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Chapter 3: ObsessiveCompulsive Disorder
(OCD)
Jonathan S. Abramowitz
Laura E. Fabricant
Ryan J. Jacoby
Diagnosis Overview
 Obsessive-compulsive disorder (OCD)
 Obsessions or compulsions
 Significant distress
 Noticeable interference with aspects of role functioning
 Obsessions
 Intrusive thoughts, ideas, images, impulses, or doubts that the
person experiences as senseless and that evoke anxiety
 Compulsions
 Urges to perform overt (e.g., checking, washing) or mental
(e.g., praying) rituals in response to obsessions or to reduce
anxiety or distress
DSM-5 Diagnostic Criteria
A. Presence of obsessions, compulsions, or both:
Obsessions:
1. Recurren, persistent, intrusive, unwanted, causing anxiety or distress.
2. Attempts to ignore or suppress such thoughts, or to neutralize them with some
other thought or action
Compulsions:
1. Repetitive behaviors or mental acts driven to perform in response to an
obsession, or using rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing anxiety, distress, or some
dreaded event
B. The obsessions or compulsions are time-consuming (for example, take more
than 1 hour a day) or cause clinically significant distress or impairment
Indicate whether OCD beliefs are currently characterized by good or fair, poor, or
absent insight
Diagnosis-Related Conditions
Body Dysmorphic Disorder (BDD)
• Both OCD and BDD can involve:
•
Intrusive, distressing thoughts concerning one’s appearance
•
Repeated checking
• The focus of BDD symptoms is limited to one’s appearance
• Similar psychological treatments are effective for both conditions.
Hoarding
• Once considered to be a symptom of OCD, hoarding is now
understood as a separate problem.
• Hoarding symptoms are no more prevalent in OCD patients than
those with other psychological disorders
Diagnosis-Related Conditions
Obsessive-Compulsive Personality Disorder (OCPD)
 Personality traits such as excessive perfectionism,
inflexibility, and need for control that negatively impact
interpersonal relationships and functioning
 OCPD is ego-syntonic while the obsessive thoughts
experienced by individuals with OCD are ego-dystonic
 Other personality disorders, such as avoidant and
dependent personality disorder, co-occur with OCD
just as frequently
Obsessive-Compulsive and
Related Disorders (OCRDs)
•
OCD moved from anxiety disorders to OCRDs, which includes
trichotillomania (hair-pulling disorder), excoriation (skin-picking),
body dysmorphic disorder (muscle dysmorphia specifier added),
hoarding, obsessional jealousy & body-focused repetitive disorder
•
Many disorders in new category differ substantially from OCD
• OCD compulsions are intentional, in contrast to mechanical or
robotic repetitive behaviors such as tics
• Repetitive behaviors in addictive disorders or in trichotillomania
or, are carried out because they produce pleasure, distraction, or
gratification while in OCD, the repetitive behaviors primarily
reduce anxiety
DSM-5 Diagnostic Criteria for
OCD
A. Presence of obsessions, compulsions, or both:
Obsessions:
1. Recurrent, persistent, intrusive, unwanted, causing anxiety or distress.
2. Attempts to ignore or suppress such thoughts, or to neutralize them with some
other thought or action
Compulsions:
1. Repetitive behaviors or mental acts driven to perform in response to an
obsession, or using rules that must be applied rigidly.
2. The behaviors or mental acts are aimed at preventing anxiety, distress or some
dreaded event
B. The obsessions or compulsions are time-consuming (for example, take more
than 1 hour a day) or cause clinically significant distress or impairment
Specifier Indicates whether OCD beliefs are currently characterized by:
good/ fair, poor, or absent insight/delusional (specifier can be used for other disorders)
Tic specifier (current or history of)
Symptoms: Obsessions
Examples of Obsessions
Category
Example
Contamination
What if I get rabies from driving over a dead animal on the
street?
Responsibility for What if I hit someone with my car without realizing it?
harm or mistakes
Symmetry/order
The books must be evenly placed on the shelf or else I will
have bad luck
Unacceptable
Image of my grandparents having sex
thoughts with
immoral, sexual,
or violent content Thought about stabbing my husband in his sleep.
Symptoms: Compulsions
 Compulsive rituals are often the most conspicuous
and functionally impairing symptoms
 Compulsive rituals are often performed to reduce
obsessional anxiety about feared consequences
 Many individuals with OCD also engage in
repeated attempts to gain ultimate certainty that
obsessional doubts are invalid
Symptoms: Obsessions
Examples of Compulsive Rituals
Category
Example
Decontamination
Wiping down all objects brought into the house for fear of
germs from recently applied pesticides on an adjacent lawn
Checking
Returning home after seeing a fire engine to make sure the
house wasn’t on fire
Repeating routine Going through a doorway over and over to prevent bad luck
activities
Retracing one’s steps to make sure that no mistakes were
made
Ordering/
Saying the word “left” whenever one hears the word “right”
arranging
Mental rituals
Canceling a bad thought by thinking of a good thought
Symptoms: Avoidance and
Insight
 Avoidance behavior is present in most people with
OCD
 Prevents obsessional fears and compulsive urges
altogether
 About 4% of patients are convinced that their
beliefs are realistic (i.e., poor or absent insight)
Prognosis
 OCD is a chronic condition with a low rate of spontaneous
remission
 Left untreated
 Symptoms and functional impairment fluctuate, with
worsening during periods of increased life stress
 With treatment
 Increased rates of symptom remission. Full recovery,
however, is the exception rather than the rule
Demographics
 Lifetime prevalence of OCD estimated at between
0.7% and 2.9%
 Slight preponderance of females
 Typically begins by age 25, although childhood or
adolescent onset is not rare
 Mean onset age is earlier in males (about 21 years)
than in females (22 to 24 years)
Etiology: Learning Model
Mowrer’s two-stage theory of fear acquisition and maintenance
• First stage: Classical conditioning
• Neutral stimulus, aka. the conditioned stimulus (CS), paired
with aversive stimulus, aka. the unconditioned stimulus (UCS)
• The CS comes to elicit a conditioned fear response, or CR
• Second stage: Operant conditioning
• Avoidance behaviors reduce anxiety; avoidance is negatively
reinforced by the immediate reduction in distress.
• Compulsive rituals develop as an escape behavior from
obsessional fear when avoidance is impossible
Etiology: Cognitive Deficit
Models
• Proposes that OCD symptoms arise from
abnormally functioning cognitive processes, such
as memory
• Cognitive deficit models cannot account for:
• Heterogeneity of OCD symptoms
• The fact that similar mild cognitive deficits are
found in many psychological disorders
• If cognitive deficits play a causal role in OCD, it is
most likely to be a nonspecific vulnerability factor
Etiology: Cognitive Behavioral
Models
• Based on Beck’s cognitive theory
• Emotional disturbance is brought about by how one
makes sense of situations or stimuli
• Unwanted intrusive thoughts (i.e., thoughts, images, and
impulses that intrude into consciousness) are a normal
experience
• Intrusions develop into a clinical obsession if the person
believes they have serious consequences
• Compulsive rituals and avoidance represent efforts to
remove intrusions and prevent feared consequences
Etiology: Salkovski’s Model
• Salkovski’s two reasons that compulsions/avoidance
become persistent and excessive:
1. Negatively reinforced by their ability to reduce distress
2. They prevent people from learning their appraisals of
intrusions are exaggerated and unrealistic
• Psychometric research indicates that there are three
principal domains of dysfunctional beliefs associated with
OCD symptoms
• These types of beliefs confer vulnerability to the onset or
worsening of obsessive-compulsive symptoms
Etiology
Domains of Dysfunctional Beliefs in OCD
Belief
Description
Inflated responsibility/ Belief that one has the power to cause or prevent
overestimation of threat negative outcomes. Belief that negative events are
likely and would be unmanageable
Exaggeration of the
importance of thoughts
and need to control
thoughts
Belief that the mere presence of a thought indicates
that the thought is significant. Belief that complete
control over one’s thoughts is both necessary and
possible
Perfectionism/intolerance Belief that mistakes and imperfection are intolerable.
of uncertainty
Belief that it is necessary and possible to be 100%
certain that negative outcomes will not occur
Etiology: Pyschosocial Factors
 Dysfunctional relationship patterns can promote the
maintenance of OCD symptoms
 Accommodation
 Friend or relative participates in rituals, facilitates
avoidance strategies, assumes daily responsibilities, or
helps to resolve problems resulting from obsessional
fears and compulsive urges
 Prevents the natural extinction of obsessional fear and
ritualistic urges
 Criticism, hostility, and emotional overinvolvement are
associated with premature treatment discontinuation and
symptom relapse
Etiology: Serotonin Hypothesis
 Obsessions and compulsions arise from a
hypersensitivity of the postsynaptic serotonergic
receptors
Three potential lines of evidence:
1. Medication outcome studies supportive
2.
Studies of biological markers—such as blood and
cerebrospinal fluid levels of serotonin metabolites—are
inconclusive
3.
Results from the pharmacological challenge paradigm
largely incompatible
Etiology: Structural Models
 Structural models hypothesize that OCD is caused
by neuroanatomical and functional abnormalities in
particular areas of the brain
 Orbitofrontal-subcortical circuits connect brain regions
involved in information processing with those involved in
the initiation of behavioral responses
 Two pathways: direct and indirect
 Overactivity of the direct pathway is thought to give rise to
OCD symptoms
Etiology: Biological Models
 No explanation has been offered for how
neurotransmitter or neuroanatomical abnormalities
translate into OCD symptoms
 For example, Why does hypersensitivity of postsynaptic
receptors cause obsessional thoughts or compulsive rituals?
 In addition, biological models are unable to explain:
 OCD symptoms are generally constrained to particular themes
 Why someone would experience one type of obsession (e.g.,
contamination), but not another (e.g., sexual)
Treatment: CBT
 Successful treatment for OCD symptoms must accomplish two things:
1.
2.
Correction of maladaptive beliefs and appraisals
Termination of avoidance and compulsive rituals preventing selfcorrection of maladaptive beliefs and extinction of anxiety
 Functional assessment
 Detailed information about antecedents and consequences of target
behaviors and emotions
 Includes:
• Assessment of obsessional stimuli
• Assessment of avoidance and compulsive rituals
• Self-monitoring
Treatment: Exposure and
Response Prevention (ERP)
 Confrontation with stimuli that provoke obsessional
fear but that objectively pose a low risk of harm
 Situational or in vivo exposure
 Imaginal exposure
 Habituation
 Over time, the anxiety (and associated physiological
responding) naturally subsides
Treatment: Exposure and
Response Prevention (ERP)
 Format
 Few hours of assessment and treatment planning
 15 (daily or twice-weekly) treatment sessions, 90 minutes each
 If intensive regimens are impractical, conducting the
treatment sessions on a weekly basis works well for
individuals with less severe OCD
 Self-supervised exposure homework practice
assigned for completion between sessions
 Home-based self-supervised exposure exercises
must last long enough for the anxiety to dissipate
Treatment: Exposure and
Response Prevention (ERP)
 Therapist must provide cogent rationale for how ERP
will be helpful in reducing OCD
 Exposure exercises
 Begin with moderately distressing situations, stimuli, and
images, and progress to the most distressing situations
 Between each treatment session, patient continues exposure
exercises for several hours in different environmental contexts
without the therapist
 Exposure to the most anxiety-evoking stimuli is completed
during the middle third of the treatment program
 During later sessions, therapist emphases generalization and
of continued application of ERP procedures after treatment
Treatment: Exposure and
Response Prevention (ERP)
 Foa and Kozak hypothesized that ERP produces its effects by
correcting patients’ overestimates of danger that underlie
obsessional anxiety
 Three requirements for successful outcome with ERP
1. Physiological arousal and subjective fear are evoked during exposure.
2. Within-session habituation
3. Between-sessions habituation
 Inhibitory learning
 Enhance the recall of the new associations relative to the older, threatbased associations
 Combining exposure and response prevention is more effective
than using either of its individual components
Treatment: Exposure and
Response Prevention (ERP)
 Majority of OCD patients experience substantial short-
and long-term benefits
 ~83% of patients are responders (at least 30% symptom
reduction) at posttreatment
 76% were responders at follow-up
 Superior to wait list, progressive muscle relaxation,
anxiety management training, pill placebo, and
pharmacotherapy with serotonergic medication
 Effectiveness studies conducted in real world show
that more than 80% of patients who complete
treatment achieve clinically significant improvement
Treatment: Cognitive Therapy
(CT)
 Rational and evidence-based challenging and correction of
faulty and dysfunctional thoughts and beliefs that underlie
emotional distress
 16-session CT include:
 Learning to conceptualize obsessive intrusions as normal stimuli
 Identifying and challenging anxiety-provoking thoughts associated
with obsessions with Socratic questioning
 Changing dysfunctional assumptions to nondistressing beliefs
 Behavioral experiments to test out the new beliefs
 Studies suggest relatively equivalent efficacy of CT and
ERP
 CT reduces drop out from ERP
Treatment: Pharmacological
 On average, serotonin medications produce a 20% to
40% reduction in obsessions and compulsions
 Advantages
 Convenience
 Little effort on the patient’s part
 Limitations
 Relatively modest improvement and residual symptoms
 High rate of nonresponse (40% to 60%)
 Side effects (may be minimized by adjusting the dose)
 Once terminated, OCD symptoms typically return rapidly