L5: OCD

In terms of the presence of obsessions and compulsions, what is needed for a diagnosis?

The presence of obsessions, compulsions, or both

Obsession definition

Compulsion definition

Egodystonic thoughts

Not in line with what we believe, in conflict with the ego

Features of OCD

• No longer considered anxiety disorder in DSM-5

• Life-time prevalence relatively low compared to other anxiety disorders (2-3%)

• 90% of individuals experience obsessions AND behavioural compulsions

• Similar prevalence in men and women

• Up to 50% experience Major Depressive Disorder at the same time

  • Depression seen as consequence of being unable to deal with symptoms of OCS

• Overlap with ASD?

Behavioural Perspective: Mowrer’s Two-Factor Theory of OCD (diagram)

• Appearance of OCD explained through classical conditioning

• Operant conditioning

  • Negative reinforcement, completing compulsion reduces negative feeling of anxiety BUT maintains negative dysfunction long-term

What two things does the Behavioural Perspective fail to explain in OCD?

1. Where does the obsession come from in the first place?

   • Model assumes obsession is already there, but where does it come from

2. 10% of people don’t show compulsions, so how are they managing their anxiety triggered by the obsession?

   • Compulsion can be mental or observable 

Treatment from Behavioural perspective

Exposure with Response Prevention (‘White Bear’ paradox)

• Can’t directly target thoughts, so through reducing behaviours can reduce obsessive thoughts (‘White Bear’ paradox)

• Fairly effective

  • 50% patients recover

• Look at in terms of threat of the obsession, not necessarily the compulsion in itself

Cognitive perspective

• Looks more at where the obsessions come from in the first place

• Rigid schemas cause of OCD

• Metacognitive process

  • Thoughts about thoughts is what drives anxiety

Cognitive Perspective: Responsibility Schemas

• Recurring experiences

  • Growing up with rigid rules of conduce

  • Being shielded from responsibility (e.g. overprotective parenting)

  • Being raised with a sense of responsibility for avoiding harm 

  • Increased responsibility for family members’ protection

• Isolated experiences 

  • Incidents in which one actually does cause harm or erroneously believes that he or she did

OCD: Cognitive Behavioural Therapy Rationale/Background

Overestimation of threat:

• Lack of self-serving positivity attributional bias

  • OCD people less likely to think that they are better than average 

• Overestimate the likelihood of harm befalling them

• Experience reduced relief compared to controls when presented with statistics about the low frequency or harmful events

OCD: CBT process

• Identification of key distorted beliefs (from responsibility schema)

• Move from specific to general (specific obsession to more general)

  • Collaborative construction of a non-threatening alternative account of obsessional fears

    • Challenge responsibility appraisals

  • Pie-chart technique

• Question the power of obsessions

• ERP is implemented as an experimental test of the new alternative theory 

• HOWEVER, research has shown that this cognitive layer does not add anything of benefit in relation to exposure with response prevention therapy 

  • THEREFORE, recommended therapy is still behavioural

What is the recommended treatment for OCD

Behavioural

Whats the Pie-chart Technique

OCD CBT

• Client and therapist work together

• Identify obsessive thought

• Aim is to highlight that there are many possibilities for why something happens (i.e. a plane crashing), by seeing how many possible explanation there are, the aim is for this to decrease the strength of the belief that their responsibility is what’s driving everything to happen 

OCD: Mindfulness-based Therapy

Mindfulness-based Cognitive Therapy (MB-CT)

• CBT doesn’t appear beneficial, so behavioural still recommended, BUT movement towards MB-CT

• Core of OCD is metacognition (thinking about thoughts), core of mindfulness is to disengage from thoughts

• This model does not put responsibility as central, more the link between thought and action itself

• THEREFORE, work around therapy is more around the beliefs over the power of your thoughts and trying to question those things

Thought action fusion

Believing that simply thinking about an action is equivalent to actually carrying out the action

Myers & Wells: Thought-action fusion experiment

• Importance of thoughts

• Students either given fake rationale (EEG makes noise when thinking about drinking) or actual (that the machine just sometimes makes noise)

• Hypothesis is that sample with high OCD traits are more likely to try and control thoughts when given false EEG rationale (found correct)

Summary