Session Thirteen (OCD)

Question 1

How are Obsessions defined according to DSM/ICD?

Answer 1

Recurrent and persistent intrusive thoughts, impulses, urges or images that are:

• unwanted
• stress or anxiety inducing
• difficult to suppress or ignore

Question 2

How are Compulsions defined according to DSM/ICD?

Answer 2

Repetitive behaviours or mental acts that the person feels driven to perform in response to an obsession, according to rigid rules, or to achieve a sense of completeness

Question 3

How do ICD and DSM define OCD?

Answer 3

• Compulsions in the presence of Obsessions.
• Must be time consuming (1+ hour/day)
• Must cause significant distress or impairment to family, social, educational, occupational, functioning.
• Not attributable to another mental disorder or drug
• Level of insight into their condition (DSM definition requires the patient to on some level understand their compulsions to be excessive and unreasonable)

Question 4

Who gets OCD?

Answer 4

• 1.2% prevalence in population
• Slightly more common in women 1.4 : 1
• Consistent across all cultures

Question 5

How have people tried to subcategorise OCD?

Answer 5

Mataix-Cox breaks it down into the following groupings:

• Symmetry and ordering obsessed
• Contamination and cleaning obsession
• Checking
• Hoarding

Bragdon and Coles take a more broad view and just subdivide it into:

• Harm avoidance
• ‘Not just right’ experiences

Question 6

What is the life impact of OCD?

Answer 6

• High rates of comorbidity with depression and GAD
• Reduces odds of being married or employed, leading to significantly reduced QoL (Torres et al, 2006)
• WHO considers it one of the top 10 most disabling conditions in the world

Question 7

Describe the course of OCD?

Answer 7

• Starts before age of 30
• Triggered or exacerbated by transitions
• Impairment in QoL persists over lifespan
• Often long delay in seeking healthcare (upwards of 10 years)

Question 8

What causes OCD?

Answer 8

Nobody knows!

• Likely a biopsychosocial element
• Combined with a stress/vulnerability element

Question 9

Give some evidence for a genetic cause of OCD?

Answer 9

Beam et al, 2017:

• Raised familial prevalence of OCD and other problems (D + A)
• No OCD-specific genetic factors have been identified

Taylor et at, 2013

• Found consistent implication of genes related to serotonin regulation in OCD
• However, mechanisms unclear
• Unlikely to be specific to OCD

Question 10

Give some evidence for a neuropsychological aspect to OCD?

Answer 10

Cougle et al, 2007:

• Found no differences in memory between OCD and HCPs
• However did find a difference in confidence in their memory

Question 11

Give some evidence for a neuroanatomical/ functional aspect of OCD?

Answer 11

No consistent findings.

However, Swedo et al, 1992:

• Orbitofrontal-subcortical hypothesis
• Improvements in OCD correlated with reduction in activity of orbitofrontal cortex.

Question 12

Give some evidence for a neuropharmacological aspect to OCD?

Answer 12

Rapoport et al, 1989:

• Serotonin hypothesis
• Based on success of tricyclic or SSRI treatments in OCD

Separate research has suggested a role for dopamine, due to some evidence for efficacy of augmentation therapy using anti-psychotics.

However Veale et al (2014) dispute this, claiming that only small or modest effect sizes were shown for Risperidone augmentation, and none at all for other anti-psychotics such as Olanzapine (on meta-analysis).

Question 13

What are the major limitations of the biological theories explaining OCD?

Answer 13

Can’t explain:

• The heterogeneity or specificity of symptoms (i.e. why someone might rather than wash)
• Effectiveness of certain therapies, for example in vivo exposure response therapy has shown to be beneficial (if OCD is neurochemical why would these therapies have an effect?)

Question 14

Briefly outline the psychoanalytical theory of OCD?

Answer 14

• Freud; ID vs Superego
• Adler; Reaction to over control in early environment
• Others have described it as a minor psychosis
• therapies are based around lifting repression and airing unresolved conflict in the open.

Issues:

• Doesn’t explain relief patients will eventually experience when they are prevented from performing their rituals
• Doesn’t explain the fact that intrusive thoughts occur in 90% of normal people (Rachman et al, 1978)

Question 15

Briefly outline the behavioural theory of OCD?

Answer 15

Classical Conditioning –> Obsessions
Operant Conditioning –> Compulsions

Rachman, 1971:

• Obsessional thoughts have become associated with anxiety through class conditioning
• Compulsions are reinforced through operant conditioning

Has solid basis in interventions, can give Exposure and Response Prevention therapy

Question 16

What is the key study supporting Rachman’s behavioural model, and outline it?

Answer 16

The Spontaneous Decay study (Rachman et al, 1971):

• Provoked the urge to check in 12 obsessional checkers
• Half allowed to check immediately and half asked to wait
• Immediate checking lead to a reduction in anxiety, but similar reductions were observed in the waiting group after about an hour
• Shows that anxiety around OCD will eventually decay spontaneously
• Anxiety and O/Cs are associated with each other but not one and the same, can be disassociated (as per Class Con explanations)

Question 17

What did Rachman and De Silva show in 1978?

Answer 17

• Intrusive thoughts (characteristic of OCD) occur in 90% of people without OCD
• Content was virtually indistinguishable from OCD intrusions
• Suggests OCD is an abnormal manifestation of potentially normal processes

Question 18

What is Exposure and Response Prevention?

Answer 18

• OCD therapy developed by Rachman
• Involves prolonged, repeated, consistent and agreed exposure to the feared stimulus +
• The identification and cessation of any responses which interfere with this exposure
• Hopefully leading to extinction or habituation

Question 19

What problems have been identified with behavioural therapy?

Answer 19

• Often doesn’t generalise
• High levels of non-adherence and drop out (requires putting yourself through high levels of anxiety)
• Doesn’t work on non-compulsive obsessions (e.g. aggressive or religious obsessions)

Question 20

Outline the Cognitive-Behavioural model of OCD?

Answer 20

• Obsessions are normal intrusive thoughts the occurrence and content of which vulnerable individuals tend to misinterpret as somehow indicative of impending harm
• Normal obsessions become problematic when either their occurrence or content is interpreted as personally meaningful and threatening
• (especially if cognitions are interpreted as an indication that the person may have been or will soon be responsible for harm or its prevention)
• Patients may also have increased sensations of responsibility with regards to these thoughts e.g. I am the only one who can prevent this harm or me thinking this is as bad as me doing it

Question 21

What are the six key belief domains identified as being relevant to OCD in the Obsessive Compulsive Cognitions Working Group, 1997?

Answer 21

• Inflated sense of responsibility
• Threat over-estimation
• Perfectionism
• Need for certainty
• Over-importance of thoughts
• Control of thoughts

(Either cognitive or behavioural factors which could make a person misinterpret an O/C)

Question 22

What are some common maintaining factors exhibited by OCD patients?

Answer 22

• Emotional reasoning
• Counterproductive safety seeking behaviours
• Reassurance seeking
• Attention/reasoning biases
• Internally referenced criteria
• Thought suppression
• Rumination
• Avoidance

All have the same effect: they prevent disconfirmation, increase the stimulus and increase preoccupation

Question 23

What forms of OCD therapy are based around the cognitive-behavioural theory

Answer 23

CBT and ERP. Both focus on interpretations and beliefs.

Key processes:

• Normalise intrusions
• Work out what is maintaining the problem
• Build evidence for less threatening account through behavioural experiments and exposure-response-prevention
• Therefore changing beliefs experientially

Question 24

What evidence supports the use of CBT in OCD?

essentially evidence supporting the role of a cognitive or behavioural element in OCD

Answer 24

Rowa et al, 2005:

• Showed that intrusive thoughts are more troubling when content is divergent from personal values
• Shows role of cognitions in OCD

Giele et al, 2012:

• Checking, Thought suppression and Avoidance increase sense of danger and doubt
• Increase frequency of and preoccupation with thoughts

Arntz et al, 2007:
- Experimental manipulations of responsibility influence checking behaviour

Question 25

What has research such as Steketee et al (2003) shown about belief domains?

Answer 25

Compulsion belief domains can be condensed into three factors: - Responsibility and threat over estimation - Perfectionism and intolerance of uncertainty - Importance and control of thoughts Steketee et al showed that: - Participants with clinical OCD are higher in these domains than healthy controls - Although these domains certainly weren't specific to OCD - There was an association between which domains were exhibited strongest and manifestation of OCD symptoms HOWEVER, a large proportion of patients with OCD do not score especially highly in these domains. Shows heterogeneity of condition and how this theory is potentially lacking

Question 26

Give some evidence in support of CBT and ERP's role in treating OCD?

Answer 26

Ost et al, 2015: - CBT and ERP both effective - Group and individual therapies both effective - CBT + medication was no better than CBT + a placebo - (although they also commented that most of the RCTs they covered suffered from cleat methodological issues, garbage in garbage out) McKay et al, 2015: - Review of meta-analyses conducted on ERP and CBT - Effects of both are durable - ERP should be first line - Although this is dependent on symptoms, as other therapies may be more effective at managing, for instance, sexual or religious obsessions - Combining the two can lead to improved distress tolerance, symptom related dysfunctional beliefs, adherence and reduced drop out rates

Question 27

What are some known issues about use of CBT in OCD?

Answer 27

- 30% of people either refuse treatment, drop out or do not respond - 50% have residual symptoms after treatment - Unknown what mediates or moderates outcome

Question 28

What are the various components of the cognitive model of OCD?

Answer 28

- Early experiences: predisposition, vulnerability - Assumptions: beliefs about self/others/the world - Intrusions: thoughts, images, impulses and doubts - MEANING behind these intrusions: risk assessment, inflated sense of responsibility - Safety seeking behaviours: checking, rituals, avoidance, suppression - Attention and Reasoning biases: seeking out triggers - Mood changes: distress, anxiety, depression

Question 29

What does the evidence say about CBT vs ERP?

Answer 29

- Essentially impossible to compare, two are so similar and often overlap massively, so findings are unclear. - Whittal et al, 2005, showed benefits to both (ERP lead to belief change, but CBT lead to slightly better improvements and recovery rates) - McKay et al, 2015, showed that ERP with imaginal exposure to catastrophic outcomes was associated with largest effect size

Question 30

What are some predictors of poor CBT outcome?

Answer 30

- Earlier onset - Symptom severity - Depression - Subtypes (mixed evidence but obsessions of a sexual or religious nature are traditionally associated with worst outcomes) - High levels of family accommodation BUT strong evidence all of these can be overcome by giving the patient more sessions or more intense sessions

Question 31

What are some predictors of better outcome in CBT?

Answer 31

- Treatment adherence (in any form e.g. attendance to group therapy, engagement, homework completion) - Involving families in treatment

Question 32

What are the current UK NICE guidelines for the stepwise management of OCD in adults?

Answer 32

Step 1: Awareness and recognition Step 2: Recognition and assessment Step 3: Brief individual or group CBT/ERP with SH materials, or SSRI Step 4: CBT + SSRI, consider alternative SSRI or Clomipramine Step 5: Consider augmentation strategies or admission Step 6: Care coordination, as above and consider admission or special living arrangements

Question 33

Outline how a CBT programme for OCD might run?

Answer 33

Sessions 1-3: - Assessment and formulation - Developing an alternative explanation (theory A vs theory B) - Setting goals Sessions 4-8: - Building up belief in theory B through behavioural experiments (including but not limited to ERP) - Additional interventions as required e.g. addressing thought-action fusion, responsibility beliefs, working with significant others - Work on generalising Sessions 9-12: - Relapse prevention - Follow ups recommended

Question 34

What assessment or monitoring tools can be used for OCD?

Answer 34

- Y-BOCS (Yale-Brown OC scale) - OCI (OC Inventory) - Obsessive beliefs questionnaire - RAS and RIQ

Question 35

How can Normalising techniques be used to treat OCD?

Answer 35

- Intrusive thoughts, images, doubts are very common - They can even be helpful - People are upset by thoughts they don't like, that don't fit in with their values and beliefs - Appraisal of thoughts is dependent on context, even positive thoughts can be upsetting Goal is to make patient realise what they are experiencing is essential normal, reducing anxiety surrounding it

Question 36

How can Theory A vs B be helpful in OCD CBT?

Answer 36

- Challenging the problem is difficult without an alternative explanation - Contrast the person's threat appraisal with an alternative and less threatening explanation - e.g. namely that the problem is a worry or confidence issue - Therapist then draws up both therapies and see which fits most, which makes most sense - Examine the evidence in favour of theory A and B - Importantly both parties come up with a plan for what to do if either theory proves to be true

Question 37

How can goals be used in the context of CBT to treat OCD?

Answer 37

Short term goals can reasonably be attempted in the next few sessions, starting now Medium term goals, what can be achieved by the ned of therapy Long term goals are what the client would like to do over the next few years

Question 38

What behavioural techniques can be used to treat OCD?

Answer 38

- Thought suppression - ERP - Testing out particular beliefs - Imaginal exposure (loop tapes, have patient record their obsession and listen to it over and over until it loses all meaning) One method involves obsessing over positive things and see how those don't happen either. Alternatively imagine negative things happening to others and watch as those also don't ever happen.

Question 39

How can you build up patients faith in theory B?

Answer 39

- Act out as if it's definitely true - Treat thoughts as just thoughts - Learn to tolerate anxiety, temporarily - behavioural experiments such as ERP enable them to discover what happens to beliefs and anxiety when nothing is done Crucially, theory B must involve them reclaiming their life for them to stick to it

Question 40

How should you go about ending CBT treatment?

Answer 40

- Space out last few sessions to allow for real world practice and follow up sessions - NICE says after successful treatment patients should receive a review every 12 months - Rapid re-refferal in cases of relapse - Emphasis flexibility, can be difficult adjusting to life post OCD - Create a blueprint for post-OCD life (with relapse prevention plan - Own notes or recordings, so there is always something to refer back to

Question 41

What evidence is there regarding treatment resistance in OCD?

Answer 41

- OCD has high rates of supposed treatment failure - However, Rachman (1983) described the difference between serious failure (adequate delivery but failure to progress) and technical failure (treatment not delivered appropriately) - Stobie et al (2007) suggested as much as 84% of patients considered treatment refectory are actually in the technical category - In reality treating OCD is very difficult and often therapists just get it wrong