OCD

Question 1

Criteria

Answer 1

A. Presence of obsessions, compulsions, or both:

Obsessions defined as (1) and (2):
1. Recurrent PERSISTENT THOUGHTS, URGES or images experienced at some time during the disturbance as INTRUSIVE and unwanted, and that in most individuals cause marked ANXIETY or distress
2. The individual attempts to ignore or SUPPRESS thoughts, urges or images or NEUTRALISE them with some other thought or action (i.e. by performing a compulsion)

Compulsions defined by (1) and (2):
1. REPITITIVE BEHAVIOURS (e.g. hand washing, ordering, checking) or mental acts (e.g. praying, counting, repeating words silently) 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 some dreaded event or situation; however, these behaviours or mental acts are NOT CONNECTED in a realistic way with what they are designed to neutralize or prevent, or are clearly excessive.
Note: Young children may not be able to clearly articulate the aims of these behaviours or mental acts.

B. TIME CONSUMING (e.g. more than 1 hour per day) or clinically significant impairment.

Question 2

Salkowski’s Cognitive Model of OCD

Answer 2

obsessional intrusive thoughts and images start off as normal intrusions but are appraised as more threatening and personally relevant. People with OCD have a sense of responsibility and overestimation of importance for bringing about harm or preventing harm.

To manage this fear, people engage in Safety Behaviours such as:
* avoidance,
* reassurance-seeking and
* cognitive or motor rituals,
which prevent them from learning that the worries are not accurate or that anxiety will actually decline without performing rituals.

The neutralizing behaviour is intended to reduce distress from these appraisals (compulsions) but ends up maintaining the cycle.

Question 3

Psychometric

Answer 3

BAI
SPAI

Question 4

Differentials

Answer 4

ASD
OCPD

Question 5

Assessment

Answer 5

Gaining an understanding of the client’s triggers, obsessions, rituals, avoidance and feared consequences is essential.

• For a template of key information to get about a client’s OCD in order to do an OCD map (formulation), see Functional assessment of OCD symptoms available from
• http://www.jabramowitz.com/resources-and-free-stuff.html

Question 6

Evidence based best treatment approach

Answer 6

CBT with ERP = mild to moderate;

add SSRIs for higher severity (or if limited treatment response)

• There is limited evidence to support the efficacy of pure CT (without exposure or behavioural experiments)

Question 7

The most common obsessional worries:

Answer 7

Fears of contamination = leading to washing or cleaning rituals;

Fears of missing something potentially dangerous (e.g. electric switches which have been left on, or an unlocked front door) = leading to checking and/or repeating rituals

Over-concern with orderliness and perfection = repeating actions until things ‘feel right’

Fears of uncontrollable and inappropriate actions (e.g. swearing in public, or sexual or aggressive behaviour) = unhelpful attempts to control thoughts.

Question 8

The most common Safety Behaviours are:

Answer 8

BEHAVIOURAL rituals (e.g. cleaning, checking and repeating actions);

COGNITIVE rituals: neutralising ‘bad’ thoughts by thinking other thoughts (e.g. prayers or ‘safe’ incantations, or other ‘good’ thoughts);

AVOIDANCE of situations, people or objects that trigger the obsessional worries;

seeking REASURRANCE about the worries from family, doctors or others;
* thought suppression.

Question 9

Key cognitions

Answer 9

thought–action fusion: the idea that having a ‘bad’ thought can result in ‘bad’ consequences (e.g. if I think about harm coming to someone, that may make that harm happen in reality),
or that having a thought about something ‘bad’ is morally just as bad as carrying out a bad action;

• inflated responsibility: an assumption that one has the power and the obligation to prevent bad things from happening;
• beliefs about the controllability of thoughts: for example, the belief that one ought to be able to control ‘bad’ thoughts;
• perfection: the dichotomous assumption that only the best is effective or acceptable;
• overestimation of threat, which is often related to
• intolerance of uncertainty: a belief that things can and must be certain
  (e.g. ‘I ought to be able to be sure that an action is safe’).

Question 10

order of Tx of OCD

Answer 10

Detailed assessment

Psychoeducation and Goal Setting

Cognitive Restructuring (often via Behavioural Experiments)

Exposure with Response Prevention (ERP)

Relapse Prevention / Maintenance

Question 11

OCD Tx psychoeducation

Answer 11

PSYCHOEDUCATOIN

1. Not dangerous, most people get them
   * Metaphor: mental “hiccup”; popcorn machine [random firing]
   * Stress that intrusions are NORMAL (~90% of the population get them)
2. Avoidance / trying to push away, or get rid of thoughts
   * Metaphor: beach ball under water as soon as u get distracted it pops up - supression not helpful
3. Stand up to the OCD ‘bully’ [instead of being bossed around by it]
   * “Turn down the volume” on symptoms, so they can regain their lives
4. Externalise the OCD
   * “What lies does your OCD tell you about ___?”
   * make it the problem (removes blame, easier for families to understand)

Why rituals are not helpful
- Negative reinforcement in OCD: short term gain, long term pain
- metaphor of an itchy bite:
It itches, so you scratch it, and feel… RELIEF for a few brief moments, then…The itch comes back WORSE than ever,and the bite gets BIGGER and BIGGER…
- They prevent disconfirmation of OCD beliefs and new learning from occurring

Question 12

OCD Tx EXPOSURE RESPONSE PREVENTION (ERP)

Answer 12

EXPOSURE RESPONSE PREVENTION (ERP)
* best-established intervention for OCD.

• Graded, Repeated, Prolonged, Without Distraction, Without Compulsion
• The aim is to expose himself to the feared situation without engaging in his usual safety behaviour
• A cognitive approach (BE) the client learns that his obsessional predictions of disaster are not justified and that he can tolerate distress.
• Rituals are essentially SBs and therefore ERP is exactly analogous to reducing SBs in any other anxiety disorder.
  STEPS TO DELIVERING ERP
  1. formulation
  2. ERP rational to reduce symptoms
  3. Introduce SUDS (Fear Thermometer)
  4. Hierarchy of triggering stimuli based on SUDS
  5. Design exposure tasks to confront stimuli and “ban” rituals
  6. Ascend up the hierarchy, altering as necessary for generalizability

OTHER ERP TO CONSIDER:
- Do the task with them (if possible/practical)
- Rapport is key
- Check in every 5 minutes to see where their distress/discomfort level is at (0-100); record
- During/after the exposure, discuss with the client how they interpret the reduction in distress/ discomfort (processing), the outcome of their predictions, and help them elaborate this learning.

Question 13

OCD tx CR and BE

Answer 13

COGNITIVE RESTRUCTURING
- The aim is to learn that OCD is not about the need to prevent a real threat but rather about being excessively worried about such a threat.

BEHAVIOURAL EXPERIMENTS
the purpose of behavioural experiments is to explore hypotheses about what would happen without these behaviours, rather than to facilitate habituation.

Question 14

OCD vs ED

Answer 14

Similar = rules, restriction, need for contorl

ED = core low self esteem
OCD = inflatted self esteem

The main difference is the relationship that they have with their thoughts/behaviour. OCD is egodystonic (their thought and behaviours and not aligned with their identity and values and cause them distress) while eating disorders are generally egosyntonic (they feel aligned with their thoughts and behaviours/part of their identity and do not tend to see the harm).

Eating disorders have repetitive thinking and behaviours, but they are really only about eating, weight and shape while OCD they have obsessive thoughts about a range of things.

In OCD they try to get rid of these thoughts with their compulsions (because it’s distressing), in ED they are more aligned with their thoughts and act in accordance with them (I’ll get fat so I’ll exercise excessively). The thought that they’ll get fat might induce anxiety, but their behaviour is viewed as a good thing. In OCD they feel out of control with their compulsions and it brings them distress.