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  • 1. OCD
  • 2. What are the characteristics of someone with Obsessive-compulsive disorder (OCD)? • OCD is an anxiety disorder. The behaviours are ritualistic, (hand washing, constant checking) and is therefore is the source of great anxiety. • Interestingly the disorder is equally common in both men and women and the onset of the behaviour is usually in young adult life. • Again you could think of the disorder as having two components – Obsessions. – Compulsions. • Obsessions – recurrent, intrusive thoughts or impulses that are perceived as inappropriate, grotesque or forbidden (DSM-IVR). • The obsessions generally cause anxiety as they are unlike the sufferers typical thoughts. These thoughts are believed to be uncontrollable, the sufferer feels as though they may lose control and act upon these obsessions. The most common obsessions take the form of • DOUBTS • Compulsions – Repetitive acts that work to reduce anxiety of the sufferer by preventing some dreaded event happening (DSM-IVR). • These behaviours can be ‘hidden’ i.e. mental acts or overt i.e. hand washing. • The vast majority of sufferers realise their behaviour is irrational but feel compelled to perform the given behaviour for fear of something terrible occurring, thus the behaviour also create anxiety. IMPULSES IMAGES.
  • 4. DSM- IV • The Diagnostic and Statistical Manual of Mental Disorder (Edition 4), was last published in 1994. • The DSM is produced by the American Psychiatric Association. • It is the most widely used diagnostic tool in psychiatric
  • 5. ICD - 10 • There is also the International Statistical Classification of Diseases (known as ICD). • It is produced by the World Health Organisation (WHO) and is currently in it’s 10th edition.
  • 6. Distress • The obsessions and compulsions cause marked distress Obsessions • More than excessive worries about real life problems Compulsions • Aim to neutralise and or prevent obsessions and are time consuming and applied rigidly Unrealistic • Compulsions do not have a realistic effect to reduce obsessions and are clearly excessive Product of patients own mind Child OCD Clinical Diagnosis • Obsessions and compulsions are recognised as a product of the patient own mind • Sufferers may not recognise that their behaviour is unreasonable • Is only made if there are no other possible psychological causes
  • 7. What are the characteristics of someone with Obsessive-compulsive disorder (OCD)? • A diagnosis is given if the sufferer fits the following criteria:  Recurrent persistent thoughts, impulses or images that feel intrusive and inappropriate, and cause excessive anxiety or distress.  The sufferer partakes in regular repetitive behaviour  (hand washing). The behaviour must not be related in anyway to what they are designed to prevent.  The individual recognises the behaviour is excessive and product of their own mind.
  • 8. Prevalence of OCD
  • 9. Task • Read your case study of a patient with OCD. Which characteristics can you identify for your case?
  • 10. Questions • Explain issues associated with the classification and diagnosis of obsessive compulsive disorder. (8 marks) • Outline clinical characteristics of obsessive compulsive disorder (8 marks)
  • 11. Issues of reliability and validity
  • 12. Reliability and validity of DSMIV and ICD-10 • Diagnosing a mental disorder is almost always done using the DSM-IV and the ICD-10. • However, there is a risk of using this professional jargon. (Wording in the manuals is written for specialists to understand, not laymen). • The main issues surrounding the diagnosis of mental disorders centre on the reliability and validity of the diagnoses.
  • 13. Reliability of Diagnosis
  • 14. Measuring obsessions and compulsions • There are scales for the measurement of general anxiety and specific scales for the assessment of obsessions and compulsions. • According to Rush et al. (2007) the best is the YBOCS devised by Goodman et al. • This is a semi structured interview asking about obsessions and compulsions and the extent to which they affect everyday life. • More recently Goodman has developed a new scale – the Florida Obsessive-Compulsive Inventory.
  • 15. Reliability • This refers to the consistency of a measuring instrument such as a scale to assess fear. It can be measured in terms of whether two independent assessors give similar scores. • INTER-RATER RELIABILITY • Patients are generally diagnosed on the basis of one or more interviews with a therapist.
  • 16. • Inter-rater reliability and test-retest reliability -do bloke psychiatrists agree? thinks? Woody et al (1995) assessed 54 patients with OCD using the YBOCS and found good internal consistency. Inter-rater reliability was was reported as excellent. • However, test-retest results after an average of 48 days was lower than desirable. Other studies have however, found good test-retest reliability. I wonder what the other psychiatris t thinks?
  • 17. Reliability of Diagnosis Y-BOCS Semi structured interview used to assess symptom severity Woody et al • Assessed 54 OCD patients • Good internal consistency • Inter-rater reliability = excellent • Test-retest reliability after 50 days was lower than desired Kim et al • Good test-retest over the short term – 2 weeks
  • 18. Reliability • Brown et al carried out two interviews on 1400 patients WITH A GAP OF TWO WEEKS BETWEEN INTERVIEWS. The interrater reliability was excellent. The most likely explanation is that compulsions provide a clear behavioural indication of the presence of OCD. There were some sources of unreliability- The main one was• Differences in the symptoms reported by patients in the two bloke thinks?
  • 19. Reliability • Steinberger et al compared DSM-IV and ICD-10 in their diagnoses of OCD. There were large differences between the two systems suggested problems with consistency of diagnosis. Using DSMIV 95% of patients were diagnosed with OCD compared to only 46% using ICD-10 criteria. According to Steinberger the criteria for ICD-10 are less detailed and bloke thinks?
  • 20. Reliability of self report and computerised versions of YBOCS. • These appear to yield reliability scores similar to interviewer-administered versions. • The children‟s version has also been shown to have good inter-rater reliability.
  • 21. Validity of Diagnosis
  • 22. Validity of diagnosis • This considers whether the system of classification and diagnosis reflect the true nature of the condition as something that is real and distinct from other conditions. • Discriminant validity- refers to the ability of a diagnosis to distinguish between OCD and other conditions. • Rosenfield et al found that patients diagnosed with OCD had higher Y-BOCS scores than patients with other anxiety disorders and normal controls – therefore it does distinguish OCD patients from others. • However, Woody et al found poor discrimination with depression – patients diagnosed with OCD were often also diagnosed with depression and it can be difficult to disentangle the two disorders. (67% of people with OCD also have depression – Gibbs)
  • 23. Validity of diagnosis • Discriminant validity (continued)• OCD can resemble the delusional beliefs of schizophrenia when the nature of the thoughts is bizarre. • Obsessions and compulsions occur in a number of other disorders- e.g. eating disorders/ body dysmorphic disorder/social phobias. DSM-1v specifically warns clinicians not to diagnose OCD when the obsessions and compulsions are restricted to another disorder.
  • 24. Validity of diagnosis • Discriminant validity (continued)• There can be some overlap between OCD and obsessive personality disorder – these people who are inflexible, obstinate, rigid and prone to focusing on unimportant detail. They are frequently humourless and judgemental, with a need for perfectionism and rigidity.
  • 25. Validity -Distinguishing between „worries‟ and obsessions. • It is difficult to distinguish between obsessions and simple „worries‟ which are not pathological (related to a mental disorder.) • Worries include things such as family, finances and work. • According to Brown (1993) most clinicians can reliably distinguish between worries and obsessions.
  • 26. Validity of diagnosis. • It is possible that people may not produce honest answers to questionnaires about their OCD symptoms and this reduces the validity of any such questionnaire- (may fear interviewer will think they have a deeper mental illness or be embarrassed). It has been estimated that only about 40% of people with OCD symptoms come forward for treatment. • Patients may also be fearful of handling questionnaires because they fear they are dirty. • A further problem is that some patients may lack awareness of the severity and frequency of their symptoms. Validity is likely to be improved by interviewing close friends and partners.
  • 27. Cultural Relativism • The incidence of OCD tends to be the same in most countries/cultures (about 2-3%. • However the symptoms are often shaped by a patient‟s culture of origin. • For example a patient from India may fear contamination by touching a person from a lower social caste. • This may lead to problems with diagnostic scales because symptoms checklists may be culturally based.
  • 28. Cultural problems • Williams et al 2005 demonstrated that there were significant differences between normal populations of black and white Americans in the scores for contamination obsessions. Black Americans have less interaction with animals and have a greater fear of contamination from them – increasing the diagnosis of OCD. • However – Matsunaga studied Japanese OCD patients and found symptoms remarkably similar to those in the West – concluding that OCD transcends cultures.
  • 29. Meehl (1977) • Suggests that mental health professionals should be able to count on the diagnostic tools if they: – Paid close attention to medical records – Were serious about the process of diagnosis – Took account of the very thorough descriptions presented by the major classificatory systems – Considered all the evidence presented to them.
  • 30. Comorbidity Rosenfeld et al found patients diagnosed with OCD had higher Y-BOCS scores than patients with other anxiety disorders and normal controls The extent to which two or more conditions co-occur – is it possible to distinguish between OCD and other disorders???? Woody et al found poor discrimination with depression i.e. patients diagnosed with OCD were often diagnosed with depression suggesting the criteria aren’t very useful Can’t distinguish OCD Can distinguish OCD VALIDITY of Diagnosis
  • 31. VALIDITY of Diagnosis Validity of Diagnosis Cultural Differences  Evaluation  • The incidence of OCD tends • However  Evidence symptoms differ e.g. to be about the same in “normal’ black Americans produced most countries/cultures higher scores on contamination – 2-3% lifetime prevalence • Symptoms might be similar across cultures – Matsunaga et al studied Japanese OCD patients and found symptoms remarkably similar to those in the West concluding the disorder transcends culture than “normal” white Americans because they interact less with animals and thus have a greater concern  This problem may lead to difficulties when using diagnostic scales because checklists are culturally biased. This would lead to a likelihood of OCD diagnosis in some cultural groups
  • 32. AO1 Conventional wisdom suggests that specially trained professionals have the ability to make reasonably accurate diagnoses. My research challenges this! What is -- or is not -- “normal” may have much to do with the labels that are applied to people in particular settings. Your point is… Situational factors may be more influential when diagnosing OCD than clinical characteristics AO2 HANG ON! My research gave 74 emergency room psychiatrists a detailed case description and found that only three psychiatrists offered a diagnosis of psychotic depression and only 1/3 recommended medication Spitzer et al This suggests.
  • 33. AO2 There are problems assessing the reliability and validity of the OCD scales… Social Desirability Bias – OCD patients may feel afraid the interviewer may take the symptoms as a sign of a deeper psychosis and not answer honestly reducing the validity of any This scale suggests. OCD patients may be fearful of handling any questionnaires because of a fear they are contaminated (Anthony and Barlow) Some OCD patients may lack awareness of the severity of their symptoms which means the validity may be low. This can be This improved by interviewing close friends and family suggests.
  • 34. AO2 Validity may be increased using computer diagnosis… A computerised scale may be preferable to avoid the fear associated with being with another person. This also mean there is less effect from interviewer bias
  • 35. Questions • Discuss issues of reliability and validity associated with the classification and diagnosis of obsessive compulsive disorder (8 marks + 16 marks) • Discuss issues surrounding the classification and diagnosis of obsessive compulsive disorder (8 + 16 marks)
  • 36. AO2 AO2 AO2 AO2
  • 37. Inherited Nature of OCD Family Studies Nestadt et al found people with a first degree relative with OCD had 5 times greater risk of having OCD at some times in their lives that the general population Strong evidence for a genetic component.. Concordance rates are higher for OCD than many other disorders e.g. 87% concordance rate for MX twins compared with 46% for schizophrenia Family Studies Menzies et al OCD patients and their relatives found it difficult to control repetitive responses on a reaction test suggesting such behaviours might be inherited HOWEVER Concordance rates are not 100% which means environmental factors must play a role too, particularly when determining the symptoms Twin Studies Billet et al Meta analysis of 14 twin studies found that MZ twins were twice as likely as DZ twins to develop OCD if their co-twin had the disorder Comorbidity OCD symptoms are found in other disorders e.g. Autism and anorexia OCD appear to be one form of expression of the same gene that determines Tourettes Syndrome as both conditions appear to run in the same families The COMT Gene Terminates dopamine activity. Studies found a variation in the COMT gene occurred in 50% of OCD male sufferers tested, 10% of females and only 16% of the normal population Schindler et al confirmed the link between OCD and the COMT gene but not he gender difference Other candidate genes are being found all the time SLC6A4 (serotonin) SAPAP3 (absent in compulsive groomers)
  • 38. WHAT IS INHERITED?  Evaluation  The Worry Circuit (Frontal Cortex) •Caudate Nucleus suppresses “worry” signals from the orbitofrontal cortex (OFC) to the Thalamus. OFC sends signals to Thalamus about things that are worrying. If the caudate nucleus damaged, the thalamus is alerted as it’s receiving more ‘worry’ signals, so sends signals back to the OFC – WORRY CIRCUIT Low Levels of Serotonin •Drugs that increase dopamine induce stereotyped movements in animals resembling the compulsive behaviours found in OCD patients Strengths  PET scans show greater activity in the OFC caudate nuclei loop in OCD patients (compared with controls and this increase is correlated with severity of OCD (Schwartz et al)  SSRIs reduce dopamine levels in the basal ganglia and this is positively correlated with a reduction in OCD symptoms (Kim et al)  OCD Patients (and their close relatives) have reduced grey matter in key regions of the brain including the OFC  There is a link between the worry circuit and serotonin and dopamine as serotonin plays a key role in the OFC therefore low serotonin would cause these areas to function poorly  Dopamine is the main neurotransmitter in the basal ganglia. High levels lead to over activity in this area •Anti depressant drugs that increase serotonin reduce OCD symptoms whereas those that don't reduce serotonin don’t reduce OCD symptoms High Levels of dopamine • • Weaknesses  A recent study found OCD patients did not preform abnormally on cognitive task related to the OFC
  • 39. Evolutionary Approach Adaptive Basis Mark And Nesse Suggest • Obsessions and compulsions might be an exaggeration of behaviours that are adaptive Grooming Behaviour • Reduces parasitism and smoothes social interaction. OCD patients often wash and groom endlessly. Concern for others • Decreases ostracism from the group. OCD patients are often concerned with harming others Hoarding • Guards against future shortages. OCD patients obsessively store things  Evaluation  • Strengths  Supportive evidence from the fact OCD is so widespread across cultures suggests some evolutionary significance i.e. it may have been adaptive  Weaknesses  This is a limited explanation Evolutionary explanations are often criticised for being determinist. But this is a misunderstanding – in the case of OCD the suggestion is that our evolution simply predisposes us to worry which, when excessive leads to abnormal behaviour but the disorder only develops if there are certain proximate triggers
  • 40. Biological Treatment
  • 41. CHEMOTHERAPY - Drugs AO2  There is lots of evidence to support Evidence suggests that drugs which raise levels of serotonin can help with OCD. SSRIs in treating OCD  SSRIs reduce dopamine levels in the basal ganglia and this is positively correlated with a reduction in OCD symptoms (Kim et al)  Weaknesses  Side Effects with treatments like Tricyclic antidepressants often leaves patient with more side effects, BUT some evidence to suggest it is helpful in treating OCD  Treatment Aetiology Fallacy – just because the symptoms disappear, doesn’t mean it has been treated.  There is a higher relapse rate in OCD patients who start drugs compared to psychological treatments
  • 42. Surgery Surgical intervention may relieve symptoms of OCD. It may involve removal or disconnection of brain regions responsible •  Evaluation  .  Doughterty et al (2002) found that Greenburg used studied of up to 45%criticised 20 mins who Szasz of patients had been treat 12 OCD patients TMS to successfully treated with psychosurgery; a psychological drugs found reduction in after and showed improvement cingulotomy is not physical state of mind compulsive urges for 8 hours  Jung et al (2006) supports this with therefore illogical to treat it as HOWEVER no adverse side effects physical Weaknesses When compared with patients Plus there cansuggests the be  Koran et al sham TMS severe side who had (2007) no effects results may be biased as patients measurable being treated know they aredifference suggests HOWEVER earlier effects (i.e placebo unblinded study could have been Nyman et al followed up OCD effects) Experimental TMS group placebo effects patients to placebo group compared who received a showed no significant reduction in capsulotomy at hospital in OCD symptoms Sweden between 1978 and  Psychosurgery may affect 1991 and found IQ behaviour more globally i.e reduce performance this may explain motivation and remained intact TMS reduced OCD symptoms
  • 43. Questions • Discuss biological explanations of obsessive compulsive disorder (8 + 16 marks) • Outline and evaluate one or more biological explanations for obsessive compulsive disorder (4+ 8 marks) • Discuss biological therapies for obsessive compulsive disorder (8 + 16) • Outline at least one biological therapy for obsessive compulsive disorder and at least one psychological therapy for obsessive compulsive disorder (8 marks) • Evaluate biological and psychological therapies for obsessive compulsive disorder in terms of appropriateness and effectiveness. (16 marks)
  • 44. Psychodynamic psychologists believe that OCD arises when unacceptable impulses from the ID are only partially repressed so provoke anxiety Why? OCD suffers use defence mechanisms to reduce anxiety How? Freud believed that OCD is the result of fixation at the anal stage of development, when children are going through toilet training. Children at this stage are obtaining their sexual gratification from bowel movements, while their parents are trying to teach them to delay this gratification. AO2 If parents deal with this by making the child feel shameful and dirty they will then have a counterdesire to control the id impulses. The result of this is an anally retentive personality (being messy is equivalent to passing faeces – being tidy is equivalent to retaining faeces). Isolation from undesirable wishes and impulses, but id sometimes dominates and the impulses intrude as obsessional thoughts Undoing unacceptable impulses by doing compulsive acts Reaction formation, adopting behaviour the exact opposite of the unacceptable impulses The obsessions, therefore, come from the desire to be messy, while the compulsions come from the need to control this desire.
  • 45. Psychodynamic explanations of OCD Freud –OCD arises when unacceptable wishes and impulses from the ID are only partially repressed and so provoke anxiety. The use of ego defence mechanisms reduce the anxiety. The 3 most common defences in terms of OCD are: isolation ( people attempt to isolate themselves, or disown undesirable thoughts and impulses. When the forces of the ID dominate, the impulses intrude as obsessional thoughts.) undoing ( when isolation fails the second defence of ‘undoing’ produces compulsive acts-washing away unacceptable impulses) reaction formation (taking on traits that are opposite to the unacceptable impulses-such as compulsive kindness may be a way of countering unacceptable aggressive impulses.)
  • 46. Psychodynamic-Adler Inferiority complex explanation• Some parents dominate their children and prevent them from developing a sense of their own competence. When this happens an inferiority complex may result so that later, as adults, these people may adopt compulsive rituals such as tidying out drawers, in order to carve out an area in which they exert control of something and can feel competent.
  • 47. RESEARCH SUPPORT Explain the specific behaviours demonstrated by ‘Rat Man’ – which defence mechanisms was he using? Salzman suggested psychoanalysis, based on psychodynamic view may actually have a negative effect on recovery. The alternative is to use short term psychodynamic therapy which is more action orientated and can therefore reduce the OCD patients tendency to think too much -ve FX on recovery Freud analysed the case study of rat man. He explained this is terms of the patients conflicting thoughts about his fiancée and her father e.g. he loved the father but also wished him dead so he could inherit his money
  • 48. AO2 AO2
  • 49. OCD sufferers find it difficult to dismiss normal intrusive thoughts. This leads to self blame and an expectation that terrible things will happen as a result. (Salkovskis) OCD sufferers often have depression which weakens their ability to distract themselves from intrusive thoughts (Frost and Steketee) To avoid anticipated consequences of intrusive thoughts, the individual is driven to neutralise them E.g. washing. HOWEVER relief is temporary and every time the act is repeated it becomes harder to resist because of the relief it provides, and it becomes a compulsion – therefore more likely to do it again
  • 50. THERE IS RESEARCH TO SUPPORT People with OCD do have maladaptive thought patterns • They believe that they should have total control over their world (Bouchard et al) • They have more intrusive thoughts than “normal’ people (Clark) • They report trying to do things that will neutralise unwanted thoughts (Freeston et al) THERE ARE GENDER DIFFERENCES In males it appears that early brain injury may be associated with OCD and Tourettes In females, OCD and trichotillomania (pulling hair out) often appear after child birth and pregnancy This suggests that Obsessive-compulsive spectrum disorder may have different triggers in men and women REDUCTIONISM There is a tendancey in all explanations to suggest that anxiety disorders can be reduced to a simple set of principes, such as repressed childhood anxieties or faulty thinking. It is important to recognise that the “real” and useful explanations are likely to consist of a combination of a number of different explanations
  • 51. Change thoughts – identify, challenge and modify dysfunctional beliefs How are thought records used?
  • 52. EFFECTIVENESS Rarely used on its own, although Wilhelm et al found significant improvement in 15 patients who used CT alone for 14 weeks APPROPRIATNESS - like ERP it involves patient effort and therefore isn’t suitable for all. Ellis suggested that some people don’t want direct advice. They want to share with a therapist and not get involved with recovery behaviours AO2 Ellis believed that sometimes people who claimed to be following the principles of CT were not putting their revised beliefs into action and therefore the therapy was not effective There is research support. Studies have found that people who hold irrational beliefs form inferences that are significantly less functional than those held by people with rational beliefs (Bond and Dryden) HOWEVER irrational beliefs may be realistic. – SADDER BUT WISER EFFECT
  • 53. Behaviourists believe that OCD are LEARNED RESPONSES to stimuli Why? Treating the OCD requires BREAKING THE ASSOCIATION between the OCD stimulus and the Anxiety/compulsion response AO2 How? Learning OCD means associating a neutral stimulus with two responses ANXIETY and COMPULSIONS AO2 The person must be exposed to the stimulus and learn, using relaxation that it no longer produces anxiety. EXTINCTION NS becomes associated with anxiety e.g. child is told eating food off the floor (NS) is dirty and therefore all dirty items create anxiety Avoiding a feared stimulus (negative reinforcement) leads to positive outcomes and is thus reinforced. Patient is presented with feared stimulus repeatedly until anxiety subsides (habituation). Exposure may move from least to most threatening At same time patient is prohibited from engaging in compulsive response. This is important to show patient anxiety can be reduced without ritual.
  • 54. Behaviourist Explanation OCD behaviour is learnt through classical conditioning and operant conditioning •  Evaluation  .  Research Support  Mowrer’s theory predicts OCD patients are predisposed to rapid conditioning. Demonstrated by Tracy et al compared an OCD-like group and control group. OCD –like were conditioned more rapidly (eye blink task)  OCD patients were asked to carry out stimulus activity i.e. touching dirty and either allowed to carry out compulsion or delay it. If delayed found anxiety persists for a while but then declines Rachman concluded compulsions provides quicker relief than waiting Weaknesses  OCD like patients are a non clinical group used for ethical and practical reasons and may not be appropriate to generalise data to understanding clinical cases of OCD
  • 55. Behaviourist explanations of OCD. Mowrer suggested that the learning of fears is a two step process: Classical conditioning A neutral stimulus becomes associated with anxiety through Classical Conditioning. Operant conditioning Any action that enables the individual to avoid a negative event is negative reinforcement. Avoidance of the fear leads to positive outcomes and is therefore reinforced. Thus the compulsive behaviour becomes a way of establishing control and reducing anxiety- and as a result the behaviour is reinforced and the behaviour may become compulsive whenever the individuals face thoughts that provoke anxiety.
  • 56. Evaluating behavioural explanations • Are OCD patients more predisposed to rapid conditioning? • Are compulsive behaviours actually benefiting the OCD patient? • Is there a bio-social explanation??
  • 58. EFFECTIVNESS of ERP Albucher et al reported btwn 60% and 90% of adults improved considerably with ERP. For those with mild OCD, self directed ERP may be best. PC based program BT STEPs was found to be more effective than relaxation training alone, but less effective than therapist guided ERP (Griest et al ) APPROPRIATNESS of ERP is that it is not suitable for all. Not all are helped by ERP. Patients that are too depressed (Gershuny et al) nor patients who have cerain types of OCD such as ptients with severe hoarding behaviour (Stekeete and Frost) AO2 Exposure and Response prevention therapy MOST EFFECTIVE WHEN COMBINED WITH OTHER THERAPIES Drug therapy Foa et al found combination with (tricyclic) was more effective than either alone ALSO combined with antibiotic which acts on GABBA ERP was substantially improved SUCCESS DEPENDS ON EFFORT made by the patient and willingness to do homework – not all patients are which leads to a substantial refusal rate that may elevate the apparent success of ERP because only those patients who are willing to be helped may agree to participate
  • 59. Questions • Discuss two or more psychological explanations of obsessive compulsive disorder (8 + 16) • Discuss one or more psychological explanations for obsessive compulsive disorder (4 + 8) • Outline at least one biological therapy for obsessive compulsive disorder and at least one psychological therapy for obsessive compulsive disorder (8 marks) • Evaluate biological and psychological therapies for obsessive compulsive disorder in terms of appropriateness and effectiveness. (16 marks)