1) Sensory over-responsivity (SOR) is a type of sensory processing disorder involving negative responses to daily sensations. Research shows SOR is prevalent in OCD and associated with greater OCD severity and specific compulsion types. 2) Theories suggest SOR creates attentional biases towards stimuli leading to obsessive thoughts and compulsions. Poor sensory adaptation may also underlie the SOR-OCD relationship. 3) Sensory-based assessment and treatment involves identifying SOR, cognitive conceptualization, graded exposure, and calming techniques to prevent avoidance and regulate arousal. Treatment is multi-phasic and targets regulation of sensations, thoughts, and behaviors.

1. Sensory Over-Responsivity and OCD:
How can Research Inform Practice?
Tamar Podoly, OT, Clinical Psychologist
Ayelet Ben-Sasson, OT, ScD
IOCDF 2016

2. Outline
• Concept: Sensory over-responsivity
• Research: How SOR and OC interplay?
• Theory: Why SOR and OC interplay?
• Practice: Sensory-based intervention

3. Sensory Over-Responsivity
• Type of sensory modulation disorder manifested by negative,
intense, rapid, prolonged responses towards daily sensations:
– Auditory, tactile, vision, taste, smell, vestibular
– Particularly in unstructured, unpredictable situations
– Temporal and cumulative effects
– Indicators: avoidance, resistance, aggression vs. distress,
distractibility, irritability
• Affects 5% of pediatric population (Ahn et al., 2004)
• Prevalent in many developmental disorders such as in ASD and
ADHD (Ben-Sasson et al., 2009)
• SOR is an imbalance between sensitivity and habituation: high
sensitization and low habituation to stimuli

4. Is SOR the Sensory Phenomena in OCD?
Bodily sensations
1. Tactile
2. Muscular/visceral
Mental sensations
1. Need for the “just
right” visual, tactile,
auditory sensation
2. Incompleteness
3. Need for energy
release
4. General urge
Sensory
Phenomena
(Miguel et al., 2001; Rosário-Campos et al., 2005)
Inflated responsibility?
Need for control?
Imperfection?
Sensory modulation
disorder?

5. Outline
• Concept: Sensory over-responsivity
• Research: How SOR and OC interplay?
• Theory: Why SOR and OC interplay?
• Practice: Sensory-based intervention

6. Research: SOR and OC interplay
1. SOR manifestation in OCD
2. Types of OC symptoms associated with SOR
3. OCD sub-typing and SOR

7. 1. SOR manifestation in OCD:
– Tactile, auditory, taste, smell, visual SOR (Dar et al.,
2012; Lewin et al. 2014; Taylor et al., 2014)
– Clinical pediatric and adolescent samples (Hazen et
al., 2008; Reik & Anderson, 2009; Lewin et al. 2014)
– SOR + poor sensory registration and less sensation
seeking (Reik & Anderson, 2009)
– Bothering sensation can replace obsession in
triggering compulsion (Hazen et al., 2008)
Research: SOR and OC interplay

8. Sensory Profile in Adults with OCD
0
5
10
15
20
25
30
35
40
45
50
55
60
sensitivity avoidance low
registration
seeking
OCD
ADHD
ASD
TYPICAL
(Clince et al. 2016 ; Reik & Anderson, 2009)

9. Rates (%) of SOR in OCD
(Lewin et al., 2014)
0
5
10
15
20
25
30
35
40
45
50
TotalPreschoolChildAdolescent
Tactile
SOR
Taste/Smell SOR
Visaul/Auditory SOR

10. Adults with Tourette Syndrome Report Higher
Sensitivity (Belluscio et al., 2011)
• 80% report SOR across 5 modalities
• Bothersome stimuli= faint, repetitive,
constant, non-salient
• No dif in tactile and olfaction detection
thresholds
• Higher intensity perception for faint
stimuli

11. Research: SOR and OC interplay
2. Specific types of OC symptoms implicated?
– SOR associated with greater OC severity (Lewin et al.,
2014; Podoly & Ben-sasson, under review; Taylor et al.,
2014)
– SOR associated only with compulsions not with
obsessions? NO
– If sensitive towards a certain modality is compulsion more
likely to be in that modality? NO
– SOR associated with incompleteness vs. harm avoidance?
NO
• E.g.: Higher SOR in OCD associated with presence of
contamination obsessions, symmetry compulsions,
ritualized eating and NJRE (Lewin et al., 2014)

12. OCD subtyping and SOR
3. OCD subtyping and SOR
N=272 neurotypical adults, Age =33.6 (13.2) yrs, 39.4% Males
• Using K-means with SOR and OC scores results in a 4 cluster
solution: None=114; SOR=78; OCS=67, Both=15
1
2
3
4
5
6
7
8
None Both OCS SOR
Meananxietyscores
Clusters
(Podoly & Ben-Sasson, in review)

13. OCD subtyping and SOR
OCD + sensory symptoms are more likely to have:
• Early onset
• Elevated OC severity
• Have tics and co-morbid TS
• Anxiety and depression
• Response to pharmacological intervention
• Poor response to traditional interventions
(Ferrao et al., 2012; Shavitt et al., 2006; Summerfeldt, 2004; Wang
et al., 2012)

14. Outline
• Concept: Sensory over-responsivity
• Research: How SOR and OC interplay?
• Theory: Why SOR and OC interplay?
• Practice: Sensory-based intervention

15. Theory: Why SOR and OC interplay?
• SOR creates attention bias towards stimuli
which in turn leads to obsessive thoughts and
compulsions.
• SOR as a vulnerability factor for
psychopathology (Levit-Binnun et al., 2013)
• Anxiety mediates the relation between SOR
and OCD

16. Model
Explaining the
Role of SOR in
OCD
Compulsion
Obsession
Attentional
bias sensory
stimuli
Dysfunc’
beliefs
SOR

17. Theory: poor sensory adaptation
(Guclu et al. 2015)
• Tactile sensitivity similar in OCD= detection
threshold
• Worse amplitude discrimination
• Reduced adaptation

18. Outline
• Concept: Sensory over-responsivity
• Research: How SOR and OC interplay?
• Theory: Why SOR and OC interplay?
• Practice: Sensory-based intervention

19. Sensory based OCD-Identification
• Childhood and infancy history.
• Parents reports.
• Obsessions that involve specific body
sensations.
• Compulsions that involve avoidance of specific
body sensations.

20. Sensory based OCD- Assessment
SMD assessments available:
• Sensory Profile
• Sensory Over Responsivity Scale (SensorR)
• Sensory Processing Measure (SPM)
• Adult Sensory Questionnaire (ASQ)
• Adult Sensory Interview (ADULT-SI)
• Sensory Perception Quotient (SPQ)
• Sensory Habituation Questionnaire (S-HAB-Q)

21. Sensory based OCD- Assessment
• Family Accommodation Scale for OCD, Interviewer
rated (FAS-IR)
• Cognitive Conceptualization, case formulation (Beck)

22. Cognitive conceptualization form (Beck, 1995)
Relevant data
Core belief
Assumptions and
rules
Coping Strategies

23. Cognitive conceptualization form (Beck, 1995)
Situation
Automatic
thoughts
Meaning of AT
Emotion
Behavior

24. Sensory based OCD-
Differential diagnosis
• ADHD
• ASD
• Schizophrenia
• Panic disorder

25. The ‘Interacting Systems’ principle
(Lang,1968)
Assumptions in cognitive theory
(Alford & Beck,1997)

26. Levels of cognition
Automatic thoughts
(negative/adaptive)
"I can not deal with this thing"
"I can not stand it"
"It hurts me a lot"
Functional/Dysfunctional assumptions
"Always look for danger and expect it”
"If I experience discomfort I might get
hurt"
"I have to control the environment in
order to feel safe"
Core belief, schema
"I am sensitive”
"The world is not a safe place
for me”
Specificity
accessibility
flexibility

27. Sensory intervention
• Sensory integration
• Attentional and Emotional regulation
• Focusing on the kinesthetic system

28. Sensory intervention
self regulation
First order regulation – automatic, not controlled.
Second order regulation – controlled, Not always
conscious.
Third order regulation – controlled, conscious, and
requires high-functioning.

29. Sensory intervention
Arousal levels
Sensory system
Bottom
upTop-
down

30. Sensory based OCD
Goals
 Preventing sensory overflow, yet with no avoidance
behaviors.
 Calming , recovery.
 Optimal level of arousal, behavioral regulation and
organization .
Coping with anxiety-provoking stimuli
Reducing anxiety with cognitive restructuring in relation to
stimulus

31. Sensory based OCD
Techniques
• Psycho-education
• Use of sensory stimulation for regulation.
• Use of cognition for regulation.
• Gradual exposure (sensory based)
• Classic ERP

32. Adjustments for OCD
• Therapeutic contract with family/parents and client.
• High family/parental involvement.
• Interesting, funny and challenging exposures.
• Flexible sensory diet to avoid ritualization.
• Do not attack all fronts at once.
• Client control and lead the exposure.

33. The course of treatment
Phase I – Psycho-education
Phase II - Analysis of automatic thoughts
Phase III - Planning exposure.
Phase IV – Adjusting exposure to different settings.
Phase V – Exposure level, practices at home and at
school
Phase VI - When do you know that the treatment
has ended?

34. Psycho-education
• Sensory system
• Course of treatment
• Exposure
• Parents/children

35. CASE conceptualization (Beck, 1995)
Relevant data
Core belief
Assumptions and
rules
Coping Strategies

36. CASE conceptualization (Beck, 1995)
Situation
Automatic
thoughts
Meaning of AT
Emotion
Behavior

37. Exposure

38. Calming techniques

39. Intervention program for sensory based OCD
Target population Pediatric OCD
Adult OCD
Adjustments of the human
environment
At the beginning, and gradually reducing
Adjustments of the non human
environment
The program should take place in a variety of
locations
Important elements of
intervention
Psycho-education
Cognitive conceptualization
Exposure
Calming techniques
Duration At least 6 month
Frequency At least 2 time per week with everyday practice.

40. Selected References
Belluscio, B. A., Jin, L., Watters, V., Lee, T. H., & Hallett, M. (2011). Sensory sensitivity to external stimuli
in Tourette syndrome patients. Movement Disorders, 26(14), 2538-2543.
Conelea, C. A., Carter, A. C., & Freeman, J. B. (2014). Sensory Over-Responsivity in a Sample of Children
Seeking Treatment for Anxiety. Journal of Developmental & Behavioral Pediatrics, 35(8), 510-521.
Dar, R., Kahn, D.T., & Carmeli, R. (2012). The relationship between sensory processing, childhood rituals
and obsessive-compulsive symptoms. Journal of Behavior Therapy and Experimental Psychiatry,
43(1), 679-684.
Güçlü, B., Tanıdır, C., Çanayaz, E., Güner, B., İpek Toz, H., Üneri, Ö. Ş., & Tommerdahl, M. (2015). Tactile
processing in children and adolescents with obsessive–compulsive disorder. Somatosensory & motor
research, 32(3), 163-171.
Hazen, E.P., Reichert, E.L., Piacentini, J.C., Migule, E.C., Do Rosario, M.D., Pauls, D., & Geller, D.A. (2008).
Case Series: Sensory Intolerance as a Primary Symptom of Pediatric OCD. Annual Clinical Psychiatry,
20(4), 199–203.
Lewin, A.B., Wu, S.M., Murphy, T.K., & Storch. E.A. (2014). Sensory over-responsivity in pediatric
obsessive compulsive disorder. Journal of Psychopathology and Behavioral Assessment, 36, 201-211.
Podoly, T. & Ben-Sasson, A. (under review). Cluster analysis of sensory over-responsivity and obsessive
compulsive symptosm.
Rieke, E.F., & Anderson, D. (2009). Adolescent/adult sensory profile and obsessive– compulsive disorder.
American Journal of Occupational Therapy, 63, 138–145.
Summerfeldt, L. J. (2004). Understanding and Treating Incompleteness in Obsessive Compulsive
Disorder. Journal of Clinical Psychology, 60(11), 1155-1168.
Taylor, S., Conelea, C.A., McKay, D., Crowe, K.B., & Abramowitz, J.S. (2014). Sensory intolerance: latent
structure and psychopathologic correlates. Comprehensive Psychiatry, 55(5), 1279-1284.