This document provides an overview of cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD). It defines obsessions and compulsions, describes common OCD symptoms and cognitive biases, and outlines the CBT model for treating OCD, including cognitive restructuring, exposure and response prevention techniques, and assessment of patients. The goal of CBT for OCD is to help patients learn to live with uncertainty and reduce avoidance behaviors by exposing them to feared thoughts and situations without performing compulsions.
This document provides an overview of cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD). It defines obsessions and compulsions, describes common OCD symptoms and cognitive biases, and outlines the CBT model for treating OCD, including cognitive restructuring, exposure and response prevention techniques, and assessment of patients. The goal of CBT for OCD is to help patients learn to live with uncertainty and reduce avoidance behaviors by exposing them to feared thoughts and situations without performing compulsions.
This document provides an overview of cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD). It defines obsessions and compulsions, describes common OCD symptoms and cognitive biases, and outlines the CBT model for treating OCD, including cognitive restructuring, exposure and response prevention techniques, and assessment of patients. The goal of CBT for OCD is to help patients learn to live with uncertainty and reduce avoidance behaviors by exposing them to feared thoughts and situations without performing compulsions.
This document provides an overview of cognitive behavioral therapy (CBT) for obsessive-compulsive disorder (OCD). It defines obsessions and compulsions, describes common OCD symptoms and cognitive biases, and outlines the CBT model for treating OCD, including cognitive restructuring, exposure and response prevention techniques, and assessment of patients. The goal of CBT for OCD is to help patients learn to live with uncertainty and reduce avoidance behaviors by exposing them to feared thoughts and situations without performing compulsions.
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CBT for OCD
Basic Principles Prof. Tamer A. Goueli & Dr. Maie Helmy Cairo University What is an OBSESSION? Definition of an Obsession
An obsession is an unwanted intrusive thought, doubt, image or urge
that repeatedly enters a person’s mind. Obsessions are Universal • Intrusive thoughts, doubts or images are almost universal in the general population and their content is indistinguishable from that of clinical obsessions. • The difference between a normal intrusive thought and an obsessional thought lies both in the meaning that individuals with OCD attach to the occurrence or content of the intrusions and in their response to the thought or image. Definition of an Obsession
Obsessions are distressing and ego-dystonic but are acknowledged as
originating in the person’s mind and as being unreasonable or excessive. A minority are regarded as overvalued ideas and, rarely, delusions. What is a COMPULSION? Definition of a Compulsion
• An irresistible persistent impulse to perform an act.
• The state of being forced to do something Compulsions • Can be overt “door checking”, or covert “mentally repeating a phrase”. • Highly reinforcing. • May function as a means of avoiding discomfort, as in obsessional slowness • Terminates when feeling comfortable not when the objective target has been achieved, e.g., hand cleaning. • Mainly safety seeking behaviour, e.g., checking for AIDs, repetitive questioning. The OCD Vicious Circle
• The content of obsessions, compulsions and avoidance behaviour in OCD
are closely related. • When avoidance is high compulsions are less, e.g., avoiding hand shaking. • An ever reinforcing cycle. Behaviour is the strongest reinforcer. Most Common Obsessions Contamination Doubt Intrusive Religious or Blasphemous Thoughts Intrusive Sexual Thoughts Intrusive Thoughts of Violence or Aggression The Need for Order & Symmetry Morbid Hesitancy Superstition Most common Compulsions • Checking (e.g. gas taps; reassurance-seeking) • Cleaning/washing • Repeating actions • Mental compulsions (e.g. special words or prayers repeated in a set manner) • Ordering, symmetry or exactness • Hoarding Thought Action Fusion Thought Action Fusion • An important cognitive process in OCD is the way thoughts or images become fused with reality. This process is called ‘thought–action fusion’ or ‘magical thinking’ • A related process is ‘moral thought–action fusion’, which is the belief that thinking about a bad action is morally equivalent to doing it. • There is also ‘thought–object fusion’, which is a belief that objects can become contaminated by ‘catching’ memories or other people’s experiences Exaggeration of Danger (WCS) Responsibility Responsibility
• An overinflated sense of responsibility for harm or its prevention.
• Patients with obsessions appraisal of the harm is usually exaggerated and leads to severe anxiety. • Individuals with OCD believe they can and should prevent harm from occurring, which leads to compulsions and avoidance behaviours. Non-specific Cognitive Biases • Belief in being more vulnerable to danger • Intolerance of uncertainty, ambiguity and change • The need for control • Excessively narrow focusing of attention to monitor for potential threats • Excessive attentional bias on monitoring intrusive thoughts, images or urges • Reduced attention to real events Dominant Emotions in OCD
Anxiety Dominant Emotions in OCD
Disgust Dominant Emotions in OCD
Shame & Guilt
Dominant Emotions in OCD
Anger, Frustration, Irritability & Discomfort
Avoidance Behaviour • An integral part of OCD. • Includes avoidance of contamination, certain situations or behaviours. Part II: CBT for OCD A List of Obsessions • Repeating Wedo • Counting prayers • أغسل ايدي بعد أكل الموز كذا مره • I can’t touch kids HزجهHHت ائنا لHك • Drink in a separate cup, bottle and never after anyone. I have to be the first to eat or drink. • Fold everything into a perfect squareسكوتHHHو ورقة بHHحتيل A List of Obsessions • Take medicine in order from left to right. • All furniture and carpets have to be parallel or perpendicular. • Check my phone regularly after each call and every now and then • Open jars, bottles from the side not the top. • Clean tooth paste and soap. • Use odd numbers in everything 3 HلطهHHلقسHHاH مع5 ,لقرزHHاHمع A List of Obsessions • Wash my glasses after getting back home. • Wash and smell my hands regularly, specially after touching anything و ايا ديتولعليطولHمع • Climb stairs with my right foot first • Can’t eat food people prepared by hands. • Re-arrange everything in orderبقيمقلوبHHألسنانمينفعشيHHمعجونا • Use any pen while the cap is on the left side A List of Obsessions • Brush my hair from left to right. • Put brush on comb. • Open candy, chocolate bars on the right side HالسمHHبلاHHتفتح قHHHت • Hang the towel on the right side, left higher than right, dark side out. • If anything changes its place it is the end of the world. • Whenever I get back home, my clothes has to go into the laundry basket. A List of Obsessions • Everything must be perfect. • Taking control if I go out. • Hate stepping on my shoes بساهاHو مشالHHزمتيلHدوسعليجHHد يHيحHأ • Never change my place on the couch • Have to clean the W.C after anyone, and before using it.ألولHH أدخلاHزمHال The Classical CBT Model Steps of Therapy • List of Obsessions (nothing should be left out). • Help the patient create a hierarchy • Teach the patient the concept of CBT and how OCD operates. • Tackle thoughts and behaviour simultaneously • Exposure and Response prevention Working on Obsessive Thoughts
Initially it involves having sufferers develop a healthy and informed
understanding of how the mechanisms of OCD operate. Help the patient understand ideas of cognitive fusion (and even test it), over estimation of danger and heightened responsibility. (Cognitive Conceptualization) Working on Obsessive Thoughts
The main target is to make the patient that he/she needs to live with doubt.
The Target is to tolerate uncertainty, not to eliminate it.
Working on Obsessive Thoughts
Teaching the patient to constantly re-examine the logic of the Automatic
thoughts.
Keep asking WHY?
“It is not me, it is my Obsession” Working on Obsessive Thoughts Interpretation of obsessional meaning, degree of danger (evidence) and possible alternatives.
Evidence (Facts), not Interpretations or doubt (what ifs?)
Working on Obsessive Thoughts
• Work on erroneous beliefs, e.g. safety and contamination.
• Teach the patient to acknowledge & reframe their obsessive behaviour. • “I washed my hands because I could not tolerate the anxiety, not because there was a real chance of contracting AIDS. Working on Obsessive Thoughts
• Why isn’t medicine enough?!!!
• Fighting an occupational force that will fight back. • Changing structure and habits. Exposure & Response Prevention (ERP) • The goal of ERP is straightforward – to expose one’s self to the feared thought or situation, without doing any compulsive or avoidant responses. • Explain the reinforcing nature of compulsions. • Start with the least anxiety provoking obsession and move up the ladder. • The main concept is de-learning, i.e. habituation, extinction, desensitization. Exposure & Response Prevention (ERP) • Exposure can happen during sessions (real and imaginary). • Point out the compulsions & avoidance behaviour that happens in session. • Learning to live with the “anxiety”, i.e. tolerating the discomfort. • Response prevention can be partial (decrease the number of compulsions). • Delaying response is a step on the way. • Distraction can be used to delay or prevent response. • Involve family when possible. Assessment of OCD for CBT Assessment Nature of the Obsession: • Content • Degree of insight • Frequency • Triggers • Feared consequence • Meaning of the obsession to the patient Assessment
Emotional State • The main emotion related to the obsession or intrusion. • Ego syntonic or dystonic. • Associated secondary mood Assessment Compulsions and Neutralizing Behaviour: • Degree of stress on resistance • Feared consequence of resistance • How is the compulsion terminated (number of repetitions, degree of comfort). • Frequency Assessment Avoidance Behavior: • Rated on a scale from 0-100 • Frequency • Degree of distress that leads to avoidance Assessment Family Involvement: • Degree of accommodation of the obsessions. • Expressed emotions towards the patient’s behaviour (e.g., hoarding, bathroom use, etc….). • Degree of distress of family members. • Identify the role they can play in the treatment process. Assessment
Degree of Handicap: Social, Physical & Occupational
Assessment
Commitment to Change and ability to join CBT
Assessment Use of Scales: • The Yale–Brown Obsessive–Compulsive Scale • The Obsessive–Compulsive Inventory • Helps to set a baseline for therapy and can be used in follow-up.
