Clinical L4

OCD

OCD criteria

Obsessions or compulsions

interfere with functioning

Not due to drugs/medical condition

Not better explained by another disorder

obsessions

•in form of words, images or impulses

•involve ideas or content that is inconsistent with your personality, moral values, ideals and goals.

•Defining characteristics of obsessive thoughts include:

•intrusive quality

•unwanted

•involve resistance

•uncontrollable

•seem uncharacteristic

•These types of thoughts do not just occur in individuals with OCD

compulsions

•Any mental or physical action the individual engages in to reduce the distress they feel as a result of their obsession

•When an act is repeated the same way every time= compulsion

•Compulsions can be external behaviours you engage in or internal behaviours / mental acts

prevalence of OCD

•affects 1-4% of the pop in their lifetime (but estimates in the lit vary)

•In England, prevalence in adults is 1.3%

•little geographical variation and males and females affected equally

•Onset often in adolescence and young adulthood

•Psychiatric comorbidity (having another diagnosis at same time is very common) is present in the majority of people with OCD

NICE 2024

Psychodynamic accounts: importance of unconscious

•Obsessions and compulsions are seen as symptoms of some deeper problems in the person’s unconscious mind

•Unconscious feelings and emotions: unacceptable to the self

• or unconscious trauma

•can lead to internal conflicts, if an emotion/memory is deemed unacceptable

psychodynamic accounts: The role of defence mechanisms

•Compulsive acts and obsessional thoughts are seen as defence reactions that suppress the real, hidden anxieties

•People cope with conflicts using a variety of methods

•May include avoiding the emotion (repression), focussing the emotion on something else (displacement), and experiencing the emotion from another person (projection)

•People often seek help for the defence mechanism without realising the key issue is the unconscious conflict

•In OCD, key defence mechanisms may be “displacing” the anxiety and “undoing” the bad thought (anger, aggression, sexuality etc.)

Learning theory: Mowrer’s 1939 two factor theory

•Classical conditioning – anxiety is associated with stimuli that are associated with painful or aversive experiences

•Operant conditioning – avoidant behaviour/ compulsions develops because it reduces the anxiety

Types of appraisals

Thought Action Fusion (TAF)

Inflated Responsibility

Overestimation of Threat

Mental Control

Intolerance of Uncertainty

evidence for thought suppression

•recurrence of thoughts high in the 1st 60s after suppression, and may then decline over time.

•thought suppression and TAF are correlated with severity of OCD; and can reduce after successful psychotherapy

•Lab studies have shown that asking people with OCD to suppress their most distressing obsessional thought leads to the behaviour occurring more freq once the period of suppression or inhibition is over (= “rebound” effect)

•argued that suppression of an unpleasant thought also leads to strong -ve emotional states

Role of self-efficacy and distress tolerance

•Lower self-efficacy is related to dysfunctional coping strategies under distress

•Low self-efficacy predicts more severe OCD symptoms and lower quality of life in clinical and non-clinical samples

•Low distress tolerance is a vulnerability factor for OCD.

•less able to tolerate distress of obsessions may be more vulnerable to alleviating this distress though compulsions.

•Lower distress tolerance effects the outcomes with treatment

•Those who can complete treatment show higher levels of distress tolerance post treatment compared to pre-treatment.

what is ERP?

Exposure and Response Prevention

designed to treat OCD in 2 ways:

1.Expose the person to face their fears (exposure)

2.Letting obsessive thoughts occur, without attempting to ‘putting them right’ or ‘neutralising’ them with any form of internal or external compulsive behaviour (response prevention)

what assumption is ERP based on?

as an individual is systematically exposed to stimuli that elicit obsessional thoughts and anxiety, whilst disengaging from any form of compulsive behaviour, their anxiety will diminish over time through the process of extinction = better functioning

•Breaks the links between obsessions and compulsions

•Disconfirms dysfunctional beliefs by forcing pxs to encounter feared stimuli and without the compulsive behaviour

Stepped care treatment model: NICE Guidelines (2005)

1.Low degree functional impairment  - Low intensity psychological treatments (brief individual, telephone or group CBT; incl. ERP) for mild symptoms of OCD

2.Mild functional impairment for whom low intensity was inadequate or appropriate – More intensive CBT (incl. ERP) OR course of an SSRI

3.Moderate impairment – SSRI OR more intensive CBT (incl. ERP)

4.Severe functional impairment – combined SSRI & CBT (incl. ERP)

Abramowitz evidence for ERP in OCD

•(1996) meta-analysis assessing the impact of ERP on OCD & found a large ES of 1.16 – lack of control comparison

•(1997) examined RCTs of ERP for OCD cf. other interventions. Large ES with ERP cf. relaxation but, cf. cog therapy or individual components of ERP no signif effect of ERP was found

methodological issues in ERP evidence studies

•       Small RCTs,

•       Exclusion of active controls (mainly cf. waiting list controls cf. receiving alternative treatment)

•       Reliance on self-report measures

•       Exclusion of non-experimental designs

•       Failure to address publication bias

•       +ve effects restricted to studies showing evidence of researcher allegiance in favour of CBT with ERP, questioning generalisability

Rapp et al (2016) ‘gold standard’ in clinician-administered assessment tools for OCD severity

The Y-BOCS/ Y-BOCS-II