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(C)BT of OCD. Adam C. Chodkiewicz MD FRCP(C) Maureen L. Whittal, Ph.D UBC Hospital November, 2006. OCD Facts. 1990 WHO study - OCD listed as 5th in disease burden for women aged 15-44 Estimated lifetime prevalence rates 2-3%, 6-month point prevalence - 1.6% Impaired quality of life

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c bt of ocd

(C)BT of OCD

Adam C. Chodkiewicz MD FRCP(C)

Maureen L. Whittal, Ph.D

UBC Hospital

November, 2006

ocd facts
OCD Facts
  • 1990 WHO study - OCD listed as 5th in disease burden for women aged 15-44
  • Estimated lifetime prevalence rates 2-3%, 6-month point prevalence - 1.6%
  • Impaired quality of life
  • Delay in appropriate treatment
  • Age of onset - earlier for men (19 yoa) compared to women (22 yoa)
  • Gender ratio - approx equal as adults
  • Course - majority are episodic with incomplete remission and a small percentage progressively deteriorate
  • 1/3 comorbid with depression
  • 24% with another anxiety disorder
  • 8% with an eating disorder
  • 5% with tourette’s
assessment of ocd
Assessment of OCD
  • Obsessive Compulsive Inventory
  • Padua Inventory (PI-WSUR)
  • Obsessional Belief Questionnaire
  • Interpretations of Intrusions Inventory
  • Personal Significance Scale (PSS)
  • Gold standard treatment outcome measure
  • Obsessions subscale and compulsions subscale. Scores range from 0-40.
  • 0-7=subclinical, 8-15=mild, 16-23=mod,

24-31=severe, and 32-40=extreme

ocd subtypes
OCD Subtypes
  • Contamination and doubting most common obsessions followed by somatic, need for symmetry, aggression, and sexual intrusions
  • Checking and washing most common compulsions followed by counting, the need to confess, ordering, and hoarding
forms of obsessions
Forms of Obsessions
  • Thoughts
    • Ideas experienced as unacceptable or unwanted (e.g., idea of stabbing my child)
  • Images
    • Mental visualizations that are experienced as troubling or distressing (e.g., one’s elderly grandparents having sex)
  • Impulses
    • Unwanted urges or notions to behave in inappropriate ways (e.g., to yell obscenities)
typical content of obsessions
Typical Content of Obsessions
  • Violence
    • Impulse: to attack a helpless person
    • Image: loves one’s being dismembered
    • Impulse to reach for a police officer’s gun
  • Sex
    • Impulse: to stare at peoples’ genitals
    • Thought: what it’s like to be homosexual
  • Blasphemy and sacrilege
    • Image: Jesus with an erection on the cross
    • Thought: God is dead
what is not an obsession
What is NOT an Obsession
  • Worries about real-life issues (e.g., work)
  • Depressive ruminations
  • Recurrent appetitive sexual fantasies
  • Jealousy
  • Preoccupation with a new car, boyfriend, etc.
  • Cravings to gamble, steal, drink alcohol, etc.
mental rituals neutralization vs obsessions
Mental Rituals (Neutralization)vs. Obsessions
  • Often confused for one another
  • Obsessions are intrusive, unwanted thoughts that evoke anxiety or distress
  • Mental rituals are deliberate mental acts designed to neutralize or reduce anxiety or distress
  • Overt or covert responses to intrusions
  • Designed to counteract the obsession and to decrease the anxiety the latter produces
  • Sense of having ‘no choice’, is time-consuming, excessive and senseless
  • Egs include checking, washing, repeating, counting, ordering, silent praying etc.
learning theory view of ocd
Learning Theory View of OCD
  • Obsessions give rise to anxiety or distress
  • Compulsions reduce obsessional anxiety
  • The performance of compulsions prevents the extinction of obsessional anxiety
  • Compulsions are negatively reinforced by the brief reduction of anxiety they engender
behavior therapy techniques
Behavior Therapy Techniques
  • In vivo (situational) exposure
    • Gradual confrontation with situations that evoke obsessional thoughts
  • Imaginal exposure
    • Gradual confrontation with the unwanted thoughts (via loop tapes, etc.)
  • Response prevention
    • Refrain from neutralizing, mental rituals, reassurance-seeking, and thought control strategies, etc.
criteria for fear reduction during exposure therapy
Criteria for Fear Reduction During Exposure Therapy
  • Elicit fear
  • Allow habituation to occur
  • Provide corrective information
exposure and response prevention erp
Exposure and Response Prevention (ERP)
  • Psychosocial treatment of choice shortly after it was developed in the 1960s
  • Establish a fear hierarchy beginning with relatively easy items and gradually getting more difficult
  • Graduated exposure to triggers and habituation of fear response
the treatment of fear
The Treatment of Fear
  • Exposure to fear-eliciting stimuli or situations
  • Abstinence from escape/avoidance behaviors
  • Anxiety increases initially, followed by habituation
setting up the treatment plan
Setting Up the Treatment Plan
  • Generate list of situations and thoughts that would evoke anxiety and urges to neutralize
  • Patient rates subjective units of discomfort (SUDS) for each situation or thought
  • Collaborative effort in generating exposure hierarchy
    • Start with situations of moderate difficulty
    • Highest items must be included
  • Situations are realistically safe, but will evoke obsessional distress
treatment outcome using erp
Treatment outcome using ERP
  • Approximately 80% of treatment completers report beneficial effects
  • Up to 6 years following treatment approximately 70% of people maintain their gains
  • However, ERP is not a panacea
problems with erp
Problems with ERP
  • “benefit” is defined as a 30% decline in YBOCS
  • High refusal/drop out rate
  • Particularly problematic for people who suffer from primary obsessions
cognitively focused treatment of ocd
Cognitively focused treatment of OCD
  • Based on knowledge that unwanted intrusive thoughts are normal
  • It’s not the intrusion that causes the anxiety and the compulsive behavior, but the appraisal of the intrusion
  • Goal is to cognitively challenge appraisal and identify less threatening appraisals
cbt model for the maintenance of ocd
CBT model for the maintenance of OCD


Leaving the house

Intrusive thought

On, open, or unplugged?


My fault if something

bad happens





overimportance of thoughts
Overimportance of thoughts
  • Having a thoughts means it’s important
  • Likelihood thought action fusion (having the thought makes the outcome seem more likely)
  • Moral thought action fusion (having the thought and engaging in the act are equal)
thought action fusion taf
Thought Action Fusion (TAF)
  • Likelihood self - because I’ve had the thought it’s more likely to happen to me
  • likelihood others - because I’ve had the thought, it’s more likely to happen to others (e.g., MVA)
  • moral - the thought is as reprehensible as the action
challenging likelihood taf
Challenging likelihood TAF
  • Thought experiments - e.g., purposely having a negative thought about something bad happening to somebody yourself or something
  • ongoing list of ‘premonitions’ and their outcome
challenging moral taf
Challenging moral TAF
  • Continuum
  • normalization of ITs
  • List qualities of a good and bad person
  • Identification of a possible double standard
the need to control thoughts
The need tocontrol thoughts

The role of thought suppression and attention

Belief that I must be in

control of my thoughts

and emotions at all times

Experiences a normal

intrusive thought, but

appraises it as dangerous

Further attempts to

control thoughts

Efforts are made to fight,

control, suppress, distract,

or neutralize the thought

Not trying hard

enough to control



more ITs

Increased vigilance

or attention

challenging the need for thought control
Challenging the needfor thought control
  • Set up an alternating days experiment where half of the days are “fight and dwell” and the other half are “come and go”
  • have patients make predictions ahead of time
the paradox of thought control
The paradox of thought control
  • The interaction between attention to thoughts and the frequency of thoughts
  • attention experiments
challenging responsibility with piecharting
Challenging responsibility with piecharting

Me 10%

Wife 5%

Toy makers


Son 20%

Weather 10%