CBT is an effective treatment for OCD due to its ability to trigger lasting neural changes through learning. It involves psychoeducation, challenging irrational assumptions, exposure to feared situations without compulsions, and response prevention. Studies show large effect sizes for CBT compared to medications alone. CBT aims to reduce anxiety and distress from obsessions by stopping thoughts and using distractions, while exposure therapy targets compulsions. Success requires understanding all symptoms, motivated patients, and therapists able to systematically implement the CBT techniques.

1. 1
CBT FOR OCD
Dr V.Sabitha
Associate Professor
Institute of Mental Health
Chennai

2. 2
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-
thalamo-striatal circuitry.
 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.

3. 3
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
Psychiatry 2009).
 Etc.

4. 4
TREATMENT OF OCD
 SRI drugs and CBT
 Meta-analysis 1:
 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)

5. 5
ADVANTAGES OF CBT
 Effective as monotherapy.
 Large effect size [caveat: biases
could arise from sample selection
and consenting processes].
 Improves long-term outcomes
with drugs.
 Treating with drugs+CBT may
offer the best outcomes.

6. 6
TREATMENT OF OCD
 The proper treatment of
OCD with CBT requires a
complete understanding of
the spectrum of symptoms
that the patient displays.

7. 7
OCD
 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.

8. 8
NOTE
 By definition, mental preoccupations or repetitive
behaviors are not considered under OCD if they
occur in the context of another DSM-IV Axis I
disorder
(e.g. hypochondriasis; eating disorders;
trichotillomania)

9. 9
OBSESSIONS AND
COMPULSIONS
 Obsessions are repeated thoughts.
 E.g. “My son is going to die.”
 E.g. “I will get AIDS.”
 Compulsions are repeated actions.
 E.g. Handwashing.
 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.]

10. 10
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
different.

11. PSYCHOPATHOLOGY OF
OCD
 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
removes anxiety
11

12. OCD COGNITIONS
 Inflated sense of Personal Responsibility
 Undue Importance to Thoughts
 A need to control thoughts
 Overestimation of threat
 Intolerance of Uncertainity
 Perfectionism
12

13. 13
TYPES OF OBSESSIONS
[obsessions provoke anxiety]
 Obsessive thoughts
 Obsessive ruminations
 Obsessive doubts
 Obsessive vacillations
 Obsessive phobias
 Obsessive impulses
 Obsessive images

14. 14
TYPES OF COMPULSIONS
[compulsions relieve anxiety]
 Almost always secondary to obsessions
 May be behavioral or mental
 Yielding:
 Counting
 Checking
 Ordering
 Cleaning/washing
 Resisting:
 Repeating thoughts or actions to prevent or undo a
feared event
 (Overlap may be present)

15. 15
ASSESSMENT
(2-4 h)
 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.

16. 16
ASSESSMENT
(contd.)
 Make a chart with each symptom rated:
 Frequency (occasions per day)
 Time spent (minutes or hours)
 Distress (0-10)
 Impairment (0-10, with examples of impairment)
 Overall severity
 This chart can be used to monitor progress.
 Use the Y-BOCS or LOI or other scales.

17. 17
YALE-BROWN OBSESSIVE-
COMPULSIVE SCALE
 10 items (5 for obsessions, 5 for compulsions)
 Semi-structured interview based on an explanation
to the patient about what obsessions and
compulsions are.
 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.

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LEYTON OBSESSIONAL
INVENTORY
 69 items
 Identification of OCD s/s
 Assessment of resistance
 Assessment of interference
 Plus: Common OCD s/s listed individually
 Minus: Rare s/s are omitted.

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CORNERSTONES OF CBT
 Common to both obsessions and compulsions:
 Psychoeducation
 Challenging assumptions
 [Family support, if indicated]
 Obsessions:
 Thought-stopping
 Distraction
 Compulsions:
 Exposure
 Response prevention

20. 20
CBT FOR OBSESSIONS
 Psychoeducation
 Challenging assumptions
 Family support
 Thought stopping
 Distraction

21. 21
PSYCHOEDUCATION FOR
OBSESSIONS
 Explain about OCD
 Destigmatize the illness
 Explain the principles of drug
therapy
 Explain the principles of CBT
 Discuss plan of management
 Review patient understanding
 Time: 1-2 hours

22. 22
CHALLENGING
ASSUMPTIONS
 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]

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CHALLENGING
ASSUMPTIONS
 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.

24. 24
THOUGHT-STOPPING
 Terminates the obsession
 Slapping the table or pinching one’s thigh
 Shouting stop
 Snapping a rubber band on the wrist
 Doing these physically or imaginally

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OTHER DISTRACTOR
TECHNIQUES
 Taking up a chore that demands attention
 Phoning a friend
 Speaking to a family member
 Examining details in the environment
 Etc. [plan these out]

26. 26
STRATEGY FOR TACKLING
OBSESSIONS
 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
overcome.

27. 27
CBT FOR COMPULSIONS
 Psychoeducation
 Challenging assumptions
 Recruit family support
 Exposure
 Response prevention

28. 28
CHALLENGING ASSUMPTIONS:
CHECKING COMPLSIONS
 Did I lock the door?
 Strategy
 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?]

29. 29
CHALLENGING ASSUMPTIONS:
WASHING COMPLSIONS
 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.

30. 30
MORE ABOUT DIRT
 Why are bodily secretions
dirty the moment they leave
the body?
 Smelling a fart and airborne
particles
 Do not tell the patient this!

31. 31
CHALLENGING
ASSUMPTIONS
 [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.

32. 32
CHALLENGING
ASSUMPTIONS
 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.

33. 33
EXPOSURE AND RESPONSE
PREVENTION
 Systematic desensitization
 Flooding
 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.

34. 34
EXPOSURE AND RESPONSE
PREVENTION
 E.g. stepping on paper
 E.g. touching footwear
 E.g. handling currency notes
 E.g. checking a locked door
 Therapist-assisted exposure (provides
support)
 Self-driven exposure (provides
confidence, improves generalization)

35. 35
DEALING WITH
BATHING RITUALS
 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.

36. 36
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.

37. 37
DEALING WITH
OBSESSIVE SLOWNESS
 Suggestions:
 Challenge assumptions.
 Set timetable with
attention to problem
specifics.
 Enlist family supervision.

38. 38
COMMENTS
 Patients sometimes develop
substitute rituals after their
primary symptoms are addressed.
 E.g. rubbing hands to replace
washing.
 Not all patients are suited for
CBT; not all patients will respond;
however, some improvement is
better than no improvement.

39. 39
SESSIONS
 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).

40. 40
IMPORTANT THERAPIST AND
CLIENT CHARACTERISTS
 Client:
 Motivation and compliance
 Therapist:
 Effort to identify the symptoms in their entirety
 Ability to successfully challenge assumptions.

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ENFIN…
 That’s it, folks;
thanks for listening!