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CBT for OCD

On a day to day basis we have hundreds of different types of thoughts running through our head. Some of these thoughts might be pleasant or neutral, but some of these thoughts may be more distressing. For instance, you may have experienced a thought that you have forgotten to lock the front door as you left the house or that you have left the oven on. Typically, in response to a thought of this type, we might then remember that we have locked the door, or we might just want to check once, just to make sure. Once we have done this, we feel satisfied that that the door is locked, and we can get on with our day. Even if we have the thought again, we are assured that we have taken the adequate action and we are able to dismiss it.

In Obsessive Compulsive Disorder (OCD) however, the individual may have difficulty dismissing these thoughts, such that they become the obsessive focus of their attention. Due to the potential negative consequences associated with not responding to these thoughts (e.g. the house getting broken into, the kitchen going on fire) the individual will feel an increase in anxiety and will seek to respond to the thought in a way that decreases the distress (e.g. checking the door multiple times, asking family members for reassurance that the cooker is turned off). When the individual experiences a short term relief of anxiety for engaging in the particular behaviour, the behaviour becomes negatively reinforced, meaning that the behaviour is more likely to be used again as a way of reducing anxiety associated with the thought. A vicious circle then begins:
OCD maintenance cycle

But what about our thoughts?  Why do we obsess with OCD?

It may be surprising for you to learn that unwanted, intrusive thoughts are experienced by most people.  A 1992 study carried out by researchers Christine Purdon and David A. Clark, examined the prevalence of intrusive thoughts in a non-clinical population.  They listed 52 different potentially distressing thoughts, ranging from accidently leaving the stove on to stabbing a family member, and asked participants to rate whether or not they had experienced these thoughts. You can find a list of the thoughts, and percentages of people admitting to having experienced them here.  They found that many of the participants had experienced, even quite potentially distressing, thoughts at some time.  It’s important to remember here that this was a non-clinical sample.  If we were to assume that the outcomes of this study were relatable to the wider population, we may believe that intrusive thoughts are a very common phenomenon.

So if intrusive thoughts are so common, why doesn’t everybody develop OCD?

Many Cognitive Behavioural models of OCD suggest that it is not the intrusive thought itself which leads to the emotional distress, but the individual’s appraisal of it.  We tend to find that people with OCD appraise the thought as potentially being indicative of a catastrophic occurrence actually happening, and that they have a high level of responsibility for this.  This “inflated sense of responsibility” is a key ingredient of the OCD presentation and underpins the excesses that individuals will go to to prevent the feared event actually happening.  Take a look at the below diagram to understand this further.

OCD appraisal of intrusions

Here, we see that the appraisal “the kids could die and I would be responsible” leads to anxiety, which in turn leads to compulsive behaviours.  This is true of other types of intrusive thoughts which people with OCD may have:

OCD appraisals examples

Cognitive Behavioural Therapy for OCD.

CBT has a well-developed body of evidence to support its effectiveness in treating OCD.  Exposure and Response prevention (ERP) is one CBT approach to OCD treatment which encourages the individual to deliberately expose themselves to a feared scenario and develop tolerance to their anxiety without engaging in their typical compulsion.  ERP relies upon a behavioural principle called habituation, in which an individual’s automatic responses will lessen over time in response to repeated exposure of a given trigger.  Look at the example below to understand this further:

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Dean has OCD.  He fears that he may contaminate other people with germs from his hands and as such will wash his hands as frequently as 15 times each day, for up to 30 minutes at a time.  He does a lot of handwashing.  He agrees to try ERP with his CBT therapist.  They identify a trigger for exposure which is relevant to Dean’s germ obsessions, touching a toilet door handle, and one of his typical compulsive responses.  At his therapist’s encouragement, Dean grasps the door handle, keeps hold of it for around a minute, rubs the handle and brushes it against the back of his hand.  He is then asked by the therapist to rub his hands together and rub his hands over his clothes and hair.  Dean has now been exposed to his feared scenario, and he reports to his therapist that his anxiety is at about 95%.

Whereas at this stage Dean would typically rush to wash his hands, he has agreed with the therapist that he is going to attempt to avoid this response for a full 90 minutes.  Instead, Dean and his therapist talk through the exercise, and to avoid Dean engaging in any “secret” anxiety reducing responses, the therapist regularly reminds Dean that he has been in contact with the toilet door and that there are germs all over his hands.  Throughout the course of the ERP session, Dean is asked to rate his anxiety as a percentage which the therapist records on a graph.  Over the full 90 minutes, Dean finds that his anxiety scores actually reduce, despite the fact that he has not washed his hands.  At the end of the session, Dean rates his anxiety at 30%.  This is habituation in action!

As a between session task, Dean agrees to continue with ERP on a daily basis, touching the handle just as he had done within the session, not rushing off to wash his hands, and rating his anxiety every 10 minutes.  At the end of his first week, his anxiety rating has reduced to just 10% when first touching the door handle.  He and his therapist then agree to move onto the next exposure target – Touching the toilet seat!  And so on.

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Cognitive Techniques
Whilst ERP is an effective treatment in its own right, it has been complemented with the use additional cognitive techniques to enable the individual to gain extra leverage over their OCD.  These techniques typically enable the client to critique and evaluate their assumptions about intrusive thoughts and develop alternative perspectives which may be more accurate.  One such example is called Theory A vs Theory B.

Let’s call the individual’s initial appraisal of their intrusive thoughts “Theory A.”  This is the appraisal that leads to the anxiety, which in turn leads to the compulsive behaviours.  Theory B, is an alternative, often less distressing, explanation for the distress experienced by the individual.  Have a look at the table below an illustration of this based upon the earlier OCD examples.

OCD Theory A vs Theory B
As we can see here, the Theory B’s provide an alternative explanation for why the individual experiences so much distress in relation to their intrusive thoughts.   What is now left for us to do is to look at the evidence for Theory A vs Theory B and make a decision about which of our theories are most accurate.  Do we have any evidence that our client is a sexual deviant who will sexually assault their colleague?  Do we have any evidence to support our alternative hypothesis, that they actually are a very caring person who respects other people?

Other cognitive techniques are employed throughout CBT for OCD all of which enable the client to develop alternative hypotheses for their OCD related distress.  Dependent upon severity of the OCD, it is typical for a client to start to feel the benefits of therapy within 6 to 8 sessions, and for a more sustained recovery to be achieved in between 12 to 16 sessions.