CBT FOR OCD
Institute of Mental Health
WHY CBT FOR OCD?
All thought processes arise from activity in
appropriate neural circuits.
OCD phenomena arise from aberrant thought
processes, likely due to disturbances in the cortico-
Neural circuits can be strengthened or weakened.
Drugs modulate neural circuit activity through
receptor effects and later neuroplasticity changes.
CBT triggers learning which is hardwired into the
brain, and may be more enduring in its effects.
BIOLOGICAL EFFECTS OF
CBT IN OCD
Decreased metabolic activity in the right caudate
nucleus (reviewed by Linden, Molecular Psychiatry 2006).
Decreased right frontal anterior cingulate cortex
and bilateral thalamic activity (Saxena et al, Molecular
TREATMENT OF OCD
SRI drugs and CBT
Effect size for drugs was 0.48 (13 trials)
Effect size for CBT was 1.45 (5 trials)
(Watson and Rees, J Child Psychol Psychiatry 2008)
Meta-analysis 2 (13 trials):
Effect size for group CBT pre vs post: 1.18
Effect size for group CBT vs wait list controls: >1.12
(Jonsson and Hougaard, Acta Psychiatrica Scand 2009)
ADVANTAGES OF CBT
Effective as monotherapy.
Large effect size [caveat: biases
could arise from sample selection
and consenting processes].
Improves long-term outcomes
Treating with drugs+CBT may
offer the best outcomes.
TREATMENT OF OCD
The proper treatment of
OCD with CBT requires a
complete understanding of
the spectrum of symptoms
that the patient displays.
Prevalence, 2-5% (severe in 0.5%)
The only DSM-IV anxiety disorder in which anxiety
is not the main symptom.
Primary symptoms: obsessions and/or compulsions.
Secondary symptoms include depression.
Underlying OCPD in 50% of patients.
Comorbidities include tic disorder.
OCD may be secondary to other conditions; e.g.
schizophrenia, atypical antipsychotic therapy.
By definition, mental preoccupations or repetitive
behaviors are not considered under OCD if they
occur in the context of another DSM-IV Axis I
(e.g. hypochondriasis; eating disorders;
Obsessions are repeated thoughts.
E.g. “My son is going to die.”
E.g. “I will get AIDS.”
Compulsions are repeated actions.
Every time a patient sees a picture of a deity, he
feels compelled to say a short, mental prayer to
the deity. Is this an obsession or a compulsion.
[In CBT, the approach to treatment differs between
obsessions and compulsions.]
Thoughts which are deliberately repeated to
relieve anxiety are compulsions, not obsessions.
E.g. Compulsively repeating a prayer a certain number
of times to ward off evil after a trigger event.
E.g. Repeating a prayer over and over again just in
case it was not properly said previously (scrupulosity).
Important to differentiate obsession from
compulsion because the treatment approach is
Fear acquired through classical conditioning and
maintained by operant conditioning
Eg. Checker associates electrical
appliance(conditioned stimulus) with
death(unconditional stimulus;danger of fire) and
thus feels anxiety (unconditional response and
conditioned response) in the presence of a stove
Checking behaviour:Negative Reinforcer as it
Inflated sense of Personal Responsibility
Undue Importance to Thoughts
A need to control thoughts
Overestimation of threat
Intolerance of Uncertainity
TYPES OF COMPULSIONS
[compulsions relieve anxiety]
Almost always secondary to obsessions
May be behavioral or mental
Repeating thoughts or actions to prevent or undo a
(Overlap may be present)
It is important to comprehensively document all
aspects of the phenomenology present.
List all obsessions.
List all compulsions.
Understand the contexts which generate each.
Arrange in a hierarchy of severity.
Assess insight into the irrationality of each.
Assess motivation to change each.
Make a chart with each symptom rated:
Frequency (occasions per day)
Time spent (minutes or hours)
Impairment (0-10, with examples of impairment)
This chart can be used to monitor progress.
Use the Y-BOCS or LOI or other scales.
10 items (5 for obsessions, 5 for compulsions)
Semi-structured interview based on an explanation
to the patient about what obsessions and
Rated 0-4; range of possible scores, 0-40
For obsessions: Time occupied by obsessive
thoughts, obsession-free interval, interference,
distress, resistance, control.
Ditto for compulsions.
Identification of OCD s/s
Assessment of resistance
Assessment of interference
Plus: Common OCD s/s listed individually
Minus: Rare s/s are omitted.
CORNERSTONES OF CBT
Common to both obsessions and compulsions:
[Family support, if indicated]
CBT FOR OBSESSIONS
Explain about OCD
Destigmatize the illness
Explain the principles of drug
Explain the principles of CBT
Discuss plan of management
Review patient understanding
Time: 1-2 hours
Obsessions are, by definition, irrational thoughts.
Patients don’t always recognize their irrationality.
Taking each obsession by turn, challenge the
flawed logic that underlies it.
Goal: To reduce anxiety through the realization
that the thought is irrational and can be ignored.
E.g. Obsessive fears: “What if that man [on the bus] is
carrying a bomb?”
E.g. “What if I get AIDS?” [by using public cutlery]
Generalization: The patient must
learn how to reduce anxiety by
arguing against his own beliefs
when the obsessions arise
outside the clinic.
Challenging assumptions should
result in full insight. So, take as
much time as the patient requires
to fully grasp, appreciate, accept,
and articulate the arguments.
Terminates the obsession
Slapping the table or pinching one’s thigh
Snapping a rubber band on the wrist
Doing these physically or imaginally
Taking up a chore that demands attention
Phoning a friend
Speaking to a family member
Examining details in the environment
Etc. [plan these out]
STRATEGY FOR TACKLING
Take one obsession at a time.
Go from education to challenging assumptions to
thought stopping and distraction.
Preferably move to the next obsession only after
the previous obsession has been satisfactorily
CBT FOR COMPULSIONS
Recruit family support
Did I lock the door?
Be aware that this is a problem.
When locking, say “I have done it” [lays memory trace].
When the doubt arises, recall the memory.
Learn to trust the memory [if you cannot trust yourself,
whom will you trust?]
Recall past experience [has there been any occasion that
you checked and repeatedly checked and found that the
door was unlocked?]
What is dirt?
Why is dirt dirty?
When is dirt dirty?
Can dirt be good (prevents allergy, builds immunity)
Why is water clean?
Note that, after the first wash, washing/soaping
removes layers of skin, not dirt.
MORE ABOUT DIRT
Why are bodily secretions
dirty the moment they leave
Smelling a fart and airborne
Do not tell the patient this!
[Same as with obsessions]
E.g. for checking whether a door was locked
E.g. for removing dirt from the hand
E.g. for repeated rituals lest a deity be offended
E.g. for repeated rituals after stepping on paper
E.g. for rituals that seek to ward off harm.
Challenging assumptions should result in full
insight. So, take as much time as the patient
requires to fully grasp, appreciate, accept, and
articulate the arguments.
This is necessary to ensure motivation in exposure
and response prevention exercises.
EXPOSURE AND RESPONSE
Imaginal (as part of the desensitization hierarchy, or if in
vivo exposure is not feasible)
Voluntary response prevention (should not be forced
by family, hospital staff e.g. as in turning off the water supply
in a patient with washing compulsions)
Goal: Anxiety reduction through habituation
Time: At least 30-120 min per exposure session;
anxiety reduction must be substantial.
EXPOSURE AND RESPONSE
E.g. stepping on paper
E.g. touching footwear
E.g. handling currency notes
E.g. checking a locked door
Therapist-assisted exposure (provides
Self-driven exposure (provides
confidence, improves generalization)
Identify and tackle underlying obsessions.
Break up the rituals into their component parts
[wetting, soaping, rinsing, wiping].
Define what is the purpose of each, and what is the
normal limit of behavior for each.
Practice behavior within these set limits while
simultaneously challenging the assumptions which
were responsible for the obsessions.
DEALING WITH RELIGIOUS
OBSESSIONS AND RITUALS
Understand the cultural context.
Tread carefully, respect beliefs, challenge
assumptions only with informed consent.
Discuss source of beliefs and practices; consider
the ‘tying the dog story’.
Probe inconsistencies between obsessions and
beliefs about the nature of God.
Remind patient that idols and pictures are
representations, not personifications, of God.
Set timetable with
attention to problem
Enlist family supervision.
Patients sometimes develop
substitute rituals after their
primary symptoms are addressed.
E.g. rubbing hands to replace
Not all patients are suited for
CBT; not all patients will respond;
however, some improvement is
better than no improvement.
3-5 sessions a week for 3-5 weeks.
Each session up to 2 hours.
15 min for review of previous session, homework.
45-90 min for exposure and response prevention.
15 min for setting homework.
Ideally, when a symptom is addressed, there should be
100% compliance with therapy directions [e.g. response
prevention]; otherwise, the therapy work is undermined.
Booster sessions (maintenance therapy).
IMPORTANT THERAPIST AND
Motivation and compliance
Effort to identify the symptoms in their entirety
Ability to successfully challenge assumptions.
That’s it, folks;
thanks for listening!