Rachman 2003
Common obsessions include
- aggressive actions
- thoughts of harming or harm coming to family or children
- sexual acts
- fear of inappropriate acts or gestures
- images of sex with inappropriate partners
- blasphemous acts
- fear of making sacrilegious gestures in a holy place
- pollution of prayers with impure thoughts
Course of OCD
- usually begins adolescence or early adulthood
- onset usually gradual - some acute cases diagnosed early
- may experience waxing and waning course
- ~5% have episodic course with minimal/no symptoms between episodes
- progressive deterioration in occupational and social functioning
- 90% can expect to have moderate benefit with optimum treatment
How to approach an OCD formulation
Presenting problems - what’s troubling them?
Predisposing factors - what factors left them vulnerable to these problems?
Precipitating factors - why have they developed these problems now?
Perpetuating cognitions and consequences - what thoughts are they eperiencing and behaviours they are engaging in to maintain these problems?
Mowrer’s 2-Factor theory
- obsessions evoke anxiety through classical conditioning i.e. there is a conditioning event
- anxiety reduced through compulsions which are reinforced (operant conditioning)
Cognitive behavioural formulation
Salkovskis
- obsessions - intrusive vognitions which are interpreted at indicating they may be responsible for harm to themselves and others unless they take action to prevent it
- compulsive behaviours
- neutralisation - cognitive equiv of compulsions. Can be just thinking about a counter thought e.g. counter thoughts of evil or harm with “Jesus cares for me”
- Avoiding situations related to obsessional thoughts
- seeking reassurance - repeadedly seeking assurance that the feared outcome won’t happen
- diluting/sharing responsibility - ask others to take some responsibility or get reassurance that the individual isn’t fully responsible for potential harm to others
Wells - Fusion beliefs
3 domains of fusion beliefs
- thought-event fusion - having a thought - event happened/will happen
- thought-action fusion - thinking something will lead to uncontrollable commision of unwanted actions
- thought-object fusion - thoguhts, feelings, memories can be transferred into objects and/or ‘caught’ from objects
These + meta-belief that behav/cognitive rituals may prevent harm arising from potentially damaging thought fusion
How to treat OCD
Exposure with Response Prevention (ERP) for cognitive intrusions
Focus on here-and-now causes
Teach skills - help them cope better
- cognitive intrusions -
- responsibility (normalise thoughts / find other explanation)
- thought = action
- neutralising (experiments to show thought suppression increases thought frequency)
- exposure (cued intrusions - can be systematic desensitisation, flooding - prevent safety behaviours))
- include…
- relaxation techniques
- self talk
- cognitive challenge
- include…
Relaxation training
Reduce physiological arousal
- situations of high threat = panic / fear cognition
- get rid of excess tension
- breathing techniques - deep breathing through diaphragm
- Progressive muscle relaxation
Self-talk
Meichenbaum, 1985
- Literally just repeating phrases over and over - positive self talk “I can do this,” “this feeling will pass,” “nothing bad is going to happen if I do this”…
- targets negative thoughts and beliefs - calming!
Cognitive challenge
Beck et al., 1997
- socratic dialogue or behavioural hypothesis retesting
- socratic dialogue - structured conversation to answer questions about cognitions and behaviours
- behavioural hypothesis testing - “I believe this bad thing will happen if I don’t wash my hands!” yeah but it won’t look here let me show you
