CBT of OCD

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CBT FOR OCD
Dr V.Sabitha
Associate Professor
Institute of Mental Health
Chennai

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WHY CBT FOR OCD?
 All thought processes arise from activity in
appropriate neural circuits.
 OCD phenomena arise from aberrant thought
processes, likely due to disturbances in the cortico-
thalamo-striatal circuitry.
 Neural circuits can be strengthened or weakened.
 Drugs modulate neural circuit activity through
receptor effects and later neuroplasticity changes.
 CBT triggers learning which is hardwired into the
brain, and may be more enduring in its effects.

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BIOLOGICAL EFFECTS OF
CBT IN OCD
 Decreased metabolic activity in the right caudate
nucleus (reviewed by Linden, Molecular Psychiatry 2006).
 Decreased right frontal anterior cingulate cortex
and bilateral thalamic activity (Saxena et al, Molecular
Psychiatry 2009).
 Etc.

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TREATMENT OF OCD
 SRI drugs and CBT
 Meta-analysis 1:
 Effect size for drugs was 0.48 (13 trials)
 Effect size for CBT was 1.45 (5 trials)
 (Watson and Rees, J Child Psychol Psychiatry 2008)
 Meta-analysis 2 (13 trials):
 Effect size for group CBT pre vs post: 1.18
 Effect size for group CBT vs wait list controls: >1.12
 (Jonsson and Hougaard, Acta Psychiatrica Scand 2009)

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ADVANTAGES OF CBT
 Effective as monotherapy.
 Large effect size [caveat: biases
could arise from sample selection
and consenting processes].
 Improves long-term outcomes
with drugs.
 Treating with drugs+CBT may
offer the best outcomes.

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TREATMENT OF OCD
 The proper treatment of
OCD with CBT requires a
complete understanding of
the spectrum of symptoms
that the patient displays.

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OCD
 Prevalence, 2-5% (severe in 0.5%)
 The only DSM-IV anxiety disorder in which anxiety
is not the main symptom.
 Primary symptoms: obsessions and/or compulsions.
 Secondary symptoms include depression.
 Underlying OCPD in 50% of patients.
 Comorbidities include tic disorder.
 OCD may be secondary to other conditions; e.g.
schizophrenia, atypical antipsychotic therapy.

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NOTE
 By definition, mental preoccupations or repetitive
behaviors are not considered under OCD if they
occur in the context of another DSM-IV Axis I
disorder
(e.g. hypochondriasis; eating disorders;
trichotillomania)

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OBSESSIONS AND
COMPULSIONS
 Obsessions are repeated thoughts.
 E.g. “My son is going to die.”
 E.g. “I will get AIDS.”
 Compulsions are repeated actions.
 E.g. Handwashing.
 Every time a patient sees a picture of a deity, he
feels compelled to say a short, mental prayer to
the deity. Is this an obsession or a compulsion.
 [In CBT, the approach to treatment differs between
obsessions and compulsions.]

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COMPULSIONS
 Thoughts which are deliberately repeated to
relieve anxiety are compulsions, not obsessions.
 E.g. Compulsively repeating a prayer a certain number
of times to ward off evil after a trigger event.
 E.g. Repeating a prayer over and over again just in
case it was not properly said previously (scrupulosity).
 Important to differentiate obsession from
compulsion because the treatment approach is
different.

11. PSYCHOPATHOLOGY OF
OCD
 Fear acquired through classical conditioning and
maintained by operant conditioning
 Eg. Checker associates electrical
appliance(conditioned stimulus) with
death(unconditional stimulus;danger of fire) and
thus feels anxiety (unconditional response and
conditioned response) in the presence of a stove
 Checking behaviour:Negative Reinforcer as it
removes anxiety
11

12. OCD COGNITIONS
 Inflated sense of Personal Responsibility
 Undue Importance to Thoughts
 A need to control thoughts
 Overestimation of threat
 Intolerance of Uncertainity
 Perfectionism
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TYPES OF OBSESSIONS
[obsessions provoke anxiety]
 Obsessive thoughts
 Obsessive ruminations
 Obsessive doubts
 Obsessive vacillations
 Obsessive phobias
 Obsessive impulses
 Obsessive images

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TYPES OF COMPULSIONS
[compulsions relieve anxiety]
 Almost always secondary to obsessions
 May be behavioral or mental
 Yielding:
 Counting
 Checking
 Ordering
 Cleaning/washing
 Resisting:
 Repeating thoughts or actions to prevent or undo a
feared event
 (Overlap may be present)

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ASSESSMENT
(2-4 h)
 It is important to comprehensively document all
aspects of the phenomenology present.
 List all obsessions.
 List all compulsions.
 Understand the contexts which generate each.
 Arrange in a hierarchy of severity.
 Assess insight into the irrationality of each.
 Assess motivation to change each.

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ASSESSMENT
(contd.)
 Make a chart with each symptom rated:
 Frequency (occasions per day)
 Time spent (minutes or hours)
 Distress (0-10)
 Impairment (0-10, with examples of impairment)
 Overall severity
 This chart can be used to monitor progress.
 Use the Y-BOCS or LOI or other scales.

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YALE-BROWN OBSESSIVE-
COMPULSIVE SCALE
 10 items (5 for obsessions, 5 for compulsions)
 Semi-structured interview based on an explanation
to the patient about what obsessions and
compulsions are.
 Rated 0-4; range of possible scores, 0-40
 For obsessions: Time occupied by obsessive
thoughts, obsession-free interval, interference,
distress, resistance, control.
 Ditto for compulsions.

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LEYTON OBSESSIONAL
INVENTORY
 69 items
 Identification of OCD s/s
 Assessment of resistance
 Assessment of interference
 Plus: Common OCD s/s listed individually
 Minus: Rare s/s are omitted.

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CORNERSTONES OF CBT
 Common to both obsessions and compulsions:
 Psychoeducation
 Challenging assumptions
 [Family support, if indicated]
 Obsessions:
 Thought-stopping
 Distraction
 Compulsions:
 Exposure
 Response prevention

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CBT FOR OBSESSIONS
 Psychoeducation
 Challenging assumptions
 Family support
 Thought stopping
 Distraction

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PSYCHOEDUCATION FOR
OBSESSIONS
 Explain about OCD
 Destigmatize the illness
 Explain the principles of drug
therapy
 Explain the principles of CBT
 Discuss plan of management
 Review patient understanding
 Time: 1-2 hours

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CHALLENGING
ASSUMPTIONS
 Obsessions are, by definition, irrational thoughts.
 Patients don’t always recognize their irrationality.
 Taking each obsession by turn, challenge the
flawed logic that underlies it.
 Goal: To reduce anxiety through the realization
that the thought is irrational and can be ignored.
 E.g. Obsessive fears: “What if that man [on the bus] is
carrying a bomb?”
 E.g. “What if I get AIDS?” [by using public cutlery]

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CHALLENGING
ASSUMPTIONS
 Generalization: The patient must
learn how to reduce anxiety by
arguing against his own beliefs
when the obsessions arise
outside the clinic.
 Challenging assumptions should
result in full insight. So, take as
much time as the patient requires
to fully grasp, appreciate, accept,
and articulate the arguments.

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THOUGHT-STOPPING
 Terminates the obsession
 Slapping the table or pinching one’s thigh
 Shouting stop
 Snapping a rubber band on the wrist
 Doing these physically or imaginally

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OTHER DISTRACTOR
TECHNIQUES
 Taking up a chore that demands attention
 Phoning a friend
 Speaking to a family member
 Examining details in the environment
 Etc. [plan these out]

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STRATEGY FOR TACKLING
OBSESSIONS
 Take one obsession at a time.
 Go from education to challenging assumptions to
thought stopping and distraction.
 Preferably move to the next obsession only after
the previous obsession has been satisfactorily
overcome.

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CBT FOR COMPULSIONS
 Psychoeducation
 Challenging assumptions
 Recruit family support
 Exposure
 Response prevention

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CHALLENGING ASSUMPTIONS:
CHECKING COMPLSIONS
 Did I lock the door?
 Strategy
 Be aware that this is a problem.
 When locking, say “I have done it” [lays memory trace].
 When the doubt arises, recall the memory.
 Learn to trust the memory [if you cannot trust yourself,
whom will you trust?]
 Recall past experience [has there been any occasion that
you checked and repeatedly checked and found that the
door was unlocked?]

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CHALLENGING ASSUMPTIONS:
WASHING COMPLSIONS
 What is dirt?
 Why is dirt dirty?
 When is dirt dirty?
 Can dirt be good (prevents allergy, builds immunity)
 Why is water clean?
 Note that, after the first wash, washing/soaping
removes layers of skin, not dirt.

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MORE ABOUT DIRT
 Why are bodily secretions
dirty the moment they leave
the body?
 Smelling a fart and airborne
particles
 Do not tell the patient this!

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CHALLENGING
ASSUMPTIONS
 [Same as with obsessions]
 E.g. for checking whether a door was locked
 E.g. for removing dirt from the hand
 E.g. for repeated rituals lest a deity be offended
 E.g. for repeated rituals after stepping on paper
 E.g. for rituals that seek to ward off harm.

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CHALLENGING
ASSUMPTIONS
 Challenging assumptions should result in full
insight. So, take as much time as the patient
requires to fully grasp, appreciate, accept, and
articulate the arguments.
 This is necessary to ensure motivation in exposure
and response prevention exercises.

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EXPOSURE AND RESPONSE
PREVENTION
 Systematic desensitization
 Flooding
 Imaginal (as part of the desensitization hierarchy, or if in
vivo exposure is not feasible)
 Voluntary response prevention (should not be forced
by family, hospital staff e.g. as in turning off the water supply
in a patient with washing compulsions)
 Goal: Anxiety reduction through habituation
 Time: At least 30-120 min per exposure session;
anxiety reduction must be substantial.

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EXPOSURE AND RESPONSE
PREVENTION
 E.g. stepping on paper
 E.g. touching footwear
 E.g. handling currency notes
 E.g. checking a locked door
 Therapist-assisted exposure (provides
support)
 Self-driven exposure (provides
confidence, improves generalization)

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DEALING WITH
BATHING RITUALS
 Identify and tackle underlying obsessions.
 Break up the rituals into their component parts
[wetting, soaping, rinsing, wiping].
 Define what is the purpose of each, and what is the
normal limit of behavior for each.
 Practice behavior within these set limits while
simultaneously challenging the assumptions which
were responsible for the obsessions.

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DEALING WITH RELIGIOUS
OBSESSIONS AND RITUALS
 Understand the cultural context.
 Tread carefully, respect beliefs, challenge
assumptions only with informed consent.
 Discuss source of beliefs and practices; consider
the ‘tying the dog story’.
 Probe inconsistencies between obsessions and
beliefs about the nature of God.
 Remind patient that idols and pictures are
representations, not personifications, of God.

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DEALING WITH
OBSESSIVE SLOWNESS
 Suggestions:
 Challenge assumptions.
 Set timetable with
attention to problem
specifics.
 Enlist family supervision.

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COMMENTS
 Patients sometimes develop
substitute rituals after their
primary symptoms are addressed.
 E.g. rubbing hands to replace
washing.
 Not all patients are suited for
CBT; not all patients will respond;
however, some improvement is
better than no improvement.

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SESSIONS
 3-5 sessions a week for 3-5 weeks.
 Each session up to 2 hours.
 15 min for review of previous session, homework.
 45-90 min for exposure and response prevention.
 15 min for setting homework.
 Ideally, when a symptom is addressed, there should be
100% compliance with therapy directions [e.g. response
prevention]; otherwise, the therapy work is undermined.
 Booster sessions (maintenance therapy).

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IMPORTANT THERAPIST AND
CLIENT CHARACTERISTS
 Client:
 Motivation and compliance
 Therapist:
 Effort to identify the symptoms in their entirety
 Ability to successfully challenge assumptions.

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ENFIN…
 That’s it, folks;
thanks for listening!