrategyâadoptedâbyâtheâpatientâ aimsâtoâcreateâmoreâharmâ
preventsâdisconfirmationâofâtheâintrusiveâthought isâidenticalâtoâaâcompulsion.
2 Cognitive processes in OCD include:
thoughtâactionâdissociationâ toleranceâofâuncertaintyâ overinflatedâsenseâofâresponsibilityâforâharm finishingâwashingâritualâwhenâseeingâthatâoneâsâhandsâ areâcleanâ underestimationâofâtheâlikelihoodâofâharm. 3 Compulsions in OCD: canâleadâtoâpsychosisâifâresistedâ
mayâ initiallyâ functionâ asâ aâ meansâ ofâ avoidingâ anxiety
canâ beâ resistedâ byâ focusingâ attentionâ inwardsâ onâ subjectiveâfeelingsâandânotâbyâexternalâinformation areâentirelyâvoluntaryâ
cannotâbeâmentalâacts.â
4 Unwanted intrusive thoughts and images:
areâindistinguishableâinâcontentâbetweenâpeopleâwithâ OCDâandâtheâânormalââpopulation canâbeâsuppressedâinâtheâlongâterm doânotâdifferâinâtheâmeaningâthatâpeopleâwithâOCDâ attachâtoâtheirâoccurrenceâand/orâcontentâcomparedâ withâtheâânormalââpopulation aďż˝ bďż˝ cďż˝ dďż˝ eďż˝ aďż˝ bďż˝ cďż˝ dďż˝ eďż˝ aďż˝ bďż˝ cďż˝ dďż˝ eďż˝ aďż˝ bďż˝ cďż˝ MCQ answers 1â â 2â â 3â â 4â â 5
aâ Fâ aâ Fâ aâ Fâ aâ Tâ aâ F
bâ Fâ bâ Fâ bâ Tâ bâ Fâ bâ F
câ Fâ câ Tâ câ Fâ câ Fâ câ F
dâ Tâ dâ Fâ dâ Fâ dâ Fâ dâ T
eâ Fâ eâ Fâ eâ Fâ eâ Fâ eâ F
areâunnecessaryâforâthinkingâcreativelyâandâproblem-solving
areârareâinâtheâgeneralâpopulation.
5 Assessment for cognitiveâbehavioural therapy in OCD: doesânotârequireâknowledgeâofâtheâdegreeâofâfamilyâ involvement doesânotârequireâknowledgeâofâtheâpatientâsâdegreeâofâ insightâorâovervaluedâideation requiresâforensicâassessmentâofâintrusiveâthoughtsâandâ urgesâ
requiresâ assessmentâ ofâ theâ patientâsâ readinessâ toâ change requiresâanalysisâofâcountertransference. dďż˝ eďż˝ aďż˝ bďż˝ cďż˝ dďż˝ eďż˝