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disorder(OCD)recommendcognitivebehaviouraltherapy,includingexposureandresponseprevention, as an effective treatment for the disorder. This article introduces a cognitivebehavioural model of themaintenanceofsymptomsinOCD.Itdiscussestheprocessofengagementandhowtodevelopa formulationtoguidethestrategiesforovercomingthedisorder.
Delivering cognitivebehavioural therapy (CBT) forobsessivecompulsivedisorder(OCD)requires a detailed understanding of the phenomenology and the mechanism by which specific cognitive processesandbehavioursmaintainthesymptoms ofthedisorder.Atextbookdefinitionofanobsession is an unwanted intrusive thought, doubt, image or urge that repeatedly enters a persons mind. Obsessions are distressing and ego-dystonic but are acknowledged as originating in the persons mind and as being unreasonable or excessive. A minorityareregardedasovervaluedideas(Veale, 2002) and, rarely, delusions. The most common obsessionsconcern:
exampleistheurgetopushsomeoneontoarailway track. The difference between a normal intrusive thoughtandanobsessionalthoughtliesbothinthe meaningthatindividualswithOCDattachtothe occurrenceorcontentoftheintrusionsandintheir responsetothethoughtorimage.
Thoughtaction fusion
AnimportantcognitiveprocessinOCDistheway thoughtsorimagesbecomefusedwithreality.This processiscalledthoughtactionfusionormagical thinking(Rachman,1993).Thus,ifapersonthinks ofharmingsomeone,theythinkthattheywillact onthethoughtormighthaveactedonitinthepast. Arelatedprocessismoralthoughtactionfusion, whichisthebeliefthatthinkingaboutabadaction is morally equivalent to doing it. Lastly, there is thoughtobjectfusion,whichisabeliefthatobjects canbecomecontaminatedbycatchingmemoriesor otherpeoplesexperiences(Gwilliam et al,2004).
the prevention of harm to the self or others resultingfromcontamination(e.g.dirt,germs, bodily fluids or faeces, dangerous chemicals) thepreventionofharmresultingfrommaking amistake(e.g.adoornotbeinglocked) intrusivereligiousorblasphemousthoughts intrusive sexual thoughts (e.g. of being a paedophile) intrusivethoughtsofviolenceoraggression (e.g.ofstabbingonesbaby) theneedfororderorsymmetry.
Responsibility
OneofthecorefeaturesofOCDisanoverinflated senseofresponsibilityforharmoritsprevention. Responsibilityisdefinedhereas:Thebeliefthatone haspowerthatispivotaltobringaboutorprevent subjectivelycrucialnegativeoutcomes.Theseoutcomesmaybeactual,thatishavingconsequencesin therealworld,and/oratamorallevel(Salkovskis
David Veale is an honorary senior lecturer at the Institute of Psychiatry, Kings College London and a consultant psychiatrist in cognitivebehaviouraltherapyattheSouthLondonandMaudsleyTrust(CentreforAnxietyDisordersandTrauma,TheMaudsley Hospital,99DenmarkHill,LondonSE58AF.Email:David.Veale@iop.kcl.ac.uk;website:http://www.veale.co.uk)andthePrioryHospital NorthLondon.HeisPresidentoftheBritishAssociationofBehaviouralandCognitivePsychotherapies,wasamemberoftheNational InstituteforHealthandClinicalExcellencegroupthatproducedguidelinesontreatingobsessivecompulsivedisorder(OCD)andbody dysmorphicdisorder(BDD)andrunsanationalspecialistunitattheBethlemRoyalHospitalforrefractoryOCDandBDD.
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incontactwithacontaminant.Othersfeelashamed and condemn themselves for having intrusive thoughts of, for example, a sexual or aggressive nature, that they believe they should not have. Occasionally,apersonwithOCDbelievesthatthey areresponsibleforabadeventinthepast;insuch cases,themainemotionisguilt.Manyindividuals arealsodepressed,withvarioussecondaryproblems causedbythehandicap;comorbiditywithamood disorder is relatively common. At times, anger, frustrationandirritabilityareprominent.Becauseof therangeofemotions,itisnotsurprisingthatsome patientsfinditdifficulttoarticulateanduntangle theirdominantemotion.
et al,1995).ThedifferenceinOCDistheindividuals appraisalofsituations:thebeliefthatharmmight occurtotheself,alovedoneoranothervulnerable person through what the individual might do or failtodo.Harmisinterpretedinthebroadestsense andincludesmentalsuffering;forexample,some peoplewithobsessiveworriesaboutcontamination feartheywillgocrazyorthattheanxietywillgoon forever.IndividualswithOCDbelievetheycanand shouldpreventharmfromoccurring,whichleads tocompulsionsandavoidancebehaviours.
seeking)
Emotion
The dominant emotion in an obsession may be difficult for some patients to articulate but it is commonlyanxiety.Somealsoexperiencedisgust, especiallywhentheythinkthattheycouldhavebeen
prayersrepeatedinasetmanner)
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Compulsionsareusuallycarriedoutinarelatively stereotypedwayoraccordingtoidiosyncratically defined rules. The compulsion to hoard refers to theacquisitionofandfailuretodiscardpossessions thatappeartobeuselessoroflimitedvalue,andto clutteringthatpreventstheappropriateuseofliving space(Frost&Hartl,1996). Theindividualscriteriaforterminatingcompulsionsareanimportantfactorintheirmaintenance. SomeonewithoutOCDfinishesanactionsuchas hand-washingwhentheycanseethattheirhandsare clean;someonewithOCDandafearofcontamination finishesnotonlywhentheycanseethattheirhands arecleanbutwhentheyfeelcomfortableorjust right. Others may end a compulsion when they haveaperfectmemoryofanevent.Theseadditional criteriaforterminatingcompulsionsmaycausethem tolastevenlonger.ProgressinovercomingOCD canbemadeonlywhenthecriteriaforterminating acompulsionarerestrictedtoobjectivecriteria. Asafety-seekingbehaviourisanactiontaken in a feared situation with the aim of preventing catastropheandreducingharm(Salkovskis,1985); itthereforeincludescompulsionsandneutralising behaviours.Neutralisingisanyvoluntaryoreffortfulmentalactioncarriedouttopreventorminimise harmandanxietywiththegoalofeithercontrollinga thoughtorchangingitsmeaningtopreventnegative consequencesfromoccurring(e.g.visualisingthat the doctor is telling me that I dont have cancer untilIfeelrelief).Othersafety-seekingbehaviours includementalactivitiessuchastryingtobesure oftheaccuracyofonesmemory,tryingtoreassure oneself and trying to suppress or distract oneself from unacceptable thoughts. Such behaviours mayreduceanxietyintheshorttermbutleadtoa paradoxical enhancement of the frequency of the thoughtinareboundmanner.
Assessment
ClinicalassessmentofOCDissummarisedinBox 3.Theassessmentofavoidancerequiresaratingof predicted distress, so that a hierarchy of avoided situations without safety-seeking behaviours may be identified for therapy, together with an understandingofhowtheavoidanceinteractswith theobsessionsandthedistressexperienced.Some patientsalsotrytoavoidideas,thoughtsorimages bydistractionorattemptstosuppressthem. The patients problems, goals in therapy and valued directions (e.g. to be a good parent and partner)shouldbeclearlydefined.Progressshould be rated on standard outcome scales at regular intervals. The standard observer-rated tool is the YaleBrownObsessiveCompulsiveScale(Goodman et al,1989).TheObsessiveCompulsiveInventory (Foaet al,1998)isastandardsubjectivelyratedscale. Patients are usually offered time-limited CBT for between6and20sessions,dependingontheseverity andchronicityoftheproblem.Patientswithmore severeOCDmayrequireamoreintensiveprogramme inaresidentialunitorintheirhome.
Avoidance
Although avoidance is not part of the definition ofOCD,itisanintegralpartofthedisorderand ismostcommonlyseeninfearsofcontamination. Anexampleofavoidanceisawomanwithafear of contamination who will not touch toilet seats, doorhandlesortapsusedbyothers.Shewillhover over the toilet seat, use her elbow to open doors andtaps,userubberglovestoputrubbishinthe dustbin,avoidpickingupitemsfromthefloor,avoid shakinghandswithpeopleortouchingasubstance that looks dangerous to her. Avoidance can also occurmentally:tryingnottothinkorfeelsomething upsetting. Not all situations can be avoided and safety-seekingbehavioursareoftenusedwithina fearedsituation.
Family involvement
Somefamiliesaccommodateanindividualsavoidance and compulsions; some are overprotective, aggressive or sarcastic; they may minimise the problemoravoidtheindividualasmuchaspossible. SometimesthebehavioursassociatedwiththeOCD restrict the activities of family members (such as gainingaccesstothebathroom)ortheirfreedomto usecertainroomsinthehomebecauseofhoarding. PeoplewithOCDmayreactwithaggressionwhen
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tent; the degree of insight; the frequency oftheiroccurrence;thetriggers;thefeared consequence(Whatistheworstthingthat canhappen?);thepatientsappraisalofthe obsession (What did having the intrusive thoughtmeantoyou?Whatsensedidyou makeofit?Couldharmoccurasaresultof this?Whatwouldhappenifyoucouldnot getridoftheintrusions?) The main emotion(s) linked with the obsessionorintrusion The compulsion(s) and neutralising: what thepersondoesinresponsetotheobsession; aratingofpredicteddistressifthecompulsionisresisted;thefearedconsequencesof resistingit;theirexperienceoftryingtostopa compulsion;thecriteriausedforterminating thecompulsionandtheassumptionsheldif theystoppedusingacompulsion.Indirect assessmentmightincludeactivitiessuchas thenumberofrollsoftoiletpaperorbarsof soapusedperweek Theavoidancebehaviour:allthesituations, activitiesorthoughtsavoidedarelistedand ratedonascale(e.g.0100instandardunits ofdistress),accordingtohowmuchdistress the person anticipates if they experience the thought or situation without a safetyseekingbehaviour Thedegreeoffamilyinvolvement The degree of handicap in the persons occupational,socialandfamilylife Goalsandvalueddirectionsinlife Readiness to change and expectations of therapy, including previous experience of CBTforthedisorder
theircompulsionsarenotadheredtobytheirfamily. Frequently,familymembershavedifferentcoping mechanisms,leadingtofurtherdiscordwhenthey disagree over the best way of dealing with the situation.Assessmentshouldfocusonhowdifferent members of the family cope and their attitudes to treatment. The goals of CBT include helping familymemberstobeconsistentandemotionally supportive,withoutaccommodatingtheOCD.They maybeencouragedtoassistinexposuretasksand behavioural experiments if these would facilitate recoveryfromOCD.
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Therapist-supervisedexposureisgenerallymore effective than exposure and response prevention practisedalonebythepatientashomeworkassignments.However,itisessentialthattheinvolvement of the therapist fades over time, with the patient takingresponsibilityfortheirprogress.Prolonged (90 minute) exposure sessions held several times weeklywithfrequenthomeworkwillresultingreater symptomreduction.Combiningactualandimagined exposureissuperiortoactualexposurealone.
effortanddurationdoes.Patientslearnthatintrusive thoughtsandurgesarepartofthehumancondition andarenecessaryforproblem-solvingandthinking creatively. Therapy therefore seeks to modify the waytheindividualinterpretstheoccurrenceand/ orcontentoftheirintrusions,aspartofaprocess ofreachinganalternative,lessthreateningviewof intrusivethoughts.Theconclusiontobedrawnis thattheproblemliesnotwiththeintrusionsbutwith themeaningthattheindividualattachestothose thoughtsandthevariousstrategiesthattheyadopt totrytocontrolorsuppressthem.Patientslearnthat theircurrentstrategiesincreaseratherthancontrol thefrequencyofintrusivethoughts,theirlevelsof distressandtheurgetoneutralisetheirthoughts.
Therapy in practice
The formulation
Take the example of Ella, a woman with OCD who has intrusive thoughts of molesting a child. Hertherapistwoulddrawupaformulationofthe factorsmaintainingthesymptomsandwouldshare itwithher(Fig.1).Engagementmaybeassistedby aSocraticdialogueandsettinguptwocompeting theories to be tested out (Clark et al, 1998). The therapistssideofsuchaninteractionisoutlinedin Box4.Inthisexample,Ellawasabletopredictthatif
Box 4 How does Ella prove to herself that her problem is worrying that she is a paedophile? Therapist: I want to see if we can build a better understanding of what your problem is and therefore how to solve it. It seems to metherearetwoexplanationstotestout.The first explanation, which I will call theory A, is the one you have been using for the past fewyears,thatis,theproblemisthatyouare apaedophile.TheoryB,whichwewouldlike totestoutintherapy,isthatyouareextremely worriedaboutbeingapaedophileandinyour valuescareverydeeplyaboutchildren. Haveyounoticedthattreatingitastheory Amakestheworryanddistressaboutbeinga paedophileworse? Haveyouevertriedtodealwiththeproblem asifwasaworryproblem? Would you be prepared to act as if it was theoryBforatleast3monthsandthenreview your progress? You can always go back to treatingitasapaedophileproblemifitsnot working.Thiswillmeangraduallydropping allyoursafetyandavoidancebehaviours.
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reflectanactualevent).Thismayleadtoamental experiment of trying deliberately to induce bad actionsorevents(e.g.havingthoughtsofcausing thetherapisttohaveaseriousaccidentbeforethe nextappointmentorhavingthoughtsofharming thetherapistwhileholdingaknifeagainsthisor herneck).
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Thismaylaterbeextendedtotheirownintrusive thought.Behaviouralexperimentsmayappearto be the same as exposure but with a rationale of testingoutcertainbeliefsaboutsafetybehaviours andmakingpredictionsaboutwhatwouldhappen weretheynotperformed.
Distancing
Animportantstrategyistohelpthepatientdistance themselves from their thoughts or urges and to ceasetoengagein(buyinto)them.Ametaphorfor thoughtsandurgesarecarsonaroad.Ifoneengages withthecars(thoughts)thenonemightstandinthe roadandtrytodivertthem(andgetrunover)ortry togetintoacarandparkit.However,evenwhen onehasmanagedtodivertortoparkonecarthere arealwaysmorecarstobedealtwith.Thekeyisto acknowledgethethoughts(andthankonesmind foritscontributiontoonesmentalhealth),butnot toattempttostopthemortocontrolthem.Thegoal istoembraceintrusivethoughtsandurges,towalk alongthesideoftheroad,andtoengagewithlife. Thismeansalwaysexperiencingtrafficnoiseinthe backgroundintrusivethoughtsnevergoawayand reflectapersonsworries.Ifapatientstruggleswith distancingthemselvesfromtheirintrusivethoughts, thismaybelinkedtobeliefsabouttheconsequences ofnotrespondingtothem(e.g.apersonwhofears beingcontaminatedmaybelievethattheywould losecontrolandgomad).Ingeneral,patientsare taughttonoticeandexperiencetheirthoughtsand feelingswithouttryingtoevaluatethemortrying toavoidorcontrolthem.
impossibletodisprove.ForexampleMark,theman with OCD mentioned earlier, demands to know for certain whether he is HIV positive, despite repeatedreassurancefromnegativetestsorpositive explanationsforhissymptoms.Suchpatientsalways have a nagging doubt the blood sample could havebeenaccidentallyswitched,therecouldbea newtypeofHIVwhichhasnotyetbeendiscovered, thesero-conversionhasnotyetoccurredandsoon. Markisdemandinga100%guaranteeorabsolute certainty,whichisofcourseimpossible.However, while he continues to believe that he has to be 100%certain,hewillfocusonthepossibledoubts. Obviously the feared situations are possible, but theyarehighlyimprobable.Itisimportantnotto getinvolvedinadetailedanalysisofprobabilities buttohelpthepatienttofocusontheprocessand recognisethelinkbetweenthedemandforcertainty andtheirdistressandfurtherdoubt.Thiswillhelp them to step back and focus on the much higher likelihoodofapoorqualityoflifeiftheycontinue toseekreassurance.Patientscanbehelpedtotackle theirbeliefsusinghumour:wecanguaranteetwo thingsinlifedeathandtaxes!Athirdguarantee is that while the patient continues to demand a guaranteethatafearedconsequencewillnotoccur theywillcontinuetodisturbthemselveswiththeir symptoms.
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L. J. (eds) (2007) Psychological Treatment of ObsessiveCompulsive Disorder: Funda mentals and Beyond.AmericanPsychological Association. disorders.InCognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide (eds K.Hawton,P.M.Salkovskis,J.Kirk,et al), pp.129168.OxfordUniversityPress. Obsessive Compulsive Disorder: A SelfHelp Guide Using Cognitive Behavioral Techniques. Constable&Robinson. Metacognition, pp. 179199. John Wiley & Sons.
Salkovskis,P.M.&Kirk,J.(2007)Obsessional
Declaration of interest
None.
References
Clark, D. M., Salkovskis, P. M., Hackmann, A., et al (1998) Two psychological treatments for hypochondriasis. A randomised controlled trial. British Journal of Psychiatry, 173, 218225. Foa, E. B., Kozak, M. J., Salkovskis, P. M., et al (1998) The validationofanewobsessive-compulsivedisorderscale:the ObsessiveCompulsive Inventory. Psychological Assessment, 10,206214. Frost,R.O,&Hartl,T.L.(1996)Acognitivebehaviouralmodel ofcompulsivehoarding.Behaviour Research and Therapy,34, 34150. Goodman,W.K.,Price,L.H.,Rasmussen,S.A.,et al (1989)The Yale-BrownObsessiveCompulsiveScale.I:development,use andreliability.Archives of General Psychiatry,46,10061011. Gwilliam, P., Wells, A. & Cartwright-Hatton, S. (2004) Does meta-cognitionorresponsibilitypredictobsessivecompulsive symptoms:atestofthemetacognitivemodel.Clinical Psychology and Psychotherapy,11,137144. NationalCollaboratingCentreforMentalHealth(2005)Obsessive Compulsive Disorder: Core Interventions in the Treatment of ObsessiveCompulsive Disorder and Body Dysmorphic Disorder (Clinical guideline CG31). British Psychological Society & Royal College of Psychiatrists. http://www.nice.org.uk/ CG031 Rachman, S. J. (1993) Obsessions, responsibility and guilt. Behaviour Research and Therapy,31,149154. Rachman, S. J. & de Silva, P. (1978) Abnormal and normal obsessions.Behaviour Research and Therapy,16,233248. Salkovskis, P. M. (1985) Obsessivecompulsive problems: a cognitivebehaviouralanalysis.Behaviour Research and Therapy, 23,571583. Salkovskis,P.M.,Richards,C.H.&Forrester,E.(1995)Therelationshipbetweenobsessionalproblemsandintrusivethoughts. Behavioural and Cognitive Psychotherapy,23,281299.
lemsandgoalsfortherapy
theproblemthatprovidesaneutralexplanationofthesymptomsandofhowtrying toavoidandcontrolintrusivethoughtsand urges maintains the patients distress and disability Do not become engaged in the content of obsessionsandrequestsforreassurance,and donotargueaboutthelikelihoodofabad eventhappeninghelppatientstousetheir formulationandthecognitivebehavioural modelofOCD,anduseaSocraticdialogue to focus on the process and consequences oftheiractions Donotgiveupusingexposureandresponse prevention: integrate it with the cognitive approachintheformofbehaviouralexperimentstomakepredictions Ensurethatpatientsdonotincorporatenew appraisals or self-reassurance as another compulsionorwayofneutralising
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Veale, D. (1993) Classification and treatment of obsessional slowness.British Journal of Psychiatry,162,198203. Veale, D. (2002) Over-valued ideas: a conceptual analysis. Behaviour Research and Therapy,40,383400.
d areunnecessaryforthinkingcreativelyandproblemsolving e arerareinthegeneralpopulation. 5 Assessment for cognitivebehavioural therapy in OCD: a doesnotrequireknowledgeofthedegreeoffamily involvement b doesnotrequireknowledgeofthepatientsdegreeof insightorovervaluedideation c requiresforensicassessmentofintrusivethoughtsand urges d requires assessment of the patients readiness to change e requiresanalysisofcountertransference.
MCQs
1 a b c d e 2 a b c d Neutralising an intrusive thought or image: leadstoanimmediateincreaseinanxiety isaninvoluntarystrategyadoptedbythepatient aimstocreatemoreharm preventsdisconfirmationoftheintrusivethought isidenticaltoacompulsion.
Cognitive processes in OCD include: thoughtactiondissociation toleranceofuncertainty overinflatedsenseofresponsibilityforharm finishingwashingritualwhenseeingthatoneshands areclean e underestimationofthelikelihoodofharm. 3 Compulsions in OCD: a canleadtopsychosisifresisted b may initially function as a means of avoiding anxiety c can be resisted by focusing attention inwards on subjectivefeelingsandnotbyexternalinformation d areentirelyvoluntary e cannotbementalacts. 4 Unwanted intrusive thoughts and images: a areindistinguishableincontentbetweenpeoplewith OCDandthenormalpopulation b canbesuppressedinthelongterm c donotdifferinthemeaningthatpeoplewithOCD attachtotheiroccurrenceand/orcontentcompared withthenormalpopulation
MCQ answers 1 a F b F c F d T e F 2 a F b F c T d F e F 3 a F b T c F d F e F 4 a T b F c F d F e F 5 a F b F c F d T e F
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