Obsessive

Compulsive
Disorder
Presented By:
1. Kanza Batool
2. Muhammad Zeeshan
3. Nimra Riaz
4. Sibgha Sarwar
Contents of our Presentation

Muhammad Zeeshan 1. Introduction to OCD

2. Models of OCD

Kanza Batool Case Formulation of OCD

Nimra Riaz Aims of Cognitive Therapy

Sibgha Sarwar 1. Behavioral Retribution

2. Additional consideration
 01.
Introduction
I just feel, its not clean!!!
 Introduction

Definition: OCD is characterized by recurrent obsessions or compulsions that are time-consuming

or cause significant distress.
Obsessions: Intrusive and inappropriate thoughts, impulses, or images (e.g., contamination fears,
aggressive impulses).
Compulsions: Repetitive behaviors or mental acts aimed at reducing anxiety (e.g., hand washing,
praying).

1. Overt compulsions include hand washing, checking, ordering or alignment of objects.

2. Covert compulsions are mental acts such as praying, counting, or repeating words. The
goal of these acts is to prevent or reduce anxiety or distress.
 Prevlence
Normal obsessions occur
in 80–88% of individuals
The content of normal and
without causing distress or
abnormal obsessions is
impairment.
often similar.

Lifetime prevalence of
Six-month prevalence rate
OCD is approximately
of OCD is about 1.6%,
2.5%.
making it the fourth most
common psychiatric
disorder in the USA
 Cognitive Models of OCD

Perfectionistic Beliefs: Some models emphasize the role of perfectionistic standards in

OCD (McFall & Wollersheim, 1979).
Inflated Responsibility: Patients may feel an exaggerated sense of responsibility for
preventing harm (Rachman, 1976; Salkovskis, 1985).
Thought-Action Fusion: The belief that thinking about an action is equivalent to
performing it (Rachman, 1993).
Meta-Cognitive Beliefs: Concerns about the control and consequences of thoughts
(Clark & Purdon, 1993; Wells & Matthews, 1994)
 Wells and Matthews Meta-
Cognitive Model
Intrusions and Beliefs: Intrusions activate beliefs about their significance, leading to
distress.
Thought-Action Fusion: Beliefs that equate thoughts with actions increase anxiety and
checking behaviors (e.g., thinking about harming children means one might harm them).
Behavioral Responses: Behaviors like checking are intended to neutralize intrusions but
often reinforce them.
Reinforcement of Neutralizing: Behaviors aimed at reducing anxiety can become
sources of distress due to their time-consuming nature.
 Salkovskis Cognitive Model
Appraisal of Intrusions: Distress from OCD arises from how patients appraise intrusive
thoughts as significant and dangerous.
Inflated Responsibility: Patients feel they must neutralize thoughts to prevent harm,
leading to compulsive behaviors (e.g., hand-washing).
Thought-Action Fusion: The belief that thinking about an action is equivalent to
performing it (Rachman, 1993).
Neutralizing Responses: These behaviors temporarily reduce anxiety but reinforce the
belief in their necessity.
Automatic Thoughts: Negative appraisals occur as automatic thoughts, often
exacerbated by depressed mood, leading to more frequent intrusions
Working Model
 02.
Case Formulation
How does it work? Whats the
logic Behind it??
 Developing Case
Formulation
In order to translate the preliminary model into individual case
formulation it is necessary to elicit information concerning
1. Nature of the obsessional and compulsive symptoms;
2. Triggering influences
3. Appraisals of the meaning and significance of obsessions and
compulsions.
 Symptom Profile

OCD symptoms can be assessed in terms of parameters

such as frequency, duration and associated distress using
subjective visual analogue ratings or diary measures.

The data can be useful for discovering patterns in symptoms,

and establishing triggers and relationships among affect,
intrusive experiences and situational cues
 Trigging Influence

• Therapists should review with the patient’s recent obsessive compulsive episode and
attempt to elicit triggers for overt and covert neutralizing, checking behavior .
• An initial aim of treatment should be to increase the patient’s level of meta-cognitive
awareness so that he/she is able to identify intrusive thoughts, doubts or feelings
prior to the commission of behavioral responses.
• This task can be initiated through a detailed review of several recent episodes,
through behavior tests involving exposure to problematic situations, and through
detailed self-monitoring.
 Eliciting dysfunctional appraisals

• Therapists should aim to explore different categories of

appraisals of intrusions, and of responses to intrusions.
• In assessing appraisals of intrusions, questions should be
directed at eliciting dangers linked with intrusions, and the real-
world validity of intrusions.
 Appraisals of intrusions

• When you had (intrusion) how did you feel (e.g. anxious, afraid, guilty)?
• When you felt (e.g. anxious) what thoughts went through your mind?
• Did you have any negative thoughts about the intrusion?
• What did having the thought mean to you?
• What sense do you make out of having these intrusions?
• Do they tell you anything? What do they tell you about your actions or about events?
• Could anything bad happen as a result of having the intrusion? What could happen?
• Does the intrusion mean something bad has happened? What is that?
• Is it normal to have thoughts like this?
• What would happen if you couldn’t get rid of these intrusions? What’s the worst that could happen?
 Appraisals of behavioral
responses
In developing cognitive conceptualizations of OCD it is
useful to explore the appraisals and beliefs associated
with the use of ritual behaviors. Some patients are fearful
of giving up behaviors because of negative beliefs
concerning the consequences of doing this. In other
words they have positive beliefs about rituals. In some
cases negative beliefs about rituals exist that contribute
to distress
 Example!!
In a recent case of compulsive finger-nail cleaning, it was
evident that the behavior was triggered by subjective
feelings of distress. The individual concerned believed that if
she did not perform the behavior her emotions would
become ‘overwhelming’ and she would not be able to
function. Furthermore, she believed that her negative
feelings would become permanent. However, she also
reported negative appraisals concerning loss of control of
her ritual finger-nail cleaning. This negative appraisal
contributed to her general level of distress, thus increasing
the perceived need to engage in the ritual. Thus the patient
was trapped in a vicious cycle of feeling compelled to
perform the ritual to reduce distress but appraising the ritual
in a way that contributed to distress.
 Question…
• Do you do anything to prevent (catastrophe associated with intrusion) from happening?
• What do you do?
• Could anything bad occur if you continue to use the strategy? What is that?
• What’s the worst that could happen if you didn’t use the strategy?
• Are you bothered by (checking, neutralizing, ruminating)? (If so) Why don’t you just stop?
• How much control do you have over your (checking, neutralizing, rumination)?
• What’s the worst that could happen if you don’t stop it?
• How does (checking, ruminating, neutralizing) help?
• Does your (checking, ruminating, neutralizing) keep you safe in some way?
• How does that work?
• Have you tried to stop? Is there a reason for not trying to stop?
• What happens to your feelings/thoughts when you are prevented from (neutralizing, etc.)?
 Case conceptualization in OCD

Jane Doe, 25, experiences significant distress from OCD. She fears contamination, leading to excessive
handwashing and cleaning. Her symptoms worsen over the past year, affecting daily life and work.
Background Information : Jane, a single graphic designer, has a history of anxiety and a family
history of anxiety and OCD. She had a normal childhood but exhibited early signs of perfectionism
and cleanliness anxiety. Core Beliefs Jane believes germs are omnipresent and harmful, and she is
responsible for preventing illness. Intermediate Beliefs : She holds attitudes, rules, and
assumptions emphasizing cleanliness as essential for health and believes she must clean
thoroughly to prevent sickness. Automatic Thoughts : Jane frequently thinks, "Did I touch
something dirty? I need to wash my hands again," and "This surface might have germs; I have to
clean it immediately. "Consequences : Her compulsions lead to high anxiety, fear of contamination,
guilt, and persistent worry. Behaviorally, she compulsively washes hands and avoids public places,
while cognitively, she struggles to focus on work. Maintaining Factors: Jane's beliefs about
contamination and responsibility, along with the temporary relief from anxiety after compulsions,
reinforce her behavior.
 Socialization

As usual, socialization proceeds by sharing the

conceptualization with the patient. Socialization
begins in communicating the concept that
negative beliefs about intrusions along with
behavioral responses, and worry about intrusions
are the main problem, rather than the
occurrence of the intrusion alone.
 03.
Aims of Cognitive
Therapy
What I think matters!!!!
 Modification of Dysfunctional
Appraisals and Beliefs
• Intrusive Experiences: Altering the perception of intrusive thoughts to reduce
their perceived danger.
• Thought-Action Fusion: Addressing the belief that thinking something is
equivalent to acting on it.
• Ritual/Checking Responses: Challenging beliefs about the necessity and
consequences of engaging in these behaviors.
• Adoption of Detached Acceptance: Encouraging patients to view intrusive
thoughts as irrelevant and unworthy of further action or processing.
 Overlap with Treatment of Generalized
Anxiety Disorder (GAD)

• Although there are specific differences in beliefs and behaviors

between GAD and OCD, some treatment strategies are
applicable to both conditions.
• In summary, cognitive therapy aims to change the way
individuals appraise and respond to their intrusive thoughts,
promoting a more detached and accepting attitude, and
leveraging behavioral experiments and the suspension of
rumination to achieve these changes.
 VERBAL REATTRIBUTION

• Worry-Postponement Strategies: Initially managing appraisal of intrusions by postponing

worry. This involves practicing detached mindfulness (Wells & Matthews, 1994, 1997), where
patients do not engage with intrusions through rumination or neutralizing strategies.
Instead, they passively let go of intrusions, reducing distress and demonstrating that
responses to intrusions are the problem, not the intrusions themselves.
• Disengagement from Intrusions: Some patients may be reluctant to disengage due to
beliefs about the negative consequences of not responding to intrusions. These beliefs
should be explored and weakened using verbal reattribution methods to enhance
compliance with behavioral experiments.
• Normalizing Obsessions: Educating patients that obsessions are normal and occur in
about 90% of people. This can be substantiated by showing research papers and
encouraging patients to conduct a mini-survey asking others about their experiences with
intrusive thoughts.
 CONT…

• Dysfunctional Thoughts Record (DTR): Recording the content of

worries about intrusions and challenging them using a modified DTR
for obsessional problems. This helps separate intrusions from worries
about intrusions, providing focus for treatment on the latter. Verbal
reattribution techniques, such as labeling cognitive distortions,
questioning evidence, and generating rational responses, can be
applied.
• Avoiding Rumination: The reattribution process should not become a
rumination experience. If there is a danger of this, it is better to return
to worry abandonment strategies and challenge underlying beliefs
through behavioral experiments.
 Thought–Action Defusion

• Explanation and Questioning: The concept of TAF is explained, and the mechanism is
questioned: ‘How does thinking a thought cause an action …?’. The incongruence of TAF
beliefs is also questioned: ‘What sort of a person is likely to worry about thoughts of
harming someone? Is it the sort who is likely to act on the thought? Are you the type of
person who wants to act on the thought? Where’s the evidence that you will?’
• Historical Review: Reviewing occasions when the patient experienced an obsessional
thought but was unable to neutralize it or prevent feared outcomes. These episodes serve
as evidence that thoughts do not lead to action.
• Behavioral Experiments: These are reviewed in the behavioral reattribution section. To
maximize effectiveness, detailed verbal pre-operationalization of the effects observable
based on TAF beliefs should be conducted, followed by thought manipulation experiments.
 Thought–Event Defusion

• Increasing Awareness: The therapist needs to increase patients’ awareness of the

influences of tacit knowledge. Patients often act as if their intrusive thoughts are valid,
leading to behaviors such as retracing their journey to check if they knocked someone
down.
• Challenging Beliefs: Thought–event defusion aims to challenge beliefs about the
ecological validity of intrusions and teach alternative strategies for responding. The first
step involves establishing a mental framework for an alternative belief system, socializing
patients in the role of tacit beliefs through guided discovery and hypothetical examples.
• Meta-Cognitive Level: Shifting patients from catastrophic thinking or feelings of
responsibility (Type 1 appraisal level) to challenging the ‘appraised’ validity of intrusions at
the meta-cognitive level (Wells, 1995). This involves focusing on the validity of the intrusion
and abandoning counter-productive invalidation strategies.
.
 Strategies

1. How does thinking a thought cause an action?

2. What sort of person is likely to worry about these thoughts?
3. Where's the evidence that you will act on these thoughts?

These strategies help patients understand the tacit nature of their beliefs and
challenge the perceived validity of their intrusive thoughts.
Identify Images
 CONT…

• Questioning Evidence: It can be helpful to question the evidence that supports the validity
of the image.
• Emotional Reasoning: When ‘feelings’ predominate as evidence, it can be useful to teach
the concept of emotional reasoning and have the patient label the feeling when it occurs as
part of devaluing the validity of the intrusion.
• Imagery Modification: Practicing imagery modification, where the patient is encouraged to
imagine having successfully completed an action after having completed it, serves as a
replacement for ‘mentally undoing’ the action in imagery or negative thought form.
• Temporary Strategy: This technique may serve as a temporary strategy for reducing the
emotional salience of imagery and its effect on urges to check, but it is not intended to
become a covert ritual in its own right.
.
 04.
Behavioural
Reattribution
What should I do?
 Behavioral Reattribution

A cognitive approach that reconceptualises the

aim of exposure a response prevention (ERP).
As a behavioral experiment for challenging
specific beliefs about intrusive thoughts and
ritual behaviors
 Exposure an response prevention: the
behavioral perspective

• The behavioral perspective is based on the principal that the actions

that relieve obsessive fear or discomfort are negatively reinforced.
• In order to overcome anxiety associated with obsessive stimuli it is
necessary to expose the individual to the stimuli in the absence of
rituals
• For example, an obsessional individual with contamination fears is
exposed to a feared contaminant (e.g. kitchen towel ) and prevented
from washing for an extended time period so that anxiety habituates
 Exposure and response prevention: A cognitive
reconceptualization

• Mental rituals in particular prolong rumination

episodes and maintain preoccupation with
thinking
• Overt rituals are easier to identify and manage
than mental rituals and thus the blocking of
them is more readily accomplished
 Exposure and response prevention: A cognitive
reconceptualization

• Mental rituals in particular prolong rumination episodes and

maintain preoccupation with thinking
• Overt rituals are easier to identify and manage than mental rituals
and thus the blocking of them is more readily accomplished.
• The cognitive perspective alters the rationale for exposure and
response prevention
• In a cognitive therapy framework, the rationale should emphasizes
on exposure to thoughts, contaminants, or events as a means of
challenging beliefs concerning the catastrophic nature of contact
with such a stimuli.
 Challenging specific beliefs

• Different forms of exposure and response prevention experiment

(ERP-E) can be used to challenge belief in negative appraisals and
predictions arising from the patient’s beliefs
• These include, increasing the frequency or duration of unwanted
thoughts in an attempt to cause a predicted catastrophe, or
behaving in ‘dangerous’ ways (that actually have no danger in
reality)
 Challenging specific beliefs

• Different forms of exposure and response prevention experiment

(ERP-E) can be used to challenge belief in negative appraisals and
predictions arising from the patient’s beliefs
• These include, increasing the frequency or duration of unwanted
thoughts in an attempt to cause a predicted catastrophe, or
behaving in ‘dangerous’ ways (that actually have no danger in
reality)
 Example!!
An obsessional patient had thoughts about harming herself
in her sleep. In particular she believed that she might hang
herself from the light cord while sleep walking. She also had
obsessional thoughts about knives. (Note: She had no desire
to harm herself or others.) In order to challenge her belief in
her thoughts about hanging herself during sleep, she was
asked to sleep with a length of rope coiled on the floor at
the foot of her bed. At first she was reluctant to engage in
the experiment as she believed 100 per cent that she would
harm herself. With careful explanation of the rationale for
the experiment and with the use of a graded approach in
which she practiced sleeping with the rope in another room
and then with it progressively closer to the bed, her belief
declined to 20 per cent.
 Cont…
• Once her confidence had increased the next step
involved sleeping with knives in the same room. Initially
they were kept in a box, and then a knife was placed on
the window-ledge in the bedroom. In this way the
patient learned that her thoughts about harming
herself or others were untrue
• This type of experiment can also provide a powerful
means of demonstrating that unwanted negative
thoughts of harming oneself or others in OCD do not
lead to performance of these actions (thought–action
defusion)
 Additional Considerations – Rituals and
emotional avoidance

• In some cases it seems that rituals are used to avoid unpleasant emotions, in a similar
manner to which Borkovec and Inz (1990) suggest that GAD subjects use verbal
rumination in the form of worry to avoid unpleasant affect
• Exploration of the meaning and significance of not eliminating unwanted affect
through the use of rituals
• Some claim that nothing bad would happen if they allowed the emotion to occur, but
that it would feel unpleasant
• While others express concepts of emotion running out of control or negative feelings
becoming permanent.
• Techniques such as activity scheduling, and encouraging patients to engage in new
‘absorbing’ activities such as hobby pursuits or exercise, can be helpful.
 Doubt reduction

• The occurrence of compulsive checking has been linked to deficits in

memory function in obsessive compulsives (e.g. Sher, et al., 1984, 1989).
• It is more likely that checkers merely show reduced confidence in their
memory.
• Tallis (1993) reports three cases of compulsive checking treated with a
doubt reduction procedure that used distinctive stimuli. The procedure
consisted of providing patients with a set of coloured cardboard shapes
(star, square, triangle, circle, rectangle). Each particular shape was the same
color (e.g. all triangles were red, all squares were green, etc.) but each shape
ranged in size forming a graded continuum of size. Tallis (1995) suggests
also that psychometric tests may be used to show patients that their
memory function falls within the normal range.
 Doubt reduction

• The occurrence of compulsive checking has been linked to deficits in

memory function in obsessive compulsives (e.g. Sher, et al., 1984, 1989).
• It is more likely that checkers merely show reduced confidence in their
memory.
• Tallis (1993) reports three cases of compulsive checking treated with a
doubt reduction procedure that used distinctive stimuli. The procedure
consisted of providing patients with a set of coloured cardboard shapes
(star, square, triangle, circle, rectangle). Each particular shape was the same
color (e.g. all triangles were red, all squares were green, etc.) but each shape
ranged in size forming a graded continuum of size. Tallis (1995) suggests
also that psychometric tests may be used to show patients that their
memory function falls within the normal range.
Obsessive-compulsive disorder is challenging to model and treat due to its
complexity. A new model is proposed in this chapter that explores the
relationships between cognitive, behavioral, and mood variables, along with the
influence of meta-cognitive beliefs. The model emphasizes the importance of
addressing beliefs related to intrusive thoughts, ritual behaviors, and emotions to
effectively treat OCD. Strategies focus on challenging and changing these beliefs
to reduce symptoms.

—The End