Obsessive Compulsive Disorder

Question 1

What are Obsessions defined as? What do most obsessive thoughts involve?

Answer 1

1. Recurrent and persistent thoughts, urges or images that are experienced as intrusive and unwanted, and that in most individuals cause anxiety/distress. 2. The individual attempts to ignore or suppress these, or neutralise them with some thought or action (i.e. perform a compulsion). Most obsessive thoughts involve fears of contamination, fears of harming oneself or others, and pathological doubt. Other fairly common themes are concerns about or need for symmetry, sexual obsessions, and obsessions concerning religion or aggression. These themes are consistent across cultures and life spans (Pallanati, 2009).

Question 2

What are Compulsions defined as? What are the five types of compulsive rituals?

Answer 2

1. Repetitive behaviours or mental acts that the individual feels driven to perform in response to an obsession or according to rules that must be applied rigidly. 2. The behaviours or mental acts are aimed at preventing/reducing anxiety/distress, or preventing some dreaded event or situation; however, these behaviours or mental acts are not connected realistically with what they are designed to neutralise or prevent, or are clearly excessive. There are five types of compulsive rituals: cleaning, checking, repeating, ordering or arranging, and counting (Mathews, 2009). Many people display multiple types. Less commonly, the compulsion is primary obsessional slowness. Cleaning rituals can vary from mild to severe, for example washing ones hands for 15-20 minutes after going to the bathroom, compared to washing one’s hands with severe disinfectant for hours until they bleed. Checking rituals can range from mild to severe. Both are often performed a specific number of times for a specific length of time.

Question 3

Why is OCD egodystonic?

Answer 3

Obsessive compulsive disorder is considered to be egodystonic as the thoughts and compulsions experienced or expressed are not consistent with the individual’s self-perception, meaning the patient realizes the obsessions are unreasonable.

Question 4

Outline the behavioural causal factors of OCD? (Mowrer, 1947; Two Factor Theory)

Answer 4

Here, neutral stimuli become associated with frightening thoughts or experiences through classical conditioning and come to elicit anxiety. The individual may then discover behaviours which reduce this anxiety, and so these behaviours are reinforced, creating compulsions. Once learned, avoidance responses are very resistant to extinction. This model predicts that exposure to feared objects or situations should be useful in treating OCD if the exposure is followed by prevention of the ritual, enabling the person to see that the anxiety will subside naturally in time. This is the core of the most effective behavioural therapy for OCD. However, this theory does not explain why people with OCD develop obsessions in the first place, and why some obsessive people do not develop compulsions.

Question 5

How did Salvosky summarise the behavioural perspective of OCD?

Answer 5

1. Obsessions are conditioned stimuli. 2. Compulsions reduce anxiety or distress through a process of negative reinforcement, thus they become associated with the obsession. Once learned these responses (compulsions) are resistant to extinction 3. Avoidance is also used to avoid confrontation with the situation and obsessions associated that originate anxiety and distress This model provided important contributions for intervention but did not help to explain why people develop obsessions in the first place and why some people do not develop compulsions

Question 6

Outline and evaluate exposure therapy with response prevention.

Answer 6

• Exposure to stimuli that provokes obsessions. - Prevention of compulsions. (Meyer, 1966; Rachman, Hodgson, & Marks, 1971; Rachman, Marks, & Hodgson, 1973). - Better to be done without the presence of the therapist, as its presence reduces the perception of ‘danger’ associated with obsessions (Roper & Rachman, 1976) - Patients should carry out a large variety of self-directed and self-monitored tasks outside the treatment sessions - HIGH DROP OUT of treatment - Better than medication

Question 7

Outline the Cognitive Perspective (Salkovsky, 1985) of OCD.

Answer 7

• The content of normal intrusive thoughts and obsessions is indistinguishable and intrusions occur in at least 90% of the general population (DEMONSTRATED EMPIRICALLY: Rachman & de Silva, 1978) Anxiety ONLY occurs when stimuli or situations (OBSESSIONS) are interpreted in a negative fashion. - INTERPRETATION = AUTOMATIC THOUGHTS An obsessional pattern would occur if intrusive cognitions were interpreted as an indication that the person may be, may have been, or may come to be, RESPONSIBLE for harm or its prevention - It is the RESPONSIBILITY interpretation that creates ANXIETY and the need to NEUTRALISE the thoughts (through compulsions) - RESPONSIBILITY = The belief that one has power which is pivotal to bring about or prevent subjectively crucial negative outcomes. These outcomes are perceived as essential to prevent. They may be actual, that is, having consequences in the real world, and/or at a moral level - OCD results from the way in which the person interprets the occurrence of intrusive thoughts, images, impulses and doubts - MISINTERPRETATION: 1. Thinking = acting 2. The failure to prevent self or other’s harm is the same as being responsible for that harm 3. Responsibility is never attenuated by other factors, such as low probability of a given event occurring) 4. Not trying to prevent or neutralize an obsession is the same as wishing that the event occurs 5. People must (and can) control their own thought - The interpretation of obsessions according to such dysfunctional schemes leads to 1. Increased anxiety, distress and depression 2. Increased accessibility of original or related thoughts 3. SAFETY STRATEGIES: Ineffective attempts to reduce thought and associated responsibility: avoidance/thought control (do not think about the white elephant) 4. COMPULSIONS 5. Reinforcement of OBSESSIONS

Question 8

Outline and evaluate the efficacy of cognitive behavioural therapy for OCD (Salkovsky, 1999).

Answer 8

• Identification of key distorted beliefs (responsibility) - Collaborative construction of a nonthreatening alternative account of obsessional fears - Challenge of responsibility appraisals: e.g., pie-chart technique - Question the power of obsessions: e.g., - Let’s obsess about winning the lottery, shall we? - ERP is implemented as an experimental test of the new alternative theory Should not focus on proving that obsessions will not lead to feared consequences. That would be meeting the same function compulsions have and would not prove beneficial. 1. Therapy aims to help the patient conclude that obsessional thoughts, however distressing they originally are, are irrelevant to further action. - ‘Which explains things best: that you are a child molester, or that you fear being a child molester?’ - E.g., well let’s obsess about winning the lottery, shall we? They should not be the target of control strategies (THOUGHT CONTROL) and the patient is helped to see how such strategies are actually counter- productive, having the effect of increasing pre-occupation, the urge to neutralise and distress. EXERCICE: do not think of the white elephant 2. Therapy seeks to modify the way the person interprets the occurrence and/or content of their intrusions as part of a general process of reaching an alternative, less threatening view of their problem. - ERP : don’t trust me, test it yourself - Mostly done thorough GUIDED DISCOVERY - Does not appear to be superior to ERP (Clark, 2005) Cognitive therapy was thought to be possibly important in helping to prevent DO observed in ERP

Question 9

Outline the process of logic reanalysis.

Answer 9

The patients has to note his negative thoughts about PA consequences And note how many times they came true (most likely will be zero) Then, he/she has to think about if zero, then why continue to worry about it: Several possibilities are presented and the patients has to see which apply and detail it according to his specific case Then, describe the evidence in favour and against After this analysis he has to note the odds of the negative thought occurring (here should be already small) And finally, point other possible more adaptive thoughts that apply in the same situation (note that his thoughts are one among many different possibilities) As you can see here, we work on thoughts to help patients then cope with difficult emotions. It is not that in CBT we only want to change thought. Ultimately the all emotional setting will change as response behaviours, but it is very hard for people in general to work on emotions per se (especially when being intensively experienced), so thoughts are the tool

Question 10

What are the cognitive causal factors of OCD?

Answer 10

• The effects of attempting to suppress obsessive thoughts: Paradoxically in both individuals with and without OCD, attempting to suppress thoughts leads to an increase in them. For OCD, this increase is twofold. Beyond the frequency of obsession, suppression leads to a general increase in obsessive-compulsive symptoms. - Appraisals of responsibility for intrusive thoughts: People with OCD often have an inflated sense of responsibility, which can sometimes associated with beliefs that simply thinking about doing something, is morally equivalent to having done it, or at least increases the chance of doing it. This is known as thought-action fusion (Shafran & Rahman, 2004). This motivates compulsive behaviours. - Cognitive biases and distortions: OCD sufferers’ attention is more drawn to disturbing detail relevant to their obsessive concerns, much like other anxiety disorders. They also have difficulty blocking out negative, irrelevant input or distracting information, so they may attempt suppression. These people have low confidence in their memory ability, which may contribute to their repeating their ritualistic behaviours over and over again.

Question 11

Outline potential genetic, neurotransmitter, and neuroanatomical abnormalities in OCD.

Answer 11

Genetic Factors Moderately high concordance rates of OCD diagnosis in twins, implying moderate genetic heritability, although it may be at least partially a nonspecific “neurotic” predisposition (van Grootheest et al. 2007). Early-onset OCD has a higher genetic loading than later-onset OCD. OCD and the Brain Abnormalities occur primarily in certain cortical structures as well as in the subcortical structures of the basal ganglia. This is in turn, linked to the amygdala and the limbic system, which control emotional behaviours. PET studies have also shown abnormally high levels of activity in the orbital frontal cortex and the cingulate cortex/gyrus, also linked to the limbic area. Abnormally high activity in the subcortical caudate nucleus is also implicated, and is involved in primitive behavioural patterns such as sex, aggression, and hygiene. This all combines in the cortico-basal-ganglionic-thalamic circuit, which is normally involved in the preparation of complex sets of interrelated behavioural responses in specific situations. When the circuit is dysfunctional, inappropriate behavioural responses may occur. Neurotransmitter Abnormalities Serotonin has been strongly implicated in OCD. SSRIs that have relatively selective effects on serotonin are fairly effective in the treatment of OCD. The exact nature of the disruption in the serotonergic system is unclear. Believed that increased serotonin is involved in OCD symptoms- drugs that indiscriminately activate the serotonergic system leads to a worsening of symptoms. Other neurotransmitter symptoms such as the dopaminergic, GABA, and glutamate systems are also involved.